Rapamycin compositions and their use in the treatment of microcystic lymphatic malformations

Abstract

Embodiments herein are directed to methods and compositions for treating microcystic lymphatic malformations, more specifically, topical rapamycin gels and methods of use thereof that are effective in reducing the size, severity, or number of lesions, improving the quality of life and ability to function in subjects with microcystic lymphatic malformations.

Description

[Technical field]

[0001] (CROSS REFERENCE TO RELATED APPLICATIONS) This application claims the benefit under 35 U.S.C. § 119(e) to U.S. Application No. 63 / 244,391, filed September 15, 2021. The disclosure of each prior application is deemed to be part of, and is incorporated by reference into, the disclosure of this application. Background

[0002] Lymphatic malformations (LM) are rare disorders of the lymphatic system characterized by abnormal blood vessels, sacs, and cysts filled with lymphatic fluid. According to the International Society for the Study of Vascular Anomalies (ISSVA), microcystic LM is one of three morphological types of LM based on the size of the individual cysts (relative to the total size of the LM): macrocystic (>2 cm), microcystic (<2 cm), and combined.

[0003] The symptoms of LM vary in their presentation and anatomical location (i.e., skin for microcystic LM or deep tissues for macrocystic LM), but are always the result of diffuse infiltration and overgrowth of a localized mass. Unlike macrocystic LM, microcystic LM invades the subcutaneous tissue and presents clinically in the skin. Microcystic LM can occur in any anatomical area of ​​the body that has a lymphatic network. Microcystic LM is a lesion formed by the aggregation of multiple small cysts. The actual size of the lesion depends on the total number of individual small cysts.

[0004] Microcystic LM is the result of a congenital anomaly of the lymphatic system that is thought to have occurred during lymphatic duct development and is present at birth. All cases arise from postzygotic mutations early in embryogenesis, resulting in malformations of the lymphatic system, persistent lymphatic infiltration of soft tissues, and locally invasive masses with pathological sequelae. Microcystic LM affects boys and girls equally, although some may be influenced by hormonal changes during puberty. The natural history of microcystic LM is progressive, worsening throughout life with increasing numbers of cysts, leading to increased overall size, complications, and morbidity.

[0005] The natural history of microcystic LM is progressively worsening throughout life with increasing size, number, complications, and morbidity of the lesions. Microcystic LM, often referred to as LM lesions, infiltrate the skin and spontaneously leak lymphatic and blood fluids from the pathological vesicles. Bacteria can enter these LM lesions and spread rapidly through the affected tissues, resulting in recurrent severe infections. This results in a significant impairment of quality of life by limiting function and may lead to life-threatening consequences such as sepsis. Furthermore, when accompanied by significant bleeding, these lesions may also cause generalized anemia.

[0006] Based on the need for an effective therapy to treat microcystic LM, this Phase 2 clinical trial was designed to evaluate the safety, PK, and efficacy of PTX-022 in participants with microcystic LM. The study will evaluate safety, including measurement of sirolimus plasma concentrations. Efficacy will be assessed using patient and clinician assessments. Because microcystic LM rarely resolves, each participant will serve as their own control in this open-label study.

[0007] The natural history of microcystic LM is a progressive worsening throughout life, with an increase in size, number, complications, and morbidity. Microcystic LM can occur in any anatomical site throughout the body that has a lymphatic network, but approximately 48% occur in the head and neck.

[0008] Affected patients suffer from a variety of complications associated with microcystic LM (also called LM lesions). Complications include bleeding, leakage (lymphorrhea), pain, pruritus, impaired function, infection, and disfigurement. Bleeding and leakage can cause swelling, pain, and recurrent infection of the LM lesion, which can lead to dissemination. Furthermore, LM lesions significantly impair quality of life and persistently limit function.

[0009] LM results from mutations in the formation of blood and lymphatic vessels during early embryonic development, resulting in abnormalities in the organization and connectivity of these vessels. LM is congenital, sporadic, and results from somatic germline mutations, and is usually present and diagnosed at birth. In some cases, it is exacerbated by hormonal changes during puberty. Males and females are affected equally.

[0010] Effective management of LM requires multidisciplinary care. CT and / or MRI imaging is often performed before treatment is initiated to help guide treatment selection and predict prognosis. Unfortunately, many treatments (sclerotherapy, laser therapy, surgery) are invasive and painful and may induce further inflammation / scarring. Furthermore, the efficacy of these treatments, especially for microcystic LM, is generally incomplete and transient, with a high recurrence rate. As such, many patients with microcystic LM continue to experience lifelong clinical and psychosocial morbidity, often resulting in a worsened quality of life. Although there are no FDA-approved drugs for microcystic LM, many recommend oral sirolimus as first-line therapy for this highly morbid condition.

[0011] Despite the severe and fatal nature of microcystic LM, there is no FDA-approved treatment for the disease. In fact, the currently available treatments (surgery, sclerotherapy, laser, cryotherapy) are invasive and may further induce scarring / inflammation. Ultimately, there is a dire need for treatments that can address the underlying causes of such abnormal lymphangiogenesis. Summary of the Invention

[0012] In one embodiment, the invention provides a method of treating microcystic lymphatic malformation in a subject in need thereof using topical administration of a therapeutically effective amount of an anhydrorapamycin gel composition to a microcystic lymphatic malformation skin lesion of the subject once daily, wherein the microcystic lymphatic malformation is treated.

[0013] In one embodiment, the microcystic lymphatic malformation skin lesion is about 25 cm 2In one embodiment, the symptoms associated with the microcystic lymphatic malformation skin lesion occur at least 1-2 days per week. In one embodiment, treating a microcystic lymphatic malformation in a subject is to improve the symptoms of the microcystic lymphatic malformation skin lesion, such as leakage (lymphorrhea), bleeding, redness, crusting, hyperkeratosis, raised spots, or a combination thereof. In one embodiment, the anhydrous rapamycin gel composition comprises about 0.1% to about 6% rapamycin, about 80% to about 99% of one or more solvents, a gelling agent, and an antioxidant. In one embodiment, the anhydrous rapamycin gel composition comprises about 0.1% to about 6% rapamycin, about 80% to about 99% of one or more solvents, about 0.1% to about 5% gelling agent, and about 0.001% to about 1% antioxidant. In one embodiment, the one or more solvents are diisopropyl adipate, glycerol, PEG, or isopropyl alcohol.In one embodiment, the anhydrous rapamycin gel composition has about 3.9% rapamycin, about 15% isopropyl alcohol, about 54.9% polyethylene glycol 400, about 15% diisopropyl adipate, about 10% glycerol, about 0.75% hydroxypropyl cellulose, about 0.05% propyl gallate, about 0.02% ascorbyl palmitate, about 0.002% α-tocopherol, and citric acid.

[0014] In one embodiment, the administering step comprises applying the anhydrorapamycin gel composition as a thin layer to the skin of the subject. In one embodiment, the anhydrorapamycin gel composition is administered once daily for at least 12 weeks.

[0015] In one embodiment, the subject shows improvement in one or more scores on assessments selected from the group consisting of Patient Global Impression of Change (PGI-C), Patient Global Impression of Severity (PGI-S), Patient Global Impression of Severity for Leakage (PGI-SL), Patient Global Impression of Severity for Bleeding (PGI-SB), Clinician Global Impression of Change (CGI-C), Clinician Global Impression of Severity (CGI-S), and combinations thereof. In one embodiment, the subject shows improvement in scores on the Dermatology Quality of Life Assessment (DLQI). In one embodiment, the subject experiences a decrease in the number of days that lesions report leaking. In one embodiment, the subject experiences a decrease in the number of days that lesions report bleeding. In one embodiment, one or more of lesion size, lesion thickness, lesion height, or number of lesions is reduced. In one embodiment, the severity of lesion pain, lesion crust, or lesion redness based on the Microcystic LM Symptom Severity (SS) Scale is reduced. In one embodiment, no field radiation (XRT) is required to be administered to the microcystic lymphatic malformation skin lesion.

