Topical Compositions and Methods

Abstract

The present invention relates to a pharmaceutical composition comprising L-epinephrine or a pharma- ceutically acceptable salt thereof; and a carrier vehicle comprising ethanol and water. The pharmaceutical composition has a molecular oxygen concentration of less than 5% (wt / vol) and a pH of less than 3. The present invention also relates to the use of the composition in the prevention of chemotherapy- or radiotherapy-induced conditions. The present invention also relates to a method of producing the pharmaceutical composition.

Description

[Technical field]

[0001] The present invention relates to pharmaceutical compositions comprising L-epinephrine, an alpha-adrenergic vasoconstrictor; and a carrier vehicle comprising ethanol and water. The present invention also relates to the use of these pharmaceutical compositions to prevent chemotherapy and / or radiation therapy induced patient conditions, such as oral mucositis, changes in patient speech and voice, dermatitis, alopecia, acute skin and mucositis, skin rash, skin ulceration, mucosal ulceration, depigmentation, pigmentation, scarring, and chronic fibrosis. The present invention also relates to methods of producing the pharmaceutical compositions. [Background technology]

[0002] Anticancer drug treatments are often associated with cytotoxic effects primarily against cancer cells, but also cause cytotoxic effects on non-malignant cells, tissues, and organs.

[0003] Radiation-induced oral mucositis (RIOM) and chemotherapy-induced oral mucositis (CIOM) occur when radiation and cytotoxic chemotherapy regimens destroy mucosa dividing basal cells of the mucosa, resulting in destruction of the cell layer lining the oral surface and predisposing mucosal tissue to ulceration and infection. It is the most common, debilitating and serious complication of cancer treatment and manifests as erythematous, edematous, or ulcerative lesions. Oral mucositis is almost always painful, affects eating, sleeping, and speaking, increases the risk of infection due to mucosal breaks, and significantly impacts quality of life and continuity of cancer treatment. Most importantly, oral mucositis often leads to interruption or cessation and modification of anticancer treatment regimens, resulting in less effective cancer control.

[0004] Similar basal cell damage and hair follicle stem cell damage induced by radiation and / or cytotoxic chemotherapy can lead to acute dermatitis and alopecia, and subsequent chronic ulcers or fibrotic changes.

[0005] Although skin and mucosal damage after anticancer treatment appears to be self-limiting and partially or mostly healable after the end of cancer treatment, it is particularly difficult to obtain optimal anticancer effects in patients who are physically and psychologically exhausted by side effects, including acute and chronic damage to normal skin and mucosa. In particular, oral mucositis after anticancer treatment is considered a dose-limiting early effect, as it leads to interruption of cancer treatment, poor local tumor control, and modification of dose fractionation, which may prolong the overall treatment period and impair local control and overall survival. Side effects of radiation-induced oral mucositis include oral pain in 69% of patients, dysphagia in 56% of patients, opioid use in 53% of patients, weight loss of 3 to 7 kg, feeding tube insertion and hospitalization (ICU admission) in 15% of patients, and modification or interruption of treatment in 11 to 16% of patients (Maria OM, 2017).

[0006] Numerous efforts have been made to identify effective agents for the management of chemotherapy-induced oral mucositis in cancer patients. These interventions include aloe vera, amifostine, cryotherapy, granulocyte colony-stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser irradiation, polymyxin / tobramycin / amphotericin (PTA) antibiotic tablets / paste, sucralfate, and natural and homeopathic medicines, which offer some benefits in terms of preventing or reducing the severity of mucositis associated with cancer treatment. Among them, cryotherapy, palifermin, and sucralfate have shown statistically significant benefits in preventing or reducing the severity of mucositis induced by some types of chemotherapy. However, their routine use is not recommended for patients undergoing treatment for solid tumors such as head and neck cancer (De Sanctis V, 2016).

[0007] Currently, there is no single agent or management regimen that significantly improves the prevention of radiotherapy-induced severe mucositis to a satisfactory and clinically meaningful level, representing a significant unmet clinical need for many cancer patients (De Sanctis V, 2016; Maria, 2017; Chaveli-Lopez B, 2016; Alvarino-Martin C, 2014).

[0008] The main therapeutic indications for epinephrine are for the treatment of reduced cardiac output, anaphylactic shock, acute bronchospasm, laryngotracheobronchitis, urticaria, or angioedema. The action of epinephrine is dose-dependent, being primarily a beta agonist at low concentrations and an alpha agonist at higher concentrations, increasing systemic vascular resistance, the latter possibly decreasing cardiac output. Epinephrine has a potent bronchodilator effect, most pronounced when bronchial muscles are constricted. Besides intramuscular, intravenous, subcutaneous, and intra-arterial routes of administration for the main clinical indications, topical epinephrine (i.e., inhaled, intraocular, and topical) has also been used extensively in humans. Epinephrine may be added to solutions of some local anesthetics to reduce the rate of vascular absorption of the anesthetic. Epinephrine is also used topically, primarily during surgery, to control superficial bleeding from arterioles and capillaries in the skin and in the mucous membranes of the eyes, nose, mouth, throat, or larynx. This drug is particularly useful in oral surgery. In ophthalmology, topical epinephrine is used primarily to relieve elevated IOP in the treatment of open-angle (chronic simple) glaucoma. Epinephrine may be applied topically to the nasal mucosa as a decongestant and may be used to temporarily relieve episodic symptoms of bronchial asthma and reversible bronchospasm (AHFS Drug Information 2009).

[0009] WO 2006 / 138691 A1 describes the use of topical vasoconstrictors to protect cells during cancer chemotherapy and radiation therapy. The present inventors have further developed a series of L-epinephrine modified formulations as oral topical mouthwashes and skin topical solutions / semi-solutions to prevent radiation-induced acute oral mucositis, dermatitis, and alopecia in cancer patients undergoing radiation therapy and / or chemoradiotherapy.

[0010] L-epinephrine and its salt forms, such as the non-selective adrenergic agonist epinephrine HCl, are endogenous catecholamines secreted from the adrenal medulla in response to stress. It has a pronounced effect on α- and β-adrenergic receptors, and its effect depends on the tissue distribution of the α- and β-adrenergic receptors to which it binds. In general, α-1 and α-2 adrenergic receptors are present in the smooth muscle cells of the vascular wall, especially in the dermal blood vessels, and are involved in peripheral vasoconstriction.

[0011] Early studies in several animal models using topical application of vasoconstrictors such as epinephrine, norepinephrine, and phenylephrine showed that they successfully prevented mucositis, dermatitis, and alopecia induced by ironing radiation (Soref, 2014; Soref, 2015; Fahl, 2016).

[0012] Another report showed that local application of the adrenergic vasoconstrictors phenylephrine, epinephrine, or norepinephrine did not prevent radiotherapy effects on cancer tissue in three xenograft tumor mouse models, a result consistent with historical observations that human tumor vasculature lacks the adrenergic receptor-bearing smooth muscle cells required to respond to adrenergic vasoconstrictors (Fahl, 2014; Graul-Conroy, 2016).

[0013] In addition, several clinical studies have been conducted to preliminarily observe the safety and potential efficacy of topical application of norepinephrine and phenylephrine in preventing and reducing radiation- or chemoradiation-induced dermatitis, alopecia, and oral mucositis (Cleary, 2017; Graul-Conroy, 2018). These preliminary clinical readouts showed a favorable safety profile of topical oral and cutaneous application of adrenergic vasoconstrictors in the cancer patients studied. However, norepinephrine or phenylephrine is half or one-fifth as potent as epinephrine (Fahl, 2016). For this reason, further inventions are undertaken to develop a topical composition using epinephrine, a highly effective vasoconstrictor, particularly L-epinephrine, the active form of epinephrine, as an active pharmaceutical ingredient, which has good pharmaceutical stability and can be applied locally to the oral cavity and / or skin, for use as a pharmaceutical for preventing mucositis, dermatitis, and alopecia induced by cancer treatment in cancer patients. Summary of the Invention

[0014] The present invention discloses pharmaceutical compositions comprising the vasoconstrictor L-epinephrine and methods for preventing or reducing side effects often experienced during the course of cancer treatment by topically applying these pharmaceutical compositions to the oral mucosa, skin, or scalp at empirically determined concentrations and times.

[0015] In a first aspect of the present invention, there is provided a pharmaceutical composition comprising 0.9 mg / ml to 15 mg / ml of L-epinephrine or a pharma- ceutically acceptable salt thereof. The composition also comprises a carrier vehicle comprising ethanol and water. The pharmaceutical composition has a molecular oxygen concentration of less than 5% (wt / vol) and a pH of less than 3.

[0016] This pharmaceutical composition has been surprisingly and advantageously found to be particularly effective at penetrating the oral mucosa and delivering the adrenergic vasoconstrictor L-epinephrine to the oral submucosal vasculature, inducing transient vasoconstriction and hypoxia at the treatment site, such that upon subsequent irradiation with radiotherapy, the treatment area is deprived of oxygen, and any ROS-modified DNA nucleotides produced decay (within milliseconds) back to their original basal state, without radiation toxicity.

[0017] Constriction of blood vessels by the pharmaceutical compositions of the present invention can protect healthy cells in the treatment area from any systemic chemotherapeutic agents because the blood supply containing cytotoxic agents and inflammatory cytokines / chemokines is reduced at the site of vasoconstriction, reducing exposure to these harmful agents.

[0018] As a result, the death of healthy cells in the oral mucosa caused by radiation therapy and / or chemotherapy is reduced by the pharmaceutical composition of the present invention.

[0019] Furthermore, this pharmaceutical formulation also exhibits a high degree of stability compared to prior art formulations, and is therefore a promising improved treatment for radiotherapy- or chemotherapy-induced conditions affecting the oral mucosa.

[0020] Thus, a second aspect of the invention provides a pharmaceutical composition according to the first aspect for use in preventing chemotherapy-induced and / or radiotherapy-induced oral mucositis and / or speech and voice changes in a patient, the pharmaceutical composition being for orotopical administration to surfaces of the patient's oral cavity or oropharyngeal cavity.

