Method and composition for treating edema unresponsive to oral diuretics

Abstract

The present invention features methods and compositions for the intranasal, sublingual, and subcutaneous administration of bumetanide to treat subjects suffering from edema refractory to oral diuretics.

Description

Technical Field

[0001] The present disclosure features methods and compositions for treating edema refractory to oral diuretics.

Background Art

[0002] Congestive heart failure (CHF) is a common heart disease. The incidence of congestive heart failure has been increasing in recent years, and its diagnosis is associated with a significant morbidity and mortality. In fact, congestive heart failure is a highly lethal disease with a high probability that the majority of affected patients, both men and women, will die within 5 years. Congestive heart failure results from the loss or impairment of normal cardiac function. This loss or impairment reduces cardiac output. As a result, both blood flow and blood pressure in the kidneys are reduced. This reduction in blood flow and blood pressure triggers the renin-angiotensin response, which exacerbates congestive heart failure. Since angiotensin II stimulates the secretion of aldosterone from the adrenal cortex, resulting in an increase in salt and water retention in the kidneys, the blood volume increases. The increase in blood volume and the corresponding vasoconstriction cause an increase in blood pressure and, thus, cardiac fluid overload, further deteriorating the condition of the heart.

[0003] To treat CHF, physicians administer a strict low-sodium diet to patients and monitor their fluid intake. Some patients are restricted to just 1 liter of fluid per day. The most important medications physicians use to counteract fluid overload are a type of drug called diuretics. Diuretics affect kidney function in a way that inhibits fluid reabsorption. As a result, urine output increases, contrary to the neurohormonal signals the kidneys receive. Physicians may also treat patients with medications that improve the heart's pumping capacity, raise blood pressure, and attempt to reactivate the body's control systems to a more normal function. This is generally effective in keeping many heart failure patients alive. However, in hundreds of thousands of patients, treatment with medication and diet alone is ineffective. When patients are edematous and experiencing fluid overload, gastrointestinal absorption is impaired, and therefore the effectiveness of oral diuretics may be limited. As a result, patients are often instructed to increase their oral diuretic dosage, further burdening their kidneys. Eventually, oral diuretics become insufficient to remove excess fluid, and patients seek intravenous diuretics to avoid gastrointestinal absorption. As a result, patients are frequently hospitalized for intensive care and IV diuretic administration, and are at risk of excessive diuresis (in each event) once gastrointestinal absorption recovers. Ultimately, excessive diuresis can lead to renal failure. When available treatments are no longer sufficient to remove fluid by existing renal function, renal replacement therapies such as hemoperfusion or dialysis are increasingly used as a method of removing fluid in acute CHF conditions. Acute heart failure may be treated in the hospital ICU with continuous renal replacement therapy (also known as artificial kidney or dialysis machine).

[0004] Therefore, patients with heart failure who are in acute distress due to fluid overload still need treatment options that reduce the risk of hospitalization and renal failure. [Overview of the Initiative]

[0005] The present invention is characterized by a composition and method for treating edema unresponsive to oral diuretics.

[0006] In a first embodiment, the present invention is characterized by a pharmaceutical composition comprising (i) an aqueous solution having a pH of about 5 to about 9 (e.g., pH 5±1, 6±1, 7±1, 8±1, or 9±1), (ii) a potassium bumetanide salt in a concentration of about 4 mg / mL to about 20 mg / mL (e.g., 4±1, 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 12±1, 13±1, 14±1, 15±1, 16±1, 17±1, 18±1, 19±1, or 20±1 mg / mL), and (iii) one or more pharmaceutically acceptable excipients.

[0007] In some embodiments, the pharmaceutical composition comprises an aqueous solution containing a bumetanide potassium salt in a concentration of about 5 mg / mL to about 10 mg / mL (e.g., 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 11.5±1, 12±1, 13±1, or 14±1 mg / mL), one or more pharmaceutically acceptable excipients, wherein the aqueous solution has a pH of about 6 to about 8 (e.g., pH 6±1, 7±1, 8±1).

[0008] In a related embodiment, the present invention features a pharmaceutical composition comprising an aqueous solution of bumetanidearginine salt and one or more pharmaceutically acceptable excipients. The aqueous solution may contain bumetanidearginine salt in a concentration of about 4 mg / mL to about 15 mg / mL (e.g., 4 to 12, 5 to 10, 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 11.5±1, 12±1, 13±1, or 14±1 mg / mL), the aqueous solution may have a pH of about 5 to about 9 (e.g., a pH of 5±1, 6±1, 7±1, 8±1, or 9±1), and one or more pharmaceutically acceptable excipients.

[0009] In any one embodiment of the above pharmaceutical composition, the pharmaceutically acceptable excipients include a surfactant or a permeation enhancer. In some embodiments, the pharmaceutical composition includes a permeation enhancer present in the aqueous emulsion.

[0010] In another embodiment of any of the above-described aspects, the pharmaceutical composition is formulated for intranasal, sublingual, or subcutaneous administration.

[0011] In any one embodiment of the above pharmaceutical composition, the aqueous solution has a pH of about 6 to about 8.

[0012] In some embodiments of any of the above pharmaceutical compositions, one or more pharmaceutically acceptable excipients include low viscosity carboxymethylcellulose sodium or a pharmaceutically acceptable salt thereof.

[0013] In any other embodiment of the above pharmaceutical compositions, one or more pharmaceutically acceptable excipients further include (a) viscosity improvers, (b) buffers, (c) preservatives, and / or (d) isotonic agents.

[0014] The present invention further comprises a method for the transmucosal administration of potassium bumetanide to a subject, characterized in that potassium bumetanide is administered intranasally or sublingually. In some embodiments, potassium bumetanide is the pharmaceutical composition of the present invention. In other embodiments, potassium bumetanide is administered transmucosally to treat edema. The present invention further comprises a method for treating edema in a subject requiring such treatment, comprising administering the pharmaceutical composition of the present invention to the subject in an effective amount. Administration may involve delivering a dosage volume of the pharmaceutical composition of the present invention of 25 μl to 250 μl (e.g., 35 ± 10, 50 ± 10, 75 ± 25, 125 ± 25, 150 ± 25, or 200 ± 50 μl) to the subject intranasally, sublingually, or subcutaneously. In certain embodiments, doses are delivered 1 to 4 times or less over a 6-hour period. In certain embodiments, four doses of approximately 100 μL each are delivered over a 1-hour period. In certain embodiments, two doses of approximately 100 μL each are delivered to the subject, followed by two more doses of approximately 100 μL each about 30–60 minutes later. In other embodiments, the subject suffers from edema unresponsive to oral diuretics. In certain embodiments, the subject has congestive heart failure. In certain embodiments, the subject suffers from pulmonary edema (e.g., pulmonary edema). In some embodiments, the pharmaceutical composition is administered intranasally to the subject in an external environment. In certain embodiments, the pharmaceutical composition is self-administered.

[0015] This method may be particularly beneficial when the subject has not achieved diuresis with oral diuretic therapy prior to intranasal or sublingual administration. The subject being treated may have experienced lower extremity swelling, shortness of breath, dyspnea, or chest pain that has not been resolved with oral diuretic therapy prior to intranasal or sublingual administration. In some embodiments, the subject has experienced reduced bowel motility prior to intranasal or sublingual administration.

[0016] In a related embodiment, the present invention provides a method for treating edema unresponsive to oral diuretics in a subject having congestive heart failure, comprising administering to the subject an effective amount of a pharmaceutical composition comprising any one of the pharmaceutical compositions described herein. In some embodiments, the pharmaceutical composition is administered transmucosally (e.g., intranasally or sublingually). In certain embodiments, the pharmaceutical composition is administered intranasally or sublingually.

[0017] In certain embodiments, 0.5 mg to 10 mg (e.g., 0.75 ± 0.25, 1.0 ± 0.5, 1.5 ± 0.5, 2.5 ± 0.5, 5.0 ± 2.0, or 7.5 ± 2.5 mg) of bumetanide or a pharmaceutically acceptable salt thereof is delivered to the subject in 1 to 4 doses or less over a period of 6 hours. In certain embodiments, the pharmaceutical composition comprises (i) an aqueous solution having a pH of about 5 to about 9 (e.g., pH 5±1, 6±1, 7±1, 8±1, or 9±1), (ii) bumetanide or a pharmaceutically acceptable salt thereof in a concentration of about 5 mg / mL to about 23 mg / mL (e.g., 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 12±1, 13±1, 14±1, 15±1, 16±1, 17±1, 18±1, 19±1, or 20±3 mg / mL), and (iii) one or more pharmaceutically acceptable excipients. In certain embodiments, the aqueous solution has a pH of about 6 to about 8. In other embodiments, one or more pharmaceutically acceptable excipients include (a) viscosity improvers, (b) buffers, (c) preservatives, (d) surfactants, (e) permeation enhancers, and / or (f) isotonic agents. In some embodiments, administration includes delivering a dose of the pharmaceutical composition in the nasal cavity of the subject in a quantity of 25 μl to 250 μl (e.g., 35±10, 50±10, 75±25, 125±25, 150±25, or 200±50 μl). In certain embodiments, administration includes delivering a dose of the pharmaceutical composition in the sublingual portion of the subject in a quantity of 25 μl to 250 μl (e.g., 35±10, 50±10, 75±25, 125±25, 150±25, or 200±50 μl). In some embodiments, administration includes delivering a dose of the pharmaceutical composition in the subcutaneous portion of the subject in a quantity of 25 μl to 250 μl (e.g., 35±10, 50±10, 75±25, 125±25, 150±25, or 200±50 μl). This method may be particularly beneficial when the subject has not been able to achieve diuresis with oral diuretic therapy prior to administration. The subject being treated may have experienced lower extremity swelling, shortness of breath, dyspnea, or chest pain that has not been resolved with oral diuretic therapy prior to administration. In some embodiments, the subject has experienced reduced bowel motility prior to administration.

[0018] In any embodiment of the above method, the patient remains upright during administration and for at least 30 minutes, 1 hour, 2 hours, or 3 hours after administration.

[0019] In any embodiment of the above method, the patient remains in a supine position during intranasal administration and for at least 2 minutes after administration (e.g., at least 5 minutes, at least 30 minutes, or at least 1 hour).

[0020] In any embodiment of the above method, the subject has been treated with at least one dose of an oral diuretic within the last 24 hours prior to administration. At least one oral diuretic may be selected from loop diuretics such as bumetanide, furosemide, or torsemide, or potassium-sparing diuretics such as amiloride or spironolactone.

[0021] In some embodiments of any of the above methods, the patient does not receive a total of more than approximately 10 mg of bumetanide salt over a 12-hour period. In some embodiments, a patient who receives a total of more than 10 mg of bumetanide salt over a 12-hour period should consult a doctor.

[0022] In some embodiments of the above methods, the risk of hospitalization for the subject due to complications associated with edema is reduced.

[0023] In any embodiment of the above method, the pharmaceutical composition is administered in 1, 2, 3, or 4 doses over a 12-hour period. In some embodiments, the pharmaceutical composition is administered in a single dose. In some embodiments, a dose of 1 to 2.5 mg of bumetanide salt is administered in 1, 2, 3, or 4 doses over a 12-hour period. In some embodiments, a dose of 2 to 5 mg of bumetanide salt is administered in 1, 2, 3, or 4 doses over a 12-hour period. In some embodiments, a dose of 3 to 7.5 mg of bumetanide salt is administered in 1, 2, 3, or 4 doses over a 12-hour period. In some embodiments, a dose of 4 to 10 mg of bumetanide salt is administered in 1, 2, 3, or 4 doses over a 12-hour period.

[0024] In some embodiments of any of the above methods, the pharmaceutical composition has a pH of about 5 to about 9 (e.g., a pH of 5±1, 6±1, 7±1, 8±1, or 9±1), about 4 mg / mL to about 15.0 mg / mL (e.g., 4 to 12, 5 to 10, 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 11.5±1, 12±1, 13±1 or 14±1 mg / mL) of bumetanide arginine salt, and one or more acceptable excipients, and is an aqueous composition.

[0025] In some embodiments of any of the above methods, the pharmaceutical composition has a pH of about 5 to about 9 (e.g., a pH of 5±1, 6±1, 7±1, 8±1, or 9±1), about 4 mg / mL to about 20.0 mg / mL (e.g., 4 to 12, 5 to 10, 5±1, 6±1, 7±1, 8±1, 9±1, 10±1, 11±1, 11.5±1, 12±1, 13±1 or 14±1, 15±1, 16±1, 17±1, 18±1 or 19±1 mg / mL) of bumetanide potassium salt, and one or more acceptable excipients, and is an aqueous composition.

[0026] In some embodiments of any of the above methods, the pharmaceutical composition has a pH of about 6 to about ⑧ (e.g., a pH of 6±1, 7±1, 8±1), about 5 mg / mL to about 10 mg / mL (e.g., 5±1, 6±1, 7±1, 8±1, 9±1, 10±1) of bumetanide potassium salt, and one or more pharmaceutically acceptable excipients, and is an aqueous composition.

[0027] It should be noted that there is an incorrect symbol "⑧" in the original text of ID=9, which should probably be "8". The above translation is based on the original content.In related aspects, the present invention is a method for treating edema in a subject having congestive heart failure, comprising administering subcutaneously to the subject at a dose of from about 100 μl to about 300 μl (e.g., 125 ± 25, 150 ± 50, 175 ± 50, 200 ± 25, 250 ± 50, or 275 ± 25 μl) an aqueous emulsion having a pH of from about 5 to about 9 (e.g., a pH of 5 ± 1, 6 ± 1, 7 ± 1, 8 ± 1, or 9 ± 1) and containing bumetanide arginine salt at a concentration of from about 7.0 mg / mL to about 15.0 mg / mL (e.g., 8 ± 1, 9 ± 1, 10 ± 1, 11 ± 1, 12 ± 1, 13 ± 1 or 14 ± 1 mg / mL). In certain embodiments, the aqueous emulsion comprises medium-chain triglycerides (MCT), lecithin (E80), a polysorbate surfactant, and / or a polyglycolized glyceride. In some embodiments, the formulation provides for sustained release of bumetanide such that no more than 2 doses are administered to the subject over 48 hours or no more than 1 dose is administered to the subject over 72 hours.

[0028] In certain embodiments of any of the above methods, the pharmaceutical composition comprises a surfactant, a permeation enhancer, a buffer, a preservative, a viscosity enhancer, or an isotonicity agent (e.g., any surfactant, permeation enhancer, buffer, preservative, viscosity enhancer, or isotonicity agent described herein). In certain embodiments, the pharmaceutical composition comprises a surfactant selected from glycerides, alkyl saccharides, ester saccharides, polyglycolized glycerides, and polysorbate surfactants (e.g., any glyceride, alkyl saccharide, ester saccharide, polyglycolized glyceride, or polysorbate surfactant described herein).

