Dry Powder Formulation of Tacrolimus for Once-Daily (QD) Administration by Inhalation

Abstract

The present disclosure provides a method of using and a pharmaceutical composition of tacrolimus that can be administered by inhalation once a day.The method and composition can be used to provide a therapeutically effective range of plasma concentration of tacrolimus using only one dose per day.Once-a-day administration can result in fewer adverse events and reduced side effects while increasing patient compliance.

Description

[Technical field]

[0001] This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 187,774, filed May 12, 2021, the entire contents of which are incorporated herein by reference.

[0002] 1. Field The present disclosure relates generally to the fields of medicine and medicine manufacturing, and more particularly to compositions and methods for administering tacrolimus in a once-daily formulation. [Background technology]

[0003] 2. Description of Related Art Tacrolimus, an immunosuppressant, is used in transplant medicine. Based on data from the ISHLT, tacrolimus is currently used in more than 80% of lung transplant patients. Similarly, tacrolimus usage is high in heart, kidney, and liver transplant patients. Usage of tacrolimus for immunosuppressive therapy is high, despite many challenges for patients and physicians when used long-term. Tacrolimus can cause kidney toxicity, especially when used in high doses.

[0004] Tacrolimus (Prograf®) is currently available as an injectable solution, granules for suspension, or gelatin-coated capsules. None of the current formulations are suitable for inhalation. Prograf is indicated for the prevention of organ rejection in adult and pediatric patients undergoing allogeneic liver, kidney, or heart transplants, in combination with other immunosuppressants. It is not indicated for prophylaxis in lung, heart-lung, or bilateral lung transplants. However, it is widely prescribed in lung transplants, and therapeutic drug monitoring recommendations based on heart and lung transplantation are C 2 + / - 100 mg / kg for the first few weeks after transplantation. min The trough concentration is 15–20 ng / mL (Brunet et al. 2019), with lower concentrations thereafter.

[0005] According to the Prograf® label, tacrolimus, when administered orally, is administered twice daily at a dose range of 0.1-0.3 mg / kg / day. This is approximately 7-21 mg / day for a 70 kg human. Absorption of tacrolimus is incomplete (<25%) and variable depending on the study (%CV range of 28-58%). Furthermore, absorption can be affected by food, with the presence of food decreasing the rate and extent of absorption, which is most pronounced after a high-fat meal. Tacrolimus is also extensively metabolized by CYP3A4 / 5 in the liver and intestinal wall (Chen and Prasad, 2018), and therefore drugs similarly metabolized by this CYP isoenzyme, such as ketoconazole, cyclosporine A, diltiazem, erythromycin, and fluconazole, are known to interact with tacrolimus metabolism (Iwasaki, 2007). Rifampicin is an inducer of CYP3A4 and therefore may decrease tacrolimus concentrations in kidney and liver transplant patients. Identifying patients' genotypes for CYP3A4 and CYP3A5 polymorphisms can help improve initial dose targeting and future dose adjustments, but adequate therapeutic drug monitoring remains a challenge.

[0006] One of the biggest challenges the medical community faces with tacrolimus is balancing patient compliance with adverse event monitoring. There are a significant number of warnings and precautions for the use of Prograf® (oral tacrolimus), including lymphoma, serious infections, new-onset diabetes after transplant, nephrotoxicity, neurotoxicity, hyperkalemia, hypertension and QTc prolongation. However, adverse reactions associated with multiple daily oral administration may be of greater concern. The observed rate of adverse reactions may vary depending on the transplant procedure and concomitant drug therapy. Consistently, across multiple studies, diarrhea was the predominant gastrointestinal adverse reaction, with an incidence of 25%-72%, depending on the study, followed by nausea, vomiting and constipation (Prograf® label). In the case of lung transplantation, being able to bypass the gastrointestinal tract and deliver tacrolimus directly to the target tissue may reduce this incidence and improve patient compliance. There is a strong need for compositions that achieve the goal of reducing the frequency of administration while maintaining a therapeutically effective concentration of tacrolimus. Summary of the Invention

[0007] overview The present disclosure provides a method and composition of tacrolimus that can be administered in a once-daily formulation while achieving therapeutically effective concentrations throughout 24 hours.In some aspects, the present disclosure provides a method of modulating immune response in a patient in need thereof, comprising administering an appropriate amount of a dry powder composition of drug particles comprising tacrolimus to the lungs of the patient by inhalation, wherein the patient is administered one dose once during a 24-hour period, the dose being sufficient to provide a blood concentration of tacrolimus of at least 3ng / mL in the patient at 24 hours after administration when the patient is administered the dose for three consecutive days.

[0008] In some embodiments, the patient is administered the dose for 7 consecutive days. In some embodiments, the patient is not administered any additional tacrolimus other than the dose. In some embodiments, the dose is administered using a single inhaler capsule. In other embodiments, the dose is administered at once using an appropriate amount of multiple inhaler capsules.

[0009] In some embodiments, the blood concentration of tacrolimus is at least 5 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 15 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 12 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 7.5 ng / mL at 24 hours after administration.

[0010] In some embodiments, the composition includes a sugar such as lactose. In some embodiments, the drug particles include tacrolimus and sugar in a weight ratio of 5:1 to about 1:20. In some embodiments, the weight ratio is about 1:1 to about 1:10. In some embodiments, the weight ratio is about 1:2.5 to about 1:10.

[0011] In some embodiments, the composition comprises a dose of tacrolimus of about 0.05 mg to about 3.5 mg. In some embodiments, the dose of tacrolimus is about 0.1 mg to about 3.0 mg. In some embodiments, the dose of tacrolimus is about 0.25 mg to about 2.5 mg. In some embodiments, the dose of tacrolimus is about 1.5 mg.

[0012] In some embodiments, the tacrolimus is in amorphous form. In some embodiments, at least 90% of the tacrolimus is in amorphous form. In some embodiments, at least 95% of the tacrolimus is in amorphous form. In some embodiments, at least 98% of the tacrolimus is in amorphous form. In some embodiments, at least 99% of the tacrolimus is in amorphous form.

[0013] In some embodiments, the drug particles have a mass median aerodynamic diameter (MMAD) of about 0.5 μm to about 5.0 μm. In some embodiments, the MMAD is about 1.0 μm to about 3.5 μm. In some embodiments, the MMAD is about 1.5 μm to about 2.5 μm. In some embodiments, the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8. In some embodiments, the GSD is about 1 to about 6. In some embodiments, the GSD is about 2 to about 5.

[0014] In some embodiments, the tacrolimus composition is loaded into a capsule. In some embodiments, the capsule is configured for use in an inhaler. In some embodiments, the composition is loaded into an inhaler. In some embodiments, the inhaler is a high resistance inhaler. In some embodiments, the inhaler is a dry powder inhaler.

[0015] In some embodiments, the drug particles have an emitted dose of at least 70% when emitted from the inhaler. In some embodiments, the emitted dose is at least 80%. In some embodiments, the emitted dose is at least 90%.

[0016] In some embodiments, the drug particles, when released from the inhaler, have a fine powder fraction as a percentage of the recovered dose of at least 40%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is at least 45%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is at least 50%. In some embodiments, the drug particles, when released from the inhaler, have a fine powder fraction as a percentage of the recovered dose that is about 40% to about 95%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is about 45% to about 90%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is about 50% to about 85%.

[0017] In some embodiments, the drug particles have a fine powder fraction as a percentage of the delivered dose when released from the inhaler that is at least 50%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is at least 55%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is at least 60%. In some embodiments, the drug particles have a fine powder fraction as a percentage of the delivered dose that is about 50% to about 98% when released from the inhaler. In some embodiments, the fine powder fraction as a percentage of the delivered dose is about 55% to about 95%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is about 60% to about 90%.

[0018] In some embodiments, the tacrolimus composition is a tacrolimus and lactose composition comprising a dose of about 0.1 mg to about 2.5 mg of tacrolimus loaded into a capsule for use in an inhaler. In some embodiments, the modulation of the immune system is sufficient to prevent or delay rejection of a transplanted organ, such as rejection of a transplanted kidney, heart, liver, or lung. In some embodiments, the modulation of the immune system is sufficient to suppress the patient's immune system, such as inhibiting calcineurin.

[0019] In some embodiments, the patient is a human. In some embodiments, the patient is identified as a rapid metabolizer of tacrolimus and the method further comprises increasing the dose administered to the patient. In other embodiments, the patient is identified as a slow metabolizer of tacrolimus and the method further comprises decreasing the dose administered to the patient.

[0020] In another aspect, the present disclosure provides a composition for use in modulating an immune response in a patient, comprising: (A) one dose of tacrolimus; and (B) Sugar wherein the composition is formulated for pulmonary administration via inhalation, and wherein the dose results in a blood concentration of tacrolimus in a patient of greater than 3 ng / mL 24 hours after the dose is administered, when the patient is administered the dose for three consecutive days.

[0021] In some embodiments, the patient is administered said dose for 7 consecutive days. In some embodiments, the patient has not received tacrolimus since said administration. In some embodiments, the sugar is lactose.

[0022] In some embodiments, the blood concentration of tacrolimus is at least 5 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 15 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 12 ng / mL at 24 hours after administration. In some embodiments, the blood concentration of tacrolimus is about 3 ng / mL to about 7.5 ng / mL at 24 hours after administration.

[0023] In some embodiments, the composition includes a sugar such as lactose. In some embodiments, the drug particles include tacrolimus and sugar in a weight ratio of 5:1 to about 1:20. In some embodiments, the weight ratio is about 1:1 to about 1:10. In some embodiments, the weight ratio is about 1:2.5 to about 1:10.

[0024] In some embodiments, the composition comprises a dose of tacrolimus of about 0.05 mg to about 3.5 mg. In some embodiments, the dose of tacrolimus is about 0.1 mg to about 3.0 mg. In some embodiments, the dose of tacrolimus is about 0.25 mg to about 2.5 mg. In some embodiments, the dose of tacrolimus is about 1.5 mg.

[0025] In some embodiments, the tacrolimus is in amorphous form. In some embodiments, at least 90% of the tacrolimus is in amorphous form. In some embodiments, at least 95% of the tacrolimus is in amorphous form. In some embodiments, at least 98% of the tacrolimus is in amorphous form. In some embodiments, at least 99% of the tacrolimus is in amorphous form.

[0026] In some embodiments, the drug particles have a mass median aerodynamic diameter (MMAD) of about 0.5 μm to about 5.0 μm. In some embodiments, the MMAD is about 1.0 μm to about 3.5 μm. In some embodiments, the MMAD is about 1.5 μm to about 2.5 μm. In some embodiments, the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8. In some embodiments, the GSD is about 1 to about 6. In some embodiments, the GSD is about 2 to about 5.

[0027] In some embodiments, the tacrolimus composition is loaded into a capsule. In some embodiments, the capsule is configured for use in an inhaler. In some embodiments, the composition is loaded into an inhaler. In some embodiments, the inhaler is a high resistance inhaler. In some embodiments, the inhaler is a dry powder inhaler.

[0028] In some embodiments, the drug particles have an emitted dose of at least 70% when emitted from the inhaler. In some embodiments, the emitted dose is at least 80%. In some embodiments, the emitted dose is at least 90%.

[0029] In some embodiments, the drug particles, when released from the inhaler, have a fine powder fraction as a percentage of the recovered dose of at least 40%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is at least 45%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is at least 50%. In some embodiments, the drug particles, when released from the inhaler, have a fine powder fraction as a percentage of the recovered dose that is about 40% to about 95%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is about 45% to about 90%. In some embodiments, the fine powder fraction as a percentage of the recovered dose is about 50% to about 85%.

[0030] In some embodiments, the drug particles have a fine powder fraction as a percentage of the delivered dose when released from the inhaler that is at least 50%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is at least 55%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is at least 60%. In some embodiments, the drug particles have a fine powder fraction as a percentage of the delivered dose that is about 50% to about 98% when released from the inhaler. In some embodiments, the fine powder fraction as a percentage of the delivered dose is about 55% to about 95%. In some embodiments, the fine powder fraction as a percentage of the delivered dose is about 60% to about 90%.

[0031] In some embodiments, the tacrolimus composition is a tacrolimus and lactose composition comprising a dose of about 0.1 mg to about 2.5 mg of tacrolimus loaded into a capsule for use in an inhaler. In some embodiments, the modulation of the immune system is sufficient to prevent or delay rejection of a transplanted organ, such as rejection of a transplanted kidney, heart, liver, or lung. In some embodiments, the modulation of the immune system is sufficient to suppress the patient's immune system, such as inhibiting calcineurin.