[0021] In a third aspect, the present invention provides a pharmaceutical composition comprising 0.92 mg / ml to 36.6 mg / ml of L-epinephrine or a pharma- ceutically acceptable salt thereof. The composition also comprises a carrier vehicle comprising ethanol and water. The pharmaceutical composition has a molecular oxygen concentration of less than 5% (wt / vol) and a pH of less than 3.

[0022] The applicant has found that this pharmaceutical composition is particularly suitable for transdermal delivery of L-epinephrine to the subcutaneous vasculature of the skin or scalp, inducing a transient state of vasoconstriction and hypoxia at the treatment site, which, when the treatment area is subsequently subjected to radiation therapy, mitigates the death of healthy squamous epithelial cells as a result of oxygen deprivation due to the action of the vasoconstrictor.

[0023] Blood vessel constriction also prevents cellular damage from these chemotherapy agents by reducing the amount of blood carrying these agents in the vicinity of the cells at the treatment site.

[0024] As a result, the death of healthy cells in the epidermis of the skin or hair follicles caused by radiation therapy and / or chemotherapy is mitigated.

[0025] Furthermore, this pharmaceutical formulation also exhibits a high degree of stability compared to prior art formulations, and is therefore a promising improved treatment for radiotherapy-induced or chemotherapy-induced conditions affecting the squamous epithelium or scalp.

[0026] Thus, in a fourth aspect, the present invention provides a pharmaceutical composition according to the third aspect for use in the prevention of a radiotherapy induced condition selected from the group consisting of dermatitis, alopecia, acute dermatitis and mucositis, skin rash, skin rash, skin ulceration, mucosal ulceration, depigmentation, pigmentation, scarring and chronic fibrosis, wherein the composition is for topical administration to the squamous epithelium and / or scalp of a patient.

[0027] A fifth aspect of the invention provides a method for producing a pharmaceutical composition, the method comprising the steps of: a) adding water to a container; b) purging the water in the vessel with nitrogen gas until the amount of dissolved molecular oxygen reaches 5% (wt / vol) or less; c) adding ethanol to the vessel followed by at least one antioxidant to form a composition; d) adding to said composition at least one adrenergic vasoconstrictor or a pharma- ceutically acceptable salt thereof; and e) adjusting the pH of the composition to less than 3; Includes.

[0028] Compositions produced in this manner have a molecular oxygen concentration of less than 5% (wt / vol).

[0029] This method results in the production of highly stable pharmaceutical compositions that maintain their therapeutic efficacy even after long-term storage. [Brief description of the drawings]

[0030] [Figure 1] FIG. 1 is a schematic diagram of the mechanism of action by which locally applied adrenergic vasoconstrictors protect normal skin / mucosa from radiation and chemotherapy damage, thereby enhancing anticancer therapy. [Diagram 2] FIG. 2 shows the stepwise HCl titration of L-epinephrine base dissolved in an oral topical delivery vehicle until a final formulation pH of 2.50 was achieved. [Diagram 3] FIG. 3 shows the peak areas of L-epinephrine and adrenochrome measured by HPLC when samples of "L-epi-Base" (pH 2.50) and "L-epi-HCl" (pH 5.05) were stored at 40° C. in the dark for 10 days. [Figure 4] Figure 4 (from Kerr et al, J Dental Res, 1991) outlines the typical internal surface area of ​​the human oral cavity. [Diagram 5] Figure 5 shows a lip blanching study in four healthy volunteers using four concentrations of L-epinephrine in an oral topical solution. The lip blanching photograph shows blanching after application of a 5.5 mg / ml L-epinephrine solution to the lower lip. The symbols and their meanings are as follows:- no blanching response;+ slight blanching response;++ moderate blanching response;+++ marked blanching response. [Figure 6]Figure 6 (from Fahl WE., Arch Dermatol Res. 2016 Dec) shows the relative efficacy of three adrenergic vasoconstrictors, epinephrine, norepinephrine, and phenylephrine, in suppressing radiation-induced dermatitis 13 days after 17.5 Gy of radiation to a shaved rat dorsal skin patch. [Figure 7] 7 shows a skin blanching study on the forearm of a healthy volunteer using topical application of a pharmaceutical composition containing 3 mg / ml L-epinephrine and ethanol. The treated area of ​​the skin showed visible blanching, most notably around the hair roots (arrows), beginning 14 minutes after topical application. [Figure 8] FIG. 8 shows that a pharmaceutical formulation containing a carrier vehicle containing ethanol and water; and L-epinephrine; deoxygenated to a molecular oxygen concentration of less than 5% (wt / vol) has a pH greater than 6. Excess HCl is added to the formulation to achieve a final pH less than 3, preferably about pH 2.3. The increase in HCl loading volume and L-epinephrine concentration show a linear correlation. This correlation can be expressed as: Y=5.6297*X-5.3044, correlation ratio R2=0.9916 X: L-epinephrine concentration (mg / ml); Y: 2N HCl loading volume in the pharmaceutical composition. The correlation is calculated based on measurements taken during the manufacture of a carrier vehicle formulation without L-epinephrine, a 0.92 mg / ml L-epinephrine formulation solution, and a 5.5 mg / ml L-epinephrine formulation solution. [Figure 9]9 shows the blanching response on the forearm of a human subject 30 minutes after topical application of a pharmaceutical composition containing L-epinephrine and a carrier vehicle containing ethanol and water, deoxygenated to a molecular oxygen concentration of less than 5% (wt / vol), and adjusted to a pH of 2.33. Forearm skin blanching test (from left to right): 1. L-epi 3.6 mg / ml formulation (pH 2.33), with ethanol, deoxygenated; blanched 30 minutes after skin application. 2. L-epi 3.6 mg / ml formulation (pH 2.33), without ethanol, deoxygenated; no blanching. 3. L-epi 3.6 mg / ml formulation (pH 2.33), no antioxidant; no blanching. 4. L-epi 3.6 mg / ml formulation (pH 5.5), deoxygenated; no blanching. 5. L-epi 3.6 mg / ml formulation (pH 2.33), deoxygenated, exposed to sunlight for 24 hours; blanched 30 minutes after skin application. The absence of blanching from solutions without ethanol, oxygen scavengers, or adjustment of pH to <3 further confirmed the critical contribution of a carrier vehicle containing ethanol and water, deoxygenated to <5% oxygen (wt / vol), in combination with a pH <3, to L-epinephrine bioavailability and stability. [Figure 10] 10 is a photograph of a pharmaceutical composition containing 5 mM (0.92 mg / ml) L-epinephrine and a molecular oxygen concentration of 20% (wt / vol) at temperatures of 40° C. and 60° C. (Example 9). Under high temperature stress conditions at 60° C., the color of the sample changed from colorless and transparent to light brown. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0031] In a first aspect, the present invention provides a pharmaceutical composition comprising 0.9 mg / ml to 36.6 mg / ml of L-epinephrine or a pharma- ceutically acceptable salt thereof. In addition, the composition comprises a carrier vehicle comprising ethanol and water. The pharmaceutical composition has a molecular oxygen concentration of less than 5% (wt / vol). The pH of the final pharmaceutical composition is less than 3.

[0032] This pharmaceutical composition was developed to protect normal epithelial cells of the oral mucosa of a patient from the toxic effects of treatment with radiation or chemotherapeutic agents commonly used in cancer therapy, which can be understood by reference to FIG.

[0033] FIG. 1 is a schematic representation of the mechanism of action by which locally applied adrenergic vasoconstrictors protect normal skin / mucosa from radiation and chemotherapy damage, thereby enhancing anticancer therapy.

[0034] Part A of Figure 1 shows the mechanism for normal skin and mucosa blood vessels. Due to the presence of intact smooth muscle in the peripheral vascular walls of normal skin and mucosa, local application of vasoconstrictors successfully induces vasoconstriction via α-adrenergic receptors. Transient induction of vasoconstriction creates a transient hypoxic state around the basal cells, which switches the cells temporarily into the G0 cell cycle, which "hides" the radiation-vulnerable basal cells from radiation damage. After radiation, the transient vasoconstriction effect is reduced, and undamaged basal cells re-enter the division cycle after treatment, facilitating healing of the skin and mucosa structures. Meanwhile, the reduced blood supply minimizes the production of reactive oxygen species (ROS), which in turn reduces ROS-induced DNA damage. Approximately 70% of the cytotoxic effects of ionizing radiation and chemotherapy are due to ROS-mediated DNA damage. Thus, minimizing ROS production is a major contributor to the protective effect of local application of vasoconstrictors on basal cells from radiation and chemotherapy damage. Furthermore, a reduced blood supply can also reduce inflammatory cytokines and chemokines, which in turn can reduce the incidence and symptoms of inflammation.

[0035] Part B of Figure 1 shows the mechanism of blood vessels in cancer tissues. Most of the blood vessels in such cancer tissues are immature and lack smooth muscle containing α-adrenergic receptors in the vessel wall. Therefore, local application of adrenergic vasoconstrictors does not induce vasoconstriction and hypoxia in cancer tissues. Therefore, local application of vasoconstrictors does not protect cancer tissues from damage caused by radiation therapy and chemotherapy.

[0036] The claimed concentrations of L-epinephrine, when applied topically to the oral mucosa, skin, or scalp of a patient, are sufficient to transiently constrict submucosal or subcutaneous blood vessels, reducing the amount of oxygenated blood reaching stem cells within the mucosa, epidermis, or hair follicles.

[0037] During subsequent radiation therapy, the treatment area becomes oxygen-deprived, so any ROS-modified DNA nucleotides generated decay (within milliseconds) back to their original ground state, without any radiation toxicity.

[0038] Also, the constriction of blood vessels by the pharmaceutical composition of the present invention can reduce the amount of oxygenated blood in the treatment area and protect healthy cells in the treatment area from any systemic chemotherapy agents, thereby mitigating the death of healthy cells around the treatment site.