[0029] In some embodiments of any of the above methods in which the pharmaceutical composition is formulated for intranasal administration, the pharmaceutical composition is administered intranasally and the pharmaceutical composition comprises a permeation enhancer.

[0030] In some embodiments of any of the above methods, the pharmaceutical composition is formulated for sublingual administration, the pharmaceutical composition is administered sublingually, and the pharmaceutical composition optionally contains a permeation enhancer. In some embodiments of any of the above methods, the pharmaceutical composition comprises an emulsion (e.g., a nanoemulsion). The emulsion may comprise medium-chain glycerides (MCTs), lecithin (E80), polysorbate surfactants, and / or polyglycolated glycerides. In certain embodiments, the emulsion is a nanoemulsion comprising soy lecithin and glycocholic acid. In some embodiments, the pharmaceutical composition of any of the above methods does not comprise any emulsion. In certain embodiments, the pharmaceutical composition does not comprise any surfactant. In some embodiments, the pharmaceutical composition does not comprise any permeation enhancer. In certain embodiments, the pharmaceutical composition does not comprise any buffer.

[0031] In some embodiments of the above methods, the subject is a mammal. In a particular embodiment, the subject is a dog. In a particular embodiment, the subject is a human.

[0032] In any one embodiment of the above-described aspects, the pharmaceutical composition comprises about 0.5 to 2 percent bumetanide (wt / wt), about 0.1 percent sodium carboxymethylcellulose (low viscosity) (wt / wt), about 0.50 percent benzyl alcohol (wt / wt), about 0.078 to 0.31 percent potassium (e.g., potassium ions) (wt / wt), and about 2 to 4 percent mannitol (wt / wt), with a concentration of 5 mg / mL to 20 mg / mL, and a pH of about 6 to about 8 in water.

[0033] In another embodiment of any of the above aspects, the pharmaceutical composition comprises about 0.5 to 1.5 percent bumetanide (wt / wt), about 0.1 percent carboxymethylcellulose sodium (low viscosity) (wt / wt), about 0.5 percent benzyl alcohol (wt / wt), about 0.45 to 1.35 percent L-arginine (wt / wt), and about 2 to 4.0 percent mannitol (wt / wt), wherein the concentration of the arginine salt of bumetanide is 5 mg / mL to 15 mg / mL, and the pH of the solution is about 6 to about 8 in water.

[0034] In another embodiment, the present invention is characterized by a solid comprising a bumetanidearginine salt. [Brief explanation of the drawing]

[0035] [Figure 1] This graph shows the solubility (mg / mL) of various bumetanide salt forms compared to the weight (mg) of excipients added per 20 mg of bumetanide. [Figure 2] This graph shows the concentration of bumetanide (ng / mL) in the plasma of New Zealand white (NZW) rabbits over a period of 2 to 240 minutes, after intravenous (IV) administration of approximately 0.5 mg of commercially available bumetanide, or intranasal (IN) administration of approximately 0.5 mg of a bumetanide compound, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1), on a logarithmic scale. [Figure 3] This graph shows the concentration of bumetanide (ng / mL) in rabbit plasma over a period of 2 to 240 minutes after in vitro administration of 0.5 mg of bumetanide compounds F69, F70, FE-9, or FNE-1, on a linear scale. [Figure 4] This graph shows the area under the curve (AUC) (ng*h / mL) of bumetanide concentration in rabbit plasma over a period of 2 to 240 minutes after intravenous administration of approximately 0.5 mg of commercially available bumetanide, or intravenous administration of approximately 0.5 mg of bumetanide preparations such as F69, F70, FE-9, or FNE-1. [Figure 5]This graph shows the concentration of bumetanide in dog serum (ng / mL) over a period of 2 to 240 minutes after 0.5 mg IV or IN administration. It compares the bumetanide concentration achieved in serum using commercially available IV bumetanide with the bumetanide concentration achieved with approximately 0.5 mg IN administration of bumetanide preparations such as F69, F70, FE-9, or FNE-1. [Figure 6] This graph shows, on a logarithmic scale, the concentration of bumetanide in canine serum (ng / mL) over a period of 2 to 240 minutes after in vitro administration of 0.5 mg of bumetanide compounds, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1). [Figure 7] This graph shows the concentration of bumetanide (ng / mL) in canine serum over a period of 2 to 240 minutes after in vitro administration of 0.5 mg of bumetanide compounds, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1), on a linear scale. [Figure 8] This graph shows the concentration of bumetanide (ng / mL) in canine serum over a period of 2 minutes to 180 minutes after intravenous administration of commercially available bumetanide 0.5 mg in two different doses in dogs. [Figure 9] This graph shows the concentration of bumetanide (ng / mL) in canine serum over a period of 2 to 240 minutes after two intravenous administrations of commercially available bumetanide 0.5 mg, or after intravenous administration of 0.5 mg of a bumetanide compound, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1), on a logarithmic scale. [Figure 10]This graph shows, on a logarithmic scale, the concentration of bumetanide (ng / mL) in canine serum over a period of 2 to 240 minutes after sublingual (SL) administration of 0.5 mg of bumetanide compounds, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1). [Figure 11] This graph shows the concentration of bumetanide (ng / mL) in canine serum from 2 minutes to 240 minutes after intravenous administration of commercially available bumetanide 0.5 mg, or sublingual administration (SL) of 0.5 mg of bumetanide compounds, including bumetanide arginine salt preparation (F69), bumetanide potassium salt preparation (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1), on a logarithmic scale. [Figure 12] This graph, on a logarithmic scale, shows the concentration of bumetanide (ng / mL) in dog serum from 2 minutes to 240 minutes after intravenous administration of commercially available bumetanide 0.5 mg, compared to the concentration of bumetanide achieved by sublingual administration of bumetanide potassium (F70). [Figure 13] This graph shows the concentration of bumetanide (ng / mL) in canine serum over a period of 2 to 120 minutes after SL administration of 0.5 mg of bumetanide compound F69, F70, FE-9, or FNE-1, on a linear scale. [Figure 14] This graph shows the area under the curve (AUC) (ng*h / mL) of bumetanide concentration in canine serum over a period of 2 to 240 minutes after intravenous administration of commercially available bumetanide 0.5 mg, or intravenous or stolic administration of bumetanide preparations F69, F70, FE-9, or FNE-1. [Figure 15] This graph shows the area under the curve (AUC) (ng*h / mL) of bumetanide concentration in dog serum over a period of 2 to 240 minutes after intravenous administration of commercially available bumetanide 0.5 mg, or single-dose administration of bumetanide preparations F69, F70, FE-9, or FNE-1. [Figure 16]This graph shows the area under the curve (AUC) (ng*h / mL) of bumetanide concentration in canine serum over a period of 2 to 240 minutes after intravenous administration of commercially available bumetanide 0.5 mg or intravenous administration of bumetanide preparations F69, F70, FE-9, or FNE-1. [Modes for carrying out the invention]

[0036] definition As used herein, the term "approximately" refers to a value that is 10% or less above or below the stated value. For example, the expression "approximately 6 mg / mL" refers to a value between 5.4 and 6.6 mg / mL.

[0037] As used herein, the term “effective dose” refers to the amount of a pharmaceutical composition that, when administered to a subject, such as a human subject, is sufficient to produce a beneficial or desired outcome, such as a clinical result. For example, in the context of edema as described herein, this term refers to the amount of the composition sufficient to achieve a reduction in the symptoms of edema compared to the response obtained without administration of the composition. The amount of a given composition described herein that corresponds to such a dose depends on various factors, such as the given drug, pharmaceutical formulation, route of administration, and identifying information of the subject being treated (e.g., age, sex, weight).

[0038] As used herein, “emulsion” means a two-phase colloidal system, such as a mixture of two or more immiscible liquids, which can be added to a pharmaceutical composition as an excipient. A liquid emulsion is one in which both the dispersed phase and the continuous phase are liquids. Forming an emulsion typically requires energy input by shaking, stirring, homogenization, or a spraying process. For example, an emulsion may contain an aqueous phase and a non-aqueous phase, may contain a self-emulsifying system, or the emulsion may be nanoparticles containing an aqueous phase and a non-aqueous phase (e.g., a nanoemulsion or microemulsion). “Nanoemulsion or microemulsion” means a clear, stable, isotropic liquid mixture of oil, water, and a surfactant, sometimes combined with an auxiliary surfactant. The aqueous phase may contain salts and / or other components in addition to the biological surfactant. Unlike ordinary emulsions, microemulsions are formed by simply mixing the components and do not require the high shear conditions typically used in the formation of ordinary emulsions. The two basic types of microemulsions are normal phase (oil dispersed in water, o / w) and reverse phase (water dispersed in oil, w / o).

[0039] As used herein, the terms “pulmonary edema” or “pulmonary edema” refer to a condition in which there is an excess of fluid in a patient’s lungs, causing difficulty breathing. Pulmonary edema may be caused by conditions associated with heart failure, pneumonia, trauma, allergic reactions, or other causes.

[0040] As used herein, the term “oral diuretic-refractory edema” refers to edema that does not respond to oral diuretic treatment, in which diuresis is not achieved with oral diuretics, resulting in the retention of excess fluid and consequently a persistent edematous state.

[0041] As used herein, the term "failure to achieve diuresis" refers to a situation in which the administration of oral diuretics does not increase the patient's fluid excretion, resulting in a persistent edematous state.

[0042] As used herein, the terms "intranasal" or "in the nasal cavity" refer to a method of administering a pharmaceutical composition in which the composition is delivered through the nasal cavity.

[0043] As used herein, the term “loop diuretic” means a drug used to reduce symptoms of hypertension and edema in patients with congestive heart failure or renal insufficiency. Loop diuretics belong to a type of diuretic that increases urine secretion by reducing the reabsorption of sodium and chloride by the kidneys.

[0044] As used herein, the terms "low viscosity carboxymethylcellulose sodium" or "low viscosity CMC sodium" refer to carboxymethylcellulose sodium having a viscosity of 30 cP to 45 cP (e.g., 30±1 cP, 31±1 cP, 32±1 cP, 33±1 cP, 34±1 cP, 35±1 cP, 36±1 cP, 37±1 cP, 38±1 cP, 39±1 cP, 40±1 cP, 41±1 cP, 42±1 cP, 43±1 cP, 44±1 cP, and 45±1 cP) in a 2% aqueous solution at 25°C, or 50 to 200 cP in a 4% aqueous solution at 25°C. Low viscosity carboxymethylcellulose sodium may have a molecular weight of approximately 90 kDa.

[0045] As used herein, the term “pharmaceutically acceptable” means a compound, substance, composition, and / or dosage form that is suitable for contact with the tissues of a subject, such as those of a mammal (e.g., human), without excessive toxicity, irritation, allergic reactions, and other problematic ailments, and that provides a reasonable benefit-to-risk ratio.

[0046] As used herein, the term “pharmaceutically acceptable salt” refers to a salt suitable for use in human treatment without excessive toxicity. pharmaceutically acceptable salts are well known in the art. For example, pharmaceutically acceptable salts are described in Berge et al., J. Pharmaceutical Sciences 66:1-19, 1977 and Pharmaceutical Salts: Properties, Selection, and Use (Eds. PHStahl and CGWermuth), Wiley-VCH, 2008. Salts may be prepared, for example, in situ during the final isolation and purification of the compounds described herein, or separately by reacting a free basic group with a suitable organic acid. Typical acid addition salts include acetate, adipine, alginate, ascorbate, aspartate, benzenesulfonate, benzoate, bisulfate, borate, butyrate, camphorate, camphor sulfonate, citrate, cyclopentanepropionate, digluconate, dodecyl sulfate, ethanesulfonate, fumarate, glucoheptonate, glycerophosphate, hemisulfate, heptoneate, hexanoate, hydrobromide, hydrochloride, hydroiodide, 2-hydroxyethanesulfonate, and lactate. This includes, but is not limited to, biotates, lactates, laurates, lauryl sulfates, malates, maleates, malons, methanesulfons, 2-naphthalenesulfons, nicotinates, nitrates, oleates, oxalates, palmitates, pamoates, pectins, persulfates, 3-phenylpropionates, phosphates, picrates, pivalates, propions, stearates, succinates, sulfates, tartrates, thiocyans, toluenesulfons, undecanoates, valersates, and others.Typical alkali metal salts or alkaline earth metal salts include, but are not limited to, sodium, lithium, potassium, calcium, magnesium, and non-toxic ammonium, quaternary ammonium, and amine cations, including, but are not limited to, ammonium, tetramethylammonium, tetraethylammonium, methylamine, dimethylamine, trimethylamine, triethylamine, ethylamine, L-α-phosphatidylethanolamine, bis(2-ethylhexyl)amine, and soy lecithin. Typical amino acid salts include lysine, arginine, glycine, and histidine. Those skilled in the art will recognize that any mention of a drug compound includes, within its scope, pharmaceutically acceptable salts of the indicated drug compound.

[0047] As used herein, the term “potassium-sparing diuretic” refers to a type of diuretic that does not promote potassium secretion into the urine and therefore increases fluid excretion. These diuretics may be used alone or in combination with loop diuretics or thiazide diuretics.

[0048] As used herein, the term "reduced bowel motility" refers to a slowing of the activity of the gastrointestinal tract in question. One effect of this slowing of activity may be reduced absorption, which in turn hinders the effective absorption of the pharmaceutical composition. For example, this reduced bowel motility may be caused by edema (e.g., fluid overload resulting from congestive heart failure), which hinders the adequate absorption of oral diuretics necessary for treating the edema.

[0049] As used herein, the term “hospitalization risk” refers to the potential possibility that a patient will be hospitalized for the treatment of edema rather than effectively managing it without hospitalization by self-administering bumetanide using the method of the present invention. The reduction in hospitalization risk is assessed by comparing the rate at which patients self-administering bumetanide are hospitalized for the treatment of edema with that of patients relying solely on oral diuretics for the treatment of edema, for a given patient population of a particular severity (e.g., patients with congestive heart failure). Using the bumetanide method of the present invention can reduce the hospitalization rate for edema treatment in a patient population by at least 10%, 20%, 30%, or 50%, and thus reduce the hospitalization risk for individual patients using bumetanide.

[0050] As used herein, the terms “sublingual” and “sublingual” refer to a method of administering a pharmaceutical composition in which the composition is delivered under the tongue and the pharmaceutical composition is diffused into the bloodstream through the tissues under the tongue, including the mucous glands.

[0051] As used herein, the term “supine” in relation to the patient’s position during treatment refers to the patient maintaining a reclining position during and / or for a period of time after administration of the pharmaceutical composition. If the patient cannot lie down, the patient may recline or raise their head.

[0052] As used herein, “treatment” and “to treat” refer to therapies for subjects requiring diuresis, such as therapies to alleviate one or more symptoms of edema in subjects suffering from edema, or therapies to preventively reduce the risk of one or more symptoms of edema in subjects at risk of edema.

