Anticholinergic and Muscarinic Agents for the Treatment of Demodex-Associated Diseases - Patent application

Abstract

Provided herein are methods for treating skin disorders, ophthalmological disorders, or autoimmune diseases, comprising administering or applying an active agent to an individual having a skin disorder in a dosage sufficient to inactivate Demodex mites and / or Demodex mites from the individual's hair follicles and / or skin, resulting in amelioration or cessation of the manifestation of allergic and / or vasomotor responses to the mites that cause symptoms and signs of the disorder or disease in the individual. Formulations suitable for any of the above methods are also provided herein.

Description

[Background technology]

[0001]

[0002] Provided herein are methods for the treatment of various disorders in humans that use topically applied or orally administered anticholinergics and / or muscarinic agonists to inactivate certain organisms associated with the skin disorder. The methods reduce or eliminate, for example, Demodex organisms from affected skin areas, thereby reducing the clinical signs of the skin disorder that are primarily due to the body's allergic and vasomotor responses to the organisms and the bacteria they carry.

[0002]

[0003] Rosacea, originally called acne rosacea, is a chronic inflammatory skin disease that most commonly affects the face and eyelids of middle-aged adults. Clinical signs include erythema (redness), dryness, papules, pustules, and nodules, either alone or in combination, in the involved skin areas. Eyelid involvement may be manifested by mild conjunctival irritation or inflammation of the meibomian (sebaceous) glands at the eyelid margin. Chronic eyelid irritation may result in loss of eyelashes. Chronic involvement of the nose by rosacea in men may cause bulbous enlargement known as rhinophyma. In the classical setting, the disease develops in adults between the ages of 30 and 50. Certain lesions of rosacea resemble those of acne vulgaris, a separate and distinct process, with the main differences being the presence of comedones (whiteheads and blackheads) in only acne vulgaris and not in rosacea, the characteristic central facial localization and facial flushing of rosacea that is not seen in acne, and the possibility of eyelid involvement in rosacea that does not occur in acne.

[0003]

[0004] Rosacea progresses in four stages over several years, with attacks aggravated by temperature changes, alcohol, spices, exposure to sun, and emotions. The individual stages of the disease include:

[0004]

[0005] Stage 1: Stage of erythema onset. The patient has erythema attacks due to sudden dilation of the arterioles in the face, which then give a congestive red appearance. These attacks are triggered by emotions, meals and temperature changes.

[0005]

[0006] Stage 2: Red nose, a long-lasting stage of erythema due to telangiectasia. Some patients also have edema on the cheeks and forehead.

[0006]

[0007] Stage 3: Inflammatory stage, presenting with inflammatory papules and pustules but without affecting the sebaceous follicles and therefore without cysts and comedones.

[0007]

[0008] Stage 4: Rhinophyma stage. This final stage affects primarily men. Patients have a bumpy, voluminous, red nose with hyperplasia of the sebaceous glands and fibrous reordering of the connective tissue.

[0008]

[0009] The pathogenesis of rosacea is still not fully understood, but many theories have been put forward. It is a topic of frequent discussion in the medical community, but no full consensus has been reached. Regarding this aspect of the disease, attention has been paid to the prominent presence of erythema (redness) and flushing of the face of affected individuals, exacerbated by heat, sun and alcohol. A common hypothesis is based on the presence of Demodex folliculorum, a characteristic parasite, in the case of patients suffering from rosacea. Other factors have been described as possibly contributing to the progression of rosacea, such as hormonal factors, especially endocrine factors, climatic and immunological factors, as well as bacterial factors due to the presence of Helicobacter pylori, a bacterium associated with gastrointestinal disorders.

[0009]

[0010] Drug treatment to prevent such vasomotor flushing is ineffective against other aspects of the disease, such as papules and pustules. Oral and topical antibiotic treatment has been shown to effectively prevent the progression of rosacea, either through poorly understood anti-inflammatory mechanisms or by destroying Demodex mites associated with bacteria, but studies have shown that these drugs do not work by killing Demodex mites organisms on affected skin. Antibiotics must be administered continuously and are often only marginally effective. Patients often cannot tolerate the side effects associated with oral antibiotics.

[0010]

[0011] Demodex brevis and Demodex mites have been hypothesized to be the underlying cause of rosacea, many subtypes of rosacea, and seborrheic dermatitis, but no consensus has yet been reached and no commercially viable pharmacological solutions are available to treat Demodex brevis and Demodex mites. Demodex mange resembles rosacea or seborrheic dermatitis, but has been identified as being caused by mites of the Demodex genus.

[0011]

[0012] In a study funded by the American Rosacea Society, Maynooth, National University of Ireland, found that the Bacillus oleronius bacteria stimulated an immune system response, including high levels of T-cell proliferation, in 79 percent of patients with subtype 2 rosacea, compared with only 29 percent of patients without the disease. T-cell proliferation induces an inflammatory response evident as papules and pustules. This indicates that the Bacillus bacteria found in Demodex mites produces antigens that may be responsible for the tissue inflammation associated with papulopustular rosacea. Many current antibiotic treatments for rosacea are theorized to be effective based on their ability to effectively combat Bacillus oleronius.

[0012]

[0013] Traditionally, rosacea is treated orally or topically with antibiotics such as tetracycline, erythromycin or clindamycin, but also with vitamin A, salicylic acid, antifungals, steroids, anti-infectives such as benzoyl peroxide, or in severe cases, isotretinoin, or most commonly metronidazole (an antibacterial agent).

[0013]

[0014] Metronidazole is known for its antiparasitic, antiprotozoal and antibacterial properties. It is used especially to treat Helicobacter pylori infections. It is also prescribed in the treatment of rosacea due to its favorable properties against inflammatory lesions of rosacea, especially papules and pustules. Metronidazole exerts selective toxicity against anaerobic microorganisms and also against hypoxic cells. For the latter, metronidazole is reduced to various derivatives capable of changing the structure of their DNA.

[0014]

[0015] U.S. Patent Application Publication No. 2013 / 0095051 (published April 18, 2013) describes a method of treating rosacea with topical avermectin / metronidazole. U.S. Patent No. 5,952,372 describes a method of treating rosacea with oral or topical ivermectin to reduce and eliminate the parasitic Demodex folliculorum present on the patient's skin.

[0015]

[0016] Ivermectin belongs to the avermectin family, a group of macrocyclic lactones produced by the fungus Streptomyces avermitilis. The avermectins include, inter alia, ivermectin, invermectin, avermectin, abamectin, doramectin, eprinomectin, and selamectin. Ivermectin is known in the prior art for its antiparasitic and anthelmintic properties. The antiparasitic activity is believed to be due to the opening of chloride channels in the membranes of the parasite's neurons under the influence of an elevated release of the neuromediator GABA (gamma-aminobutyric acid), which induces a neuromuscular paralysis that can lead to the death of certain parasites. Ivermectin also interacts with other chloride channels, especially those that depend on the neuromediator GABA (gamma-aminobutyric acid).

[0016]

[0017] Ivermectin has been traditionally administered in the dermatological treatment of internal parasitic manifestations, such as onchocerciasis and myiasis. US Patent No. 6,133,310 describes the use of ivermectin in the treatment of rosacea to reduce and eliminate the parasite Demodex mites present on the skin of a patient. US Patent No. 6,133,310 describes the use of ivermectin in the treatment of rosacea to reduce and eliminate the parasite Demodex mites present on the skin of a patient.

[0017]

[0018] However, these treatments and compounds have drawbacks, such as irritation and hypersensitivity phenomena, especially when administered over a long period of time. All current rosacea treatments appear to only suppress and not cure, especially acting on the pustular attacks that occur during the inflammatory phase.

[0018]

[0019] According to the American Rosacea Society, an estimated 16 million Americans have rosacea, but only a small percentage are treated. The etiology of rosacea is currently under debate in the dermatology community. Rosacea is a common skin condition that often causes redness and small, red, pus-filled bumps on the face. If left untreated, rosacea tends to worsen over time. The signs and symptoms of rosacea may be severe for weeks to months, then subside, and then become severe again. Rosacea may be mistaken for acne, an allergic reaction, or other skin problems. There is no cure for rosacea, and current treatments can only help to regulate and reduce the signs and symptoms of the disease.

[0019]

[0020] Rosacea is typically observed in individuals after age 30 as redness on the cheeks, nose, chin, or forehead that comes and goes. In some cases, rosacea can also occur on the neck, chest, scalp, or ears. Over time, the redness tends to become more rosy and more persistent, and visible blood vessels may appear. If left untreated, bumps and pimples often develop, and in severe cases, the nose can become distended and bumpy with excess tissue. This condition is called rhinophyma, and it gave the late comedian WC Fields his trademark bulbous nose. In many rosacea patients, the eyes are also affected and appear to be burning, watery, or bloodshot.

[0020]

[0021] Rosacea may affect all parts of the population, but light-skinned individuals who tend to be easily flushed or irritated are considered to be at highest risk. The disease is more frequently diagnosed in women, but more severe symptoms tend to be seen in men. Rosacea may vary substantially from individual to individual, and most will exhibit some, but not all, of the underlying signs or symptoms. According to a consensus committee and review committee of 17 medical experts from around the world, rosacea always includes at least one of the following main signs, and various secondary signs and symptoms may also develop.

[0021]

[0022] The main signs of rosacea include: (1) Facial flushing: Many people with rosacea have a history of frequent flushing or flushing. This redness can come and go and is often the first sign of the disease. (2) Persistent redness: Persistent redness is the most common individual sign of rosacea and can resemble a flush and sunburn that does not go away. (3) Bumps and pimples: Small, solid red bumps or pus-filled pimples often grow. These can resemble acne, but there are no blackheads and burning or pain can occur. (4) Visible blood vessels: Many people with rosacea have tiny blood vessels that become visible on the skin. (6) Other potential signs and symptoms include eye irritation. In many people with rosacea, the eyes can appear to be burning, watery or bloodshot, a condition known as ocular rosacea. The eyelids can also become red and swollen, and styes are common. Severe cases can result in corneal damage and blindness if medical help is not sought. Burning or soreness: A burning or sore sensation often occurs in the face. Itching or a feeling of pressure may also develop. Dry appearance: The skin in the center of the face may appear rough and therefore very dry. Plaques: Raised red patches known as plaques may develop without changes to the surrounding skin. Skin thickening: The skin may become thickened and wide with excess tissue, most commonly on the nose. Known as rhinophyma, this condition affects more men than women. Swelling: Facial swelling, known as edema, may occur with or independently of other signs of rosacea. Signs beyond the face: Rosacea signs and symptoms may also progress beyond the face, most commonly to the neck, chest, scalp or ears.

[0022]

[0023] The various subtypes of rosacea include subtype 1 (erythematotelangiectatic rosacea), which is characterized by facial flushing and persistent redness that may contain visible blood vessels; subtype 2 (papulopustular rosacea), which is characterized by persistent redness accompanied by transient bumps and whiteheads; subtype 3 (phymatous rosacea), which is characterized by thickening of the skin often resulting in an enlarged nose due to excess tissue; and subtype 4 (ocular rosacea), which is characterized by ocular manifestations such as dry eyes, tearing and burning, eyelid swelling, recurrent styes, and potential blindness due to corneal damage.

[0024] Many patients experience features of more than one subtype at the same time, which can often occur consecutively. Rosacea may or may not evolve from one subtype to another, but each individual sign or symptom may progress from mild to moderate to severe. Early diagnosis and treatment are recommended.

[0025] Eyelid involvement may manifest as mild conjunctival irritation or inflammation of the meibomian (sebaceous) glands at the eyelid margin. Chronic eyelid irritation may result in loss of eyelashes. Meibomian gland dysfunction resulting from irritation and inflammation may lead to chronic dry eye disease and / or blepharitis.

[0023]

[0026] Demodex is hypothesized to be the root cause of meibomian gland dysfunction-associated dry eye, but no consensus has been reached and no commercially viable pharmacological solution is available to treat Demodex and Demodex on the eyelid.The presence or metabolic activity of Demodex mites in eyelash follicles has been discussed as a cause of blepharitis, but previous studies in which topical miticides other than anticholinergics and direct muscarinic agonists were used have shown inconsistent and insignificant results.Demodex seems to play a role in meibomian gland dysfunction, which may ultimately lead to chronic dry eye disease.

[0024]

[0027] The pathogenesis of dry eye disease is becoming more and more fully understood. Dry eye disease is progressive in nature and is fundamentally due to insufficient tear coverage of the ocular surface. This insufficient tear coverage prevents healthy gas exchange and nutrient transport to the ocular surface, promotes cellular drying, and results in an insufficient refractive surface for vision. Insufficient tear coverage typically results from excessive evaporation of aqueous tears due to dysfunction of the meibomian glands. The meibomian glands, located at the margin of the eyelid within the tarsal plate, are responsible for the supply of meibum, an oily substance that prevents evaporation of the tear film of the eye. When the flow of meibum is impeded by Demodex (or indirectly, an inflammatory response to Demodex), cylindrical dandruff caused by Demodex, or inflammation caused by Demodex or bacteria proliferated by Demodex, the lack of meibum causes a cascade effect resulting in chronic dry eye disease. Low tear volume causes a hyperosmolar environment that induces an inflammatory state of the ocular surface. This inflammatory response induces apoptosis of surface cells, which in turn prevents proper distribution of the tear film on the surface of the eye, making any given tear volume ineffective. This initiates a vicious positive feedback loop cycle in which more inflammation can result in more surface cell damage, and so on. Furthermore, the sensory neurons on the surface of the eye are damaged, thus preventing the neural control loop that regulates the activation of reflexive tear production. As a result, less tear production leads to loss of neurons, which leads to even less tear production, and so on, resulting in a second vicious cycle leading to further disease progression.

[0025]

[0028] There are a wide range of treatments for dry eye disease, but none provide substantial efficacy in treating the disease. Treatment options include artificial tear substitutes, ointments, gels, hot packs, environmental modification, topical cyclosporine, omega-3 fatty acid supplements, punctal plugs, and humidifying goggles. Patients with severe disease may be further treated with punctal cauterization, systemic cholinergics, systemic anti-inflammatory drugs, mucolytics, autologous serum eye drops, PROSE scleral contact lenses, and tarsorrhaphy. Despite these treatment options, dry eye disease continues to be considered one of the most difficult to treat diseases in ophthalmology. Therefore, it is desirable to have a more effective treatment for dry eye.

[0026]

[0029] Traditionally, dry eye is treated with frequent use of artificial tears or other moistening eye drops. Artificial tears are usually the first step in dry eye treatment. RESTASIS® eye drops are the most commonly prescribed pharmaceutical intervention for dry eye (RESTASIS® (cyclosporine ophthalmic emulsion) 0.05%) and contain cyclosporine, an immunosuppressant. Cyclosporine can increase tear production that is reduced due to inflammation in the eye. RESTASIS® eye drops are used to treat chronic dry eye, which may be caused by inflammation. Ocular rosacea is characterized by ocular manifestations such as dry eyes, tearing and burning, eyelid swelling, recurrent styes, and potential blindness due to corneal damage. There is a need in the art for safe and effective treatments of ophthalmic disorders, particularly Demodex-induced inflammatory eye disorders such as meibomian gland dysfunction, conjunctivitis, keratoconjunctivitis, hyperemia, dry eye, and blepharitis.

[0027]

[0030] Demodex mites are hypothesized to be somewhat benign human ectoparasites, but have been implicated as playing a causative role in the autoimmune diseases lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile and adult dermatomyositis, Sjogren's syndrome, and are involved in the treatment of porphyria cutanea tarda. There are no commercially viable pharmacological solutions available to treat Demodex and Demodex mites in autoimmune diseases. Responses to the presence or metabolic activity of Demodex mites in the human epidermis have already been described in skin diseases, such as rosacea and acne vulgaris, and in meibomian gland dysfunction, an ophthalmological disease believed to be the main cause of dry eye disease. All autoimmune diseases have a parasitic component, especially those with a dermatological component, where evidence for the use of the drugs hydroxychloroquine and / or chloroquine as effective interventions is considered to have an antiparasitic component, such as those acting on Demodex in the pathogenesis of the disease.

[0028]

[0031] Repositioning of anticholinergic and direct muscarinic agonist compounds to treat autoimmune diseases suspected to involve Demodex mites has shown promise in treating systemic lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile and adult dermatomyositis, Sjogren's syndrome, porphyria cutanea tarda, relapsing rheumatoid arthritis, eosinophilic fasciitis, polymorphous actin eruption, granuloma annulare, lichen planus, lupus panniculitis, discoid lupus, and other autoimmune diseases. It provides a new form of treatment for patients suffering from autoimmune diseases, including porphyria cutanea tarda, psoriatic arthritis, chronic ulcerative stomatitis, refractory chronic urticaria, sarcoidosis, frontal fibrosing alopecia, necrobiosis lipoidica, actinic reticuloid, actinic prurigo, epidermolysis bullosa, Kikuchi-Fujimoto disease, graft-versus-host disease, erythema nodosum chronica, localized scleroderma and systemic sclerosis, pemphigus vulgaris, pemphigus foliaceus, and pemphigoid of gestation.

[0029]

[0032] The pathogenesis of the diseases systemic lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile and adult dermatomyositis, Sjogren's syndrome, porphyria cutanea tarda, relapsing rheumatoid arthritis, eosinophilic fasciitis, polymorphous photoeruption, granuloma annulare, lichen planus, lupus panniculitis, discoid lupus, porphyria cutanea tarda, psoriatic arthritis, chronic ulcerative stomatitis, refractory chronic urticaria, sarcoidosis, frontal fibrosing alopecia, necrobiosis lipoidica, actinic reticulosis, actinic prurigo, epidermolysis bullosa, Kikuchi-Fujimoto's disease, graft-versus-host disease, chronic erythema nodosum, localized scleroderma and systemic sclerosis, pemphigus vulgaris, pemphigus foliaceus, and pemphigoid of gestationis is not fully understood. Autoimmune diseases are defined as diseases in which the body produces antibodies that attack its own tissues, causing the deterioration and sometimes destruction of such tissues. In some people, the immune system may actually be upregulated by the presence of the ubiquitous human Demodex mites or pathogens carried on or within the mites.