[0032] In some embodiments, the patient is a human. In some embodiments, the patient is identified as a rapid metabolizer of tacrolimus and the method further comprises increasing the dose administered to the patient. In other embodiments, the patient is identified as a slow metabolizer of tacrolimus and the method further comprises decreasing the dose administered to the patient.

[0033] In yet another aspect, the present disclosure provides a method of preventing organ rejection in a patient, comprising administering to a patient in need thereof a therapeutically effective amount of a composition described herein.

[0034] In some embodiments, the organ rejection is rejection of a transplanted lung. In other embodiments, the organ rejection is rejection of a transplanted heart. In other embodiments, the organ rejection is rejection of a transplanted kidney. In other embodiments, the organ rejection is rejection of a transplanted liver. In some embodiments, the method comprises administering the composition once in a 24 hour period.

[0035] In some embodiments, the method comprises administering the composition as a single dose, hi other embodiments, the method comprises administering the composition as multiple doses at once.

[0036] In yet another aspect, the present disclosure provides a method of modulating an immune system response in a patient in need thereof, comprising administering to the patient a therapeutically effective amount of a composition described herein.

[0037] In some embodiments, the method comprises administering the composition once in a 24 hour period. In some embodiments, the method comprises administering the composition as a single dose. In other embodiments, the method comprises administering the composition as multiple doses at once.

[0038] In yet another aspect, the present disclosure provides a method for producing a method for manufacturing a semiconductor device comprising: (A) a dose of tacrolimus, said dose being from about 0.1 mg to about 2.5 mg; and (B) Lactose wherein the composition is formulated for administration via inhalation, the dose provides a blood concentration of tacrolimus in a patient greater than 2 ng / mL 24 hours after the dose is administered, and the composition comprises a weight ratio of lactose to the dose of tacrolimus of about 8:1 to about 12:1. In some embodiments, the composition is formulated in a capsule for use in an inhaler or is formulated in an inhaler.

[0039] Other objects, features and advantages of the present disclosure will become apparent from the following detailed description. It should be understood, however, that the detailed description and specific examples, while indicating specific embodiments of the present invention, are presented by way of illustration only, since various changes and modifications within the spirit and scope of the invention will become apparent to those skilled in the art from this detailed description. [Brief description of the drawings]

[0040] The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present disclosure. The disclosure may be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein. [Figure 1] Tacrolimus plasma exposure following inhalation of 1 mg BID for 7 days is shown. [Figure 2A] Plasma concentrations of tacrolimus after days 1 and 7 plotted as a function of time for 1.0 mg BID are shown. [Figure 2B] Plasma concentrations of tacrolimus after days 1 and 7 plotted as a function of time for 1.0 mg BID are shown. [Figure 3A] Plasma concentrations of tacrolimus after days 1 and 7 plotted as a function of time for 1.0 mg BID are shown along with simulated plasma concentrations of tacrolimus for 1.0 mg and 1.5 mg SIM. [Figure 3B]Plasma concentrations of tacrolimus after days 1 and 7 plotted as a function of time for 1.0 mg BID are shown along with simulated plasma concentrations of tacrolimus for 1.0 mg and 1.5 mg SIM. [Figure 4] Simulated plasma concentrations of tacrolimus for 1.0 mg and 1.5 mg SIM are shown. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0041] Description of exemplary embodiments In some aspects of the present disclosure, the pharmaceutical compositions provided herein may include a formulation of tacrolimus that can be administered once a day while achieving therapeutically effective blood concentration of the drug.These compositions can provide sufficient blood concentration over 24 hours, and patients only need to receive one dose once.Reducing the number of doses can result in reduced side effects, reduced adverse events, and increased patient compliance.For example, the composition can reduce nephrotoxicity, blood creatinine level, or blood urea nitrogen level, or increase glomerular filtration rate.

[0042] Also provided herein are methods of preparing and using these compositions. Details of these compositions are provided below.

[0043] I. Pharmaceutical Compositions In some aspects, the present disclosure provides pharmaceutical compositions that include an active agent, such as tacrolimus, and may include excipients. These compositions may be formulated for administration by inhalation, and such inhalation may be to the lungs. Administration of tacrolimus may be a single dose once a day as a single capsule, or may be administered as multiple capsules administered at once. Additionally, these pharmaceutical compositions may include one or more properties that allow for delivery to the lungs through an inhaler. These particles exhibit an enhanced ability to break down into smaller components. The particles may exhibit high surface area, low tap density, or low bulk density. The surface area of ​​the particles is less than 10 m2 / g, 25m 2 / g or more than 50m 2 The bulk density of the particles may be less than 1 g / mL, less than 0.5 g / mL, or less than 0.25 g / mL. Finally, the tap density of the particles may be less than 0.1 g / cm 3 Less than 0.05g / cm 3 Less than or equal to 0.025g / cm 3 Additionally, these compositions may exhibit improved flowability or compressibility, such as a low Carr's Index of less than 20, less than 15, or less than 10.

[0044] These compositions may be used to achieve therapeutically effective plasma concentrations or simply blood levels for a period of at least 18 hours, 20 hours, 22 hours, 24 hours, or 26 hours. In some embodiments, the compositions administered herein may achieve a blood level of at least 2 ng / mL in humans for that period. The blood level may be at least 2 ng / mL, at least 3 ng / mL, at least 4 ng / mL, or at least 5 ng / mL. The compositions may achieve a blood level of about 2 ng / mL to about 15 ng / mL, about 3 ng / mL to about 12 ng / mL, or about 3 ng / mL to about 7.5 ng / mL. The blood concentration of tacrolimus can be about 2ng / mL, about 3ng / mL, about 4ng / mL, about 5ng / mL, about 6ng / mL, about 7.5ng / mL, about 8ng / mL, about 10ng / mL, about 12ng / mL, about 12.5ng / mL, about 14ng / mL, about 16ng / mL, about 18ng / mL, about 20ng / mL, about 22ng / mL, about 24ng / mL, about 25ng / mL, or any range derivable therein. The plasma concentration is determined by LCMS or ELISA. The blood concentration is obtained after administration of the composition to the patient for 2, 3, 4, 5, 6, 7, or 14 days.

[0045] A. Tacrolimus The pharmaceutical compositions described herein include tacrolimus as an active agent. The pharmaceutical compositions described herein include tacrolimus in an amount between about 1% to about 25%, about 2% to about 20%, about 5% to about 15%, or about 7.5% to about 12.5% ​​by weight of the total composition. In some embodiments, the amount of tacrolimus is about 1%, 2%, 3%, 4%, 5%, 6%, 7.5%, 8%, 10%, 12%, 12.5%, 14%, 15%, 20%, to about 25% by weight, or a range derivable therein. In some embodiments, the pharmaceutical compositions have a dose of tacrolimus of about 0.05 mg to about 3.5 mg, about 0.1 mg to about 3.0 mg, or about 0.25 mg to about 2.5 mg. The dose of tacrolimus can be from about 0.05 mg, about 0.1 mg, about 0.25 mg, about 0.5 mg, about 0.75 mg, about 1.0 mg, about 1.25 mg, about 1.5 mg, about 1.75 mg, about 2.0 mg, about 2.25 mg, about 2.5 mg, about 2.75 mg, about 3.0 mg, about 3.25 mg, to about 3.5 mg, or any range therein.

[0046] In some aspects, various different forms of tacrolimus may be used. Tacrolimus has the chemical name (1R,9S,12S,13R,14S,17R,18E,21S,23S,24R,25S,27R)-1,14-dihydroxy-12-[(E)-1-[(1R,3R,4R)-4-hydroxy-3-methoxycyclohexyl]prop-1-en-2-yl]-23,25-dimethoxy-13,19,21,27-tetramethyl-17-prop-2-enyl-11,28-dioxa-4-azatricyclo[22.3.1.0 4,9] is the active substance of octacos-18-ene-2,3,10,16-tetrone. Tacrolimus is sold under the trade names Prograf®, Protopic®, Advagraf®, Envarsus XR®, and Chiesi®, but is also known as Fujimycin, with the CAS number 104987-11-3. Tacrolimus is an immunosuppressant used to reduce the risk of organ rejection. In addition, tacrolimus may be used for other indications in which immunomodulation may be required. This compound, a macrolide lactone, acts through the inhibition of calcineurin and regulates the production of interleukin-2. Tacrolimus is metabolized by cytochrome P450, and therefore modifications of this enzyme or other compounds that modulate the enzyme activity are known to cause changes in the metabolism of tacrolimus. Therefore, patients with mutations in the CYP3A4 / 5 enzyme should be genotyped to determine the effect on tacrolimus administration. If the patient is a rapid metabolizer, the dose will need to be increased. Conversely, if the patient is a slow metabolizer, the dose will need to be decreased. Similarly, the tacrolimus dose will need to be adjusted if the patient is taking another API that modulates CYP3A4 / 5 or has a diet rich in foods that modulate this enzyme.

[0047] In some embodiments, the particles comprise at least 80% tacrolimus in the amorphous phase. In some embodiments, the amount of tacrolimus in the amorphous phase is about 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99%, 99.1%, 99.2%, 99.3%, 99.4%, 99.5%, 99.6%, 99.7%, 99.8%, to about 99.9%, or any range derivable therein.

[0048] In some embodiments, the drug particles have a mass median aerodynamic diameter of about 0.5 μm to about 5.0 μm, about 1.0 μm to about 3.5 μm, or about 1.5 μm to about 2.5 μm. In some embodiments, the drug particles have a mass median aerodynamic diameter of about 0.5 μm, 0.6 μm, 0.8 μm, 1.0 μm, 1.2 μm, 1.4 μm, 1.5 μm, 1.6 μm, 1.8 μm, 2.0 μm, 2.2 μm, 2.4 μm, 2.5 μm, 2.6 μm, 2.8 μm, 3.0 μm, 3.2 μm, 3.4 μm, 3.5 μm, 4.0 μm, 4.5 μm, to about 5.0 μm, or any range derivable therein. Aerodynamic size distributions, including mass median aerodynamic diameter (MMAD), fine particle fraction (FPF), geometric standard deviation (GSD) and emitted fraction (EF), were calculated using Copley Inhaler Testing Data Analysis Software (CITDAS) version 3.10 (Copley Scientific, Nottingham, UK). Mass median aerodynamic diameter (MMAD) and geometric standard deviation (GSD) were assessed as cumulative percentages of mass and aerodynamic diameter.

[0049] In some embodiments, the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8, about 1 to about 6, or about 2 to about 5. In some embodiments, the particles comprising tacrolimus have a geometric standard deviation (GSD) of about 0.5, 0.6, 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, 2.4, 2.6, 2.8, 3.0, 3.2, 3.4, 3.6, 3.8, 4.0, 4.2, 4.4, 4.6, 4.8, 5.0, 5.2, 5.4, 5.6, 5.8, 6.0, 6.2, 6.4, 6.6, 6.8, 7.0, 7.2, 7.4, 7.6, 7.8, to about 8.0, or any range derivable therein.

[0050] In some embodiments, the drug particles when loaded into an inhaler have a fine particle fraction of the recovered dose greater than 40%, greater than 45%, or greater than 50%. In some embodiments, the fine particle fraction of the recovered dose of the drug particles is greater than 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, or 60%. In some embodiments, the drug particles have a fine particle fraction of about 40% to about 95%, about 45% to about 90%, or about 50% to about 85% of the recovered dose. In some embodiments, the fine fraction of the delivered dose is about 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99% to about 99.5%, or any range derivable therefrom. The fine fraction of the recovered dose is calculated by dividing the fine fraction dose by the total mass (recovered dose), and the fine fraction of the delivered dose is calculated by dividing the fine fraction dose by the delivered dose. Fine fraction dose and fraction are calculated at 5 μm cutoff. Furthermore, the recovery percentage is calculated by dividing the total mass (recovered dose) by the NGI by the loaded dose.

[0051] In some embodiments, the drug particles when loaded into an inhaler have a fine particle fraction of the delivered dose of greater than 50%, greater than 55%, or greater than 60%. In some embodiments, the drug particles have a fine particle fraction of the delivered dose of greater than 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, or 60%. In some embodiments, the drug particles have a fine particle fraction of the delivered dose of about 50% to about 98%, about 55% to about 95%, or about 60% to about 90%. In some embodiments, the fine fraction of the delivered dose is from about 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99%, to about 99.5%, or any range derivable therein.

[0052] In some embodiments, the drug particles when loaded into the inhaler have an emitted fraction measured by NGI of greater than 70%, greater than 80%, or greater than 90%. In some embodiments, the pharmaceutical composition has an emitted fraction of particles containing tacrolimus measured by NGI of greater than 70%, 75%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, or 95%. The emitted fraction (EF) was calculated as the total amount of emitted dose from the device as a percentage of the total amount collected by NGI.

