Immunosuppressive dosage forms and methods of use

Abstract

The present disclosure relates to ready-to-use, surfactant free, oral, aqueous suspension formulations comprising one or more immunosuppressive agents. The ready-to-use suspension formulations of the present disclosure can be useful in treating organ or stem cell transplant recipients or T-cell mediated diseases.

Description

IMMUNOSUPPRESSIVE DOSAGE FORMS AND METHODS OF USETECHNICAL FIELD

[0001] Embodiments of the present disclosure relate generally to ready-to-use, aqueous suspension formulation comprising an immunosuppressive agent for use in the treatment of organ and stem cell transplant recipients (e.g., liver, kidney, heart, or lung transplant recipients) and for the treatment of other T-cell mediated diseases. In particular, the invention relates to ready-to-use, aqueous suspension formulation comprising tacrolimus or a polymorph thereof for prophylaxis of organ rejection in adult and pediatric patients receiving allogeneic liver, kidney, heart, or lung transplants, in combination with other immunosuppressants. Further included are methods of manufacturing and stabilizing ready-to-use, aqueous suspension formulations comprising an immunosuppressive agent.BACKGROUND

[0002] Tacrolimus (also known as FK-506 / Fujimycin) is a calcineurin-inhibitor immunosuppressive agent that can be used after organ or stem cell transplants to reduce the activity of the patient’s immune system and so lower the risk of organ rejection. It can reduce interleukin- 2 (IL-2) production by T-cells. Tacrolimus can also be used in topical preparation for the treatment of severe atopic dermatitis (eczema), severe refractory uveitis after bone marrow transplants, and the skin condition vitiligo. Tacrolimus was discovered in 1987 from the fermentation broth of a Japanese soil sample that contained the bacteria Streptomyces tsukubaensis.

[0003] Tacrolimus is a 23-membered macrolide lactone having the following chemical structure.

[0004] The drug is sold under the trade names PROGRAF® given twice daily (oral granules for suspension) or as a continuous infusion (intravenous); ASTAGRAF®XL, which is an extendedrelease formulation allowing once daily dosing (oral capsules); ENVARSUS®XR, which is an extended release oral tablet with once daily dosing; and PROTOPIC®, which is a topical formulation.

[0005] For PROGRAF, ®the injection options include 5 mg tacrolimus base / ml for intravenous administration. The approved granules for oral suspension dosage form of PROGRAF® includes 0.2 mg base / packet and 1 mg base / packet. The contents of unit dose packets containing solid granules comprising either 0.2 mg or 1 mg of anhydrous tacrolimus are suspended in water prior to administration. Because tacrolimus has a narrow therapeutic index, it can be difficult to treat patients with the currently approved oral dosage forms (e.g., tablets, capsules, and granules for suspension). Precise dosing is difficult to achieve with the current tablet, capsule or granules for suspension formulations and if more precise titration is required, the current dosage forms are intravenous. In addition, due to the complications of transplant operations, patients, especially pediatric and geriatric patients, are oftentimes unable to swallow tablets and capsules. When this occurs, patients may be admitted to the hospital to receive tacrolimus intravenously, which presents difficulties if there is no other reason for the patient to be admitted; or the patient may receive a compounded suspension from the pharmacy, which requires accurate dose titration by the prescriber and right dilution by the pharmacy. The currently approved oral suspension presents issues because the approved suspension dosage form includes granules for oral administration as a suspension containing equivalent of 0.2 mg or 1 mg of anhydrous tacrolimus / packet. Required weight of granules must be diluted with a specified amount of water to provide a therapeutic dose based on dose titration (e.g., dose titration based on the patient’s target therapeutic blood level to achieve immunosuppression without inducing toxicity, as well as the condition treated, the compound administered, the route of delivery, the age, weight, severity of the patient's symptoms and response pattern of the patient). The ready-to-dilute oral suspensions also present issues related to maintaining the drug in suspension. Poorly formulated suspension allows the drug to settle out as a sediment thereby reducing therapeutic drug concentration in the suspension. This results in underdosing or overdosing of the patient, which may seriously compromise patient’s recovery, specially, with the narrow therapeutic index drugs, e.g., tacrolimus. Additionally, a possibility of inaccurate dosing exists if portions of the suspended tacrolimus remain (adhered) to the dosing cup or dosing syringe in which the oral suspension is created and administered.

[0006] It would be desirable to provide formulations, dosage forms and methods that allow for the flexibility of dosing, dose titration and can ease the oral administration to patients, including pediatric and geriatric patients. It would be desirable to provide a ready-to-use suspension formulation comprising an immunosuppressive agent for use in the treatment of organ and stem cell transplant recipients (e.g., liver, kidney or heart transplant recipients) and for the treatment of other T-cell mediated diseases, and can provide improved stability and consistent bioavailability. It is desirable to provide ready-to-use oral suspension formulation comprising an immunosuppressive agent, wherein the suspension has acceptable taste and mouthfeel, and does not require reconstitution, mixing and / or dilution prior to administration.

[0007] The present invention provides stable, ready-to-use, oral, aqueous suspension compositions of immunosuppressive agents, wherein the suspensions minimize drug degradation on storage, provide accurate dosing, do not form cake-type agglomerates during manufacturing and storage, and exhibit good taste and mouthfeel.SUMMARY

[0008] The present invention relates to ready-to-use, aqueous suspension formulation comprising tacrolimus or a polymorph thereof for prophylaxis of organ rejection in patients receiving allogeneic liver, kidney, heart, or lung transplant, in combination with other immunosuppressants.

[0009] In a first exemplary embodiment, the present disclosure provides a ready-to-use, surfactant free, oral aqueous suspension formulation comprising tacrolimus or a polymorph thereof; and (b) at least one pharmaceutically acceptable suspending agent. The formulation comprises about 0.1% -2% wt / vol of the suspending agent and is free of a pharmaceutical vehicle that can dissolve greater than 0.1 mg / ml of tacrolimus or polymorph thereof. The formulation is substantially free of a surfactant, a wetting agent and / or an emulsifying agent.

[0010] In certain embodiments, the at least one pharmaceutically acceptable suspending agent is selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methylcellulose, hydroxyethyl cellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof.

[0011] In certain embodiments, the suspending agent is substantially soluble in water.

[0012] In certain embodiments, the suspending agent is xanthan gum.

[0013] In certain embodiments, the suspension comprises from about 0.1% -1% wt / vol of the suspending agent.

[0014] In certain embodiments, the suspending agent is a viscosity enhancing agent.

[0015] In certain embodiments, the tacrolimus is tacrolimus polymorph. In certain embodiments, the tacrolimus polymorph is anhydrous tacrolimus. In certain embodiments, the anhydrous tacrolimus has a D90 particle size of from about 0.1 pm to about 10 pm. In certain embodiments, the anhydrous tacrolimus has a D90 particle size of from about 1 pm to about 7 pm. In certain embodiments, the suspension comprises from about 0.1-1.5 mg / ml of anhydrous tacrolimus.

[0016] In certain embodiments, the suspension formulation is substantially free of a pharmaceutical vehicle selected from the group consisting of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils, and mixtures thereof.

[0017] In certain embodiments, the suspension formulation further comprises at least one pharmaceutically acceptable excipient selected from the group consisting of flavoring agents, sweeteners, preservatives, pH adjusting agents / buffers, and mixtures thereof.

[0018] In certain embodiments, the 0.1% wt / vol-2 % wt / vol of the suspending agent provides a viscosity of between 20 cp and 20,000 cp, measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry.

[0019] In certain embodiments, the suspension formulation exhibits a pH of between 1 and 6.

[0020] In certain embodiments, the suspension formulation on storage under accelerated storage conditions for 6 months maintains a pH of between 2 and 6.