[0030]

[0033] Many of the factors that cause inflammation in rosacea overlap with those that cause autoimmune inflammation, especially lupus (SLE). The lupus rash is similar to the rash seen in rosacea patients and tends to occur in the T-zone and U-zone of the face. In lupus, the rash is called a malar rash or butterfly rash. Antibiotics that treat rosacea, especially tetracycline, can induce lupus. Antibiotics can act on mites, which in turn can cause drug-induced lupus. The most effective current method of treating drug-induced lupus is to discontinue the drug that initiated the reaction. It should also be noted that tetracycline antibiotics are used to treat acne, rosacea, and meibomian gland dysfunction. It is not yet fully understood whether the antibiotic acts as an antibacterial agent to kill Demodex or acts on the gut bacteria of the mites. We can show in our in vitro assay that doxycycline has activity against mites.

[0031]

[0034] The antimalarial drugs hydroxychloroquine and chloroquine treat autoimmune diseases by acting as anthelmintics against Demodex. The same drugs that treat dry eye, in which Demodex is now suspected to play a causative role, are used to treat many of these autoimmune diseases. Cyclosporine and lifitegrast work by downregulating the patient's T cells or T lymphocytes. The immunosuppressant tacrolimus has also been reported to treat dry eye. These immunosuppressants downregulate the host's immune response to Demodex mites in many different diseases that could be redefined as a significant allergic or immune response to Demodex mites or pathogens carried by the mites.

[0032]

[0035] Mites of the genus Demodex have been found in the lymph glands of dogs. Demodex canis could be used as a surrogate model to better understand human Demodex and Demodex mites. It should also be noted that dogs suffer from a form of lupus called canine discoid erythematosus, which may have an underlying causative effect associated with Demodex canis.

[0033]

[0036] Intense pulsed light (IPL) has been used to treat rosacea and dry eye. Demodex has been implicated as playing a causative role in both diseases. IPL treatment has been shown to kill Demodex mites. See Prieto V et al., "Effects of intense pulsed light on sun-damaged human skin, routine, and ultrastructural analysis" (2002); Timothy Kirn, "Intense pulsed light eradicates Demodex mites," Skin Allergy News (2002). In 2000, Dr. JL Levy described the treatment of chronic facial erythema of systemic lupus erythematosus in "Intense pulsed light treatment for chronic facial erythema of systemic lupus erythematosus: a case report." In the report, a 33-year-old woman already diagnosed with systemic lupus erythematosus presented with chronic erythema of the face and rosacea. The patient suffered from flushing and hot flashes of the facial skin and sought pretreatment with antimalarial drugs. After various treatment options were discussed with the patient, the patient agreed to undergo intense pulsed light therapy. Improvement was seen after the first session, and 75% clearance was observed one month after the second session. There were no adverse effects associated with the treatment. After one year, the results of the two treatments were observed to be maintained. Photosensitivity is one of the most widespread symptoms of lupus and the most commonly reported cause of lupus inflammation due to ultraviolet light, either from the sun or artificial light. The use of IPL in lupus patients is very difficult to understand. The clearance obtained in the case report is consistent with the mechanism for the removal of Demodex mites from the patient's facial skin.

[0034]

[0037] U.S. Patent Nos. 10,709,135 and 10,500,183 relate to the treatment of skin disorders by inactivating Demodex mites and / or Demodex mites with organophosphates and acetylcholinesterase inhibitors.U.S. Patent No. 11,446,241 relates to the treatment of ophthalmic disorders by inactivating Demodex mites and / or Demodex mites with selected acetylcholinesterase inhibitors.

[0035]

[0038] There is a need in the art for treatments for these autoimmune diseases that have substantial efficacy. Conventional treatments focus on improving quality of life by controlling symptoms and minimizing attacks. Treatment management includes life cycle management and drugs such as anti-inflammatory drugs, steroids, and immunosuppressants. Other treatments include acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs), sometimes in combination with antimalarials. Acetaminophen and NSAIDs are often sufficient to alleviate symptoms. Antimalarials include hydroxychloroquine (Plaquenil) and chloroquine. Low dose corticosteroids and / or corticosteroid creams or ointments are used. Corticosteroids include prednisolone and the like. Immunosuppressant drugs such as azathioprine, belimumab, cyclophosphamide, methotrexate, or mycophenolate mofetil may also be used. Corticosteroids are the first-line treatment for muscle lesions of dermatomyositis, but skin lesions often recur upon reduction or cessation. There is a large unmet need for new therapeutic strategies that focus on skin lesions in systemic autoimmune diseases, including those caused by mites. Summary of the Invention

[0036]

[0039] There is a need in the art for new therapeutic strategies to treat various diseases associated with Demodex mites.Provided herein is a method of treatment for Demodex-induced inflammatory diseases, including skin diseases and / or eye diseases, including administering or applying a specific active agent to inactivate, for example, paralyze, kill, and / or eliminate Demodex mites, thereby alleviating, eliminating, or otherwise reducing or preventing any one or more clinical symptoms associated with Demodex-induced inflammatory skin diseases and / or eye diseases.Exemplary active agents include anticholinergics and / or muscarinic agonists that are effective in inactivating Demodex mites.

[0037]

[0040] Based on the understanding of the role of Demodex mites in various diseases, various treatments are provided herein that specifically target this Demodex-induced mechanism by applying an active agent. In a typical embodiment, the active agent applied can be a topically applied anticholinergic agent(s) and / or muscarinic agonist(s) that is applied to the hair follicle, skin, eye, eyelid, eyelashes or meibomian gland of an individual. In one embodiment, for example, the topically applied active agent penetrates the outer layer of the skin of an individual, thereby exposing Demodex mites and / or Demodex mites that are present under the outer layer of the skin of the eyelid to the active agent. In one embodiment, for example, the topically applied active agent penetrates the subcutaneous region of the eyelid of an individual, thereby exposing Demodex mites and / or Demodex mites that are present in and around the meibomian gland to the active agent. Any formulation of topical active agent useful in the methods provided herein includes one or more compositions that enhance skin penetration, such as a formulation that includes an active agent and a skin penetration agent, such as dimethyl sulfoxide (DMSO).

[0038]

[0041] In a typical embodiment, the topically applied active agent is applied to the affected skin area at least once and at most twice daily for about 2-12 weeks. In one embodiment, the topically applied active agent is applied to the affected and / or non-affected areas during a first application period, thereby paralyzing, killing, and / or removing adult Demodex mites, including Demodex folliculorum, from hair follicles, skin, eyes, eyelids, eyelashes, and / or meibomian glands. In one embodiment, the topically applied active agent is further applied to the affected and / or non-affected areas during a second application period, thereby paralyzing, killing, and / or removing adult Demodex mites and / or Demodex folliculorum from the individual's hair follicles, skin, eyes, eyelids, eyelashes, or meibomian glands that have developed from the larval and / or egg forms present on and / or in the skin during the first application period. In one embodiment, the topically applied active agent is further applied to affected and / or unaffected areas during a third application period, thereby paralyzing, killing and / or removing from the individual's hair follicles, skin, eyes, eyelids, eyelashes or meibomian glands Demodex mites and / or Demodex mites that have developed from the larval and / or egg forms that were present on and / or in the skin and / or hair follicles during the first application period and / or second application period.

[0039]

[0042] Provided herein are methods for treating various autoimmune diseases in humans, including inactivating certain organisms associated with the autoimmune disease using active agents including anticholinergics and / or muscarinic agonists that are topically applied, orally administered, or intravenously administered.For example, by reducing or eliminating Demodex organisms from a patient, including an infected site, the methods reduce the clinical signs or symptoms of the autoimmune disease that are primarily due to the body's inflammatory and / or immune response to Demodex organisms and / or pathogens carried by Demodex organisms.

[0040]

[0043] The embodiments described herein relate to treating ophthalmic disorders by topical, intraocular or oral use of one or more active agents.By effectively reducing or eliminating Demodex mite populations in affected skin areas and areas where Demodex mites may be present, this treatment achieves a more complete remission of clinical signs and symptoms of ophthalmic disorders than any of the above-mentioned methods.The embodiments of the present invention are useful for treating ophthalmic disorders associated with Demodex-induced inflammatory eye diseases, including meibomian gland dysfunction, conjunctivitis, keratoconjunctivitis, hyperemia (excessive blood supply to the eye), blepharitis and dry eye disease.

[0041]

[0044] Also provided herein is a method for treating an individual with Demodex-induced inflammatory eye disease. The method may include applying an active agent to an individual in need thereof in a dosage sufficient to inactivate Demodex and / or Demodex from the eye area of ​​the individual, so that a sufficient amount of Demodex and / or Demodex is inactivated to improve or stop the manifestation of allergic and / or inflammatory reactions to Demodex mites that cause inflammatory eye disease, the eye area including one or more of hair follicles, eyelids, eyelashes and meibomian glands in and around the eye area. This sufficient amount may correspond to at least 50%, 70%, 90% or 95% removal, including reduction in and around the eye area and / or whole body, depending on the sensitivity of the individual.

[0042]

[0045] The inflammatory eye disease may correspond to one or more of meibomian gland dysfunction, dry eye, blepharitis, conjunctivitis, keratoconjunctivitis or hyperemia.

[0043]

[0046] For any of the applications described herein, application may be topical, including to the affected skin area(s) of an individual and / or around the eye in the eye area, preferably avoiding direct application to the ocular surface. The eye area may correspond to an area of ​​at least between 1 cm and 10 cm around the outermost border defined by the eye, eyelid, eyebrow and eyelashes.

[0044]

[0047] Also provided herein are methods of treatment to alleviate, eliminate, or otherwise reduce or prevent any one or more of the above clinical symptoms by administering or applying anticholinergics and direct muscarinic agonists, naturally occurring anticholinergics and direct muscarinic agonists.

[0045]

[0048] The embodiments of the invention described herein relate to treating skin disorders with topical or oral use of one or more anticholinergics and direct muscarinic agonists, including naturally occurring anticholinergics or direct muscarinic agonists. By effectively reducing or eliminating the population of Demodex mites in affected skin areas and in areas where Demodex mites may be present, the treatment achieves a more complete remission of the clinical signs and symptoms of the skin disorder than any of the aforementioned methods. The embodiments of the invention are useful for treating skin disorders including acne vulgaris, seborrheic dermatitis, perioral dermatitis, acneiform rash, transient acantholytic dermatosis, acne necrotica milliaris, psoriasis, steroid-induced dermatitis, primary irritant dermatitis, rosacea, and sweat gland abscess.

[0046]

[0049] An exemplary method embodiment includes orally or topically administering to an individual having a skin disorder an anticholinergic agent and a direct muscarinic agonist in a dosage sufficient to inactivate Demodex mites and / or Demodex mites from the individual's hair follicles and / or skin, resulting in amelioration or cessation of manifestations of allergic and / or vasomotor responses to the mites that cause symptoms and signs of the skin disorder in the individual. Optionally, the skin disorder affects the facial skin or eyelids or both.

[0047]

[0050] In a typical embodiment, the anticholinergic and direct muscarinic agonist are applied topically. In an embodiment, for example, the topically applied anticholinergic and direct muscarinic agonist are formulated in a carrier, such as a lotion, cream, soap, wash, shampoo, or gel. Optionally, the concentration of the anticholinergic and direct muscarinic agonist in the topically applied lotion, cream, soap, wash, shampoo, or gel is about 0.001 to 5 weight percent, or about 0.01 to 1 weight percent. In a typical embodiment, the concentration of the anticholinergic and direct muscarinic agonist in the topically applied lotion, cream, soap, wash, shampoo, or gel is the minimum concentration effective to kill Demodex mites. In one embodiment, the dosage of the anticholinergic and direct muscarinic agonist in the topically applied lotion, cream, soap, wash, shampoo, or gel is less than about 150 mg / kg body weight, or between about 0.01 mg / kg and 50 mg / kg body weight. In an exemplary embodiment, the dosage of the anticholinergic and direct muscarinic agonist in the topically applied lotion, cream, soap, wash, shampoo or gel is the minimum effective dose to kill Demodex mites. Optionally, the topically applied anticholinergic and direct muscarinic agonist are encapsulated in microliposomes prior to being incorporated into the carrier lotion, cream, soap, wash, shampoo or gel.

[0048]

[0051] In general, the method of the present invention comprises that topically applied anticholinergics and direct muscarinic agonists are applied to skin areas affected by skin disorders.However, in certain embodiments, topically applied anticholinergics and direct muscarinic agonists are also applied to skin areas not affected by skin disorders.For example, in one embodiment, topically applied anticholinergics and direct muscarinic agonists are applied to body skin areas where Demodex and / or Demodex mites are present.In typical embodiments, topically applied anticholinergics and direct muscarinic agonists are applied to the entire skin area.

[0049]

[0052] Optionally, the method of the present invention further comprises applying an anticholinergic agent and a direct muscarinic agonist to the individual's clothing, linen, or both clothing and linen. Such application is useful, for example, to prevent the individual's clothing or linen from becoming a source of Demodex mites to re-enter the individual's skin. Similarly, the method of the present invention optionally further comprises administering orally or topically an anticholinergic agent and a direct muscarinic agonist to another person who has come into contact with the individual in a dosage sufficient to fill and remove Demodex mites and / or Demodex mites from the hair follicles and / or skin of the other person. For example, in an embodiment, the other person includes a household member, a child, a spouse, a partner, a family member, or a household pet.

[0050]

[0053] In a typical embodiment of the present invention, the topically applied anticholinergic agent and direct muscarinic agonist are applied to the hair follicles and / or skin of an individual. In one embodiment, for example, the topically applied anticholinergic agent and direct muscarinic agonist penetrate the outer layer of the individual's skin, thereby exposing Demodex mites and / or Demodex mites present under the outer layer of the skin to the anticholinergic agent and direct muscarinic agonist. In one embodiment, for example, the topically applied anticholinergic agent and direct muscarinic agonist penetrate the subcutaneous region of the individual's skin, thereby exposing Demodex mites and / or Demodex mites present under the subcutaneous region of the skin to the anticholinergic agent and direct muscarinic agonist. Certain formulations of topical anticholinergic agents and direct muscarinic agonists useful in the methods of the present invention optionally include one or more compositions that enhance skin penetration, such as dimethyl sulfoxide (DMSO).

[0051]

[0054] In typical embodiments, the topically applied anticholinergic and direct muscarinic agonist are applied to affected skin areas at least once and at most twice daily for about 2-6 weeks. In one embodiment, the topically applied anticholinergic and direct muscarinic agonist are applied to affected and / or unaffected skin areas during a first application period, thereby filling and removing adult Demodex mites and / or Demodex mites from hair follicles of the individual's skin. In one embodiment, the topically applied anticholinergic and direct muscarinic agonist are further applied to affected and / or unaffected skin areas during a second application period, thereby filling and removing adult Demodex mites and / or Demodex mites from hair follicles and / or skin of the individual that have developed from larval and / or egg forms that were present on and / or in the skin during the first application period. In one embodiment, the topically applied anticholinergic and direct muscarinic agonist are further applied to affected and / or unaffected skin areas during a third application period, thereby filling and removing from the individual's hair follicles and / or skin Demodex mites and / or Demodex mites that have developed from larval and / or egg forms that were present on and / or in the skin and / or hair follicles during the first application period and / or second application period.

[0052]

[0055] Optionally, the first application period and the second application period are separated by at least 5 days, but at most 10 days. Optionally, the first application period and the second application period are separated by at least 7 days. In an exemplary embodiment, the first application period and the second application period are separated by a time sufficient to allow larval forms to develop into adult forms and / or egg forms to develop into adult forms.

[0053]

[0056] Optionally, the second application period and the third application period are separated by at least 5 days, but at most 10 days. Optionally, the second application period and the third application period are separated by at least 7 days. In an exemplary embodiment, the second application period and the third application period are separated by a time sufficient to allow larval forms to develop into adult forms and / or egg forms to develop into adult forms.

[0054]

[0057] In an exemplary embodiment, the anticholinergic and direct muscarinic agonist are orally administered or topically applied in an intermittent regimen of sufficient duration for prophylactic management of Demodex mite populations in the hair follicles and / or skin of an individual.

[0055]

[0058] In another embodiment, the active agent is orally administered. In certain embodiments, for example, the orally administered anticholinergic and direct muscarinic agonist is administered at an oral dose of about 150 mg / kg body weight or less, or between about 0.01 mg / kg body weight and 50 mg / kg body weight of the anticholinergic and direct muscarinic agonist. In typical embodiments, the orally administered anticholinergic and direct muscarinic agonist is administered at the lowest oral dose of the anticholinergic and direct muscarinic agonist effective for killing Demodex mites. In certain embodiments, the orally administered anticholinergic and direct muscarinic agonist are formulated as prodrugs or pharma- ceutically acceptable salts.

[0056]

[0059] Optionally, the orally administered anticholinergics and direct muscarinic agonists are administered as a daily dose of 10 mg / kg body weight. Optionally, the orally administered anticholinergics and direct muscarinic agonists are administered as a daily dose of 7.5 mg / kg body weight. Optionally, the orally administered anticholinergics and direct muscarinic agonists are administered as a dose of 5 mg / kg body weight three times a day. Optionally, the orally administered anticholinergics and direct muscarinic agonists are repeated about 2-4 times with 3-7 days between them.

[0057]

[0060] In various embodiments, removal of Demodex mites and / or Demodex mites from the individual's hair follicles and / or skin results in a reduction in the population of one or more bacteria in the individual's hair follicles and / or skin. For example, in some embodiments, an allergic reaction and / or a vasomotor reaction to mites is caused by the presence of one or more bacteria associated with mites in the individual's hair follicles and / or skin. In certain embodiments, the one or more bacteria include one or more bacteria of the genus Staphylococcus or Bacillus. For example, in one embodiment, the one or more bacteria include Bacillus orellonius. In one embodiment, for example, the one or more bacteria include Staphylococcus epidermidis. Optionally, the one or more bacteria are present in the digestive system of Demodex mites and / or Demodex mites.