[0053] 1. Inhalation In some embodiments, the present disclosure relates to respirable particles that should be in the aerodynamic size range of about 0.5-5 micrometers or 0.5-3 micrometers in aerodynamic diameter. Typical approaches to obtain particles in this size range are by air jet milling, spray drying, thin film freezing, and other methods known in the art. Drug particles can be blended by mixing with suitable carrier particles using conventional mixing, or drug and carrier can be prepared simultaneously from solution or suspension formulations, such as by spray drying or thin film freezing processes.

[0054] In some embodiments, the present disclosure provides a method for administering the inhalable tacrolimus composition provided herein using a device.Administering can be, but is not limited to, the inhalation of tacrolimus using an inhaler.In some embodiments, the inhaler is a simple passive dry powder inhaler (DPI), such as Plastiape RSO1 single dose DPI.In a simple dry powder inhaler, dry powder is stored in a capsule or reservoir and delivered to the lungs by inhalation without the use of a propellant.

[0055] In some embodiments, the inhaler is a single-dose DPI, such as DoseOne™, Spinhaler, Rotohaler™, Aerolizer™, or Handihaler. In some embodiments, the inhaler is a multi-dose DPI, such as Plastiape RS02, Turbuhaler™, Twisthaler™, Diskhaler™, Diskus™, or Ellipta™. In some embodiments, the inhaler is Twincer™, Orbital™, TwinCaps™, Powdair, Cipla Rotahaler, DP Haler, Revolizer, Multi-haler, Twister, Starhaler, or Flexhaler™. In some embodiments, the inhaler is a multiple single-dose DPI for simultaneously delivering single doses of multiple drugs, such as Plastiape RS04 multiple single-dose DPI. Dry powder inhalers have a drug stored in an internal reservoir and deliver the drug by inhalation, with or without the use of a propellant. Dry powder inhalers may require inhalation flow rates of more than 30 L / min, such as about 30-120 L / min, for effective delivery.

[0056] In some embodiments, the inhalable tacrolimus is delivered in a propellant formulation, such as an HFA propellant.

[0057] In some embodiments, the inhaler may be a metered dose inhaler. A metered dose inhaler delivers a defined amount of drug to the lungs in a short burst of aerosolized drug, assisted by the use of a propellant. A metered dose inhaler includes three main parts: a canister, a metered dose valve, and an actuator. A drug formulation, including a propellant and any necessary excipients, is stored in the canister. The metered dose valve allows the drug formulation to be dispensed in a defined amount. The actuator, i.e., the mouthpiece, of the metered dose inhaler includes a jointed discharge nozzle, and typically includes a dust cap to prevent contamination.

[0058] In some embodiments, the composition may be administered on a daily schedule. As used herein, a daily schedule refers to a predetermined designated period of time. A daily schedule may include the same period of time or periods of different lengths, as long as the schedule is predetermined. For example, a daily schedule may include administration every day, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, weekly, monthly, or any set number of days or weeks in between. Or, a predetermined daily schedule may include administration on a twice-daily basis for the first week, followed by a once-daily basis for several months, and the like. In some embodiments, tacrolimus is administered once a day. In some embodiments, the total dose of tacrolimus is between 0.05-5 mg, such as between 0.1-2.5, 0.25-2, 0.5-1.5, or 1-1.5 mg.

[0059] In some embodiments, tacrolimus may be provided in a unit dosage form, such as a capsule, blister, or cartridge, where the unit dosage comprises at least 0.1 mg of tacrolimus, for example at least 0.1 mg, 1.5 mg, or 2.5 mg of tacrolimus per dosage. In certain aspects, the unit dosage form does not include the administration or addition of any excipients, and is simply used to hold the powder for inhalation (i.e., no capsule, blister, or cartridge is administered). In some embodiments, tacrolimus may be administered at a high emitted dose, such as at least 0.1 mg, preferably at least 1.5 mg, and more preferably at least 2.5 mg. In some embodiments, administration of tacrolimus results in a high deep lung fine particle dose, such as greater than 0.25 mg. Preferably, the deep lung fine particle dose is at least 0.5 mg, and more preferably at least 1.5 mg.

[0060] In some embodiments, the change in pressure drop across the device results in a change in emitted dose. In some embodiments, the change in pressure drop across the device of 3 kPa, for example 4 kPa to 1 kPa, results in a decrease in emitted dose of less than 35%, for example 34%, 33%, 32%, 31%, 30%, 29%, 28%, 27%, 26%, 25%, 24%, 23%, 22%, 21%, 20%, 19%, 18%, 17%, 16%, 15%, or less. In some embodiments, the change in inhalation pressure drop across the device results in a change in microparticle dose. In some embodiments, a change in inhalation pressure drop across the device of 3 kPa, e.g., 4 kPa to 1 kPa, results in a reduction in fine particle dose of less than 35%, e.g., 34%, 33%, 32%, 31%, 30%, 29%, 28%, 27%, 26%, 25%, 24%, 23%, 22%, 21%, 20%, 19%, 18%, 17%, 16%, 15%, or less.

[0061] 2. Use of the Composition Tacrolimus (TAC) is a widely used immunosuppressant isolated from Streptomyces tsukubaensis. It has proven to be a potent immunosuppressant in transplant medicine for the treatment of organ rejection and different immune diseases such as pulmonary fibrosis and bronchial asthma. TAC was first introduced as a salvage therapy when cyclosporine A (CsA) therapy failed to prevent graft rejection. Its mechanism of action is similar to CsA, but its immunosuppressive activity is 10- to 100-fold more potent than CsA. TAC is currently available in both intravenous and oral dosage forms (commercially known as Prograf®). However, these currently available dosage forms are poorly tolerated and have variable and / or low bioavailability. Oral formulations of TAC present a considerable challenge as the drug is practically water insoluble and extensively metabolized within the intestinal epithelium by both CYP3A4 metabolism and p-glycoprotein efflux transport. Oral bioavailability of TAC varies from 4% to 93%. Inefficient or inconsistent drug absorption is primarily the result of incomplete absorption from the gastrointestinal tract and first-pass metabolism, which is subject to considerable interindividual variability.

[0062] A. Lung transplant Pulmonary disease continues to increase and is now one of the leading causes of death. Lung transplantation, introduced in the 1980s, has been a successful treatment for selected patients with end-stage lung disease. Immunosuppression is a key factor for the success of organ transplantation, and the advent of cyclosporine led to a marked improvement in patient survival (Calne et al., 1978). The first successful lung transplants used the en bloc technique with tracheal anastomosis, which evolved into a more natural transplantation method that avoided cardiopulmonary bypass (if necessary) (Patterson et al., 1988). This technique is today the standard for bilateral lung transplantation.

[0063] Indications for lung transplantation can be broadly categorized into the following major categories of end-stage lung disease: obstructive pulmonary disease, septic pulmonary disease, fibrotic pulmonary disease, and vascular pulmonary disease. Of these categories, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), interstitial pulmonary fibrosis (IPF), and primary pulmonary arterial hypertension are the most common indications in their respective categories (Christie et al., 2012). Lung transplantation for pulmonary malignancies has also been shown to be effective in highly selected patients (Machuca et al., 2012).

[0064] Current International Society for Heart and Lung Transplantation (ISHLT) and American Thoracic Society (ATS) selection criteria include appropriate age, clinically and physiologically severe disease, ineffective or unavailable medical therapy, substantial limitations in activities of daily living, limited life expectancy, adequate cardiac function without significant coronary disease, ambulatory rehabilitation, acceptable nutritional status, and satisfactory psychosocial characteristics and mental support system (Table 1). Patients undergoing lung transplantation will be under lifelong immunosuppression and monitoring. Thus, lung transplant candidates with smoking or drug dependence, psychiatric problems affecting compliance with postoperative care, or who lack a reliable social support network are generally not candidates for lung transplantation. Previous malignancies, especially those within 2 years of receiving transplantation, are also contraindications due to the need for lifelong immunosuppression. In fact, immunosuppression enhances infection, but chronic infection is an essential part of septic lung disease and creates challenges in these patients. In cystic fibrosis patients, nontuberculous mycobacteria, multidrug-resistant bacteria, and Aspergillus species are commonly isolated (Helmi et al., 2003; Gilljam et al., 2010). Prior to and after transplantation, efforts are made to eradicate infections or at least minimize colonization with these organisms; the use of immunosuppressants only exacerbates existing infections.

[0065] Patients who require a lung transplant are placed on a waiting list. Because demand for lung transplants exceeds supply, strategies have been developed to select patients based on their need for a lung transplant and their probability of survival after transplant (Egan et al., 2006). The Lung Allocation Score (LAS) is calculated using a statistical model based on the patient's clinical and physiological characteristics, along with an index of urgency (number of days expected to survive without transplant during the additional year on the waiting list) and an index of post-transplant survival (number of days expected to survive during the year after transplant). The index of urgency is subtracted from the index of benefit and then standardized to obtain the LAS. Patients with higher scores are allocated lungs sooner. Since the introduction of the LAS system, waiting times have decreased and the number of transplants has increased. Furthermore, the LAS score has gradually increased, representing the increasing urgency of patients on the list.

[0066] Although lung transplantation has been shown to increase survival in patients with end-stage lung disease, the survival rate after lung transplantation is approximately 80% at 1 year, but still only 50% at 5 years (Christie et al., 2010). The main causes of death after lung transplantation vary with the time after transplantation. Thirty-day mortality is generally related mainly to surgical problems, problems with donor lung preservation, and primary graft dysfunction (PGD) (Studer et al., 2004). Infectious causes, malignancies, and chronic pulmonary graft dysfunction (CLAD) are very common in the subsequent post-transplant period. Improvements in donor organ preservation and surgical techniques have significantly improved short-term outcomes, but long-term survival after lung transplantation remains around 50% at 5 years, mostly due to the occurrence of CLAD (Christie et al., 2010).

[0067] Immunosuppression for lung transplantation generally consists of a triple therapy, although the exact composition varies between centers. A calcineurin inhibitor (cyclosporine or tacrolimus), a nucleotide blocker (azathioprine or mycophenolate mofetil), and a corticosteroid make up the triplet. Induction therapy is the use of potent immunosuppressants that deplete T cells, such as anti-IL2R antibodies, anti-CD52 antibodies, or antithymocyte globulin, but is controversial in lung transplantation. Immunosuppression is required for life.

[0068] According to the 2012 ISHLT registry report, tacrolimus was the most frequently used calcineurin inhibitor, with 83% of patients receiving tacrolimus 1 year after transplant and 77% receiving tacrolimus 5 years after transplant ( Christie et al., 2012 ).

[0069] B. Excipients In some aspects, the present disclosure includes one or more excipients formulated into a pharmaceutical composition. "Excipient" refers to a pharma- ceutically acceptable carrier, a relatively inert substance used to facilitate the administration or delivery of an active pharmaceutical ingredient (API) to a subject, or to facilitate the processing of an API into a drug formulation that can be pharma- ceutically used for delivery to a subject's site of action. Non-limiting examples of excipients include stabilizers, surfactants, surface modifiers, solubility enhancers, buffers, encapsulating agents, antioxidants, preservatives, non-ionic wetting or clarifying agents, viscosity enhancers, and absorption enhancers.

[0070] In some aspects, the amount of excipient in the pharmaceutical composition is about 40% to about 99% by weight, about 50% to about 98% by weight, about 60% to about 96% by weight, or about 75% to about 95% by weight. The amount of excipient in the pharmaceutical composition is about 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 92.5%, 95%, 96%, 98% by weight, to about 99% by weight, or any range derivable therein, of the total pharmaceutical composition. In one embodiment, the amount of excipient in the pharmaceutical composition is 75% to 95% by weight of the total weight of the pharmaceutical composition. The weight ratio of tacrolimus to sugar in the composition is from 5:1 to about 1:20, from about 1:1 to about 1:10, or from about 1:2.5 to about 1:10.

[0071] In some aspects, the present disclosure may further include one or more excipients, such as sugars or amino acids. Some compositions may further include a mixture of excipients, including multiple sugars or amino acids.

[0072] 1. Sugars and amino acids In some aspects, the present disclosure includes one or more excipients formulated in pharmaceutical composition.In some embodiments, the excipient used herein is a water-soluble excipient.These water-soluble excipients include carbohydrates or sugars, such as disaccharides such as sucrose, trehalose, or lactose, trisaccharides such as fructose, glucose, galactose, which constitute raffinose, polysaccharides such as starch or cellulose, or sugar alcohols such as xylitol, sorbitol, or mannitol.In some embodiments, these excipients are solid at room temperature.Some non-limiting examples of sugar alcohols include erythritol, threitol, arabitol, xylitol, ribitol, mannitol, sorbitol, galactitol, fucitol, iditol, inositol, volemitol, isomalt, maltitol, lactitol, maltotritol, maltotetraitol, or polyglycitol. In other aspects, larger molecules such as amino acids, peptides and proteins, including leucine, trileucine, histidine, etc., are incorporated to facilitate inhalation delivery.