[0039] The pure L-epinephrine enantiomer is not pharmacologically diluted by the inactive R-enantiomer. It is therefore twice as potent as the racemic + / - epinephrine HCl used in many injectable epinephrine products (Nutman et al., Crit Care Med 1994). Existing art describing the formulation of racemic + / - epinephrine HCl salt or (-) epinephrine bitartrate salt does not provide guidance on how to formulate the aromatic free base form of L-epinephrine in the water + alcohol carrier required for transmucosal and transdermal delivery for oral topical and local administration, and in which the free base is chemically insoluble. Thus, the present inventors have devised specific conditions that can be effectively used to deliver the pure L-enantiomer through the oral mucosa, through squamous epithelium, or into scalp hair follicles.

[0040] The L-epinephrine contained in the pharmaceutical composition of the present invention may be present as a pharma- ceutically acceptable salt. By "pharma-ceutically acceptable salt" is meant a salt of a free acid or base of a compound that is non-toxic, biologically acceptable, or biologically suitable for administration to a subject. Such pharma-ceutically acceptable salts are known to those skilled in the art.

[0041] Examples of suitable pharma- ceutically acceptable salts include salts that are pharmacologically effective and suitable for contact with the tissues of a subject without undue toxicity, irritation, or allergic response. The compounds of the present invention may have sufficient acidic groups, sufficient basic groups, or both types of functional groups, such that they may react with a number of inorganic or organic bases, and inorganic and organic acids, to form pharma- ceutically acceptable salts.

[0042] Pharmaceutically acceptable acid addition salts can be formed with inorganic and organic acids, and pharma- ceutically acceptable base addition salts can be formed with inorganic and organic bases.

[0043] Examples of pharma- ceutically acceptable salts include sulfates, sulfites, phosphates, chlorides, hydrochlorides, bromides, iodides, acetates, propionates, acrylates, formates, benzoates, sulfonates, citrates, lactates, glycolates, tartrates, and bitartrates, among others.

[0044] Particularly preferred salts of L-epinephrine include L-epinephrine hydrochloride and L-epinephrine bitartrate.

[0045] The inventors of the present application have found that by ensuring that the amount of dissolved oxygen in the pharmaceutical composition is less than 5% (wt / vol), the stability of the pharmacologically active ingredient L-epinephrine is greatly improved and can be maintained for at least 3 months. It has also been found that the aerosol phase of the final product in the final container / vial also has a better stability if the amount of oxygen is less than 5% (wt / vol). This provides an improvement to the problem that the pharmacologically active ingredient L-epinephrine is easily oxidized and decomposed in known compositions with oxygen concentrations exceeding 5% (wt / vol), resulting in a decrease in therapeutic efficacy.

[0046] Methods for measuring the amount of oxygen in a solution are known to those skilled in the art. In the method described in the examples herein, an industrial oxygen concentration meter with a probe, Oxysense 325i, is used.

[0047] As shown by the examples herein, compositions comprising L-epinephrine and a carrier vehicle comprising water and ethanol will not inherently have less than 5% (wt / vol) oxygen unless the oxygen is actively controlled and reduced, which can be accomplished by adding antioxidants such as sodium metabisulfite to neutralize oxygen during the manufacturing process in combination with a nitrogen purge.

[0048] Ensuring that the pH of the carrier solution is less than 3 advantageously improves the dissolution and stabilization of L-epinephrine free base, such that pharmaceutical compositions according to the invention contain more dissolved, bioavailable L-epinephrine drug molecules to induce vasoconstriction, resulting in improved efficacy.

[0049] The pharmaceutical composition may include hydrochloric acid. This ingredient may be added to the pharmaceutical composition to reach the pH required in claim 1. Hydrochloric acid may be the only additional acidic compound added to lower the pH. Alternatively, hydrochloric acid may be added in combination with other acidic compounds to lower the pH of the pharmaceutical composition.

[0050] The volume of hydrochloric acid added to the composition may exhibit a linear correlation to the concentration of L-epinephrine. In some embodiments, the linear correlation equation can be written as follows: Y=5.6297*X-5.3044, correlation ratio R2=0.9916 X: L-epinephrine concentration (mg / ml); Y: The added volume of 2N HCl in the pharmaceutical composition of claim 1.

[0051] Hydrochloric acid can effectively solubilize L-epinephrine by lowering the pH of the pharmaceutical composition, thereby allowing it to be administered effectively to patients, and this lowered pH also improves the long-term storage stability of the pharmaceutical composition, resulting in an improved commercial product with a longer shelf life.

[0052] The carrier vehicle, which includes ethanol and water, renders the pharmaceutical composition suitable for transdermal delivery of L-epinephrine to the subcutaneous vasculature of the skin or scalp, or buccal topical delivery to the submucosal vasculature of the oral cavity.

[0053] In one embodiment according to the first aspect of the invention, the carrier vehicle further comprises glycerol and / or propylene glycol, preferably both glycerol and propylene glycol, which is particularly suitable for transdermal delivery of L-epinephrine for topical application of the pharmaceutical composition to the skin or scalp.

[0054] Preferably, the carrier vehicle of this embodiment comprises 2%-10% (vol / vol) ethanol, 2%-10% (vol / vol) glycerol, 4%-12% (vol / vol) propylene glycol, and 70%-90% (vol / vol) water. In one embodiment according to the first aspect of the invention, the carrier vehicle comprises a vol:vol ratio of ethanol:glycerol:propylene glycol:water of 6:6:8:80. It is also envisioned that the carrier vehicle according to the invention may exclude (i.e., not include) the specific vol:vol ratio of ethanol:glycerol:propylene glycol:water of 6:8:8:80.

[0055] The pharmaceutical composition according to the first aspect of the present invention comprises L-epinephrine or a pharma- ceutically acceptable salt thereof in an amount of 0.9 mg / ml to 15 mg / ml. Preferably, L-epinephrine or a pharma- ceutically acceptable salt thereof is present in the range of 0.9 mg / ml to 11 mg / ml, 0.9 mg / ml to 9 mg / ml, 1.8 mg / ml to 9 mg / ml, 1.8 mg / ml to 7.5 mg / ml, 2.7 mg / ml to 7.5 mg / ml, and most preferably 2.7 mg / ml to 5.5 mg / ml. Alternatively, L-epinephrine may be contained in an amount of 0.9 mg / ml to 5.5 mg / ml.

[0056] The L-epinephrine concentration in mM, which corresponds to the above values ​​in mg / mL, may be 5 mM to 80 mM, preferably 5 mM to 60 mM, 5 mM to 50 mM, 10 mM to 50 mM, 10 mM to 40 mM, 15 mM to 40 mM, and most preferably 15 mM to 30 mM. Alternatively, L-epinephrine may be contained in an amount of 5 mM to 30 mM.

[0057] The pharmaceutical composition according to the invention has a molecular oxygen content of less than 5% (wt / vol). Preferably, the molecular oxygen concentration of the pharmaceutical composition is less than 4.5% (wt / vol), preferably less than 4.0% (wt / vol), preferably less than 3.5% (wt / vol), preferably less than 3.0% (wt / vol), most preferably less than 2.5% (wt / vol).

[0058] In addition to L-epinephrine, the pharmaceutical composition may further comprise an additional vasoconstrictor, such as D-epinephrine, DL-epinephrine, and / or pharma- ceutically acceptable salts thereof.

[0059] The pharmaceutical composition may also further comprise one or more antioxidants, preferably in an amount of 0.01-0.5% (wt / vol), which can inhibit oxidation that can generate ROS and chain reactions that can damage cells.

[0060] Preferably, the antioxidant is selected from the group consisting of bisulfites such as sodium metabisulfite, citric acid, vitamin C, vitamin E, L-cysteamine, or combinations thereof. Most preferably, the antioxidant is sodium metabisulfite, citric acid, or a combination thereof.

[0061] The pharmaceutical compositions of the invention may also include one or more penetration enhancers. Examples of suitable penetration enhancers include isopropyl myristate (supplied by Tegosoft M) or medium chain monoglycerides.

[0062] The pharmaceutical compositions according to the invention may comprise one or more keratolytic ingredients. One example of a suitable keratolytic ingredient is lactic acid.

[0063] The pharmaceutical composition may also further comprise one or more sweeteners, preferably in an amount of 0.01-5% (wt / vol). Instead of or in addition to a sweetener, the pharmaceutical composition may comprise one or more flavorings, preferably in an amount of 0.05-2% (wt / vol). The inclusion of a sweetener and / or flavoring in the pharmaceutical composition improves the palatability of the pharmaceutical composition to the patient and allows for prolonged topical application to the oral cavity. The composition comprises a sucralose sweetener and / or a cherry flavoring.

[0064] It is contemplated that the present invention may explicitly exclude (i.e., not include) pharmaceutical compositions having the following combinations of features: 0.01-0.5% (wt / vol) of one or more antioxidants; 0.01 to 5% (wt / vol) of one or more sweeteners; and 0.05-2% (wt / vol) of one or more flavorings.

[0065] It is also contemplated that the present invention may explicitly exclude (i.e., not include) pharmaceutical compositions comprising a carrier vehicle comprising the specific ratio of ethanol:glycerol:propylene glycol:water of 6:6:8:80 (vol:vol) in combination with 0.01-5% (wt / vol) of one or more sweeteners and / or 0.05-2% (wt / vol) of one or more flavoring agents.

[0066] The composition can be formulated in many ways. Preferably, the composition is formulated in a way that allows for easy and effective oral topical application to the patient's oral mucosa. Preferably, such compositions are formulated as mouthwashes, gels, balms, oils, pastes, or aerosols.

[0067] According to a second aspect, the present invention provides a pharmaceutical composition according to the first aspect for use in the prevention of chemotherapy-induced and / or radiotherapy-induced oral mucositis in a patient and / or speech and voice changes in a patient, the composition being for oral topical administration to surfaces of the patient's oral cavity or oropharyngeal cavity.