[0021] In certain embodiments, the suspension formulation, on storage under accelerated storage conditions for 6 months, comprises a total impurity of less than 1% wt / vol. In certain embodiments, the accelerated storage conditions comprise storage at 40°C and 75% relative humidity.

[0022] In certain embodiments, the suspension formulation comprises from about 0.1 mg / ml to about 1.5 mg / ml of anhydrous tacrolimus. In certain embodiments, the suspension formulation comprises from about 0.1 mg / ml to about 1 mg / ml of anhydrous tacrolimus.

[0023] In certain embodiments, the disclosure provides a ready-to-use oral, aqueous suspension formulation comprising (a) anhydrous tacrolimus, and (b) a pharmaceutically acceptable suspending agent selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methylcellulose, hydroxyethylcellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof. The suspension is substantially free of polyethylene glycols, propylene glycols, triacetin, ethanol, polysorbate oils, and mixtures thereof. The formulation comprises from about 0.1 to about 2% wt / vol of the suspending agent. The formulation is substantially free of a surfactant, a wetting agent, and / or an emulsifying agent. The formulation is substantially free of a pharmaceutical vehicle that can dissolve greater than 0.1 mg / ml of anhydrous tacrolimus.

[0024] In certain embodiments, the suspending agent isxanthan gum. In certain embodiments, the anhydrous tacrolimus has D90 particle size of from about 0.1 pm to about 10 pm. In certain embodiments, the anhydrous tacrolimus has D90 particle size of from about 1 pm to about 10 pm.

[0025] In certain embodiments, the about 0.1 to about 2% wt / vol of the suspending agent provides a suspension viscosity of between 20 cp and 20,000 cp, measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry.

[0026] In certain embodiments, the suspension formulation comprises from about 0.1 mg / ml to about 1.5 mg / ml of anhydrous tacrolimus. In certain embodiments, the suspension formulation comprises from about 0.5 mg / ml to about Img / ml of anhydrous tacrolimus

[0027] In certain embodiments, the suspension formulation exhibits a pH of between 2 and 6.

[0028] In certain embodiments, the suspension formulation on storage under accelerated storage conditions for 6 months, comprises a total impurity of less than 1% wt / vol.

[0029] In certain embodiments, the accelerated storage conditions comprise storage at 40°C and 75% relative humidity.

[0030] In certain embodiments, the suspension formulation on storage under accelerated storage conditions for 6 months maintains the pH of between 2 and 6.

[0031] In certain embodiments, the suspension formulation further comprises at least one pharmaceutically acceptable excipient selected from the group consisting of flavoring agents, sweeteners, preservatives, pH adjusting agents / buffers, and mixtures thereof.

[0032] In certain embodiments, the disclosure provides a method for prophylaxis of organ rejection in patients receiving allogeneic kidney transplant, liver transplant, heart transplant, or lung transplant, the method comprising orally administering to the patient, a ready-to-use, aqueous suspension formulation comprising anhydrous tacrolimus and at least one suspending agent. Thesuspension formulation is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof. The formulation is substantially free of a surfactant, a wetting agent, and / or an emulsifying agent. The formulation comprises from about 0.1% wt / vol to about 2% wt / vol of the suspending agent. The formulation is administered in combination with azathioprine, mycophenolate mofetil (MMF), or corticosteroids.

[0033] In certain embodiments, the suspension formulation comprises from about 0.5 mg / ml to about 1.5 mg / ml of anhydrous tacrolimus. In certain embodiments, the dosage is based on whole blood trough concentration.

[0034] In certain embodiments, the suspending agent is xanthan gum. In certain embodiments, the anhydrous tacrolimus has D90 particle size of from about 0.1 pm to about 10 pm. In certain embodiments, the anhydrous tacrolimus has D90 particle size of from about 1 pm to about 10 pm.

[0035] In certain embodiments, the about 0.1 to about 2% wt / vol of the suspending agent provides a suspension viscosity of between 20 cp and 20,000 cp, measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry.

[0036] In certain embodiments, the suspension formulation exhibits a pH of between 2 and 6.

[0037] In certain embodiments, the suspension formulation further comprises at least one pharmaceutically acceptable excipient selected from the group consisting of flavoring agents, sweeteners, preservatives, pH adjusting agents / buffers, and mixtures thereof.BRIEF DESCRIPTION OF DRAWINGS

[0038] Figure 1 depicts dissolution profile of the suspension compositions of the disclosure (Suspension 1) with D90 particle size of ~ 44pm, ~24pm, ~7pm, and ~5.5pm; PROGRAF® granules for suspension, and ADVAGRAF® capsule composition.

[0039] Figure 2 depicts dissolution profiles of Test Products T1 (Tacrolimus Oral Suspension 1 (un-micronized)) and T2(Tacrolimus Oral Suspension 1 (micronized, D 90 particle size 5-6 pm)), and Reference Products R1 (Tacrolimus Oral Suspension- 1 mg / packet) and R2 (commercially available PROGRAF® CAPSULE) in 0.1 N HC1.

[0040] Figure 3 depicts dissolution profiles of Test Products T1 (Tacrolimus Oral Suspension 1 (un-micronized)) and T2(Tacrolimus Oral Suspension 1 (micronized, D 90 particle size 5-6 pm)), and Reference Products R1 (Tacrolimus oral suspension- 1 mg / packet) and R2 (commerciallyavailable PROGRAF® CAPSULE) in pH 4.5 acetate buffer containing 0.005% hydroxypropyl cellulose.

[0041] Figure 4 depicts single-dose oral bioavailability in Fed State from Test Product T1 (Tacrolimus Oral Suspension 1 (un-micronized)), Test Product T2 (Tacrolimus Oral Suspension 1 (micronized, D 90 particle size 5-6 pm)), commercially available PROGRAF® granules (Tacrolimus Oral Suspension) 1 mg / packet (Rl), and commercially available PROGRAF® CAPSULE (R2).

[0042] Figure 5 depicts single-dose oral bioavailability in Fed State from Test Product T1 (Tacrolimus Oral Suspension 1 (D 90 particle size-2.53 pm)), Test Product T2 (Tacrolimus oral solution 1 mg / ml) and commercially available PROGRAF® granules (Tacrolimus oral suspension, D90 particle size 2 pm) 1 mg / packet (R).

[0043] Figure 6 depicts single-dose oral bioavailability in Fasted State from Test Product T1 (Tacrolimus Oral Suspension 1 (D 90 particle size-2.53 pm)), Test Product T2 (Tacrolimus Oral Solution 1 mg / ml) and commercially available PROGRAF® granules (Tacrolimus oral suspension, D 90 particle size-2 pm) 1 mg / packet (R).DETAILED DESCRIPTION

[0044] The following detailed description is exemplary and explanatory and is intended to provide further explanation of the present disclosure described herein. Other advantages, and novel features will be readily apparent to one of ordinary skill in the art from the following detailed description of the present disclosure.

[0045] The present disclosure provides one or more oral pharmaceutical formulations comprising at least one FK binding protein ligand. In certain embodiments, the FK binding protein ligand is an immunosuppressive FK binding protein ligand. In certain embodiments, the FK binding protein ligand is a non-immunosuppressive FK binding protein ligand. In one embodiment, the present disclosure comprises novel ready-to-use, oral, aqueous suspension formulations comprising an immunosuppressive agent as the active ingredient. The formulations described herein are useful in organ and stem cell transplant recipients and other T-cell mediated diseases in patients by administering one or more of the formulations to patients in need thereof. In particular, the formulations described herein are useful for the prophylaxis of organ rejection in patients receiving allogeneic liver, kidney or heart transplants, in combination with other immunosuppressants. The formulations described herein are particularly desirable because of their ease of dose titration, easeof administration in pediatric and geriatric population, population with symptoms of dysphagia, administration of titrated dose without dilution, unexpected superior stability e.g., (physical and chemical stability) over a predetermined period, and improved efficacy.DEFINITIONS

[0046] The terminology used in the present disclosure is for the purpose of describing particular embodiments only and is not intended to be limiting.