[0073] II. Manufacturing method A. Thin film freezing Thus, in one aspect, the present disclosure provides pharmaceutical compositions that can be prepared using a thin film freezing process. Methods for preparing pharmaceutical compositions using thin film freezing are described in U.S. Patent Application No. 2010 / 0221343, Watts, et al., 2013, Engstrom et al. 2008, Wang et al. 2014, Thakkar at el. 2017, O'Donnell et al. 2013, Lang et al. 2014a, Lang et al. 2014b, Carvalho et al. 2014, Beinborn et al. 2012a, Beinborn et al. 2012b, Zhang et al. 2012, Overhoff et al. 2009, Overhoff et al. 2008, Overhoff et al. 2007a, Overhoff et al. 2007b, Watts et al. 2010, Yang et al. 2010, DiNunzio et al. al. 2008, Purvis et al. 2007, Liu et al. 2015, Sinswat et al. 2008, and U.S. Patent No. 8,968,786, all of which are incorporated herein by reference. In some embodiments, these methods include dissolving the components of the pharmaceutical composition in a solvent to form a pharmaceutical mixture. The solvent may be either water or an organic solvent. Some non-limiting examples of organic solvents that may be used include volatile organic solvents such as 1,4-dioxane, acetonitrile, acetone, methanol, ethanol, isopropanol, dichloromethane, chloroform, tetrahydrofuran, tert-butyl alcohol, dimethyl sulfoxide, N,N-dimethylformamide, diethyl ether, ethyl acetate, isopropyl acetate, butyl acetate, propyl acetate, toluene, hexane, heptane, pentane, or combinations thereof. In some embodiments, the pharmaceutical mixture may contain less than 100 mg / mL of therapeutic agent and excipients. The pharmaceutical mixture may comprise less than 100, 90, 80, 70, 60, 50, 40, 30, 20, 17.5, 15, 12.5, 10, 7.5, 5, 2.5, or 1 mg / mL, or any range derivable therein.

[0074] The pharmaceutical mixture may be deposited on a surface at a temperature that causes the pharmaceutical mixture to freeze. In some embodiments, the temperature may be below the freezing point of the solution at ambient pressure. In other embodiments, a vacuum may be applied to the surface to freeze the solution at a temperature below the freezing point at ambient pressure. The surface may also be moved on a rotating or moving conveyor type system to evenly distribute the pharmaceutical mixture on the surface. Alternatively, the pharmaceutical mixture may be applied to the surface in such a manner as to produce a uniform surface.

[0075] After application of the pharmaceutical mixture to the surface, the solvent may be removed to obtain the pharmaceutical composition. Any suitable method for removing the solvent may be applied, including evaporation under reduced pressure or elevated temperature or freeze-drying. In some embodiments, freeze-drying may include reduced pressure and / or low temperature. Such low temperature may be 25°C to about -200°C, 20°C to about -175°C, about 20°C to about -150°C, 0°C to about -125°C, -20°C to about -100°C, -75°C to about -175°C, or -100°C to about -160°C. The temperature may be from about -20°C, -30°C, -35°C, -40°C, -45°C, -50°C, -55°C, -60°C, -70°C, -80°C, -90°C, -100°C, -110°C, -120°C, -130°C, -140°C, -150°C, -160°C, -170°C, -180°C, -190°C to about -200°C, or a range derivable therein. Additionally, the solvent may be removed at reduced pressures of less than 500mTorr, 450mTorr, 400mTorr, 375mTorr, 350mTorr, 325mTorr, 300mTorr, 275mTorr, 250mTorr, 225mTorr, 200mTorr, 175mTorr, 150mTorr, 125mTorr, 100mTorr, 75mTorr, 50mTorr, or 25mTorr, or any range of pressures derivable therein.

[0076] Compositions prepared using these methods and the like can exhibit brittleness such that the composition is easily sheared into small particles when processed through a device. These compositions have high skeletal density and high surface area, and exhibit improved flowability of the composition. Such flowability can be measured, for example, by Carr's index or other similar measurement methods. In particular, Carr's index can be measured by comparing the bulk density of the powder with the tapped density of the powder. Such compounds exhibit favorable Carr's index, which can result in better shearing of the particles to obtain smaller particles when the composition is processed through a secondary device to deliver the drug.

[0077] III. Definition When used in conjunction with the term "comprising" in the claims and / or specification, the use of the words "a" or "an" can mean "one," but is also consistent with the meanings of "one or more," "at least one," and "one or more." As used herein, "another" can mean at least a second or more.

[0078] As used herein, the terms "drug," "pharmaceutical agent," "active agent," "therapeutic agent," and "therapeutically active agent" are used interchangeably to refer to compounds that induce a therapeutic or pharmacological effect in humans or animals and are used to treat a disease, disorder, or other condition. In some embodiments, these compounds have been approved through regulatory approval for administration to an organism.

[0079] Use of the term "or" in the claims is used to mean "and / or" unless expressly indicated to refer to alternatives only or unless the alternatives are mutually exclusive. As used herein, "another" may mean at least a second or more.

[0080] The terms "composition," "pharmaceutical composition," "formulation," "pharmaceutical formulation," "preparation," and "pharmaceutical preparation" are used synonymously and interchangeably herein.

[0081] "Treating" a disease or condition or treatment refers to carrying out a protocol that may include administering one or more drugs to a patient to alleviate the signs or symptoms of the disease. The desired effects of treatment include reducing the rate of disease progression, improving or alleviating the disease state, and remission or improving prognosis. Alleviation can occur before the signs or symptoms of the disease or condition appear, as well as after their appearance. Thus, "treating" or "treatment" can include "preventing" or "prevention" of a disease or undesirable condition. In addition, "treating" or "treatment" specifically includes protocols that do not require complete alleviation of signs or symptoms, do not require a cure, and have only a minor effect on the patient.

[0082] The term "therapeutic benefit" or "therapeutically effective" as used throughout this application refers to promoting or enhancing the well-being of a subject with respect to the medical treatment of the condition. This includes, but is not limited to, reducing the frequency or severity of signs or symptoms of a disease. For example, treating cancer can include, for example, reducing tumor size, reducing the invasiveness of a tumor, reducing the rate of cancer growth, or preventing metastasis. Treating cancer can also refer to extending the survival of a subject with cancer.

[0083] "Subject" and "patient" refer to either humans or non-humans, such as primates, mammals, and vertebrates. In certain embodiments, the subject is a human.

[0084] As used herein generally, "pharmacologically acceptable" refers to compounds, materials, compositions, and / or dosage forms that are suitable for use in contact with the tissues, organs, and / or body fluids of human beings and animals without undue toxicity, irritation, allergic response, or other problem or complication, within the scope of sound medical judgment, commensurate with a reasonable benefit / loss ratio.

[0085] "Pharmaceutically acceptable salts" refers to salts of the compounds disclosed herein that are pharma- ceutically acceptable, as defined above, and have the desired pharmacological activity. Such salts include acid addition salts formed with inorganic acids, such as hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and the like; or with 1,2-ethanedisulfonic acid, 2-hydroxyethanesulfonic acid, 2-naphthalenesulfonic acid, 3-phenylpropionic acid, 4,4'-methylenebis(3-hydroxy-2-ene-1-carboxylic acid), 4-methylbicyclo[2.2.2]oct-2-ene-1-carboxylic acid, acetic acid, aliphatic mono- and dicarboxylic acids, aliphatic sulfuric acid, aromatic sulfuric acid, benzenesulfonic acid, benzoic acid, camphorsulfonic acid, carbonic acid, cinnamic acid, citric acid, cyclopentanepropionic acid, and the like. Pharmaceutically acceptable salts include acid addition salts formed with organic acids such as ethanesulfonic acid, fumaric acid, glucoheptonic acid, gluconic acid, glutamic acid, glycolic acid, heptanoic acid, hexanoic acid, hydroxynaphthoic acid, lactic acid, lauryl sulfuric acid, maleic acid, malic acid, malonic acid, mandelic acid, methanesulfonic acid, muconic acid, o-(4-hydroxybenzoyl)benzoic acid, oxalic acid, p-chlorobenzenesulfonic acid, phenyl-substituted alkanoic acids, propionic acid, p-toluenesulfonic acid, pyruvic acid, salicylic acid, stearic acid, succinic acid, tartaric acid, t-butylacetic acid, trimethylacetic acid, and the like. Pharmaceutically acceptable salts also include base addition salts which may be formed when acidic protons present are capable of reacting with inorganic or organic bases. Acceptable inorganic bases include sodium hydroxide, sodium carbonate, potassium hydroxide, aluminum hydroxide, and calcium hydroxide. Acceptable organic bases include ethanolamine, diethanolamine, triethanolamine, tromethamine, N-methylglucamine, and the like. It should be understood that the particular anion or cation forming part of any salt of the present invention is not critical, so long as the salt, as a whole, is pharmacologically acceptable. Further examples of pharmaceutically acceptable salts and methods of their preparation and use are provided in Handbook of Pharmaceutical Salts: Properties, and Use (PH Stahl & CG Wermuth eds., Verlag Helvetica Chimica Acta, 2002).

[0086] The term "derivative thereof" refers to a chemically modified polysaccharide in which at least one of the monomeric sugar units has been modified by substitution of an atom or molecular group or bond. In one embodiment, the derivative is a salt thereof. Salts are, for example, salts with suitable mineral acids, such as hydrohalic acids, sulfuric acid or phosphoric acid, for example the hydrochlorides, hydrobromides, sulfates, hydrogen sulfates or phosphates, with suitable carboxylic acids, for example optionally hydroxylated lower alkanoic acids, for example acetic acid, glycolic acid, propionic acid, lactic acid or pivalic acid, with optionally hydroxylated and / or oxo-substituted lower alkanedicarboxylic acids, for example oxalic acid, succinic acid, fumaric acid, maleic acid, tartaric acid, citric acid, pyruvic acid, malic acid, ascorbic acid, and also with aromatic, heteroaromatic or araliphatic carboxylic acids, such as benzoic acid, nicotinic acid or mandelic acid, and also with suitable aliphatic or aromatic sulfonic acids or N-substituted sulfamic acids, for example the methanesulfonates, benzenesulfonates, p-toluenesulfonates or N-cyclohexylsulfamates (cyclamates).

[0087] The term "dissolution" as used herein refers to the process by which a solid substance, here an active ingredient, is dispersed in molecular form in a medium. The dissolution rate of the active ingredient of a pharmaceutical dose of the present invention is defined by the amount of drug substance that goes into solution per unit time under standardized conditions of liquid / solid interface, temperature and solvent composition.

[0088] As used herein, the term "aerosol" refers to a dispersion in air of solid or liquid particles that are sufficiently fine in particle size so that they have a low settling rate and therefore are stable in air (see Knight, V., Viral and Mycoplasmal Infections of the Respiratory Tract. 1973, Lea and Febiger, Phila. Pa., pp. 2).

[0089] As used herein, "inhalation" or "pulmonary inhalation" is used to refer to administration of a pharmaceutical preparation by inhalation, such that it reaches the lungs, and in certain embodiments, the alveolar region of the lung. Typically, inhalation is through the mouth, although alternative embodiments may require inhalation through the nose.

[0090] As used herein, "dry powder" refers to a particulate composition that is not suspended or dissolved in an aqueous liquid.

[0091] "Simple dry powder inhaler" refers to a device for delivery of medicament to the respiratory tract, which delivers the medicament as a dry powder in a single-use, single-dose format. In certain aspects, a simple dry powder inhaler has fewer than 10 working parts. In some aspects, a simple dry powder inhaler is a passive inhaler, such that the dissipative energy is provided by the inhalation force of the patient, rather than by application of an external energy source.

[0092] "Median particle size" refers to the geometric diameter as measured by laser diffraction or image analysis. In some aspects, at least 50% or 80% by volume of the particles are in the median particle size range.

[0093] "Mass Median Aerodynamic Diameter (MMAD)" refers to the aerodynamic diameter (as opposed to the geometric diameter) and is measured by laser diffraction.

[0094] The term "amorphous" refers to a non-crystalline solid in which the molecules are not organized in a definite lattice pattern. Alternatively, the term "crystalline" refers to a solid in which the molecules in the solid have a definite lattice pattern. The crystallinity of the active substance in the composition is measured by powder X-ray diffraction.