[0068] According to the method of using the oral topical formulation developed by the applicant, sufficient L-epinephrine can be rapidly and efficiently delivered to the submucosal blood vessels within the time constraints of clinical practice (a few minutes) by ensuring sufficient drug molecules, drug formulation volume, and contact time of the drug formulation with the oral mucosa, thereby providing protection against short-term (a few seconds to a few minutes) radiation therapy damage or long-term chemotherapy damage by repeated application by causing rapid and sufficient vasoconstriction.

[0069] L-epinephrine may be applied topically to the oral mucosa by "swish and spit" administration (i.e., mouthwash) for 1-3 minutes, preferably 1.5-2.5 minutes, which offers the following advantages over existing oral cryotherapy techniques: i) There is no discomfort associated with filling the mouth with ice; ii) It can also be used in head and neck radiotherapy patients who cannot use ice; iii) adrenergic agonist-induced vasoconstriction can be controlled in a predictable manner by standard dosing and application time strategies; i.e., by a single application of vasoconstrictor prior to each daily radiotherapy session, with a rapid dissipation of the transient hypoxic effect, or by multiple applications of vasoconstrictor over several hours, with sustained clearance of blood-borne chemotherapy from the oral mucosa over 1-2 plasma half-lives of systemic chemotherapy; iv) Protection of the epithelium of the oral cavity and tongue surfaces, which come into contact with vasoconstrictors administered topically in the oral cavity, may also result in protection of the taste buds.

[0070] The pharmaceutical composition for use according to the second aspect preferably contains from 0.03 to 3 milligrams per cm 2 The present invention is for administering L-epinephrine to a patient in a dosage suitable for providing 0.9 mg / ml to 7.5 mg / ml of L-epinephrine to surfaces of the oral or oropharyngeal cavity to be treated. Applicants have determined that a particular formulation concentration range of 0.9 mg / ml to 7.5 mg / ml of L-epinephrine is administered within 1 cm of the mucosal surface. 2The authors found that this was associated with an oral topical dose range of L-epinephrine of 0.03 mg to 3 mg per dose.

[0071] Preferably, the pharmaceutical composition for use is for administration to oral or oropharyngeal surfaces of a patient undergoing radiotherapy and / or chemoradiotherapy. The pharmaceutical composition may be administered within 50 minutes prior to the first and each subsequent fraction of radiation administered to the oral or oropharyngeal surfaces to be treated.

[0072] Preferably, the pharmaceutical composition is administered within 45 minutes, preferably within 40 minutes, preferably within 35 minutes, preferably within 30 minutes prior to radiation exposure.

[0073] In one embodiment, the L-epinephrine pharmaceutical composition may be delivered locally to the oral cavity via a single mouthwash for 30 seconds to 2 minutes to protect the oral mucosa from daily doses of 0.5 to 5 Gy of radiation therapy to the head and neck region.

[0074] In a third aspect, the present invention provides a pharmaceutical composition comprising 0.92 mg / ml to 36.6 mg / ml of L-epinephrine or a pharma- ceutically acceptable salt thereof. The composition comprises a carrier vehicle comprising ethanol and water. The pharmaceutical composition has a molecular oxygen concentration of less than 5% (wt / vol), and the pH of the pharmaceutical composition is less than 3.

[0075] This pharmaceutical composition is particularly suitable for protecting normal epidermal stem cells of the squamous epithelium as well as differentiated stem cells of the scalp epidermis and hair follicles from the toxic effects of radiation or chemotherapy treatment.

[0076] Preferably, the pharmaceutical composition according to the third aspect comprises hydrochloric acid. This ingredient may be added to the pharmaceutical composition to reach the pH required in claim 13. Hydrochloric acid may be the only additional acidic compound added to lower the pH. Alternatively, hydrochloric acid may be added in combination with other acidic compounds to lower the pH of the pharmaceutical composition.

[0077] The volume of hydrochloric acid added to the composition may exhibit a linear correlation to the concentration of L-epinephrine. In some embodiments, the linear correlation equation can be written as follows: Y=5.6297*X-5.3044, correlation ratio R2=0.9916 X: L-epinephrine concentration (mg / ml); Y: The added volume of 2N HCl in the pharmaceutical composition of claim 1.

[0078] Hydrochloric acid can effectively solubilize L-epinephrine by lowering the pH of the pharmaceutical composition, thereby allowing it to be administered effectively to patients, and this lowered pH also improves the long-term storage stability of the pharmaceutical composition, resulting in an improved commercial product with a longer shelf life.

[0079] The carrier vehicle of the pharmaceutical composition preferably comprises 60%-80% (vol / vol) ethanol; and 20%-40% (vol / vol) water. In one embodiment, the ratio of ethanol:water in the carrier vehicle is 70:30 (vol:vol). This carrier vehicle is suitable for transdermal delivery of L-epinephrine to the skin or subcutaneous vasculature of the scalp. The present invention may explicitly exclude pharmaceutical compositions comprising a carrier vehicle that comprises the specific ratio of 70:30 (vol:vol) ethanol:water.

[0080] Preferably, one or more antioxidants are included in the pharmaceutical composition, preferably in an amount of 0.01 to 0.5% (wt / vol).

[0081] The pharmaceutical composition according to the third aspect may be formulated in a number of ways suitable for topical application to the skin or scalp of a patient. Preferably, the composition is formulated as a gel, shampoo, balm, oil, paste, or cream.

[0082] According to a fourth aspect, the present invention provides a pharmaceutical composition according to the third aspect of the invention for use in the prevention of a radiotherapy-induced condition, the condition being selected from the group consisting of dermatitis, alopecia, acute dermatitis, rash, ulceration, mucosal ulceration, depigmentation, pigmentation, scarring and chronic fibrosis, the pharmaceutical composition being for topical administration to the squamous epithelium and / or scalp of a patient.

[0083] The method of using the topical formulation developed by the applicant ensures sufficient drug molecules, formulation volume, and contact time of the drug formulation with the squamous epithelium or scalp, so that sufficient L-epinephrine can be delivered to the subcutaneous blood vessels quickly and efficiently within the time constraints of clinical practice (a few minutes). As a result, vasoconstriction is caused quickly and for a sufficient period of time, providing protection against short-term (seconds to minutes) radiation therapy damage, or long-term chemotherapy damage through repeated topical application to the scalp. This is based on the scalp branching time per unit dose of L-epinephrine determined by the inventors of the present application.

[0084] In one embodiment, the pharmaceutical composition is administered at a dose of 0.03 mg to 3 mg / cm2 onto the treated squamous epithelial surface or scalp surface of the patient. 2 The present applicants have determined that a particular formulation concentration range of 0.9 mg / ml to 15 mg / ml of L-epinephrine is suitable for administration to a subject at a dose suitable to provide 100 mg / ml of L-epinephrine per cm of the skin or scalp surface. 2 They found that this was associated with a local dose range of L-epinephrine of 0.03 mg to 3 mg per minute.

[0085] Preferably, the composition is for administration to the squamous epithelium or scalp surface of a patient undergoing radiotherapy and / or chemoradiotherapy. Preferably, the composition is for administration within 5-50 minutes prior to the first and each subsequent fractionated radiation exposure to the squamous epithelium or scalp surface of the patient.

[0086] Preferably, the pharmaceutical composition is administered within 50 minutes, preferably within 45 minutes, preferably within 40 minutes, preferably within 35 minutes, preferably within 30 minutes prior to radiation exposure.

[0087] In one embodiment, an L-epinephrine pharmaceutical composition may be delivered locally, with or without an applicator, directly to the scalp surface of a patient within 40 minutes of irradiation of the skin and scalp, thereby protecting hair follicle stem cells of the scalp from fractionated radiation during the patient's radiation therapy.

[0088] In another embodiment, the L-epinephrine pharmaceutical composition may be administered topically to the scalp, for example, once every 2 hours, preferably for 4-6 hours, to allow blood-derived chemotherapeutic agents to be removed from hair follicle stem cells for a long period of time, thereby reducing the undesirable death of hair follicle stem cells as a side effect of the use of systemic chemotherapy. Removal of blood-derived chemotherapeutic agents from scalp hair follicle stem cells for 4-6 hours may be sufficient to provide one to several half-lives of most cancer chemotherapeutic agents from the patient's blood, thereby reducing the dose of chemotherapeutic agents to hair follicle stem cells to a level that allows sufficient stem cell survival and sustained hair shaft growth.

[0089] A fifth aspect of the invention provides a method for producing a pharmaceutical composition, the method comprising the steps of: a) adding water to a container; b) purging the water in the vessel with nitrogen gas until the amount of dissolved molecular oxygen reaches 5% (wt / vol) or less; c) adding ethanol to the vessel followed by at least one antioxidant to form a composition; d) adding to said composition at least one alpha-adrenergic vasoconstrictor; and e) adjusting the pH of the composition to less than 3; Includes.

[0090] The composition has a molecular oxygen concentration of less than 5% (wt / vol).

[0091] The antioxidant may be selected from the group consisting of citric acid, vitamin C, vitamin E, L-cysteamine, bisulfite, or a combination thereof. Preferably, the antioxidant is selected from citric acid, sodium metabisulfite, or a combination thereof.

[0092] The alpha-adrenergic vasoconstrictor may be selected from L-epinephrine, D-epinephrine, norepinephrine, phenylephrine, or mixtures thereof. Most preferably, the alpha-adrenergic vasoconstrictor is L-epinephrine.

[0093] The alpha-adrenergic vasoconstrictor is introduced into the container after the ingredients in step c) have been added, and the inventors have found that this particular order provides improved antioxidant activity and stability.

[0094] In step c) of the method, at least one stabilizing agent may be added to the composition. Preferably, the stabilizing agent is glycerol, propylene glycol, or a mixture thereof.

[0095] In step c), at least one flavoring agent may be added to the composition. Preferably, the flavoring agent is sucralose, citric acid, or a mixture thereof.

[0096] An ingredient such as citric acid may function simultaneously as both an antioxidant and a flavoring agent.

[0097] In step e), the pH of the composition is adjusted, preferably to less than 2.5. The lowering of the pH in step e) may be achieved by the addition of hydrogen chloride.