[0047] As used herein, the word “a” or “an” when used in conjunction with the term “comprising” in the claims and / or the specification can mean “one,” but it is also consistent with the meaning of “one or more,” “at least one,” and “one or more than one.” Still further, the terms “having,” ‘including,” “containing,” or “comprising” are interchangeable, and one of skill in the art is cognizant that these terms are open-ended terms.

[0048] The words “comprise”, “comprises”, and “comprising” are to be interpreted inclusively rather than exclusively. The words “consist,” “consisting,” and its variants, are to be interpreted exclusively, rather than inclusively.

[0049] As used herein, the term “and / or” refers to and encompasses any and all possible combinations of one or more of associated listed items.

[0050] As used herein, the terms “about” or “approximately,” mean a variability of 10% or less from the reference given, unless otherwise specified.

[0051] As used herein, the term “free” means the composition, formulation or material does not contain the component modified by the term “free”.

[0052] As used herein, the term “substantially free” means the composition, formulation or material contains small amounts (less than 5 wt%, based on total formulation weight) of the component modified by the term “substantially free”. For example, a formulation that is substantially free of ethanol may contain less than 5.0%, 4.75%, 4.5%, 4.25%, 4.0%, 3.75%, 3.5%, 3.25%, 3.0%, 2.75%, 2.5%, 2.25%, 2.0%, 1.75%, 1.5%, 1.25%, 1.0%, 0.95%, 0.90%, 0.85%, 0.80%, 0.75%, 0.70%, 0.65%, 0.60%, 0.55%, 0.50%, 0.45%, 0.40%, 0.35%, 0.30%, 0.25%, 0.20%, 0.15%, or 0.10% weight percent ethanol, based on total formulation weight.

[0053] As used herein the term “non-aqueous” should be accorded its normal meaning which may mean the composition, formulation or material does not contain any added or additional water other than the amount of water commonly associated with the non-water components present in the composition, formulation or material. For example, a non-aqueous composition comprisingsolvents such as glycerin or propylene glycol will contain trace amounts of water because the United States Pharmacopeia allows glycerin to contain up to 5.0% water and propylene glycol to contain up to 0.2% water.

[0054] As used herein the term “aqueous” should be accorded its normal meaning which may mean the composition, formulation or material that contains water as a pharmaceutical solvent / medium.

[0055] The term “pharmaceutical vehicle, as used herein, refers to any substance that acts as a solvent or a medium in which a drug is administered.

[0056] The term “tacrolimus,” as used herein, includes tacrolimus and polymorphs thereof.

[0057] A “patient” or “subject” is a mammal, e.g., a human patient or subject. In certain embodiments, the pharmaceutical formulations of the present disclosure can be administered to an adult patient or a pediatric patient. In one embodiment, the pediatric patient can be between the ages of six months to ten years.

[0058] The term “treating “or “treatment” is meant to encompass administering to a subject a compound of the present disclosure for the purposes of prophylaxis and / or amelioration of one or more symptoms of a disease or disorder, including palliative care. As used herein, an “effective amount” or a “therapeutically effective amount” is used interchangeably and refers to an amount of a pharmaceutical formulation of the present disclosure which provides the desired treatment of a subject. As would be appreciated by one of ordinary skill in the art, the therapeutically effective amount of the present pharmaceutical formulations to treat a given disease, disorder or condition will vary from subject to subject, depending on factors such as age, general condition of the subject, the severity of the condition being treated, the particular compound and / or formulation administered, and the like. An appropriate therapeutically effective amount of the present pharmaceutical formulations suitable for any individual subject can be readily determined by one of ordinary skill in the art from the information provided herein.

[0059] The terms “suspension,” as used herein, refers to ready-to-use, oral, aqueous suspension containing finely divided drug (the suspensoid) distributed somewhat uniformly throughout the suspending medium (suspending vehicle) in which the drug exhibits a minimum degree of solubility. In an ideal suspension, insoluble particulate matter or drugs are uniformly suspended in three dimensions throughout the vehicle and remain so even after prolonged periods of time.Here, every fixed dose from the suspension will contain the same amount of drug and will give the same clinical effect to the patient.

[0060] The term “soluble,” as used herein with respect to drug / immunosuppressive agent or an excipient, refers to drug or excipient solubility of at least about 10 mg / ml.

[0061] The term “substantially soluble,” as used herein with respect to drug / immunosuppressive agent or an excipient, refers to drug or excipient solubility of between 1 mg and 10 mg / ml.

[0062] The term “insoluble,” as used herein with respect to drug / immunosuppressive agent or an excipient, refers to drug or the excipient solubility of less than or equal to about 1 mg / ml.

[0063] The pharmaceutical formulations of the present disclosure are in biologically compatible form suitable for administration to subjects, for example to humans. The pharmaceutical formulations can further comprise at least one pharmaceutically acceptable excipient. The term “pharmaceutically acceptable” means suitable for use in humans or animals, for example as approved by a governmental regulatory agency (such as the US Food and Drug Administration) or listed in the U.S. Pharmacopeia (USP) or other generally recognized pharmacopeia, or which are generally recognized as safe (GRAS).

[0064] As used herein, the term “excipient” refers to an inactive ingredient with which the immunosuppressive agent is administered. Pharmaceutically acceptable excipients are described in various reference materials such as the USP 29 (2008) and Rowe et al., eds., Handbook of Pharmaceutical Excipients, 7th Edition, London: Pharmaceutical Press, 2012. Some examples of suitable pharmaceutically acceptable excipients can be sterile liquids, such as water. Water can be a pharmaceutically acceptable excipient when the pharmaceutical formulation is administered orally or parenterally. Other suitable pharmaceutically acceptable excipients include suspending agents, thickening agents, pH adjusting agents, buffering agents, preservatives, sweeteners, bodying agents, and flavoring agents.

[0065] As used herein, the term “bodying agent” refers to excipients used to impart body, richness, density, and / or sensory properties without necessarily increasing viscosity of the formulation. Bodying agents can make the emulsion denser, creamier, and richer.

[0066] As used interchangeably herein, the terms “pH adjusting agent” and “buffering agent,” refer to acids and bases that modify and / or stabilize the acidity or alkalinity (pH) of the suspension. Commonly used pH adjusting agents / buffering agents include HC1, NaOH, H2SO4, HNO3,phosphoric acid, acetic acid, citric acid, fumaric acid, lactic acid, phosphoric acid, malic acid, tartaric acid, salts thereof, and mixtures thereof.

[0067] As used herein, the term “suspending agent” refers to pharmaceutical excipient(s) useful for stabilization of the suspension, in particular, by lowering the sedimentation rate / settling of the solid particles in the liquid medium / suspension medium. In certain embodiments, the suspending agent is a viscosity enhancing agent.

[0068] As used herein, the term “narrow therapeutic index” refers to drugs where small differences in dose or blood concentration may lead to serious therapeutic failures and / or adverse drug reactions that are life threatening or significant disability or incapacity.

[0069] As used herein the term “controlled room temperature (CRT) conditions” refers to 12- month storage of the suspension formulation at 25°C and 60% relative humidity (RH).

[0070] As used herein the term “Interim storage conditions (ISC)” refers to 6-month storage of the suspension formulation at 30°C and 65% relative humidity (RH).