[0095] As used in the specification and claims, the words "comprising" (and any form of comprising, such as "comprise" and "comprises"), "having" (and any form of having, such as "have" and "has"), "including" (and any form of including, such as "includes" and "include"), or "containing" (and any form of containing, such as "contains" and "contain") are inclusive or open-ended and do not exclude additional, unrecited elements or method steps.

[0096] The term "significant" (and any form of "significant", such as "significantly") as used herein does not imply a statistical difference between two values, but only the importance of a parameter or the extent of the difference.

[0097] The term "patient" or "subject" as used herein refers to a living mammalian organism, such as a human, monkey, cow, sheep, goat, dog, cat, mouse, rat, guinea pig, or a transgenic species thereof. In certain embodiments, the patient or subject is a primate. Non-limiting examples of human patients are adults, adolescents, infants, and fetuses.

[0098] Throughout this application, the term "about" is used to indicate that a value includes equipment error, inherent variation of the method being used to determine the value, or variation that exists among test subjects or experimental testing. Unless another definition is applicable, the term "about" refers to ±5% of the indicated value.

[0099] As used herein, the term "substantially free of" or "substantially free" in reference to a particular component is used herein to mean that none of the particular component is intentionally formulated in the composition and / or is present only as a contaminant or in trace amounts. The total amount of all containments, by-products, and other materials is present in the composition in an amount less than 2%. The term "essentially free of" or "essentially free" is used to indicate that the composition contains less than 1% of a particular component. The term "entirely free of" or "entirely free" contains less than 0.1% of a particular component.

[0100] Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the invention are approximations, the numerical values ​​set forth in the specific examples are reported as precisely as possible, however, any numerical value inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements and parameters.

[0101] Other objects, features and advantages of the present disclosure will become apparent from the following detailed description. It should be understood, however, that the detailed description and specific examples, while indicating preferred embodiments of the present disclosure, are given by way of illustration only, since various changes and modifications within the spirit and scope of the present disclosure will become apparent to those skilled in the art from this detailed description.

[0102] IV. Aspects of the Disclosure 1. A method of modulating an immune response in a patient in need thereof, comprising: administering by inhalation to the lungs of said patient an appropriate amount of a dry powder composition of drug particles comprising tacrolimus; the patient is administered one dose during a 24 hour period, the dose being sufficient to provide a blood concentration of tacrolimus in the patient of at least 3 ng / mL at 24 hours after administration, when the patient is administered one dose on three consecutive days; The method. 2. The method of embodiment 1, wherein said patient is administered said dose for 7 consecutive days. 3. The method of embodiment 1 or embodiment 2, wherein said patient is not receiving any additional tacrolimus beyond said dose. 4. The method of any one of aspects 1-3, wherein the dose is administered using a single inhaler capsule. 5. The method of any one of aspects 1-3, wherein the dose is administered at one time using multiple inhaler capsules of appropriate amount. 6. The method of any one of aspects 1-5, wherein said blood concentration of tacrolimus is at least 5 ng / mL 24 hours after said administration. 7. The method of any one of aspects 1 to 6, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 15 ng / mL 24 hours after said administration. 8. The method of any one of aspects 1 to 7, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 12 ng / mL 24 hours after said administration. 9. The method of any one of aspects 1 to 8, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 7.5 ng / mL 24 hours after said administration. 10. The method of any one of aspects 1-9, wherein the composition comprises a sugar. 11. The method of embodiment 10, wherein the sugar is lactose. 12. The method of any one of aspects 1-11, wherein the drug particles comprise tacrolimus and sugar in a weight ratio of from 5:1 to about 1:20. 13. The method of embodiment 12, wherein the weight ratio is from about 1:1 to about 1:10. 14. The method of embodiment 12 or embodiment 13, wherein the weight ratio is from about 1:2.5 to about 1:10. 15. The method of any one of aspects 1-14, wherein the composition comprises tacrolimus in a dose range of about 0.05 mg to about 3.5 mg. 16. The method of embodiment 15, wherein said dose of tacrolimus is from about 0.1 mg to about 3.0 mg. 17. The method of embodiment 16, wherein the dose of tacrolimus is from about 0.25 mg to about 2.5 mg. 18. The method of embodiment 17, wherein said dose of tacrolimus is about 1.5 mg. 19. The method of any one of aspects 1-18, wherein the tacrolimus is in amorphous form. 20. The method of any one of aspects 1-19, wherein at least 90% of the tacrolimus is in amorphous form. 21. The method of any one of aspects 1-20, wherein at least 95% of the tacrolimus is in amorphous form. 22. The method of any one of aspects 1-21, wherein at least 98% of the tacrolimus is in amorphous form. 23. The method of any one of aspects 1-22, wherein at least 99% of the tacrolimus is in amorphous form. 24. The method of any one of aspects 1-23, wherein the drug particles have a mass median aerodynamic diameter (MMAD) of about 0.5 μm to about 5.0 μm. 25. The method of embodiment 24, wherein the MMAD is from about 1.0 μm to about 3.5 μm. 26. The method of embodiment 24 or embodiment 25, wherein the MMAD is from about 1.5 μm to about 2.5 μm. 27. The method of any one of aspects 1-26, wherein the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8. 28. The method of embodiment 27, wherein the GSD is from about 1 to about 6. 29. The method of embodiment 27 or embodiment 28, wherein the GSD is about 2 to about 5. 30. The method of any one of aspects 1-29, wherein the tacrolimus composition is loaded into a capsule. 31. The method of embodiment 30, wherein the capsule is configured for use in an inhaler. 32. The method of any one of aspects 1-31, wherein the composition is loaded into an inhaler. 33. The method of embodiment 32, wherein the inhaler is a high resistance inhaler. 34. The method of any one of aspects 32 or 33, wherein the inhaler is a dry powder inhaler. 35. The method of any one of aspects 1-34, wherein the drug particles have at least 70% emitted dose when emitted from the inhaler. 36. The method of embodiment 35, wherein the emitted dose is at least 80%. 37. The method of any one of embodiment 35 or embodiment 36, wherein the emitted dose is at least 90%. 38. The method of any one of aspects 1-37, wherein the drug particles, when released from the inhaler, have a fine powder fraction as a percentage of the recovered dose of at least 40%. 39. The method of embodiment 38, wherein the fine powder fraction as a percentage of the recovered dose is at least 45%. 40. The method of any one of embodiment 38 or embodiment 39, wherein the fine powder fraction as a percentage of the recovered dose is at least 50%. 41. The method of any one of aspects 1-40, wherein the drug particles, when released from an inhaler, have a fine powder fraction as a percentage of the recovered dose that is about 40% to about 95%. 42. The method of embodiment 41, wherein the fine powder fraction as a percentage of the recovered dose is about 45% to about 90%. 43. The method of any one of embodiment 41 or embodiment 42, wherein the fine powder fraction as a percentage of the recovered dose is about 50% to about 85%. 44. The method of any one of aspects 1-43, wherein the drug particles have a fine powder fraction as a percentage of the delivered dose when released from the inhaler of at least 50%. 45. The method of embodiment 44, wherein the fine powder fraction as a percentage of the delivered dose is at least 55%. 46. ​​The method of any one of embodiment 44 or embodiment 45, wherein the fine powder fraction as a percentage of the delivered dose is at least 60%. 47. The method of any one of aspects 1-46, wherein the drug particles, when released from an inhaler, have a fine powder fraction as a percentage of the delivered dose that is about 50% to about 98%. 48. The method of embodiment 47, wherein the fine powder fraction as a percentage of the delivered dose is about 55% to about 95%. 49. The method of any one of embodiment 47 or embodiment 48, wherein the fine powder fraction as a percentage of the delivered dose is about 60% to about 90%. 50. The composition of tacrolimus comprising: A tacrolimus and lactose composition comprising a dose of about 0.1 mg to about 2.5 mg of tacrolimus loaded into a capsule for use in an inhaler. The method of any one of embodiments 1-49, wherein 51. The method of any one of aspects 1-50, wherein the modulation of the immune system is sufficient to prevent or delay rejection of a transplanted organ. 52. The method of embodiment 51, wherein said rejection of a transplanted organ is rejection of a transplanted kidney, heart, liver, or lung. 53. The method of any one of aspects 1-52, wherein the modulation of the immune system is sufficient to suppress the patient's immune system. 54. The method of any one of aspects 1 to 53, wherein the modulation of the immune system is inhibition of calcineurin. 55. The method of any one of aspects 1 to 54, wherein the patient is a human. 56. The method of any one of aspects 1-55, wherein the patient has been identified as a rapid metabolizer of tacrolimus. 57. The method of embodiment 56, further comprising increasing the dose administered to the patient. 58. The method of any one of aspects 1-55, wherein the patient has been identified as a slow metabolizer of tacrolimus. 59. The method of embodiment 58, further comprising the step of decreasing the dose administered to the patient. 60. A composition for use in modulating an immune response in a patient, said composition comprising: (A) one dose of tacrolimus; and (B) Sugar wherein the composition is formulated for pulmonary administration via inhalation and the dose results in a blood concentration of tacrolimus in the patient of greater than 3 ng / mL 24 hours after the dose is administered, when the dose is administered to the patient on three consecutive days. 61. The composition of embodiment 60, wherein the patient is administered the dose for 7 consecutive days. 62. The composition of either embodiment 60 or embodiment 61, wherein the patient has not received tacrolimus since said administration. 63. The composition of any one of aspects 60-62, wherein the sugar is lactose. 64. The composition of any one of aspects 60-63, wherein the blood concentration of tacrolimus is at least 5 ng / mL 24 hours after said administration. 65. The composition of any one of aspects 60 to 64, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 25 ng / mL 24 hours after said administration. 66. The composition of any one of aspects 60 to 65, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 15 ng / mL 24 hours after said administration. 67. The composition of any one of aspects 60 to 66, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 7.5 ng / mL 24 hours after said administration. 68. The composition of any one of aspects 60-67, which produces a blood concentration of tacrolimus of at least 10 ng / mL at a second time point 15 minutes after administration. 69. The composition of any one of aspects 60-68, which produces a blood concentration of tacrolimus of at least 20 ng / mL at a second time point 15 minutes after administration. 70. The composition of any one of aspects 60-69, which produces a blood concentration of tacrolimus of at least 25 ng / mL at a second time point 15 minutes after administration. 71. The composition of any one of aspects 60 to 70, which produces a blood concentration of tacrolimus of about 10 ng / mL to about 50 ng / mL. 72. The composition of any one of aspects 60-71, wherein the method results in a blood concentration of tacrolimus of about 20 ng / mL to about 40 ng / mL. 73. The composition of any one of aspects 60 to 72, which produces a blood concentration of tacrolimus of about 25 ng / mL to about 35 ng / mL. 74. The composition of any one of aspects 60-73, wherein the drug particles comprise tacrolimus and the sugar in a weight ratio of from 5:1 to about 1:20. 75. The composition of embodiment 74, wherein the weight ratio is from about 1:1 to about 1:10. 76. The composition of embodiment 74 or embodiment 75, wherein the weight ratio is from about 1:2.5 to about 1:10. 77. The composition of any one of aspects 60-76, comprising tacrolimus in a dose range of about 0.05 mg to about 3.5 mg. 78. The composition of any one of aspects 60 to 77, wherein the dose of tacrolimus is from about 0.1 mg to about 3.0 mg. 79. The composition of any one of aspects 60 to 78, wherein the dose of tacrolimus is from about 0.25 mg to about 2.5 mg. 80. The composition of any one of aspects 60-79, wherein the dose of tacrolimus is about 1.5 mg. 81. The composition of any one of aspects 60-80, wherein the dose of tacrolimus is in amorphous form. 82. The composition of any one of aspects 60-81, wherein at least 90% of the tacrolimus is in amorphous form. 83. The composition of any one of aspects 60-82, wherein at least 95% of the tacrolimus is in amorphous form. 84. The composition of any one of aspects 60-83, wherein at least 98% of the tacrolimus is in amorphous form. 85. The composition of any one of aspects 60-84, wherein at least 99% of the tacrolimus is in amorphous form. 86. The composition of any one of aspects 60-85, wherein the drug particles have a mass median aerodynamic diameter (MMAD) of about 0.5 μm to about 5.0 μm. 87. The composition of embodiment 86, wherein the MMAD is from about 1.0 μm to about 3.5 μm. 88. The composition of any one of embodiment 86 or embodiment 87, wherein the MMAD is from about 1.5 μm to about 2.5 μm. 89. The composition of any one of aspects 60-88, wherein the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8. 90. The composition of embodiment 89, wherein the GSD is about 1 to about 6. 91. The composition of any one of embodiment 89 or embodiment 90, wherein the GSD is about 2 to about 5. 92. The composition of any one of aspects 60 to 91, wherein the composition is loaded into a capsule. 93. The composition of embodiment 92, wherein the capsule is configured for use in an inhaler. 94. The composition of any one of aspects 60 to 93, wherein the composition is loaded into an inhaler. 95. The composition of embodiment 94, wherein the inhaler is a high resistance inhaler. 96. The composition of any one of embodiment 94 or embodiment 95, wherein the inhaler is a dry powder inhaler. 97. The composition of any one of aspects 60-96, wherein the drug particles have an emitted dose of at least 70% when released from the inhaler. 98. The composition of embodiment 97, wherein the emitted dose is at least 80%. 99. The composition of any one of embodiment 97 or embodiment 98, wherein the emitted dose is at least 90%. 100. The composition of any one of aspects 60-99, wherein the drug particles have a fine powder fraction as a percentage of recovered dose when released from an inhaler of at least 40%. 101. The composition of embodiment 100, wherein the fine powder fraction as a percentage of the recovered dose is at least 45%. 102. The composition of any one of embodiment 100 or embodiment 101, wherein the fine powder fraction as a percentage of the recovered dose is at least 50%. 103. The composition of any one of aspects 60-102, wherein the drug particles have a fine powder fraction, as a percentage of the recovered dose when released from an inhaler, that is about 40% to about 95%. 104. The composition of embodiment 103, wherein the fine powder fraction as a percentage of the recovered dose is about 45% to about 90%. 105. The composition of any one of embodiment 103 or embodiment 104, wherein the fine powder fraction as a percentage of the recovered dose is about 50% to about 85%. 106. The composition of any one of aspects 60-105, wherein the drug particles have a fine powder fraction as a percentage of the delivered dose when released from an inhaler of at least 50%. 107. The composition of embodiment 106, wherein the fine powder fraction as a percentage of the delivered dose is at least 55%. 108. The composition of any one of embodiment 106 or embodiment 107, wherein the fine powder fraction as a percentage of the delivered dose is at least 60%. 109. The composition of any one of aspects 60-108, wherein the drug particles have a fine powder fraction, when released from an inhaler, that is about 50% to about 98% as a percentage of the delivered dose. 110. The composition of embodiment 109, wherein the fine powder fraction as a percentage of the delivered dose is about 55% to about 95%. 111. The composition of any one of embodiment 109 or embodiment 110, wherein the fine powder fraction as a percentage of the delivered dose is about 60% to about 90%. 112. The composition of any one of aspects 60-111, comprising a dose of about 0.1 mg to about 2.5 mg of tacrolimus loaded into a capsule for use in an inhaler. 113. The composition of any one of aspects 60 to 112, wherein the modulation of the immune system is sufficient to prevent or delay rejection of a transplanted organ. 114. The composition of embodiment 113, wherein said rejection of a transplanted organ is rejection of a transplanted kidney, heart, liver, or lung. 115. The composition of any one of aspects 60-114, wherein the modulation of the immune system is sufficient to suppress the patient's immune system. 116. The composition of any one of aspects 60 to 115, wherein the modulation of the immune system is inhibition of calcineurin. 117. The composition of any one of aspects 60 to 116, wherein the patient is a human. 118. The composition of any one of aspects 1-117, wherein the patient has been identified as a rapid metabolizer of tacrolimus. 119. The composition of embodiment 118, further comprising increasing the dose administered to the patient. 120. The composition of any one of aspects 1-117, wherein the patient is identified as a slow metabolizer of tacrolimus. 121. The composition of embodiment 120, further comprising the step of decreasing the dose administered to the patient. 122. A method for preventing organ rejection in a patient, comprising administering to a patient in need thereof a therapeutically effective amount of the composition of any one of aspects 60-112. 123. The method of embodiment 122, wherein the organ rejection is rejection of a transplanted lung. 124. The method of embodiment 122, wherein the organ rejection is rejection of a transplanted heart. 125. The method of embodiment 122, wherein the organ rejection is rejection of a transplanted kidney. 126. The method of embodiment 122, wherein the organ rejection is rejection of a transplanted liver. 127. The method of any one of embodiments 122-126, comprising administering the composition once in a 24 hour period. 128. The method of any one of embodiments 122-127, comprising administering the composition as a single dose. 129. The method of any one of embodiments 122-127, comprising administering the composition as multiple doses at once. 130. A method for modulating an immune system response in a patient in need thereof, comprising administering to the patient a therapeutically effective amount of a composition of any one of aspects 60 to 112. 131. The method of embodiment 130, comprising administering the composition once during a 24-hour period. 132. The method of any one of embodiment 130 or embodiment 131, comprising administering the composition as a single dose. 133. The method of any one of embodiment 130 or embodiment 131, comprising administering the composition as multiple doses at once. 134. (A) A dose of tacrolimus, the dose being from about 0.1 mg to about 2.5 mg; and (B) Lactose 14. A composition comprising: said composition formulated for administration via inhalation, said dose providing a blood concentration of tacrolimus of greater than 2 ng / mL in a patient 24 hours after said dose is administered, and said composition comprising a weight ratio of lactose to said dose of tacrolimus of about 8:1 to about 12:1. 135. The composition of embodiment 134, which is formulated in a capsule for use in an inhaler, or which is formulated in an inhaler. EXAMPLES

