Stable preservative-free mydriatic and Anti-inflammatory solutions for injection

Abstract

To provide stable, preservative- and antioxidant-free liquid formulations for injection of phenylephrine and ketorolac.SOLUTION: The present invention relates to stable, preservative- and antioxidant-free liquid formulations for injection of phenylephrine and ketorolac. The invention provides a preservative-free and antioxidant-free sterile liquid pharmaceutical formulation for injection of phenylephrine that is a mydriatic and ketorolac that is an anti-inflammatory agent. The above formulation may be suitably injected into an intraocular irrigation carrier, and used to irrigate ocular tissues during surgery. The above formulation avoids the potential toxicity that may be associated with preservatives and antioxidants but has adequate stability.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] I. Field of the Invention The present invention relates to a stable, preservative-free, antioxidant-free liquid pharmaceutical formulation of ketorolac and phenylephrine in an ophthalmic intraocular irrigation solution for injection. [Background technology]

[0002] II. Background of the Invention Ophthalmic surgery often requires the use of physiological irrigation solutions to protect and maintain the physiological integrity of intraocular tissues. Examples of ophthalmic surgical procedures that typically require irrigation solutions include cataract extraction and lens replacement, and refractive lens exchange procedures, corneal transplant procedures, and vitreoretinal surgery, as well as trabeculectomy procedures for glaucoma. Throughout intraocular surgery, the patient's pupils must be sufficiently dilated to allow a clear surgical field and to limit the trauma that may be associated with the procedure.

[0003] Pupil dilation (mydriasis) is typically achieved by dilating the eye preoperatively with topical administration of a mydriatic. Preoperatively applied mydriatics that may typically be administered include sympathomimetics (e.g., alpha-1 adrenergic receptor agonists), and anticholinergics (e.g., antimuscarinics). Anticholinergics may be selected when a longer period of action is desired because they provide both cycloplegia (paralysis of the ciliary muscle) and mydriasis. Tropicamide, for example, exhibits a half-life of about 4-6 hours. However, for many procedures, alpha-1 adrenergic agonists are preferred because they provide mydriasis but not cycloplegia. Alpha-1 adrenergic agonists are therefore shorter acting, causing mydriasis during the surgical procedure and allowing the pupil to return to its normal state shortly after completion of the procedure.

[0004] During surgery, as the tip of the surgical tool is inserted into the anterior chamber, the iris sphincter muscle tends to contract (miosis), reducing the window defined by the pupil. If the pupil diameter is not adequately maintained throughout the procedure, the risk of damaging intraocular structures increases, often lengthening the required surgical time. Clinically significant reductions in pupil diameter are associated with increased procedure-related complications, including posterior capsule tears, retained lens fragments, and vitreous leaks.

[0005] Many ophthalmic surgeons may incorporate epinephrine into the intraocular irrigation solution to help maintain pupil dilation. Toxic anterior segment syndrome (TASS) is an acute non-infectious inflammation of the anterior segment of the eye. TASS is a serious complication that may be associated with anterior segment surgery, most commonly cataract surgery. Various contaminants have been implicated as the cause of TASS. The use of epinephrine with preservatives in intraocular irrigation solutions is one of many factors that have been associated with the incidence of TASS after cataract surgery. See, for example, http: / / www.cdc.gov / mmwr / preview / mmwrhtml / mm5625a2.htm (accessed July 9, 2012). Furthermore, "preservative-free" epinephrine (i.e., epinephrine without antimicrobial agents) still contains sodium metabisulfite as an antioxidant that has also been implicated by ophthalmologists as being associated with potential toxicity to the corneal endothelium (Slack, et al., A bisulfite-free intraocular epinephrine solution, Am J Ophthalmol.;110(1):77-82 (1990)).

[0006] Phenylephrine is another alpha-1 adrenergic agonist. It is sometimes administered topically preoperatively to promote pupil dilation, but is not approved in the United States in a preservative-free, antioxidant-free form for single-use injection. An example of an approved phenylephrine HCl solution is 0.01% benzalkonium chloride (AK-DILATE® by Akorn).TM (available in 2 ml and 5 ml plastic dropper bottles; from Falcon Pharmaceuticals and Alcon Laboratories in multi-use 3 ml and 5 ml dropper bottles), and a "preservative-free" formulation that does not contain an antimicrobial preservative but still contains 2 mg of sodium metabisulfite as an antioxidant (Neo-Synephrine® available in a spray bottle from InterMed Medical Ltd.).

[0007] It is also desirable to reduce postoperative pain and irritation for the comfort of the patient. For this reason, patients may be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively or postoperatively. Although cataract surgery (for example) is not typically associated with high levels of postoperative pain, there is a need to minimize the number of minority of patients who experience more severe postoperative pain. This is important both because such patients experience discomfort and there may be concern that their procedure has not worked, and because patients may need to be re-examined as a precaution to ensure that there are no serious complications that result in pain.

[0008] Various methods of delivery of ocular drugs (e.g., NSAIDs) have been used in the past, but each of them has limitations. These limitations may include corneal and conjuctival toxicity, tissue damage, eyeball perforation, optic nerve trauma, central retinal artery and / or vein occlusion, direct retinal drug toxicity, and systemic side effects. For example, topical medications applied by drops are frequently prevented from reaching the targeted ocular site due to the natural protective surface of the eye. In many situations, only a fairly small percentage of medications applied to the ocular surface actually reach the desired therapeutic action site.

[0009] To achieve sufficient concentrations of drug delivered to the back of the eye, drugs (e.g., NSAIDs) are frequently administered systemically in very high doses. These levels must cross the blood-retinal barrier, which protects the back of the eye from selected drug molecules coming from the bloodstream. For surgical procedures, injectable drug solutions are sometimes injected directly into the back of the eye. Subconjuctival and peribulbar periocular injections are used when higher local concentrations are required and when drugs with poor permeation properties need to be delivered. Intracameral injections directly into the anterior chamber are used in cataract surgery.

[0010] Ketorolac is an NSAID that is commercially available in a preserved form for ophthalmic use. Allergan's Acular® is a ketorolac tromethamine solution (available in 3 ml and 6 ml dropper bottles) with benzalkonium chloride 0.01% as a preservative. Bedford Laboratories also supplies concentrated forms of ketorolac tromethamine (15 mg or 30 mg in 1 ml, or 60 mg or 300 mg in 10 ml) for intravenous or intramuscular injection. Allergan also supplies a preservative-free 0.45% ketorolac tromethamine ophthalmic solution, which contains sodium carboxymethylcellulose, sodium chloride, sodium citrate dihydrate, and 1,2-dihydro-1,3-tetrahydrofuran (1,2-dihydro-2,4-trimethylammonium chloride) in individual use vials under the trade name Acuvail®. The company supplies 1,000 mg of erythropoietin (formulated with erythropoietin dehydrate).

[0011] While intracameral injection provides a rapid method to achieve a certain concentration, it may be associated with corneal toxicity. However, this method suffers from the fact that these drugs are rapidly removed by the natural circulatory process of the eye. Thus, injectable solutions lose their therapeutic benefits quickly and often require frequent large-dose injections that may have a risk of toxicity. Sustained-release formulations (e.g., viscoelastic gels containing microcapsules) are injected into the eye for a longer duration of action. However, there may be some delay in achieving a local therapeutic concentration of the drug. Thus, there is a need for a controlled ophthalmic delivery method during ophthalmic procedures.

[0012] Solutions that have been used in ophthalmic surgical irrigation include normal saline, lactated Ringer's solution, and Hartmann's lactated Ringer's solution, which are not optimal due to potential adverse corneal and endothelial effects. Other aqueous solutions containing agents such as electrolytes, buffers for pH regulation, glutathione, and / or energy sources (e.g., dextrose) better protect ocular tissues but do not address other physiological processes associated with surgery. One commonly used solution for ophthalmic irrigation is a two-part buffered electrolyte and glutathione solution disclosed in U.S. Pat. No. 4,550,022 to Garabedian et al., the disclosure of which is expressly incorporated herein by reference. The two parts of this solution are mixed immediately prior to administration to ensure stability. These solutions are formulated with the goal of maintaining the health of ocular tissues during surgery.

[0013] Another example of a modified solution is disclosed in International PCT Application WO 94 / 08602 to inventors Gan et al., the disclosure of which is incorporated herein by reference. This application discloses the inclusion of a mydriatic drug (e.g., epinephrine) in the ocular irrigation solution. Yet another example is disclosed in International PCT Application WO 94 / 08602 to inventors Cagle et al., the disclosure of which is incorporated herein by reference. 95 / 16435, which discloses the inclusion of a nonsteroidal anti-inflammatory drug (NSAID) in an ophthalmic irrigating solution. [Prior art documents] [Patent documents]

[0014] [Patent Document 1] U.S. Pat. No. 4,550,022 [Patent Document 2] International Publication No. 94 / 08602 [Patent Document 3] International Publication No. 95 / 16435 [Non-patent literature]

[0015] [Non-Patent Document 1] Slack, et al., A bisulfite-free intraocular epinephrine solution, Am J Ophthalmol.;110(1):77-82 (1990) Summary of the Invention [Means for solving the problem]

[0016] III. Summary of the Invention The present invention provides a sterile, preservative-free and antioxidant-free liquid formulation of the mydriatic drug phenylephrine and the anti-inflammatory drug ketorolac for injection.The formulation can be appropriately injected into an intraocular irrigation carrier and used to irrigate ocular tissue during surgery.The formulation has sufficient stability while avoiding the potential toxicity that may be associated with preservatives and antioxidants.

[0017] In one embodiment of the present invention, when stored at a temperature of 5±3°C to 25±2°C, the The present invention provides a preservative-free, antioxidant-free, sterile, liquid pharmaceutical formulation comprising phenylephrine, ketorolac and a buffer system in an aqueous carrier, which is stable for at least 24 months. Preferably, the formulation is stable for at least 24 months when stored at a temperature between 5±3° C. and 25±2° C.