[0071] As used herein the term “Accelerated storage conditions” refers to 6- month storage of the suspension formulation at 40°C and 75% RH.TACROLIMUS SUSPENSION FORMULATIONS

[0072] The pharmaceutical formulations of the present disclosure can take any suitable aqueous dosage form for oral administration to a subject, such as a human subject, for example suspensions, emulsions, and the like. In a specific embodiment, a pharmaceutical formulation of the disclosure comprises an effective amount of an immunosuppressive agent together with a suitable amount of one or more pharmaceutically acceptable excipients to provide the form for proper administration to the patient, for example by oral administration via a ready-to-use suspension. For a discussion of the properties of solid and aqueous pharmaceutically acceptable excipients which are suitable for use in the present pharmaceutical formulations, see, e.g., the excipients described in the Rowe et al., eds., Handbook of Pharmaceutical Excipients, 7th Edition, London: Pharmaceutical Press, 2012, which is incorporated herein by reference.

[0073] Any suitable immunosuppressive agent can be used in the present pharmaceutical formulations, including: a calcineurin inhibitor (e.g., cyclosporin (CsA) and analogs thereof, ISA(TX) 247, and Tacrolimus); azathioprine (AZ); mycophenolate mofetil (MMF); mizoribine (MZ); leflunomide (LEF); adrenocortical steroids (also known as adrenocortical hormones, corticosteroids, or corticoids) such as prednisolone and methylprednisolone; sirolimus (alsoknown as rapamycin); everolimus; FK778; TAFA-93; deoxyspergualin (DSG); and 2-amino-2-[2- (4- octylphenyl)ethyl]-l,3-propanediol hydrochloride (FTY720).

[0074] Other suitable immunosuppressive agents include: cyclophosphamide; 15- deoxyspergualin (Gusperimus); interferons; sulfasalazine; mimoribine; misoprostol; anti-IL-2 receptor antibodies; thalidomide; anti-tumor necrosis factor antibodies; anti-CD2 antibodies; anti- CD147 antibodies; anti-CD4 antibodies; anti-CD8 antibodies and anti-thymocyte globulin antibodies; ORTHOCLONE® (also known as OKT3, from Ortho Biotech, Raritan, N.J ); SANDIMMUNE® ORAL (cyclosporine), available for example from Sandoz Pharmaceuticals, Hanover, N.J.; PROGRAF®, also known as Tacrolimus, available for example from Fujisawa Pharmaceuticals, Deerfield, Ill.); CELLCEPT®, also known as mycophenolate, available for example from Roche Pharmaceuticals, Nutley, N.J.; and RAPAMUNE®, also known as sirolimus, available for example from Pfizer, Inc., Collegeville, Pa ). In some embodiments, the immunosuppressive agents are rapamycin, tacrolimus, mycophenolic acid, azathioprine or cyclophosphamide. Still other suitable immunosuppressive agents include an interleukin-2 alphachain blocker (e.g., basiliximab and daclizumab); an inhibitor of inosine monophosphate dehydrogenase (e.g., mycophenolate mofetil); or an inhibitor of dihydrofolic acid reductase (e.g., methotrexate). In one embodiment of the present disclosure, the immunosuppressive agent is Tacrolimus.

[0075] In certain embodiments, the pharmaceutical formulations of the present disclosure comprise at least one FK binding protein ligand. Examples include FK-506 (Tacrolimus) and derivatives / analogs thereof, including 506BD and L0685,818; rapamycin and derivatives / analogs thereof including Way-124466, RAD001, CCI-779, and AP23573; ascomycin and derivatives / analogs thereof including pimecrolimus. See, e.g., Liu et al., 23(11) EXPERT OPIN. THER. PATENTS 1435-49 (2013), the entire disclosure of which is herein incorporated by reference. Furthermore, although the immunosuppressive agent Tacrolimus / FK-506 is an FK binding protein ligand, in certain embodiments, an FK binding protein ligand can comprise a nonimmunosuppressive FK binding protein ligand. Examples of non-immunosuppressive ligands include meridamycin, antascomicins, and synthetic ligand of FKBP (SLF).

[0076] In certain embodiments, the present disclosure provides ready-to-use, oral, aqueous suspension formulations comprising tacrolimus or a polymorph thereof, e.g., ready-to-use tacrolimus suspension. In certain embodiments, the ready-to-use tacrolimus suspension isadministered along with administration of azathioprine (AZ). In certain embodiments, the ready- to-use tacrolimus suspension is administered along with administration of mycophenolate mofetil (MMF). In certain embodiments, the ready-to-use tacrolimus suspension is administered along with adrenocortical steroids (also known as adrenocortical hormones, corticosteroids, or corticoids) such as prednisolone and methylprednisolone.

[0077] In certain embodiments, the pharmaceutical formulations of the present disclosure are ready-to-use, oral, aqueous suspension formulations for the prophylaxis of organ rejection, in patients receiving allogeneic kidney transplant, liver transplant, heart transplant, or lung transplant in combination with other immunosuppressants, wherein the aqueous suspension comprises: (a) an immunosuppressive agent; and (b) at least one pharmaceutically acceptable suspending agent.

[0078] In certain embodiments, the pharmaceutical formulations of the present disclosure are ready-to-use, oral, aqueous suspension formulations for the treatment of an organ or stem cell transplant recipient, or a T-cell mediated disease wherein the aqueous suspension formulation comprises: (a) an immunosuppressive agent; and (b) at least one pharmaceutically acceptable suspending agent.

[0079] In certain embodiments, at least one immunosuppressive agent is selected from the group comprising cyclosporine, tacrolimus, sirolimus, everolimus, polymorphs, and mixtures thereof. In certain embodiments, at least one immunosuppressive agent is tacrolimus. In certain embodiments, the immunosuppressive agent is anhydrous tacrolimus. In certain embodiments, the immunosuppressive agent is tacrolimus monohydrate. In certain embodiments, the immunosuppressive agent is present in an amount of from about 0.001% wt / vol to about 15% wt / vol of the, preferably about 0.01% wt / vol to about 10% wt / vol, and most preferably from about 0.05% wt / vol to about 1% wt / vol of the ready-to-use suspension formulation. In certain embodiments, the immunosuppressive agent is present in an amount of about 0.05% w / vol, about 0.06% wt / vol, about 0.07% wt / vol, about 0.08% wt / vol, about 0.09% wt / vol, about 0. 1% wt / vol, about 0.15% wt / vol, about 0.2% wt / vol, about 0.3% wt / vol, about 0.4% wt / vol, about 0.5% wt / vol, about 0.6% wt / vol, about 0.7% wt / vol, about 0.8% wt / vol, about 0.9% wt / vol, about 1% wt / vol, or any intermediate values therein.

[0080] In certain embodiments, immunosuppressive agent has a D90 particle size of less than ~20 pm, less than ~19 pm, less than ~18 pm, less than ~17 pm, less than ~16 pm, less than ~15 pm, less than ~14 pm, less than ~13 pm, less than ~12 pm, less than ~11 pm, less than ~10 pm, lessthan -9 pm, less than ~8 pm, less than -7 pm, less than -6 pm, less than ~5 pm, less than -4 pm, less than -3 jam, ~ 2.9 pm, ~2.8 jam, -2.7 pm, ~2.6 pm, ~2.5 pm, ~2.4 pm, ~2.3 pm, -2.2 jam, ~ 2.1 pm, - 2.0 pm, ~1.9 pm, -1.8 pm, -1.7 pm, -1,6 pm, -1,5 pm, -1.4 pm, -1.3 pm, -1.2 pm, -1.1 pm, -1 pm, -0.9 pm, -0.8 jam, -0.7 pm, -0.6 pm, -0.5 pm, -0.4 pm, -0.3 pm, -0.2 pm, - 0.1 pm, or intermediate values therein.