[0016] In one embodiment, topical administration of the anhydrous rapamycin gel composition to the skin of the subject achieves a maximum epidermal concentration of rapamycin in the epidermis of the subject at about 120-990 micromolar rapamycin.In one embodiment, topical administration of the anhydrous rapamycin gel composition to the skin of the subject achieves a maximum dermal concentration of rapamycin in the dermis of the subject at about 50-200 micromolar rapamycin. [Brief description of the drawings]

[0017] [Figure 1] 1 is a graph showing Clinician Global Impression of Change (CGI-C) for subjects 1-10. [Diagram 2] Graph showing Clinician Global Impression of Severity Change (CGI-C) for eschar / hyperkeratosis, erythema, height, bleeding, and leakage for subjects 1-10. [Diagram 3] Graph showing Patient Global Impression of Change (PGI-C) scores for subjects 1-10. [Figure 4]1 shows the assessment of microcystic LM at baseline, days 28, 56, and 84 for subject 1. [Diagram 5] 1 shows the assessment of microcystic LM at baseline, days 28, 56, and 84 for subject 2. [Figure 6] 1 shows the assessment of microcystic LM at baseline, day 28, and day 56 for subject 3. [Figure 7] 1 shows the assessment of microcystic LM at baseline, days 28, 56, and 84 for subject 5. [Figure 8] 1 shows the assessment of microcystic LM at baseline, day 28, and day 56 for subject 6. [Figure 9] 1 shows the assessment of microcystic LM at baseline and day 28 for subject 7. [Figure 10] 1 shows the assessment of microcystic LM at baseline and day 28 for subject 8. [Figure 11] 13 shows the assessment of microcystic LM at baseline and day 28 in subject 9. [Figure 12] 1 shows the assessment of microcystic LM at baseline and day 28 in subject 10. Detailed Description of the Invention

[0018] Various aspects are described more fully below. However, such aspects may be embodied in many different forms and should not be construed as limited to the embodiments set forth herein, but rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey its scope to those skilled in the art.

[0019] How to use Disclosed herein is a method for treating microcystic lymphatic malformation (microcystic LM) in a subject. In particular, the anhydrorapamycin gel composition provided reduces one or more symptoms of microcystic LM, including lymphorrhea frequency, bleeding frequency, lesion severity, lesion size, lesion height, lesion number, pruritus severity and frequency, and pain severity and frequency.

[0020] Embodiments described herein are directed to a method of treating a microcystic lymphatic malformation in a subject in need thereof, comprising topically administering a therapeutically effective amount of an anhydrorapamycin gel composition to a microcystic lymphatic malformation skin lesion of the subject once daily, whereby the microcystic lymphatic malformation is treated.

[0021] In certain embodiments, the microcystic lymphatic malformation skin lesion is about 25 cm 2 Greater than.

[0022] In certain embodiments, the symptoms associated with microcystic LM skin lesions occur at least 1-2 days per week or 5 or more days in the past 14 days. In certain embodiments, the symptoms associated with microcystic LM skin lesions are selected from the group consisting of leaking, bleeding, redness, crusting, hyperkeratosis, raised spots, and combinations thereof.

[0023] Thus, in one aspect, the disclosure provides a method of treating microcystic LM in a subject in need thereof, the method comprising topically administering once daily to a microcystic LM skin lesion of the subject a therapeutically effective amount of an anhydrous rapamycin gel composition comprising about 0.1% to about 6% by weight rapamycin, about 80% to about 99% by weight of one or more solvents, a gelling agent, and an antioxidant. In any embodiment, the anhydrous rapamycin gel composition comprises about 0.1% to about 6% by weight rapamycin, about 80% to about 99% by weight of one or more solvents, about 0.1% to about 5% by weight of a gelling agent, and about 0.001% to about 1% by weight of an antioxidant. For example, a method of treating microcystic LM in a subject in need thereof comprises topically administering once daily to the subject's microcystic LM skin lesions a therapeutically effective amount of an anhydrous rapamycin gel composition comprising about 0.1% to about 6% by weight rapamycin, about 5% to about 30% by weight diisopropyl adipate, about 5% to about 30% by weight glycerol, about 40% to about 60% by weight polyethylene glycol (PEG), about 5% to about 30% by weight isopropyl alcohol, a gelling agent, and optionally an antioxidant (such as citric acid).

[0024] In a preferred embodiment, a method of treating microcystic LM in a subject in need thereof comprises topically administering once daily to a microcystic LM skin lesion of the subject a therapeutically effective amount of an anhydrous rapamycin gel composition comprising about 3.9% by weight rapamycin, about 15% by weight diisopropyl adipate, about 10% glycerol, about 54.9% by weight polyethylene glycol (PEG), about 15% by weight isopropyl alcohol, about 0.75% hydroxypropyl cellulose, about 0.05% propyl gallate, about 0.02% ascorbyl palmitate, about 0.002% α-tocopherol, and citric acid.

[0025] As used herein, "rapamycin" or "sirolimus" are used interchangeably and refer to a macrocyclic lactone produced by the organism Streptomyces hydroscopicus isolated from soil samples on Easter Island (Rapa Nui) and having the following structure: TIFF2024533480000002.tif72141

[0026] The anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein is administered topically by any method disclosed herein.For example, administration includes topically applying the anhydrous rapamycin gel composition as disclosed herein as a thin layer on one or more of the microcystic LM skin lesions, where the skin lesions are anywhere on the body, including the chest, neck, scalp, back, or face.By topically administering the anhydrous rapamycin gel composition as disclosed herein, rapamycin reaches one or both of the epidermal layer and the dermal layer of the skin via absorption.Advantageously, the topical administration of the anhydrous rapamycin gel composition as disclosed herein does not result in or minimizes systemic absorption of rapamycin.

[0027] Topical administration of the anhydrous rapamycin gel composition disclosed herein is performed in the evening at least 1 hour before going to bed.The anhydrous rapamycin gel composition disclosed herein should be applied to microcystic LM skin lesions once a day.Topical administration of the anhydrous rapamycin gel composition disclosed herein is performed once a day, twice a day, or three times a day.Alternatively, the anhydrous rapamycin gel composition as disclosed herein is topically administered three times a week, twice a week, once a week, or once every other day.

[0028] Topical administration of anhydrous rapamycin gel compositions as disclosed herein is administered for a period of at least 1 week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks, at least 9 weeks, at least 10 weeks, at least 11 weeks, or preferably at least 12 weeks. More preferably, topical administration of anhydrous rapamycin gel compositions as disclosed herein is administered for a period of at least 24 weeks, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 8 months, at least 12 months, or more.

[0029] Topical administration of the anhydrous rapamycin gel compositions disclosed herein is performed in dosing cycles in which the anhydrous rapamycin gel compositions are administered for a period of time, administration is discontinued for a period of time, and then administration is resumed again for another period of time, as described herein. The period of cessation of administration of the anhydrous rapamycin gel compositions as disclosed herein is from about 1 week to about 12 weeks.

[0030] In any embodiment, topical administration of an anhydrorapamycin gel composition to the affected skin of a subject with microcystic LM reduces the thickness of the lesion, the height of the lesion, or the size of the lesion on the subject's skin. In the embodiments described herein, topical administration of an anhydrorapamycin gel composition to the affected skin of a subject with microcystic LM reduces the thickness of the microcystic lymphatic malformation skin lesion to about 25 cm. 2 Reduce to less than.

[0031] In any embodiment, topical administration of an anhydrorapamycin gel composition to the skin of a subject with microcystic LM reduces the number of lesions on the subject's skin.

[0032] In any embodiment, topical administration of an anhydrorapamycin gel composition to the skin of a subject with microcystic LM reduces the total surface area covered by lesions on the subject's skin. In the embodiments described herein, topical administration of an anhydrorapamycin gel composition to the affected skin of a subject with microcystic LM reduces the total surface area covered by lesions by about 200 cm. 2 Reduce to less than.

[0033] In any embodiment, topical administration of anhydrous rapamycin gel composition to the skin of a subject with microcystic LM reduces lesion bleeding on the skin of the subject.In any embodiment, lesion bleeding is reduced to less than 7 days per week, less than 6 days per week, less than 5 days per week, less than 4 days per week, less than 3 days per week, less than 2 days per week, less than 1 day per week, or lesion bleeding stops.In any embodiment, lesion bleeding is reduced to less than 13 days per 14 days, less than 12 days per 14 days, less than 11 days per 14 days, less than 10 days per 14 days, less than 9 days per 14 days, less than 8 days per 14 days, less than 7 days per 14 days, less than 6 days per 14 days, less than 5 days per 14 days, less than 4 days per 14 days, less than 3 days per 14 days, less than 2 days per 14 days, less than 1 day per 14 days, or lesion bleeding stops.