[0053] As used herein, the terms “unit dose” or “dosage” as used in relation to therapeutic compositions refer to physically distinct units suitable as unit doses for a subject, each unit containing a predetermined amount of active substance calculated to produce the desired therapeutic effect in relation to the necessary diluent, i.e., carrier, or vehicle.

[0054] As used herein, the term “upright” as used in relation to the positioning of a patient during treatment means that the patient maintains an upright posture of the torso and / or entire body. Specifically, the patient does not lie down during and / or for any period after the administration of the pharmaceutical composition.

[0055] Detailed explanation The present invention features pharmaceutical compositions and methods for treating edema refractory to oral diuretics. Bumetanide can be formulated for intranasal, sublingual, or subcutaneous delivery in a salt form that allows for the delivery of a therapeutically effective dose of bumetanide in small volumes (about 100-150 μL), particularly suitable for intranasal delivery. The concentration of bumetanide is optimally 5 mg / mL or 10 mg / mL so that the ideal dose can be achieved in these small volumes. To ensure suitable shelf-life stability of the pharmaceutical product, it is necessary to consider changes in solubility that occur as a result of changes in temperature and storage conditions, so the concentration of bumetanide salt in solution approaches its saturation limit. This further highlights the need for the present invention to address salt forms that are stable at least 5 mg / mL.

[0056] Using these bumetanide salt concentrations, administering bumetanide intranasally, sublingually, or subcutaneously to patients experiencing oral diuretic-refractory edema due to edema (e.g., in patients with reduced bowel motility associated with edema) can alleviate edema and restore the effectiveness of orally administered diuretics without the need for hospitalization. The patient may self-administer the pharmaceutical composition based on their symptoms, thus eliminating the need for hospitalization, or, if the patient is experiencing acute distress, a healthcare professional (e.g., a physician, paramedic, or nurse) may administer the pharmaceutical composition.

[0057] Furthermore, the method of the present invention can reduce the risk of renal failure in certain patients, such as those suffering from congestive heart failure. When such patients are edematous and experiencing fluid overload, gastrointestinal absorption is impaired, and therefore the effectiveness of oral diuretics may be limited. As a result, patients are often instructed to increase the dosage of oral diuretics, placing an additional burden on their kidneys. Eventually, oral diuretics become insufficient to remove excess fluid, and patients are hospitalized to receive intravenous diuretics to avoid the gastrointestinal system. Consequently, patients are at risk of excessive diuresis once gastrointestinal absorption is restored. This excessive diuresis can lead to renal failure.

[0058] Pharmaceutical composition The bumetanide formulations of the present invention may be solutions, suspensions, or emulsions. The formulations may contain surfactants, antioxidants, pH adjusters (e.g., acids or bases), buffers, preservatives, isotonic agents, viscosity improvers (e.g., carboxymethylcellulose), surfactants, and / or permeation enhancers. The formulations may be administered as aqueous solutions or in the form of emulsions, including nanoemulsions and microemulsions. The formulations may be provided in single-dose or multi-dose forms. The formulations may be administered subcutaneously, sublingually, or intranasally. In the case of droppers or pipettes, administration may be achieved by administering a predetermined volume of solution appropriate to the subject. In the case of sprays, this may be achieved, for example, by means of a metered spray pump. The metered spray pump may be a single-dose metered spray pump device (e.g., APTAR® Unidose, Unidose® Xtra) or a multi-dose metered pump device (e.g., APTAR® Bidose (BDS), MK® pump).

[0059] Emulsion Emulsions can be obtained by adding an emulsifier and purified water to an active ingredient and emulsifying them by an appropriate method for homogenizing the components. That is, the components of an emulsion preferably include, but are not limited to, an active ingredient, a solvent, an emulsifier, a buffer, and an isotonic agent. Examples of emulsifiers that may be used in the formulation of the present invention include carboxyvinyl polymer, carboxymethylcellulose sodium, highly purified egg yolk lecithin, glycerin, hydrogenated soybean phospholipid, squalane, squalene, polyoxyl 45 stearate, stearic acid, polyoxyl 55 stearate, purified soybean lecithin, purified egg yolk lecithin, sorbitan sesquioleate, sorbitan ester of fatty acid, soybean lecithin, hydroxypropylcellulose, partially hydrogenated soybean phospholipid, propylene glycol, polyoxyethylene hydrogenated castor oil, polyoxyethylene hydrogenated castor oil 5, polyoxyethylene hydrogenated castor oil 10, polyoxyethylene hydrogenated castor oil 20, polyoxyethylene hydrogenated Examples include castor oil 40, polyoxyethylene hydrogenated castor oil 50, polyoxyethylene hydrogenated castor oil 60, polyoxyethylene castor oil, polyoxyethylene behenyl ether, polyoxyethylene (160) polyoxypropylene (30) glycol, polyoxyethylene (1) polyoxypropylene (1) cetyl ether, polyoxyethylene (10) polyoxypropylene (4) cetyl ether, polyoxyethylene (20) polyoxypropylene (4) cetyl ether, polyoxyethylene (20) polyoxypropylene (8) cetyl ether, polysorbate 80, macrogol 400, cottonseed oil-soybean oil mixture, and sorbitan monostearate.Preferred examples include highly purified egg yolk lecithin, hydrogenated soybean phospholipids, squalane, squalene, polyoxyl 45 stearate, polyoxyl 55 stearate, purified soybean lecithin, purified egg yolk lecithin, sorbitan sesquioleate, sorbitan esters of fatty acids, soybean lecithin, partially hydrogenated soybean phospholipids, polyoxyethylene hydrogenated castor oil, polyoxyethylene hydrogenated castor oil 5, polyoxyethylene hydrogenated castor oil 10, polyoxyethylene hydrogenated castor oil 20, polyoxyethylene hydrogenated castor oil 40, polyoxyethylene hydrogenated castor oil 50, Examples include polyoxyethylene hydrogenated castor oil 60, polyoxyethylene castor oil, polyoxyethylene behenyl ether, polyoxyethylene (160) polyoxypropylene (30) 15 glycol, polyoxyethylene (1) polyoxypropylene (1) cetyl ether, polyoxyethylene (10) polyoxypropylene (4) cetyl ether, polyoxyethylene (20) polyoxypropylene (4) cetyl ether, polyoxyethylene (20) polyoxypropylene (8) cetyl ether, and sorbitan monostearate. Preferred emulsifiers include poloxamers (e.g., low molecular weight poloxamers (e.g., poloxamers with an average molecular weight of less than 10 kDa, e.g., poloxamer 188)), polysorbates (e.g., polysorbate 80 and polysorbate 20), polyoxyethylene alkyl ethers (Brij), alkylphenyl polyoxyethylene ethers (Triton-X), sodium dodecyl sulfate (SDS), medium-chain triglycerides (MCT), glycolic acid, polyvinylpyrrolidone (PVP), 1,2-propylene glycol, Cremofor EL, Cremofor RH40, lecithin (E-80), soy lecithin (PL90G), tert-butanol, ethanol, or polyoxyethylene stearate. Preferred emulsifiers are polysorbate, lecithin, MCT, and glycolic acid.For example, polysorbate 80 is present in intranasal pharmaceutical compositions (e.g., solutions) at concentrations of 1% (w / w) to 15% (w / w), 1% (w / w) to 10% (w / w), 1% (w / w) to 5% (w / w), 2% (w / w) to 5% (w / w), 2% (w / w) to 10% (w / w), 2% (w / w) to 15% (w / w), 3% (w / w) to 5% (w / w), 3% (w / w) to 10% (w / w), and 3% (w / w) to 10% (w / w). It can be used at concentrations such as %(w / w)~15%(w / w), 4%(w / w)~5%(w / w), 4%(w / w)~10%(w / w), 4%(w / w)~15%(w / w), 5%(w / w)~10%(w / w), 5%(w / w)~15%(w / w), 0.003%(w / v)~0.1%(w / v), 0.1%(w / v)~5%(w / v), 0.1%(w / v)~4%(w / v), and 0.1%(w / v)~3%(w / v).

[0060] surfactant In some embodiments of the pharmaceutical composition, a surfactant may be added, which may be cationic, anionic, nonionic, or zwitterionic. The surfactant may be added to the composition to increase the solubility of bumetanide. Surfactants that may be useful in the formulations of the present invention include, but are not limited to, tetradecyl-β-D-maltoside, soy lecithin, distearoylglycerol-3-phosphatidylamine, L-α-phosphatidylethanolamine, and bis(2-ethylhexyl)amine. Examples of surfactants that may be used in the pharmaceutical compositions of the present invention include, but are not limited to, glycerides, alkyl saccharides, ester saccharides, polyglycolated glycerides, soy lecithin, lecithin (E80), and polysorbate surfactants.

[0061] Glycerides Glycerides may be used in the pharmaceutical compositions of the present invention. Glycerides are fatty acid monoesters, fatty acid diesters, and fatty acid triesters of glycerol. Glycerides include saturated and unsaturated monoglycerides, diglycerides (1,2-diglycerides and 1,3-diglycerides), and triglycerides having mixed and unmixed fatty acid compositions. In this specification, each glyceride is denoted as (Cn:m), where n is the length of the fatty acid side chain and m is the number of double bonds (cis or trans) in the fatty acid side chain. Examples of commercially available monoglycerides include monocaprylin (C8; i.e., glyceryl monocaprylate) (Larodan), monocaprin (C10; i.e., glyceryl monocaprate) (Larodan), monolaurin (C12; i.e., glyceryl monolaurate) (Larodan), monopalmitorein (C16:1) (Larodan), glyceryl monomyristate (C14) (Nikkol® MGM, Nikko), glyceryl monooleate (C18:1) (PECEOL®, Gattefosse), glyceryl monooleate (Myverol®, Eastman), glycerol monooleate / linoleate (OLICINE®, Gattefosse), glycerol monolinoleate (Maisine, Gattefosse), and monoelaidin (C18:1) (Larodan). Examples of commercially available mono / diglycerides and triglycerides include Capmul MCM C8EP (C8:C10 mono / diglyceride) and Capmul MCM C10 (mono / diglyceride).Examples of commercially available diglycerides include glyceryl laurate (Imwitor® 312, Huls), glyceryl caprylate / caprate (Capmul® MCM, ABITEC), diglyceryl caprylate (Imwitor® 988, Huls), glyceryl caprylate / caprate (Imwitor® 742, Huls), dicapryline (C8) (Larodan), dicaprine (C10) (Larodan), dilaurin (C12) (Larodan), and glyceryl dilaurate (C12) (Capmul® GDL, ABITEC®). Examples of commercially available triglycerides include tricaprylin (C8; i.e., glyceryl tricaprylate) (Larodan), capatex 100 (C10), tricaprin (C10; i.e., glyceryl tricaprate) (Larodan), trilaurin (C12; i.e., glyceryl trilaurate) (Larodan), dimyristate (C14) (Larodan), dipalmitine (C16) (Larodan), distearin (Larodan), and glyceryl dilaurate (C12). Examples include (Capmul® GDL, ABITEC), glyceryl dioleate (Capmul® GDO, ABITEC®), glycerol esters of fatty acids (GELUCIRE® 39 / 01, Gattefosse), dipalmitorein (C16:1) (Larodan), 1,2-diolein and 1,3-diolein (C18:1) (Larodan), dielysin (C18:1) (Larodan), and dilinolein (C18:2) (Larodan).

[0062] Polyglycolated glycerides Polyglycolated glycerides may be used in the pharmaceutical compositions of the present invention. Polyglycolated glycerides include polyethylene glycol glyceride monoesters, polyethylene glycol glyceride diesters, polyethylene glycol glyceride triesters, and mixtures thereof containing various amounts of free polyethylene glycol, such as polyethylene glycol-oil transesterification products. Polyglycolated glycerides may contain either monodisperse (i.e., single molecular weight) or polydisperse polyethylene glycol moieties of a predetermined size or size range (e.g., PEG2 to PEG40). Polyethylene glycol glycerides include, for example, PEG-15 glyceryl caprate, PEG-15 glyceryl laurate, PEG-15 glyceryl laurate (Glycerox L series, Croda), PEG-15 glyceryl laurate (Glycerox L series, Croda), PEG-40 glyceryl laurate (Glycerox L series, Croda), PEG-20 glyceryl stearate (Capmul EMG, ABITEC), and Aldo MS-20 KFG, Lonza), PEG-20 glyceryl oleate (Tagat O, Goldschmidt), and PEG-30 glyceryl oleate (Tagat O2, Goldschmidt). Caprylocapryl PEG glycerides include, for example, caprylic / caprate PEG-8 glyceride (Labrasol®, Gattefosse), caprylic / caprate PEG-4 glyceride (Labrafac® Hydro, Gattefosse), and caprylic / caprate PEG-6 glyceride (SOFTIGEN® 767, Huls). Oleoyl PEG glycerides include, for example, oleoyl PEG-6 glyceride (Labrafil® M1944 CS, Gattefosse). Lauroyl PEG glycerides include, for example, lauroyl PEG-32 glyceride (Gelucire® ELUCIRE 44 / 14, Gattefosse).Stearoyl PEG glycerides include, for example, stearoyl PEG-32 glycerides (Gelucire® 50 / 13, Gelucire® 53 / 10, Gattefosse).PEG castor oils include PEG-3 castor oil (Nikkol® CO-3, Nikko), PEG-5, 9, and 16 castor oils (ACCONON® CA series, ABITEC), PEG-20 castor oil (Emalex® C-20, Nihon Emulsion), PEG-23 castor oil (Emulgante® EL23), PEG-30 castor oil (Incrocas® 30, Croda), PEG-35 castor oil (Incrocas-35®, Croda), PEG-38 castor oil (Emulgante® EL 65, Condea), PEG-40 castor oil (Emalex® C-40, Nihon Emulsion), and PEG-50 castor oil (Emalex® C-50, Nihon Emulsion). Emulsion), PEG-56 castor oil (Eumulgin® PRT 56, Pulcra SA), PEG-60 castor oil (Nikkol® CO-60TX, Nikko), PEG-100 castor oil, PEG-200 castor oil (Eumulgin® PRT 200, Pulcra SA), PEG-5 hydrogenated castor oil (Nikkol® HCO-5, Nikko), PEG-7 hydrogenated castor oil (Cremofor® WO7, BASF), PEG-10 hydrogenated castor oil (Nikkol HCO-10 (Nikko), PEG-20 Hydrogenated Castor Oil (Nikkol® HCO-20, Nikko), PEG-25 Hydrogenated Castor Oil (Simulsol® 1292, Seppic), PEG-30 Hydrogenated Castor Oil (Nikkol® HCO-30, Nikko), PEG-40 Hydrogenated Castor Oil (Cremofor® RH 40, BASF), PEG-45 Hydrogenated Castor Oil (Cerex ELS 450, Auschem Spa), PEG-50 Hydrogenated Castor Oil (Emalex® HC-50, Nihon This product contains Emulsion, PEG-60 hydrogenated castor oil (Nikkol® HCO-60, Nikko), PEG-80 hydrogenated castor oil (Nikkol® HCO-80, Nikko), and PEG-100 hydrogenated castor oil (Nikkol® HCO-100, Nikko).Further polyethylene glycol-oil transesterification products include, for example, stearoyl PEG glyceride (Gelucire® 50 / 13, Gattefosse). Polyglycolated glycerides useful in the formulations of the present invention may include polyethylene glycol glyceride monoesters, diesters, and / or triesters of acetic acid, propionic acid, butyric acid, valeric acid, hexanoic acid, heptanoic acid, caprylic acid, nonanoic acid, capric acid, lauric acid, myristic acid, palmitic acid, heptadecanoic acid, stearic acid, arachidic acid, behenic acid, lignoceric acid, alpha-linolenic acid, stearidonic acid, eicosapentaenoic acid, docosahexaenoic acid, linoleic acid, gamma-linolenic acid, dihomo-gamma-linolenic acid, arachidonic acid, oleic acid, elaidic acid, eicosenoic acid, erucic acid, or nervonic acid, or mixtures thereof. The polyglycol portion in polyglycolated glycerides may be polydisperse, that is, it may have various molecular weights.