[0058]

[0061] Another typical method of treating a skin disorder includes topically applying an active ingredient to an individual with a skin disorder in a dosage sufficient to fill and remove Demodex mites and / or Demodex mites from the individual's hair follicles and / or skin, resulting in the cessation of the appearance of allergic and / or vasomotor responses to the mites that cause the symptoms and signs of the individual's skin disorder, the topically applied active ingredient being applied to skin areas affected by the skin disorder and to skin areas not affected by the skin disorder.In certain embodiments, the topically applied active ingredient is applied to the entire skin of the individual, thereby filling and removing Demodex mites and / or Demodex mites from the entire skin of the individual.Again, the method of the present invention is useful for treating skin diseases including, for example, acne vulgaris, seborrheic dermatitis, perioral dermatitis, acneiform rash, transient acantholytic dermatosis, necrotizing acne, psoriasis, steroid-induced dermatitis, primary irritant dermatitis, rosacea, or hidradenitis suppurativa. In an exemplary embodiment, the skin condition is caused by, exacerbated by, or otherwise coexists with infestation of skin and / or hair follicles by Demodex mites.

[0059]

[0062] In some embodiments, anticholinergics and direct muscarinic agonists include the anticholinergics atropine (Atropen), belladonna alkaloids, benztropine mesylate (Cogentin), clidinium, cyclopentolate (Cyclogyl), darifenacin (Enablex), dicyclomine, fesoterodine (Toviaz), flavoxate (Urispas), glycopyrrolate, homatropine hydrobromide, hyoscyamine (Levsinex), ipratropium (Atrovent), orphenadrine, oxybutynin (Ditropan), benzodiazepine (Bordeaux ... XL), propantheline (Pro-banthine), scopolamine, methscopolamine, solifenacin (VESIcare), tiotropium (Spiriva), tolterodine (Detrol), trihexyphenidyl, trospium, citalopram, fluoxetine, fluvoxamine, paroxetine, amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine, desipramine, amoxapine, maprotiline, clozapine, quetiapine, biperiden, chlorpheniramine, dimenhydrinate, diphenhydramine, doxepin, doxylamine, glycopyrronium, oxitropium, promethazine, solifenacin, tropicamide, and umeclidinium. Direct muscarinic agonists, acetylcholine, carbachol, methacholine, bethanechol, muscarine, nicotine, pilocarpine, oxotremorine, bupropion, dextromethorphan, doxacurium, hexamethonium, mecamylamine, tubocurarine, cytisine, suxamethonium chloride (succinylcholine chloride), and varenicline.

[0060]

[0063] In another embodiment, the anticholinergics and direct muscarinic agonists correspond to compounds currently used in medicine, including those with established safety profiles in humans. These include the direct muscarinic agonists atropine (Atropen), belladonna alkaloids, benztropine mesylate (Cogentin), clidinium, cyclopentolate (Cyclogyl), darifenacin (Enablex), dicyclomine, fesoterodine (Toviaz), flavoxate (Urispas), glycopyrrolate, homatropine hydrobromide, hyoscyamine (Levsinex), ipratropium (Atrovent), orphenadrine, oxybutynin (Ditropan), and the like. XL), propantheline (Pro-banthine), scopolamine, methscopolamine, solifenacin (VESIcare), tiotropium (Spiriva), tolterodine (Detrol), trihexyphenidyl, trospium, citalopram, fluoxetine, fluvoxamine, paroxetine, amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, trimipramine, desipramine, amoxapine, maprotiline, clozapine, quetiapine, biperiden, chlorpheniramine, dimenhydrinate, diphenhydramine, doxepin, doxylamine, glycopyrronium, oxitropium, promethazine, solifenacin, tropicamide, and umeclidinium. Direct muscarinic agonists, acetylcholine, carbachol, methacholine, bethanechol, muscarine, nicotine, pilocarpine, oxotremorine.

[0061]

[0064] Any of the methods provided herein may employ anti-nicotine agents, including but not limited to bupropion, dextromethorphan, doxacurium, hexamethonium, mecamylamine, tubocurarine, cytisine, suxamethonium chloride (succinylcholine chloride), and / or varenicline.

[0062]

[0065] Formulations suitable for any of the methods described herein are also provided herein.The use of any of the compounds described herein for the treatment of mite-induced disorders caused by the presence of Demodex mites or one or both of Demodex mites is also provided herein.The use of any of the compounds described herein in the manufacture of a medicament for the treatment of mite-induced skin disorders, wherein the mite is Demodex mites or one or both of Demodex mites, is also provided herein.

[0063]

[0066] Methods for treating mites to at least reduce clinical symptoms are provided herein.For example, the method may be for treating an individual with Demodex mites that cause one or more mite-induced clinical symptoms, and the method may comprise applying an active agent to the individual with mites in a dosage sufficient to inactivate Demodex mites from the individual's hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands, resulting in improvement or cessation of mite-induced clinical symptoms.The active agent may be selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof. The individual in need of treatment may suffer from a skin disorder, an ophthalmic disorder, or an autoimmune disease.

[0064]

[0067] Also provided herein is a method for treating skin disorders caused by Demodex mites.For example, the method may be for treating an individual with a skin disorder, and may include topically or orally administering an active agent to the individual with the skin disorder in a dosage sufficient to inactivate Demodex mites from the individual's hair follicles and / or skin, resulting in the improvement or cessation of the appearance of allergic and / or vasomotor responses to the mites that cause the symptoms and signs of the individual's skin disorder.The active agent may be selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

[0065]

[0068] Also provided herein is a method for treating an autoimmune disease caused by Demodex mites.For example, the method may be for treating an individual with an autoimmune disease, the method may comprise administering an active agent to the individual in a dosage sufficient to inactivate at least a portion of Demodex mites in or on the individual, the inactivation resulting in attenuation or cessation of one or more symptoms associated with the inflammatory and / or immune response to Demodex mites that cause one or more symptoms associated with the autoimmune disease of the individual.The active agent may be selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

[0066]

[0069] Also provided herein is a method for treating an ophthalmic disorder in an individual.For example, the method may be for treating an individual with an ophthalmic disorder, and the method may include topically or orally administering an active agent to the individual with an ophthalmic disorder in a dosage sufficient to inactivate Demodex mites from the individual's hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands, resulting in the improvement or cessation of the manifestation of the allergic and / or inflammatory response to Demodex mites that cause the symptoms and signs of the individual's ophthalmic disorder.The active agent may be selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

[0067]

[0070] The active agent may be an anticholinergic and / or a muscarinic agonist, including a direct muscarinic agonist, so long as it is capable of directly or indirectly inactivating the Demodex mites that cause the underlying condition.

[0068]

[0071] The Demodex mites may be Demodex mites and Demodex folliculorum.

[0069]

[0072] The step of topically applying or orally administering the active agent may kill Demodex mites, paralyze Demodex mites, and / or render at least a portion of the Demodex mites unable to reproduce. Inactivation may be characterized as "substantial inactivation" and refers to a reduction in the number of mites in a selected area by at least 50%, at least 70%, at least 90%, at least 95%, at least 98%, at least 99%. Functionally, the reduction is empirically characterized as being sufficient to improve, attenuate, and / or cause the cessation of clinical symptoms. Of course, reinfestation of mites is typically expected, so treatment may be repeated, either on an ongoing basis or periodically, as needed.

[0070]

[0073] The active agent may be selected from the group of active agents that kill Demodex mites, for example, the active agent may be selected from the group consisting of benztropine, dicyclomine, fluvoxamine, imipramine, promethazine, dextromethorphan, mecamylamine, bupropion, and pharma- ceutically acceptable salts thereof.

[0071]

[0074] The active agent may be selected from the group consisting of promethazine hydrochloride, benztropine mesylate, dicyclomine hydrochloride, fluvoxamine, imipramine maleate, dextromethorphan hydrobromide, mecamylamine hydrochloride, bupropion hydrochloride.

[0072]

[0075] The active agent may be selected from the group of active agents that paralyze Demodex mites. The active agent may be selected from the group consisting of fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, and pharma- ceutically acceptable salts thereof.

[0073]

[0076] The active agent may be selected from the group consisting of fesoterodine fumarate, paroxetine hydrochloride, trihexyphenidyl hydrochloride, nortriptyline hydrochloride, chlorpheniramine maleate, clidinium bromide, and quetiapine fumarate.

[0074]

[0077] The active agent may be any one or more of the compounds described in Figures 1A-1E, whether or not they have been screened in an in vitro Demodex assay.

[0075]

[0078] The skin disorder may be one or more of acne vulgaris, seborrheic dermatitis, perioral dermatitis, acneiform rash, transient acantholytic dermatosis, necrotizing acne, psoriasis, steroid-induced dermatitis, primary irritant dermatitis, rosacea, or hidradenitis suppurativa.

[0076]

[0079] The skin disorder may affect the facial skin, the eyelids, or both.

[0077]

[0080] The active agent may be applied topically to the individual.

[0078]

[0081] Topically applied active agents may be formulated in a carrier such as a lotion, cream, soap, wash, shampoo or gel.

[0079]

[0082] The concentration of the active agent in a topically applied lotion, cream, soap, wash, shampoo or gel may be between 0.001 and 5 percent by weight.

[0080]

[0083] The concentration of topically applied active agent may be the minimum concentration effective to substantially inactivate (eg, kill or paralyze at least a significant proportion of) Demodex mites.

[0081]

[0084] The dosage of active agent in a topically applied lotion, cream, soap, wash, shampoo or gel is between about 0.01 mg / kg and 150 mg / kg of body weight.

[0082]

[0085] Topically applied active agents may be encapsulated within the microliposomes before being incorporated into the carrier lotion, cream, soap, wash, shampoo or gel.

[0083]

[0086] The active agent may be topically applied to at least a portion of the skin area affected by the skin disorder and, optionally, to at least a portion of the skin area not affected by the skin disorder. The active agent may be topically applied to the skin area of ​​the body where Demodex mites and / or Demodex mites are present. The active agent may be topically applied to substantially the entire skin area of ​​the individual.

[0084]

[0087] The ophthalmic disorder may be one or more of Demodex-induced inflammatory eye diseases, such as meibomian gland dysfunction, conjunctivitis, keratoconjunctivitis, hyperemia, dry eye, and blepharitis.

[0085]

[0088] The ophthalmic disorder may be one or more of meibomian gland dysfunction, blepharitis, dry eye disease. The ophthalmic disorder may affect the eye or eyelid or both the eye and eyelid.

[0086]

[0089] Demodex mites may be present in the hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands of an individual upon corresponding application of an active agent.

[0087]

[0090] The active agent may be applied topically and provided in a formulation for efficient delivery of the active ingredients of the active agent to the epidermal or subcutaneous area of ​​an individual.

[0088]

[0091] The autoimmune disease may be one or more of lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile dermatomyositis, adult dermatomyositis, Sjogren's syndrome, or porphyria cutanea tarda.

[0089]

[0092] The autoimmune disease may be one or more of systemic lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile and adult dermatomyositis, Sjogren's syndrome, porphyria cutanea tarda, relapsing rheumatoid arthritis, eosinophilic fasciitis, polymorphous actinitis, granuloma annulare, lichen planus, lupus panniculitis, discoid lupus, porphyria cutanea tarda, psoriatic arthritis, chronic ulcerative stomatitis, refractory chronic urticaria, sarcoidosis, frontal fibrosing alopecia, necrobiosis lipoidica, actinic reticulosis, actinic prurigo, epidermolysis bullosa, Kikuchi-Fujimoto's disease, graft versus host disease, chronic erythema nodosum, localized scleroderma and systemic sclerosis, pemphigus vulgaris, pemphigus foliaceus, or pemphigoid of gestation.

[0090]

[0093] Autoimmune diseases may affect the skin, lymphatic system, muscles, joints, or internal organs of an individual.

[0091]

[0094] Formulations for carrying out any of the described methods are also provided herein. Also provided herein is an active agent(s) for use in treating any of the diseases described herein, including clinical symptoms, skin disorders, autoimmune diseases and / or ophthalmological disorders caused by the presence of Demodex mites or one or both of Demodex mites.

[0092]

[0095] Provided herein is a formulation for inactivating Demodex mites that cause one or more mite-induced clinical symptoms, the formulation comprising a therapeutically effective amount of an active agent selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

[0093]

[0096] The formulation may further comprise DMSO or any additional skin penetration enhancer.

[0094]

[0097] The formulation may further comprise an ophthalmically acceptable excipient selected from the group consisting of buffered saline, mineral oil, vegetable oil, petrolatum, Miglyol™ 182, alcoholic solutions, liposomes and liposome-like products.

[0095]

[0098] The formulation may further comprise one or more of a preservative, an antioxidant, an antibiotic and an immunosuppressant.

[0096]

[0099] The formulation may be formulated into a pad or gel stick.

[0097]

[0100] While not wishing to be bound by any particular theory, beliefs or understandings about the underlying principles relating to the devices and methods disclosed herein may be discussed herein, and it is recognized that regardless of the ultimate accuracy of any mechanistic explanation or hypothesis, embodiments of the invention may still be operative and useful. Compound and Nomenclature Statement

[0101] In an embodiment, the composition or compound used by the method of the present invention is isolated or purified. In an embodiment, the isolated or purified compound is at least partially isolated or purified as understood in the art. In an embodiment, the composition or compound of the present invention has a purity of 95% chemical purity, optionally 99% in some applications, optionally 99.9% in some applications, optionally 99.99% in some applications, and optionally 99.999% in some applications.

[0098]

[0102] Many of the compounds used in the method of the present invention contain one or more ionizable groups. Ionizable groups include groups that can remove (e.g. -COOH) or add (e.g. amine) protons, and groups that can be quaternized (e.g. amine). All possible ionic forms of such molecules and their salts are intended to be included individually in the disclosure of this specification. With respect to salts of the compounds herein, those skilled in the art can select from a wide variety of available counterions suitable for preparing the salt of the present invention for a given application. In certain applications, the selection of a given anion or cation for preparing a salt can result in an increase or decrease in the solubility of the salt. [Brief description of the drawings]

[0099] [Figure 1A] 1A-1E are tables summarizing in vitro assays of various substances on survival time and paralysis of Demodex mites. [Figure 1B] 1A-1E are tables summarizing in vitro assays of various substances on survival time and paralysis of Demodex mites. [Figure 1C] 1A-1E are tables summarizing in vitro assays of various substances on survival time and paralysis of Demodex mites. [Figure 1D] 1A-1E are tables summarizing in vitro assays of various substances on survival time and paralysis of Demodex mites. [Figure 1E] 1A-1E are tables summarizing in vitro assays of various substances on survival time and paralysis of Demodex mites. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0100]

[0104] Generally, the terms and expressions used herein have their art-recognized meanings, which can be found by reference to standard texts, reference journals, and contexts known to those of skill in the art. The following definitions are provided to clarify their specific use in the context of the present invention.

[0101]

[0105] "Active agent" refers to a composition capable of inactivating Demodex mites, particularly Demodex mites that cause one or more clinical symptoms ("mite-induced clinical symptoms"), including those associated with skin disorders, autoimmune diseases, or ophthalmic disorders.

[0102]

[0106] "Inactivate" is used broadly herein to refer to the functional ability to reduce the effect of Demodex mites and / or Demodex mites. For example, inactivation may be due to the paralysis and / or death of mites caused by application of an active agent. Alternatively, inactivation may refer to the inability of mites to reproduce, so that mites die of age without reproducing, and thus die off one after another. As long as the treatment results in an adverse effect on Demodex mites and / or Demodex mites that corresponds to an improvement in clinical outcome, e.g., an improvement in symptoms, the treatment is considered to be inactivating Demodex mites and / or Demodex mites herein.

[0103]

[0107] "Anticholinergic agents" refer to substances that block the action of acetylcholine (ACh) on the nervous system of ticks. These substances compete with Ach at receptors in the nervous system so that Ach cannot bind to the receptors and cause cholinergic effects. Many of these substances interact with muscarinic cholinergic receptors in the brain, glands, heart, smooth muscle and eye. "Muscarinic agonists" refer to agonists that activate the ability of muscarinic acetylcholine receptors. Application of these classes of substances can be useful for inactivating ticks, including killing or paralyzing a significant proportion of ticks, thereby reducing the overall associated tick population, and improving and / or stopping the clinical symptoms caused by the corresponding ticks.

[0104]

[0108] Demodex and Demodex mites may play a role in disorders including rosacea disease. Elevated populations of Demodex have been observed in rosacea patients. In most people, Demodex mites live harmlessly on the skin, either as a result of downregulating host immunity or simply evading host immune defenses. There is a lively debate within the dermatology community as to whether they are the causative agent of skin diseases such as rosacea and blepharitis (inflammation of the eyelids), a common problem seen in rosacea patients.

[0105]

[0109] Humans are the only hosts for this ubiquitous mite. In fact, these two species of mites are considered to be the most common ectoparasites of humans. Women tend to have a higher rate of Demodex infection. The rate of infection also seems to be age-related, with 84% of people aged 60 years carrying mites, rising to 100% in those aged 70 years and older. It is not known whether immune-compromised individuals are more susceptible to infection and have a higher infestation rate, although some studies have shown that patients with acquired immune deficiency syndrome and leukemia are more susceptible and may have higher than average numbers.

[0106]

[0110] Mites are most commonly found on the scalp, face and upper chest area, where Demodex mites prefer hair follicles and Demodex mites prefer sebaceous ducts and meibomian glands at the edge of the eyelids (sebaceous ducts move waxy sebum that moisturizes the skin and hair from the sebaceous glands, and meibomian glands are a special type of such gland). Demodex mites are clumpy and tend to congregate in the follicular area of ​​hair or eyelashes, protruding their rear ends through the pores of the hair follicle. Demodex mites, on the other hand, tend to be more gregarious and live singly in sebaceous glands. Both species are very small, less than 0.4 mm, with a long, thin, transparent body and four pairs of stout legs. Demodex mites are usually a little shorter than Demodex mites, about 0.1 mm. They both have ridges along the cephalothorax and sharp, pointed teeth.