[0018] In one aspect of the invention, the buffer system is selected from a sodium phosphate buffer system and a sodium citrate buffer system. Preferably, the buffer system is a sodium citrate buffer system (e.g., about 20 mM sodium citrate buffer system). In another aspect of the invention, the formulation has a pH of 5.8 to 6.8.

[0019] In another aspect of the invention, the formulation is contained within a single-use container, such as a vial closed with a closure from which the injection can be withdrawn, and a pre-filled syringe.

[0020] Suitable formulations of the invention include 46-76 mM phenylephrine and 8.5-14 mM ketorolac, and in one example may include about 60.75 mM phenylephrine and about 11.25 mM ketorolac. Formulations of the invention may include phenylephrine and ketorolac in a molar ratio of 1:1 to 13:1 phenylephrine:ketorolac, and suitably include these agents in a molar ratio of 3:1 to 10:1 phenylephrine:ketorolac.

[0021] Another embodiment of the invention provides a preservative-free, antioxidant-free, sterile liquid pharmaceutical formulation comprising phenylephrine, ketorolac and a buffer system in an aqueous carrier, and an intraocular perfusion carrier into which the formulation is injected such that, after injection, the phenylephrine is present at a concentration of 30-720 μM and the ketorolac is present at a concentration of 44-134 μM. In another aspect of the invention, after injection into the intraocular perfusion carrier, the phenylephrine is present at a concentration of 240-720 μM and the ketorolac is present at a concentration of 10-270 μM.

[0022] Another embodiment of the invention provides a sterile liquid pharmaceutical formulation consisting essentially of phenylephrine, ketorolac and a buffer system in an aqueous carrier, wherein the formulation is stable for at least 6 months when stored at a temperature of 5±3° C. to 25±2° C. Preferably, the formulation is stable for a period of at least 24 months when stored at a temperature of 5±3° C. to 25±2° C.

[0023] In one aspect of the invention, the buffer system is selected from a sodium phosphate buffer system and a sodium citrate buffer system. Preferably, the buffer system is a sodium citrate buffer system (e.g., about 20 mM sodium citrate buffer system). In another aspect of the invention, the formulation has a pH of 5.8 to 6.8.

[0024] In another aspect of the invention, the formulation is contained within a single-use container, such as a vial closed with a stopper from which the injection can be withdrawn, and a pre-filled syringe.

[0025] Another aspect of the invention provides an injectable sterile pharmaceutical liquid dosage form comprising phenylephrine, ketorolac, a buffer system and an aqueous carrier packaged in a single-use container for injection.

[0026] In another aspect of the present invention, there is provided a sterile liquid pharmaceutical formulation comprising phenylephrine, ketorolac, a buffer system and an intraocular irrigation carrier, wherein the phenylephrine is present at a concentration of 30-720 μM and the ketorolac is present at a concentration of 10-270 μM, or preferably, the phenylephrine is present at a concentration of 90-720 μM and the ketorolac is present at a concentration of 44-134 μM. The formulation is also preservative-free and antioxidant-free. Yes, it could be.

[0027] Also disclosed is a method for preparing a preservative-free, antioxidant-free, sterile, liquid pharmaceutical formulation comprising phenylephrine, ketorolac and a buffer system in an aqueous carrier, which is stable for at least 6 months when stored at a temperature of 5±3° C. to 25±2° C. Preferably, the formulation is stable for a period of at least 24 months when stored at a temperature of 5±3° C. to 25±2° C.

[0028] Further disclosed is a method for preparing a sterile liquid pharmaceutical formulation comprising phenylephrine, ketorolac, a buffer system and an intraocular irrigation carrier, wherein the phenylephrine is present at a concentration of 30-720 μM and the ketorolac is present at a concentration of 10-270 μM, or preferably, the phenylephrine is present at a concentration of 90-720 μM and the ketorolac is present at a concentration of 44-134 μM. The formulation may also be preservative-free and antioxidant-free. [Brief description of the drawings]

[0029] IV. Brief Description of the Drawings The invention will now be described in further detail, by way of example, with reference to the accompanying drawings, in which:

[0030] [Figure 1] FIG. 1 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period, as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient, using the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite, when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Diagram 2]FIG. 2 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12-month period, as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient, using the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite, when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Diagram 3] FIG. 3 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 4] FIG. 4 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Diagram 5] FIG. 5 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 6]FIG. 6 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 7] FIG. 7 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 8] FIG. 8 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 9] FIG. 9 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredients with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 10]FIG. 10 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredient with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 11] FIG. 11 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredients with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 12] FIG. 12 provides the results of a stability study of a phenylephrine and ketorolac combination formulation at various time points over a 12 month period as determined by measuring the percentage of related substances resulting from degradation of the active pharmaceutical ingredients with the variables of active pharmaceutical ingredient concentration, various buffer systems, addition of the preservative EDTA, and addition of the preservative EDTA plus the antioxidant sodium metabisulfite when stored at controlled temperatures ranging from 2-8° C. to 60° C. [Figure 13] FIG. 13 provides the results of a study evaluating the effect of nitrogen overlay on the stability of two phenylephrine and ketorolac combination formulations, with and without the preservative EDTA, at various time points over a one-year period when stored at controlled temperatures between 4° C. and 60° C. [Figure 14] FIG. 14 provides the results of a study evaluating the effect of nitrogen overlay on the stability of two phenylephrine and ketorolac combination formulations, with and without the preservative EDTA, at various time points over a one-year period when stored at controlled temperatures between 4° C. and 60° C. [Figure 15]FIG. 15 provides the results of a study evaluating the effect of various antioxidants on the stability of phenylephrine and ketorolac combination formulations at time points over a one-month period following storage of samples at temperatures ranging from 2-8° C. to 60° C. [Figure 16] FIG. 16 provides the results of a study evaluating the effect of various antioxidants on the stability of phenylephrine and ketorolac combination formulations over a one-month period following storage of samples at temperatures ranging from 2-8° C. to 60° C. [Figure 17] FIG. 17 provides the results of a study evaluating the effect of various antioxidants on the stability of phenylephrine and ketorolac combination formulations at time points over a one-month period following storage of samples at temperatures ranging from 2-8° C. to 60° C. [Figure 18] FIG. 18 provides the results of a study evaluating the effect of various antioxidants on the stability of phenylephrine and ketorolac combination formulations over a one-month period after storage of samples at temperatures ranging from 2-8° C. to 60° C. [Figure 19] FIG. 19 provides the results of a study evaluating the stability of high concentration phenylephrine formulations over a four month period when stored at temperatures between 4° C. and 40° C. [Figure 20] 20A and 20B show the potency of phenylephrine and ketorolac, respectively, in a combination phenylephrine and ketorolac formulation when stored at 2-8° C. for 30 months. [Figure 21] FIG. 21 illustrates the results of a concentration-ranging efficacy study in non-human primates evaluating phenylephrine and ketorolac in terms of observed pupillary dilation (FIGS. 21 and 22) and flare (FIGS. 23-25) measures when given individually and in combination in balanced salt solution (BSS) by intraocular irrigation during phacoemulsification lens extraction and exchange surgery. [Figure 22]FIG. 22 illustrates the results of a concentration-ranging efficacy study in non-human primates evaluating phenylephrine and ketorolac in terms of observed pupillary dilation (FIGS. 21 and 22) and flare (FIGS. 23-25) measures when given individually and in combination in balanced salt solution (BSS) by intraocular irrigation during phacoemulsification lens extraction and exchange surgery. [Diagram 23] FIG. 23 illustrates the results of a concentration-ranging efficacy study in non-human primates evaluating phenylephrine and ketorolac in terms of measurements of observed pupillary dilation (FIGS. 21 and 22) and flare (FIGS. 23-25) when given individually and in combination in balanced salt solution (BSS) by intraocular irrigation during phacoemulsification lens extraction and exchange surgery. [Figure 24] FIG. 24 illustrates the results of a concentration-ranging efficacy study in non-human primates evaluating phenylephrine and ketorolac in terms of measurements of observed mydriasis (FIGS. 21 and 22) and flare (FIGS. 23-25) when given individually and in combination in balanced salt solution (BSS) by intraocular irrigation during phacoemulsification lens extraction and exchange surgery. [Diagram 25] FIG. 25 illustrates the results of a non-human primate concentration-ranging efficacy study evaluating phenylephrine and ketorolac in terms of measurements of observed mydriasis (FIGS. 21 and 22) and flare (FIGS. 23-25) when given individually and in combination in balanced salt solution (BSS) by intraocular irrigation during phacoemulsification lens extraction and exchange surgery. [Figure 26] FIG. 26 illustrates the results of a non-human primate study evaluating the effect of a phenylephrine and ketorolac combination formulation on pupil dilation (FIG. 26) and flare (FIGS. 27-28) when delivered by intraocular irrigation in BSS during phacoemulsification lens extraction and exchange surgery. [Figure 27]FIG. 27 illustrates the results of a non-human primate study evaluating the effect of a phenylephrine and ketorolac combination formulation on pupil dilation (FIG. 26) and flare (FIGS. 27-28) when delivered by intraocular irrigation in BSS during phacoemulsification lens extraction and exchange surgery. [Figure 28] FIG. 28 illustrates the results of a non-human primate study evaluating the effect of a phenylephrine and ketorolac combination formulation on pupil dilation (FIG. 26) and flare (FIGS. 27-28) when delivered by intraocular irrigation in BSS during phacoemulsification lens extraction and exchange surgery. [Figure 29] FIG. 29 illustrates the results of a dose ranging study evaluating various concentrations of a combination phenylephrine and ketorolac formulation for mydriasis when delivered in BSS during phacoemulsification lens extraction and exchange surgery in non-human primates. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0031] V. Detailed Description The present invention provides a sterile formulation of irrigation solution for perioperative local application (including intraocular application and topical application) to ocular tissue, which contains phenylephrine as a mydriatic agent and ketorolac as an anti-inflammatory agent.These formulations are both preservative- and antioxidant-free, yet unexpectedly exhibit good stability.They are preferably packaged in a single-use container for injection, and can be injected into a larger volume of intraocular irrigation carrier before and during intraocular procedures (e.g., cataract extraction and lens replacement, and refractive lens exchange procedures).