[0063] Alkylsaccharide Alkyl saccharides may be used in the pharmaceutical compositions of the present invention. Alkyl saccharides are sugar ethers of hydrophobic alkyl groups (for example, typically with a length of 9 to 24 carbon atoms). Alkyl saccharides include alkyl glycosides and alkyl glucosides. In certain embodiments, cefepime is a sugar C 8-14 It is formulated together with an alkyl ether. Alkyl glycosides that can be used in the oral dosage form of the present invention include α or β-D-maltoside, -glucoside, or -sucroside, alkylthiomaltoside, e.g., heptyl, octyl, dodecyl-, tridecyl-, and tetradecyl-β-D-thiomaltoside; alkylthioglucoside, e.g., heptyl- or octyl 1-thioα- or β-D-glucopyranoside; alkylthiosucrose; and alkylmaltotrioside C 8-14This includes, but is not limited to, alkyl (e.g., octyl-, nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-, or tetradecyl-) ethers. For example, bumetanide can be formulated with octyl maltoside, dodecyl maltoside, tridecyl maltoside, or tetradecyl maltoside. Alkyl glucosides that can be used in the oral dosage forms of the present invention include C13 glucosides such as dodecyl glucoside or decyl glucoside. 8-14 This includes, but is not limited to, alkyl (e.g., octyl-, nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-, or tetradecyl-) ethers.

[0064] Ester saccharide Ester saccharides may be used in the pharmaceutical compositions of the present invention. Ester saccharides are sugar esters of hydrophobic alkyl groups (for example, typically with a length of 8 to 24 carbon atoms). Ester saccharides include glycoside esters and glucoside esters. In certain embodiments, cefepime is a sugar C 8-14 It is formulated together with an alkyl ester. The glycoside ester that can be used in the oral dosage form of the present invention is α or β-D-maltoside, -glucoside, or -sucroside C 8-14 This includes, but is not limited to, alkyl (e.g., octyl-, nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-, or tetradecyl-) esters. For example, bumetanide may be formulated with monododecanoate sucrose, monotridecanoate sucrose, or monotetradecanoate sucrose. Glucoside esters that may be used in the oral dosage forms of the present invention include C13 of glucosides such as dodecanoate glucose or decanoate glucose. 8-14 This includes, but is not limited to, alkyl (e.g., octyl-, nonyl-, decyl-, undecyl-, dodecyl-, tridecyl-, or tetradecyl-) esters.

[0065] Polysorbate surfactant Polysorbate surfactants may be used in the pharmaceutical compositions of the present invention. Polysorbate surfactants are oily liquids derived from PEGylated sorbitan esterified with fatty acids. Common trade names for polysorbates include Alkest, Canarcel, and Tween. Polysorbate surfactants include, but are not limited to, polyoxyethylene 20-sorbitan monolaurate (TWEEN® 20), polyoxyethylene (4)-sorbitan monolaurate (TWEEN® 21), polyoxyethylene 20-sorbitan monopalmitate (TWEEN® 40), polyoxyethylene 20-sorbitan monostearate (TWEEN® 60), and polyoxyethylene 20-sorbitan monooleate (TWEEN® 80).

[0066] Viscosity improver Viscosity improvers may be used in the pharmaceutical compositions of the present invention formulated for intranasal administration. Viscosity improvers that may be used in accordance with the present invention include, but are not limited to, cellulose derivatives, carbomer (Carbopol), gum, and hyaluronic acid (hyaluronic acid salt), dextran, polyvinyl alcohol, polyacrylic acid, povidone, polyethylene glycol, polyol (e.g., glycerol), propylene glycol, and chitosan. Particularly preferred cellulose derivatives are one or more of the following: high molecular weight carboxymethylcellulose ("CMC") blend, low molecular weight CMC blend, medium molecular weight CMC blend, sodium CMC (low viscosity), methylcellulose, methylcellulose 4000, hydroxymethylcellulose, hydroxypropylcellulose ("HPC"), high molecular weight hydroxypropyl methylcellulose blend ("HPMC"), hydroxypropyl methylcellulose 2906, high molecular weight carboxypropyl methylcellulose blend ("CPMC"), hydroxyethylcellulose, or hydroxyethylcellulose, and hyaluronic acid. In certain embodiments, the viscosity improver is sodium CMC, which is preferably combined with a polyol selected from the group consisting of mannitol, xylitol, sorbitol, isosorbide, erythritol, glycerol, maltitol, and combinations thereof.

[0067] Isotonic agent In the pharmaceutical compositions of the present invention, isotonic agents may be used to adjust the tonicity of the liquid pharmaceutical composition. Tonicity is generally related to the osmotic pressure of a solution and is typically evaluated in relation to that of human serum. The pharmaceutical composition (e.g., pharmaceutical dosage form) may contain an isotonic agent to increase the molal osmotic concentration. Non-limiting examples of isotonic agents include substantially neutral buffers (e.g., phosphate-buffered saline, Tris buffer, or extralymphatic fluid), dextrose, mannitol, trehalose, sucrose, sorbitol, glycerin (also known as glycerol), potassium chloride, and sodium chloride (e.g., as hypertonic, isotonic, or hypotonic saline), as well as amino acids (e.g., arginine, glycine, ornithine, lysine, histidine, glutamic acid, aspartic acid, isoleucine, leucine, alanine, phenylalanine, tyrosine, tryptophan, methionine, serine, and proline). The pharmaceutical composition (e.g., pharmaceutical dosage form) contains a sufficient amount of isotonic agent to administer the hypertonic pharmaceutical dosage form to the target.

[0068] cushioning agent In some embodiments, the pharmaceutical composition includes a buffer. The buffer may be included in the pharmaceutical composition to increase the stability of the composition by maintaining a certain pH range. The buffer may improve the performance of the composition as absorbed by the target. Furthermore, the buffer may act to increase the solubility of the composition. The buffer may increase the solubility of a drug by maintaining high drug solubility within a certain pH range, preferably pH 6-8. Buffers that may be used according to the present invention include, but are not limited to, potassium hydroxide, arginine, and lysine. One or more components of the pharmaceutical composition (e.g., potassium hydroxide, arginine, and lysine) can act as counterionic species in the buffer, and bumetanide also functions as a buffer. The buffer may be added to the pharmaceutical composition depending on whether the administration method requires the maintenance of a specific pH range.

[0069] Preservatives In some embodiments of the pharmaceutical composition, a preservative is included as part of the pharmaceutical composition to increase the stability and / or shelf life of the pharmaceutical composition. The preservative may be in the form of, for example, an antioxidant, an antimicrobial agent, or a chelating agent. Antioxidants may be added to the pharmaceutical composition to prevent oxidation of other components in the composition that may be oxidation-sensitive in the presence of oxygen or sunlight. Antimicrobial agents may be included in the pharmaceutical composition to prevent contamination of the pharmaceutical composition by microorganisms. Chelating agents may be added to the pharmaceutical composition to bind to the pharmaceutically active ingredient, protect it from degradation, and increase its stability. Preservatives that may be used according to the present invention include, but are not limited to, benzyl alcohol, benzoic acid, and ethylenediaminetetraacetic acid (EDTA).

[0070] Permeation enhancer In some embodiments of the pharmaceutical composition for intranasal administration, a permeabilis enhancer may be included in the formulation to increase the intranasal bioavailability of bumetanide. Examples of permeabilis enhancers that may be used in the pharmaceutical composition of the present invention include alcohol, aprotinin, benzalkonium chloride, benzyl alcohol, capric acid, ceramide, cetylpyridinium chloride, chitosan, cyclodextrin, deoxycholic acid, glycocholic acid, decanoyl, dimethyl sulfoxide, glyceryl monooleate, glycoflor, glycosylated sphingosine, glycylretinic acid, 2-hydroxypropyl-P-cyclodextrin, laureth-9, lauric acid, lauroyl carnitine, sodium lauryl sulfate, lysophosphatidylcholine, menthol, poloxamer 407 or F68, poly-L-arginine, polyoxyethylene-94 auryl ether, isopropyl myristate, isopropyl palmitate, lanolin, and linoleic acid. Examples include, but are not limited to, combinations thereof, of sucrose, medium-chain triglycerides (MCTs), menthol, myristic acid, myristyl alcohol, oleic acid or its salts, oleyl alcohol, palmitic acid, polysorbate 80, propylene glycol, polyoxyethylene alkyl ethers, polyoxylglycerides, pyrrolidone, quillaja saponin, salicylic acid, sodium salts, β-sitosterol bD-glucoside, sucrose cocoate, taurocholic acid, taurodeoxycholic acid, taurodihydrofusidic acid, thymol, tricaprylin, triolein, and alkyl saccharides, as well as dodecyl maltoside, dodecyl-D-maltoside, tetradecyl maltoside, tetradecyl-bD-maltoside, and sucrose dodecanoate. Certain permeation enhancers, including but not limited to glycerides, alkyl saccharides, ester saccharides, polyglycolated glycerides, and polysorbate surfactants, may also function as surfactants (solubilizers) for bumetanide.In certain embodiments, the permeation enhancer used in the pharmaceutical composition of the present invention is selected from tetradecyl-β-D-maltoside, soybean lecithin, lecithin (E80) distearoylglycerol-3-phosphatidylamine, L-α-phosphatidylethanolamine, and bis(2-ethylhexyl)amine.

[0071] Medication regimen The drug regimen used in the treatment methods described herein may vary depending on many factors, such as the recipient's age, health status, and weight, the nature and severity of the edema, and the frequency and type of concomitant treatments, if any. Those skilled in the art can determine the appropriate dosage based on the above factors. The compounds used in the methods described herein may initially be administered in a preferred dosage, and the dosage may be adjusted as needed according to the individual response. Generally, preferred doses of bumetanide according to the present invention are in the range of 0.5 to 10 mg of bumetanide (e.g., 0.5, 2.0, and 5 mg) in 1 to 4 doses over 1 to 4 hours until the patient is no longer in an edematous state. Four doses of the pharmaceutical composition at 100 μL per dose may be delivered to the subject in less than 1 hour. Alternatively, two doses at approximately 100 μL per dose may be delivered to the subject, followed by two more doses at approximately 100 μL each at approximately 30 to 60 minutes later. Bumetanide may be administered to the patient at the onset of edematous symptoms. Alternatively, bumetanide may be administered to a patient after previously administered oral diuretics have failed to treat edema and symptoms persist. If oral diuretics are ineffective, the patient may be limited to an initial dose of less than 5 mg of bumetanide over at least one or two hours to further reduce the risk of excessive diuresis, which can manifest as dehydration and hypotension in subjects with excessive diuresis.

[0072] For sustained-release formulations administered as subcutaneous depots, preferred doses of bumetanide according to the present invention are in the range of 0.75 to 10 mg of bumetanide in 1 to 2 doses over 1 to 5 days (e.g., 1.5±0.5, 2.5±0.5, 3.5±0.5, 4.5±0.5, 5.5±0.5, 6.5±0.5, 7.5±0.5, 8.5±0.5, and 9.5±0.5 mg). Subcutaneous depots of bumetanide may be administered to patients to prophylactically treat edema symptoms and reduce the risk of readmission.

[0073] Oral diuretics This disclosure features methods and compositions for treating edema unresponsive to oral diuretics. Oral diuretics have long been used to alleviate fluid retention, a characteristic of congestive heart failure. Aggressive use of diuretics can reduce hospitalization and improve exercise capacity, even in people using ACE inhibitors. Diuretics act on the kidneys to remove excess salt and water from the body. They reduce fluid accumulation in the lower extremities, abdomen, and lungs, lower blood pressure, and improve circulatory efficiency. Side effects of diuretics include hypotension, dehydration, and renal dysfunction. They can also induce gout, increase blood glucose and triglyceride, LDL, and overall cholesterol levels, and deplete the vitamin B thiamine. Many diuretics are available, generally classified as thiazide and loop diuretics, and are used with or alone potassium-sparing agents. An important point to note is that recent studies have revealed an increased hospitalization rate in patients using nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with diuretics. Common NSAIDs include aspirin, ibuprofen, and naproxen. Thiazides such as hydrochlorothiazide (HydroDIURIL, Esidrix), chlorothiazide (Diuril), metrazone (Zaroxolyn), and chlorthalidone (Hygroton) are usually prescribed for patients with mild heart failure and good renal function.

[0074] Loop diuretics such as furosemide (Lasix), bumetanide (BumeX), and ethacrine (Edecrine) are generally used for more severe heart failure, especially in cases of impaired renal function. Loop diuretics are administered intravenously to treat pulmonary edema and acute congestive heart failure, and thiazide and loop diuretics may be administered simultaneously. Even after standard treatment for congestive failure, fluid may remain in the lungs, limiting the patient's ability to function normally. In one study, patients with this condition were treated very aggressively with furosemide to further reduce fluid, but no improvement was observed. Another method using filtration techniques proved more effective.

[0075] Potassium loss is a major concern with diuretic use. Unless a patient is taking ACE inhibitors to raise potassium levels, a physician may recommend potassium supplements or the combination of potassium-sparing diuretics such as spironolactone (Aldactone), amiloride (Midamor), and triamterene (Dyrenium) with thiazide or loop diuretics. All patients taking diuretics, with or without potassium-sparing medications, should have their blood potassium levels monitored regularly.

[0076] The methods of the present invention may include the bumetanide therapy described herein, used for managing patient edema in combination with oral diuretics such as loop diuretics, potassium-sparing diuretics, thiazides, or other oral diuretics. Typically, bumetanide, administered intranasally or subcutaneously, is given to patients who have previously taken oral diuretics, for example, within the past hour, two hours, or four hours, for edema known to be refractory to oral diuretics. For example, a patient may have taken oral diuretics such as potent loop diuretics (e.g., furosemide, ethacrine, torsemide, and bumetanide), thiazides (e.g., hydrochlorothiazide), carbonic anhydrase inhibitors (e.g., acetazoleamide and metazolamide), potassium-sparing diuretics (e.g., the aldosterone antagonist spironolactone, and the epithelial sodium channel blockers amiloride and triamterene), and / or calcium-sparing diuretics. After successfully treating the edema using the method of the present invention, the patient can continue their usual regimen of oral diuretics.