[0107]

[0111] The life cycle of the ticks, short-lived creatures, from eggs to larvae to adults, lasts 14-18 days. Adults emerge from hair follicles and ducts to reproduce on the surface of the skin, then females lay eggs in the sebaceous glands. The larvae develop through two larval stages in the glands and then enter the hair follicles and ducts as adults to start the cycle anew. Both species of ticks feed on sebum as their initial food source, but it has been hypothesized that they can also feed on the follicular and glandular epithelium. They are considered to be obligate ectoparasites that cannot grow outside the human host.

[0108]

[0112] Some studies have shown that average mite densities are greater than cm 2They found that more than five mites per 1000 stools seem to play a role in these two disorders in patients. The researchers suggest that blockage of hair follicles and sebaceous ducts by mites may result in epithelial hyperplasia, triggering a granulomatous reaction of phagocytes, or an inflammatory reaction by waste products. The fact that treatment with certain antibiotics can reduce the severity of rosacea strongly suggests a microbial component to mite-related disorders. In fact, in 2007, researchers isolated the bacterium Bacillus oleronium from Demodex mites, which triggers an inflammatory reaction, in 73% of rosacea patients, but only 29% of controls. These results suggest that patients with rosacea may be sensitized to bacteria and may be immunologically susceptible to mites, bacteria, or both.

[0109]

[0113] Two antigenic proteins found on the bacterial cell surface appear to be responsible for the inflammatory response, particularly by stimulating the proliferation of peripheral blood mononuclear cells; one 83 kDa protein showed similarity to heat shock proteins, and the other 62 kDa protein had amino acid sequence homology to protease enzymes found to be involved in neurotransmission and carbohydrate metabolism. Stronger evidence for the pathogenic role of B. orellonius in rosacea can also be found in the susceptibility of the bacteria to many antibiotics, particularly tetracycline, doxycycline, and minocycline, that have been shown to be effective in the treatment of rosacea.

[0110]

[0114] In a typical embodiment, the anticholinergic and direct muscarinic agonist are administered topically to a patient with an ongoing skin disease whose root cause is Demodex mites. Because the target organisms Demodex mites and Demodex are ectoparasites of the mite family, an effective treatment must be able to eradicate the entire life cycle of the microscopic insects, including their egg, larval and adult stages. This embodiment therefore treats such patients with several doses. Such spacing allows time for Demodex eggs to hatch and become immature mites that are killed before they can develop into egg-laying adults. After the anticholinergic and direct muscarinic agonist have carried out their acaricidal activity against the Demodex mites and Demodex mites on the skin, the inflammatory response to them begins to subside, but the remains of the dead mites still cause some flushing and lesion formation until they are removed by the body's cleansing process, a process that requires 6-8 weeks. During this initial phase of administration of anticholinergics and direct muscarinic agonists, conventional anti-rosacea drugs, such as oral tetracycline and topical metronidazole, can be optionally used to suppress early attacks and provide an early clinical response. Such drugs are not required to treat rosacea manifestations after 6-8 weeks have passed. Treatment can be repeated if classic signs begin to reappear after a long interval of relief from rosacea symptoms. Such retreatments are optional and need not be more than once or twice per year. The anticholinergics and direct muscarinic agonists are formulated into a cosmetically acceptable topical lotion, cream, shampoo or gel and applied to the skin affected by rosacea, and in particular to any areas where Demodex and Demodex mites may harbor. Due to the well-known barrier effect of the skin against the penetration of topical drugs, such treatment routes with anticholinergics and direct muscarinic agonists are expected to require one or two applications per day for as long as six weeks to obtain sufficient hair follicle penetration and effective acaricidal activity. Topical formulations that have been able to achieve this effect contain up to about 5% of an anticholinergic and a direct muscarinic agonist.The low percentage of anticholinergics and direct muscarinic agonists that can be used while still receiving the acaricidal effect and successfully treating the skin disease is ideal to limit any possible chemical side effects. Additionally, systemic treatment is optionally useful to prevent reinfestation of the skin by mites from other body locations, such as facial skin.

[0111] [Detailed Description of the Invention]

[0104] Generally, the terms and expressions used herein have their art-recognized meanings, which can be found by reference to standard texts, reference journals, and contexts known to those skilled in the art. The following definitions are provided to clarify their specific use in the context of the present invention.

[0112]

[0105] "Active agent" refers to a composition capable of inactivating Demodex mites, particularly Demodex mites that cause one or more clinical symptoms ("mite-induced clinical symptoms"), including those associated with skin disorders, autoimmune diseases, or ophthalmic disorders.

[0113]

[0106] "Inactivate" is used broadly herein to refer to the functional ability to reduce the impact of Demodex mites and / or Demodex mites. For example, inactivation may be due to paralysis and / or death of the mites resulting from application of an active agent. Alternatively, inactivation may refer to the inability of the mites to reproduce, whereby the mites age and die without reproducing, leading to a subsequent death of the mites. A treatment is considered to inactivate Demodex mites and / or Demodex mites as long as the treatment results in an adverse effect on Demodex mites and / or Demodex mites that corresponds to an improvement in clinical outcome, e.g., improvement in symptoms.

[0114] "Anticholinergic agents" refer to substances that block the action of acetylcholine (ACh) on the nervous system of mites. These substances compete with ACh at receptors in the nervous system so that ACh cannot bind to the receptors and cause a cholinergic effect. Many of these substances interact with muscarinic cholinergic receptors in the brain, glands, heart, smooth muscle and eye. "Muscarinic agonists" refer to agonists that activate the ability of muscarinic acetylcholine receptors. Application of these classes of substances can be useful for inactivating mites, including killing or paralyzing a significant proportion of mites, thereby reducing the overall associated mite population, and improving and / or stopping the clinical symptoms caused by the corresponding mites.

[0115] Demodex and Demodex mites may play a role in disorders including rosacea disease. Elevated populations of Demodex have been observed in rosacea patients. In most people, Demodex mites live harmlessly on the skin, either as a result of downregulating host immunity or simply evading host immune defenses. There is a lively debate within the dermatology community about whether they are the causative agent of skin diseases such as rosacea and blepharitis (inflammation of the eyelids), a common problem seen in rosacea patients.

[0116] Humans are the only hosts for this ubiquitous mite. In fact, these two species of mites are thought to be the most common ectoparasites of humans. Women tend to have a higher rate of Demodex infection. The rate of infection also appears to be age-related, with 84% of people aged 60 years carrying mites, rising to 100% in those aged 70 years and older. It is not known whether immune-compromised individuals are more susceptible to infection and have a higher infestation rate, although some studies have shown that patients with acquired immune deficiency syndrome and leukemia are more susceptible and may have higher than average numbers.

[0117] Mites are most commonly found on the scalp, face and upper chest area, where Demodex mites prefer hair follicles and Demodex mites prefer sebaceous ducts and meibomian glands at the edge of the eyelids (sebaceous ducts move waxy sebum that moisturizes the skin and hair from the sebaceous glands, and meibomian glands are a special type of such gland). Demodex mites are gregarious and tend to congregate in the follicular area of ​​hair or eyelashes, protruding their rear ends through the pores of the hair follicle. Demodex mites, on the other hand, tend to be more gregarious and live singly in sebaceous glands. Both species are very small, less than 0.4 mm, with a long, thin, transparent body and four pairs of stout legs. Demodex mites are usually a little shorter than Demodex mites, about 0.1 mm. They both have ridges along the cephalothorax and sharp, pointed teeth.

[0118] The life cycle of the ticks, short-lived creatures, from eggs to larvae to adults, lasts 14-18 days. Adults emerge from hair follicles and ducts to reproduce on the surface of the skin, then females lay eggs in the sebaceous glands. The larvae develop through two larval stages in the glands and then enter the hair follicles and ducts as adults to start the cycle anew. Both species of ticks feed on sebum as their initial food source, but it has been hypothesized that they can also feed on the follicular and glandular epithelium. They are considered to be obligate ectoparasites that cannot grow outside the human host.

[0119]

[0112] Several studies have shown that mite densities are greater than average and are 2They found that more than five mites per 1000 stools seem to play a role in these two disorders in patients. The researchers suggest that blockage of hair follicles and sebaceous ducts by mites may result in epithelial hyperplasia, triggering a granulomatous reaction of phagocytes, or an inflammatory reaction by waste products. The fact that treatment with certain antibiotics can reduce the severity of rosacea strongly suggests a microbial component to mite-related disorders. In fact, in 2007, researchers isolated the bacterium Bacillus oleronium from Demodex mites, which triggers an inflammatory reaction, in 73% of rosacea patients, but only 29% of controls. These results suggest that patients with rosacea may be sensitized to bacteria and may be immunologically susceptible to mites, bacteria, or both.

[0120] Two antigenic proteins found on the bacterial cell surface appear to be responsible for the inflammatory response, particularly by stimulating the proliferation of peripheral blood mononuclear cells; one 83 kDa protein showed similarity to heat shock proteins, and the other 62 kDa protein had amino acid sequence homology to protease enzymes found to be involved in neurotransmission and carbohydrate metabolism. Stronger evidence for the pathogenic role of B. orellonius in rosacea can also be found in the susceptibility of the bacteria to many antibiotics, particularly tetracycline, doxycycline, and minocycline, that have been shown to be effective in the treatment of rosacea.

[0121] In a typical embodiment, the anticholinergic and direct muscarinic agonist are administered topically to a patient with an ongoing skin disease whose root cause is Demodex mites. Because the target organisms Demodex mites and Demodex folliculorum are ectoparasites of the mite family, an effective treatment must be able to eradicate the entire life cycle of the microscopic insects, including their egg, larval and adult stages. For this reason, this embodiment treats such patients with several doses. Such spacing allows time for Demodex eggs to hatch and become immature mites that are killed before they can develop into egg-laying adults. After the anticholinergic and direct muscarinic agonist have carried out their acaricidal activity against the Demodex mites and Demodex folliculorum organisms on the skin, the inflammatory response to them begins to subside, but the remains of the dead mites still cause some flushing and lesion formation until they are removed by the body's cleansing process, a process that requires 6-8 weeks. During this initial phase of administration of anticholinergics and direct muscarinic agonists, conventional anti-rosacea drugs, such as oral tetracycline and topical metronidazole, can be optionally used to suppress early attacks and provide an early clinical response. Such drugs are not required to treat rosacea manifestations after 6-8 weeks have passed. Treatment can be repeated if classic signs begin to reappear after a long interval of relief from rosacea symptoms. Such retreatments are optional and need not be more than once or twice per year. The anticholinergics and direct muscarinic agonists are formulated into a cosmetically acceptable topical lotion, cream, shampoo or gel and applied to the skin affected by rosacea, and in particular to any areas where Demodex and Demodex mites may harbor. Due to the well-known barrier effect of the skin against the penetration of topical drugs, such treatment routes with anticholinergics and direct muscarinic agonists are expected to require one or two applications per day for as long as six weeks to obtain sufficient hair follicle penetration and effective acaricidal activity. Topical formulations that have been able to achieve this effect contain up to about 5% of an anticholinergic and a direct muscarinic agonist.The low percentage of anticholinergics and direct muscarinic agonists that can be used while still receiving the acaricidal effect and successfully treating the skin disease is ideal to limit any possible chemical side effects. Additionally, systemic treatment is optionally useful to prevent reinfestation of the skin by mites from other body locations, such as facial skin.

[0122] Example 1: Representative Active Agent(s)

[0115] A variety of compounds may be useful as active agents in the present invention. As discussed, the active agent may be selected from the group consisting of anticholinergic agents, antidepressants that are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, antimuscarinic agents, antinicotinic agents, and direct muscarinic agonists.

[0123] The active agent may be an anticholinergic selected from the group consisting of atropine (Atropen), belladonna alkaloids, benztropine mesylate (Cogentin), clidinium, cyclopentolate (Cyclogyl), darifenacin (Enablex), dicyclomine, fesoterodine (Toviaz), flavoxate (Urispas), glycopyrrolate, homatropine hydrobromide, hyoscyamine (Levsinex), ipratropium (Atrovent), orphenadrine, oxybutynin (Ditropan XL), propantheline (Pro-banthine), scopolamine, methscopolamine, solifenacin (VESIcare), tiotropium (Spiriva), tolterodine (Detrol), trihexyphenidyl, and trospium.

[0124]

[0117] The active agent may be an antidepressant that is a selective serotonin reuptake inhibitor (SSRI) selected from the group consisting of citalopram, fluoxetine, fluvoxamine, and paroxetine.

[0125] The active agent may be a tricyclic antidepressant selected from the group consisting of amitriptyline, clomipramine, desipramine, imipramine, nortriptyline, trimipramine, amoxapine, and maprotiline.

[0126] The active agent may be an antimuscarinic agent selected from the group consisting of clozapine, quetiapine, biperiden, chlorpheniramine, dimenhydrinate, diphenhydramine, doxepin, doxylamine, glycopyrronium, oxitropium, promethazine, solifenacin, tropicamide, and umeclidinium.

[0127]

[0120] The active agent may be an anti-nicotine agent selected from the group consisting of bupropion, dextromethorphan, doxacurium, hexamethonium, mecamylamine, tubocurarine, cytisine, suxamethonium chloride (succinylcholine chloride), and varenicline.

[0128] The active agent may be a muscarinic agonist selected from the group consisting of acetylcholine, methacholine, bethanechol, muscarine, oxotremorine, nicotine, pilocarpine, and carbachol.

[0129] 1A-1E are a summary of various substances tested in in vitro assays for paralyzing and / or killing Demodex mites. The efficacy of various substances is evaluated in Demodex characterization and / or survival time experiments, including in terms of LT50 (time at which 50% Demodex mites are killed) and / or associated time (hours:min, or total in min). Certain active agents achieve an LT50 of 12 hours or less. Interestingly, some of these active agents are not typically recognized as cholinergic agents, although they all have cholinergic properties.

[0130] Anticholinergics are substances that reduce or block the action of acetylcholine on its parasympathetic receptors in smooth muscle cells, glands, and the central nervous system. Cholinergic receptors are usually classified as nicotinic or muscarinic. Selective serotonin reuptake inhibitors (SSRIs) can modulate other neurotransmitter systems by inhibiting neuronal nicotinic acetylcholine receptors. Tricyclic antidepressants (TCAs) act primarily by blocking the reuptake of norepinephrine or serotonin, and also affect the cholinergic and histamine systems. They have a narrow therapeutic index and can be associated with significant central nervous system (CNS) toxicity. Interestingly, within any given class in the Demodex assay, at least one substance was effective and at least one was ineffective, as reflected in Figures 1A-1E.

[0131] In an embodiment, the active agent is characterized as having an LT50 of less than 12 hours, as determined in an in vitro Demodex assay and summarized in Figures 1A-1E. In an embodiment, the active agent is characterized as having paralytic activity, as determined in an in vitro Demodex assay and summarized in Figures 1A-1E.

[0132]

[0125] The invention provided herein is of course more broadly compatible with any antiparasitic compound that inactivates parasites, more specifically mites of the Demodex genus, including Demodex mites and Demodex folliculorum. With regard to paralytic compounds, paralysis of the mites prevents them from feeding and ultimately leads to death. Paralysis may also result in a reduction in mite reproduction, thereby reducing the mite burden and mite population of an individual. The mechanism of paralysis also results in the migration of mites from the skin and clearance by the immune system of the individual.

[0133]

[0126] Studies with oral paroxetine have demonstrated effects on rosacea. Application of paroxetine has been shown to be effective and well tolerated, with 42.9% of patients showing improvement in clinical symptoms. Paroxetine is a selective serotonin reuptake inhibitor. See https: / / www.healio.com / news / dermatology / 20230221 / paroxetine-effective-in-refractory-erythema-of-rosacea-treatment and Wang et al., "Paroxetine is an effective treatment for refractory erythema of rosacea: Primary results from the Prospective Rosacea Refractory Erythema Randomized Clinical Trial," J Am Acad Dermatol (February 15, 2023) S0190-9622(23)00197-4. doi:10.1016 / j.jaad.2023.01.044, which further supports the assay results in Figure 1 for 1% paroxetine, which demonstrated paralysis of Demodex mites within 1 hour and for a period of at least 12 hours. Thus, even for paralytics that do not have a corresponding LT50 of 12 hours or less, paralytics are useful in treating mite-induced symptoms and diseases.

[0134] Example 2: Administration and Formulation

[0127] Salts and Prodrugs: The present invention contemplates pharma- ceutical active compounds either chemically synthesized or formed by in vivo biotransformation into the compounds (e.g., active agents) described herein.

[0135]

[0128] The active agents of the present invention and the compounds useful in the methods of the present invention include the compounds and formula(s) described herein, as well as the pharma- ceutically acceptable salts and esters of those compounds. In embodiments, salts include any salts derived from the acids and bases of the formulas herein that are acceptable for use in human or veterinary applications. In embodiments, the term ester refers to hydrolyzable esters of the compounds of the names and formulas herein. In embodiments, salts and esters of the compounds of the formulas herein can include those that have the same or better therapeutic, diagnostic or pharmaceutical (human or veterinary) general properties as the compounds of the formulas herein. In embodiments, the compositions of the present invention are compounds or salts or esters thereof suitable for formulation.