[0032] (definition) "Preservative" as used herein means an antimicrobial agent added to a pharmaceutical product to maintain stability and prevent degradation due to microbial growth. Common antimicrobial preservatives that may be included in pharmaceutical compositions include sorbic acid and its salts, benzoic acid and its salts, calcium propionate, sodium nitrite (and sodium nitrate, which converts to sodium nitrite "in situ"), sulfites (sulfur dioxide, sodium bisulfite, potassium bisulfite, etc.), and the metal chelator sodium ethylenediaminetetraacetate (also called disodium edetate, EDTA, or Na2EDTA).

[0033] "Antioxidant" as used herein refers to a substance that reacts preferentially with oxygen, thereby protecting the pharmaceutical product to which it is added from degradation due to oxidation.Examples of water-soluble or oil-soluble antioxidants that can be included in pharmaceutical compositions include sodium bisulfite, sodium sulfite, sodium metabisulfite, sodium thiosulphite, sodium formaldehyde sulfoxylate, l-ascorbic acid and d-ascorbic acid, acetylcysteine, cysteine, thioglycerol, thioglycolic acid, thiolactic acid, thiourea, dihithreitol, glutathione, propyl gallate, butylated hydroxyanisole, butylated hydroxytoluene, tertiary butylhydroquinone, ascorbyl palmitate, nordihydroguaiaretic acid and α-tocopherol.

[0034] A "preservative-free" solution refers to a solution that does not contain benzalkonium chloride or other antimicrobial agents.

[0035] An "antioxidant-free" solution refers to a solution that does not contain sodium metabisulfite or other agents included for their sole function or acting as antioxidants, although an antioxidant-free solution may contain a pH buffer system, a component of which may have antioxidant activity.

[0036] "Ketorolac" means ketorolac in salt form (e.g., ketorolac tromethamine [(±)-5-benzoyl-2,3-dihydro-1H-pyrrolidine-1-carboxylic acid:2-amino-2(hydroxymethyl)-1,3-propanediol (1:1)]).

[0037] "Phenylephrine" means phenylephrine in a salt form (e.g., phenylephrine HCl [(-)-m-hydroxy-a-[(methylamino)methyl]benzyl alcohol hydrochloride]).

[0038] "Related substances" for a given pharmaceutical ingredient refer to substances resulting from the degradation of the ingredient (expressed as a percentage of the total concentration of the pharmaceutical ingredient in the formulation). As used herein with respect to the present invention, "total related substances" refers to the sum of all related substances resulting from the degradation of the active pharmaceutical ingredients ketorolac and phenylephrine in the formulation (expressed as a percentage of the total concentration of the pharmaceutical ingredients in the formulation). Any related substances present below the lower limit of quantification (e.g., 0.1%) for the assay used to measure related substances are not included in the total when determining total related substances. In the figures accompanying the examples herein, reference to 0% related substances for a component means that there were no related substances of the component present at levels above the lower limit of quantification (e.g., 0.1%) for the substance being assayed.

[0039] "Stable" refers to a liquid pharmaceutical formulation that contains less than 5% total related substances at the end of a specified storage period. In one embodiment, a stable liquid formulation is stable at a temperature of 5±3°C (i.e., 2-8°C) to 25±2°C (i.e., 23-27°C) for a period of at least 6 months. In a preferred embodiment, a stable liquid formulation is stable at a temperature of 5±3°C to 25±2°C for a period of at least 1 year. In a preferred embodiment, a stable liquid formulation is stable at a temperature of 5±3°C to 25±2°C for a period of at least 24 months. In a preferred embodiment, a stable liquid formulation is stable at a temperature of 5±3°C to 25±2°C for a period of at least 30 months. In a preferred embodiment of the invention, a stable formulation of the invention has less than 1.0% total related substances after a given storage period.

[0040] The term "about" is understood to mean that there may be variations in the concentration of the components of the described formulation, which may be 5%, 10%, 15% or up to and including 20% ​​of the given value. For example, the phrase "a formulation having about 20 mM sodium citrate" is understood to mean that the formulation may have between 16 mM and 24 mM sodium citrate.

[0041] The term "sterile" refers to a pharmaceutical product that has been aseptically processed and is free of live bacteria, fungi, and other microorganisms.

[0042] (Pharmaceutical Agents) The present invention provides a stable, preservative-free, antioxidant-free liquid pharmaceutical formulation that combines two active pharmaceutical ingredients (APIs), phenylephrine as a mydriatic and the NSAID, ketorolac, as an anti-inflammatory agent.

[0043] (Ketorolac) "Ketorolac" in the preferred formulation of the present invention is included as ketorolac tromethamine salt [(±)-5-benzoyl-2,3-dihydro-1H-pyrrolidine-1-carboxylic acid:2-amino-2(hydroxymethyl)-1,3-propanediol (1:1)]. Ketorolac is a member of the pyrrolo-pyrrole group of nonsteroidal anti-inflammatory drugs. Ketorolac HCl is a racemic mixture of R-(+) and S-(-) enantiomers that can exist in three crystalline forms, all of which are equally water soluble. The drug discolors upon prolonged exposure to light, and therefore light-resistant packaging (e.g., over-boxing or use of amber vials) can be appropriately utilized to package the formulation of the present invention.

[0044] (Phenylephrine) "Phenylephrine" refers to phenylephrine in a salt form (e.g., phenylephrine HC It stands for l[(-)-m-hydroxy-a-[(methylamino)methyl]benzyl alcohol hydrochloride]. Phenylephrine is an alpha receptor sympathomimetic drug. Phenylephrine HCl is freely soluble in water and alcohol.

[0045] (Aqueous carrier) In the addition of API to aqueous solvent as carrier, the inventors have determined that no solubilizer is required.The aqueous carrier is suitably water for injection (WFI), which is a sterile solute-free preparation of distilled water.Instead, other aqueous carriers that are not harmful to intraocular tissue and do not adversely affect the stability of the formulation can be used (e.g., deionized water, or saline or balanced salt solutions such as those described below, after first evaluating the potential effect on stability).

[0046] (Buffer system) The formulations of the present invention are adjusted to a pH of 5.8 to 6.8, and preferably to about 6.3. Sodium hydroxide and hydrochloric acid may be added as needed to adjust the formulation to this pH. The desired pH is suitably maintained by using a buffer system. One such suitable system is a citrate buffer (comprising citric acid monohydrate and sodium citrate dihydrate), and another suitable system is a sodium phosphate buffer (comprising dibasic sodium phosphate and monobasic sodium phosphate). Either buffer system may be used at a suitable concentration ranging from 10 mM to 100 mM, suitably 20 mM. As described in Example 1 below, sodium citrate is a preferred buffering agent for use in preservative-free formulations. The citric acid in the citrate buffer has the ability to chelate to divalent cations, and thus may also prevent oxidation, providing an antioxidant effect and a buffering effect. However, its presence does not reduce stability as other antioxidants do (Example 3 below). As used herein, the term "antioxidant-free" excludes the use of other antioxidants, but does not exclude the use of buffering agents (e.g., citric acid) included as part of a buffer system.

[0047] (No other excipients) In a further aspect of the present invention, in addition to being free of any preservatives or antioxidants, the formulation according to the present invention also does not contain any excipients other than the buffer system. For example, no solubilizers (e.g., ethanol or ethanol) are used (i.e., the formulation is solubilizer-free). The preferred formulation of the present invention consists essentially of two APIs in water for injection and a buffer system, resulting in a very pure formulation with reduced potential toxicity to intraocular tissues.

[0048] (single-use container) In a further aspect of the present invention, the phenylephrine and ketorolac combination formulation of the present invention is contained in a container that facilitates such single-use administration and does not facilitate multi-use administration during intraocular surgery in an amount sufficient for single use. Thus, a sufficient amount of the drug composition formulated according to the present invention is contained in a single-use container that facilitates administration of the drug composition by injection, equal to or only slightly greater than the amount of drug composition that is desired to be added to a standard container of an intraocular irrigation carrier (i.e., no more than 25% excess). For example, the desired single-use amount of the phenylephrine and ketorolac combination drug composition can be packaged in a glass vial closed with a stopper or other closure, including a septum through which a hypodermic needle can be inserted to withdraw the drug composition, or can be packaged in a pre-filled syringe. One example of a suitable container and closure system is a 5mL USP Type 1 borosilicate flint glass vial with a West 20mm gray butyl stopper and a 20mm flip-off seal.

[0049] Prior to closing the container, it may be desirable to expose the drug composition formulated according to the invention to a nitrogen overlay (i.e., displacing air from the headspace in the vial with nitrogen before sealing the vial), based on the results described below in Example 2. Other methods of evacuating air and replacing it with an inert gas may also be utilized (e.g., sparging an inert gas through the solution).

[0050] (Intraocular Perfusion Carrier) The above-mentioned phenylephrine and ketorolac combination drug composition (i.e., combination drug product) is suitably added by injection into a bag, bottle or other container of intraocular irrigation solution before administration by intraocular or topical irrigation or washing.Suitable intraocular irrigation solutions include saline, lactated Ringer's solution, balanced salt solution, or any other irrigation solution that is compatible with aqueous formulations and is not harmful to eye tissue.A suitable intraocular irrigation carrier includes one or more, and preferably all, of the following supplements: sufficient electrolytes to provide a physiological balanced salt solution; a cellular energy source; a buffering agent; and a free radical scavenger. One suitable solution (referred to in the examples below as "balanced salt solution" or "BSS") contains the following: electrolytes at 50-500 millimolar sodium ion, 0.1-50 millimolar potassium ion, 0.1-5 millimolar calcium ion, 0.1-5 millimolar magnesium ion, 50-500 millimolar chloride ion, and 0.1-10 millimolar phosphate ion; bicarbonate as a buffer at 10-50 millimolar; a cellular energy source selected from dextrose and glucose at 1-25 millimolar; and glutathione as a free radical scavenger (i.e., antioxidant) at 0.05-5 millimolar.