[0103] V. Working Examples In order to facilitate a better understanding of the present disclosure, the following examples of specific embodiments are provided. Those skilled in the art should understand that the techniques disclosed in the following examples represent techniques discovered by the inventors to work well in the implementation of the present disclosure, and therefore may be considered to constitute preferred modes for its implementation. However, those skilled in the art should understand in light of the present disclosure that many changes can be made in the specific embodiments disclosed and still obtain the same or similar results without departing from the spirit and scope of the present disclosure. In no way should the following examples be read as limiting or defining the full scope of the present disclosure.

[0104] Example 1 - Administration of Tacrolimus A. Study Design i. Part A This study was a blinded, randomized, placebo-controlled, single-dose, dose-escalation study. Thirty-two healthy adult male and female subjects (non-reproductive potential females only) were enrolled. Eight subjects were assigned to each of the four dose levels. Subjects were screened within 28 days prior to receiving their first dose.

[0105] Study subjects were randomized to receive placebo (2 per group) or tacrolimus inhalation powder (6 per group) by inhalation. Subject allocation was blinded to the investigator, study coordinator, and study subjects. Subjects who discontinued the study before dosing were automatically replaced. Dose levels were 0.5, 1.0, 2.5, and 5.0 mg. Dose was sentinel-escalated only in the SAD portion. On day 1, two subjects assigned to the lowest dose cohort received a single dose of tacrolimus or placebo via Plastiape® inhaler. Blood samples and safety measurements were collected over 48 hours (up to day 3) after drug administration. If the drug was deemed safe by the TFF medical monitor and the investigator after reviewing the safety information, the remaining subjects in the cohort were immediately recruited to the CRU on day 4 for dosing the next day. Blood samples and safety measurements were collected again over 48 hours.

[0106] Escalation did not proceed unless sufficient safety was confirmed for all dose cohorts. Safety data were evaluated by the SMC to recommend whether dose escalation could proceed. The next cohort of the highest dose was not dosed for a minimum of 3 days after the last subject in the preceding cohort had been harvested and safety assessments completed. Dosing continued in a sentinel fashion until all cohorts were completed or a serious adverse event (grade 3 or greater) considered drug- or inhaler-related was observed in two or more subjects and / or a discontinuation criterion was met. If any AEs meeting discontinuation criteria were reported and / or the SMC recommended against dose escalation, the next dose cohort repeated the dose level prior to the level at which the adverse event was seen (i.e., the dose level lower than the one at which the adverse event was seen). Part A ended upon completion of that level.

[0107] Subjects randomized to receive the 2.5 mg inhaled dose participated in two doses, one with and one without food. In this cohort, subjects received two 2.5 mg inhaled doses, separated by at least 7 days. Dosing was not randomized, and all subjects received the first dose in a fasting state, and the second dose after a standardized high-fat breakfast. The second dose was not initiated until the SMC had reviewed the safety data from the first dose and confirmed the subject's safety for the second dose. For the second dose, the inhaled dose was administered within 5 minutes of breakfast intake. Blood samples were collected for PK measurements over a 48-hour period following each dose. Subjects were not replaced if treatment was discontinued for safety reasons related to tacrolimus or the inhaler.

[0108] ii. Part B The study is a blinded, randomized, placebo-controlled, multiple-dose, dose-escalation study. Part B will begin immediately after the completion of the first three cohorts of Part A and review of safety data. Twenty-four healthy adult male and female subjects (women of non-childbearing potential only) were enrolled. Eight subjects were assigned to each of three dose levels (1.0 mg BID, 0.5 mg BID, or either 1.0, 1.5, or 2.0 mg QD doses, determined by the SMC upon completion of Cohort 2 and after reviewing safety and TDM data for that cohort), with six subjects receiving inhaled tacrolimus and two subjects receiving placebo per cohort.

[0109] Subjects were screened within 28 days prior to the first dose. Study subjects were randomized to receive placebo or tacrolimus inhalation powder by inhalation. Subject allocation was blinded to the investigator, study coordinator, and study subjects. Subjects who discontinued the study before dosing were automatically replaced. On Day 1, subjects in each cohort began receiving tacrolimus or placebo twice daily (every 12 hours) in cohorts 1 and 2, and tacrolimus or placebo once daily (every 24 hours) in cohort 3 via the Plastiape® inhaler. Blood samples and safety measurements were performed as scheduled over a one-week period.

[0110] Escalation to the next cohort did not proceed unless safety was confirmed by the SMC for the entire dosing cohort. The next cohort did not begin dosing until at least 3 days after discharge of the last subject in the preceding cohort. Dosing continued until all cohorts were completed, or serious adverse events (grade 3 or higher) considered drug- or inhaler-related were observed in two or more subjects, or discontinuation criteria were met. The SMC could recommend that the next dosing cohort repeat the dose level used prior to the level at which the serious adverse event was observed (i.e., a dose level lower than the level at which the adverse event was present). Dose levels in Part B may be modified depending on safety observed in previous studies.

[0111] iii. Selection Criteria Subjects met all of the following inclusion criteria to be eligible to participate in the study: 1. Healthy adult men and women aged 18-65 years at the time of screening (non-reproductive women only). We will attempt to enroll in a 1:1 female / male ratio. 2. Continuous non-smoker who has not used nicotine-containing products (including e-cigarettes) for at least 3 months prior to first dose and throughout the study period, based on subject self-report and urinary cotinine concentrations at screening and check-in. 3. Body mass index (BMI) ≥ 18.0 and ≤ 32.0 kg / m2 at screening, and a minimum weight of at least 50.0 kg and a maximum weight of at least 120.0 kg at screening. 4. Medically healthy with no clinically significant abnormalities in medical history, physical examination, neurological examination, laboratory values, vital signs, or electrocardiogram, as determined by the Principal Investigator (PI) and designee. 5. Women of non-childbearing potential must have undergone (and have formal documentation of) one of the following fertility procedures at least 6 months prior to receiving their first dose: a. Hysteroscopic sterilization; b. Bilateral tubal ligation or bilateral salpingectomy; c. Hysterectomy; Super d. Bilateral oophorectomy; e. Or, postmenopausal with amenorrhea for at least 1 year prior to first dose, with a follicle-stimulating hormone (FSH) serum level greater than 40 mIU / mL consistent with postmenopausal status. 6. Non-vasectomized male subjects must agree to use highly effective contraception with their female partners of childbearing potential throughout the study period and for 90 days after treatment. Highly effective contraception is defined as a method that has a failure rate of <1% when used correctly and consistently. For example, a. Male subjects must use condoms; and their female partners must use one of the following highly effective methods of contraception: i. Hormonal contraception methods that involve ovulation inhibition, or ii. Intrauterine contraceptive devices; b. Abstinence, if consistent with the participant's usual lifestyle. For vasectomized male subjects, no restrictions are necessary if the vasectomy was performed (and formally documented) 4 months or more prior to Study Day 1. Subjects who had a vasectomy less than 4 months prior to Study Day 1 or who do not have formal documentation of a vasectomy must follow the same restrictions as non-vasectomized subjects. 7. Men must agree not to donate sperm from the first dose until 90 days after the final dose. 8. Agree to abstain from recreational drug use for the duration of the study, from screening through follow-up. 9. Understand the study procedures in the Interpersonal Companion Document (ICF) and be willing and able to comply with the protocol. 10. Creatinine clearance estimated by Cockcroft-Gault formula is ≥80 mL / min. 11. Pass training in using the device by inhaling an empty capsule up to two times. 12. Subjects must have an FEV1 ≥ 80%.