[0098] The method according to the fifth aspect comprises the steps of: f) filtering the composition through a filter having a pore size of 0.3 to 0.5 μm and then 0.18 to 0.28 μm; It may further comprise:

[0099] In one embodiment, the composition is filtered through a filter pore size of 0.45 μm and then 0.22 μm.

[0100] The purpose of this filtration step is to homogenize and sterilize the composition. This is an important step prior to placing the composition into a container, such as a vial or other package suitable for storing unused composition. The filtration step ensures that undesirable particles, such as bacteria and fungi, as well as large undissolved particles, are removed from the composition.

[0101] The method may further comprise, prior to step a), purging the air in the container with nitrogen until the oxygen concentration of the air in the container is less than 5% (wt / vol). EXAMPLES

[0102] Example 1 L-epinephrine free base is the only chemical form of L-epinephrine available in cGMP form acceptable for pharmaceutical formulation. Although the inventors have previously identified a water:alcohol-based delivery vehicle as being most suitable for delivering catecholamine vasoconstrictors to mammalian oral mucosa, they conducted experiments to determine the conditions under which L-epinephrine free base could be solubilized in the delivery vehicle. [ka]

[0103] Applicants reason that stepwise addition titration with HCl results in the formation of the HCl salt of the L-epinephrine amine group (* in schematic), which i) allows for the dissolution of the otherwise insoluble L-epinephrine base in a water:alcohol vehicle to achieve the L-epinephrine concentration required for localized delivery; and ii) provides stability to the dissolved L-epinephrine, allowing for formulation and subsequent storage at or below room temperature for a minimum of 18 months.

[0104] In experiment 1, the titration consisted of solid L-epinephrine free base powder in a water:alcohol buccal delivery vehicle (Table 1).** ) and titrated with 5N HCl with stirring until the solution became clear, then 1.0 ml of the sample was applied topically to the lips of human subjects to observe the time it took to elicit a branching reaction in the oral mucosal tissue. The results are summarized in Table 1. At pH 4.95, the solution was clear and colorless, and it took approximately 20 minutes for the labial branching reaction to be observed. After 18 hours, the clear solution turned pink (consistent with the production of adrenochrome, a product of oxidative epinephrine metabolism) and a flocculent reprecipitate appeared on the surface. [Table 1] ** The oral topical delivery vehicle consisted of the following: nitrogen gas purged ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)), 0.025% (wt:vol) sucralose sweetener, 0.2% sodium metabisulfite, 0.1% citric acid.

[0105] In experiment 2, the titration consisted of solid L-epinephrine free base powder in a water:alcohol buccal delivery vehicle (Table 1). ** ) and titrated with 2N HCl with stirring until the solution was clear and had a pH of 2.50 (see Figure 2). A rapid drop in pH occurred at pH 6.10 with immediate disappearance of turbidity. Table 2 summarizes the pH values ​​obtained from this titration and shows the experimentally determined moles of HCl required to achieve a pH of 2.50 in this particular formulation. [Table 2]

[0106] A 1.0 ml sample of a 20 mM L-epinephrine formulation at pH 2.50 was applied topically to the lips of human subjects to observe the time it took to induce a blanching reaction in the oral mucosal tissue. The results of the lip blanching are summarized in Table 2 above.

[0107] At pH 2.50, the solution was clear and colorless, and it took 8 minutes for a strong lip branching reaction to be observed. After 48 hours, the drug solution was clear and colorless. In experiment 1, the formulation was visually clear at pH 4.95, but there was insufficient moles of HCl to achieve complete dissolution and stabilization of L-epinephrine free base, detected by the fact that there were fewer L-epinephrine drug molecules dissolved and bioavailable to induce lip branching (hence the longer time to lip branching and weaker branching).

[0108] Example 2 Experiments were conducted to determine the chemical stability of L-epinephrine when formulated as described in the "Experiment 2" section of Example 1. In previous studies, commercially available "epinephrine HCl" crystals were directly dissolved and formulated. These crystals were dissolved directly into the oral topical formulation ("Delivery / Carrier Vehicle") described in Table 1 of Example 1. The final pH of this formulation is typically 5.05.

[0109] Following the pH titration with HCl to a stable endpoint of pH 2.50 shown in Example 1, Applicants reasoned that L-epinephrine formulated at pH 2.50 would be more chemically stable than L-epinephrine at pH 5.05. At pH 5.05, the formulation appears "clear" to the naked eye, but is exactly in the center of the sharp drop in pH presumably associated with ionization of the amine groups on epinephrine in the pH 5-6 zone.

[0110] To quantitatively compare the chemical stability of L-epinephrine formulations, 1. by dissolving L-epinephrine HCl crystals in an oral "delivery vehicle" with a final pH of 5.05, as we have done previously; or 2. by dissolving L-epinephrine base powder in an oral "delivery vehicle" and then adjusting the pH to 2.50 with HCl, as newly described in Example 1; Applicants did the following: 1. L-Epinephrine HCl crystals (MW: 219) were dissolved by vortexing in an oral topical delivery vehicle consisting of ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)), 0.025% sucralose (wt:vol), 0.2% sodium metabisulfite, 0.1% citric acid to a final concentration of 3.6 mg / ml. The pH was measured to be 5.05. 200 μl aliquots were dispensed into 2.0 ml glass vials and sealed with Teflon-coated septa ("epi-HCl vials"). 2. L-epinephrine free base (MW: 183) was mixed by vortexing in an oral topical delivery vehicle consisting of ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)), 0.025% sucralose sweetener (wt:vol), 0.2% sodium metabisulfite, 0.1% citric acid to a final concentration of 20 mM (3.6 mg / ml). The pH reading was adjusted to 2.50 by the addition of 2N HCl. 200 μl aliquots were dispensed into 2.0 ml glass vials and sealed with Teflon-coated septa ("epi-Base" vials"). 3. Both the "epi-HCl" and "epi-Base" vials were incubated under "stress conditions", i.e. at 40°C in the dark. 4. HPLC analysis of epinephrine peak area was performed on each of the freshly prepared epi-HCl and epi-Base formulations, as well as on samples from vials stored over the following 10 days. The analysis was performed using a published HPLC protocol using a C18 reversed-phase column and elution with pH 2.7% methanol solvent.

[0111] FIG. 3 shows the results of this stability comparison experiment.

[0112] Panel A shows a significant difference in epinephrine stability (P=0.0002): no degradation was observed in the "epi-Base" formulation, whereas 20% degradation was observed within the first 10 days of storage in the "epi-HCl" formulation.

[0113] Panel B shows that a rose-brown color change occurred in the "epi-HCl" vial on day 10, consistent with the production of adrenochrome oxidative catabolism of epinephrine, and no color change was observed in the "epi-Base" vial on day 10.

[0114] Panel C shows HPLC quantification of both epinephrine and adrenochrome peaks in samples taken from the "epi-HCl" vial on day 10.

[0115] Panel D shows that there is a substantial difference in the L-epi / adrenochrome area ratios for samples taken from the epi-Base and epi-HCl vials.

[0116] Example 3 Experiments were conducted to determine the actual dose of L-epinephrine retained on topical surfaces in the human oropharyngeal cavity. In this quantification assay, a surrogate drug molecule, phenylephrine, was employed as a surrogate for L-epinephrine to facilitate quantification of a small drug molecule when: i) it was delivered to the human oral cavity in 10-15 ml of delivery vehicle, ii) it was rinsed for 1-2.0 minutes, and iii) it was expectorated after 2.0 minutes. [ka]

[0117] Applicants reason that phenylephrine is a suitable substitute for L-epinephrine delivery for the following reasons. i) Both molecules are aromatic amines and differ in molecular weight by only 8%. Phenylephrine was originally invented as an analogue of epinephrine. ii) HPLC chromatographic analysis of phenylephrine has been performed in our laboratory and was used in previous regulatory submissions.

[0118] Applicants reasoned that the conditions that were optimal for phenylephrine dissolved in the oral topical delivery vehicle of the present invention (i.e., nitrogen gas purged ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)) plus sweeteners and antioxidants) with respect to i) drug:vehicle dose volume and ii) drug:vehicle contact time with the oral mucosa would also be optimal for L-epinephrine delivery.

[0119] In these experiments, three subject human volunteers were provided with a vial containing a 5 mM solution of phenylephrine HCl in an oral topical delivery vehicle of the present invention and instructed as follows: i) delivering the contents of the vial into the mouth; ii) Rinse your mouth with the liquid and then gargle twice for 5 seconds; and iii) The liquid is expelled at specific time points into a glass vial.

[0120] The administered and expelled volumes for each subject were recorded, and the phenylephrine concentrations in the administered and expelled solutions were analyzed by HPLC for each of the three subject volunteers. The results are summarized in Table 3. [Table 3] [Table 4]

[0121] That is, in three healthy adult subjects, after topical oral administration via a standard 2-minute rinse and gargle, the mean percentage of adrenergic vasoconstrictor actually retained on topical oral surfaces in the subjects' mouths was 24%.

[0122] Published data (Kerr et al.) shown in Figure 4 indicate that the average height of a human adult is approximately 188 cm. 2 It has been calculated that the oral cavity has a local surface area of

[0123] These data show that when 1.8 mg / ml or 3.6 mg / ml L-epinephrine is administered in the present invention to the oral cavity of an adult human with an empirically determined and optimized drug formulation and delivery protocol, said drug formulation comprising i) an optimized delivery vehicle composition, and ii) an optimized L-epinephrine chemical formulation, approximately 20-30% of the L-epinephrine dose from the oral topical solution is delivered to the oral mucosa, as summarized in Table 4.