[0051] An example of a suitable method for diluting and administering the combination drug composition of the present invention utilizes the formulation of the present invention set forth in Table 2 below as Formula 2. A 4.5 mL aliquot of this solution (including 4.0 mL as the amount intended for single use and an overfill of 0.5 mL) is contained in a sterile, closed, single-use vial and is intended for mixing with an irrigation solution for administration during intraocular surgery. From the vial, 4 mL is withdrawn with a syringe and mixed with 500 mL of BSS by injecting into a 500 mL bag or bottle of BSS to provide a final concentration of 483 μM phenylephrine and 89 μM ketorolac in the irrigation solution for local delivery to the eye.

[0052] In another aspect of the present invention, a sterile liquid pharmaceutical formulation for perfusion can be provided, in which the phenylephrine and ketorolac are already mixed in an intraocular perfusion carrier, so that the phenylephrine and ketorolac are diluted to the concentration of each active pharmaceutical ingredient desired for local delivery to intraocular tissue during surgery and are contained in a sterile bag, bottle or other single-use perfusion container.For example, such a formulation for perfusion can contain phenylephrine at a concentration of 30-720 μM and ketorolac at a concentration of 10-270 μM, or preferably, phenylephrine at a concentration of 90-720 μM and ketorolac at a concentration of 44-134 μM.In one embodiment, the phenylephrine and ketorolac combination is mixed in a balanced salt solution (e.g., as described above) as an intraocular perfusion carrier. The pharmaceutical formulations for perfusion may suitably be completely preservative-free and antioxidant-free, or may optionally contain only antioxidants typically included in non-medicated intraocular perfusion carriers (e.g., glutathione in the balanced salt solutions described above), but no preservatives at all.

[0053] Exemplary Formulations As described above, the sterile liquid pharmaceutical formulations of the present invention comprise phenylephrine and ketorolac in a buffered aqueous carrier. The concentration ranges from 10 mM to 500 mM, and preferably from 45 mM to 112 mM. The suitable concentration of ketorolac in the combination drug composition of the present invention ranges from 2 mM to 75 mM, and preferably from 8.5 mM to 24 mM. The buffer system (e.g., sodium citrate buffer system) is suitably included at a concentration of 10 to 100 mM, and preferably about 20 mM. Two exemplary formulations according to the present invention are shown in Tables 1 and 2 below. In each case, sodium hydroxide and / or hydrochloric acid are added, if necessary, when preparing the formulation to adjust the pH to about 6.3. [Table 1] [Table 2]

[0054] The amount of pharma- ceutically active ingredient contained in the formulation can be expressed by molar ratio. The molar ratio of phenylephrine to ketorolac can range from 1:1 to 13:1, more suitably from 3:1 to 10:1. An exemplary molar ratio of phenylephrine and ketorolac as represented by Formula 1 in Table 1 above is 8:1 phenylephrine:ketorolac. Another exemplary molar ratio of phenylephrine and ketorolac as represented by Formula 2 in Table 2 above is 5.4:1 phenylephrine:ketorolac.

[0055] After dilution of the formulation of the present invention into an intraocular perfusion carrier for local delivery, the administration concentration of phenylephrine may be 3-7,200 μM, more suitably 30-720 μM, more suitably 90-720 μM, even more suitably 240-720 μM, and most suitably about 483 μM. After dilution of the formulation of the present invention into an intraocular perfusion carrier for local delivery, the administration concentration of ketorolac may be 3-900 μM, more suitably 10-270 μM, more suitably 44-134 μM, even more suitably 30-90 μM, and most suitably about 90 μM.

[0056] (Usage) The stable liquid formulations of the present invention can be utilized in a variety of ophthalmic procedures after mixing with an intraocular irrigation carrier, including cataract extraction and lens replacement procedures, as well as refractive lens exchange procedures, corneal transplant procedures and vitreoretinal surgery, and trabeculectomy procedures for glaucoma.

[0057] An example of a suitable method for diluting and administering the combination drug composition of the present invention utilizes the formulation of the present invention described as Formulation 2 in Table 2 above. A sterile single-use 5mL vial containing 4.5mL of the composition is provided, from which 4mL of the composition is withdrawn with a syringe and mixed with 500mL of BSS by injecting into a 500mL bag or bottle of BSS to provide a final concentration of 483μM phenylephrine and 89μM ketorolac. This solution is perfused through the anterior chamber at a constant concentration throughout the procedure. Thus, in this example, the drug product is administered only intracamerally during the procedure.

[0058] The active pharmaceutical agent is contained in an intraocular perfusion carrier in a dilute concentration. The concentration of the agent is determined according to the teachings of the present invention for direct topical application to ocular tissue during surgery. The application of the solution can be performed perioperatively, i.e., intraoperatively; preoperatively and intraoperatively; intraoperatively and postoperatively; or preoperatively, intraoperatively and postoperatively.

[0059] It must be noted that as used herein and in the appended claims, the singular forms "a," "and," and "the" include plural references unless the context clearly indicates otherwise. Thus, for example, reference to "an excipient" includes a plurality of such excipients and equivalents thereof known to those skilled in the art, and so forth.

[0060] The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein should be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Further, the publication dates provided may be different from the actual publication dates which may need to be independently confirmed. All citations are incorporated herein by reference. EXAMPLES

[0061] (Examples 1 to 5) In the studies described in Examples 1-5 below, the presence and availability of related substances (RS) was measured by high performance liquid chromatography with UV detection (HPLC-UV), using an increase in the percentage of related substances detected as an indication of the presence of degradation products as an indicator of stability. In these studies, the HPLC-UV utilized a Zorbax XDB-C8, 5 μM, 4.6 mm×150 mm column at a flow rate of 1.2 ml / min. Mobile phases A and B were as follows: Mobile phase A: 650 mL of 1.1 mg / mL 1-octanesulfonic acid (pH 3.0): 50 mL Milli-Q water: 300 mL methanol; Milli-Q water: 300 mL methanol; Mobile phase B: 300 mL of 1. 1 mg / mL 1-octanesulfonic acid (pH 3.0): 50 mL Milli-Q water: 650 mL methanol. The diluent used was mobile phase A. A gradient of 100% A to 100% B in 40 minutes was used. A 280 nm UV detector was used.

[0062] Example 1: Comparison of formulation stability depending on the use of preservatives and antioxidants, and using various buffers. An experiment was conducted comparing various formulations of the combination of two active pharmaceutical ingredients (APIs), phenylephrine HCl (PE) and ketorolac tromethamine (KE), each at equal concentrations in aqueous solution of either 5 mM or 1 mM. Two different buffer systems were utilized to maintain the solutions at three different pHs: 20 mM sodium phosphate buffer (dibasic sodium phosphate and monobasic sodium phosphate) for pH 7.4; 20 mM sodium citrate buffer (citric acid monohydrate and sodium citrate dihydrate) for pH 6.5; and 20 mM sodium citrate buffer for pH 5.5. Four preservative-free and antioxidant-free formulations of these APIs were developed (each aliquoted into multiple 1 mL vials for storage and sampling as follows): [Table 3]

[0063] Additional formulations were then prepared either without the addition of preservatives or antioxidants (control group), or by adding the preservative sodium ethylenediaminetetraacetate (also known as disodium edetate or EDTA), or EDTA plus the antioxidant sodium metabisulfite, as follows: [Table 4]

[0064] Samples of the various formulations in each of these groups were then stored under light-protected conditions at controlled temperatures of either 2-8° C., 25° C., 40° C., or 60° C. Samples of each formulation were withdrawn at various time points over a 12 month period and analyzed for degradation of the APIs as determined by measuring related substances for each API. The results of this experiment are presented in the tables of Figures 1-12, and the following conclusions were reached:

[0065] Based on stability evaluation after 1 month of storage: 1. The control group (G1) demonstrated that both APIs were stable in Na phosphate buffer at pH 7.4, and in Na citrate buffers at pH 6.5 and pH 5.5. The control group showed some degradation at 60° C., with a maximum at pH 4.5 (Na citrate). 2. Comparing group G2 with group G1 demonstrates that EDTA inhibits the degradation of PE at higher temperatures. 3. Group G3 surprisingly demonstrates that sodium metabisulfite significantly increases the degradation of API, especially KE, at elevated temperatures. Moreover, at 1 month, some G3 samples stored at 40°C and 60°C were yellowish in color.

[0066] Based on stability evaluation after 6 months storage: 4. EDTA surprisingly does not appear to have a significant effect on the stability of any of the APIs, especially in citrate buffer at pH 6.5. 5. The greatest increase in % of related substances at 6 months occurs in samples held at 60°C. 6. Both APIs appear to be stable at 4° C. and 25° C. At 40° C., there is a small increase in % of related substances, especially in citrate buffer at pH 6.5. 7. At 6 months, the 40°C and 60°C samples appear bright yellow with no visible precipitation or crystallization.

[0067] Example 2: Effect of Nitrogen Overlay on Stability A study was then conducted to determine the effect of nitrogen overlay (i.e., purging air from the headspace in the vial with nitrogen before sealing the vial). Formulation F2 of Example 1 (5 mM ketorolac, 5 mM phenylephrine in sodium citrate buffer adjusted to pH 6.5 in aqueous solution) was evaluated either without any preservatives or antioxidants (Group 1, G1) or with 0.05% w / v EDTA added as a preservative (Group 2, G2). Related substances for each API were measured at time points over a 1-year period after storage of samples at temperatures ranging from 4° C. to 60° C.

[0068] The results of this study are shown in Figures 13 and 14 and demonstrate that the use of a nitrogen overlay significantly reduced the degradation of both APIs compared to the presence of oxygen-containing air, especially at the elevated temperatures of 40° C. and 60° C. When a nitrogen overlay was used, the presence or absence of EDTA made little difference to the stability of the APIs.