[0081] In certain embodiments the suspending agent is a thickening agent useful for maintaining particulate ingredients in suspension and lowering sedimentation rate of the particulate ingredients and their agglomeration in the suspension. The suspending agent is not a surfactant. In certain embodiments, the suspending agent is substantially soluble in water. In certain embodiments, the suspending agent is selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methylcellulose, hydroxyethyl cellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof.

[0082] In certain embodiments, the aqueous suspension formulation, comprising tacrolimus or a polymorph thereof and a suspending agent, exhibits a viscosity of from about 20 to about 20,000 cp, measured using Rheometer at - 0.1 1 / s and 40 mm stainless steel plate geometry. In certain embodiments, the aqueous suspension formulation, comprising tacrolimus or a polymorph thereof and a suspending agent, exhibits sufficient viscosity to remain stable at pH of from about 1 to about 13. In certain embodiments, the suspending agent is xanthan gum, a white to cream colored, free-flowing powder, which is highly soluble in hot and cold water due to its ordered conformation. Moreover, xanthan gum remains stable in both acidic and alkaline conditions due to its rigid structure and resistance to any pH change. It retains its viscosity under various pH conditions (pH- 1-13).

[0083] Table 1 provides characteristics of some of the suspending agents that can be used in the ready-to-use, oral, aqueous suspension formulations of the disclosure:Table 1

[0084] In certain embodiments, the ready-to-use, oral, aqueous suspension formulation may comprise one or more suspending agents in an amount of from about 0.01% wt / vol to about 2% wt / vol, based on the total weight of the suspension formulation. In certain embodiments, the total amount of one or more suspending agents comprises from about 0.01 % wt / vol to about 2% wt / vol, from about 0.1% wt / vol to about 2% wt / vol, about 0.2% wt / vol, about 0.3% wt / vol, about 0.4% wt / vol, about 0.5% wt / vol, about 0.6% wt / vol, about 0.7% wt / vol, about 0.8% wt / vol, about 0.9% wt / vol, about 1% wt / vol, about 1.5 % wt / vol, about 2% wt / vol, or any intermediate values therein, of the suspension formulation.

[0085] In certain embodiments the ready-to-use, oral, aqueous suspension formulation comprising tacrolimus or a polymorph thereof, further comprises one or more pharmaceutically acceptable excipients selected from the group consisting of bodying agents, flavoring agents, preservatives, sweeteners, pH adjusting agents / buffering agents, and mixtures thereof. In certain embodiments, the excipients are soluble or substantially soluble in aqueous medium. In preferred embodiments, the suspension formulation is free or substantially free of a pharmaceutical vehicle that can dissolve greater than 0.1 mg / ml of tacrolimus or polymorphs thereof. In certain embodiments, the suspension is free or substantially free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof.

[0086] Taste is one of the most important parameters governing patient compliance. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the disclosure comprise taste masking agents to mask the unpalatable taste of the immunosuppressive agent, e.g., tacrolimus, e.g., tacrolimus and polymorphs thereof, e.g., tacrolimus monohydrate, anhydrous tacrolimus. In certain embodiments, the taste masking agent is a flavoring agent, and / or a sweetening agent / sweetener. In certain embodiments, the taste masking agent is soluble or substantially soluble in aqueous medium. In certain embodiments, the flavoring agent is soluble or substantially soluble in aqueous medium. In certain embodiments, the sweetening agent is soluble or substantially soluble in aqueous medium.

[0087] Examples of flavors / flavoring agents that may be employed in the ready-to-use, oral, aqueous suspension formulations of the present invention include citric acid, peppermint oil,wintergreen oil, menthol, lemon, lime, orange, grape, cherry, strawberry, vanilla extract, and mixtures thereof. In certain embodiments, the total amount of one or more flavoring agents ranges from about 0.001% wt / vol to about 20% wt / vol, from about 0.001% wt / vol to about 15% wt / vol, from about 0.001% wt / vol to about 10% wt / vol, from about 0.001% wt / vol to about 5% wt / vol, from about 0.001% wt / vol to about 1% wt / vol, from about 0.001% wt / vol to about 0.01% wt / vol, about 0.002% wt / vol, about 0.003% wt / vol, about 0.004% wt / vol, about 0.005% wt / vol, about 0.006% wt / vol, about 0.007% wt / vol, about 0.008% wt / vol, about 0.009% wt / vol, about 0.01% wt / vol, about 0.02%wt / vol, 0.03% wt / vol, 0.04% wt / vol, 0.05% wt / vol, 0.06% wt / vol, 0.07% wt / vol, 0.08% wt / vol, 0.09% wt / vol, 0.1% wt / vol, 0.2% wt / vol, 0.3% wt / vol, 0.4% wt / vol, 0.5% wt / vol, 0.6% wt / vol, 0.7% wt / vol, 0.8% wt / vol, 0 0.9% wt / vol, 1% wt / vol, or any intermediate values therein, of the ready-to-use, aqueous suspension formulation.

[0088] Examples of sweetening agents / sweeteners that may be used in the ready-to-use, oral, aqueous suspension formulations of the present invention include artificial sweeteners such as aspartame, sucralose, saccharin, dipotassium glycyrrhizinate, stevia, sodium cyclamate, thaumatin, and any mixtures thereof. In certain embodiments, the sweetening agents may further include sorbitol solution and / or glycerol. In certain embodiments, the sorbitol solution is a commercially available 70% sorbitol solution. In certain embodiments, the sweetener is a mixture of sucralose, sorbitol solution, and glycerol. In certain embodiments, the sweetening agent improves mouthfeel of the suspension. In certain embodiments, the total amount of one or more sweetening agents ranges from about 0.01% wt / vol to about 50% wt / vol, from about 0. 01% wt / vol to about 40% wt / vol, from about 0.01% wt / vol to about 30% wt / vol, from about 0.01% wt / vol to about 20% wt / vol, from about 0.01% wt / vol to about 10% wt / vol, from about 0.01% wt / vol to about 1% wt / vol, from about 0.01% wt / vol to about 0.1% wt / vol, or any intermediate values therein, of the suspension formulation. In certain embodiments, sweetening agents are present in amount of about 5% wt / vol, about 10% wt / vol, about 15% wt / vol, about 20% wt / vol, about 25% wt / vol, about 30% wt / vol, about 35% wt / vol, about 40% wt / vol, about 45% wt / vol, about 50% wt / vol, or any intermediate values therein, of the suspension formulation.

[0089] Examples of preservatives that may be used in the ready-to-use, oral, aqueous suspension formulations include, sodium benzoate, benzoic acid, ethylenediaminetetraacetic acid (EDTA), edetate disodium, sorbic acid, potassium sorbate, methyl-4-hydroxybenzoate, propyl-4- hydroxybenzoate, propylene glycol, methyl paraben, methylparaben sodium, ethyl paraben, propylparaben, propyl paraben sodium, butyl paraben, and mixtures thereof. In certain embodiments, the preservative is sodium benzoate. In certain embodiments, the preservative is soluble or substantially soluble in aqueous medium.

[0090] In certain embodiments, the preservatives are present in an amount of less than or equal to about 1% wt / vol of the suspension formulation. In certain embodiments, the preservatives are present in an amount of about 0.1% wt / vol, about 0.2% wt / vol, about 0.3% wt / vol, about 0.4% wt / vol, about 0.5% wt / vol, about 0.6% wt / vol, about 0.7% wt / vol, about 0.8% wt / vol, about 0.9% wt / vol, about 1% wt / vol, or any intermediate values therein.