[0034] In any embodiment, topical administration of anhydrous rapamycin gel composition to the skin of a subject with microcystic LM reduces the lesion lymphatic leakage, leakage, or exudation on the skin of the subject.In any embodiment, lesion leakage or exudation is reduced to less than 7 days per week, less than 6 days per week, less than 5 days per week, less than 4 days per week, less than 3 days per week, less than 2 days per week, less than 1 day per week, or lesion leakage or exudation is stopped.In any embodiment, lesion leakage or exudation is reduced to less than 13 days per 14 days, less than 12 days per 14 days, less than 11 days per 14 days, less than 10 days per 14 days, less than 9 days per 14 days, less than 8 days per 14 days, less than 7 days per 14 days, less than 6 days per 14 days, less than 5 days per 14 days, less than 4 days per 14 days, less than 3 days per 14 days, less than 2 days per 14 days, less than 1 day per 14 days, or lesion leakage or exudation is stopped.

[0035] In any embodiment, topical administration of anhydrous rapamycin gel composition to the skin of a subject with microcystic LM reduces the pruritus of the skin of the subject.In any embodiment, pruritus is reduced to less than 7 days per week, less than 6 days per week, less than 5 days per week, less than 4 days per week, less than 3 days per week, less than 2 days per week, less than 1 day per week, or pruritus ceases.In any embodiment, pruritus is reduced to less than 13 days per 14 days, less than 12 days per 14 days, less than 11 days per 14 days, less than 10 days per 14 days, less than 9 days per 14 days, less than 8 days per 14 days, less than 7 days per 14 days, less than 6 days per 14 days, less than 5 days per 14 days, less than 4 days per 14 days, less than 3 days per 14 days, less than 2 days per 14 days, less than 1 day per 14 days, or pruritus ceases.

[0036] In any embodiment, topical administration of anhydrorapamycin gel composition to the skin of a subject with microcystic LM reduces the redness (or color of the lesion) of the subject's skin. In any embodiment, the redness is reduced to less than 7 days per week, less than 6 days per week, less than 5 days per week, less than 4 days per week, less than 3 days per week, less than 2 days per week, less than 1 day per week, or the redness disappears. In any embodiment, the redness is reduced to less than 13 days in 14 days, less than 12 days in 14 days, less than 11 days in 14 days, less than 10 days in 14 days, less than 9 days in 14 days, less than 8 days in 14 days, less than 7 days in 14 days, less than 6 days in 14 days, less than 5 days in 14 days, less than 4 days in 14 days, less than 3 days in 14 days, less than 2 days in 14 days, less than 1 day in 14 days, or the redness ceases.

[0037] In any embodiment, topical administration of anhydrous rapamycin gel composition to the skin of a subject with microcystic LM reduces the crusting of the subject's skin.In any embodiment, the crusting is reduced to less than 7 days per week, less than 6 days per week, less than 5 days per week, less than 4 days per week, less than 3 days per week, less than 2 days per week, less than 1 day per week, or the crusting disappears.In any embodiment, the crusting is reduced to less than 13 days per 14 days, less than 12 days per 14 days, less than 11 days per 14 days, less than 10 days per 14 days, less than 9 days per 14 days, less than 8 days per 14 days, less than 7 days per 14 days, less than 6 days per 14 days, less than 5 days per 14 days, less than 4 days per 14 days, less than 3 days per 14 days, less than 2 days per 14 days, less than 1 day per 14 days, or the crusting ceases.

[0038] In any embodiment, topical administration of an anhydrorapamycin gel composition to the skin of a subject with microcystic LM reduces hyperkeratinization of the subject's skin. In any embodiment, the thickness of the lesion is reduced. In any embodiment, the raised spots are reduced.

[0039] In any embodiment, topical administration of an anhydrorapamycin gel composition to the skin of a subject with microcystic LM results in the elimination of any additional therapy for the treatment of microcystic LM, including field radiation (XRT), episcleral therapy, or laser therapy.

[0040] In any embodiment, topical administration of an anhydrorapamycin gel composition to the skin of a subject with microcystic LM reduces pain or redness of the subject's skin, which can be measured by ranking using a 0-10 scale, with 0 (no symptoms) to 10 (severe). For example, a subject may experience an improvement of at least 1 point, at least 2 points, at least 3 points, at least 4 points, at least 5 points, at least 6 points, at least 7 points, at least 8 points, or at least 9 points in the relevant score after topical administration once daily of an anhydrorapamycin gel composition disclosed herein.

[0041] In any embodiment, the improvement of symptoms of microcystic LM is reported by the subject's clinician, for example, via the Clinician Global Impression of Severity (CGI-S), a global index used to assess the clinician's perception of the severity of a particular condition, or the Clinician Global Impression of Change (CGI-C), which reflects the clinician's belief in the effectiveness of treatment. For example, the subject may experience an improvement in CGI-S score of at least 1 point, at least 2 points, at least 3 points, at least 4 points, or 5 points after topically administering an anhydrous rapamycin gel composition as disclosed herein once a day. Similarly, the subject may experience an improvement in CGI-C score of at least 1 point, at least 2 points, at least 3 points, at least 4 points, at least 5 points, or 6 points after topically administering an anhydrous rapamycin gel composition as disclosed herein once a day.

[0042] In any embodiment, improvement in symptoms of microcystic LM is reported by the subject, for example, through a Dermatology Quality of Life Assessment (DLQI). For example, a subject may experience an improvement in DLQI score of at least 2 points, at least 3 points, at least 4 points, at least 5 points, at least 6 points, at least 7 points, at least 8 points, at least 9 points, at least 10 points, at least 15 points, at least 20 points, at least 25 points, or at least 30 points after topical administration of an anhydrorapamycin gel composition as disclosed herein once daily.

[0043] In any embodiment, improvement in symptoms of microcystic LM is reported by the subject himself, for example, through the Patient Global Impression of Severity (PGI-S). The PGI-S is a global index used to assess a patient's perception of the severity of a particular condition, ranking the severity on a scale of 0 (not at all) to 4 (very severe). For example, after topically administering an anhydrous rapamycin gel composition as disclosed herein once daily, a subject may experience an improvement in the PGI-S score of at least 1 point, at least 2 points, at least 3 points, or at least 4 points. The PGI-S can be used to assess the severity of certain symptoms, such as lesion bleeding (PGI-SB) and / or leakage (PGI-SL). Thus, in any embodiment, after topically administering an anhydrous rapamycin gel composition as disclosed herein once daily, a subject may experience an improvement in the PGI-SB score for lesion bleeding of at least 1 point, at least 2 points, at least 3 points, or at least 4 points. Similarly, a subject may experience an improvement in lesion leakage of at least 1 point, at least 2 points, at least 3 points, or 4 points on the PGI-SL score after once-daily topical administration of an anhydrous rapamycin gel composition as disclosed herein.

[0044] In any embodiment, improvement in microcystic LM symptoms is reported by the subject themselves, for example, through the Patient Global Impression of Change (PGI-C), which reflects the patient's thoughts on the effectiveness of treatment on a scale of -3 (much worse) to 3 (much improved). For example, following once-daily topical administration of an anhydrous rapamycin gel composition as disclosed herein, there may be an improvement in the PGI-C score of at least 1 point, at least 2 points, at least 3 points, at least 4 points, at least 5 points, or 6 points.

[0045] In any embodiment, after once daily topical administration of an anhydrous rapamycin gel composition as disclosed herein, a subject may experience an overall improvement in their ability to function, including an increase in the number of days they are able to carry out their daily activities with little disruption from bleeding or leaking lesions.

[0046] Topical Compositions Anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein comprise about 0.1% to about 6% rapamycin by weight, about 80% to about 99% by weight of one or more solvents, about 0.1% to about 5% by weight of a gelling agent, about 0.001% to about 1% by weight of an antioxidant, and optionally a buffering agent.

[0047] In any embodiment, the anhydrous rapamycin gel composition comprises about 0.1% to about 5% by weight, about 0.1% to about 4.5% by weight, about 0.1% to about 4% by weight, about 0.1% to about 3.5% by weight, about 0.1% to about 3% by weight, about 0.1% to about 2.5% by weight, about 0.1% to about 2% by weight, or about 0.1% to about 1.5% by weight. For example, the anhydrous rapamycin gel compositions disclosed herein include rapamycin in an amount of about 0.1% to about 1% by weight, about 1% to about 5% by weight, about 1.5% to about 5% by weight, about 2% to about 5% by weight, about 2.5% to about 5% by weight, about 3% to about 5% by weight, about 3.5% to about 5% by weight, about 4% to about 5% by weight, or about 4.5% to about 5% by weight. Preferably, the anhydrous rapamycin gel compositions disclosed herein contain about 3.9% by weight rapamycin.

[0048] Solvent System Anhydrous rapamycin gel compositions suitable for use in treating microcystic LM disclosed herein include one or more solvents in an amount of about 80% to about 99% by weight, about 80% to about 98% by weight, about 80% to about 97% by weight, about 80% to about 96% by weight, about 80% to about 95% by weight, about 80% to about 90% by weight, or about 80% to about 85% by weight. Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include about 95% by weight of one or more solvents. More preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include four solvents present in a total amount of about 94.9% by weight.