[0069] Example 3: Effect of various antioxidants on stability A study was then conducted to evaluate the effect of adding alternative antioxidants to formulation F2 of Example 1 (5 mM ketorolac, 5 mM phenylephrine in sodium citrate buffer adjusted to pH 6.5 in aqueous solution) (Group 2, G2), which also contained 0.05% w / v EDTA as a preservative. The antioxidants evaluated were 0.1% ascorbic acid (A1), 0.1% L-cysteine ​​HCl monohydrate (A2), 0.1% L-glutathione (reduced) (A3) and 0.1% monothioglycerate (A4). Related substances for each API were measured at time points over a one-month period following storage of samples at temperatures ranging from 2-8°C to 60°C.

[0070] The results of this study are presented in Figures 15-18 and show that at one month, each of these four antioxidants surprisingly increased the degradation of each API, especially at the elevated temperatures of 40°C and 60°C.

[0071] Example 4: Evaluation of the stability of higher concentrations of phenylephrine To evaluate whether the concentration of phenylephrine in a phenylephrine HCl and ketorolac tromethamine combination formulation could be increased without adverse effects on phenylephrine stability, an aqueous formulation of 450 mM phenylephrine in calcium citrate buffer adjusted to pH 6.5 with no added preservatives, antioxidants or other excipients was prepared and samples were evaluated when stored at temperatures between 4° C. and 40° C. over a four month period.

[0072] The results of this study are provided in Figure 19. This high concentration phenylephrine formulation was stable between 4°C and 30°C for over four months.

[0073] Example 5: Evaluation of the long-term stability of the combination of phenylephrine and ketorolac Long-term stability studies were conducted on a combination formulation of fixed phenylephrine HCl (12.37 mg / mL) and ketorolac tromethamine (4.24 mg / mL) in 20 mM sodium citrate buffer adjusted to pH 6.5 without adding any preservatives or antioxidants. Samples of the above formulation aliquoted into 5 mL USP Type 1 glass vials and closed with Daiko D777-1 Flurotec® coated 20 mm stoppers were stored inverted and wrapped in foil to protect from light, and then maintained under long-term storage conditions (5±3°C) and accelerated storage conditions (25±2°C / 60±5% RH). Each vial contained 4.5 mL of solution (including a 0.5 mL overfill).

[0074] There was no measurable change in product appearance, solution pH, or potency when measured after 30 months of storage under these conditions. At this 30 month time point, storage at 5°C and 25°C yielded 1.17% and 1.36% total related substances, respectively. Graphical representations of the measured potencies of phenylephrine HCl and ketorolac tromethamine for this formulation held under the labeled storage conditions of 2°C to 8°C are provided in Figures 20A and 20B, respectively. As evidenced by these figures, there was no significant decrease in potency observed through 30 months (three vials were assayed at each time point).

[0075] (Examples 6 to 9) Examples 6-9 below provide the results of in vivo studies of phenylephrine HCl and ketorolac tromethamine combination formulations according to the present invention that were diluted by injection into an irrigation solution and then used for intraocular irrigation during lens replacement and exchange surgery. The following formulations were evaluated in this series of studies: (a) phenylephrine HCl only (PE), (b) ketorolac tromethamine only (KE), (c) phenylephrine HCl and ketorolac tromethamine in combination (PE-KE), or (d) no active pharmaceutical ingredient (vehicle control). In each case, 20 mM phenylephrine HCl was added, adjusted to pH 6.5, without the addition of any preservatives or antioxidants. The formulations were formulated in aqueous solutions containing sodium citrate buffer and provided in 2.5 mL aliquots in each case. In each case, aliquots of the formulations were infused into balanced salt solution (BSS, Baxter Healthcare, product code 1A7233) as the perfusion vehicle carrier to the specified final dose concentrations as described below. The study also utilized proparacaine HCl (0.5%, Bausch & Lomb), tropicamide (1.0%, Bausch & Lomb), and ciprofloxacin HCl (3%, Alcon) to the extents described below.

[0076] The mydriatic and anti-inflammatory properties of the test agents were evaluated in an African green monkey model of human phacoemulsification surgery. Prior to surgery, baseline measurements and evaluations were performed on both eyes of each monkey to determine pupil diameter, lens and iris integrity, corneal thickness, and anterior chamber flare and cell counts by quantitative scoring under biomicroscopy and quantitative flare photometry using a Kowa FM-500 instrument. Phacoemulsification surgery and lens replacement with a polymethylmethacrylate (PMMA) artificial lens were performed using a Storz Premier anterior phacoemulsification machine. The above procedures were performed only on the right eye to minimize surgical position variability and to allow the left eye to serve as a control and minimize the consequences of any potentially induced vision loss.

[0077] Test animals were placed in the prone position under ketamine / xylazine anesthesia augmented with one drop of topical proparacaine. A small incision was made in the right cornea with an MVR 20 G lance blade through which 0.4–0.6 mL of viscoelastic (2% hydroxypropyl methylcellulose, EyeCoat, Eyekon Medical) was introduced into the anterior chamber via a viscoelastic syringe. A corneal incision was made 1.0 mm anterior to the limbus using a 2.65 mm straight clear cornea bi-beveled blade. Irrigation was applied with a phacoemulsification handpiece to remove the viscoelastic and introduce the test irrigant solution. After a total of 4 min of irrigation, irrigation was stopped and the anterior chamber was refilled with viscoelastic. A capsulorhexis was performed and the phacoemulsification tip was reintroduced into the anterior chamber with application of phacoemulsification energy to break up the lens and allow for aspiration and lens fragment removal. Irrigation was extended for a period of time after lens removal to standardize intraocular irrigation fluid delivery across all treatment groups (a total of 14 minutes during this phacoemulsification segment of irrigation). After the phacoemulsification and irrigation procedure, a PMMA intraocular lens (IOL) was inserted and irrigated for an additional 2 minutes, after which the corneal incision was closed with two 12.0 nylon sutures. Irrigation with test fluid or vehicle control was performed for a total of 20 minutes before, during, and after phacoemulsification and lens replacement, as described below, at a flow rate of 20 mL / min.

[0078] In these studies, laser flare photometry was performed at baseline, 4.5 hours, 24 hours, 48 ​​hours, and 1 week after starting the surgical procedure using a Kowa FM-500 (Kowa Company, Tokyo Japan). The Kowa FM-500 measures laser light scattering to quantify anterior chamber flare. A laser is directed at the anterior chamber and proteins released into the anterior chamber during inflammatory responses pass through a focal point to scatter the laser light. This light scattering is quantified by a photomultiplier tube as photons per millisecond. At each observation point, measurements were collected until seven acceptable readings (difference between two background measurements <15%) were obtained, the lowest and highest readings were erased, and the mean ± standard deviation was calculated as specified by the manufacturer.

[0079] The time course of the pupil dilation effect was recorded by video recording of the pupil during the irrigation procedure. The pupil diameter and the fixation width of the eyelid speculum (11 mm) were measured from the video, and the pupil diameter was calculated in millimeters. Measurements were taken at periodic intervals during the course of the injection procedure according to the video time log for each recorded treatment.

[0080] The primary efficacy variables were pupil diameter and laser flare photometry measurements. Primary efficacy variables were analyzed in the protocol correct population (all subjects who completed the study without major protocol deviations) using one-way repeated measures ANOVA with post-hoc Student Newman-Keuls tests using SAS (SAS Institute Inc.). Analysis terms included sequence (=time, confounded with carryover effects), eye, monkey and treatment. Appropriate model-based comparisons were used to detect treatment differences at a significance level of p<0.05 for pupil diameter and flare measurements at all time points.

[0081] Example 6: Concentration ranging study of phenylephrine and ketorolac following intraoperative irrigation in a phacoemulsification surgery model. A non-GLP study was performed as a concentration-ranging efficacy study to evaluate PE and KE when given individually and in combination by intraocular irrigation in BSS during cataract surgery. The objective was to evaluate the benefit of each agent on both mydriatic and inflammatory endpoints.

[0082] In the first series of experiments (designated Phase 1), 16 animals were divided into groups of four and studied to establish the maximum effective concentration of phenylephrine in the BSS irrigation solution in this model of phacoemulsification surgery. Four of the monkeys in the Phase 1 cohort received tropicamide (a muscarinic mydriatic) to serve as positive controls and to allow for the determination of the endpoint measurements of interest under adequate pupil dilation by a standard local preoperative route of delivery. The phenylephrine treatment groups received BSS irrigation solutions containing low (3 μM), medium (10 μM), high (30 μM) and highest (90 μM) concentrations of phenylephrine. The low and highest treatment groups consisted of two animals each, and a decision was made to evaluate higher concentrations of phenylephrine when part of Phase 1 was underway. The primary endpoint of phenylephrine efficacy was mydriasis. Postoperative inflammatory endpoints were also evaluated.

[0083] BSS irrigation solution was delivered through the phacoemulsification needle either without phenylephrine or with phenylephrine at concentrations of 3.0 μM, 10 μM, 30 μM, or 90 μM (see Table 1). Stage 1 irrigation (0:00-2:00 min) was applied to remove the viscoelastic and evaluate the mydriatic effect of phenylephrine and continued throughout stage 2 irrigation (2:00-4:00 min). Viscoelastic was then reintroduced into the anterior chamber and a capsulorhexis was performed. Stage 3 irrigation (4:00-18:00 min) began after the capsulorhexis and continued for a total of 14 min. During the initial stage, the lens was fragmented and aspirated by application of phacoemulsification energy. Stage 4 irrigation was performed after introduction of the PMMA lens to drain the viscoelastic introduced for the procedure and to remove any additional lens fragments. The tropicamide control animals were pretreated with 2 drops of 1% tropicamide 20 minutes before initiating anterior chamber irrigation with BSS alone.

[0084] After surgery on the first few animals, the duration of irrigation prior to the first phacoemulsification was increased from 2 to 4 minutes to obtain maximal pupil dilation.