[0136]

[0129] The active agents of the present invention used in the methods of the present invention can have a prodrug form. Prodrugs of the compounds of the present invention are useful in the embodiments, including the compositions and methods. Any compound that is converted in vivo to provide a biologically, pharma- ceutical, diagnostically or therapeutically active form of the active agent of the present invention is a prodrug. Various examples and forms of prodrugs are well known in the art. Examples of prodrugs are found, inter alia, in Design of Prodrugs, edited by H. Bundgaard (Elsevier, 1985); Methods in Enzymology, Vol. 42, pp. 309-396, edited by K. Widder et al. (Academic Press, 1985); A Textbook of Drug Design and Development, edited by Krosgaard-Larsen and H. Bundgaard, Chapter 5, "Design and Application of Prodrugs", by H. Bundgaard, pp. 113-191 (1991); H. Bundgaard, Advanced Drug Delivery Reviews, Vol. 8, pp. 1-38 (1992); H. Bundgaard et al., Journal of Pharmaceutical Sciences, Vol. 77, pp. 285 (1988); and Nogrady (1985) Medicinal Chemistry A Biochemical Approach, Oxford University Press, New York, pp. 388-392). A prodrug, e.g., a pharma- ceutically acceptable prodrug, can refer to a prodrug of a compound of the invention that is, within the scope of sound medical judgment, suitable for use in contact with the tissues of humans and lower animals without undue toxicity, irritation, allergic response, etc., commensurate with a reasonable benefit / risk ratio, and effective for the intended use. Prodrugs of the invention can be rapidly transformed in vivo, for example, by hydrolysis in blood or other cell, tissue, organ or system processes, to the parent compound of the compounds described herein.Further discussion is provided in T. Higuchi and V. Stella, Pro-drugs as Novel Delivery Systems, Volume 14 of the ACS Symposium Series; and Edward B. Roche, ed., Bioreversible Carriers in Drug Design, American Pharmaceutical Association and Pergamon Press (1987). For example, loxapine may be considered a prodrug of amoxapine, since amoxapine is an N-demethylated metabolite of loxapine.

[0137] The active agents of the present invention can be formulated with pharma- ceutically acceptable anions and / or cations. Pharmaceutically acceptable cations include, among others, alkyl metal cations (e.g., Li + , Na + , K + ), alkaline earth metal cations (e.g. Ca 2+ , Mg 2+ ), non-toxic heavy metal cations, and ammonium (NH4 + ) and substituted ammonium (N(R')4 + , R' is hydrogen, alkyl or substituted alkyl, i.e., methyl, ethyl or hydroxyethyl, particularly trimethylammonium, triethylammonium and triethanolammonium cations. Pharmaceutically acceptable anions include, among others, halides (e.g., F - , Cl - , Br - , At - ), sulfates, acetates (eg, acetate, trifluoroacetate), ascorbates, aspartates, benzoates, citrates, and lactates.

[0138]

[0131] Pharmaceutically acceptable salts include pharma- ceutically acceptable anions and / or cations. As used herein, the term "pharmaceutically acceptable salts" can refer to acid or base addition salts of the compounds of the present disclosure. A pharma- ceutically acceptable salt is any salt that retains at least part of the activity of the parent compound and does not impart significant harmful or undesirable effects to the subject to whom it is administered under the circumstances in which it is administered. Pharmaceutically acceptable salts include metal complexes and salts of both inorganic and organic acids. Pharmaceutically acceptable salts include metal salts, such as aluminum, calcium, iron, magnesium, manganese, and complex salts. Pharmaceutically acceptable salts include acetic acid, aspartic acid, alkylsulfonic acid, arylsulfonic acid, axetil, benzenesulfonic acid, benzoic acid, bicarbonate, bisulfate, bitartaric acid, butyric acid, calcium edetate, camsylic acid, carbonic acid, chlorobenzoic acid, cilexetil, citric acid, edetic acid, edisylic acid, estolic acid, esyl, esylic acid, formic acid, fumaric acid, gluceptic acid, gluconic acid, glutamic acid, glycolic acid, glycolylarsanilic acid, hexamic acid, hexylresorcjnoic acid, hydrabamic acid, hydrobromic acid, and the like. The pharmaceutically acceptable salts include, but are not limited to, acid salts such as hydrochloric acid, hydroiodic acid, hydroxynaphthoic acid, isethionic acid, lactic acid, lactobionic acid, maleic acid, malic acid, malonic acid, mandelic acid, methanesulfonic acid, methyl nitrate, methyl sulfate, mucic acid, muconic acid, napsylic acid, nitric acid, oxalic acid, p-nitromethanesulfonic acid, pamoic acid, pantothenic acid, phosphoric acid, monohydrogen phosphate, dihydrogen phosphate, phthalic acid, polygalacturonic acid, propionic acid, salicylic acid, stearic acid, succinic acid, sulfamic acid, sulfanilic acid, sulfonic acid, sulfuric acid, tannic acid, tartaric acid, teoclic acid, toluenesulfonic acid, etc. Pharmaceutically acceptable salts can be derived from amino acids, including, but not limited to, cysteine.Other pharma- ceutically acceptable salts can be found, for example, in Stahl et al., Handbook of Pharmaceutical Salts: Properties, Selection, and Use, Wiley-VCH, Verlag Helvetica Chimica Acta, Zurich, 2002 (ISBN 3-906390-26-8).

[0139] Efficacy: Typically, the compounds of the invention, or their pharma- ceutically acceptable salts, are administered to a subject in a diagnostically or therapeutically effective amount. Those skilled in the art can generally determine appropriate dosages.

[0140]

[0133] The compositions for oral administration can be prepared, for example, in such a way that a single dose of one or more oral preparations contains at least about 20 mg of the compound per square meter of the subject's body surface area, or at least about 50, 100, 150, 200, 300, 400, or 500 mg of the compound per square meter of the subject's body surface area (the average body surface area of ​​a human is, for example, 1.8 square meters). In particular, a single dose of the composition for oral administration can contain about 20 to about 600 mg, in certain embodiments about 20 to about 400 mg, in other embodiments about 20 to about 300 mg, and in yet other embodiments about 20 to about 200 mg of the compound per square meter of the subject's body surface area. Compositions for parenteral administration can be prepared in such a way that a single dose contains at least about 20 mg of the compound per square meter of the subject's body surface area, or at least about 40, 50, 100, 150, 200, 300, 400, or 500 mg of the compound per square meter of the subject's body surface area. In particular, a single dose in one or more parenteral preparations contains about 20 to about 500 mg of the compound per square meter of the subject's body surface area, in certain embodiments about 20 to about 400 mg, in other embodiments about 20 to about 450 mg, and in still other embodiments about 20 to about 350 mg of the compound. It should be recognized that these oral and parenteral dosage ranges represent typical preferred dosage ranges and are not intended to limit the invention. The dosage regimens actually employed can vary widely and therefore may deviate from the typical preferred dosage regimens. It is contemplated that one of skill in the art will tailor these ranges for individual subjects.

[0141] The toxicity and therapeutic efficacy of such compounds and bioconjugates are evaluated using LD 50 (the dose that causes death in up to 50% of the population) and ED 50 The dose that is therapeutically effective in 50% of the population can be determined by standard pharmaceutical procedures in cell cultures or experimental animals. The dose ratio between toxic and therapeutic effects is called the LD 50 / ED 50The therapeutic index can be expressed as: The therapeutic index (TRI) ...

[0142] The data obtained from cell culture assays and animal studies can be used in formulating various dosages for use in humans and other mammals. The dosage of such compounds and bioconjugates is preferably administered at or above the ED 50 and results in a clinically effective result (i.e., alleviation of disease symptoms). Dosages can vary within this range depending on the dosage form employed and the route of administration utilized. For any compound and bioconjugate of the invention, the therapeutically effective amount can be estimated initially from cell culture assays. Dosages can be determined based on the ED determined in cell culture. 50 The compound can be formulated in animal models to achieve a circulating plasma concentration range that includes (the concentration of the test compound that achieves half-maximal inhibition of symptoms). Such information can be used to more accurately determine useful dosages in humans and other mammals. Levels of the compound and bioconjugate in plasma can be measured, for example, by high performance liquid chromatography.

[0143]

[0136] The amount of compound or bioconjugate that can be combined with a pharma- ceutically acceptable carrier to make a single dosage form varies depending on the patient to be treated and the specific method of administration. Those skilled in the art will recognize that the unit content of compound / bioconjugate contained in each individual dose of each dosage form does not necessarily constitute a therapeutically effective amount in itself, since the required therapeutically effective amount can be achieved by administration of multiple individual doses. The choice of dosage depends on the dosage form used, the condition to be treated, and the specific purpose to be achieved as determined by those skilled in the art.

[0144]

[0137] Dosages and administration regimens for treating a disease or condition can be selected according to a variety of factors, including the type, age, weight, sex, diet and / or medical condition of the patient, the route of administration, pharmacological considerations such as the activity, efficacy, pharmacokinetic and / or toxicological profile of the particular compound / bioconjugate used, whether a compound / bioconjugate delivery system is utilized, and / or whether the compound / bioconjugate is administered as part of a prodrug or drug combination. Thus, the administration regimen actually used can vary widely from subject to subject or from disease to disease, and different routes of administration can be used in different clinical settings.

[0145]

[0138] Certain compounds / bioconjugates manage, treat, inhibit, modulate, and / or prevent, or at least partially arrest or partially prevent, diseases and conditions of interest, and can be administered to a subject in a therapeutically effective amount and optionally a diagnostically effective amount. The compositions / formulations of the invention comprise a therapeutically effective amount (which can optionally include a diagnostically effective amount) of at least one compound or bioconjugate of the invention. The subject receiving treatment with a compound / bioconjugate of the invention is preferably an animal (e.g., a mammal, reptile, and / or bird), more preferably a human, horse, cow, dog, cat, sheep, pig, and / or chicken, and most preferably a human.

[0146]

[0139] Administration: Preferred compositions depend on the route of administration. Any route of administration can be used so long as the target of the active agent or pharma- ceutically acceptable salt is available via that route. Suitable routes of administration include, for example, oral, intravenous, parenteral, inhalation, rectal, intranasal, topical (e.g., transdermal and intraocular), intravesical, intrathecal, intestinal, intrapulmonary, intralymphatic, intracavitary, intravaginal, transurethral, ​​intradermal, intraaural, intramammary, buccal, orthotopic, intratracheal, intralesional, transdermal, endoscopic, transmucosal, sublingual, and intestinal administration.

[0147] In an embodiment, the invention provides a method of treating a medical condition comprising administering a therapeutically effective amount of a composition of the invention, e.g., an active agent comprising a composition of an anticholinergic and a direct muscarinic agonist, to a subject (e.g., a patient) in need thereof. In an embodiment, the invention provides a method of diagnosing or aiding in the diagnosis of a medical condition comprising administering a diagnostically effective amount of a composition of the invention to a subject in need thereof. In an embodiment, the medical condition is a skin disorder or disease.

[0148]

[0141] The diagnostic and therapeutic formulations of the present invention can be administered alone or with a pharmaceutical carrier selected on the basis of the chosen route of administration and standard pharmaceutical practice.

[0149]

[0142] Any suitable mode of administration can be used in connection with the diagnostic and therapeutic preparations of the present invention. The diagnostic and therapeutic preparations of the present invention can be administered intravenously, in oral dosage forms, intraperitoneally, subcutaneously, or intramuscularly, all using dosage forms well known to those skilled in the pharmaceutical arts.

[0150] The compositions, preparations and formulations can be formulated into diagnostic or therapeutic compositions for enteral, parenteral, topical, aerosol, inhalation or dermal administration. Topical or dermal delivery of the compositions, preparations and formulations can also include aerosol formulations, creams, gels, solutions, and the like. The compositions, preparations and formulations are administered in effective doses to achieve the desired diagnostic and / or therapeutic effect. Such doses can vary widely depending on the specific composition used in the composition, the organ or tissue being tested, the equipment used in the clinical procedure, the effectiveness of the treatment to be achieved, and the like. These compositions, preparations and formulations include an effective amount of the composition(s) along with conventional pharmaceutical carriers and excipients appropriate for the type of administration contemplated. These compositions, preparations and formulations can also optionally include stabilizers and skin penetration enhancers.

[0151] (i) Parenteral Administration: The compounds and bioconjugates of the invention can be formulated for parenteral administration by injection (e.g., by bolus injection or continuous infusion). Injectable formulations can be in unit dosage form in ampoules or in multi-dose containers with optional preservatives added. Parenteral preparations can be enclosed in ampoules, disposable syringes, or multiple dose vials made of glass, plastic, etc. The formulations can take such forms as suspensions, solutions, or emulsions in oily or aqueous vehicles and can contain formulating agents, such as suspending, stabilizing, and / or dispersing agents.

[0152] For example, parenteral preparations can be sterile injectable solutions or suspensions in a non-toxic parenterally acceptable diluent or solvent (e.g., a solution in 1,3-butanediol). Acceptable vehicles and solvents that can be used are water, Ringer's solution, and isotonic sodium chloride solution. In addition, sterile fixed oils are conventionally employed as a solvent or suspending medium. For this purpose, any sterile fixed oil can be used, including synthetic mono- or diglycerides. In addition, fatty acids, such as oleic acid, can be used in parenteral preparations.

[0153] Alternatively, the compounds and bioconjugates of the invention can be formulated in powder form for constitution with a suitable vehicle, such as sterile pyrogen-free water, before use. For example, a compound / bioconjugate suitable for parenteral administration can comprise a sterile isotonic saline solution containing between 0.1 weight percent and 90 weight percent of the compound / bioconjugate per volume. By way of example, a solution can contain about 5 weight percent to about 20 weight percent of the compound / bioconjugate per volume, more preferably about 5 weight percent to about 17 weight percent, more preferably about 8 weight percent to about 14 weight percent, and even more preferably about 10 weight percent of the compound / bioconjugate per volume. The solution or powder preparation can also include a solubilizing agent and a local anesthetic, such as lignocaine, to reduce pain at the site of injection. Other methods of parenteral delivery of the compound / bioconjugate are known to those of skill in the art and are within the scope of the present invention.

[0154] (ii) Oral Administration: For oral administration, the compounds / bioconjugates of the present invention can be formulated with one or more pharma- ceutically acceptable carriers (e.g., excipients such as binders, fillers, lubricants, and disintegrants) in the form of tablets or capsules prepared by conventional methods.

[0155] (iii) Controlled Release Administration: Controlled release (or sustained release) preparations can be formulated to extend the potency of the compound / bioconjugate and reduce the frequency of administration. Controlled release preparations can also be used to affect the time of onset of action or other characteristics, such as blood levels of the compound / bioconjugate, and thus the occurrence of side effects.

[0156]

[0149] Controlled release preparations can be designed to initially release an amount of compound / bioconjugate that produces a desired therapeutic effect and gradually, continuously, release other amounts of compound / bioconjugate to maintain that level of therapeutic effect over time. To maintain a near constant level of compound / bioconjugate in the body, the compound / bioconjugate can be released from the dosage form at a rate that replaces the amount of compound / bioconjugate metabolized and / or excreted from the body. Controlled release of the compound / bioconjugate can be stimulated by various inducers, such as pH change, temperature change, enzymes, water, and / or other physiological conditions or molecules.

[0157]

[0150] A controlled release system can include, for example, an infusion pump that can be used to administer the compound / bioconjugate in a manner similar to that used to deliver insulin or chemotherapeutic agents to the body generally or to a specific organ or tumor. Typically, using such a system, the compound / bioconjugate is administered in combination with a biodegradable, biocompatible polymeric implant that releases the compound / bioconjugate at a selected site over a controlled period of time. Examples of polymeric materials include polyanhydrides, polyorthoesters, polyglycolic acid, polylactic acid, polyethylenevinyl acetate, and copolymers and combinations thereof. Furthermore, a controlled release system can be placed near the therapeutic target (e.g., an organ, tissue, or group of cells), thereby requiring only a fraction of the systemic dose.

[0158] The compounds / bioconjugates of the invention can be administered by other controlled release means or delivery devices known to those of skill in the art. These include, for example, hydropropylmethylcellulose, other polymer matrices, gels, permeable membranes, osmotic systems, multi-layer coatings, microparticles, liposomes, microspheres, etc., or combinations of any of the above in various proportions to provide the desired release profile. Other methods of controlled release delivery of compounds / bioconjugates are known to those of skill in the art and are within the scope of the present invention.

[0159] (iv) Inhalation Administration: The compounds / bioconjugates of the invention can be administered directly to the lungs of a patient / subject by inhalation. For administration by inhalation, the compounds / bioconjugates can be conveniently delivered to the lungs by a number of different devices. For example, metered dose inhalers ("MDIs"), which utilize a small container containing a suitable low boiling point propellant, e.g., dichlorodifluoromethane, trichlorofluoromethane, dichlorotetrafluoroethane, carbon dioxide or other suitable gas, can be used to deliver the compounds / bioconjugates directly to the lungs. MDI devices are available from a number of suppliers, such as 3M Corporation, Aventis, Boehringer Ingleheim, Forest Laboratories, GlaxoSmithKline, Merck & Co., and Vectura.

[0160] Alternatively, dry powder inhaler (DPI) devices can be used to administer the compound / bioconjugate to the lungs. DPI devices typically use a mechanism such as a burst of gas to create a cloud of dry powder in a container, which can then be inhaled by the patient. DPI devices are also well known in the art and can be purchased from a number of suppliers, including, for example, GlaxoSmithKline, Nektar Therapeutics, Innovata, and Vectura. A popular variation is the multiple dose DPI ("MDDPI") system, which allows for the delivery of more than one therapeutic dose. MDDPI devices are available from companies such as AstraZeneca, GlaxoSmithKline, TEVA, Merck & Co., SkyePharma, and Vectura. For example, gelatin capsules and cartridges for use in inhalers or insufflators can be formulated to contain a mixed powder of the compound / bioconjugate and a suitable powder base, such as lactose or starch.

[0161] Another type of device that can be used to deliver compounds / bioconjugates to the lungs is a liquid nebulizer device, for example, supplied by Aradigm Corporation. Liquid nebulizer systems use very small nozzle holes to aerosolize liquid compound / bioconjugate formulations, which can then be inhaled directly into the lungs. For example, nebulizer devices can be used to deliver compounds / bioconjugates to the lungs. Nebulizers create aerosols from liquid compound / bioconjugate formulations, for example, by using ultrasonic energy to form fine particles that can be rapidly inhaled. Examples of nebulizers include devices supplied by Aventis and Battelle.

[0162] In another example, electrohydrodynamic ("EHD") aerosol devices can be used to deliver compounds / bioconjugates to the lungs. EHD aerosol devices use electrical energy to aerosolize a liquid compound / bioconjugate solution or suspension. When delivering this compound / bioconjugate to the lungs by an EHD aerosol device, the electrochemical properties of the compound / bioconjugate formulation are important parameters to optimize. Such optimization is routinely performed by those of skill in the art. Other methods of pulmonary delivery of compounds / bioconjugates are known to those of skill in the art and are within the scope of the present invention.