[0049] The one or more solvents suitable for use in the anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein are each independently selected from propylene glycol, benzyl alcohol, DMSO, diglycol, propylene glycol monocaprylate, diethylene glycol monoethyl ether, tetrahydrofurfuryl alcohol polyethylene glycol ether, butylene glycol, diethylene glycol, triethylene glycol, polyethylene glycol, diisopropyl adipate, isopropyl alcohol, glycerol, and combinations thereof. Preferably, the anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein comprises four solvents including isopropyl alcohol, polyethylene glycol 400, diisopropyl adipate, and glycerol.

[0050] In any embodiment, an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein includes isopropyl alcohol as one of one or more solvents in an amount of about 5% to about 55% by weight. In any embodiment, an anhydrous rapamycin gel composition includes isopropyl alcohol as one of one or more solvents in an amount of about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight. Preferably, an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein includes isopropyl alcohol in an amount of about 15% by weight.

[0051] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include polyethylene glycol as one of one or more solvents in an amount of about 10% to about 60% by weight, about 10% to about 50% by weight, about 10% to about 45% by weight, about 15% to about 60% by weight, about 15% to about 55% by weight, about 20% to about 60% by weight, about 20% to about 55% by weight, about 25% to about 55% by weight, about 30% to about 55% by weight, or about 40% to about 60% by weight. Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include polyethylene glycol 400 in an amount of about 54.9% by weight.

[0052] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include diisopropyl adipate in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight as one of the one or more solvents. Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include diisopropyl adipate in an amount of about 15% by weight.

[0053] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include about 5% to about 55%, about 5% to about 50%, about 5% to about 45%, about 5% to about 40%, about 5% to about 35%, about 5% to about 30%, about 5% to about 25%, about 5% to about 20%, about 5% to about 15%, or about 5% to about 10% glycerol by weight as one of the one or more solvents. Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include about 10% glycerol by weight.

[0054] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include propylene glycol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0055] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include benzyl alcohol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0056] Anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include DMSO as one of the one or more solvents in an amount of about 5% to about 55%, about 5% to about 50%, about 5% to about 45%, about 5% to about 40%, about 5% to about 35%, about 5% to about 30%, about 5% to about 25%, about 5% to about 20%, about 5% to about 15%, or about 5% to about 10% by weight. However, in any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein are substantially free of DMSO or are free of DMSO.

[0057] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include diglycol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0058] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include propylene glycol monocaprylate in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight as one of the one or more solvents.

[0059] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include diethylene glycol monoethyl ether as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0060] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include tetrahydrofurfuryl alcohol polyethylene glycol ether in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight as one of the one or more solvents.

[0061] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include butylene glycol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0062] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include diethylene glycol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0063] In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include triethylene glycol as one of the one or more solvents in an amount of about 5% to about 55% by weight, about 5% to about 50% by weight, about 5% to about 45% by weight, about 5% to about 40% by weight, about 5% to about 35% by weight, about 5% to about 30% by weight, about 5% to about 25% by weight, about 5% to about 20% by weight, about 5% to about 15% by weight, or about 5% to about 10% by weight.

[0064] Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include one or more solvents selected from polyethylene glycol, isopropyl alcohol, diisopropyl adipate, glycerol, and combinations thereof. Preferably, when polyethylene glycol is included, it is present in an amount of about 40% to about 60% by weight. Preferably, when isopropyl alcohol is included, it is present in an amount of about 10% to about 20% by weight. Preferably, when diisopropyl adipate is included, it is present in an amount of about 10% to about 20% by weight. Preferably, when glycerol is included, it is present in an amount of about 5% to about 20% by weight.

[0065] Gelling Agent In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein comprise from about 0.1% to about 5%, from about 0.1% to about 4.5%, from about 0.1% to about 4%, from about 0.1% to about 3.5%, from about 0.1% to about 3%, from about 0.1% to about 2.5%, from about 0.1% to about 2%, or from about 0.1% to about 1.5% by weight of a gelling agent. Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein comprise from about 0.1% to about 1% by weight of a gelling agent.

[0066] Examples of suitable gelling agents include, but are not limited to, hydroxypropylcellulose, carbomer 981, carbomer 934P, glyceryl tris-12-hydroxystearate, hydroxystearin, propylene carbonate, polyvinylpyrrolidone, and combinations thereof. In any embodiment, anhydrorapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein include gelling agents such as poloxamers and carbomers. Non-limiting examples of poloxamers are poloxamer P-188, poloxamer P-138, poloxamer P-237, poloxamer P-288, poloxamer P-124, poloxamer P-338, and poloxamer P-407. Other block copolymers such as poly(ethylene glycol / D,L-lactide-co-glyceride) poly(quadrature-caprolactam), and hydroxypropyl cellulose (KLUCEL™), glyceryl tris-12-hydroxystearate, hydroxystearin, propylene carbonate, polyvinylpyrrolidone can also be used as gelling agents. Non-limiting examples of carbomers used are carbomer 981, carbomer 934, carbomer 934P, carbomer 940, carbomer 941, carbomer 1342, polycarbophil, and calcium polycarbophil. In a preferred embodiment, the gelling agent is selected from hydroxypropyl cellulose, carbomer 981, carbomer 934P, glyceryl tris-12-hydroxystearate, hydroxystearin, propylene carbonate, polyvinylpyrrolidone, and combinations thereof. Preferably, anhydrorapamycin gel compositions suitable for use in treating microcystic LM disclosed herein contain from about 0.1% to about 1% by weight hydroxypropylcellulose.

[0067] Antioxidants In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein comprise an antioxidant in an amount of about 0.001% to about 1% by weight, about 0.001% to about 0.5% by weight, about 0.001% to about 0.1% by weight, about 0.001% to about 0.05% by weight, or about 0.001% to about 0.01% by weight. In any embodiment, an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein comprises an antioxidant such as ascorbic acid, vitamin E and its derivatives, α-tocopherol, Ψ-tocopherol, Δ-tocopherol, ascorbyl palmitate, propyl gallate (PG), octyl gallate, dodecyl gallate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), D-α-tocopheryl polyethylene glycol 1000 succinate, or a combination thereof. Preferably, an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein comprises a mixture of antioxidants including propyl gallate (PG), ascorbyl palmitate, and α-tocopherol. Preferably, the total amount of antioxidant in an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein is about 0.05% to about 0.1% by weight. Preferably, anhydrous rapamycin gel compositions disclosed herein suitable for use in treating microcystic LM include propyl gallate (PG) in an amount of about 0.01% to about 0.1% by weight. Preferably, anhydrous rapamycin gel compositions disclosed herein suitable for use in treating microcystic LM include ascorbyl palmitate in an amount of about 0.01% to about 0.05% by weight. Preferably, anhydrous rapamycin gel compositions disclosed herein suitable for use in treating microcystic LM include one or more of α-tocopherol, ascorbyl palmitate, and propyl gallate in an amount of about 0.01% to about 0.1% by weight.

[0068] formulation In one example, an anhydrous rapamycin gel composition disclosed herein suitable for use in treating microcystic LM includes about 2% to about 6% rapamycin by weight, about 5% to about 30% isopropyl alcohol by weight, about 40% to about 60% polyethylene glycol 400 by weight, about 5% to about 30% diisopropyl adipate by weight, about 5% to about 0.5% polyethylene glycol 400 by weight, about 5% to about 30% diisopropyl adipate by weight, about 5% to about 30% glycerol by weight, about 0.5% to about 1.5% hydroxypropylcellulose by weight, one or more antioxidants in a total amount of 0.05% to about 0.1% by weight, and a buffering agent. For example, the buffering agent is citric acid present in an amount of less than about 0.1% by weight.

[0069] In one example, an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein comprises about 3.9% by weight rapamycin, about 15% by weight isopropyl alcohol, about 54.9% by weight polyethylene glycol 400, about 15% by weight diisopropyl adipate, about 10% by weight glycerol, about 1% by weight hydroxypropyl cellulose, about 0.05% by weight propyl gallate, about 0.02% by weight ascorbyl palmitate, about 0.002% by weight α-tocopherol, and a buffering agent, for example citric acid present in an amount of less than about 0.1% by weight.

[0070] Preferably, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein are water-free. In any embodiment, anhydrous rapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein contain less than 1% water by weight, e.g., less than 0.5% water by weight, less than 0.1% water by weight, or substantially no detectable water.