[0077] Selection of target The methods and compositions of the present invention may be used in patients at risk of edema in general. Edema may be, for example, pectoral edema, peripheral edema, or pulmonary edema (e.g., pulmonary edema). The methods and compositions of the present invention may be used when the subject is a mammal. Specifically, the subject may be a dog if the dog requires veterinary care. Furthermore, the subject may be a human. Subjects that may be treated using the methods described herein are those with a diagnosis of congestive heart failure. Congestive heart failure (CHF) is characterized by the heart's inability to produce sufficient cardiac output to meet the body's needs. Patients with CHF experience signs and symptoms of vascular and space volume overload, such as shortness of breath, tachycardia, fluid retention in the lungs, and edema, along with indicators of insufficient tissue perfusion, such as fatigue and / or poor exercise tolerance. Patients who may be treated include those with heart failure diagnosed by standard and conventional diagnostic procedures known in the art (e.g., electrocardiography (ejection fraction), radionuclide imaging, magnetic resonance imaging, computed tomography, cardiac catheterization and angiography, myocardial biopsy, and / or assessment of blood levels of atrial natriuretic peptide (ANP) and / or B-type natriuretic peptide (BNP)).

[0078] Patients who may be treated are those currently experiencing symptoms known to be associated with congestive heart failure, such as shortness of breath (e.g., respiratory distress), fatigue, weakness, peripheral edema, or fluid overload. Patients may be taking a daily dose of oral diuretics such as loop diuretics, potassium-sparing diuretics, or thiazides to reduce fluid overload and edema along with any one of the symptoms associated with congestive heart failure.

[0079] Subjects who can be treated using the methods described herein are experiencing symptoms of renal insufficiency caused by reduced blood flow, such as decreased urine output, swelling of the lower extremities, ankles, feet, or abdomen, shortness of breath, or fatigue, resulting from fluid overload as a consequence of renal insufficiency. Subjects may experience fluid overload to a level where intestinal motility is impaired, the normal absorption of ingested nutrients is hindered, gastrointestinal absorption is insufficient, and a reduction in the bioavailability of orally administered pharmaceutical compositions is exacerbated.

[0080] Subjects treated using the methods described herein may experience symptoms of refractory edema as a result of congestive heart failure, as reduced bowel motility may prevent oral diuretics from effectively inducing diuresis and removing excess fluid. As a result of persistent edema symptoms such as fatigue, shortness of breath, and swelling of the extremities and abdomen, subjects may seek hospitalization for intravenous administration of diuretics, and thus be at risk of renal failure.

[0081] Subcutaneous administration of sustained-release depot formulations can be used to treat patients prophylactically, allowing them to receive reliable diuretic benefits over several days without complications. Sustained-release therapy may be used to treat patients at risk of readmission. For example, after hospitalization for the treatment of congestive heart failure, a patient may receive treatment after discharge that achieves diuresis over an extended period (e.g., several days) and alleviates symptoms such as shortness of breath, fatigue, and edema. [Examples]

[0082] The following examples are provided to those skilled in the art to explain how the compositions and methods described herein may be used, prepared, and evaluated, and are intended purely to illustrate the present disclosure and not to limit the scope of what the inventors consider to be their disclosure.

[0083] Example 1. Water solubility of bumetanide in the presence and absence of a surfactant. 10 mg of bumetanide in its free acid form was added to 1 mL of deionized water and mixed using a vortex and sonicator. The solution was filtered using a 0.22 μm nylon syringe filter. 100 μL of the filtered bumetanide solution was added to 900 μL of deionized water, and the concentration of bumetanide in solution was analyzed by HPLC. The concentration of bumetanide was determined using standard curves generated by bumetanide solutions of known concentrations. Most of the bumetanide in its free acid form was not water-soluble. Therefore, 1 mL of deionized water containing 1.0%, 0.5%, or 0.1% of the surfactant tetradecyl-β-D-maltoside was added to 10 mg of bumetanide. The bumetanide was then solubilized using a vortex and sonicator, and subsequently filtered using a 0.22 μm nylon syringe filter. 100 μL of filtered bumetanide solution was added to 900 μL of deionized water, and the concentration of bumetanide in the solution was analyzed using HPLC. The obtained bumetanide concentrations are recorded in Table 1. [Table 1] The addition of surfactants improved the amount of bumetanide that could be soluble in water; however, these results clearly indicate that bumetanide, when not in salt form, has very low water solubility despite the presence of surfactants.

[0084] Example 2. Solubility of bumetanide salt 20 mg of bumetanide in acid form was weighed and dissolved in 1 mL of deionized water by vortex mixing to prepare a low pH bumetanide solution. A fixed amount of base was added to this low pH bumetanide solution and mixed for 2 minutes using a vortex mixer to prepare a solution with a pH suitable for nasal administration. As the pH increased, the bumetanide salt formed in situ partially precipitated, resulting in a saturated solution of the salt form. Next, the saturated solution was filtered through a 0.22 μm filter to remove all of the precipitated bumetanide salt. The filtrate was collected and its pH was measured. Aliquots of the saturated solution were assayed for bumetanide by HPLC to determine the maximum concentration achievable in salt form in water at a nearly neutral pH.

[0085] This procedure was repeated for various bases, including arginine, lysine, potassium, sodium, glycine, histidine, and the cationic lipophilic surfactants soy lecithin, distearoylglycerol-3-phosphatidylamine, L-α-phosphatidylethanolamine, and bis(2-ethylhexyl)amine, to determine the maximum solubility of each bumetanide salt solution. To determine the maximum solubility of each bumetanide salt, the solution concentrations of bumetanide in each bumetanide salt form are recorded in Table 2. [Table 2] TIFF0007885121000003.tif122170

[0086] These solubility data clearly show that the highest solution concentrations of bumetanide salt are achieved when either arginine or potassium acts as the base, with maximum concentrations measured at 12.6 mg / mL and 20.19 mg / mL, respectively. The solubility of bumetanide salt increased significantly when potassium hydroxide acted as the base, compared to other bases such as sodium hydroxide, which measured a solubility of 6.59 mg / mL, as shown in Figure 1. Surprisingly, the solubility of bumetanide salt increased significantly when arginine acted as the base, compared to other amino acid bases such as lysine, which measured a solubility of 7.08 mg / mL. As shown in Figure 1, the potassium salt of bumetanide has the lowest mass load on transmucosal formulations, achieves the highest solubility at a pharmaceutically desirable pH (e.g., pH 6-8), and yields concentrations (as shown in animal studies) that can provide PK performance similar to that induced by IV injection without the complications and risks associated with IV administration.

[0087] Example 3. Solubility of bumetanide in different pH buffers. The solubility of bumetanide was evaluated in various pH buffers. 10 mg of bumetanide was weighed and placed in a 3 mL glass vial. 2 mL of buffer with the desired pH was added to this vial. The solution was then sonicated at room temperature (25°C) for 2 hours, followed by overnight rotation. The solution was then filtered through a 0.2 μm nylon syringe filter, and the first 0.5 mL was discarded. The filtrate was then diluted 10-fold, and at least 0.5 mL was aliquoted into HPLC vials. 1 M sodium citrate was used for F1-F4, and 1 M sodium phosphate buffer was used for F5-F9. The measured concentrations of bumetanide in each pH buffer are summarized in Table 3. [Table 3]

[0088] 1 g of Kolliphor RH40 and 9 g of ethanol were added to a 15 mL Falcon tube. The solution was mixed and vortexed as needed. 50 mg of bumetanide salt was weighed and transferred to the solution, and the solid was dissolved by mixing, vortexing, or sonication as needed to prepare a 5 mg / g stock solution. Once all the solid was dissolved, an additional 10 mg of bumetanide salt was added. 1.0 g of this stock solution was added to a 10 mL glass vial using a 0.22 μm nylon syringe filter. The pH of the solution was measured and adjusted with 0.1 N HCl or NaOH to within ±0.1 of the target pH. If no precipitate was found in the vial, 0.5 mL of each formulation was aliquoted into 1.5 mL HPLC vials, to prepare a total of 20 vials. If a precipitate was present, the solution was transferred to a 10 mL syringe along with the precipitate and filtered through a 0.45 μm filter. The filtrate was collected and aliquoted into 1.5 mL HPLC vials containing 0.5–1.0 mL of each formulation, resulting in a total of 15 vials. Each vial was crimped. Four vials were placed at 40°C, four at 50°C, and four at 60°C. Two vials were placed at -80°C as a backup. The last vial was used for T0 assay analysis. The pH and concentration of each formulation were measured on the day of storage at the indicated temperatures, as well as on days 3, 7, and 10. The results are summarized in Table 4. The recovery rate of bumetanide was also measured on these days. The results are summarized in Table 5. [Table 4] TIFF0007885121000006.tif170170 [Table 5]

[0089] Example 4. Emulsion formulation of bumetanide salt. To increase the adsorption of bumetanide during intranasal administration, an emulsion formulation of bumetanide salt was developed. Glycerol (2.25 wt%), medium-chain triglycerides (MCT) (10 wt%), and lecithin (E-80) (1.2 wt%) were weighed and dissolved by sonication for 30 minutes. Subsequently, 86 wt% deionized water was added and further mixed until a clear, colorless solution was obtained, producing the FEV-1 product shown in Table 6. FEV-2 was produced by weighing MCT and lecithin, placing them in a tare-filled 50 mL Falcon tube, and sonicating at 50°C for approximately 30 minutes to ensure all solids were dissolved. As shown in Table 6, when deionized water was mixed with the solution, a white emulsion was obtained. [Table 6] Emulsions FE-1 to FE-7 were prepared using the FE-V1 product with various emulsifiers. The FE-V2 product was used to prepare the FE-8 emulsion. These emulsions were prepared by weighing bumetanide, an emulsifier (e.g., polysorbate 80, polysorbate 20, or PEG400), and, in the case of FE-3 to FE-6, benzyl alcohol, as shown in Table 7. Each emulsion formulation was diluted to 1000 mg by using the FEV-1 solution and BB for 30 seconds. The appearance was visually inspected and the pH was measured. For FE-6, the pH was adjusted to 5.7 using 1N NaOH, and for FE-7, the pH was adjusted to 6.5 using 1N NaOH. Next, each emulsion formulation was filtered using a 0.22 μm filter syringe. The obtained filtrates were analyzed for bumetanide concentration and impurities using HPLC. [Table 7] As shown in Table 8, the highest concentration of bumetanide was obtained with emulsion formulation FE-6, which had a bumetanide concentration of 6.55 mg / g. [Table 8]

[0090] To test the stability of FE-9 at various temperatures, FE-9 was filled into multiple spray vials and placed in stability chambers at 2–8°C. Some vials were placed in a 25°C stability chamber, and others were kept at -20°C. The remaining vials were used to measure initial concentration and impurities. After 1, 2, and 4 weeks, the samples were removed from the stability chambers and their appearance was visually inspected. Next, the samples were prepared for HPLC for assay and impurity analysis. At this time, the pH and molar osmotic pressure of the formulations were measured. The molar osmotic pressure at T0 was 264 Osm, and the viscosity was 1.3 cp at 10 rpm. The results of the stability study are summarized in Table 8. Similarly, the working dose was measured for each sample at the same time point (Table 9). [Table 9] [Table 10] Particle size distribution analysis was performed using dynamic light scattering with a Malvern Panalytical Zetasizer to determine that the average particle size of the FE-9 bumetanide emulsion was less than 200 nm. The FE-9 samples were prepared for analysis by passing the emulsion through a microfluidizer twice prior to the particle size distribution analysis. This process was repeated if the measured average particle size exceeded 200 nm. The average particle size of FE-9 was 112–120 nm, both after 4 weeks of storage at room temperature and at 2–8°C, as shown in Table 10. [Table 11]

[0091] To prepare FE-8, each excipient was weighed into a tare-filled 15 mL Falcon tube (see Table 7) and then diluted to the appropriate volume using FEV-2. The pH was adjusted to 6.0 with 1 N NaOH and vortexed to ensure that no solids were present in the mixture. Sonication was used if necessary. The final pH was maintained at 6.0, and the visible appearance was inspected, the pH was measured, and the molal osmotic pressure was measured. The solution was filtered through a 0.22 μm filter, the filtrate was collected, 1.0 mL was aliquoted into 3 mL glass vials, and the vials were crimped and sealed to prepare a total of 8 vials.