[0163]

[0156] Liquid compound / bioconjugate formulations suitable for use with nebulizers and liquid spray devices and EHD aerosol devices typically include the compound / bioconjugate and a pharma- ceutically acceptable carrier. In one exemplary embodiment, the pharma- ceutically acceptable carrier is a liquid, such as alcohol, water, polyethylene glycol, or a perfluorocarbon. Optionally, another material can be added to alter the aerosol properties of the compound / bioconjugate solution or suspension. For example, this material can be a liquid, such as an alcohol, glycol, polyglycol, or a fatty acid. Other methods of formulating liquid compound / bioconjugate solutions or suspensions suitable for use in aerosol devices are known to those skilled in the art.

[0164] (v) Depot Administration: The compounds / bioconjugates of the invention can be formulated as depot preparations. Such long acting formulations can be administered by implantation (e.g., subcutaneous or intramuscular) or intramuscular injection. Thus, the compounds / bioconjugates can be formulated with suitable polymeric or hydrophobic materials, such as emulsions in acceptable oils or ion exchange resins, or as sparingly soluble derivatives, such as sparingly soluble salts. Other methods of depot delivery of the compounds / bioconjugates are known to those skilled in the art and are within the scope of the present invention.

[0165] (vi) Topical Administration: For topical application, the compound / bioconjugate can be combined with a pharmaceutically acceptable carrier, such that an effective dosage ranging from, for example, an effective dosage of 1.0 μM to 1.0 mM is delivered based on the desired activity. In one embodiment of the invention, a topical formulation of the compound / bioconjugate can be applied to the skin. The pharmaceutically acceptable carrier can be in the form of, for example, but not by way of limitation, an ointment, cream, gel, paste, foam, aerosol, suppository, pad, or gel-like stick.

[0166] Topical formulations may contain a therapeutically effective amount of the compound / bioconjugate in an ophthalmologically acceptable vehicle, such as buffered saline, mineral oil, vegetable oil, such as corn oil or peanut oil, petrolatum, Miglyol 182, an alcoholic solution, or a liposome or liposome-like product. Any of these formulations of such compounds / bioconjugates may contain preservatives, antioxidants, antibiotics, immunosuppressants, and other biologically or pharmacologic effective substances that do not have a significant detrimental effect on the compound / bioconjugate. Other methods of topical delivery of the compound / bioconjugate are known to those skilled in the art and are within the scope of the present invention. Topical formulations of the present invention further include those that contain one or more compositions useful for penetrating the skin, such as dimethylsulfoxide (DMSO).

[0167] (vii) Rectal Administration: The compounds / bioconjugates of the invention can be formulated into rectal preparations, such as suppositories or retention enemas, containing conventional suppository bases, such as cocoa butter or other glycerides, and / or binders and / or carriers, such as triglycerides, microcrystalline cellulose, gum tragacanth, or gelatin. Rectal preparations can contain, for example, in the range of 0.5% to 10% by weight of the compound / bioconjugate. Other methods of rectal delivery of the compound / bioconjugate are known to those of skill in the art and are within the scope of the present invention.

[0168] (viii) Other Administration Systems: A variety of other delivery systems are known in the art and can be used to administer the compounds / bioconjugates of the invention. Furthermore, these and other delivery systems can be combined and / or modified to facilitate optimization of administration of the compounds / bioconjugates of the invention. Exemplary formulations containing the compounds / bioconjugates of the invention are described elsewhere herein (although the compounds / bioconjugates of the invention are presented as the active ingredient, those skilled in the art will recognize that combinations of prodrugs and compounds are also meant to be encompassed by this term).

[0169] 5.d: Formulations: In embodiments, the invention provides a medicament comprising a therapeutically effective amount of one or more compositions of the invention, such as an anticholinergic and a direct muscarinic agonist compound. In embodiments, the invention provides a medicament comprising a diagnostically effective amount of one or more compositions of the invention. In embodiments, the invention provides a method of making a medicament for the treatment of a condition described herein, such as the treatment of a skin disorder or skin disease. In embodiments, the invention provides a method of making a medicament for the diagnosis or aiding in the diagnosis of a condition described herein, such as the diagnosis of a skin disorder or skin disease. In embodiments, the invention provides the use of one or more compositions described herein for the preparation of a medicament for the treatment of a skin disorder or skin disease. In embodiments, the invention provides the use of one or more compositions described herein for the treatment of a disease. In embodiments, the invention provides the use of one or more compositions described herein for the diagnosis of a disease. Compositions of the invention include formulations and preparations, such as pharma- ceutically acceptable formulations or preparations, comprising one or more of the present anticholinergics and direct muscarinic agonists provided in an aqueous solution. Optionally, the compositions of the invention further comprise one or more pharma- ceutically acceptable surfactants, buffers, electrolytes, salts, carriers, binders, coatings, preservatives and / or excipients.

[0170] In an embodiment, the invention provides a formulation having an active ingredient, such as an anticholinergic agent and a direct muscarinic agonist compound, including a composition of the invention. In an embodiment, the invention provides a method of synthesizing a composition of the invention or a formulation thereof, such as an anticholinergic agent and a direct muscarinic agonist compound. In an embodiment, the formulation includes one or more excipients, carriers, diluents, and / or other ingredients, as would be understood in the art. Preferably, the ingredients meet the criteria of the National Formulary ("NF"), the United States Pharmacopoeia ("USP"; United States Pharmacopeial Convention Inc., Rockville, Md.), or the Handbook of Pharmaceutical Manufacturing Formulations (Sarfaraz K. Niazi, complete volume, ISBN: 9780849317521, ISBN 10:0849317525; CRC Press, 2004). See, for example, United States Pharmacopeia and National Formulary (USP 30-NF 25), Rockville, MD: United States Pharmacopeial Convention (2007 and 2008), and any previous editions, respectively; The Handbook of Pharmaceutical Excipients, jointly published by the American Pharmacists Association and the Pharmaceutical Press (Pharmaceutical Press (2005) (ISBN-10: 0853696187, ISBN-13: 978-0853696186)); Merck Index, Merck & Co., Rahway, NJ; and Gilman et al., eds. (1996); Goodman and Gilman's: The Pharmacological Bases of Therapeutics, 8th Edition, Pergamon Press. In an embodiment, the formulation base of the formulation of the present invention comprises a physiologically acceptable excipient, i.e., at least one binder and optionally other physiologically acceptable excipients.Physiologically acceptable excipients are those known to be usable in the pharmaceutical technology sector and adjacent fields, in particular those mentioned in the relevant pharmacopoeias (e.g. DAB, Ph.Eur., BP, NF, USP), as well as other excipients whose properties do not impair physiological use.

[0171] The present invention also relates, in part, to pharmaceutical compositions comprising a therapeutically effective amount of a compound or salt of the present invention, and to methods of making such compositions. Such compositions typically include one or more pharma- ceutically acceptable carriers (e.g., excipients, vehicles, adjuvants, diluents) and may include other active ingredients. Formulation of these compositions can be obtained by a variety of methods known in the art. A general discussion of these methods can be found, for example, in Hoover, John E., Remington's Pharmaceutical Sciences (Mack Publishing Co., Easton, PA: 1975). See also Lachman, L., ed., Pharmaceutical Dosage Forms (Marcel Decker, New York, NY, 1980).

[0172] The diagnostic and therapeutic formulations of the invention, and the medicaments of the invention, can further comprise one or more pharma- ceutically acceptable carriers, excipients, buffers, emulsifiers, surfactants, electrolytes, or diluents. Such compositions and medicaments are prepared according to accepted pharmaceutical procedures, such as those described in Remington's Pharmaceutical Sciences, 17th ed., Edited by Alfonoso R. Gennaro, Mack Publishing Company, Easton, Pa. (1985).

[0173] Compositions of the invention include formulations and preparations, such as pharma- ceutically acceptable formulations or preparations, that include one or more of the compounds of the invention provided in an aqueous solution. Optionally, compositions of the invention further include one or more pharma- ceutically acceptable surfactants, buffers, electrolytes, salts, carriers, binders, coatings, preservatives, and / or excipients.

[0174] The compounds and bioconjugates of the invention can be formulated by known methods for administration to a subject using several routes, including but not limited to parenteral, oral, topical, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural and ophthalmic routes. Individual compounds / bioconjugates can be administered in combination with one or more additional compounds / bioconjugates of the invention and / or with other biologically active or biologically inactive substances. Such biologically active or inactive substances can be in fluid or mechanical communication with the compound(s) / bioconjugate(s) or bound to the compound(s) / bioconjugate(s) by ionic, covalent, van der Waals, hydrophobic, hydrophilic or other physical forces. Administration is preferably local in the subject, but administration can also be systemic.

[0175] The compounds and bioconjugates of the present invention can be formulated by any conventional method using one or more pharma- ceutically acceptable carriers. Thus, the compounds / bioconjugates and their pharma- ceutically acceptable salts and solvents can be specially formulated for administration, for example, by inhalation or insufflation (either through the mouth or nose), or by oral, buccal, parenteral, or rectal administration. The compounds / bioconjugates can be charged, neutral, and / or in the form of other pharma- ceutically acceptable salt forms. Examples of pharma- ceutically acceptable carriers include, but are not limited to, those described in REMINGTON'S PHARMACEUTICAL SCIENCES (ed. AR Gennaro), 20th edition, Williams & Wilkins PA, USA (2000).

[0176] The compounds and bioconjugates of the invention can be formulated into solutions, suspensions, emulsions, tablets, pills, capsules, powders, controlled or sustained release formulations, and the like. Such formulations will contain a therapeutically effective amount of the compound / bioconjugate, preferably in purified form, together with a suitable amount of carrier to provide the form for proper administration to the patient. The formulation should be compatible with the method of administration.

[0177]

[0170] Pharmaceutically acceptable carriers that can be used in combination with the compounds of the present invention are well known to those skilled in the art. Carriers can be selected based on a number of factors, including, for example, the specific compound(s) or pharma-ceutically acceptable salt(s) used, the concentration, stability, and intended bioavailability of the compound, the condition being treated, the age, size, and general condition of the subject, the route of administration, and the like. A general discussion of carriers can be found, for example, in JG Airn, Remington's Pharmaceutical Science, pp. 1492-1517 (A. Gennaro, ed., Mack Publishing Co., Easton, Pa. (1985)).

[0178]

[0171] Solid dosage forms for oral administration include, for example, capsules, tablets, gelcaps, pills, dragees, troches, powders, granules, and lozenges. In such solid dosage forms, the compound or its pharma- ceutically acceptable salts can be combined with one or more pharma- ceutically acceptable carriers. The compound and its pharma- ceutically acceptable salts can be mixed with carriers, including but not limited to lactose, sucrose, starch powder, corn starch, potato starch, magnesium carbonate, microcrystalline cellulose, cellulose esters of alkanoic acid, cellulose alkyl esters, talc, stearic acid, magnesium stearate, magnesium oxide, sodium and calcium salts of phosphoric acid and sulfate, sodium carbonate, agar, mannitol, sorbitol, sodium saccharin, gelatin, gum acacia, alginic acid, sodium alginate, tragacanth, colloidal silicon dioxide, croscarmellose sodium, polyvinylpyrrolidone, and / or polyvinyl alcohol, and then tableted or encapsulated for convenient administration.Such capsules or tablets can include controlled release formulations and can be provided with a dispersion of the compound or salt in hydroxypropylmethylcellulose.In the case of capsules, tablets and pills, the dosage form can also include a buffering agent, such as sodium citrate or magnesium or calcium salts of carbonate or bicarbonate. Additionally, tablets and pills can include a coating (e.g., an enteric coating) to delay disintegration and absorption, for example. The concentration of the compound in the solid oral dosage form can be, for example, about 5 to about 50% by weight, in certain embodiments about 8 to about 40% by weight, and in other embodiments about 10 to about 30% by weight, based on the total weight of the composition.

[0179]

[0172] Liquid dosage forms of the compounds of the invention for oral administration include, for example, pharma- ceutically acceptable emulsions, solutions, suspensions, syrups, and elixirs, containing inert diluents commonly used in the art, such as water. Such compositions may also contain adjuvants, such as wetting agents, emulsifying agents, suspending agents, flavoring agents (such as sweeteners), and / or perfumes. The concentration of the compounds in liquid dosage forms may be from about 0.01 to about 5 mg, in certain embodiments from about 0.01 to about 1 mg, and in other embodiments from about 0.01 to about 0.5 mg per ml of composition. Lower concentrations of the compounds of the invention in liquid dosage forms may be prepared when the compounds are more soluble at lower concentrations. Techniques for making oral dosage forms useful in the invention are generally described, for example, in Modern Pharmaceutics, Chapters 9 and 10, edited by Banker & Rhodes (1979). See also Lieberman et al., Pharmaceutical Dosage Forms: Tablets (1981). See also Ansel, Introduction to Pharmaceutical Dosage Forms, 2nd ed. (1976).

[0180] In some aspects of the invention, tablets or powders for oral administration can be prepared by dissolving the compound in a pharma- ceutically acceptable solvent capable of dissolving the compound to form a solution, and then evaporating if the solution is dried under vacuum. A carrier can also be added to the solution before drying. The resulting solution can be dried under vacuum to form a glass. The glass can then be mixed with a binder to form a powder. This powder can be mixed with a filler or other conventional tableting agent and then processed to form a tablet. Alternatively, the powder can be added to a liquid carrier to form a solution, emulsion, suspension, etc.

[0181] In some embodiments, a solution for oral administration is prepared by dissolving a compound in a pharma- ceutically acceptable solvent capable of dissolving the compound to form a solution. An appropriate volume of a carrier is added to the solution with stirring to form a pharma- ceutically acceptable solution for oral administration.

[0182] In some embodiments, liposomes or micelles can be utilized as carriers or vehicles for the compositions. For example, in some embodiments, the compound can be part of a lipid-soluble bilayer or micelle, and the targeting ligand, if present, can be present on the outer surface of the liposome or micelle. As another example, the targeting ligand can be externally attached to the liposome or micelle after formulation in order to target the liposome or micelle (including anticholinergics and direct muscarinic agonists) to a desired tissue, organ, or other site in the body.

[0183]

[0176] Injectable preparations (e.g., sterile injectable aqueous or oleaginous suspensions) can be formulated according to known techniques using suitable dispersants, wetting agents, and / or suspending agents. Vehicles acceptable for parenteral use include both aqueous and non-aqueous pharma- ceutically acceptable solvents. Suitable pharma-ceutically acceptable aqueous solvents include, for example, water, saline, dextrose solution (e.g., DW5), electrolyte solutions, and the like.

[0184] In one embodiment, the compound is formulated as nanoparticles or microparticles. The use of such nanoparticle or microparticle formulations can be beneficial for some applications to facilitate compound delivery, localization, target specificity, administration, etc. Potentially useful nanoparticles and microparticles include, but are not limited to, micelles, liposomes, microemulsions, nanoemulsions, vesicles, tubular micelles, cylindrical micelles, bilayers, folded sheet structures, spherical aggregates, swollen micelles, inclusion complexes, encapsulated droplets, microcapsules, nanocapsules, etc. As will be appreciated by those skilled in the art, the compound can be located inside the nanoparticle or microparticle, within the membrane or wall of the nanoparticle or microparticle, or outside (but bound to or otherwise associated with) the nanoparticle or microparticle. Substances formulated in nanoparticles or microparticles can be administered by any of the routes previously mentioned. In topically applied formulations, the compound is slowly released over time. In injectable formulations, the liposomes, micelles, capsules, etc. circulate in the bloodstream and are delivered to the desired site (e.g., target tissue).

[0185] The preparation and loading of nanoparticles and microparticles is well known in the art. As one example, liposomes can be prepared from dipalmitoylphosphatidylcholine (DPPC) or egg phosphatidylcholine (PC) because this lipid has a low thermal transition. Liposomes are made using standard procedures known to those skilled in the art (e.g., Braun-Falco et al., eds., Griesbach Conference, Liposome Dermatics, Springer-Verlag, Berlin (1992), pp. 69 81; 91 117). Polycaprolactone, poly(glycolic acid), poly(lactic acid), polyanhydrides, or lipids can be formulated as microspheres. As an illustrative example, the compound can be mixed with polyvinyl alcohol (PVA), and then the mixture is dried and coated with ethylene vinyl acetate, then cooled again with PVA. In liposomes, the compound can be present in one or both lipid bilayers, in the water between the bilayers, or in the center or core. Liposomes can be modified with other molecules and lipids to form cationic liposomes. Liposomes can also be modified with lipids to make their surface more hydrophilic, which increases their circulation time in the bloodstream. Liposomes modified in this way are called "stealth" liposomes or long-lived liposomes, as described in U.S. Patent No. 6,258,378, and Stealth Liposomes, edited by Lasic and Martin, 1995 CRC Press, London. Encapsulation methods are known to those skilled in the art and include detergent dialysis, lyophilization, membrane formation, injection, as disclosed, for example, in U.S. Patent No. 6,406,713.Optionally, the compositions and methods include micellar delivery systems, e.g., those relating to one or more PEG-based amphiphilic polymers developed for drug delivery, including PEG-poly(ε-caprolactone), PEG-poly(amino acid), PEG-polylactic acid, or PEG-phospholipid constructs, crosslinked poly(acrylic acid) polymer systems, phospholipid-based systems, and / or block copolymer systems comprising one or more of the following polymer blocks: poly(lactic acid) polymer blocks, poly(propylene glycol) polymer blocks, poly(amino acid) polymer blocks, poly(ester) polymer blocks, poly(ε-caprolactone) polymer blocks, poly(ethylene glycol) blocks, poly(acrylic acid) blocks, polylactide blocks, polyester blocks, polyamide blocks, polyanhydride blocks, polyurethane blocks, polyimine blocks, polyurea blocks, polyacetal blocks, polysaccharide blocks, and polysiloxane blocks.