[0091] In certain embodiments, the ready -to-use, oral, aqueous suspension formulations of the disclosure exhibit a pH of from about 1 to about 7; from about 1 to about 6, from about 2 to about 6; from about 2.5 to about 5, from about 3 to about 4, about 1, about 2, about 2.5, about 3, about 3.5, about 4, about 4.5, about 5, about 5.5, about 6, about 6.5, about 7, or any intermediate values therein. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the disclosure exhibit a pH of from about 3 to about 4. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the disclosure exhibit a pH of about 3. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the disclosure include a pH adjusting agent / buffering agent to modify and / or stabilize the pH from about 2 to about 7, e.g., about 2.5-3.5. Examples of pH adjusting agents / buffering agents that may be used in the suspension formulations of the disclosure include, but are not limited to, any of the pharmaceutically acceptable acids, bases, and / or salts thereof used to modify and / or stabilize the pH of pharmaceutical compositions.

[0092] In certain embodiments, the pH adjusting agents / buffering agents are used to modify the pH. In certain embodiments, the pH adjusting agents used to modify the pH include hydrochloric acid, citric acid, lactic acid, tartaric acid, glacial acetic acid, sodium hydroxide, potassium hydroxide, arginine, lysine meglamine, triethanolamine, or mixtures thereof. In certain embodiments, the pH adjusting agents used to modify the pH include hydrochloric acid, citric acid, lactic acid, tartaric acid, glacial acetic acid, or mixtures thereof. The selection and amount of pH adjusting agents is based on the desired pH, typically from 2-7, of the aqueous suspension formulation.

[0093] In certain embodiments, the pH adjusting agents / buffering agents are used to modify and / or stabilize the pH. In certain embodiments, the pH adjusting agents used to modify and / or stabilizethe pH include hydrochloric acid, citric acid, lactic acid, tartaric acid, glacial acetic acid, sodium hydroxide, potassium hydroxide, arginine, lysine meglamine, triethanolamine, or mixtures thereof.

[0094] In certain embodiments, the aqueous suspension formulation includes citric acid as a pH adjusting agent. In certain embodiments, the pH adjusting agent is anhydrous citric acid. In certain embodiments, the aqueous suspension formulations of the disclosure include pH adjusting agents in an amount of from about 0.01% wt / vol to about 1% wt / vol. In certain embodiments, the suspension formulations of the disclosure include pH adjusting agents in an amount of about 0.01% wt / vol, about 0.02% wt / vol, about 0.03% wt / vol, about 0.04% wt / vol, about 0.05% wt / vol, about 0.06% wt / vol, about 0.07% wt / vol, about 0.08% wt / vol, about 0.09% wt / vol, about 0.1% wt / vol, about 0.15% wt / vol, about 0.2% wt / vol, about 0.25% wt / vol, about 0.3% wt / vol, about 0.35% wt / vol, about 0.4% wt / vol, about 0.45% wt / vol, about 0.5% wt / vol, about 0.55% wt / vol, about 0.6% wt / vol, about 0.65% wt / vol, about 0.7% wt / vol, about 0.75% wt / vol, about 1% wt / vol, or any intermediate values therein.

[0095] The ready-to-use, oral, aqueous suspension formulations of the present disclosure are prepared with simultaneous flushing / purging with one or more sparging agents comprising an inert gas. The inert gas is selected from the group comprising nitrogen, argon, helium, and mixtures thereof. The one or more sparging agents are flushed into the suspension formulation to displace atmospheric air to avoid oxidation of the drug during the manufacturing process. In an embodiment, the suspension formulations of the disclosure are manufactured and stored after flushing with the sparging agents.

[0096] In certain embodiments, the ready-to-use, oral suspension formulations of the disclosure are aqueous suspension formulations that are substantially free of organic solvents and / or lipophilic vehicles. In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any surfactants, wetting agents, and / or emulsifiers. In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any solubilizers. In certain embodiments, the suspension formulation is free or substantially free of a pharmaceutical vehicle that can dissolve greater than 0.1 mg / ml of the tacrolimus or a polymorph thereof. In certain embodiments, the suspension is free or substantially free of solubilizers selected from the group comprising polyethylene glycols, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof.

[0097] In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any anionic, cationic, amphoteric, and / or non-ionic surfactants. In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any wetting agent and / or an emulsifying agent. In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any wetting agent and / or an emulsifying agent that works as a surfactant.

[0098] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulation of the disclosure is free or substantially free of pharmaceutical vehicles / solubilizers that can dissolve the drug (e.g., cyclosporine, tacrolimus, sirolimus, everolimus, polymorphs thereof, or mixtures thereof) to provide a solution free of any drug particles visible to naked eye. In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulation of the disclosure is free or substantially free of pharmaceutical vehicles / solubilizers that can dissolve >1 mg / ml of the immunosuppressive agent (e.g., cyclosporine, tacrolimus, sirolimus, everolimus, polymorphs thereof, or mixtures thereof). In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of pharmaceutical vehicle / solubilizer selected from the group comprising polyethylene glycols, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof. In certain embodiments, the ready-to-use, oral, aqueous suspension is free or substantially free of any oils, e.g., mineral oil, castor oil, vegetable and nut oils such as sunflower oil, corn oil, peanut oil, cottonseed oil, sesame oil, olive oil, canola oil, almond oil, safflower oil, soybean oil, and mixtures thereof.

[0099] In certain embodiments the disclosure provides ready-to-use, oral suspension formulations comprising (a) at least one immunosuppressive agent; (b) one or more pharmaceutically acceptable stabilizer selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methyl cellulose, hydroxyethyl cellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof; (c) optionally one or more pharmaceutically acceptable excipients selected for the group consisting of flavoring agents, sweetening agents, preservatives, pH adjusting agents / buffering agents, and mixtures thereof, and wherein the formulation is an aqueous formulation that is free or substantially free of organic solvents, lipophilic vehicles, any surfactant, and / or any emulsifier.

[0100] In certain embodiments, the pharmaceutical formulations of the disclosure comprise an immunosuppressive agent that can be used alone, e.g., a ready-to-use, surfactant free, oral, aqueous suspension formulation comprising an immunosuppressive agent without any other active ingredient, or in concert with at least one other active ingredient at appropriate dosages of the at least one other active ingredient as are known in the art to achieve a desired treatment, for example as defined by routine testing in order to obtain optimal efficacy while minimizing any potential toxicity.

[0101] In certain embodiments, the pharmaceutical formulations of the disclosure comprise an immunosuppressive agent that can be used alone, e.g., a ready-to-use, surfactant free, oral, aqueous suspension formulation comprising tacrolimus or a polymorph thereof without any other immunosuppressive agent, or in concert with at least one other immunosuppressive agent at appropriate dosages of the at least one other immunosuppressive agent as are known in the art to achieve a desired treatment. In certain embodiments, the other immunosuppressive agent is selected from the group consisting of azathioprine, mycophenolate mofetil, corticosteroids, and mixtures thereof.DOSING REGIMEN

[0102] Suitable therapeutically effective amounts and dosage regimens utilizing a pharmaceutical formulation of the disclosure can be selected by the ordinarily skilled clinician in accordance with a variety of factors, including species, age, weight, sex, and overall medical condition of the patient; the condition to be treated and its severity or penetration; the renal and hepatic function of the patient; and the particular pharmaceutical formulation employed.

[0103] In some embodiments, the dosing for the immunosuppressive agent can be weight based and titrated based on a patient’s blood levels. In certain embodiments, the immunosuppressive agent comprising pharmaceutical formulations of the disclosure can be administered in low dose amount. The phrase “low dose” or “low dose amount” of an immunosuppressive agent in the context of the present disclosure refers to the use of a particular amount of an immunosuppressive drug that is lower than typically used for immunosuppression, for example lower than typically used, or commercially available, for immunosuppression in a human. In one embodiment, the low dose amount refers to the use of a particular amount that is lower than typically used, or commercially available, for immunosuppression of a human organ transplant recipient that is calculated to prevent rejection.