[0092] To test stability at various temperatures, three vials were placed in a stability chamber at 2–8°C, three vials in a stability chamber at 25°C, and two vials at -20°C. The remaining vials were used to measure initial concentration and impurities. After four weeks, the samples were removed from the stability chambers and their appearance was visually inspected. Next, the samples were prepared for HPLC for assay and impurity analysis. At this time, the pH and molar osmotic pressure of the formulation were measured. Before measuring the molar osmotic pressure, 0.2 mL of the formulation was diluted with 1.8 mL of deionized water. Table 11 summarizes the concentration and recovery rate of bumetanide obtained after two weeks for samples stored at various temperatures. The molar osmotic pressure was measured at T0 with a dilution factor of 10 to 5 mOsm. [Table 12]

[0093] Example 5. Nanoemulsion formulation of bumetanide salt. To improve transmucosal absorption, a nanoemulsion formulation of bumetanide salt was developed. To prepare the nanoemulsion, first, as shown in Table 12, glycocholic acid (46.8 mg) was weighed and suspended in sterile water for injection (SWFI) (600 mg) using a vortex mixer to produce the FNEV-1 formulation. 10 N NaOH (10 μL) was added to this solution and mixed until the solution became clear. Soy lecithin (PL90 G) and benzyl alcohol were added as shown in Table 12 and completely dissolved using a vortex mixer and sonicator as needed. Deionized water was added as shown in Table 12 to bring the solution to its final weight and mixed. The pH of this solution was measured and adjusted to a final pH of 7.0, and then the solution was shaken overnight in a shaker to produce the FNEV-1 product. [Table 13]

[0094] Using the FNEV-1 product, FNE-1 nanoemulsions with various pH values ​​were prepared. Bumetanide nanoemulsions were prepared by weighing bumetanide, dissolving it in FNEV-1 solution using a vortex mixer, and adjusting the pH to 5.0 or 6.0 using 1.0N NaOH or 1.0N HCl, as described in Table 13. The solutions were allowed to stand overnight, after which the pH was measured. The solutions were filtered using a 0.22 μm centrifuge filter. The filtrate was then diluted 20 times so that 0.25 mL of filtrate was diluted to a final volume of 5 mL, mixed using a vortex mixer, and then the solution was transferred to the HPLC step. [Table 14] As shown in Table 14, the concentrations of bumetanide in FNE-1 solutions with final pH values ​​of 5.3, 5.6, and 6.1 were measured using HPLC by comparison with solutions of known bumetanide concentrations. The FNE-1 formulation with a pH of 6.1 showed the highest bumetanide solution concentration at a calculated concentration of 10.1 mg / mL. The results indicate that the bumetanide solution concentration more than doubles when the pH of the nanoemulsion changes from 5.3 to 6.1, and therefore, a pH of approximately 6 is optimal for bumetanide solution concentrations of 5 mg / mL or higher. [Table 15] The average particle size of FNE-1 bumetanide nanoemulsions was determined by dynamic light scattering analysis using a Malvern Panalytical Zetasizer. The average particle size of FNE-1 at pH 6.0 was 9–11 nm for both storage at room temperature and storage at 2–8°C for 4 weeks, as shown in Table 15. [Table 16]

[0095] To test stability at various temperatures, several filled spray vials were placed in a stability chamber at 2–8°C, several vials in a stability chamber at 25°C, and several vials at -20°C. The remaining vials were used to measure initial concentration and impurities. After 1 week, 2 weeks, and 4 weeks, the samples were removed from the stability chambers and their appearance was visually inspected. Next, the samples were prepared for HPLC for assay and impurity analysis, and the pH was also measured at this time. After 2-fold dilution, the molar osmotic pressure of the formulation was measured to be 140 Osm, and the viscosity was 6 cp at 10 rpm. The concentrations and recoveries of bumetanide obtained from samples stored at various temperatures over 4 weeks are summarized in Table 16. Working doses were also measured for these samples. The obtained measurements are summarized in Table 17. [Table 17] [Table 18]

[0096] Example 6. Stability of bumetanide salt The stability of arginine and potassium bumetanide salts stored at either 2–8°C or 25°C for four weeks was monitored during the relevant period. Bumetanide salt solutions were evaluated based on pH, bumetanide concentration in solution, assay recovery, and the presence of impurities (see Tables 18 and 19). [Table 19] [Table 20] For bumetanide arginine salt, the initial pH was 7.0, and after 4 weeks, the pH was 7.0 and 7.1 for samples stored at 5°C and 25°C, respectively. The initial concentration of bumetanide in solution was determined to be 5.07 mg / mL, and after 4 weeks, the concentrations were 4.89 mg / mL and 4.97 mg / mL for samples stored at 5°C and 25°C, respectively. The assay recovery was 100% initially, and after 4 weeks, it was 97.8% for both samples stored at 5°C and 25°C. Finally, no impurities were detected in any sample subjected to HPLC, either initially or after 4 weeks.

[0097] These data, as shown in Table 18, indicate that bumetanide arginine salt is stable for up to 4 weeks at either 5°C or 25°C. Furthermore, as shown in Table 19, these data indicate that bumetanide potassium salt is stable for up to 4 weeks at either 5°C or 25°C.

[0098] Example 7. Method for formulating pharmaceutical formulations of bumetanide arginine salt, bumetanide potassium salt, and bumetanide lysine salt. To prepare a pharmaceutical formulation of bumetanide arginine salt for intranasal administration to patients with congestive heart failure, first, 0.1 g of sodium carboxymethylcellulose was dissolved in 100 mL of deionized water and mixed to make a 0.1% sodium carboxymethylcellulose solution, which was filtered through a 0.2 μm nylon filter. Mannitol, benzyl alcohol, and 98.3% bumetanide were weighed out in amounts of 4 g, 0.5 g, and 0.5 g, respectively, and mixed. To this mixture, approximately 16 g of the 0.1% sodium carboxymethylcellulose solution was added. To this solution, 0.45 g of L-arginine was added and mixed using a vortex mixer until the solution became clear. Next, the pH of the solution was adjusted using 1.0 N HCl to reach a final pH of 7.0. The formulations of bumetanide arginine salt in both 1 g and 20 g scales were recorded in Table 20. [Table 21] [Table 22] [Table 23]

[0099] 10g batches of bumetanide arginine salt (F42), bumetanide potassium salt (F43), and bumetanide lysine salt (F44) were prepared for intranasal administration to patients with congestive heart failure according to Table 21. 0.1g of CMC sodium was added to a 250mL beaker using a stirring rod, followed by 100mL of deionized water. The mixture was thoroughly mixed to obtain a 0.1% CMC-Na solution. Bumetanide and disodium edetate dihydrate were weighed and placed in a tare-filled 15mL Falcon tube. Approximately 8g of the 0.1% CMC-Na solution was added to this tube and mixed. To this solution, the amounts of arginine, KOH, or lysine listed in Table 21 were added and vortexed until the solution became clear. An appropriate amount of base was added and vortexed until a clear solution was obtained. At this point, the pH was measured and adjusted to pH 7.0 if necessary. A total weight of 10 g of 0.1% CMC-Na solution was prepared and thoroughly mixed. The molal osmotic pressure was tested using approximately 1 mL of the solution. If necessary, the molal osmotic pressure was adjusted to approximately 290 ± 10 mOsm / kg with either NaCl or mannitol. After adjusting the molal osmotic pressure, assays and impurity analysis were performed, and the viscosity and spray capacity of the solution were measured. The measured values ​​for solubility, pH, and molal osmotic pressure are summarized in Table 22. [Table 24]

[0100] 100g batches of bumetanide arginine salt (F69) and bumetanide potassium salt (F70) were prepared for intranasal administration to patients with congestive heart failure according to Table 23. 0.3g of CMC sodium was added to a 500mL beaker using a stirring rod. 300mL of deionized water was added and mixed thoroughly to obtain a 0.1% CMC-Na solution. This mixture was then filtered through a 0.2μm nylon filter.

[0101] For the arginine salt of bumetanide (F69), bumetanide, benzyl alcohol, and mannitol were weighed and placed in a tare-weighted 125 mL Erlenmeyer flask using a stirring rod. Approximately 75 g of 0.1% CMC-Na solution was added to this flask and mixed. An appropriate amount of L-arginine was added, and the solution was vortexed until it became clear. At this point, the pH was measured, and if necessary, the pH was adjusted to 7.0. An appropriate amount of 0.1% CMC-Na solution was added to bring the total weight to 100 g, and the solution was thoroughly mixed.

[0102] For the potassium salt of bumetanide (F70), CMC sodium was weighed and placed in a suitable beaker while stirring. A certain amount of deionized water was added, and the solution was thoroughly mixed to produce a 0.1% CMC-Na solution. Next, this solution was filtered through a 0.2 μm nylon filter. Then, bumetanide, benzyl alcohol, and mannitol were weighed and added to the primary formulation container while stirring. Approximately 3 / 4 of the 0.1% CMC-Na was added to this container and mixed or stirred. An appropriate amount of 1N KOH was slowly added dropwise to this solution, and the mixture was stirred until the solution became clear. The clear solution was equilibrated until a stable pH was achieved in the pH range of 6.3 to 7.3. The pH was then measured and readjusted to 7.0 using 1N HCl if necessary. A sufficient amount of 0.1% CMC-Na solution was added and mixed thoroughly to bring the solution to the appropriate weight. The molal osmotic pressure was measured to confirm that it was within the specified range.

[0103] Both F69 and F70 were filtered through a 0.2 μm nylon filter. 3 mL of each solution was aliquoted into 10 mL nasal spray bottles, preparing a total of 10 bottles. One vial of each formulation was used for the following tests: appearance, pH, assay / impurity, molal osmotic concentration, and working dose. The results are summarized in Table 24. [Table 25]

[0104] Example 8. Analysis of lead formulations over a 5-month period. The stability of bumetanide arginine salt (F69), bumetanide potassium salt (F70), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1) over a 5-month period when stored at 25°C was investigated. One sample of F70 was opened from the bottle and observed for 10 months to test its stability. The appearance of each sample was recorded and summarized in Table 25. [Table 26] The concentrations of each of these formulations after 5 months at 25°C, and one sample of F69 stored for 10 months, were measured using HPLC analysis. The obtained concentrations are summarized in Table 26. Furthermore, the assay recovery rates over 5 months or 10 months were calculated (Table 27). [Table 27] [Table 28] The composition of each bumetanide potassium salt preparation is summarized in Table 28, along with the pH measurement, appearance, molar osmotic pressure concentration, and assay recovery rate for each preparation. [Table 29] TIFF0007885121000032.tif122170 Using dynamic light scattering analysis with Malvern Panalytical's Zetasizer, the average particle size distribution of bumetanide emulsions FE-9 and FNE-1 was determined. The average particle sizes of FE-9 and FNE-1 stored at room temperature for 5 months are shown in Table 29. [Table 30]

[0105] Under 25°C storage conditions, the F69 assay after 5 months showed a concentration of 5.13 mg / g, which was close to the T0 assay's concentration of 4.98 mg / g. The F70 assay after 5 months showed a concentration of 5.16 mg / g, which was close to the T0 assay's concentration of 4.89 mg / g. After 10 months, the F70 assay showed a concentration of 5.21 mg / g, which was close to the T0 assay's concentration of 4.89 mg / g. After 10 months, the F70 assay recovery rate was approximately 106.5% compared to T0. This may be due to the fact that the sample was taken from an opened (used) container, which may be the cause of water loss over time when stored at 25°C. The claim rate (%) after storage at room temperature for 10 months (10M) was 104%. After 5 months, the FE9 assay measured a concentration of 4.67 mg / g, which was close to the T0 assay's concentration of 4.59 mg / g. The FNE-1 assay measured 4.83 mg / g, which was close to the T0 assay's concentration of 5.09 mg / g. No impurities were observed in any of the four formulations after storage at 25°C for 5 months. For each of the F69, F70, FE-9, and FNE-1 formulations, the assay recovery rate relative to T0 was all over 94% after 5 months at 25°C. No particles, precipitates, or phase separation were observed in any of the four formulations. These data indicate that all four formulations were stable for 5 months when stored at 25°C. Furthermore, after 5 months, the particle size distributions of both FE-9 and FNE-1 were close to those of T0 or T=1W.

[0106] Example 9. Intranasal administration of arginine or potassium salt of bumetanide to a patient suffering from congestive heart failure accompanied by severe edema due to insufficient gastrointestinal absorption. According to the methods described herein, physicians in the art can treat patients, such as human patients, to reduce or alleviate symptoms of edema resulting from congestive heart failure. For this purpose, physicians in the art have patients self-administer bumetanide potassium salt or arginine salt. Bumetanide potassium salt or arginine salt is administered by patients experiencing symptoms of congestive heart failure, such as shortness of breath, fatigue, or edema, which have not been reduced by the patient's typical daily dose of oral diuretics. In this case, the patient administers bumetanide potassium salt or arginine salt intranasally. Typical doses are administered based on body weight and are in the range of approximately 0.5 to 10 mg of bumetanide potassium salt or arginine salt in 12 hours, and should not exceed 10 mg of bumetanide potassium salt or arginine salt in 12 hours without consultation with a physician in the art.

[0107] Bumetanide potassium salt or arginine salt is administered in 1, 2, 3, or 4 doses over a 4-hour period. Each dose consists of 100–150 μL of buffer containing bumetanide potassium salt or arginine salt at a concentration of approximately 5–25 mg / mL. Each unit dose contains approximately 0.5–2.5 mg of bumetanide potassium salt or arginine salt, so that the total amount of the four doses does not exceed 10 mg of the pharmaceutical composition. The bumetanide potassium salt or arginine salt is administered to the patient in an amount sufficient to treat the symptoms of congestive heart failure, as self-assessed by the patient, including reduction of swelling, increased urine output, and reduction of shortness of breath. The intranasal pharmaceutical composition is administered by the patient, and the patient maintains a supine position for at least 30 minutes after administration of the pharmaceutical composition.

[0108] Example 10. A sustained-release formulation for subcutaneous administration. The methods and compositions described herein may provide subcutaneous formulations that release bumetanide to patients over an extended period as a long-acting diuretic (e.g., 8-hour, 12-hour, 24-hour, 36-hour, 48-hour, 3-day, or 5-day diuretics). Sustained-release formulations are used to treat patients at risk of readmission after treatment for congestive heart failure. The use of long-acting diuretics allows such patients to be treated on an outpatient basis rather than being readmitted for edema-related symptoms. Sustained-release formulations are administered as subcutaneous depots (e.g., depots formed by emulsion) and released from the subcutaneous depot over an extended period.

[0109] The sustained-release formulation is formed from an aqueous emulsion of bumetanide arginine salt with a bumetanide concentration of approximately 7–15 mg / mL. Each dose consists of approximately 100–300 μL of aqueous emulsion, and the dosage level may be determined by the patient's weight and health condition. This emulsion is a mixture formed from glycerol (approximately 2.25 wt%), medium-chain triglycerides (MCTs) (approximately 10 wt%), and lecithin (E-80) (approximately 1.2 wt%).

[0110] Subcutaneous administration of the depot formulation allows patients to receive reliable diuretic benefits over several days without complications. As a result of sustained-release subcutaneous bumetanide arginine emulsion, patients at risk of readmission after hospitalization for the treatment of congestive heart failure will receive treatment after discharge to achieve long-term diuresis and alleviate symptoms such as shortness of breath, fatigue, and edema.

[0111] Example 11. Preparation of bumetanide salt To prepare bumetanide arginine salt, 1.00 g of bumetanide and 0.53 g of arginine were added to a mortar. Approximately 15 mL of 200 proof ethanol, diluted to 50% with deionized water, was added to the arginine and bumetanide in the mortar. A slurry was prepared by manually grinding the mixture into granules using a pestle for approximately 30 minutes. The resulting slurry was transferred to a tare-filled beaker. Next, the slurry was vacuum-dried overnight at -20°C. After vacuum drying for more than 24 hours, a loose, fluffy white solid was obtained, with a bumetanide-to-arginine molar ratio of 1:1.1, as shown in Table 31. All chemicals used in the production of bumetanide arginine salt are listed in Table 30. [Table 31] [Table 32]

[0112] To prepare the potassium bumetanide salt, 1.0 g of bumetanide was added to a 20 mL glass vial. 5 mL of 200-proof ethanol solution, diluted 50% with deionized water, was added to this vial and mixed by vortexing for approximately 1 minute. To the wet bumetanide, 3.0 mL of 1 N KOH solution was added and mixed by vortexing or using a spatula for approximately 10 minutes to obtain a white slurry. This mixture was frozen at -20°C for approximately 1 hour. The mixture was then vacuum-dried overnight at -20°C. Once dry, the white, fluffy, soft solid potassium bumetanide (with a bumetanide-to-potassium molar ratio of 1:1.1, as described in Table 33) was transferred to a clean glass vial. This potassium bumetanide salt was kept at 2–8°C for formulation preparation. All chemicals used in the production of the potassium bumetanide salt are listed in Table 32. [Table 33] [Table 34]

[0113] Example 12. Effects of intranasal and intravenous administration of bumetanide salt to rabbits. The purpose of this study was to evaluate the pharmacokinetic profiles of bumetanide compound formulations, including bumetanide arginine salt F69, bumetanide potassium salt F70, bumetanide emulsion FE-9, and bumetanide nanoemulsion FNE-1, administered as single intranasal doses to male and female New Zealand white (NZW) rabbits using four different vehicles, compared to administration as a single IV dose. [Table 35]

[0114] A total of eight rabbits were assigned to the study (six males and two females). All rabbits were young adults of the same age and were kept as uniform as possible in weight (approximately 3.0–3.6 kg at the start of medication).