[0085] A second series of experiments (referred to as Phase 2) assessed mydriasis and inflammation after phacoemulsification procedures using BSS irrigation solutions with low, medium, and high concentrations of ketorolac or without ketorolac (negative control). Anterior chamber irrigation was initiated using no mydriatic in the irrigation solution to assess the mydriatic effect of ketorolac and BSS alone. After 2 minutes of irrigation and assessment of mydriasis, a concentration of phenylephrine (30 μM) found to be effective in producing mydriasis in the Phase 1 experiments was included in the irrigation solution to produce sufficient dilation to perform the phacoemulsification procedure. A secondary endpoint of ketorolac efficacy was mydriasis, and the primary endpoint was laser flare photometry, a validated measure of anterior chamber inflammation.

[0086] BSS perfusate was delivered through the phacoemulsification needle either without ketorolac or with ketorolac at concentrations of 3.0 μM, 10 μM, or 30 μM (Table 1 ). Stage 1 irrigation (0:00–2:00 min) was applied to remove the viscoelastic and to evaluate the mydriatic effect of ketorolac. High-concentration phenylephrine was then added to the irrigation bottle (to achieve a concentration of 30 μM) to flush the lines, and irrigation was continued throughout stage 2 (2:00–4:00 min). Viscoelastic was then reintroduced into the anterior chamber and a capsulorhexis was performed. Stage 3 irrigation (4:00–18:00 min) began after capsulorhexis and continued for a total of 14 min, during the initial phase of which phacoemulsification energy was applied. Stage 4 irrigation was performed after the introduction of a PMMA lens.

[0087] (result) After an initial pupil dilation of 1-2 mm within the first minute of initiation of anterior chamber perfusion, pupil diameter asymptotically approached maximum dilation within approximately 5 minutes for all treatment groups with a significant effect of time on diameter (F=2.75, P<0.0001) (see Figures 21 and 22). In the first set of experiments, trends suggest that the presence of phenylephrine in the BSS perfusate contributed to a concentration-dependent increase in pupil diameter. The initial dilation (0-2 minutes) shown in the control group, which received topical tropicamide 20 minutes prior to perfusion with BSS alone, may not have been a pharmacological effect, and reflects that the component of dilation measured within the first 2 minutes of initiation of anterior chamber perfusion in all groups was associated with clearance of viscoelastic material introduced to allow for making the corneal incision and possible hydrodynamic effects of perfusion / aspiration. Notably, however, the initial dilation in the tropicamide control group began with a greater baseline dilation at the start of treatment than all other treatment groups (F=7.73, P<0.0001), resulting in a lower maximum dilation than that exhibited by the mid-, high-, and highest-concentration phenylephrine groups. The differences between the highest, high and medium phenylephrine groups and the low phenylephrine group were significant at 6:00, 8:00, 10:00, 14:00, 18:00 and 19:00 minutes (F=2.41, p<0.043; F=2.66, p<0.0315; F=3.24, p<0.0136; F=6.62, p<0.0002; F=9.26, p<0.0001; F=3.79, p<0.005, respectively; Student Newman-Keuls test, α=0.05, df=23, see Figure 21), confirming the concentration-dependent effect of phenylephrine irrigation solution on the magnitude of intraoperative pupillary dilation. Differences between the highest, high and medium phenylephrine groups versus the low phenylephrine and tropicamide control groups were significant at 14:00 and 18:00 minutes (F=6.62, p<0.0002; F=9.26, p<0.0001, respectively; Student Newman-Keuls test, α=0.05, df=23, see FIG. 21).This indicated a concentration-dependent effect of phenylephrine in prolonging intraoperative pupil dilation. Although differences between all other groups at all other time points were not significant by the Student Newman-Keuls criteria, the trends observed in mean pupil diameter within groups suggest a concentration-dependent effect on both the rate of onset and magnitude of pupil dilation across phenylephrine groups. At later time points, the mean dilation in the high phenylephrine treatment group was close to the anatomical limit of pupil dilation of 8.3 mm (corresponding to the inner diameter of the limbus) in adult eyes of this species.

[0088] In a second set of experiments in which the anterior chamber was perfused for 2 min with BSS containing 3–30 μM ketorolac or with BSS alone before the introduction of 30 μM phenylephrine, there was a rapid 1–2 mm increase in pupil diameter within 30 s of the start of perfusion, followed by a less rapid, concentration-independent increase between 30 s and 2 min. No statistical differences were observed between ketorolac- and BSS-treated animals during the first 2 min. Assuming that the same behavior was exhibited by the BSS control group, this initial dilation may be related to the clearance of viscoelastic substances and the hydrodynamic effects of perfusion / aspiration, as evidenced by the behavior of the phenylephrine and tropicamide control groups in the first set of experiments. After the introduction of 30 μM phenylephrine in all ketorolac- and BSS-treated animals at 2 min, all There was a more rapid increase in pupil diameter in all groups, reaching maximum dilation at 4 min. Maximum dilation was sustained throughout the remainder of the perfusion period after a slight decrease in pupil diameter in the interval between the initial 4 min perfusion and the start of phacoemulsification when the capsulorhexis was performed. At 14:00 and 18:00 min, there were no statistically significant group differences except between the low and medium ketorolac groups versus the BSS and high ketorolac groups (low and medium > BSS and high; F = 6.62, p < 0.0002; F = 9.26, p < 0.0001, respectively; Student Newman-Keuls test, α = 0.05, df = 23, see Figure 2). However, treatment grouping for this difference suggested that the difference did not result from a ketorolac effect, and likely reflected between-animal and between-treatment differences related to limited sample size. In all treatment groups in both experimental sets, the pupils constricted after lens placement at the end of treatment.

[0089] Baseline preoperative anterior chamber flare measurements ranged from 3.0 to 12.7 photon units / ms in treated (right) eyes in all treatment groups (mean=6.0±2.4 SD). Flare measurements in control (left) eyes remained within this range for the duration of the study. These measurements were matched to anterior chamber flare assessments performed by slit lamp microscopy, confirming the utility of laser flare photometry in quantifying protein density in the anterior chamber in the natural resting state of the eye. There was a significant effect of time on flare measurements in treated eyes in all treatment groups (F=2.16, p<0.0034). This further confirmed the utility of flare photometry in quantifying intervention-related inflammation (see Figures 23, 24, and 25). Flare measurements in treated eyes at baseline vs. 4.5 hours and 24 hours vs. 48 hours and 168 hours were significantly different across all treatment groups (F=2.16, p<0.0034; Student Newman-Keuls test, α=0.05, df=75). Differences between control and treated eyes differed across all subjects at all postoperative testing time points (F=236.64, P<0.0001; Student Newman-Keuls test, α=0.05, df=195).

[0090] In the first set of experiments, phacoemulsification duration was varied within treatment groups as ideal parameters were refined. It was established in the first four surgical procedures that phacoemulsification time was causing a severe inflammatory response and that reduction in phacoemulsification was favored. Analysis of the longer duration (45-55 seconds) phacoemulsification group versus the shorter duration (15-25 seconds) phacoemulsification group at 4.5 and 24 hours revealed a statistically significant increase in flare measurements with phacoemulsification duration (F=4.42, p<0.0018; Student Newman-Keuls test, α=0.05, df=14; see FIG. 24). This confirmed the utility of laser flare photometry in quantifying the degree of anterior chamber damage and inflammation. This difference was resolved out to 48 hours and 1 week.

[0091] Analyses excluding subjects who received high phacoemulsification energy (which included two monkeys in each of the high phenylephrine and tropicamide groups) revealed no treatment effect on flare measurements for phenylephrine compared with tropicamide controls at all time points (Student Newman-Keuls test, α=0.05, df=7).

[0092] In the second set of experiments, despite the small group sizes, there was a consistent trend toward decreased flare measures in the mid- and high-ketorolac groups. BSS control vs. There was statistical significance between flare measurements in the mid- and high-level ketorolac groups that achieved significance at 4.5 hours (when the analysis was powered by combining these two treatment groups). There was a significant difference (F=5.17, P<0.0223; Student Newman-Keuls test, α=0.05, df=13; see FIG. 25). Although flare measurements in the high and medium dose ketorolac groups remained lower compared to the control group at 24 and 48 hours, these differences did not reach statistical significance, given the power of the analysis, whether the high and medium dose ketorolac groups were analyzed together or separately. At 1 week, there were no statistically significant differences between any of the treatment groups, although the high concentration ketorolac group maintained a similar trend.

[0093] (Conclusion) The African green monkey phacoemulsification model allowed for quantification of pupillary dilation and inflammatory measures relevant to human clinical endpoints. Of these measurements, video pupil diameter assessment and anterior chamber flare photometry were the most responsive to treatment effects at the time points evaluated. Video pupil data demonstrated that intraoperative delivery of phenylephrine in the anterior chamber irrigation solution produced a rapid onset of pupillary dilation that was maintained throughout the surgical procedure. The maximum pupillary dilation obtained was concentration dependent, and sufficient pupillary dilation for the phacoemulsification surgical procedure was achieved at all concentrations evaluated. Concentrations of 10 μM and above produced pupillary dilation beyond that obtained with preoperative topical 1% tropicamide (the standard of care for cataract treatment). Flare photometry and pachymetry measurements did not demonstrate a reduction in anterior chamber inflammation or corneal edema associated with the addition of phenylephrine to the anterior chamber irrigation solution.

[0094] Video pupil data demonstrated that intraoperative delivery of ketorolac in the anterior chamber irrigation solution did not produce pupillary dilation changes substantially different from those observed with BSS alone. However, rapid dilation occurred once phenylephrine at a concentration of 30 μM was added to the irrigation solution. This confirmed the previously demonstrated utility of intraoperative delivery of phenylephrine. Flare photometry measurements demonstrated a positive effect of ketorolac on anterior chamber inflammation immediately postoperatively at 4.5 hours.

[0095] Example 7: Study of the combination of phenylephrine and ketorolac in a phacoemulsification model A non-GLP study was performed with an irrigation solution containing 90 μM PE and 30 μM KE to evaluate the effect of the combination when administered by intraocular irrigation during cataract surgery on mydriasis and inflammatory endpoints. In this experimental series, 14 monkeys were divided into groups of 7 and studied to establish the efficacy of BSS irrigation solutions containing BSS alone versus the PE and KE combination. Efficacy endpoints included mydriasis and laser flare photometry as a measure of anterior chamber inflammation. The control group was additionally given tropicamide, a muscarinic mydriatic, preoperatively to allow adequate dilation for use in the African Green Monkey model of phacoemulsification surgery.