[0071] Preferably, anhydrorapamycin gel compositions suitable for use in treating microcystic LM, as disclosed herein, do not contain a penetration enhancer.

[0072] The method of dispensing an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein is not particularly limited. For example, a hand pump is used to dispense an anhydrous rapamycin composition. For example, the hand pump is configured to dispense a required dose of rapamycin within the acceptable ranges specified by the corresponding label approved by a government regulatory agency. The hand pump delivers 0.5-10 mL of the composition per pump actuation, for example, 1, 2, 3, 4, or 5 mL of the composition per pump actuation. In any embodiment, the anhydrous rapamycin gel composition is packaged with a pharma- ceutically acceptable hand pump.

[0073] In another example, a liquid drug dispenser is used to dispense an anhydrous rapamycin gel composition suitable for use in treating microcystic LM as disclosed herein. Liquid drug dispenser systems generally have two dispensing methods: using a collapsible bag-type design or a follower piston-type design. In a collapsible bag-type design, a collapsible bag is attached to a dispensing pump and gradually collapses as the contents are dispensed. In a piston-type design, a rigid container, usually cylindrical or oval, is fitted with a follower piston that gradually reduces the volume of the container as the product is drawn by the dispensing pump. In another example, an anhydrous rapamycin gel composition is dispensed using an airless pouch, pump-activated, container system.

[0074] In some embodiments, administration of anhydrorapamycin gel compositions described herein provides a C of about 120-990 micromolar, about 120-900 micromolar, about 600-900 micromolar in the epidermis. max In some embodiments, administration of anhydrorapamycin gel compositions described herein achieves a C of about 50-200 micromolar in the dermis. max Achieve this.

[0075] Anhydrorapamycin gel compositions suitable for use in treating microcystic LM as disclosed herein are generally thick liquid or gel-like, but can reach a paste-like viscosity. Generally, the viscosity is a minimum of about 5,000 cP, 10,000 cP, or 15,000 cP, preferably about 20,000 cP, to a maximum of about 12,000,000 cP, 2,000,000 cP, or even about 600,000 cP.

[0076] Advantageously, rapamycin in anhydrous rapamycin gel compositions as disclosed herein is stable for extended periods of time, for example, rapamycin is stable in anhydrous rapamycin gel compositions as disclosed herein at temperatures of about 4° C. to about 50° C., 4° C. to about 45° C., 4° C. to about 40° C., 4° C. to about 35° C., or 4° C. to about 30° C. for 12 to 36 months.

[0077] Definitions and Terminology: The following definitions and explanations apply to all embodiments and aspects of the invention described herein, unless otherwise stated.

[0078] As used herein, an "effective amount" or "therapeutically effective amount" of rapamycin refers to an amount of the inhibitor sufficient to perform the intended task and achieve the intended result. For example, a therapeutically effective amount of rapamycin is an amount sufficient to treat a particular target indication, such as microcystic LM, or other conditions for which mTOR inhibitors are used. It is understood that various biological factors may affect the ability of a particular agent to perform its intended task. Thus, an "effective amount" or "therapeutically effective amount" may depend on such biological factors. Furthermore, the achievement of a therapeutic effect is measured by a physician or other qualified medical practitioner using assessments known in the art, although it is recognized that individual differences and responses to treatment may make the achievement of a therapeutic effect a somewhat subjective determination. The determination of an effective amount is within the ordinary skill of those in the art of pharmacy and medicine. The terms "subject," "individual," or "patient" are used interchangeably and are intended to include human and non-human animals as used herein. Non-human animals include all vertebrates, e.g., mammals and non-mammals, such as non-human primates, sheep, dogs, rats, cats, cows, horses, chickens, amphibians, and reptiles. Examples of mammals include non-human primates, sheep, dogs, cats, cows, horses, and the like. In some examples, the subject is a human or human species. The method is suitable for treating a human with a viral infection or disease. The subject may be symptomatic or asymptomatic with respect to the viral infection.

[0079] The formulations described herein contain the amount of the ingredient or ingredients reported as weight percent (wt. %). Unless otherwise noted, wt. % refers to weight percent, or the weight of the particular ingredient listed divided by the weight of the entire formulation, and then multiplied by 100 to calculate the percentage. For all formulations herein, a formulation containing all ingredients is considered to be 100%.

[0080] As used herein, the term "about" is used to provide flexibility to the endpoints of a numerical range by providing that a given value may be "a little above" or "a little below" the endpoint. As used herein, the term "about" immediately preceding a numerical value means a range of plus or minus 10% of that numerical value, unless the context of this disclosure indicates otherwise or is inconsistent with such an interpretation. For example, "about 50" means 45 to 55, and "about 25,000" means 22,500 to 27,500.

[0081] As used in this disclosure, the singular forms "a", "an", and "the" include plural references unless the context clearly dictates otherwise. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. Nothing in this disclosure is to be construed as an admission that the embodiments described in this disclosure are not entitled to antedate such disclosure by prior invention. As used herein, the term "comprising" means "including, but not limited to".

[0082] "Comprising" is used herein in the sense of "including, but not limited to." Although various compositions, methods, and apparatuses are described in terms of "comprising" various components or steps, in any embodiment, the composition or method can also "consist essentially of" or "consist of" the described components or steps, but such embodiments are not explicitly recited or included for the sake of brevity, clarity, and efficiency. In any case, the term "consisting of" should be interpreted to define and include an essentially closed group of members, as well as a completely closed group of members. Other terms used herein to indicate "including, but not limited to" are "including," "having," "have," "contain," and the like. Similarly, the term "having" should be interpreted as "having at least," and the term "includes" should be interpreted as "includes, but is not limited to."

[0083] As used herein, the term "substantially" refers to the complete or nearly complete extent or degree of an action, property, quality, state, structure, item, or result. For example, an object that is "substantially" enclosed means that the object is completely enclosed or nearly completely enclosed. The exact allowable deviation from absolute completeness may depend on the particular context in some cases. Generally speaking, however, it is a state close to completeness that would result in the same overall result as would be obtained with absolute completeness. The use of "substantially" is equally applicable when used in the negative sense to mean the complete or near absence of an action, property, quality, state, structure, item, or result. For example, the term "substantially free of," referring to the presence or absence of a particular composition or ingredient or component in a given formulation, means the complete or nearly complete absence of that component from the formulation, such that the component, if present, forms only a minor component or impurity of the formulation. When the term "substantially free" is used apart from a solvent or solvate of rapamycin, it refers to the amount of components present that should not solubilize an amount of rapamycin that would adversely affect the therapeutic efficacy of the formulation.

[0084] Those skilled in the art will further understand that if a particular number of introduced claim citations is intended, such intent will be explicitly stated in the claim, and that in the absence of such a statement, no such intent exists. For example, as an aid to understanding, the following appended claims may use the introductory phrases "at least one" and "one or more" to introduce the claim recitation. However, the use of such phrases should not be interpreted as meaning that the introduction of a claim repetition with the indefinite article "a" or "an" limits a particular claim that includes such introduced claim repetition to an embodiment that includes only one such repetition, even if the same claim includes the introductory phrases "one or more" or "at least one" and an indefinite article such as "a" or "an" (e.g., "a" and / or "an" should be interpreted to mean "at least one" or "one or more"). The same applies to the use of definite articles used at the beginning of a claim. Moreover, even if a particular number of repetitions of an introduced claim is explicitly recited, one of ordinary skill in the art will recognize that such recitation should be interpreted to mean at least the recited number (e.g., the bare recitation of "two recitations" without other qualifiers means at least two recitations, or two or more recitations). Furthermore, when a convention similar to "at least one of A, B, and C" is used, such a configuration is generally intended in the sense that one of ordinary skill in the art would understand the convention (e.g., "a system having at least one of A, B, and C" includes, but is not limited to, systems having A alone, B alone, C alone, A and B, A and C, B and C, and / or A, B, and C).Where a convention similar to "at least one of A, B, and C" is used, such configuration is intended in the sense that one of skill in the art would understand the convention (e.g., "a system having at least one of A, B, and C" includes, but is not limited to, systems having A alone, B alone, C alone, A and B, A and C, B and C, and / or A, B, and C). One of skill in the art will further appreciate that virtually any conjunctive word and / or phrase presenting two or more alternative terms, whether in the specification, claims, or drawings, should be understood to contemplate the possibility of including one of the terms, either of the terms, or both terms. For example, the phrase "A or B" is understood to include the possibilities of "A" or "B," or "A and B."