[0115] Since bumetanide is a diuretic, rabbits were given a 40 mL subcutaneous (SQ) injection of lactated Ringer's solution 30 minutes before administration of the bumetanide compound in all events. Two hours after administration, the injection of 40 mL of lactated Ringer's solution was repeated.

[0116] Rabbits were given alternating doses of various bumetanide preparations, allowing approximately 7 days of recovery between each of the events described in Table 35.

[0117] For intranasal administration, each rabbit was held in a supine position, and 50 μL of bumetanide was delivered to each nostril using a displacement pipette, for a total of 100 μL per rabbit. The rabbits were held in a supine position for approximately 60 seconds after administration. After each administration, the success of the administration was confirmed by visual inspection of the pipette tip and the rabbit's nostrils. Only administrations estimated to be at least 80% of the bumetanide were considered acceptable.

[0118] For intravenous administration, a commercially available bumetanide injection (Walgreens, 0.25 mg / mL) was used, and a total of 2 mL per rabbit was administered via the marginal auricular vein over 30 seconds.

[0119] Detailed clinical observations were performed at least once a day, and whenever abnormalities were observed. The nostrils were observed for adverse signs after medication. Further cage-side observations were performed at least once a day by animal care personnel. In addition, urine volume after medication was monitored and diuresis was assessed by observing the animals 30 minutes, 1 hour, and 2 hours after administration. Urine volume was not measured.

[0120] The body weight of each animal was measured before each dose on the day of administration and approximately 72 hours after the last dose. Body weight was provided for pharmacokinetic analysis. On each day of administration, serum was obtained by collecting 600 μL of blood from a central ear artery catheter into an uncoated polypropylene tube before administration and at 2±1, 5±1, 10±2, 15±2, 20±3, 30±3, 45±3, 60±4, 120±5, and 180±5 minutes after administration. Blood samples were centrifuged at 5000 × g for 10 minutes at 4°C. Samples collected outside the designated collection period were not considered protocol deviations; that is, the collection times were set for the purpose of pharmacokinetic analysis. After freezing and storing the serum at -20°C, it was shipped to Climax Laboratories, Inc. on dry ice via FedEx next-day delivery. The concentration of bumetanide in serum samples was quantified by liquid chromatography (LC-MS / MS) combined with tandem mass spectrometry detection. The amount of bumetanide in each drug regimen was quantified by liquid chromatography. The drug regimens and bioavailability calculations for commercially available bumetanide for F69, F70, FE-9, FNE-1, and IV administration are summarized in Tables 37-41, respectively. The bioavailability of each intranasal formulation is summarized in Table 36. [Table 36] [Table 37] [Table 38] [Table 39] [Table 40] [Table 41] [Table 42] All intranasal preparations are rapidly absorbed into the systemic circulation of rabbits. maxThe median time to administration was 5–12.5 minutes. The bumetanide potassium salt preparation F70 showed higher nasal absorption of bumetanide than the arginine bumetanide preparation F69, the bumetanide emulsion preparation FE-9, or the bumetanide nanoemulsion preparation FNE-1, as shown in Figures 2, 3, and 4, and Table 36. The bioavailability of bumetanide showed the same trend in the tested species. In rabbits, systemic exposure after intranasal administration of F70 was generally similar to that after intravenous administration, as shown in Figure 2. The variability of bumetanide in the blood after intranasal administration of F70 was similar to that of intravenous bumetanide. As shown in Figure 2, F70 showed rapid adsorption upon administration, similar to that observed with intravenous bumetanide. Furthermore, bumetanide administered intranasally showed sustained blood concentration levels, as shown in Figures 2 and 3. During this study, all rabbits appeared normal. No abnormal observations regarding the external nostrils were recorded in any animal or event. These formulations were well tolerated by the animals and did not result in death, morbidity, adverse clinical observations or effects on body weight, or visible tissue reactions or inflammatory responses. Animals treated with IV bumetanide and IN bumetanide formulations produced more urine within 2 hours post-administration compared to untreated controls.

[0121] Example 13. Administration of bumetanide salt to dogs. The purpose of this study was to evaluate the pharmacokinetic profiles of various bumetanide formulations, including bumetanide arginine salt (F69), bumetanide potassium salt (F10), bumetanide emulsion (FE-9), and bumetanide nanoemulsion (FNE-1), as shown in Table 42, when administered to male and female beagle dogs as single intranasal or sublingual doses using different vehicles, compared to single IV doses.

[0122] A total of four dogs were assigned to the study (three males, 8-12 kg, and one female, 7-11 kg). Since bumetanide is a diuretic, 100 mL of lactated Ringer's solution was administered subcutaneously (SQ) 30 minutes prior to administration in all events. Approximately two hours after administration, another 100 mL injection was given.

[0123] This study involved administering nine events in two stages (A and B) to the same animals, with a washout period of approximately 48 hours or more between events in each stage, and a rest period of approximately two weeks between stages. Specifically, the events in stage B were initiated approximately two weeks after the completion of event 5. The drug regimens for the events in stages A and B are described in Tables 43 and 44, respectively. [Table 43] [Table 44] [Table 45]

[0124] For intranasal administration, each dog was held in an upright position with its nose tilted upward. Using a positive displacement pipette, the bumetanide compound was delivered into the dog's nasal cavity at a volume of 50 μL per nostril, resulting in a total administration of 100 μL. The dogs were held with their noses tilted upward for approximately 60 seconds after administration. After each application, successful administration was confirmed by visual inspection of the pipette tip and the dog's nostrils. Only administrations estimated to be at least 80% of the total amount were permitted.

[0125] For oral (i.e., sublingual) administration, 100 μL of bumetanide compound was delivered sublingually in the oral cavity using a positive displacement pipette, ensuring a total dose of 100 μL per dog. The dogs were held horizontally with their mouths closed for approximately 60–120 seconds after administration. After each administration, successful administration was confirmed by visual inspection of the pipette tip and the dog's mouth. Only administrations estimated to be at least 80% of the total dose were permitted. No food or water was given for 1 hour before and 2 hours after administration of the bumetanide compound.

[0126] For intravenous administration, commercially available bumetanide (Walgreens, 0.25 mg / mL) was used and administered via the cephalic vein over 30 seconds (2.0 mL / dog, IV).

[0127] Detailed clinical observations were performed at least once a day during stages 1 and 2, up to 24 hours after events 5 and 9, and whenever abnormalities were observed. No other observations were performed between stages. The nostrils were observed for adverse signs after medication. Further cage-side observations were performed at least once a day by animal care staff.

[0128] Diuresis was assessed by monitoring urine output after medication administration at 30 minutes, 1 hour, 2 hours, and 4 hours. Urine volume was not measured.

[0129] The body weight of each animal was measured before each dose on the day of administration and approximately 48 hours after administration for each event. Body weight was provided for pharmacokinetic analysis.

[0130] In both stages A and B, on each day of administration, serum was obtained by collecting approximately 600 μL of serum from the jugular vein into a red-top tube (Sarstedt, Inc.-41.1392.105 or similar) equipped with a coagulation activator, both before administration and at 2±1 minutes, 5±1 minutes, 10±2 minutes, 15±2 minutes, 20±3 minutes, 30±3 minutes, 45±3 minutes, 60±4 minutes, 120±5 minutes, 180±5 minutes, and 240±5 minutes after administration. However, blood collection at 240 minutes was not performed in event 1 of IV administration. Blood was centrifuged at 5000 × g for 10 minutes at 4°C. Sample collection outside the designated collection period was not considered a protocol deviation. That is, the collection times were set for the purpose of pharmacokinetic analysis. Each serum sample was divided into two aliquots of approximately 150 μL each (one aliquot as a backup), frozen and stored at -20°C, and then one aliquot was sent to Climax Laboratories, Inc. on dry ice for bioanalysis.

[0131] Tables 50 and 51 show the individual serum concentrations and pharmacokinetic parameters of bumetanide after intravenous administration of commercially available bumetanide to dogs, and are graphically represented in Figure 8. After intravenous administration of bumetanide, the level of bumetanide also decreased rapidly. Because the serum bumetanide concentration reached an early peak and then rapidly decreased after intravenous administration, the IV step was repeated with an additional 2-minute early time point to obtain a better initial AUC. The level of bumetanide was higher in the second repeat trial, which is likely attributable in part to the addition of the 2-minute early time point. The bioavailability of the IN and SL administration routes was calculated using the mean IV PK parameters obtained from both IV dosing times.

[0132] When bumetanide preparations were delivered sublingually, bumetanide potassium preparation F70 showed the greatest absorption compared to arginine bumetanide preparation F69, bumetanide emulsion FE-9, and bumetanide nanoemulsion FNE-1, as shown in Figures 10, 11, and 13. Systemic exposure, measured by the area under the curve, shows that the sublingual dose of F70 in dogs was close to that of IV administration, as shown in Figures 14 and 15. The variability of F70 after sublingual administration was similar to that observed when bumetanide was administered intravenously, as shown in Figure 12. As shown in Figures 10, 11, and 13, F70 showed rapid absorption, reaching T30-60 minutes after administration. max The levels reached a peak and remained sustained for 240 minutes. Tables 52-55 show the individual serum concentrations and pharmacokinetic parameters of bumetanide after SL administration of F69, F70, FE-9, and FNE-1 to dogs, and Figure 10 shows the graphs. After SL administration of bumetanide preparations, bumetanide levels peaked approximately 30-60 minutes after administration and then decreased.

[0133] When bumetanide preparations were delivered intranasally, bumetanide potassium preparation F70 resulted in maximum bumetanide absorption, as shown in Figures 5, 6, and 7. Similarly, intranasal administration of F70 yielded generally similar results compared to IV administration of bumetanide, as shown in Figure 9. As with sublingual administration, intranasal administration resulted in rapid administration of F70 and more sustained levels over time compared to IV administration, as shown in Figure 9.

[0134] Tables 46-49 show the individual serum concentrations and pharmacokinetic parameters of bumetanide after intranasal administration of F69, F70, FE-9, and FNE-1 in dogs, and these are graphically represented in Figures 6 and 7. After intranasal administration of bumetanide preparations, bumetanide levels rapidly peaked (usually in 5-10 minutes) and then decreased quickly. Table 45 summarizes the calculated bioavailability for intranasal, IV, and sublingual administration of various bumetanide preparations. Systemic exposure, measured by the area under the curve, shows that the intranasal dose of F70 in dogs is close to that of IV administration, as shown in Figures 14 and 16. Table 46 Table 47 Table 48 Table 49 Table 50 Table 51 Table 52 Table 53 Table 54 Table 55 Table 56 Bumetanide was rapidly absorbed into the systemic circulation of dogs from all IN formulations, with a median Tmax of 5–10 minutes post-administration, followed by a rapid decline. After IV administration of bumetanide, bumetanide levels also decreased rapidly. After sublingual administration of bumetanide, bumetanide levels peaked approximately 30–60 minutes post-administration, followed by a decline. All animals appeared normal throughout this study. Based on the results of this study, bumetanide administered as a single intranasal or sublingual dose in four formulations using different vehicles was well tolerated in male and female beagle dogs compared to a single IV dose, and did not result in death or morbidity, biologically or toxicologically relevant clinical observations, changes in body weight, abnormal physical condition scores, or changes in clinical chemistry, hematology, or urinalysis results. After IV, IN, and sublingual administration, a diuretic effect was observed within 30 to 120 minutes post-administration, and this effect persisted for 4 hours post-administration during the observation period.

[0135] The F70 formulation containing the potassium salt of bumetanide showed higher nasal absorption of bumetanide than the other three formulations containing other bumetanide salts. The F70 formulation also showed higher sublingual absorption compared to the other three formulations tested. Furthermore, in dogs, systemic exposure after intravenous administration of F70 was generally similar to that after intravenous administration, and the variability of F70 after intravenous administration was similar to that of intravenous administration of F70, showing rapid absorption similar to that of intravenously administered bumetanide, but with more sustained levels.

[0136] Other Embodiments Various modifications and variations of the Disclosure described herein will be apparent to those skilled in the art without departing from the scope and spirit of the Disclosure. Although the Disclosure is described in relation to specific embodiments, it should be understood that the claimed disclosure should not be excessively limited to such specific embodiments. In fact, various modifications of the form described for carrying out the Disclosure, which will be apparent to those skilled in the art, are intended to be within the scope of the Disclosure.

[0137] Other embodiments are found in the claims. The following are examples of the forms of this disclosure: [1] A pharmaceutical composition comprising (i) an aqueous solution having a pH of about 5 to about 9, (ii) a bumetanide potassium salt in a concentration of about 4 mg / mL to about 20 mg / mL, and (iii) one or more pharmaceutically acceptable excipients. [2] The pharmaceutical composition according to Embodiment 1, comprising (i) an aqueous solution containing about 5 mg / mL to about 10 mg / mL of bumetanide potassium salt, (ii) one or more pharmaceutically acceptable excipients, and (iii) the aqueous solution having a pH of about 6 to about 8. [3] A pharmaceutical composition comprising an aqueous solution of bumetanide arginine salt and one or more pharmaceutically acceptable excipients. [4] The pharmaceutical composition according to embodiment 3, wherein the aqueous solution contains the bumetanidearginine salt in an aqueous solution of about 4 mg / mL to about 15.0 mg / mL, and the aqueous solution has a pH of about 5 to about 9. [5] The pharmaceutical composition according to any one of embodiments 1 to 4, wherein the pharmaceutically acceptable excipient comprises a surfactant or a permeation enhancer. [6] The pharmaceutical composition according to embodiment 5, wherein the pharmaceutical composition comprises a permeation enhancer present in an aqueous emulsion. [7] The pharmaceutical composition according to embodiment 6, wherein the aqueous solution does not contain any buffering agents other than the buffer formed by bumetanide free acid combined with potassium hydroxide. [8] The pharmaceutical composition according to any one of embodiments 1 to 7, wherein the pharmaceutical composition is formulated for intranasal administration. [9] The pharmaceutical composition according to any one of embodiments 1 to 7, wherein the pharmaceutical composition is formulated for sublingual administration.

[10] The pharmaceutical composition according to any one of embodiments 1 to 7, wherein the pharmaceutical composition is formulated for subcutaneous administration.

[11] The pharmaceutical composition according to any one of embodiments 1 to 10, wherein the aqueous solution has a pH of about 6 to about 8.