[0124] Example 4 Experiments were conducted to determine whether the empirically optimized methods of the present invention for formulating and topically administering L-epinephrine to human subjects in the oral cavity, as described in the Examples and Claims of this patent application, are effective in inducing submucosal blood vessels in a time- and L-epinephrine-dose-dependent manner that allows for routine use in human subjects within the time constraints of a clinical environment. In the following examples, L-epinephrine was formulated and four healthy volunteers were treated as follows: 1. L-Epinephrine powder (to final concentrations of 0.9 mg / ml, 1.8 mg / ml, 3.6 mg / ml, and 5.5 mg / ml) was added with stirring to an oral topical delivery vehicle consisting of nitrogen gas purged ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)), 0.025% (wt:vol) sucralose sweetener, sodium metabisulfite, and citric acid antioxidant. 2. Under stirring, 2-5N HCl was added to bring the pH to 2.5. 3. 12.5 ml of the L-epinephrine formulation from step 2 was delivered topically to the oral cavity of a human subject. The subject rinsed and gargled with 12.5 ml of the formulation for 2.0 minutes, twice for 5 seconds each, and then spat out the formulation. 4. A photograph of the subject's lips was taken 5 minutes after rinsing began, revealing a clear and strong branching reaction (see arrow in Figure 5) as a result of L-epinephrine being delivered to the submucosal blood vessels.

[0125] The oral administration of L-epinephrine to a total of four healthy volunteers induced robust mucosal branching with these characteristics within 5-60 minutes, suggesting that a protective effect may also be induced during routine clinical radiotherapy and / or radiochemotherapy.

[0126] The results of this example are shown in Figure 5. The symbols in the table and their meanings are as follows: - no branching reaction;+ slight branching reaction;++ moderate branching reaction;+++ significant branching reaction.

[0127] Example 6 Experiments were conducted to determine whether the L-epinephrine adrenergic vasoconstrictor would be best suited for use as the active pharmaceutical ingredient in a formulation developed to achieve transient vasoconstriction and associated desired transient radio- and chemoprotection by delivery across mammalian squamous epithelia.

[0128] In a previous study using a preclinical rat radiation dermatitis model (Fahl, Arch Dermatol Res 308:751-757, 2016), 75 μl of each indicated vasoconstrictor formulation in an ethanol:water (70:30) delivery vehicle was applied to 4.5 cm of shaved skin on the back of rats. 2 Patches were applied 12 minutes before the skin patch received a dose of 17.2 Gy of radiation. Rats receiving topical vehicle alone developed grade 3 radiation dermatitis in over 95% of the irradiated skin, and rats pretreated with topical vasoconstrictor showed dose-dependent suppression of radiation dermatitis to background. Figure 6 shows a visual depiction of the suppression of radiation dermatitis as well as a graphical dose-response curve for each of the three adrenergic vasoconstrictors. The relative potency of the topically applied vasoconstrictors was 1:0.5:0.2 for epinephrine:norepinephrine:phenylephrine.

[0129] Following the reported animal studies, skin blanching experiments were performed on the forearms of healthy human volunteers to demonstrate the vasoconstrictive effect of L-epinephrine formulations on human squamous epithelium. A skin topical formulation was generated containing water, 40-70% ethanol, antioxidants, and karyolitic reagents to dissolve L-epinephrine. As shown in FIG. 7, effective vasoconstrictive skin blanching was achieved when the pharmaceutical formulation according to the present invention containing 3 mg / ml L-epinephrine, water, and 40% ethanol was applied to the skin topically. In particular, at 10-14 minutes after topical application, the blanching of the skin in the area near the hair root became noticeable. The blanching continued for about 40 minutes after topical application to the skin.

[0130] Both reported animal studies and skin blanching experiments allowed us to empirically determine the optimal alcohol:water topical delivery vehicle required for transmucosal and transdermal delivery, and determined that L-epinephrine was the highly potent agent.

[0131] Example 7 L-epinephrine free base is the only chemical form of L-epinephrine available in cGMP form acceptable for pharmaceutical formulation. Experiments were conducted to determine the conditions under which L-epinephrine free base could be solubilized in a water:alcohol-based delivery vehicle previously identified as most suitable for delivering catecholamine vasoconstrictors to mammalian squamous epithelia. [ka]

[0132] What is required in the method claims of this patent is the delivery of L-epinephrine to subcutaneous blood vessels in the human skin or scalp for the purpose of inducing transient vasoconstriction of blood vessels located 1 mm subcutaneously to provide transient protection against i) cancer radiation therapy to the skin or scalp; or ii) cancer chemotherapy agents delivered to hair follicles in the scalp, respectively.

[0133] Applicants reason that the stepwise addition of L-epinephrine free base and titration with hydrochloric acid (HCl) results in the formation of the HCl salt of the L-epinephrine amine group (indicated by * in the schematic), which i) allows for the dissolution of the otherwise insoluble L-epinephrine base in a water:alcohol vehicle to achieve the necessary L-epinephrine concentration for mucosal, squamous epithelium, and scalp delivery; and ii) the addition of antioxidants provides stability to the dissolved L-epinephrine, allowing for formulation and subsequent storage for sufficient long periods of time.

[0134] In this example, the volume of HCl added was measured and it was found that there was a linear correlation between the volume of HCl added and the L-epinephrine concentration. [ka]

[0135] Because pharmaceutical formulations containing ethanol, oxygen scavengers, and L-epinephrine drug substance have a pH greater than 6, an excess of HCl is added to the formulation to achieve a final pH of less than 3, preferably a pH of about 2.3. Increasing the volume of HCl added and the L-epinephrine concentration show a linear correlation, which can be expressed by the following equation: Y=5.6297*X-5.3044, correlation ratio R 2 =0.9916 X: L-epinephrine concentration (mg / ml); Y: Volume of 2N HCl added in the final composition.

[0136] The correlation is calculated based on measurements taken during manufacture of a vehicle formulation without L-epinephrine, a 0.92 mg / ml L-epinephrine formulation solution, and a 5.5 mg / ml L-epinephrine formulation solution (Figure 8).

[0137] Example 8 Experiments were conducted to determine the concentration of L-epinephrine, when formulated as described in Example 7 and applied topically to human squamous / scalp skin, required to induce sustained skin blanching expected to confer protection from chemotherapy and / or radiation therapy in cancer patients treated with either short (minutes) to long (hours) chemotherapy or radiation therapy for seconds to minutes per treatment. It was reasoned that by applying known volumes of L-epinephrine formulated in a 70:30 (ethanol:water) vehicle as detailed in Examples 6-7 to defined areas of forearm skin of human subjects, it would be possible to empirically determine the L-epinephrine concentration and topical application volume per unit skin surface area that would result in a blanching response of appropriate onset, magnitude, and duration for a particular radiation or chemotherapy protection scenario.

[0138] To determine these parameters, the following steps were taken. 1. A 3.4 mg / ml solution of L-epinephrine was formulated topically as follows: 1) with ethanol and oxygen scavenger, pH adjusted to less than 3, specifically 2.33; 2) with oxygen scavenger, pH adjusted to 2.33, no ethanol; 3) with ethanol, pH adjusted to 2.33, no oxygen scavenger; 4) with ethanol and oxygen scavenger, pH adjusted to 5.5, not less than 3; 5) with ethanol and oxygen scavenger, pH adjusted to 2.33, left in sunlight for 24 hours. 2. Place an oil pan over the forearm of a healthy volunteer, approximately 1 cm beneath the skin. 2 Five small circles containing the patch were drawn and one drop of each solution from step 1 was placed on one circle (see Figure 9). 3. Thirty minutes after the five solutions were applied, obvious skin blanching reactions were observed in the circles of solutions 1 and 5.

[0139] The absence of blanching reactions in solutions that did not contain ethanol, did not contain oxygen scavenger, or did not adjust the pH to less than 3 further confirmed that the combination of ethanol, oxygen scavenger, and a pH less than 3 contributes substantially to the bioavailability and stability of L-epinephrine.

[0140] Thus, with the known onset, extent, and duration of cutaneous branching, clinical trials can be designed and conducted to prevent radiation dermatitis or radiation-induced alopecia (short-term lesions) and short-term lesions of chemoradiotherapy-induced alopecia (such as Adriamycin (for a few minutes)) with topical L-epinephrine.

[0141] Example 9 The stability of pharmaceutical compositions containing L-epinephrine at oxygen concentrations below 5% (wt / vol) and 20% (wt / vol) was tested and compared.

[0142] Stability of pharmaceutical compositions containing 20% ​​(wt / vol) oxygen A pharmaceutical composition containing L-epinephrine at a concentration of 5 mM (0.92 mg / ml) was produced in a chemical safety cabinet under normal ventilation conditions, and the oxygen concentration of the composition dispensed into vials was subsequently measured repeatedly to be approximately 20% (wt / vol). Stability test samples were stored in stability incubator chambers at various temperature and humidity conditions. Samples withdrawn at designated time points were evaluated for items such as L-epinephrine solution appearance, identity, solution color, solution clarity, pH, analysis, related substances, and ethanol and sodium metabisulfite content.

[0143] Under high temperature stress conditions at 60°C, the total impurities and single impurities increased significantly by more than 17% and 8%, respectively, the color of the sample changed to light brown (Figure 10), and the L-epinephrine concentration decreased by about 18%. Under 40°C stress conditions for one month, the total impurities in the sample solution reached 3.8%, and the single impurities reached nearly 1.7%. In particular, under conditions of 60°C and 40°C, especially 60°C, the concentration of the antioxidant sodium metabisulfite showed a decreasing trend, which may be one of the reasons for the significant increase in impurities under high temperature stress injury. [ka]

[0144] Stability of pharmaceutical compositions containing 5% (wt / vol) oxygen In another experiment, pharmaceutical compositions containing 5 mM (0.92 mg / ml) and 30 mM (5.5 mg / ml) L-epinephrine were prepared in an oxygen-free sealed isolator cabinet with oxygen monitoring to ensure that the composition solution was dispersed to a final dissolved oxygen of less than 5% (wt / vol). The oxygen concentration in the solution in the vial was measured using an OxySense 325i meter. The stability of the pharmaceutical composition according to the present invention having a molecular oxygen concentration of less than 5% (wt / vol) was tested. The samples for the stability test were stored at various temperatures and other conditions were the same as the previous stability test. The stability results are shown in Tables 11 and 12 below.