[0085] As will be appreciated by those of skill in the art, all ranges disclosed herein encompass all possible subranges and combinations of subranges for any purpose, including in terms of providing a written description. Any recited range can be readily recognized as fully descriptive and allowing for the same range to be broken down into at least equal halves, thirds, quarters, fifths, tenths, etc. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third, upper third, etc. As will also be appreciated by those of skill in the art, all phrases such as "up to," "at least," etc. refer to ranges that are inclusive of the recited numbers and that can then be broken down into subranges as described above. Finally, as will be appreciated by those of skill in the art, ranges include individual groups. Thus, for example, a group having 1-3 cells refers to a group having 1, 2, or 3 cells. Similarly, a group having 1-5 cells refers to a group having 1, 2, 3, 4, 5 cells, etc.

[0086] The disclosure is not limited to the specific systems, devices, and methods described, as these may vary. The terms used herein are only for describing a particular version or embodiment, and are not intended to limit the scope. The above-disclosed features and other features and functions, or variations of their alternatives, may be combined into many other different systems or applications. Various alternatives, modifications, variations, or improvements not currently foreseen or anticipated by those skilled in the art may be subsequently made, each of which is also intended to be encompassed by the disclosed embodiments.

[0087] The following examples are provided to further illustrate embodiments of the present invention, but are not intended to limit the scope of the invention. They are typical of those that may be used, but other procedures, methodologies, or techniques known to those skilled in the art may alternatively be used. Example 1

[0088] Example 1: A Multicenter, Phase 2, Open-Label Study Evaluating the Safety and Efficacy of Rapamycin 3.9% Topical Gel Without wishing to be bound by theory, the specific pathophysiology of LM, including microcystic LM, is not well understood. However, recent literature suggests that ~90% of LM is caused by somatic activating mutations in phosphatidylinositol-3-kinase (PI3KCA), specifically in the segment encoding the p110a catalytic subunit. These mutations cause aberrant activation of the PI3KCA / AKT / mTOR signaling pathway, resulting in lymphatic hyperplasia during lymphangiogenesis. Mechanistically, hyperactivation of the PI3K pathway leads to endothelial cell proliferation and migration, mural cell defects, and abnormal lymphatic network formation. This hyperplasia ultimately leads to the anatomical malformations of lymphatic ducts seen in the disease, resulting in the disease being present at birth.

[0089] These overgrown lymphatic vessels associated with microcystic LM connect to the epidermis in the form of vesicles, papules, or plaques that leak to the surface (lymphorrhea). The healed skin often becomes hyperkeratotic. These lesions may bleed, but this is usually the result of trauma to the hyperkeratotic area, producing bright red blood, differentiating them from lymphorrhea. Because microcystic LM is caused by a genetic mutation, over time the lesions tend to grow and become more papular and keratinized as they leak again and heal.

[0090] Sirolimus, an mTOR inhibitor, is a macrocyclic lactone (macrolide) produced by the bacterium Streptomyces hygroscopicus. As previously mentioned, somatic activating mutations in PI3KCA and associated signaling of downstream pathways are believed to underlie the pathogenesis of all LM, resulting in endothelial cell proliferation and the formation of abnormal lymphatic vessels. Sirolimus inhibits mTOR, a downstream element of this pathway. In doing so, sirolimus is believed to suppress the overactivation of PI3KCA / AKT / mTOR, inhibiting endothelial cell proliferation and the subsequent formation of malformed lymphatic vessels. In addition, through other mechanisms, sirolimus is believed to reduce lymphatic formation in affected tissues, helping to minimize the clinical symptoms associated with LM.

[0091] Despite the severe and potentially fatal outcomes of microcystic LM, there are no FDA-approved drugs for the disease. Indeed, currently available treatments (surgery, sclerotherapy, laser, cryotherapy) are invasive, may induce further scarring / inflammation, are not completely effective, and result in a high recurrence rate.

[0092] Clinical studies have evaluated the safety and efficacy of oral sirolimus in patients with LM, and case studies of unapproved compounded topical sirolimus therapy (0.1–1%) in patients with microcystic LM have also been reported. Systematic reviews of the efficacy and safety of sirolimus for the treatment of LM lesions have shown that sirolimus significantly improves prognosis, with one review reporting a pooled clinical efficacy (partial response, usually defined as improvement in one of three clinical categories, or complete response, usually defined as complete disappearance of lesions) of 94.9% in patients with LM, and another reporting an efficacy of 84.5%. Reviews of published studies in patients with LM showed that >90% of patients studied were <18 years of age. Thus, the current literature as a whole provides information on the efficacy of sirolimus therapy for LM in pediatric and adult patients.

[0093] However, oral sirolimus is associated with a severe adverse event profile, requiring frequent patient monitoring, especially in pediatric and adolescent patients, limiting its use.Sirolimus side effects are explained by the cellular pathways affected and the product label for its two approved indications: organ rejection prevention in renal transplant recipients (>13 years old) and in patients with lymphangioleiomyomatosis.

[0094] In clinical trials for the prevention of organ rejection in renal transplant recipients, the most common (≧30%) adverse reactions observed with RAPAMUNE® included peripheral edema, hypertriglyceridemia, hypertension, hypercholesterolemia, increased creatinine, constipation, abdominal pain, diarrhea, headache, fever, urinary tract infection, anemia, nausea, arthralgia, pain, and thrombocytopenia. Similarly, in clinical trials for lymphangioleiomyomatosis, the most common (≧20%) adverse reactions observed with RAPAMUNE® were stomatitis, diarrhea, abdominal pain, nausea, nasopharyngitis, acne, chest pain, peripheral edema, upper respiratory tract infection, headache, dizziness, myalgia, and hypercholesterolemia. Other common adverse reactions reported in both groups included acne, stomatitis, nasopharyngitis, upper respiratory tract infection, and dizziness. A more detailed description of the adverse event profile of RAPAMUNE® is provided in the product insert.

[0095] Because there is no FDA-approved treatment for LM and clinical studies have demonstrated the efficacy of oral sirolimus, sirolimus is often used in clinical practice and recommended as first-line therapy for complex LM. However, there remains a significant unmet need for targeted therapies that limit systemic absorption and reduce adverse events compared to oral sirolimus. Participants in this study were selected with the goal of delivering sirolimus to cutaneous lymphatic malformations while limiting systemic exposure.

[0096] Eligibility criteria for the study at Visit 1 were as follows: (1) Age at least 13 years at the time of the screening visit. (2) If less than 18 years of age, participants and legal guardians must provide written informed consent / assent prior to study procedures. (3) Participants must have clinically confirmed microcystic lymphatic malformations (LMs). (4) Microcystic LMs (lesions) eligible for treatment must be >25 cm2 in defined total area. 2 Larger, about 200cm 2(5) The subject consents to blood collection for safety and PK studies. (6) The investigator must confirm the presence of vesicles, papules, or plaques consistent with microcystic LM. (7) The participant reports 5 or more days of bleeding or leakage in the past 14 days. (8) The participant is willing to refrain from applying other topical medications (prescription or over-the-counter) for the duration of the study. Use of moisturizers and emollients outside of the lesions is permitted. (9) The participant is willing to forgo medical interventional treatment of microcystic LM other than study IP (i.e., interventional treatment such as drug therapy or sclerotherapy) unless the investigator believes that a delay in treatment may be harmful to the subject's health. (10) At least 4 weeks have passed since the participant underwent major surgery. (11) At least 14 days have passed since the participant completed treatment with growth factors (GFs) that support platelet, red blood cell, or white blood cell count or function. (12) Participants must not have received any investigational or biological drug within 4 weeks or 5 half-lives, whichever is longer, prior to initiating treatment with anhydrous rapamycin gel and during treatment with anhydrous rapamycin gel (except for drugs, biological products, or vaccines approved for COVID-19 under an Emergency Use Authorization). (13) At least 6 months have passed since field radiation (XRT) administered to the microcystic LM being studied. During the screening period: (14) The investigator has determined that the participant's overall health, including adequate organ function, LDL and cholesterol levels, is adequate to allow participation in the study. (15) eGFR is 90 mL / min / 1.73 m 2 or CrCl >90 mL / min and the participant has adequate renal function.