[0186]

[0179] Suitable pharma- ceutically acceptable non-aqueous solvents include, but are not limited to, the following (and mixtures thereof):

[0187] (i) Alcohols, which include, for example, σ-glycerol formal, β-glycerol formal, 1,3-butylene glycol, aliphatic or aromatic alcohols having from 2 to about 30 carbons (e.g., methanol, ethanol, propanol, isopropanol, butanol, t-butanol, hexanol, octanol, amylene hydrate, benzyl alcohol, glycerin (glycerol), glycol, hexylene, glycol, tetrahydrofuranyl alcohol, cetyl alcohol, and stearyl alcohol), fatty acid esters of fatty alcohols (e.g., polyalkylene glycols, such as polypropylene glycol and polyethylene glycol), sorbitan, sucrose, and cholesterol.

[0188] (ii) Amides, including, for example, dimethylacetamide (DMA), benzyl benzoate DMA, dimethylformamide, N-hydroxyethyl-O-lactamide, N,N-dimethylacetamide-amide, 2-pyrrolidinone, 1-methyl-2-pyrrolidinone, and polyvinylpyrrolidone.

[0189] (iii) For example, acetate esters (e.g., monoacetin, diacetin, and triacetin), aliphatic and aromatic esters (e.g., ethyl caprylate or octanoate, alkyl oleates, benzyl benzoate, or benzyl acetate), dimethyl sulfoxide (DMSO), esters of glycerin (e.g., mono-, di-, and triglyceryl citrate and tartrate), ethyl benzoate, ethyl acetate, ethyl carbonate, ethyl lactate, ethyl oleate, fatty acid esters of sorbitan, glyceryl monostearate, glyceride esters (e.g., mono-, di-, or triglycerides), fatty acid esters (e.g., isopropyl myristate), fatty acid-derived PEG esters (e.g., PEG-hydroxyoleate and PEG-hydroxystearate), N-methylpyrrolidinone, Pluronic 60, polyoxyethylene sorbitol oleate polyesters (e.g., poly(ethoxylated) 30-60 Sorbitol poly(oleate) 2-4 , poly(oxyethylene) 15-20 Monooleate, poly(oxyethylene) 15-20 Mono 12-hydroxystearate, and poly(oxyethylene) 15-20monoricinoleate), polyoxyethylene sorbitan esters (e.g., polyoxyethylene-sorbitan monooleate, polyoxyethylene-sorbitan monopalmitate, polyoxyethylene-sorbitan monolaurate, polyoxyethylene-sorbitan monostearate, and polysorbates 20, 40, 60, and 80 (from ICI Americas, Wilmington, Del.)), polyvinylpyrrolidone, alkyleneoxy-modified fatty acid esters (e.g., polyoxyl 40 hydrogenated castor oil, and polyoxyethylated castor oil, such as CREMOPHOR EL Solution or CREMOPHOR RH 40 solution), saccharide fatty acid esters (i.e., monosaccharides (e.g., pentoses, such as ribose, ribulose, arabinose, xylose, lyxose, and xylulose, hexoses, such as glucose, fructose, galactose, mannose, and sorbose, trioses, tetrose, heptose, and octose), disaccharides (e.g., sucrose, maltose, lactose, and trehalose), oligosaccharides, or mixtures thereof, with one or more C4-C 22 Esters, including fatty acids (e.g., condensation products of saturated fatty acids such as caprylic acid, capric acid, lauric acid, myristic acid, palmitic acid, and stearic acid, and unsaturated fatty acids such as palmitoleic acid, oleic acid, elaidic acid, erucic acid, and linoleic acid), and steroid esters.

[0190] (iv) Ethers, such as alkyl, aryl, and cyclic ethers having from 2 to about 30 carbons. Examples include diethyl ether, tetrahydrofuran, dimethylisosorbide, diethylene glycol monoethyl ether, and glycofurol (tetrahydrofurfuranyl alcohol polyethylene glycol ether).

[0191] (v) Ketones, typically having from about 3 to about 30 carbons. Examples include acetone, methyl ethyl ketone, and methyl isobutyl ketone.

[0192] (vi) Hydrocarbons, which are typically aliphatic, alicyclic, or aromatic hydrocarbons having from about 4 to about 30 carbons. Examples include benzene, cyclohexane, dichloromethane, dioxolane, hexane, n-decane, n-dodecane, n-hexane, sulfolane, tetramethylene sulfone, tetramethylene sulfoxide, toluene, dimethyl sulfoxide (DMSO), and tetramethylene sulfoxide.

[0193] (vii) Oils, including, for example, oils of mineral, vegetable, animal, extractive or synthetic origin. These include mineral oils, such as aliphatic and waxy hydrocarbons, aromatic hydrocarbons, mixed aliphatic and aromatic hydrocarbons, and refined kerosene, vegetable oils, such as linseed, butterwood, safflower, soybean, castor, cottonseed, peanut, rapeseed, coconut, palm, olive, corn, corn germ, sesame, apricot kernel, and groundnut oils, glycerides, such as mono-, di-, and triglycerides, animal oils, such as fish, marine, sperm whale, cod liver, halibut liver, squalene, squalane, and shark liver oils, oleic acid oils, and polyoxyethylated castor oil.

[0194] (viii) Alkyl, alkenyl, or aryl halides, including, for example, alkyl or aryl halides having from 1 to about 30 carbons and one or more halogen substituents. Examples include methylene chloride, monoethanolamine, petroleum benzine, trolamine, omega-3 polyunsaturated fatty acids (e.g., alpha-linolenic acid, eicosapentaenoic acid, docosapentaenoic acid, or docosahexaenoic acid), polyglycol esters of 12-hydroxystearic acid and polyethylene glycol (SOLUTOL HS-15, from BASF, Ludwigshafen, Germany), polyoxyethylene glycerol, sodium laurate, sodium oleate, and sorbitan monooleate.

[0195]

[0188] Other pharma- ceutically acceptable solvents for use in the present invention are well known to those skilled in the art. General discussions of such solvents can be found, for example, in The Chemotherapy Source Book (Williams & Wilkens Publishing), The Handbook of Pharmaceutical Excipients, (American Pharmaceutical Association, Washington, DC, and The Pharmaceutical Society of Great Britain, London, UK, 1968), Modern Pharmaceutics 3rd Edition, (G. Banker et al., eds., Marcel Dekker, Inc., New York, NY (1995)), The Pharmacological Basis of Therapeutics, (Goodman & Gilman, McGraw Hill Publishing), Pharmaceutical Dosage Forms, (H. Lieberman et al., eds., Marcel Dekker, Inc., New York, NY (1980)), Remington's Pharmaceutical Sciences, 19th Edition, (A. Gennaro, ed., Mack Publishing, Easton, PA, (1995)), The United States Pharmacopeia 24, The National Formulary 19, (National Publishing, Philadelphia, PA (2000); Spiegel, AJ et al., "Use of Nonaqueous Solvents in Parenteral Products," J. Pharma. Sciences, Vol. 52, No. 10, pp. 917-927 (1963).

[0196]

[0189] Solvents useful in the present invention include, but are not limited to, those known to stabilize the present compound or its pharma- ceutically acceptable salts. These can include, for example, triglyceride-rich oils, such as safflower oil, soybean oil, and mixtures thereof, as well as alkyleneoxy-modified fatty acid esters, such as polyoxyl 40 hydrogenated castor oil, and polyoxyethylated castor oil (e.g., CREMOPHOR EL solution or CREMOPHOR RH 40 solution). Commercially available triglycerides include INTRALIPID emulsified soybean oil (Kabi-Pharmacia Inc., Stockholm, Sweden), NUTRALIPID emulsion (McGaw, Irvine, CA), LIPOSYN Il 20% emulsion (a 20% fat emulsion solution containing 100 mg safflower oil, 100 mg soybean oil, 12 mg egg phospholipids, and 25 mg glycerin per ml of solution; Abbott Laboratories, Chicago, IL), LIPOSYN III 2% emulsion (a 2% fat emulsion solution containing 100 mg safflower oil, 100 mg soybean oil, 12 mg egg phospholipids, and 25 mg glycerin per ml of solution; Abbott Laboratories, Chicago, IL), and natural or synthetic glycerol derivatives containing docosahexaenoyl groups at levels of about 25 to about 100% (by weight based on total fatty acid content) (Martek Biosciences, Corp., Columbia, MD; DHA MAGURO from Daito Enterprises, Los Angeles, CA; SOYACAL; and TRAVEMULSION. Ethanol, in particular, is a useful solvent for dissolving the compound or a pharma- ceutically acceptable salt thereof to form a solution, emulsion, and the like.

[0197] Additional components may be included in the compositions of the invention for a variety of purposes commonly known in the pharmaceutical arts. These components tend to impart properties such as promoting retention of the compound or its salt at the site of administration, protecting the stability of the composition, regulating pH, and facilitating processing of the compound or its salt into formulations.Specific examples of such ingredients include cryoprotectants, substances that prevent reprecipitation of the compound or salt surface, activators, wetting agents, or emulsifiers (e.g., lecithin, polysorbate-80, TWEEN 80, Pluronic 60, and polyoxyethylene stearate), preservatives (e.g., ethyl-p-hydroxybenzoate), microbial preservatives (e.g., benzyl alcohol, phenol, m-cresol, chlorobutanol, sorbic acid, thimerosal, and parabens), substances or buffers for adjusting pH (e.g., acids, bases, sodium acetate, sorbitan monolaurate, etc.), substances for adjusting osmotic pressure (e.g., glycerin), thickeners (e.g., aluminum monostearate, stearic acid, cetyl alcohol, etc.), and the like. cellulose, stearyl alcohol, guar gum, methylcellulose, hydroxypropylcellulose, tristearin, cetyl wax esters, polyethylene glycol, etc.), colorants, dyes, flow aids, non-volatile silicones (e.g. cyclomethicone), clays (e.g. bentonite), adhesives, extenders, flavorings, sweeteners, adsorbents, fillers (e.g. sugars, e.g. lactose, sucrose, mannitol, sorbitol, cellulose, calcium phosphate, etc.), diluents (e.g. water, saline, electrolyte solutions, etc.), binders (e.g. gelatin, tragacanth, methylcellulose, hydroxypropylmethylcellulose, sodium carboxymethylcellulose, polyvinylpyrrolidone, sugars, polymers, acacia, starches such as corn starch, wheat starch, rice starch, and potato starch, disintegrating agents (e.g. starches such as corn starch, wheat starch, rice starch, potato starch, and carboxymethyl starch, cross-linked polyvinylpyrrolidone, agar, alginic acid or its salts such as sodium alginate, croscarmellose sodium, crospovidone, etc.), lubricants (e.g. silica, talc, stearic acid and its salts such as magnesium stearate, polyethylene glycol, etc.), coating agents (e.g. concentrated sugar solutions containing gum arabic, talc, polyvinylpyrrolidone, carbopol gel, polyethylene glycol, titanium dioxide, etc.), and antioxidants (e.g. sodium metabisulfite, sodium bisulfite, sodium sulfite, dextrose, phenol, thiophenol, etc.).

[0198]

[0191] Techniques and compositions for making parenteral dosage forms are generally known in the art. A formulation for parenteral administration can be prepared from one or more sterile powders and / or granules having the compound or salt of the present invention and one or more of the carriers or diluents mentioned for use in the formulation for oral administration. The powder or granules are typically added to an appropriate volume of a solvent capable of dissolving the powder or granules (typically while agitating (e.g., stirring) the solvent). Specific solvents useful in the present invention include, for example, water, polyethylene glycol, propylene glycol, ethanol, corn oil, cottonseed oil, peanut oil, sesame oil, benzyl alcohol, sodium chloride, and / or various buffers.

[0199]

[0192] Emulsions for parenteral administration can be prepared, for example, by dissolving a compound or salt of the invention in any pharma- ceutically acceptable solvent capable of dissolving the compound to form a solution, and adding an appropriate volume of a carrier to the solution with stirring to form an emulsion. Solutions for parenteral administration can be prepared, for example, by dissolving a compound or salt of the invention in any pharma- ceutically acceptable solvent capable of dissolving the compound to form a solution, and adding an appropriate volume of a carrier to the solution with stirring to form a solution.

[0200]

[0193] Suppositories for rectal administration can be prepared, for example, by mixing the drug with a suitable non-irritating excipient which is solid at ordinary temperatures but liquid at rectal temperature and therefore will melt in the rectum to release the drug. Suitable excipients include, for example, cocoa butter, synthetic mono-, di-, or triglycerides, fatty acids, and / or polyethylene glycols.

[0201]

[0194] Unless otherwise stated, any formulation or combination of ingredients described or exemplified herein can be used to practice the present invention.

[0202] (i) Binders: Binders include, but are not limited to, corn starch, potato starch or other starches, gelatin, natural and synthetic gums such as acacia, sodium alginate, alginic acid, other alginates, powdered tragacanth, guar gum, cellulose and its derivatives (e.g., ethyl cellulose, cellulose acetate, calcium carboxymethylcellulose, sodium carboxymethylcellulose), polyvinylpyrrolidone, methylcellulose, pregelatinized starch, hydroxypropyl methylcellulose (e.g., Nos. 2208, 2906, 2910), microcrystalline cellulose, and mixtures thereof. Suitable forms of microcrystalline cellulose include, for example, the materials sold as AVICEL-PH-101, AVICEL-PH-103, and AVICEL-PH-105 (available from FMC Corporation, American Viscose Division, Avicel Sales, Marcus Hook, Pennsylvania, USA). An exemplary suitable binder is a mixture of microcrystalline cellulose and sodium carboxymethylcellulose sold as AVICEL RC-581 by FMC Corporation.

[0203] (ii) Fillers: Fillers include, but are not limited to, talc, calcium carbonate (e.g., granular or powdered), lactose, microcrystalline cellulose, powdered cellulose, dextrates, kaolin, mannitol, silicic acid, sorbitol, starch, pregelatinized starch, and mixtures thereof.

[0204] (iii) Lubricants: Lubricants include, but are not limited to, calcium stearate, magnesium stearate, mineral oil, electromagnetic radiation mineral oil, glycerin, sorbitol, mannitol, polyethylene glycol, other glycols, stearic acid, sodium lauryl sulfate, talc, hydrogenated vegetable oils (e.g., peanut oil, cottonseed oil, sunflower oil, sesame oil, olive oil, corn oil, and soybean oil), zinc stearate, ethyl oleate, ethyl laurate, agar, and mixtures thereof. Further lubricants include, for example, syloid silica gel (AEROSIL 200, manufactured by W. R. Grace Co., Baltimore, Maryland, USA), coagulated aerosol of synthetic silica (sold by Deaussa Co., Plano, Texas, USA), CAB-O-SIL (a pyrogenic silicon dioxide product sold by Cabot Co., Boston, Massachusetts, USA), and mixtures thereof.

[0205] (iv) Disintegrants: Disintegrants include, but are not limited to, agar, alginic acid, calcium carbonate, microcrystalline cellulose, croscarmellose sodium, crospovidone, polacrilin potassium, sodium starch glycolate, potato or tapioca starch, other starches, pregelatinized starch, other starches, clays, other algins, other celluloses, gums, and mixtures thereof.

[0206]

[0199] Tablets or capsules can be optionally coated by methods well known in the art. When binders and / or fillers are used with the compound / bioconjugate of the invention, they are typically incorporated at about 50 to about 99 weight percent of the compound / bioconjugate. In one embodiment, about 0.5 to about 15 weight percent of disintegrant, particularly about 1 to about 5 weight percent of disintegrant, can be used in combination with the compound. A lubricant can be optionally added, typically in an amount less than about 1 weight percent of the compound / bioconjugate. Techniques and pharma- ceutical acceptable excipients for making solid oral dosage forms are described in Marshall, SOLID ORAL DOSAGE FORMS, Modern Pharmaceutics (eds. Banker and Rhodes), 7:359-427 (1979). Other formulations are known in the art.

[0207]

[0200] Liquid preparations for oral administration can take the form of solutions, syrups or suspensions. Alternatively, liquid preparations can be supplied as a dry product for constitution with water or other suitable vehicle before use. Such liquid preparations can be prepared by conventional methods using pharma-ceutically acceptable additives such as suspending agents (e.g., sorbitol syrup, cellulose derivatives or hydrogenated edible fats), emulsifying agents (e.g., lecithin or acacia), non-aqueous vehicles (e.g., almond oil, oily esters, ethyl alcohol or fractionated vegetable oils), and / or preservatives (e.g., methyl or propyl p-hydroxybenzoate or sorbic acid). Preparations can also contain buffer salts, flavorings, colorings, perfumes and sweeteners, as appropriate. Preparations for oral administration can also be formulated to achieve controlled release of the compound / bioconjugate. Oral formulations preferably contain 10% to 95% of the compound / bioconjugate. Additionally, the compounds / bioconjugates of the invention can be formulated for buccal administration in the form of tablets or lozenges that are formulated in a conventional manner. Other methods of oral delivery of the compounds / bioconjugates of the invention are known to those of skill in the art and are within the scope of the present invention.

[0208]

[0201] Formulation 1: A hard gelatin capsule prepared using the following:

[0209] [Table 1]

[0210] The ingredients are mixed and filled into hard gelatin capsules in 560 mg quantities.

[0211]

[0202] Formulation 2: A tablet formulation is prepared using the following ingredients:

[0212] [Table 2]

[0213] The ingredients are mixed and compressed to form tablets weighing 665 mg each.

[0214] Formulation 3: A dry powder inhalation formulation is prepared containing the following ingredients:

[0215] [Table 3]

[0216] The active ingredient is mixed with lactose and the mixture is added to a dry powder inhaler device.

[0217] Formulation 4: Tablets each containing 60 mg of active ingredient are prepared as follows:

[0218] [Table 4]

[0219] The active ingredient, starch and cellulose are passed through a No. 20 mesh US sieve and thoroughly mixed. The solution of polyvinylpyrrolidone is mixed with the resultant powders which are then passed through a No. 16 mesh US sieve. The resulting granules are dried at 50-60°C and passed through a No. 16 mesh US sieve. The sodium carboxymethyl starch, magnesium stearate and talc, previously passed through a No. 30 mesh US sieve, are then added to the granules which, after mixing, are compressed on a tablet machine to yield tablets each weighing 150 mg.