[12] The pharmaceutical composition according to any one of embodiments 1 to 11, wherein the one or more pharmaceutically acceptable excipients comprises low viscosity carboxymethylcellulose sodium or a pharmaceutically acceptable salt thereof.

[13] The pharmaceutical composition according to any one of embodiments 1 to 12, wherein the one or more pharmaceutically acceptable excipients include a buffer, a preservative, a viscosity improver, or an isotonic agent.

[14] The pharmaceutical composition according to any one of embodiments 1 to 13, wherein the pharmaceutical composition comprises an emulsion, and the one or more pharmaceutically acceptable excipients comprises a polysorbate surfactant, a triglyceride, or lecithin.

[15] A method for transmucosal administration of the potassium salt of bumetanide, wherein the potassium salt of bumetanide is administered into the nasal cavity or sublingually.

[16] The method according to embodiment 15, wherein the potassium salt of bumetanide is the pharmaceutical composition according to any one of embodiments 1, 2, or 5 to 14.

[17] A method for treating edema in a subject requiring such treatment, comprising administering to the subject an effective amount of a pharmaceutical composition described in any one of embodiments 1 to 14.

[18] The method according to embodiment 16 or embodiment 17, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition into the nasal cavity of the subject.

[19] The method according to embodiment 16 or embodiment 17, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition sublingually to the subject.

[20] The method according to embodiment 17, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition subcutaneously to the target.

[21] The method according to any one of embodiments 18 to 20, wherein the aforementioned dose is delivered 1 to 4 times or less over a period of 6 hours.

[22] The method according to any one of embodiments 15 to 21, wherein the subject suffers from edema unresponsive to oral diuretics.

[23] The method according to any one of embodiments 15 to 22, wherein the subject has congestive heart failure.

[24] The method according to any one of embodiments 15 to 22, wherein the subject is suffering from pulmonary edema.

[25] The method according to any one of embodiments 15-18 and 21-24, wherein the pharmaceutical composition is administered into the nasal cavity of the subject in an external environment, or the pharmaceutical composition is self-administered.

[26] The method according to any one of embodiments 15 to 25, wherein the subject was unable to achieve diuresis by oral diuretic therapy before the administration.

[27] The method according to any one of embodiments 15 to 26, wherein the subject has experienced lower extremity swelling, shortness of breath, difficulty breathing, or chest pain that has not been resolved by oral diuretic therapy prior to the administration.

[28] The method according to any one of embodiments 15 to 27, wherein the subject has experienced a reduction in bowel motility prior to the administration.

[29] A method for treating edema unresponsive to oral diuretics in a subject with congestive heart failure, comprising administering to the subject an effective amount of a pharmaceutical composition described in any one of embodiments 1 to 14.

[30] The method according to embodiment 29, wherein the pharmaceutical composition is administered via mucosal administration.

[31] The method according to embodiment 29 or embodiment 30, wherein 0.5 mg to 10 mg of the bumetanide or a pharmaceutically acceptable salt thereof is delivered to the subject in 1 to 4 doses or less over a period of 6 hours.

[32] The method according to any one of embodiments 29 to 31, wherein the pharmaceutical composition comprises (i) an aqueous solution having a pH of about 5 to about 9, (ii) about 5 mg / mL to about 23 mg / mL of the bumetanide or a pharmaceutically acceptable salt thereof, and (iii) one or more pharmaceutically acceptable excipients.

[33] The one or more viscosity improvers, or the method according to embodiment 29.

[34] The method according to embodiment 29, wherein the one or more pharmaceutically acceptable excipients include a buffer.

[35] The method according to embodiment 29, wherein the one or more pharmaceutically acceptable excipients include a surfactant or a permeation enhancer.

[36] The method according to embodiment 29, wherein the one or more pharmaceutically acceptable excipients include a preservative.

[37] The method according to embodiment 29, wherein the one or more pharmaceutically acceptable excipients include an isotonic agent.

[38] The method according to any one of embodiments 29 to 37, wherein the administration comprises delivering the pharmaceutical composition in a dose of 25 μl to 250 μl per external nostril into the nasal cavity of the subject.

[39] The method according to any one of embodiments 29 to 37, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition sublingually to the subject.

[40] The method according to any one of embodiments 29 to 37, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition subcutaneously to the subject.

[41] The method according to any one of embodiments 29 to 40, wherein the subject was unable to achieve diuresis by oral diuretic therapy before administration.

[42] The method according to any one of embodiments 29 to 41, wherein the subject has experienced lower extremity swelling, shortness of breath, difficulty breathing, or chest pain that has not been resolved by oral diuretic therapy prior to administration.

[43] The method according to any one of embodiments 29 to 42, wherein the subject has experienced a reduction in bowel motility prior to administration.

[44] The method according to any one of embodiments 15 to 43, wherein the patient remains upright during administration and for at least 30 minutes after administration.

[45] The method according to any one of embodiments 15 to 43, wherein the patient is in a supine position during and for at least 2 minutes after intranasal administration.

[46] The method according to any one of embodiments 15 to 45, wherein the subject has been treated with at least one dose of an oral diuretic within the last 24 hours prior to administration.

[47] The method according to embodiment 46, wherein at least one oral diuretic is selected from loop diuretics such as bumetanide, furosemide, or torsemide, or potassium-sparing diuretics such as amiloride or spironolactone.

[48] The method according to any one of embodiments 15 to 47, wherein the patient does not receive a total of more than approximately 10 mg of the bumetanide salt over a 12-hour period.

[49] The method according to embodiment 48, wherein if the total amount of bumetanide or a pharmaceutically acceptable salt thereof exceeds 10 mg over a 6-hour period, the patient consults a physician.

[50] The method according to any one of embodiments 15 to 49, wherein the risk of hospitalization of the subject due to complications associated with edema is reduced.

[51] The method according to any one of embodiments 15 to 50, wherein the pharmaceutical composition is an aqueous composition having a pH of about 6 to about 8 and containing about 5 mg / mL to about 10 mg / mL of bumetanide potassium salt and one or more pharmaceutically acceptable excipients.

[52] The method according to any one of embodiments 17 to 50, wherein the pharmaceutical composition is an aqueous composition having a pH of about 5 to about 9 and containing about 4 mg / mL to about 15.0 mg / mL of bumetanidearginine salt and one or more acceptable excipients.

[53] The method according to any one of embodiments 17 to 52, wherein the pharmaceutical composition comprises a surfactant selected from glycerides, alkyl saccharides, ester saccharides, polyglycolated glycerides, and polysorbate surfactants.

[54] The method according to any one of embodiments 15-18, 21-38, or 41-49, wherein the pharmaceutical composition is administered into the nasal cavity and the pharmaceutical composition contains a permeation enhancer.

[55] The method according to any one of embodiments 15 to 54, wherein the pharmaceutical composition comprises an emulsion.

[56] The method according to embodiment 55, wherein the emulsion comprises a medium-chain glyceride (MCT), lecithin (E80), a polysorbate surfactant, and / or a polyglycolated glyceride.

[57] The method according to embodiment 55, wherein the pharmaceutical composition comprises a nanoemulsion.

[58] The method according to embodiment 57, wherein the nanoemulsion comprises soy lecithin and glycocholic acid.

[59] A method for treating edema in a subject with congestive heart failure, comprising administering subcutaneously to the subject a dose of 100 μl to 300 μl of an aqueous emulsion having a pH of about 5 to about 9 and containing about 7 mg / mL to about 15.0 mg / mL of bumetanide arginine salt.

[60] The method according to embodiment 59, wherein the aqueous emulsion comprises a medium-chain glyceride (MCT), lecithin (E80), a polysorbate surfactant, and / or a polyglycolated glyceride.

[61] The method according to embodiment 59 or 60, wherein two doses or less are administered to the subject over a period of 48 hours.

[62] The method according to embodiment 59, wherein one dose or less is administered to the subject over a period of 72 hours.

[63] The method according to any one of embodiments 15 to 62, wherein the subject is a mammal.

[64] The method according to embodiment 63, wherein the subject is a dog.

[65] The method according to embodiment 63, wherein the subject is a human.

[66] A solid containing bumetanide arginine salt.

Claims

1. A stable pharmaceutical composition comprising an aqueous solution containing (a) 0.5 to 2 percent bumetanide (wt / wt), (b) 0.1 percent low viscosity carboxymethylcellulose sodium (wt / wt), (c) 0.5 percent benzyl alcohol (wt / wt), (c) 0.078 to 0.31 percent potassium ions (wt / wt), and (d) 2 to 4 percent mannitol (wt / wt) in a range of ±10% of each value, wherein the aqueous solution has a pH of 6 to 8.

2. The pharmaceutical composition according to claim 1, comprising 0.5 percent bumetanide (wt / wt).

3. The pharmaceutical composition according to claim 2, comprising 4 percent mannitol (wt / wt).

4. A pharmaceutical composition for use in a method of treating edema in a subject requiring such treatment, wherein the method comprises administering an effective amount of the pharmaceutical composition according to claim 1 to the subject.

5. The pharmaceutical composition for use according to claim 4, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition into the nasal cavity of the subject.

6. The pharmaceutical composition for use according to claim 4, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition sublingually to the subject.

7. The pharmaceutical composition for use according to claim 4, wherein the administration comprises delivering a dose of 25 μl to 250 μl of the pharmaceutical composition subcutaneously to the target.

8. The pharmaceutical composition for use according to claim 5, wherein the aforementioned dose is delivered one to four times or less over a period of six hours.

9. The pharmaceutical composition for use according to claim 4, wherein the subject suffers from edema unresponsive to oral diuretics.

10. The pharmaceutical composition for use according to claim 4, wherein the subject has congestive heart failure.

11. The pharmaceutical composition for use according to claim 4, wherein the subject is suffering from pulmonary edema.

12. The pharmaceutical composition for use according to claim 5, wherein the pharmaceutical composition is administered into the nasal cavity of the subject in an external environment, or the pharmaceutical composition is self-administered.

13. The pharmaceutical composition for use according to claim 4, wherein the subject was unable to achieve diuresis by oral diuretic therapy before the administration.

14. The pharmaceutical composition for use according to claim 4, wherein the subject has experienced lower limb swelling, shortness of breath, difficulty breathing, or chest pain that has not been resolved by oral diuretic therapy prior to the administration.

15. The pharmaceutical composition for use according to claim 4, wherein the subject has experienced a reduction in bowel motility prior to the administration.

16. A pharmaceutical composition for use in the treatment of edema unresponsive to oral diuretics in a subject having congestive heart failure, wherein the pharmaceutical composition comprises (i) an aqueous solution having a pH of 5±1 to 9±1, (ii) a potassium bumetanide salt in an amount of 4±1 mg / mL to 20±1 mg / mL, and (iii) one or more pharmaceutically acceptable excipients, wherein the method comprises administering an effective amount of the pharmaceutical composition into the nasal cavity of the subject.

17. The pharmaceutical composition for use according to claim 16, wherein 0.5 mg to 10 mg of the bumetanide or a pharmaceutically acceptable salt thereof is delivered to the subject in 1 to 4 doses over a period of 6 hours.

18. The pharmaceutical composition for use according to claim 16, wherein the pharmaceutical composition comprises (i) an aqueous solution having a pH of 6±1 to 8±1, (ii) 5±1 mg / mL to 20±1 mg / mL of the bumetanide or a pharmaceutically acceptable salt thereof, and (iii) one or more pharmaceutically acceptable excipients.

19. The pharmaceutical composition for use according to claim 16, wherein the one or more pharmaceutically acceptable excipients include a viscosity improver.

20. The pharmaceutical composition for use according to claim 16, wherein the one or more pharmaceutically acceptable excipients include a buffering agent.

21. The pharmaceutical composition for use according to claim 16, wherein the one or more pharmaceutically acceptable excipients comprises a surfactant or a permeation enhancer.

22. The pharmaceutical composition for use according to claim 16, wherein the one or more pharmaceutically acceptable excipients include a preservative.

23. The pharmaceutical composition for use according to claim 16, wherein the one or more pharmaceutically acceptable excipients include an isotonic agent.

24. The pharmaceutical composition for use according to claim 16, wherein the administration comprises delivering the pharmaceutical composition in a dose of 25 μl to 250 μl per external nostril into the nasal cavity of the target.

25. The pharmaceutical composition for use according to claim 16, wherein the subject was unable to achieve diuresis by oral diuretic therapy before administration.

26. The pharmaceutical composition for use according to claim 16, wherein the subject has experienced lower extremity swelling, shortness of breath, difficulty breathing, or chest pain that has not been resolved by oral diuretic therapy prior to administration.

27. The pharmaceutical composition for use according to claim 16, wherein the subject has experienced a reduction in bowel motility prior to administration.

28. The pharmaceutical composition for use according to claim 16, wherein the patient remains upright during administration and for at least 30 minutes after administration.

29. The pharmaceutical composition for use according to claim 16, wherein the patient is in a supine position during intranasal administration and for at least two minutes after administration.

30. The pharmaceutical composition for use according to claim 16, wherein the subject has been treated with at least one dose of an oral diuretic within the last 24 hours prior to administration.

31. The pharmaceutical composition for use according to claim 30, wherein at least one oral diuretic is selected from loop diuretics such as bumetanide, furosemide, or torsemide, or potassium-sparing diuretics such as amiloride or spironolactone.

32. The pharmaceutical composition for use according to claim 16, wherein the patient does not receive a total of more than 10 mg of the bumetanide salt over a 12-hour period.

33. The pharmaceutical composition for use according to claim 30, wherein if the total amount of bumetanide or a pharmaceutically acceptable salt thereof exceeds 10 mg over a 6-hour period, the patient consults a physician.

34. A pharmaceutical composition for use according to claim 16, which reduces the risk of hospitalization of the subject due to complications associated with edema.

35. The pharmaceutical composition for use according to claim 16, wherein the pharmaceutical composition is an aqueous composition having a pH of 6±1 to 8±1 and comprising 5±1 mg / mL to 10±1 mg / mL of a bumetanide potassium salt and one or more pharmaceutically acceptable excipients.

36. The pharmaceutical composition for use according to claim 16, wherein the pharmaceutical composition comprises an emulsion.

37. The pharmaceutical composition for use according to claim 36, wherein the emulsion comprises a medium-chain glyceride (MCT), lecithin (E80), a polysorbate surfactant, and / or a polyglycolated glyceride.

38. The pharmaceutical composition for use according to claim 36, wherein the pharmaceutical composition comprises a nanoemulsion.

39. The pharmaceutical composition for use according to claim 38, wherein the nanoemulsion comprises soy lecithin and glycocholic acid.

40. The pharmaceutical composition for use according to claim 16, wherein the subject is a mammal.

41. The pharmaceutical composition for use according to claim 40, wherein the subject is a dog.

42. The pharmaceutical composition for use according to claim 40, wherein the subject is a human.

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