[0104] In certain embodiments a low dose of an immunosuppressive agent, for example tacrolimus or polymorphs thereof, is less than about 1 / 2, 1 / 3, 1 / 4, 1 / 5, 1 / 6, 1 / 7, 1 / 8, 1 / 9, 1 / 10, 1 / 11, 1 / 12, 1 / 13, 1 / 14, or less than about 1 / 15 of a normal dose used for immunosuppression in humans. In certain embodiments, the low dose of tacrolimus is about or less than about 1 / 10 of the amount used for immunosuppression in humans.

[0105] In other embodiments, the low dose tacrolimus comprises about or less than 1 / 2, 1 / 3, 1 / 4, 1 / 5, 1 / 6, 1 / 7, 1 / 8, or about or less than about 1 / 9 of the amount used for immunosuppression in humans. In further embodiments, the low dose tacrolimus comprises about or less than about 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, 0.2, 0.1, 0.09, 0.08, 0.07, 0.06, 0.05, 0.04, 0.03, 0.02, 0.01, 0.009, 0.08, or 0.07 times than the typical amount used for a particular situation in humans to generate immunosuppression.

[0106] In other embodiments, the daily dose of tacrolimus will range from about O.Olmg / kg / day to about 1 mg / kg / day with the total daily dose being administered in divided doses such as two, three or four times a day. The following Table 2 provides some examples of the desired dosing of Tacrolimus:Table 2

[0107] Dosing should be titrated based on clinical assessments of rejections and tolerability. A lower dose than the recommended initial dose may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early post-transplant. The above dose may be adjusted based on other conditions such as renal or hepatic impairment levels.

[0108] Pediatric patients in general need a higher tacrolimus dose compared to adults. The higher dose requirement may decrease as the child grows older. Table 2 lists recommended initial dosing for pediatric transplant patients along with the whole blood concentration range.

[0109] In lung transplantation, cystic fibrosis patients may have a reduced bioavailability of orally administered tacrolimus resulting in need for higher doses to achieve target trough concentrations. Tacrolimus trough concentrations are monitored to adjust the dose accordingly.

[0110] Due to potential of tacrolimus for nephrotoxicity, patients who have received a liver, heart, or lung transplant, and have pre-existing renal impairment, require lower end of the therapeutic dose range. In kidney transplant patients with post-operative oliguria, the initial dose of tacrolimus suspension composition of the disclosure should be administered no sooner than 6 hours and within 24 hours of transplantation but may be delayed until renal function shows evidence of recovery.

[0111] Due to potential of reduced clearance and prolonged half-life of tacrolimus, patients with severe hepatic impairment may require low doses of tacrolimus suspension composition of the disclosure. In such cases, close monitoring of blood pressure is warranted. The use of tacrolimus suspension composition of the disclosure in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole blood concentrations of tacrolimus. These patients should be monitored closely, and dosage adjustment should be considered. In certain embodiments, the patients with hepatic impairment are dose adjusted to lower doses (lower than the standard prescribing dose).

[0112] In certain embodiments, the factors influencing frequency of monitoring include but are not limited to hepatic or renal dysfunction, the addition or discontinuation of potentially interacting drugs and the post-transplant time. In certain embodiments, blood concentration monitoring is not a replacement for renal and liver function monitoring and tissue biopsies. In certain embodiments, whole blood concentrations are most variable during the first week of post-transplantation.

[0113] In certain embodiments, the relative risks of toxicity and efficacy failure are related to tacrolimus whole blood trough concentration. Therefore, monitoring of whole blood trough concentration is recommended to assist in the clinical evaluation of toxicity and efficacy failure.

[0114] In certain embodiments, the disclosure provides conversion from PROGRAF® granule doses to doses of tacrolimus suspension composition of the disclosure on 1: 1 basis.

[0115] In certain embodiments, ready -to-use, surfactant free, oral, liquid, suspension formulations of the present disclosure comprise a low dose of tacrolimus (e.g., ready -to-use, low dose tacrolimus suspension formulations). In certain embodiments, the low-dose tacrolimus suspension formulations comprise tacrolimus (or polymorph thereof) in an amount of about 0.01 %w / v to about 1.0 %w / v, about 0.01 %w / v to 0.90 %w / v, about 0.01 %w / v to about 0.80 %w / v, about 0.01 %w / v to about 0.70 %w / v, about 0.01 %w / v to about 0.60 %w / v, about 0.01 %w / v to about 0.50 %w / v, about 0.01 %w / v to about 0.40 %w / v, about 0.01 %w / v to about 0.30 %w / v, about 0.01 %w / v to about 0.20 %w / v, about 0.01 %w / v to about 0.10 %w / v, and about 0.01 %w / v to about 0.05 %w / v. In certain embodiments, the low-dose tacrolimus suspension formulations comprise 0.05 %w / v to 0.1 %w / v of tacrolimus (or polymorph thereof).

[0116] In certain embodiments, the therapeutically effective amount of the immunosuppressive agent can be determined by the attending physician and may depend on the target therapeutic blood level to achieve immunosuppression without inducing toxicity, as well as the condition treated, the compound administered, the route of delivery, the age, weight, severity of the patient's symptoms and response pattern of the patient. In certain embodiments, the immunosuppressive agent may be administered in an amount that achieves immunosuppression without inducing negative effects of a low therapeutic blood level (e.g., rejection of an organ) or a high therapeutic blood level (e.g., toxicity).

[0117] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the present disclosure comprise about 0.01 mg / ml to about 10 mg / ml of tacrolimus. The concentration can be less than about 10 mg / ml, 9 mg / ml, 8 mg / ml, 7 mg / ml, 6 mg / ml, 5 mg / ml,4 mg / ml, 3 mg / ml, 2 mg / ml, 1 mg / ml, 0.9 mg / ml, 0.8 mg / ml, 0.7 mg / ml, 0.6 mg / ml, 0.5 mg / ml, 0.4 mg / ml, 0.3 mg / ml, 0.2 mg / ml, 0.1 mg / ml, 0.09 mg / ml, 0.08 mg / ml, 0.07 mg / ml, 0.06 mg / ml, 0.05 mg / ml, 0.04 mg / ml, 0.03 mg / ml, 0.02 mg / ml or 0.01 mg / ml. In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the present disclosure comprise about 0.1 to about 1.5 mg / ml, or about 0.1 to about 1.0 mg / ml of tacrolimus or polymorphs thereof. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the present disclosure comprise 0.2 mg / ml of anhydrous tacrolimus. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the present disclosure comprise about 1 mg / ml of anhydrous tacrolimus.

[0118] Therapeutically effective amounts of tacrolimus may be administered on a regular schedule, i.e., daily, weekly, monthly, or yearly basis or on an irregular schedule with varying administration days, weeks, months, etc. Alternatively, the therapeutically effective amount of tacrolimus to be administered may vary. In certain embodiments, the therapeutically effective tacrolimus amount for the first dose is higher than the therapeutically effective tacrolimus amount for one or more of the subsequent tacrolimus doses. In certain embodiments, the therapeutically effective tacrolimus amount for the first dose is lower than the therapeutically effective tacrolimus amount for one or more of the subsequent tacrolimus doses. In certain embodiments, equivalent tacrolimus doses may be administered over various time periods including, but not limited to, about every 2 hours, about every 6 hours, about every 8 hours, about every 12 hours, about every 24 hours, about every 36 hours, about every 48 hours, about every 72 hours, about every week, about every two weeks, about every three weeks, about every month, and about every two months. Alternatively, equivalent tacrolimus doses may be administered over uneven intervals in accordance with the recommended treatment of a health-care practitioner. The number and frequency of tacrolimus doses corresponding to a completed course of therapy will be determined according to the judgment of a health-care practitioner. The therapeutically effective amounts described herein refer to total amounts administered for a given time period; that is, if more than one immunosuppressive agent is administered, the therapeutically effective amounts correspond to the total amount administered.