[0145] In the 5 mM batch (0.92 mg / ml) and 30 mM batch (5.5 mg / ml) with dissolved oxygen concentrations of less than 5% (wt / vol), little increase in individual impurities or total impurities was observed for at least three months when stored at 2 to 8° C., and total impurities were at an acceptable level when stored at 25° C. Compared with a composition sample with a molecular oxygen concentration of about 20% (wt / vol) stored at 40° C. for one month, an L-epinephrine composition sample with a molecular oxygen concentration of less than 5% (wt / vol) stored at 40° C. showed significantly improved stability in terms of L-epinephrine concentration and impurity ratio, and the concentration of the antioxidant sodium metabisulfite was also stable. [ka] [ka]

[0146] Example 10 The pharmaceutical composition of the present invention was prepared according to the following protocol.

[0147] 1. Disinfection Surfaces and equipment are preferably disinfected with 75% ethanol and dried with clean compressed air. Because the pharmaceutical compositions of the present invention use ethanol as a carrier, the use of at least 75% ethanol in this process provides sufficient sterilization without introducing additional process-related impurities into the final product.

[0148] 2. Cleaning and drying the vial The vials are immersed in water and washed with water, preferably purified water. The vials are then dried in a drying oven at a temperature of 80-85°C for at least 60 minutes and then cooled to room temperature. Cooling the vials is a critical step to avoid evaporation of the ethanol excipients and degradation of the API in the hot / warm vials.

[0149] 3. Nitrogen purging of empty compounding vessel The vial for nitrogen filtration is fitted with a gas filter and associated connecting pipes, and the vial for product solution filtration is connected with a product filter and associated connecting pipes. The nitrogen pressure is preferably 0.2 MPa or higher. The compounding vessel may be purged with filtered nitrogen for at least 10 minutes until the oxygen concentration of the air in the vessel is less than 5.0% (wt / vol). The vessel is flushed with nitrogen throughout the formulation process.

[0150] 4. Formulation: Purified water loading Preferably, approximately 70-80% of the total weight of the batch volume of purified water is charged to the compounding vessel. The purified water is stirred at a set speed, preferably 200-800 rpm. While mixing, a nitrogen flush is maintained in the compounding vessel, and the solution is constantly bubbled until the dissolved oxygen content of the purified water is 5.0% (wt / vol) or less.

[0151] 5. Formulation: Material loading The following ingredients are then dispensed into the container, preferably in the following order: citric acid, sucralose, propylene glycol, anhydrous glycerol, ethanol, and sodium metabisulfite. Mixing is continued for 5 minutes at a set speed of 200-800 rpm. L-epinephrine is then added to the container. Adding L-epinephrine last provides the most antioxidant activity and improves the stability of the final product. The composition is mixed at a speed preferably between 200-800 rpm and circulated for at least 5 minutes at a set speed of 14-16 rpm.

[0152] Adjust the pH of the solution to 2.0-2.5 using 2 N hydrochloric acid solution and stir the composition. Record the total weight of the HCl solution (after pH adjustment) and calculate the net weight of hydrochloric acid.

[0153] After adjusting the pH, add purified water to the composition to bring the product to the target net weight. Continue stirring at a speed of 200-800 rpm to obtain a homogenous solution.

[0154] 6. Blending: Circulation and Filtration After the purified water is charged to the full volume, the solution is circulated through the circulation system for a minimum of 20 minutes. The buffer tank is purged with nitrogen for 3-5 minutes to make the oxygen concentration less than 5.0%. A depth filtration system commonly used in pharmaceutical GMP manufacturing is applied, using a single-stage bag filter or a two-stage magnetic filter to remove solid impurities, undissolved powders, and particles to ensure high quality of the final product and reduce the degree of biological contamination to obtain a sterile final product. At least one stage of filtration with a filter pore size of 0.22 μm is required to obtain a sterile final solution. The filtered solution is then loaded into the buffer container for filling. Nitrogen flushing is maintained at all times during batch filling.

[0155] 7. Filling line setting and filling weight calculation The filling system (pump, tubing, and needles for product solution transfer, and nitrogen blanketing pipe) is installed in a closed RABS cabinet. The RABS cabinet is purged with filtered nitrogen for approximately 20 minutes until the oxygen concentration of the air within the RABS is less than 5.0% (wt / vol). Nitrogen flushing is maintained until filling is complete.

[0156] 8. Initial vial crimp check a. Sample six empty vials and stopper each vial using lip-off caps. b. After crimping, check the appearance of the crimped cap, it should be firm and smoothly crimped without any wrinkles. c. Conduct an integrity test on the bottles. Place the bottles in the seal integrity tester and turn on the integrity tester. The test pressure range is -80.0 to -90.0 Kpa and the hold time is 180 seconds. Make sure there is no water in the vials when they are removed from the tester. This indicates that the integrity test has passed. d. If the result is unsuccessful, adjust the crimper and perform the integrity test on another six bottles.

[0157] The integrity test conditions are related to the vial size and fill volume. For the current 12.5 ml solution fill in 10 ml or 15 ml vials, the integrity test conditions are adequate.

[0158] Repeat as necessary until results are acceptable and record.

[0159] 9. Formal filling and closing Transfer the appropriate amount of empty vials and stoppers to the RABS. Flush the RABS with nitrogen, then briefly (3-5 seconds) purge the interiors of all vials.

[0160] Randomly sample six vials and check for oxygen content. If oxygen content is below 5.0%, begin the filling process as follows: Fill the formulation solution into bottles to the required weight range. b. Immediately insert the stopper into the vial. c. Next, remove all stoppered vials from the RABS and, as soon as possible, crimp the lip-off caps using the capping machine.

[0161] The above filling and capping campaign and crimping operations within the RABS are repeated until the entire batch is completed. For each filling and stoppering campaign in the RABS, six crimped vials are randomly sampled for IPC testing: three vials for weight check and three vials for oxygen content testing.

[0162] At the beginning, during and end of filling and closing, seal integrity checks will be performed as appropriate (using three empty bottles at a time) and integrity test parameters will be recorded.

[0163] Collect all product waste and record the weight. Discard the IPC sample and any unused product solution.

[0164] 10. Review and Recording After completion of the blending, filling, and closing procedures, the temperature, relative humidity, and pressure differentials are checked and recorded.

[0165] Embodiment It is contemplated that the present invention may explicitly exclude any one of the following embodiments. 1. An L-epinephrine pharmaceutical composition based on an ethanol:glycerol:propylene glycol:water (6:6:8:80 (vol:vol)) vehicle having a molecular oxygen concentration of less than 5% (wt:vol), comprising 5 mM to 30 mM L-epinephrine and a 0.9 to 1.3 molar excess of HCl relative to L-epinephrine, said composition further comprising 0.01-0.5% (wt:vol) of one or more antioxidants; 0.01 to 5% (wt:vol) of one or more sweeteners; and 0.05 to 2% (wt:vol) of one or more flavorings; A composition comprising: 2. The pharmaceutical composition of embodiment 1, wherein the vehicle has a molecular oxygen concentration of 2-5% (wt:vol). 3. The pharmaceutical composition of embodiment 1, wherein the L-epinephrine is present at 5 mM, 10 mM, 15 mM, 20 mM, or 30 mM. 4. The pharmaceutical composition of embodiment 1, wherein the antioxidant is metabisulfite or citric acid, or a combination thereof. 5. The pharmaceutical composition of embodiment 4, comprising 0.2% (wt:vol) metabisulfite and 0.1% (wt:vol) citric acid as the antioxidants. 6. The pharmaceutical composition of embodiment 1, wherein the sweetener is sucralose. 7. A pharmaceutical composition described in embodiment 6, comprising 0.025% (wt:vol) sucralose as the sucralose sweetener. 8. The pharmaceutical composition of embodiment 1, wherein the flavoring agent is cherry flavor. 9. A pharmaceutical composition described in embodiment 1, comprising 0.28% (wt:vol) cherry flavor as the flavoring agent. 10. Use of a pharmaceutical composition according to any one of embodiments 1 to 9 for the prevention of radiation-induced and / or chemoradiotherapy-induced oral mucositis in cancer patients undergoing cancer treatment including radiation exposure to the oral mucosa. 11. A method of administering the pharmaceutical composition according to embodiment 1 to the oral and oropharyngeal cavities of a patient undergoing cancer radiotherapy and / or chemoradiotherapy, comprising administering 10.0-15.0 ml of the pharmaceutical composition, and rinsing the formulation by: i) retaining the formulation in the oral and oropharyngeal cavities for 1.5-2.5 minutes, ii) expectorating the excess formulation, and iii) dispersing the administered L-epinephrine within 1 cm of the oral surface. 2 A method for achieving a final oral topical dose range of 0.1 to 0.5 μmol L-epinephrine per dose. 12. A method of administering the pharmaceutical composition of embodiment 1 to the oral and oropharyngeal cavities of a patient undergoing cancer radiotherapy and / or chemoradiotherapy within 40 to 50 minutes prior to each fractionated radiation exposure to the oral mucosa. 13. An L-epinephrine pharmaceutical composition based on an ethanol:water (70:30 (vol:vol)) vehicle having a molecular oxygen concentration of less than 0.5% (wt:vol), comprising 50 mM to 200 mM L-epinephrine and a 0.8 to 1.2 molar excess of HCl relative to L-epinephrine, said composition further comprising 0.01 to 0.5% (wt:vol) of one or more antioxidants. 14. A method for administering the pharmaceutical composition according to embodiment 13 to the squamous epithelium and / or scalp of a patient undergoing cancer radiotherapy and / or chemotherapy, comprising topically administering 20 ml to 30 ml of the pharmaceutical composition, and administering L-epinephrine to within 1 cm of the squamous epithelium and / or scalp surface. 2 A method to achieve a final local dose of 1.0 to 4.0 μmol L-epinephrine per injection.