[0096] (result) Animals perfused with the PE-KE combination achieved pupil dilation of 6.0-6.5 mm within approximately 60 seconds of perfusion (see Figure 26). These values ​​were equivalent to those obtained after preoperative treatment with tropicamide. After an initial pupil dilation of 3.0-4.0 mm within the first minute of initiating anterior chamber perfusion, pupil diameter plateaued within approximately 2.5 and 3.5 minutes, respectively, in both the tropicamide control and PE-KE-treated groups, with a significant effect of time on pupil diameter (F=86.69, P<0.0001; Student Newman-Keuls test, α=0.05, df=12) (see Figure 1). The early dilation (0–2 min) shown in the control group, which received topical tropicamide 20 min prior to irrigation with BSS alone, may not have been a pharmacological effect but may reflect dilation associated with the hydrodynamic effects of irrigation / aspiration and / or clearance of the viscoelastic material induced to allow for the creation of the corneal incision. However, of note, the early further dilation in the tropicamide control group was consistent with the greater baseline dilation at the start of treatment than in the treatment group. (F=86.69, P<0.0001; see FIG. 26), which produced a smaller maximum dilation than that exhibited by the PE-KE-treated group. PE-KE-mediated pupil dilation exceeded that achieved by preoperative administration of tropicamide within 90 seconds of the start of anterior chamber irrigation. The differences between the control group and the treatment group receiving PE-KE were significant at 0:00, 3:30, 4:00, 4:30, 5:00, 5:30, 6:00, 8:00, 10:00, 12:00, 12:30 and 13:00 minutes (F=25.08, p<0.003; F=5.61, p<0.0355; F=9.95, p<0.0083; F=14.71, p<0.0024; F=18.01, p<0.0011; F=9.93, p<0.0084; F=10.39, p<0.0073; F=14.77, p<0.0023; F=14.77, p<0.0023; F=28.65, p<0.0002; F=20.51, p<0.0007; F=8.66, p<0.0134; F=5.48, p<0.0391; Student Newman-Keuls test, α=0.05, df=12; see Figure 26).

[0097] The observed group differences confirmed the treatment effect of the PE-KE irrigation solution containing phenylephrine and ketorolac on the magnitude of intraoperative pupillary dilation and on the prolongation of intraoperative pupillary dilation. Although the differences between the two groups at early time points were not significant by the Student Newman-Keuls criteria, reflecting within-group variability, the trends observed in the mean pupil diameter suggest a treatment effect on both the rate of onset and the magnitude of the pupillary dilation effect. At later time points, the mean dilation in some subjects in the PE-KE treatment group approached the anatomical limit of pupillary dilation (corresponding to the inner diameter of the limbus) of approximately 10.5 mm in adult eyes of this species.

[0098] Baseline preoperative anterior chamber flare measurements ranged from 1.6 to 9.9 photon units / ms (mean=5.3±2.3) in the operated (right) eye in both treatment groups. There was a significant effect of time on flare measurements in the treated eye in both treatment groups, confirming the utility of flare photometry in quantifying intervention-related inflammation (see FIG. 27). Flare measurements in the treated eye at baseline vs. 2 hours, 4.5 hours, 24 hours, 48 ​​hours, and 1 week were significantly different across both treatment groups (F=4.94, p<0.0008; Student Newman-Keuls test, α=0.05, df=59).

[0099] The PE-KE treatment group had lower flare measurements over time compared to the tropicamide control group, but these did not reach statistical significance at any time point (F = 3.32, P<0.0935; Student Newman-Keuls test, α=0.05, df=12; see FIG. 27), in part reflecting the large variability in subject response to the experimental intervention. One PE-KE-treated subject exhibited more limited pupil dilation during anterior chamber irrigation complicating lens removal. Analysis of flare measurements excluding this animal reveals a statistically significant difference between the PE-KE-treated and tropicamide control groups at 2, 4.5, 24, and 48 hours (F=9.74, P<0.0097; Student Newman-Keuls test, α=0.05, df=11; see FIG. 28). At 1 week, there were no statistically significant differences between treatment groups.

[0100] (Conclusion) The African green monkey phacoemulsification model described above allowed for quantification of mydriasis and inflammatory measures that are relevant to human clinical endpoints. Of these measures, video pupil diameter assessment and anterior chamber flare photometry were the most responsive to treatment effects at the time points assessed. Video pupil data demonstrated that intraoperative delivery of PE-KE in the anterior chamber irrigation fluid produced rapid onset of mydriasis that was maintained throughout the surgical procedure. The resulting mydriasis was consistent with the phacoemulsification model. It was sufficient for the emulsification and aspiration procedure to occur within the first 60 seconds of irrigation. The degree of pupil dilation exceeded that achieved with preoperative topical 1% tropicamide (the standard of care for cataract treatment). Flare photometry measurements suggest a positive effect of PE-KE on anterior chamber inflammation immediately after surgery.

[0101] Example 8: Dose-Response Study of Phenylephrine and Ketorolac Combination in a Phacoemulsification Surgery Model This non-GLP study was conducted to establish the dose response and time course of mydriasis following intracameral delivery of perfusion solutions containing low, medium, and high concentrations of PE and KE to African green monkeys. The PE-KE formulation contained 45 mM phenylephrine and 15 mM ketorolac in a fixed ratio of 3:1 in 20 mM sodium citrate buffer (pH 6.5). A more concentrated 450 mM phenylephrine HCl (PE) formulation was provided to increase the phenylephrine concentration in the high dose group. The time course of mydriasis was assessed by video following intracameral administration of low concentrations of PE and KE (90:30 μM) perfusion solutions in four monkeys, medium concentrations (268:89 μM) in four monkeys, and high concentrations (1165:89 μM) in four monkeys. All intracameral administration volumes were 150 μL, with ejection of the syringe volume into the anterior chamber over approximately 5 seconds.

[0102] To mix the low concentration (PE:KE 90:30 μM), 1.0 mL was drawn from one vial of PE-KE drug composition and injected into a 500 mL BSS perfusion bottle. For the medium concentration (PE:KE 268:89 μM), three vials of PE-KE drug composition were used, with 1.0 mL drawn from each vial and injected into a 500 mL BSS perfusion bottle. For the high concentration group (PE:KE 1165:89 μM), additional phenylephrine HCl was added to the PE:KE in BSS solution.

[0103] (result) Monkeys injected with intracameral PE / KE perfusion solution achieved approximately 6-7 mm pupil dilation within 60 seconds of perfusion. As shown in Figure 29, after an initial rapid pupil dilation, pupil diameter plateaued at approximately 1 minute with a significant effect of time on pupil diameter among all treatment groups (F=64.33, p<0.0001). Differences between the low dose group (90:30 μM) and the high dose group (1165:89 μM) were statistically significant at 1:30, 3:00, and 3:30 minutes (Student Newman-Keuls test, α=0.05, df=9).

[0104] (Conclusion) The African green monkey mydriasis model allowed quantification of pupillary responses related to human clinical endpoints. Video pupillary data demonstrated that intracameral delivery of PE-KE to the anterior chamber produced rapid onset of mydriasis that was maintained throughout the 10-minute video recording period. The resulting mydriasis was sufficient for a phacoemulsification surgical procedure to be performed within the first 60 seconds after administration. The degree of mydriasis was greater than that obtained in the control arm of a previous efficacy study with preoperative delivery of topical 1% tropicamide (standard of care for cataract treatment) (mean pupil diameter 5.9 mm).

[0105] Example 9: Safety Study of Phenylephrine and Ketorolac Combination in a Phacoemulsification Surgery Model A non-clinical GLP toxicity study was conducted in African green monkeys. In this study, 12 male and 12 female monkeys underwent phacoemulsification surgery and lens replacement and were allowed to recover for 2 weeks. Continuous perfusion of PE-KE perfusion solution throughout the anterior chamber and associated ocular structures was performed during surgery, which represents the intended route of administration of this product. Three concentrations were evaluated: 720 μM PE and 90 μM KE (720:90) in the low concentration group; μM), 2160 μM PE and 270 μM KE (2160:270 μM) in the mid-range group, and 7200 μM PE and 900 μM KE (7200:900 μM) in the high-range group.

[0106] A separate control group was evaluated similarly. Equal numbers of male and female animals were allocated to each group, with weight ranks being assigned to achieve balanced average weights. All animals underwent surgery to replace intraocular lenses on day 0.

[0107] (result) All animals that tolerated the surgical procedure well had an uneventful recovery and survived until scheduled sacrifice and necropsy. No treatment-related effects were observed on respiratory and cardiovascular observations and all clinical laboratory parameters.

[0108] Initial intracameral delivery of 150 μL of each PE / KE perfusion solution produced rapid pupil dilation within 30 seconds, which increased in a dose-dependent manner from 6.76 ± 0.15 to 7.29 ± 0.15 mm (mean ± SD). Thirty seconds after intracameral delivery of 150 μL of BSS alone, the pupil diameter in the tropicamide control group was 5.18 ± 0.18 mm.

[0109] The low-treatment group had lower flare measurements compared to the tropicamide control group at 4.5 hours and 14 days, but they did not reach statistical significance at any time point, while the flare response in the high-treatment group was nearly equal to that of the control group at all time points. The mid-treatment group had higher flare measurements compared to the tropicamide control, low, and high at all postoperative time points, reaching significance at 2 hours, 4.5 hours, and 24 hours. These findings are believed to be secondary to the greater surgical trauma in the mid-treatment group. No concentration-dependent effect on flare was observed. At 2 weeks, there were no statistically significant differences between treatment groups.

[0110] In the control, low, and high treatment groups, intraocular pressure decreased after phacoemulsification surgery, but the difference from baseline did not reach significance. At 4.5 hours, intraocular pressure in the mid treatment group was significantly higher than in the other treatment groups, but not different than baseline. The overall trend was toward a decrease in intraocular pressure after surgery.