[0112] iv. Exclusion criteria Subjects were not enrolled in the study if they met any of the following criteria: 1. In the opinion of the PI or designee, is mentally or legally incompetent at the time of the screening visit or has significant emotional problems or is anticipated to have such problems during the conduct of the study. 2. History or presence of any clinically significant medical or psychiatric condition or illness, in the opinion of the PI or designee. 3. History of any disease that, in the opinion of the PI or designee, may confound the outcome of the study or pose additional risk to the subject from participation in the study. 4. History of any illness that, in the opinion of the PI or designee, may confound the outcome of the study or pose additional risk to the subject from participation in the study. 5. History of pulmonary disease, asthma or reactive airways disease. 6. History or presence of alcoholism or drug abuse within 2 years prior to first dose. 7. History or presence of hypersensitivity or idiosyncratic reaction to tacrolimus, cyclosporine, or any chemically related compounds (everolimus, sirolimus). 8. History of lactase deficiency. 9. Has had surgery or has any medical condition within 6 months prior to first dose that, in the opinion of the PI or designee, may affect the absorption, distribution, metabolism, or excretion of study drug. 10. Female subjects of childbearing potential. 11. Subjects with a positive pregnancy test or who are breastfeeding. 12. A positive urine drug or alcohol test at screening or initial check-in. 13. Screening results for cotinine are positive. 14. Positive tuberculosis screen (i.e., positive QuantiFERON TB-Gold result). 15. Positive results on screening for human immunodeficiency virus (HIV), hepatitis B surface antigen (HBsAg), or hepatitis C virus (HCV). 16. At screening or prior to dosing on Day 1, QTcF interval >450 msec (male) or >470 msec (female) or an ECG finding deemed a clinically significant abnormality by the PI or designee. 17. Sitting blood pressure <90 / 60mmHg or >140 / 90mmHg at screening. 18. Sitting heart rate <40 bpm (beats per minute) or >99 bpm at screening. 19. You are unable to refrain from, or are expected to refrain from, the following: Any medications, including prescription and non-prescription drugs, herbal remedies, or vitamin supplements, from 14 days prior to the first dose through the duration of the study. After the first dose, acetaminophen (up to 2 g per 24 hours) may be administered at the discretion of the PI or designee. Hormone replacement therapy is not permitted. b. Any drugs known to be strong inhibitors and / or inducers of CYP3A4 / 5 for 28 days prior to the first dose and during the study. Consult appropriate sources (e.g., Flockhart Tables) to confirm the absence of PK / PD interactions with tacrolimus. 20. Donation or loss of 50-499 mL of whole blood within 30 days prior to first dose, or donation or loss of more than 499 mL of whole blood within 56 days. 21. Plasma donation within 7 days prior to first dose. 22. Coagulation tests outside normal ranges at screening or initial check-in (a one-time confirmation of results is acceptable). 23. Platelets, hemoglobin, and hematocrit below the lower limits of normal at screening or initial check-in (a one-time review of results is acceptable). 24. Liver function tests including alanine aminotransferase (ALT), aspartate aminotransferase (AST), ALP, and total bilirubin higher than the upper limit of normal at screening and initial check-in (one-time confirmation of results is acceptable). 25. Estimated Cockcroft-Gault creatinine clearance <80 mL / min at screening. 26. Participation in another clinical trial within 30 days prior to first dose. This 30-day period is derived from the last blood draw or dose in the previous trial, whichever is later, through Day 1 of Period 1 of the current trial. 27. Prior to dosing on Study Day 1, treatment with any other investigational drug within 5 elimination half-lives if known (e.g., over-the-counter drug) or within 30 days (if elimination half-life is unknown), whichever is longer. 28. Have received any live viral vaccine within 6 weeks prior to the study or are anticipated to receive a live viral vaccine within 6 months after completion of the study. 29. Demonstrates inability to operate inhalation device after training. 30. Evidence of COVID-19 infection.

[0113] v. Test evaluation In this study, blood draws for tacrolimus concentration measurements are considered a critical parameter. Therefore, these samples were drawn as close to the scheduled time as possible. All other procedures should also be completed close to the prescribed / scheduled time, but can be staggered if necessary. The exact time of any procedure or draw should be documented.

[0114] On the check-in date for each cohort, all enrollment criteria relevant to study evaluations were reviewed (e.g., spirometry, clinical laboratory values, training in the use of the inhalation device, etc.) Any unscheduled procedures, if required for emergency evaluation of safety concerns, took precedence over all routinely scheduled procedures.

[0115] Within 28 days prior to the first dose, participants were asked to provide their sex, age, race, ethnicity, weight (kg), height (cm), and BMI (kg / m 2Medical history and demographic data, including blood pressure, blood glucose level, and smoking history, were reported. Each subject underwent a physical examination, a complete neurological examination, vital signs (heart rate, blood pressure, temperature, and respiratory rate), a 12-lead electrocardiogram, and laboratory tests including hematology, coagulation, liver function, renal function, and additional laboratory tests.

[0116] During screening, subjects were provided with a working model of the device and instructions for use. Subjects were properly trained in the use of the inhalation device. If subjects were unable to demonstrate proper use of the device, they were not allowed to enroll in the study.

[0117] A complete physical examination, including a complete neurological examination, was performed. Symptom-driven physical examinations were performed at other times if deemed necessary by the PI or designee.

[0118] Body temperature, respiratory rate, blood pressure and heart rate were measured once. Other vital signs were measured at any other time points if deemed necessary. Vital signs were performed with the subject in supine position whenever possible.

[0119] Blood pressure, heart rate, respiratory rate, and temperature were measured at each predose time point within 24 hours prior to dosing on Day 1. During Part B of the study, predose vital signs on all evenings and mornings on Days 2-6 were measured within 45 minutes of the next dose. When scheduled postdose, vital signs were performed on Day 1, within approximately 25 minutes of the 12-hour time point, and within 15 minutes of the remaining scheduled time points.

[0120] One 12-lead ECG was performed, except for the pre-dose ECG performed before the start of dosing on Day 1. For the pre-dose ECG on Day 1, two ECGs had to be performed within 15 minutes, and the QTcF values ​​were averaged to provide a pre-dose baseline value. This baseline pre-dose average QTcF must be below the threshold for exclusion criteria 16 for subjects to be eligible for dosing. These Day 1 pre-dose ECGs were performed within 90 minutes of dosing. Additional ECGs may be performed at any other time if deemed necessary by the PI or designee.

[0121] Electrocardiograms were performed at scheduled time points (± 15 min) after subjects had remained in the supine position for approximately 5 min. All ECG recordings were reviewed by the PI or designee. All ECGs must include the date and time of collection, body position, heart rate, QT interval, PR interval, QRS interval, RR interval, QTcB and QTcF, and clinical interpretation.

[0122] Subjects were remotely monitored for the first 2 hours after dosing (Part A) and for the first 2 hours after the first dose (Day 1) and after the 13th dose on Day 7 (MAD Cohorts 1 and 2) or the 7th dose (MAD Cohort 3) in Part B. If arrhythmias were observed during telemetry, unscheduled ECGs were collected with extended rhythm strips, interpreted by a board-certified cardiologist, and recorded on the CRF. The medical monitor was notified if this occurred. QTc values ​​were reviewed in detail. Fridericia's corrected QT interval (QTcF) was the primary endpoint of the study.

[0123] Additionally, weight (kg) is reported.

[0124] Forced expiratory volume in 1 second (FEV 1 ), predicted FEV 1 Percentage, Forced Vital Capacity (FVC), Percentage of Predicted FVC, Forced Expiratory Flow at 25% to 75% of Forced Vital Capacity (FEF 25-75% ) and predicted FEF 25-75% Spirometry, including percent, was performed at the indicated time points (±30 min). Pulse oximetry was monitored at the indicated time points (±30 min).

[0125] vi. Adverse Events AE means any adverse medical occurrence associated with the use of a drug in humans, whether or not considered drug-related.

[0126] Adverse device event (ADE) means any untoward and unintended reaction to a medical device. The phrase "reaction to a medical device" means that a causal relationship between the investigational device and the AE is at least reasonably possible, i.e., the relationship cannot be excluded.

[0127] Any case that either the reporting medically qualified professional or the sponsor determines to be reasonably suspected of a causal relationship to the device will qualify as a device effect, including any event attributable to deficiencies or inadequacies in instructions for use or placement of the device, and also any event attributable to user error.

[0128] A suspected adverse drug reaction (ADR) means any AE for which there is a reasonable possibility that a drug caused the AE. Reasonable possibility means that there is evidence suggesting a causal relationship between the drug and the AE. An ADR is a subset of all suspected adverse reactions for which there is reason to conclude that a drug caused the event. This includes all adverse and unintended reactions to a medicinal product, associated with any dose. Thus, an AE can be any untoward and unintended sign (including abnormal clinical laboratory findings), symptom, or disease temporarily associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product. An unexpected ADR is one whose nature or severity is inconsistent with the applicable product information.

[0129] Serious Adverse Device Events (SADEs): A serious adverse device event (SADE) is any untoward medical event seen in a patient that can be attributed, in whole or in part, to a device that caused or led to any of the characteristics of a serious adverse event. A SADE is also any event that could have led to these outcomes if appropriate action or intervention had not been taken or if circumstances had been less favorable. All cases will be adjudicated by either the reporting medically qualified professional or the sponsor.

[0130] Unanticipated Adverse Device Effect (UADE): Any serious adverse device effect to health or safety, or any life-threatening problem or death caused by or related to the device, where the effect, problem, or death was not previously identified in the protocol or application (including any supplemental protocol or application) in terms of its nature, severity, or occurrence, or any other unexpected serious problem related to the device with respect to the rights, safety, or welfare of a subject.

[0131] No device-related events were rated as “expected” according to the IFU RS01-Dry Powder Inhaler Instructions for Use.

[0132] vii. Discontinuation criteria A Safety Monitoring Committee (SMC) monitored the safety and tolerability of tacrolimus. The SMC reviewed safety and PK data as well as data completeness and the overall conduct of the study. If any individual subject had urgent medical concerns, the TFF Medical Monitor, together with the Principal Investigator, made any necessary decisions, including the decision to discontinue or not discontinue study drug treatment for a given subject, and notified the SMC of these actions accordingly. Repeat of any tests or evaluations was performed at the discretion of the Investigator and / or the TFF Medical Monitor.

[0133] The SMC met prior to dose escalation in both Part A and Part B studies and whenever deemed necessary by the TFF Pharmaceutical, Inc. medical monitor, principal investigator, and SMC chair based on SAE events. Any dose escalation was performed with unanimous consent of the SMC members, sponsor, and principal investigator. The SMC had the right to recommend a change to a lower dose than planned or to discontinue a cohort or the entire study at any time, particularly if any of the following criteria were met: 1. Absolute FEV1 decline of ≥ 20% from baseline that was not considered to be due to effort problems. Baseline values ​​were compared as follows: a. Comparison of pre-dose FEV1 (0 hours) on Day 1 with any post-dose FEV1 in both Parts A and B; b. In Part B, pre-dose FEV1 (0 h) on days 1 and 7 compared to post-dose FEV1 at other individual time points on the same days, or any other unscheduled FEV1. 2. The subject exhibits significant prolongation of the QT / QTcF interval during treatment with the study drug. There are two rules for discontinuing treatment due to the QTcF interval. Absolute QTcF value ≧500 msec at any time. The TFF Medical Monitor will be notified immediately and the subject will be discontinued from further treatment. b. An increase in QTcF of >450 msec in men and >470 msec in women on two consecutive ECGs taken 15 minutes apart. The TFF medical monitor was notified immediately and the subject discontinued further treatment. Note: Subjects with an increase in QTcF ≥ 60 msec from baseline may or may not be excluded from treatment. The Principal Investigator, in consultation with the TFF Medical Monitor, will make this decision and communicate it to the SMC.

[0134] Baseline QTcF values ​​are compared as follows: a. Comparison of mean pre-dose QTcF (0 hours) on Day 1 with all post-dose ECGs in both Parts A and B. b. In Part B, comparison of mean pre-dose QTcF on Day 1 and QTcF on Day 7 (hour 0, pre-dose 13 for MAD cohorts 1 and 2, pre-dose 7 for MAD cohort 3) with post-dose ECGs at other individual time points on the same day, or any other unscheduled ECG. 3. The subject exhibits elevated AST and / or ALT ≥ 3 x upper limit of normal (ULN) and / or elevated total bilirubin ≥ 2 x ULN during the study. Note: In this case, the subject should not receive any additional medication and should be followed with repeated clinical trials daily until AST or ALT levels are < 3 x ULN and / or total bilirubin is < 2 x ULN, with follow-up at minimum weekly intervals thereafter. This monitoring will continue until levels decline to normal levels or abnormal values ​​are deemed by the Investigator to be not clinically significant.