[0220] Formulation 5: Capsules each containing 80 mg of active ingredient are made as follows:

[0221] [Table 5]

[0222] The active ingredient, cellulose, starch, and magnesium stearate are blended, passed through a No. 20 mesh US sieve, and filled into a hard gelatin capsule in 190 mg quantities.

[0223] Formulation 6: Suppositories, each containing 225 mg of active ingredient, are made as follows:

[0224] [Table 6]

[0225] The active ingredient is passed through a No. 60 mesh US sieve and suspended in the pre-melted saturated fatty acid glycerides using minimal heat required The mixture is then poured into a suppository mold of nominal 2.0 g capacity and allowed to cool.

[0226] Formulation 7: Suspensions each containing 50 mg of active ingredient per 5.0 ml dose are made as follows:

[0227] [Table 7]

[0228] The active ingredient, sucrose and xanthan gum are mixed and passed through a No. 10 mesh US sieve and mixed with a previously made aqueous solution of microcrystalline cellulose and sodium carboxymethyl cellulose. The sodium benzoate, flavor, and color are diluted with some of the water and added, with stirring. Sufficient water is then added to produce the required volume.

[0229] Formulation 8: Capsules each containing 150 mg of active ingredient are made as follows:

[0230] [Table 8]

[0231] The active ingredient, cellulose, starch, and magnesium stearate are blended, passed through a No. 20 mesh US sieve, and filled into a hard gelatin capsule in 560 mg quantities.

[0232] Kits: Various embodiments of the invention include kits. Such kits may include the compound / bioconjugate of the invention, optionally one or more components for preparing a pharma- ceutically acceptable formulation of the compound / bioconjugate, and instructions for use (e.g., administration). When supplied as a kit, the different components of the compound / bioconjugate formulation may be packaged in separate containers and mixed immediately prior to use. If desired, such packaging of separate components may be provided in a pack or dispenser device that may include one or more unit dosage forms containing the compound / bioconjugate. The pack may, for example, comprise metal or plastic foil, e.g., a blister pack. Such packaging of separate components may also, in some cases, allow for long-term storage without compromising the activity of the components. Furthermore, if more than one route of administration is intended or more than one administration schedule is intended, the different components may be packaged separately and not mixed prior to use. In various embodiments, the different components may be packaged in one combination for administration together.

[0233]

[0210] It is further contemplated that the compounds and salts of the present invention can be used in the form of a kit packaged in a container and suitable for use in practicing the methods described herein. The kit can include the compound or compounds, and optionally a suitable diluent, a device or device parts suitable for administration, and instructions for use according to the methods of the present invention. The device can include a parenteral injection device, such as a syringe or a transdermal patch. The device parts can include a cartridge for use in an injection device, and the like. In one embodiment, the kit includes a first dosage form comprising the compound or salt of the present invention, and a second dosage form comprising another active ingredient in an amount sufficient to carry out the methods of the present invention. Both the first dosage form and the second dosage form can include a therapeutically effective amount of a compound for treating the target condition(s).

[0234] In certain embodiments, the kit may be supplied with instructions for use. The instructions may be printed on paper or other substrate and / or may be supplied as an electronically readable medium, such as a floppy disk, a mini-CD-ROM, a CD-ROM, a DVD-ROM, a Zip disk, videotape, audiotape, etc. Detailed instructions need not be physically associated with the kit; instead, the user may be directed to an internet website specified or provided as an e-mail by the kit manufacturer or distributor.

[0235]

[0212] If desired, the emulsions or solutions described above for oral or parenteral administration can be packaged in concentrated form in IV bags, vials, or other conventional containers and then diluted with a pharma- ceutically acceptable liquid (e.g., saline) to form an acceptable concentration of the compound prior to use.

[0236]

[0213] The kit can contain reagents in separate containers, such as sterile water or saline to be added to the separately packaged lyophilized active ingredient. For example, a sealed glass ampoule can contain the lyophilized superoxide dismutase analog, and separate ampoules can contain sterile water, sterile saline or sterile water, each packaged under a neutral non-reactive gas, such as nitrogen. The ampoules can be made of any suitable material, such as glass, organic polymers, such as polycarbonate, polystyrene, ceramic, metal, or any other material typically used to hold reagents. Other examples of suitable containers include bottles, which can be made from materials similar to ampoules, and packaging materials that can consist of a foil-covered interior, such as aluminum or alloy. Other containers include test tubes, vials, flasks, bottles, syringes, and the like. The container can have a sterile access port, such as a bottle with a stopper that can be pierced by a long thin injection needle. Other containers can have two compartments separated by an easily removable membrane that allows the compartments to mix upon removal. The removable membrane can be glass, plastic, rubber, and the like.

[0237] INCORPORATION BY REFERENCE AND VARIATIONS STATEMENT

[0214] All references in this application, e.g., published or issued patents or equivalents, patent application publications, and patent documents, including non-patent literature or other source materials, are hereby incorporated by reference in their entirety herein, to the extent that each reference does not at least partially contradict the disclosure of this application, as if each were individually incorporated by reference (e.g., a partially contradictory reference is incorporated by reference except for the partially contradictory portion of the reference).

[0238]

[0215] The terms and expressions used herein are used as conditions of description and not of limitation, and there is no intention in the use of such terms and expressions to exclude any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the invention as claimed. Thus, although the present invention has been specifically disclosed by preferred embodiments, exemplary embodiments, and optional features, it should be understood that modifications and variations of the concepts disclosed herein may be reclassified by those skilled in the art, and such modifications and variations are considered to be within the scope of the invention as defined by the appended claims. The specific embodiments provided herein are examples of useful embodiments of the invention, and it will be apparent to one skilled in the art that the invention may be practiced using numerous variations of the apparatus, apparatus parts, and method steps described herein. As will be apparent to one skilled in the art, the methods and apparatus useful for the present methods may include numerous optional compositions and processing elements and steps.

[0239]

[0216] When a group of substituents is disclosed herein, it is understood that all individual members of the group and all subgroups, including any isomers, enantiomers and diastereomers of the group members, are separately disclosed. When Markush groups or other groupings are used herein, all individual members of the group, and all possible combinations and subcombinations of the group, are intended to be individually included in the disclosure. For example, when a compound is described herein such that a specific isomer, enantiomer or diastereomer of the compound is not specified in the formula or chemical name, the description is intended to include each isomer and enantiomer of the described compound, individually or in any combination. Furthermore, unless otherwise specified, all isotopic variations of the compounds disclosed herein are intended to be included in the disclosure. For example, it is understood that any one or more hydrogens in the disclosed molecules can be replaced with deuterium or tritium. Isotopic variations of molecules are usually useful as standards in the assay of the molecule and in chemical and biological studies related to the molecule or its use. Methods for making such isotopic variations are known in the art. The specific names of the compounds are intended as examples, as it is known that one of skill in the art can give different names to the same compound.

[0240]

[0217] Many of the molecules disclosed herein contain one or more ionizable groups [groups that can remove (e.g. -COOH) or add (e.g. amines) a proton, or can be quaternized (e.g. amines)]. All possible ionic forms of such molecules and their salts are intended to be included individually in the disclosure of this specification. With respect to salts of the compounds herein, those skilled in the art can select from a wide variety of available counterions appropriate for preparing the salts of the invention for a given application. In certain applications, the selection of a given anion or cation for preparing a salt can result in an increase or decrease in the solubility of the salt.

[0241]

[0218] Unless otherwise stated, any formulation or combination of ingredients described or exemplified herein can be used to practice the present invention.

[0242]

[0219] Whenever a range is given herein, e.g., a temperature range, a time range, or a composition or concentration range, all intermediate ranges and subranges, as well as all individual values ​​contained within a given range, are intended to be included in the disclosure. It is understood that any subrange contained herein, or individual values ​​within a range or subrange, can be excluded from the claims.

[0243]

[0220] All patents and publications mentioned in the specification are indicative of the level of skill of those skilled in the art to which the present invention pertains. References listed in this specification are incorporated by reference in their entirety in this specification to indicate the state of the art at the time of their publication or filing date, and it is intended that this information may be used herein to exclude certain embodiments that exist in the prior art, if necessary. For example, when a composition is claimed, it should be understood that compounds that were known and available in the art prior to the applicant's invention, including compounds whose enabling disclosures are provided in the references listed in this specification, are not intended to be included in the claimed composition.

[0244]

[0221] As used herein, "comprising" has the same meaning as "including," "containing," or "characterized by," is inclusive or open-ended, and does not exclude further unrecited elements or method steps. As used herein, "consisting of" excludes any element, step, or ingredient not specified in the claim element. As used herein, "consisting essentially of" does not exclude materials or steps that do not materially affect the basic and novel characteristics of the claim. In each instance herein, any of the terms "comprising," "essentially consisting of," and "consisting of" may be replaced with any of the other two terms. The invention as adequately described herein for ease of understanding may be practiced without any element or elements, limitation, or limitations not specifically disclosed herein.

[0245]

[0222] Those skilled in the art will understand that starting materials, biological materials, reagents, synthesis methods, purification methods, analysis methods, assay methods, and biological methods other than those specifically exemplified can be used in the practice of the present invention without undue experimentation. All known functional equivalents of any such materials and methods are intended to be included in the present invention. The terms and expressions used are used as conditions of description and not of limitation, and there is no intention in the use of such terms and expressions to exclude any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the invention claimed. Thus, although the present invention has been specifically disclosed by preferred embodiments and optional features, it should be understood that modifications and variations of the concepts disclosed herein may be reclassified by those skilled in the art, and that such modifications and variations are considered to be within the scope of the present invention as defined by the appended claims.

[0246] [CROSS REFERENCE TO RELATED APPLICATIONS]

[0001] This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 334,085, filed April 22, 2022, and U.S. Provisional Patent Application No. 63 / 422,839, filed November 4, 2022, each of which is incorporated by reference in this specification to the extent not inconsistent herewith.

Claims

1. 1. A method of treating an individual having Demodex mites causing one or more mite-induced clinical symptoms, the method comprising the step of applying an active agent to the individual having Demodex mites in a dosage sufficient to inactivate Demodex mites from the individual's hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands, resulting in an improvement or cessation of the mite-induced clinical symptoms, the active agent being selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, prodrugs thereof, and pharma- ceutical acceptable salts thereof.

2. 1. A method of treating an individual having a skin disorder, comprising the step of topically or orally administering to said individual having the skin disorder an active agent in a dosage sufficient to inactivate Demodex mites from the hair follicles and / or skin of said individual, resulting in amelioration or cessation of the manifestation of an allergic and / or vasomotor response to said mites that cause symptoms and signs of said skin disorder in said individual, wherein said active agent is selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

3. 1. A method of treating an individual having an autoimmune disease, the method comprising the step of administering to the individual an active agent in a dosage sufficient to inactivate at least a portion of Demodex mites in or on the individual, wherein said inactivation results in the attenuation or cessation of one or more symptoms associated with an inflammatory and / or immune response to the Demodex mites that cause one or more symptoms associated with the autoimmune disease in the individual, the active agent being selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

4. 1. A method of treating an individual having an ophthalmic disorder, the method comprising the step of topically or orally administering to the individual having the ophthalmic disorder an active agent in a dosage sufficient to inactivate Demodex mites from the individual's hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands, resulting in amelioration or cessation of manifestations of an allergic and / or inflammatory response to the Demodex mites that cause symptoms and signs of the ophthalmic disorder in the individual, wherein the active agent is selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharma- ceutical acceptable salts thereof.

5. The method according to any one of claims 1 to 4, wherein the Demodex mites are Demodex mites and Demodex folliculorum.

6. 6. The method of any one of claims 1 to 5, wherein the step of topically applying or orally administering the active agent kills Demodex mites, paralyzes Demodex mites, and / or renders at least a portion of the Demodex mites unable to reproduce.

7. 7. The method of any one of claims 1 to 6, wherein the active agent is selected from the group consisting of benztropine, dicyclomine, fluvoxamine, imipramine, promethazine, dextromethorphan, mecamylamine, bupropion, and pharma- ceutically acceptable salts thereof.

8. 8. The method of claim 7, wherein the active agent is selected from the group consisting of promethazine hydrochloride, benztropine mesylate, dicyclomine hydrochloride, fluvoxamine, imipramine maleate, dextromethorphan hydrobromide, mecamylamine hydrochloride, and bupropion hydrochloride.

9. 7. The method of any one of claims 1 to 6, wherein the active agent is selected from the group consisting of fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, and pharma-ceutically acceptable salts thereof.

10. 10. The method of claim 9, wherein the active agent is selected from the group consisting of fesoterodine fumarate, paroxetine hydrochloride, trihexyphenidyl hydrochloride, nortriptyline hydrochloride, chlorpheniramine maleate, clidinium bromide, and quetiapine fumarate.

11. 11. The method of any one of claims 2, 5 to 10, wherein the skin disorder is one or more of acne vulgaris, seborrheic dermatitis, perioral dermatitis, acneiform rash, transient acantholytic dermatosis, necrotizing acne, psoriasis, steroid-induced dermatitis, primary irritant dermatitis, rosacea, or hidradenitis suppurativa.

12. The method of any one of claims 2, 5 to 11, wherein the skin disorder affects the facial skin or eyelids or both.

13. The method of any one of claims 1 to 12, wherein the active agent is applied topically to the individual.

14. 14. The method of claim 13, wherein the topically applied active agent is formulated in a carrier such as a lotion, cream, soap, wash, shampoo or gel.

15. 15. The method of claim 14, wherein the concentration of the active agent in a topically applied lotion, cream, soap, wash, shampoo or gel is from 0.001 to 5 percent by weight.

16. 14. The method of claim 13, wherein the concentration of said active agent in a topically applied lotion, cream, soap, wash, shampoo or gel is the minimum concentration effective to kill or paralyze said Demodex mites.

17. 14. The method of claim 13, wherein the dosage of the active agent in a topically applied lotion, cream, soap, wash, shampoo or gel is between about 0.01 mg / kg and 150 mg / kg of body weight.

18. 14. The method of claim 13, wherein the topically applied active agent is encapsulated in microliposomes prior to incorporation into the carrier lotion, cream, soap, wash, shampoo or gel.

19. 20. The method of any one of claims 1 to 19, wherein the active agent is applied topically to areas of skin affected by the skin disorder and, optionally, to at least a portion of areas of skin not affected by the skin disorder.

20. 20. The method of any one of claims 1 to 19, wherein the active agent is applied topically to areas of the body skin where Demodex mites and / or Demodex mites are present.

21. The method of any one of claims 1 to 20, wherein the active agent is applied topically to substantially the entire skin area of ​​the individual.

22. 22. The method of any one of claims 4 to 21, wherein the ophthalmic disorder is Demodex-induced inflammatory eye disease.

23. 23. The method of claim 22, wherein the Demodex-induced inflammatory eye disease is one or more of meibomian gland dysfunction, conjunctivitis, keratoconjunctivitis, hyperemia, dry eye, and blepharitis.

24. 24. The method of any one of claims 4, 22-23, wherein the ophthalmic disorder is one or more of meibomian gland dysfunction, blepharitis, dry eye disease.

25. 25. The method of any one of claims 4, 22-24, wherein the ophthalmic disorder affects the eye or eyelid, or both.

26. 26. The method of any one of claims 2 to 25, wherein the Demodex mites are present in hair follicles, skin, eyes, eyelids, eyelashes and / or meibomian glands of the individual.

27. 27. The method of any one of claims 1 to 26, wherein the active agent is applied topically and is provided in a formulation for efficient delivery of the active ingredients of the active agent to the epidermal or subcutaneous area of ​​the individual.

28. 27. The method of any one of claims 3, 5-26, wherein the autoimmune disease is one or more of lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile dermatomyositis, adult dermatomyositis, Sjogren's syndrome, or porphyria cutanea tarda.

29. The autoimmune disease is selected from the group consisting of systemic lupus erythematosus, rheumatoid arthritis, juvenile idiopathic arthritis, systemic lupus, systemic sclerosis, juvenile and adult dermatomyositis, Sjogren's syndrome, porphyria cutanea tarda, relapsing rheumatoid arthritis, eosinophilic fasciitis, polymorphous actin eruption, granuloma annulare, lichen planus, lupus panniculitis, discoid lupus, porphyria cutanea tarda, psoriatic arthritis, chronic 27. The method of any one of claims 3, 5 to 26, wherein the rash is one or more of ulcerative stomatitis, refractory chronic urticaria, sarcoidosis, frontal fibrosing alopecia, necrobiosis lipoidica, actinic reticuloid, actinic prurigo, epidermolysis bullosa, Kikuchi-Fujimoto disease, graft versus host disease, chronic erythema nodosum, localized scleroderma and systemic sclerosis, pemphigus vulgaris, pemphigus foliaceus, or pemphigoid gestationis.

30. 30. The method of any one of claims 3, 5 to 29, wherein the autoimmune disease affects the epidermis, lymphatic system, muscles, joints or internal organs of the individual.

31. 10. The method of claim 1, wherein the individual suffers from a skin disorder, an ophthalmic disorder, or an autoimmune disease.

32. 1. A formulation for inactivating Demodex mites causing one or more mite-induced clinical symptoms, said formulation comprising a therapeutically effective amount of an active agent selected from the group consisting of promethazine, benztropine, dicyclomine, fluvoxamine, imipramine, dextromethorphan, mecamylamine, bupropion, fesoterodine, paroxetine, amoxapine, trihexyphenidyl, nortriptyline, clozapine, dimenhydrinate, chlorpheniramine, clidinium, quetiapine, prodrugs thereof, and pharmaceutically acceptable salts thereof.

33. 33. The formulation of claim 32, further comprising DMSO.

34. 34. The formulation of claim 32 or 33, further comprising an ophthalmically acceptable excipient selected from the group consisting of buffered saline, mineral oil, vegetable oil, petrolatum, Miglyol™ 182, alcoholic solutions, liposomes, and liposome-like products.

35. 35. The formulation of any one of claims 32 to 34, further comprising one or more of a preservative, an antioxidant, an antibiotic and an immunosuppressant.

36. The formulation according to any one of claims 32 to 35, formulated into a pad or gel stick.

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