[0097] Participants will be excluded from the study if: At Visit 1: (1) they have used sirolimus within the past 6 weeks; (2) they have participated in a clinical trial evaluating an investigational drug for the treatment of vascular abnormalities, including microcystic LM, within the past 3 months; (3) they are using topical, oral, or interventional therapies that may interfere with the evaluation of study IP. These include the use of: (a) myelosuppressive chemotherapy within 4 weeks; (b) photodynamic therapy (PDT) or other lesion-directed laser surgery within 3 months; (c) chronic treatment with systemic steroids or other immunosuppressants; or (d) a medically significant infection requiring antibiotic treatment within the past 2 months. (4) they require medications that inhibit / induce CYP3A4 activity and OTC supplements for control of an intercurrent medical condition; (5) the lesions being treated by the participant are primarily located within moist mucosa or the orbital rim; (6) they have known hypersensitivity to any component of the study drug formulation. (7) The participant has a known history of HIV seropositivity or a known immunodeficiency. (8) The participant has complex vascular abnormalities with severe systemic symptoms requiring systemic therapy. (9) The participant has a serious and / or uncontrolled medical illness that may impair compliance with the safety monitoring requirements of sirolimus. (10) The participant has been treated for invasive cancer within the past 5 years, unless the investigator concludes that a history of cancer is not confounding to safety. (11) The participant is a woman who is pregnant, breastfeeding, or planning to become pregnant during the study period, including the follow-up period. (12) A participant of childbearing potential who is unwilling or unable to adhere to contraceptive measures. (13) The participant has a condition or situation that, in the investigator's opinion, may place the subject at significant risk, may confound the study results, or may significantly interfere with the subject's participation in the study. (14) The participant is determined by the investigator to be unwilling or unable to comply with all tests and procedures, adherence to the investigational drug regimen, and other activities required by the study protocol. (15) The participant has received either COVID-19 or a COVID-19 vaccine within the past 6 weeks.

[0098] Inclusion criteria for the open-label treatment period: 1) Completion of the screening period, 2) Completion of the baseline period: a) the participant had leaked or bleed on an average of ≥5 days in the past 14 days prior to Day 1, or b) had leaked or bleed on ≥9 days out of the 14 days, 3) maintained >70% compliance with completing the PDD during the baseline period. Exclusion criteria for the open-label treatment period: 1) Participants who, in the investigator's judgment, were unwilling or unable to maintain compliance with all tests and procedures, including adherence to the study drug dosing regimen and other protocol-required activities.

[0099] The anhydrous rapamycin gel is formulated as set forth in Table 1 below. [Table 1]

[0100] All subjects completed 12 weeks of treatment and received topical anhydrorapamycin gel in the evening at least 1 hour before bedtime. The gel was applied once daily to the affected area only, over an area of ​​200 cm. 2 The specific method of use is described in the participant's instruction manual. 2 If less than this amount, the gel should be applied to cover the area and any remaining gel should be discarded.

[0101] Safety will be assessed by adverse event (AE) assessments. During the study, subjects will be evaluated for the occurrence of new and ongoing AEs. Description of AEs will include date of onset, date of resolution (if resolved), maximum severity, seriousness, actions taken with study drug, corrective actions, outcome, and the investigator's assessment of causality. At any visit, AEs will be followed until resolved (return to normal or baseline state) or clinically stable as determined by the investigator.

[0102] Efficacy evaluations included: Clinician Global Impression of Severity (CGI-S) Clinician Global Impression of Change (CGI-C) ●Patient Global Severity Impression (PGI-S) ● Patient Global Impression of Change (PGI-C) Patient Global Impression of Severity for Leak (PGI-SL) Patient Global Impression of Severity of Bleeding (PGI-SB) Number of days leakage from the lesion was reported Number of days bleeding from the lesion was reported Number of days when leakage or bleeding from the lesion was reported Changes in the impact of lesions on function Severity of pain, crusting, and redness at the lesion based on the LM Symptom Severity Scale Skin Disease Quality of Life Assessment (DQLI) (participants aged ≥16 years) or Pediatric Skin Disease Quality of Life Assessment (participants aged ≤15 years) Thickness / height or size of the lesion Overall participant satisfaction

[0103] Analysis population: Safety / Intention-to-Treat (ITT) population: All subjects who received at least one dose of study intervention. Protocol population: All subjects who completed treatment without any major protocol violations affecting efficacy endpoints.

[0104] Efficacy endpoints were as follows: Change in CGI-S from baseline to Day 84. CGI-S is measured separately in the following domains: Height of the lesion (including vesicles, papules, and macules) Appearance of lymphorrhea ○ The occurrence of bleeding ○Appearance of crusts / hyperkeratinization ○Appearance of erythema Overall severity CGI-C from baseline to day 84 Change in leakage frequency from baseline to day 84 Change in bleeding frequency from baseline to day 84 Change in PGI-SL for leakage from baseline to day 84 Change in PGI-SB for bleeding from baseline to day 84 Change in frequency of leakage or bleeding from baseline to day 84 Change in participant-reported symptoms from baseline to Day 84. The following symptoms will be measured: ○Pain ○Scabbing Change in global PGI-S from baseline to day 84 ●PGI-C ●PGI-CL ●PGI-CB Change in functional impact of lesions from baseline to day 84 ●Changes in skin disease quality of life assessment (participants aged ≥16 years) or pediatric skin disease quality of life assessment (participants aged ≤15 years) using a 10-item questionnaire. Change in height or size of the lesion as measured photographically ● Overall satisfaction of participants according to TSQM Example 2

[0105] Example 2: Evaluation Clinician Global Impression of Severity (CGI-S) The CGI-S is a global summary measure of disease activity as determined by the clinician. Clinicians complete the CGI-S at each visit on a 5-point Likert scale. Clinicians consider the data available at the time of the evaluation.

[0106] Below are the questions and scales presented to clinicians in the CGI-S. Questions in each domain must be answered independently: TIFF2024533480000004.tif134141

[0107] Clinician Global Impression of Change (CGI-C) The Clinician Global Impression of Change (CGI-C), a 7-point Likert scale, will be used. TIFF2024533480000005.tif27141

[0108] The CGI-C is completed on paper by the investigator at various time points. The 7-point Likert scale remains the same, but the questions asked at each time point are different and refer to the same baseline period.

[0109] Patient Global Impression of Change (PGI-C) The Patient Global Impression of Change (PGI-C), a 7-point Likert scale, will be used. TIFF2024533480000006.tif27141

[0110] The PGI-C is completed by the investigator on paper at various time points. The 7-point Likert scale remains the same, but the questions asked at each time point are different and refer to the same baseline period.

[0111] Patient Global Severity Impression (PGI-S) Participants' overall impression of the severity of their lesions (Patient Global Severity Impression) was self-reported and captured on a 5-point Likert scale at each visit. Below are the questions and scale presented to participants: TIFF2024533480000007.tif39141

[0112] In addition to participants' global impression of severity, participants also self-report the Patient Global Impression of Severity for Leakage (PGI-SL) and Patient Global Impression of Severity for Bleeding (PGI-SB) weekly in the PDD. TIFF2024533480000008.tif77141

[0113] Microcystic LM Symptom Severity Scale In addition to the overall severity impression, participants are asked to rate the severity of pain (daily) and the severity of crusting and redness symptoms (weekly) on the PDD using the 11-point LM Symptom Severity Scale: TIFF2024533480000009.tif52141

[0114] Assessment of lesion leakage Participants will be asked daily in the PDD whether they have experienced leakage from any LM lesions identified for the study. TIFF2024533480000010.tif22141

[0115] Assessment of lesion bleeding Participants will be asked daily in the PDD whether they have experienced bleeding from LM lesions identified for the study. TIFF2024533480000011.tif23141

[0116] Assessment of lesions for function Participants were asked daily in the PDD whether bleeding or leakage from their LM lesions had affected their daily life. TIFF2024533480000012.tif79141

[0117] Change in size of the lesion The size and height of the lesion will be measured using 3D digital photography according to the SoA and photography manual.