[0111] Baseline clinical assessments of the pupil, cornea, lens, and iris were within normal limits in the operated (right) and non-operated (left) eyes of all animals. Pupil diameter returned to baseline at 24 hours, indicating minimal residual treatment-related mydriatic or miotic effects.

[0112] Example 10: Clinical Study A Phase 2b human clinical trial evaluated a ketorolac and phenylephrine combination drug composition formulated according to Formulation 1 of the present invention for its effectiveness in maintaining intraoperative mydriasis (pupil dilation) and reducing postoperative pain and sensitivity resulting from cataract and other lens replacement surgery. The combination drug composition was diluted in a balanced salt solution perfusion carrier prior to intraocular administration during the intraocular surgical procedure.

[0113] The subject Phase 2b study was a randomized, parallel group, vehicle-controlled, factorial design study evaluating the efficacy and safety of phenylephrine (PE), ketorolac (KE), or ophthalmic solution in subjects undergoing unilateral cataract extraction and lens replacement (CELR) using a coaxial phacoemulsification process and acrylic lens insertion. ) and a combination drug composition containing both PE and KE. Administration of the test irrigation solutions was performed in a double-blind fashion. The study evaluated the contribution of two active pharmaceutical ingredients (PE and KE, alone and in combination) to maintaining pupil dilation and reducing postoperative pain when administered diluted in balanced salt solution (BSS) in a four-arm full factorial design. The study also investigated the effect of the combination drug composition, PE, and KE, on postoperative inflammation. Subjects were randomized in a 1:1:1:1 fashion to one of the following four treatment arms: a.BSS vehicle b.483μM PE in BSS c. 89 μM KE in BSS d. Combination drug composition containing 483 μM PE and 89 μM KE in BSS

[0114] All subjects in this study were given preoperative mydriatics and anesthetics. Each of the four groups received their respective irrigation treatment as a single irrigation of the anterior chamber of the eye during the CELR surgical procedure, with an average exposure of 8 minutes in this study. Additionally, at the end of the procedure, the anterior chamber was filled with irrigation. The pupil diameter change over time from surgical baseline (just before surgical incision) to the end of the surgical procedure (wound closure) was measured during postoperative pain on the day of surgery, as well as at 2 hours, 4 hours, 6 hours, 8 hours, and 10-12 hours by visual analog scale (VAS), before taking pain rescue medication, and other time measurements recorded by the patient.

[0115] In this 223-patient Phase 2b clinical trial, subjects treated with the combination drug composition demonstrated statistically significant (p<0.0001) and clinically meaningful maintenance of pupil dilation throughout the cataract procedure compared to either the BSS or KE groups. Maintenance of pupil dilation is important for a safe and successful lens exchange, considering that the ophthalmologist operates through the pupil. If pupil dilation is not maintained throughout the procedure, there is an increased risk of damaging intraocular structures and often prolongs the required surgical time. Any reduction in pupil size during surgery impedes the surgical procedure. In this study, the mean pupil diameter was 8.3 mm at the time of incision. A reduction of 2.5 mm or more ("extreme constriction") represents a loss of 30% of the diameter and 52% of the mean pupil area, with extreme potential impacts on the procedure. Unexpectedly, this study demonstrated that 21% of subjects in the BSS group and 21% of subjects in the KE group experienced this extreme shrinkage, compared to only 4% of subjects in the combination drug composition group.

[0116] Intraoperative complications are increased when the pupil diameter is less than 6 mm during lens exchange surgery. A categorical analysis on an intent-to-treat basis of intraoperative pupil diameter to identify characteristics of study subjects who experienced this level of pupil constriction. In this study, the combination drug composition was statistically significantly superior in preventing this degree of pupil constriction, i.e., miosis to a diameter of less than 6 mm, when compared to each of the other three treatment arms (Table XX). [Table 5]

[0117] A clinically significant decrease in pupil diameter is associated with an increase in procedure-related complications, including posterior capsule rupture, retained lens fragments, and vitreous leakage. These findings demonstrate that phenylephrine and ketorolac each contribute and act synergistically in preventing clinically significant miosis.

[0118] This finding is surprising because phenylephrine is a potent mydriatic drug and would be predicted to inhibit only miosis. Surprisingly, ketorolac also provided an antimiotic effect in addition to the effects of phenylephrine.

[0119] Furthermore, the combined drug composition also significantly reduced pain in the early postoperative period (10-12 hours after surgery) compared to either the PE group (p=0.0089) or the BSS group (p=0.0418). Surprisingly, the combined drug composition also reduced the frequency of moderate and severe pain complaints (2.5-fold more complaints in BSS-treated subjects). The drug composition was safe and well tolerated in this study.

[0120] This study demonstrates that the compositions and uses of the present invention claimed in the above-identified applications prevent extreme pupil constriction to a surprising degree and produce an unexpected reduction in moderate and severe post-operative pain for up to 10-12 hours after surgery after only a few minutes of exposure to the test drug during surgery.

[0121] Although the foregoing invention has been described in some detail by way of illustration and example, for purposes of clarity of understanding, it will be readily apparent to those skilled in the art in light of the teachings of the invention that certain changes and modifications can be made thereto without departing from the spirit or scope of the appended claims.

[0122] In a preferred embodiment of the present invention, for example, the following is provided:

[0123] (Section 1) A sterile, liquid pharmaceutical formulation comprising phenylephrine, ketorolac and a buffer system in an aqueous carrier, wherein the formulation is preservative-free and antioxidant-free and is stable for at least six months when stored at a temperature between 5±3° C. and 25±2° C. (Section 2) Item 2. The pharmaceutical formulation according to item 1, wherein the buffer system is selected from a sodium phosphate buffer system and a sodium citrate buffer system. (Section 3) Item 3. The pharmaceutical formulation according to item 2, wherein the buffer system comprises a sodium citrate buffer system. (Section 4) The pharmaceutical composition according to claim 3, wherein the buffer system comprises a 20 mM sodium citrate buffer system. formulation. (Section 5) Item 2. The pharmaceutical formulation according to item 1, wherein the pharmaceutical formulation has a pH of 5.8 to 6.8. (Section 6) 5. The pharmaceutical formulation according to item 4, having a pH of 5.8 to 6.8. (Section 7) Item 10. The pharmaceutical formulation according to item 1, wherein the formulation is stable for a period of at least 24 months when stored at a temperature of 5±3°C to 25±2°C. (Section 8) Item 10. The pharmaceutical formulation according to item 1, wherein the formulation is contained in a single-use container. (Section 9) Item 2. The pharmaceutical formulation according to item 1, wherein the formulation comprises 46 to 76 mM phenylephrine and 8.5 to 14 mM ketorolac. (Section 10) 10. The pharmaceutical formulation of claim 9, wherein the formulation comprises about 60.75 mM phenylephrine and about 11.25 mM ketorolac. (Section 11) Item 1. The pharmaceutical formulation according to item 1, further comprising an intraocular perfusion carrier into which the formulation is injected, wherein after injection, the phenylephrine is present at a concentration of 30-720 μM and the ketorolac is present at a concentration of 44-134 μM. (Section 12) Item 1. The pharmaceutical formulation according to item 1, further comprising an intraocular perfusion carrier into which the formulation is injected, wherein after injection, the phenylephrine is present at a concentration of 240-720 μM and the ketorolac is present at a concentration of 10-270 μM. (Section 13) Item 2. The pharmaceutical formulation according to item 1, wherein the phenylephrine and ketorolac are contained in a molar ratio of 1:1 to 13:1 phenylephrine:ketorolac. (Section 14) Item 2. The pharmaceutical formulation according to item 1, wherein the phenylephrine and ketorolac are contained in a molar ratio of 3:1 to 10:1 phenylephrine:ketorolac. (Section 15) A sterile, liquid pharmaceutical formulation consisting essentially of phenylephrine, ketorolac and a buffer system in an aqueous carrier, wherein the formulation is stable for at least six months when stored at a temperature between 5±3° C. and 25±2° C. (Section 16) Item 16. The pharmaceutical formulation according to item 15, wherein the buffer system comprises a sodium citrate buffer system. (Section 17) Item 16. The pharmaceutical formulation according to item 15, having a pH of 5.8 to 6.8. (Section 18) Item 16. The pharmaceutical formulation according to item 15, wherein the formulation is stable for a period of at least 24 months when stored at a temperature between 5±3°C and 25+2°C. (Section 19) Item 16. The pharmaceutical formulation according to item 15, wherein the formulation is contained in a single-use container. (Section 20) 16. The pharmaceutical formulation of claim 15, wherein the formulation comprises about 60.75 mM phenylephrine and about 11.25 mM ketorolac. (Section 21) Item 16. The pharmaceutical formulation of item 15, further comprising a perfusion carrier into which the formulation is infused, wherein after infusion, the phenylephrine is present at a concentration of 240-720 μM and the ketorolac is present at a concentration of 10-270 μM. (Section 22) Item 16. The pharmaceutical formulation according to item 15, wherein the phenylephrine and ketorolac are contained in a molar ratio of 3:1 to 10:1 phenylephrine:ketorolac. (Section 23) A sterile pharmaceutical liquid dosage form for injection, comprising phenylephrine, ketorolac, a buffer system and an aqueous carrier, packaged in a single-use container for injection. (Section 24) 24. The dosage form according to claim 23, wherein the container is selected from a vial closed with a closure from which the injection can be removed and a prefilled syringe. (Section 25) A sterile liquid pharmaceutical formulation comprising phenylephrine, ketorolac, a buffer system and an intraocular irrigation carrier, wherein the phenylephrine is present in a concentration of 30-720 μM and the ketorolac is present in a concentration of 10-270 μM. (Section 26) 26. The pharmaceutical preparation according to item 25, wherein the phenylephrine is contained at a concentration of 90 to 720 μM, and the ketorolac is contained at a concentration of 44 to 134 μM. (Section 27) 26. The pharmaceutical formulation according to claim 25, wherein the formulation is preservative-free and antioxidant-free.

Claims

【Request 1】 Mydriasis.

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