[0135] All subjects were randomly assigned to receive K 2 Venous blood samples are collected in EDTA-containing tubes. PK blood samples are collected pre-dose within 15 minutes prior to dosing. Post-dose blood samples are collected within the following windows at the scheduled time points (Table 1):

[0136] (Table 1) Timing windows TIFF2024520912000001.tif25128

[0137] Samples were processed according to the laboratory manual and transported according to the institution's standard operating procedures and the sponsor's or bioanalytical laboratory's instructions. Instructions for blood collection, collection, processing, and sample transport were provided separately.

[0138] Plasma tacrolimus PK parameters will be calculated as follows, as appropriate. AUC 0-24 : Area under the concentration-time curve from time 0 to 24 hours, calculated by the linear trapezoidal method. If the 24-hour plasma concentration is absent, below the limit of quantification, or not reportable, this parameter is not calculated. AUC 0-t : Area under the concentration-time curve from time 0 to the last observed non-zero concentration, calculated by the linear trapezoidal method. AUC 0-τ : Area under the concentration-time curve from time 0 to the end of the dosing interval. AUC 0-inf AUC: Area under the concentration-time curve from time 0 to extrapolated infinity. 0-inf is AUC 0-t It is calculated as the sum of the ratios of the last measurable plasma concentrations plus the elimination rate constant. AUC %extrap : (1 - AUC 0-t / AUC 0-inf )*100, the extrapolated AUC 0-inf Percent of C max : Highest concentration observed. CL / F: Dose / AUC 0-inf The apparent total body clearance after oral administration was calculated as: T max : C max If the maximum value occurs at multiple points in time, T max is defined as the first time point of this value. Kel: Apparent first-order terminal elimination rate constant calculated from a semi-log plot of the plasma concentration versus time curve. The parameter is calculated by linear least-squares regression analysis using the maximum number of points in the terminal log-linear phase (e.g., 3 or more non-zero plasma concentrations). t 1 / 2 : The apparent first-order terminal elimination half-life is calculated as 0.693 / Kel. Vz / F: (Dose / AUC 0-inf ) × Kel, the apparent volume of distribution in the terminal elimination phase after oral dosing.

[0139] For cases not showing a terminal log-linear phase in the concentration-time profile, values ​​of Kel, AUC0-inf, AUC%extrap, t1 / 2, CL / F, or Vz / F will not be reported. For subjects with two or fewer consecutive time points with detectable concentrations, PK parameters will not be calculated. Individual and mean plasma concentration-time curves (both linear and log-linear) will be included in the final report. Dose proportionality will be tested at all doses used in Part A and Part B using standard power regression methods. max will be analyzed using nonparametric analysis (Walsh means and appropriate quartiles of the Wilcoxon signed rank test statistic). Tmax will not be ln transformed.

[0140] viii. Tacrolimus composition used in the study The tacrolimus drug product is a tacrolimus inhalation powder for oral inhalation use. The tacrolimus drug product consists of a capsule containing tacrolimus powder for oral inhalation, and the use of a Plastiape Monodose dry powder inhalation device (RS01). In human trials, the tacrolimus capsule contains 0.5 mg or 2.5 mg of tacrolimus and lactose monohydrate and leucine in concentrations required to facilitate capsule filling and delivery, and is filled into a hypromellose capsule with a white opaque cap and a white opaque body. The placebo drug product consists of a capsule containing only lactose monohydrate, and the use of the same Plastiape Monodose dry powder inhalation device (RS01). The compositions of 0.5 mg and 2.5 mg tacrolimus inhalation powder are shown in Tables 2 and 3, respectively.

[0141] Table 2: Composition of tacrolimus inhalation powder 0.5 mg TIFF2024520912000002.tif65164 1 The white, empty hypromellose hard capsule shell is composed of titanium dioxide and hypromellose. The capsule shell is not a compendial item, but is composed of compendial materials that are tested against current compendial standards.

[0142] Table 3: Composition of tacrolimus inhalation powder 2.5 mg TIFF2024520912000003.tif60164 1 The white, empty hypromellose hard capsule shell is composed of titanium dioxide and hypromellose. The capsule shell is not a compendial item, but is composed of compendial materials that are tested against current compendial standards.

[0143] The composition of the placebo inhalation powder is shown in Table 4.

[0144] Table 4. Composition of placebo inhalation powder TIFF2024520912000004.tif37164 1The white, empty hypromellose hard capsule shell is composed of titanium dioxide and hypromellose. The capsule shell is not a compendial item, but is composed of compendial materials that are tested against the current compendium.

[0145] The manufacturing process for 2.5 mg capsules of tacrolimus inhalation powder began with the preparation of a 50:50 (w / w) tacrolimus / lactose monohydrate powder using thin film freezing. The thin film freezing process begins with dissolving the required amount of tacrolimus and lactose monohydrate in a co-solvent mixture of acetonitrile and water. The solution is then frozen by dripping onto the surface of a rotating drum cooled with liquid nitrogen. The frozen solution is collected and dried by lyophilization to remove acetonitrile and water. Acetonitrile levels are controlled below 410 parts per million (ppm) in accordance with ICH Q3C. The 50% tacrolimus powder for inhalation is amorphous as characterized by X-ray diffraction.

[0146] Tacrolimus inhalation powder 0.5 mg drug product is packaged for clinical use in white high density polyethylene (HDPE) bottles with polypropylene (PP) caps containing silica gel desiccant for storage at 36°F to 46°F (2°C to 8°C).

[0147] Tacrolimus inhalation powder 2.5 mg drug product and placebo drug product were packaged for clinical use in white high density polyethylene (HDPE) bottles with polypropylene (PP) caps containing silica gel desiccant for storage in a dry location at 68°F to 77°F (20°C to 25°C); variation tolerance range 59°F to 86°F (15°C to 30°C).

[0148] Tacrolimus and placebo inhalation powders were used in a Plastiape Monodose inhaler. This drug product inhalation (DPI) device is manufactured by Plastiape SpA, Osnago, Italy. Plastiape has filed US DMF No. 17864 for the RS01 device. A high resistance version of the RS01 device device was used with the tacrolimus inhalation powder. The Plastiape Monodose DPI device was used with Bronchitol® (mannitol powder for inhalation) and Aridol® (mannitol), both of which are currently approved in Australia. The Plastiape inhaler consists of a white protective cap and a base with a mouthpiece, capsule chamber, and two push buttons.

[0149] In vitro aerosol performance of tacrolimus inhalation powder 0.5 mg and 2.5 mg was evaluated according to USP 6.1 - Apparatus 5 <601> The aerodynamic properties of 0.5 mg and 2.5 mg tacrolimus inhalation powders from a representative development batch of the drug product were compared.

[0150] Table 5. Aerodynamic characteristics of tacrolimus inhalation powder at 60 L / min using the Plastiape Monodose RS01 high resistance dry powder inhaler device product. TIFF2024520912000005.tif37128MMAD=Aerodynamic mass median diameter GSD=geometric standard deviation FPF = fine particle fraction 1 Average value (standard deviation)

[0151] B. Pharmacokinetic Analysis Recent data in healthy volunteers from the 1 mg BID repeat dose group (Figure 1) were generally consistent with predicted 75% F (absorption) oral PK model developed to simulate the systemic exposure of tacrolimus after pulmonary inhalation. See Figures 2A and 2B. The actual arithmetic mean of 45 ng / mL was consistent with a simulated geometric mean exposure of slightly greater than 45 ng / mL. The actual trough values ​​at 12 hours after dosing on days 1 and 7 were close to the upper 90% confidence interval of the simulated exposure. This preliminary pharmacokinetic data suggests that it is possible to deliver low mg doses of tacrolimus by inhalation and achieve similar concentration values ​​at trough within the TDM concentration range of 10-15 ng / mL at lower total daily doses. See Figures 3-4. More importantly, the 12 hour C min Trough concentrations were slightly higher than predicted by the oral PK model and, equally important, the observed C max This inverse correlation of lower peak and higher trough concentrations provides more consistent exposure (reduced variability) and may lead to: 1) fewer GI AEs due to the route of administration, which may improve patient compliance; and 2) higher TDM C at lower mg doses. min provides trough concentrations, and 3) may represent a viable dosing strategy with low drug burden.

[0152] All compositions and methods disclosed and claimed herein can be made and carried out without undue experimentation in light of this disclosure.Although the compositions and methods of this disclosure have been described in terms of preferred embodiments, it will be clear to one skilled in the art that variations can be applied to the methods and steps or sequence of steps of the methods described herein without departing from the concept, spirit and scope of this disclosure.More specifically, it will be clear that certain agents that are both chemically and physiologically related can be substituted for the agents described herein with the same or similar results.All such similar substitutes and modifications that are clear to one skilled in the art are deemed to be within the spirit, scope and concept of this disclosure as defined by the appended claims.

[0153] References The following references, to the extent that they provide exemplary procedural or other details supplementary to those set forth herein, are specifically incorporated herein by reference. TIFF2024520912000006.tif209160TIFF2024520912000007.tif136161

Claims

1. 1. A composition for use in a method of modulating an immune response in a patient in need thereof, the composition comprising a dry powder of drug particles comprising tacrolimus, the method comprising administering by inhalation an appropriate amount of the composition to the lungs of said patient; the patient is administered one dose during a 24 hour period, the dose being sufficient to provide a blood concentration of tacrolimus in the patient of at least 3 ng / mL at 24 hours after administration, when the patient is administered one dose on three consecutive days; composition.

2. 2. The composition of claim 1, wherein the patient is administered the dose for 7 consecutive days.

3. 2. The composition of claim 1, wherein the patient is not receiving any additional tacrolimus beyond the dose.

4. The composition of any one of claims 1 to 3, wherein the dose is administered using a single inhaler capsule.

5. The composition of any one of claims 1 to 3, wherein the dose is administered once using an appropriate amount of multiple inhaler capsules.

6. The composition of any one of claims 1 to 3, wherein the blood concentration of tacrolimus is at least 5 ng / mL 24 hours after said administration.

7. 4. The composition of any one of claims 1 to 3, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 15 ng / mL 24 hours after said administration.

8. The composition of any one of claims 1 to 3, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 12 ng / mL 24 hours after said administration.

9. 4. The composition of any one of claims 1 to 3, wherein the blood concentration of tacrolimus is from about 3 ng / mL to about 7.5 ng / mL 24 hours after said administration.

10. The composition of any one of claims 1 to 3, wherein the composition comprises sugar.

11. 11. The composition of claim 10, wherein the sugar is lactose.

12. 4. The composition of any one of claims 1 to 3, wherein the drug particles comprise tacrolimus and sugar in a weight ratio of from 5:1 to about 1:

20.

13. 13. The composition of claim 12, wherein the weight ratio is from about 1:1 to about 1:

10.

14. 14. The composition of claim 13, wherein the weight ratio is from about 1:2.5 to about 1:

10.

15. The composition of any one of claims 1 to 3, wherein the composition comprises tacrolimus in a dose range of about 0.05 mg to about 3.5 mg.

16. 16. The composition of claim 15, wherein said dose of tacrolimus is from about 0.1 mg to about 3.0 mg.

17. 17. The composition of claim 16, wherein said dose of tacrolimus is from about 0.25 mg to about 2.5 mg.

18. 18. The composition of claim 17, wherein the dose of tacrolimus is about 1.5 mg.

19. The composition of any one of claims 1 to 3, wherein the tacrolimus is in amorphous form.

20. The composition of any one of claims 1 to 3, wherein at least 90% of the tacrolimus is in amorphous form.

21. The composition of any one of claims 1 to 3, wherein at least 95% of the tacrolimus is in amorphous form.

22. The composition of any one of claims 1 to 3, wherein at least 98% of the tacrolimus is in amorphous form.

23. The composition of any one of claims 1 to 3, wherein at least 99% of the tacrolimus is in amorphous form.

24. 4. The composition of any one of claims 1 to 3, wherein the drug particles have a mass median aerodynamic diameter (MMAD) of about 0.5 μm to about 5.0 μm.

25. 25. The composition of claim 24, wherein the MMAD is from about 1.0 μm to about 3.5 μm.

26. 26. The composition of claim 25, wherein the MMAD is from about 1.5 μm to about 2.5 μm.

27. 4. The composition of any one of claims 1 to 3, wherein the drug particles have a geometric standard deviation (GSD) of about 0.5 to about 8.

28. 28. The composition of claim 27, wherein the GSD is from about 1 to about 6.

29. 29. The composition of claim 28, wherein the GSD is from about 2 to about 5.

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