[0118] Skin Disease Quality of Life and Pediatric Skin Disease Quality of Life (DQLI) TIFF2024533480000013.tif161141TIFF2024533480000014.tif189141TIFF2024533480000015.tif189141

[0119] Treatment Satisfaction Questionnaire (TSQM) The Treatment Satisfaction with Medication Questionnaire (TSQM-9) is a measure of treatment satisfaction that can be compared across different medications and health conditions. The purpose of the TSQM-9 in this study is to assess participants' satisfaction with the study medication. The questionnaire will be completed by participants on day 84. TIFF2024533480000016.tif193141TIFF2024533480000017.tif184141TIFF2024533480000018.tif53141 Example 3

[0120] Example 3: Results of Subject 1 Subject 1 had moderate microcystic LM. Figure 4 shows the baseline assessment of microcystic LM and assessments at days 28, 56, and 84 after treatment. Clinician assessments at clinical visits (Table 2), patient assessments at clinical visits (Table 3), and daily or weekly patient assessments (Table 4) are shown below. TIFF2024533480000019.tif54141TIFF2024533480000020.tif76141TIFF2024533480000021.tif64141 Example 4

[0121] Example 4: Results for Subject 2 Subject 2 had severe microcystic LM. Figure 5 shows the baseline microcystic LM assessments and assessments at days 28, 56, and 84 after treatment. Clinician assessments at clinical visits (Table 5), patient assessments at clinical visits (Table 6), and patient daily or weekly assessments (Table 7) are shown below. TIFF2024533480000022.tif55141TIFF2024533480000023.tif95141TIFF2024533480000024.tif58141 Example 5

[0122] Example 5: Results for Subject 3 Subject 3 had moderate microcystic LM. Figure 6 shows the baseline microcystic LM assessments and the assessments at days 28 and 56 after treatment. Clinician assessments at clinical visits (Table 8), patient assessments at clinical visits (Table 9), and patient assessments daily or weekly (Table 10) are shown below. TIFF2024533480000025.tif51141TIFF2024533480000026.tif88141TIFF2024533480000027.tif54141 Example 6

[0123] Example 6: Results of Subject 4 Subject 4 had moderate microcystic LM. Baseline assessments of microcystic LM and assessments at days 28, 56, and 84 after treatment were performed according to protocol. Clinician assessments at clinical visits (Table 11), patient assessments at clinical visits (Table 12), and patient daily or weekly assessments (Table 13) are shown below. TIFF2024533480000028.tif53141TIFF2024533480000029.tif91141TIFF2024533480000030.tif54141 Example 7

[0124] Example 7: Results of Subject 5 Subject 5 had moderate microcystic LM. Figure 7 shows the baseline microcystic LM assessments and assessments at days 28, 56, and 84 after treatment. Clinician assessments at clinical visits (Table 14), patient assessments at clinical visits (Table 15), and patient daily or weekly assessments (Table 16) are shown below. TIFF2024533480000031.tif66141TIFF2024533480000032.tif105141TIFF2024533480000033.tif59141 Example 8

[0125] Example 8: Results of Subject 6 Subject 6 had moderate microcystic LM. Figure 8 shows the baseline microcystic LM assessments and the assessments at days 28 and 56 after treatment. Clinician assessments at clinical visits (Table 17), patient assessments at clinical visits (Table 18), and patient assessments daily or weekly (Table 19) are shown below. TIFF2024533480000034.tif48141TIFF2024533480000035.tif73141TIFF2024533480000036.tif57141 Example 9

[0126] Example 9: Results of Subject 7 Subject 7 had moderate microcystic LM. Figure 9 shows the baseline microcystic LM assessment and the 28 day post-treatment assessment. Clinician assessments at clinical visits (Table 20), patient assessments at clinical visits (Table 21), and patient daily or weekly assessments (Table 22) are shown below. TIFF2024533480000037.tif49141TIFF2024533480000038.tif74141TIFF2024533480000039.tif54141 Example 10

[0127] Example 10: Results for Subject 8 Subject 8 had severe microcystic LM. Figure 10 shows the baseline microcystic LM assessment and the 28 day post-treatment assessment. Clinician assessments at clinical visits (Table 23), patient assessments at clinical visits (Table 24), and patient assessments daily or weekly (Table 25) are shown below. TIFF2024533480000040.tif50141TIFF2024533480000041.tif71141TIFF2024533480000042.tif53141 Example 11

[0128] Example 11: Results for Subject 9 Subject 9 had moderate microcystic LM. Figure 11 shows the baseline microcystic LM assessment and the 28 day post-treatment assessment. Clinician assessment at clinical visit (Table 26), patient assessment at clinical visit (Table 27), and patient daily or weekly assessment (Table 28) are shown below. TIFF2024533480000043.tif46141TIFF2024533480000044.tif74141TIFF2024533480000045.tif60141 Example 12

[0129] Example 12: Results for Subject 10 Subject 10 had severe microcystic LM. Figure 12 shows the baseline microcystic LM assessment and the 28 day post-treatment assessment. Clinician assessments at the clinical visit (Table 29) and patient assessments at the clinical visit (Table 30) are shown below. TIFF2024533480000046.tif51141TIFF2024533480000047.tif69141 Example 13

[0130] Example 10: Safety Treatment-related adverse events (TRAEs) are shown in Table 23. One subject reported mild TRAEs including itching, nodular tenderness, and tingling. Two subjects reported moderate TRAEs including application site pain, burning, itching, nausea, and redness. There were no clinically significant laboratory or vital sign abnormalities. TIFF2024533480000048.tif92141

[0131] Although the invention has been described with reference to the above examples, it will be understood that modifications and variations are encompassed within the spirit and scope of the invention. Accordingly, the invention is limited only by the scope of the following claims.

Claims

1. An anhydrous rapamycin gel composition comprising: for use in treating microcystic lymphatic malformations in a subject in need thereof, The composition is administered topically once daily to the subject's microcystic lymphatic malformation skin lesion in a therapeutically effective amount.

2. 10. The composition of claim 1, wherein the microcystic lymphatic malformation skin lesion is about 25 cm ２ Larger, composition.

3. 3. The composition of claim 1 or claim 2, wherein the symptoms associated with the microcystic lymphatic malformation skin lesions occur at least 1-2 days per week.

4. 10. The composition of claim 1, wherein treating a microcystic lymphatic malformation in a subject improves symptoms of the microcystic lymphatic malformation skin lesion selected from the group consisting of leakage (lymphorrhea), bleeding, redness, crusting, hyperkeratosis, raised patches, and combinations thereof.

5. 10. The composition of claim 1, wherein the anhydrous rapamycin gel composition comprises from about 0.1% to about 6% rapamycin, from about 80% to about 99% of one or more solvents, gelling agents, and antioxidants.

6. 6. The composition of claim 5, wherein the anhydrous rapamycin gel composition comprises from about 0.1% to about 6% rapamycin, from about 80% to about 99% of one or more solvents, from about 0.1% to about 5% of a gelling agent, and from about 0.001% to about 1% of an antioxidant.

7. 10. The composition of claim 1, wherein the anhydrous rapamycin gel composition is administered once daily for at least 12 weeks.

8. 7. The composition of claim 5 or 6, wherein the one or more solvents comprise diisopropyl adipate, glycerol, PEG, and isopropyl alcohol.

9. 10. The composition of claim 1, wherein the anhydrous rapamycin gel composition comprises: approximately 3.9% rapamycin; Approximately 15% isopropyl alcohol, about 54.9% polyethylene glycol 400; about 15% diisopropyl adipate; About 10% glycerol, about 0.75% hydroxypropyl cellulose; about 0.05% propyl gallate; approximately 0.02% ascorbyl palmitate; about 0.002% α-tocopherol, and Citric acid and A composition comprising:

10. 10. The composition of claim 1, wherein administering comprises applying the anhydrorapamycin gel composition as a thin layer to the skin of the subject.

11. 10. The composition of claim 1, wherein the subject exhibits improvement in scores on one or more of the assessments selected from the group consisting of Patient Global Impression of Change (PGI-C), Patient Global Impression of Severity (PGI-S), Patient Global Impression of Severity for Leakage (PGI-SL), Patient Global Impression of Severity for Bleeding (PGI-SB), Clinician Global Impression of Change (CGI-C), Clinician Global Impression of Severity (CGI-S), and combinations thereof.

12. 10. The composition of claim 1, wherein the subject shows improvement in a Dermatological Quality of Life Index (DLQI) score.

13. 10. The composition of claim 1, wherein the subject experiences a reduction in the number of days with reported lesion leakage.

14. 10. The composition of claim 1, wherein the subject experiences a reduction in the number of days with reported lesion bleeding.

15. 10. The composition of claim 1, wherein one or more of lesion size, lesion thickness, lesion height, or lesion number is reduced.

16. 10. The composition of claim 1, wherein the severity of lesion pain, lesion crust, or lesion redness based on the Microcystic Leukemia Symptom Severity (SS) Scale is reduced.

17. 10. The composition of claim 1, wherein no field radiation (XRT) is required to be administered to the microcystic lymphatic malformation skin lesion.

18. 10. The composition of claim 1, wherein topical administration of the anhydrorapamycin gel composition to the skin of the subject achieves a maximum epidermal concentration of rapamycin in the epidermis of the subject at about 120 to 990 micromolar rapamycin.

19. 20. The composition of claim 18, wherein topical administration of the anhydrorapamycin gel composition to the skin of the subject achieves a maximum dermal concentration of rapamycin in the dermis of the subject of about 50 to 200 micromolar rapamycin.

Images