[0166] References: Alvarino-Martin C, Sarrion-Perez MG. Prevention and treatment of oral mucositis in patients receiving chemotherapy. J Clin Exp Dent. 2014 Feb 1;6(1):e74-80. doi: 10.4317 / jced.51313. eCollection 2014 Feb. Chaveli-Lopez B, Bagan-Sebastian JV. Treatment of oral mucositis due to chemotherapy. J Clin Exp Dent. 2016 Apr 1;8(2):e201-9. doi: 10.4317 / jced.52917. eCollection 2016 Apr. Cleary JF, Anderson BM, Eickhoff JC, Khuntia D, Fahl WE. Significant suppression of radiation dermatitis in breast cancer patients using a topically applied adrenergic vasoconstrictor. Radiat Oncol. 2017 Dec 22;12(1):201. De Sanctis V, Bossi P, Sanguineti G, Trippa F, Ferrari D, Bacigalupo A, Ripamonti CI, Buglione M, Pergolizzi S, Langendjik JA, Murphy B, Raber-Durlacher J, Russi EG, Lalla RV. Mucositis in head and neck cancer patients treated with radiotherapy and systemic therapies: Literature review and consensus statements. Crit Rev Oncol Hematol. 2016 Apr;100:147-66.Doi:10.1016 / j.critrevonc.2016.01.010. Epub 2016 Feb 1. Fahl WE., Complete prevention of radiation-induced dermatitis using topical adrenergic vasoconstrictors. Arch Dermatol Res. 2016 Dec;308(10):751-757. Graul-Conroy A, Hicks EJ, Fahl WE., Equivalent chemotherapy efficacy against leukemia in mice treated with topical vasoconstrictors to prevent cancer therapy side effects. Int J Cancer. 2016 Jun 15;138(12):3011-9. doi: 10.1002 / ijc.30037. Graul-Conroy A, Hoover-Regan M, DeSantes KB, Sondel PM, Callander NS, Longo WL, Fahl WE. Reduction in oral mucositis severity using a topical vasoconstrictor: A case report of three bone marrow transplant patients. Integr Cancer Sci Ther. 2018 Dec;5(6):10.15761 / ICST.1000293. doi: 10.15761 / ICST.1000293. Epub 2018 Nov 29. PMID: 31832233; PMCID: PMC6907163. Maria OM, Eliopoulos N, Muanza.T, Radiation-Induced Oral Mucositis. Front Oncol. 2017; 7: 89. 2017. Soref CM, Fahl WE., A new topical vasoconstrictor-based strategy for prevention of oral mucositis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Apr;117(4):454-61. Soref CM, Fahl WE., A new strategy to prevent chemotherapy and radiotherapy-induced alopecia using topically applied vasoconstrictor. Int J Cancer. 2015 Jan 1;136(1):195-203.

Claims

1. 0.9 mg / ml to 15 mg / ml of L-epinephrine or a salt thereof; and a carrier vehicle comprising ethanol and water; A pharmaceutical composition comprising: the pharmaceutical composition having a molecular oxygen concentration of less than 5% (wt / vol); the pharmaceutical composition has a pH of less than 3; Pharmaceutical compositions.

2. 10. The pharmaceutical composition of claim 1 comprising hydrochloric acid.

3. the carrier vehicle further comprises glycerol and / or propylene glycol; Preferably, the carrier vehicle is 2% to 10% (vol / vol) ethanol; 2% to 10% (vol / vol) glycerol; 4% to 12% (vol / vol) propylene glycol; and 70% to 90% (vol / vol) water; The pharmaceutical composition according to claim 1 or 2, comprising:

4. 4. The pharmaceutical composition of claim 1, wherein the L-epinephrine or a salt thereof is present in the range of 0.9 mg / ml to 11 mg / ml, 0.9 mg / ml to 9 mg / ml, 0.9 mg / ml to 5.5 mg / ml, 1.8 mg / ml to 9 mg / ml, 1.8 mg / ml to 7.5 mg / ml, 2.7 mg / ml to 7.5 mg / ml, or 2.7 mg / ml to 5.5 mg / ml.

5. 5. The pharmaceutical composition of claim 1, having a molecular oxygen concentration of less than 4.5% (wt / vol), less than 4.0% (wt / vol), less than 3.5% (wt / vol), less than 3.0% (wt / vol), less than 2.5% (wt / vol), or less than 1% (wt / vol).

6. The pharmaceutical composition according to any one of claims 1 to 5, further comprising D-epinephrine, DL-epinephrine, and / or salts thereof.

7. further comprising one or more antioxidants; Preferably, the amount is between 0.01 and 0.5% (wt / vol); and / or Preferably, the antioxidant is selected from the group consisting of metabisulfite, citric acid, DL-α-tocopherol, or a combination thereof; The pharmaceutical composition according to any one of claims 1 to 6.

8. A pharmaceutical composition according to any of claims 1 to 7, wherein the composition further comprises one or more penetration enhancers, preferably wherein the penetration enhancers are selected from isopropyl myristate or medium chain monoglycerides.

9. A pharmaceutical composition according to any of claims 1 to 8, wherein said composition further comprises one or more keratolytic ingredients, preferably said keratolytic ingredient is lactic acid.

10. further comprising one or more sweeteners, preferably in an amount of 0.01 to 5% (wt / vol); and / or further comprising one or more flavoring agents, preferably in an amount of 0.05-2% (wt / vol); The pharmaceutical composition according to any one of claims 1 to 9.

11. The pharmaceutical composition of any one of claims 1 to 10, formulated as a mouthwash, gel, balm, oil, paste, or aerosol.

12. A pharmaceutical composition according to any one of claims 1 to 11 for use in the prevention of chemotherapy-induced and / or radiotherapy-induced oral mucositis in a patient and / or speech and voice changes in a patient, comprising: A pharmaceutical composition intended for oral topical administration to surfaces of the patient's oral or oropharyngeal cavity with or without an applicator device.

13. 0.03 mg to 3 mg / cm ２ 13. The pharmaceutical composition for use according to claim 12, for administration in a dosage suitable to provide L-epinephrine to the treated oral mucosal or oropharyngeal cavity surface of the patient.

14. 14. A pharmaceutical composition for use according to claim 12 or 13, for administration to the oral mucosal or oropharyngeal surfaces of a patient undergoing radiotherapy and / or chemoradiotherapy within 50 minutes prior to the first and each subsequent fractionated radiation exposure to the oral or oropharyngeal surfaces to be treated.

15. 0.92 mg / ml to 36.6 mg / ml of L-epinephrine or a salt thereof; and a carrier vehicle comprising ethanol and water; A pharmaceutical composition comprising: having a molecular oxygen concentration of less than 5% (wt / vol); has a pH of less than 3; Pharmaceutical compositions.

16. 16. The pharmaceutical composition of claim 15, comprising hydrochloric acid.

17. The carrier vehicle is 30% to 80% (vol / vol) ethanol; and 20% to 70% (vol / vol) water; 17. The pharmaceutical composition of claim 15 or 16, comprising:

18. further comprising one or more antioxidants; Preferably the amount is 0.01-0.5% (wt / vol); The pharmaceutical composition according to any one of claims 15 to 17.

19. The pharmaceutical composition of any one of claims 15 to 18, formulated as a gel, shampoo, balm, oil, paste, or cream.

20. 20. A pharmaceutical composition according to any one of claims 15 to 19 for use in the prevention of a radiotherapy-induced condition selected from the group consisting of dermatitis, alopecia, acute dermatitis, rash, ulceration, mucosal ulceration, depigmentation, pigmentation, scarring and chronic fibrosis; for topical administration to the squamous epithelium and / or scalp of a patient; Pharmaceutical compositions.

21. 0.03mg~3mg / cm ２ 21. The pharmaceutical composition for use according to claim 20, for administration of L-epinephrine in a dosage suitable for providing the treated squamous epithelial or scalp surface and hair follicles of a patient.

22. 22. The pharmaceutical composition for use according to claim 20 or 21, for administration to the squamous epithelium or scalp surface of a patient undergoing radiotherapy and / or chemoradiotherapy within 5 to 50 minutes prior to the first and each subsequent fractionated radiation exposure to the squamous epithelium or scalp surface to be treated.

23. a) adding water to a container; b) purging the water in the vessel with nitrogen gas until the amount of dissolved molecular oxygen reaches 5% (wt / vol) or less; c) adding ethanol and at least one antioxidant to said container to form a composition; d) adding to said composition at least one α-adrenergic vasoconstrictor; and e) adjusting the pH of the composition to less than 3; Including; the composition has a molecular oxygen concentration of less than 5% (wt / vol); Methods for producing pharmaceutical compositions.

24. the antioxidant is selected from the group consisting of citric acid, vitamin C, vitamin E, L-cysteamine, bisulfite, or a combination thereof; Preferably, the antioxidant is selected from citric acid or sodium metabisulfite, or a combination thereof; 24. The method of claim 23.

25. the α-adrenergic vasoconstrictor is selected from L-epinephrine, D-epinephrine, norepinephrine, phenylephrine, or a mixture thereof; Preferably, the α-adrenergic vasoconstrictor is L-epinephrine; 25. The method of claim 23 or 24.

26. In step c) at least one stabilizer is added to the composition; Preferably, the stabilizing agent is glycerol, propylene glycol, or a mixture thereof; The method according to any one of claims 23 to 25.

27. In step c) at least one flavoring agent is added to the composition; Preferably, the flavoring agent is sucralose, citric acid, or a mixture thereof; The method according to any one of claims 23 to 26.

28. In step e), the pH of the composition is adjusted with hydrogen chloride; and / or The pH of the composition is adjusted to less than 2.5; The method according to any one of claims 23 to 27.

29. f) filtering the composition through a filter pore size of 0.3-0.5 μm and then 0.18-0.28 μm. The method of any one of claims 23 to 28, further comprising:

30. 30. The method of any one of claims 23 to 29, further comprising, prior to step a), purging the air in the container with nitrogen until the oxygen concentration of the air in the container is less than 5% (wt / vol).

31. 31. The method of any one of claims 23 to 30, further comprising adjusting the dissolved oxygen concentration in both the final solution and in the vial headspace aerosol to less than 5% by filling the vials in a closed nitrogen environment.

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