[0119] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus may be administered at least once a week over the course of several weeks. In certain embodiments, the suspension formulations of thedisclosure are administered at least once a week over several weeks to several months. In another embodiment, the suspension formulations of the disclosure are administered once a week over four to eight weeks. In yet another embodiment, the ready-to-use suspension formulations of the disclosure are administered once a week over four weeks.

[0120] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered at least once a day for about 2 days, at least once a day for about 3 days, at least once a day for about 4 days, at least once a day for about 5 days, at least once a day for about 6 days, at least once a day for about 7 days, at least once a day for about 8 days, at least once a day for about 9 days, at least once a day for about 10 days, at least once a day for about 11 days, at least once a day for about 12 days, at least once a day for about 13 days, at least once a day for about 14 days, at least once a day for about 15 days, at least once a day for about 16 days, at least once a day for about 17 days, at least once a day for about 18 days, at least once a day for about 19 days, at least once a day for about 20 days, at least once a day for about 21 days, at least once a day for about 22 days, at least once a day for about 23 days, at least once a day for about 24 days, at least once a day for about 25 days, at least once a day for about 26 days, at least once a day for about 27 days, at least once a day for about 28 days, at least once a day for about 29 days, at least once a day for about 30 days, or at least once a day for about 31 days. In certain embodiments, the suspension formulations of the disclosure can be administered at least once a day for longer periods, e.g., from about one month to about one year or more, depending upon the patient’s condition.

[0121] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered at least twice a day for about 2 days, at least twice a day for about 3 days, at least twice a day for about 4 days, at least twice a day for about 5 days, at least twice a day for about 6 days, at least twice a day for about 7 days, at least twice a day for about 8 days, at least twice a day for about 9 days, at least twice a day for about 10 days, at least twice a day for about 11 days, at least twice a day for about 12 days, at least twice a day for about 13 days, at least twice a day for about 14 days, at least twice a day for about 15 days, at least twice a day for about 16 days, at least twice a day for about 17 days, at least twice a day for about 18 days, at least twice a day for about 19 days, at least twice a day for about 20 days, at least twice a day for about 21 days, at least twice a day for about 22 days, at least twice a day for about 23 days, at least twice a day for about 24 days, at least twice a day for about25 days, at least twice a day for about 26 days, at least twice a day for about 27 days, at least twice a day for about 28 days, at least twice a day for about 29 days, at least twice a day for about 30 days, or at least twice a day for about 31 days. In certain embodiments, the ready -to-use suspension formulations of the disclosure can be administered at least twice a day for longer periods, e.g., from about one month to about one year or more, depending upon the patient’s condition.

[0122] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered every other day for about 2 days, every other day for about 3 days, every other day for about 4 days, every other day for about 5 days, every other day for about 6 days, every other day for about 7 days, every other day for about 8 days, every other day for about 9 days, every other day for about 10 days, every other day for about 11 days, every other day for about 12 days, every other day for about 13 days, every other day for about 14 days, every other day for about 1 days, every other day for about 16 days, every other day for about 17 days, every other day for about 18 days, every other day for about 19 days, every other day for about 20 days, every other day for about 21 days, every other day for about 22 days, every other day for about 23 days, every other day for about 24 days, every other day for about 25 days, every other day for about 26 days, every other day for about 27 days, every other day for about 28 days, every other day for about 29 days, every other day for about 30 days, or every other day for about 31 days or more. In certain embodiments, the ready-to-use suspension formulations of the disclosure can be administered every other day for longer periods, e g., from about one month to about one year or more, depending upon the patient’s condition.

[0123] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered about once every day, about once every 2 days (also sometimes stated herein as once every other day), about once every 3 days, about once every 4 days, about once every 5 days, about once every 6 days, about once every 7 days, about once every 8 days, about once every 9 days, about once every 10 days, about once every 11 days, about once every 12 days, about once every 13 days, about once every 14 days, about once every 15 days, about once every 16 days, about once every 17 days, about once every 18 days, about once every 19 days, about once every 20 days, about once every 21 days, about once every 22 days, about once every 23 days, about once every 24 days, about once every 25 days, about once every 26 days, about once every 27 days, about once every 28 days, about once every 29 days, about once every 30 days, or about once every 31 days. In certainembodiments, the ready-to-use suspension formulations of the disclosure, can be administered every other day.

[0124] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered about once every week, about once every 2 weeks, about once every 3 weeks, about once every 4 weeks, about once every 5 weeks, about once every 6 weeks, about once every 7 weeks, about once every 8 weeks, about once every 9 weeks, about once every 10 weeks, about once every 11 weeks, about once every 12 weeks, about once every 13 weeks, about once every 14 weeks, about once every 15 weeks, about once every 16 weeks, about once every 17 weeks, about once every 18 weeks, about once every 19 weeks, or about once every 20 weeks.

[0125] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered at least about once every month, about once every 2 months, about once every 3 months, about once every 4 months, about once every 5 months, about once every 6 months, about once every 7 months, about once every 8 months, about once every 9 months, about once every 10 months, about once every 11 months, or about once every 12 months.

[0126] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered at least once a week for about 2 weeks, at least once a week for about 3 weeks, at least once a week for about 4 weeks, at least once a week for about 5 weeks, at least once a week for about 6 weeks, at least once a week for about 7 weeks, at least once a week for about 8 weeks, at least once a week for about 9 weeks, at least once a week for about 10 weeks, at least once a week for about 11 weeks, at least once a week for about 12 weeks, at least once a week for about 13 weeks, at least once a week for about 14 weeks, at least once a week for about 15 weeks, at least once a week for about 16 weeks, at least once a week for about 17 weeks, at least once a week for about 18 weeks, at least once a week for about 19 weeks, or at least once a week for about 20 weeks.

[0127] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising tacrolimus can be administered at least once a week for about 1 month, at least once a week for about 2 months, at least once a week for about 3 months, at least once a week for about 4 months, at least once a week for about 5 months, at least once a week for about 6 months, at least once a week for about 7 months, at least once a week for about8 months, at least once a week for about 9 months, at least once a week for about 10 months, at least once a week for about 11 months, or at least once a week for about 12 months.

[0128] The term “tacrolimus,” as used herein, includes tacrolimus and any polymorphs thereof. In certain embodiments, tacrolimus is anhydrous tacrolimus. In certain embodiments, tacrolimus is tacrolimus monohydrate.METHOD OF TREATMENT

[0129] In certain embodiments, the disclosure provides a method for prophylaxis of organ rejection in a patient receiving allogeneic liver, kidney, heart, or lung transplant; the method comprising administering to the patients a ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure, comprising an immunosuppressant selected from the group comprising cyclosporine, tacrolimus, sirolimus, everolimus, polymorphs thereof, and mixtures thereof. In certain embodiments, the immunosuppressive agent is tacrolimus or a polymorph thereof. In certain embodiments, the immunosuppressive agent is anhydrous tacrolimus. In certain embodiments, the immunosuppressive agent is tacrolimus monohydrate.

[0130] In certain embodiments, the disclosure provides a method for prophylaxis of organ rejection in a patient receiving allogeneic liver, kidney, heart, or lung transplant, the method comprising administering to the patient a ready-to-use, surfactant free, oral, aqueous suspension formulation comprising tacrolimus or a polymorph thereof; wherein the ready-to-use suspension is administered in combination with other immunosuppressants. In certain embodiments, the ready-to-use suspension formulation includes anhydrous tacrolimus. In certain embodiments, the ready-to-use suspension formulation includes tacrolimus monohydrate. In certain embodiments, the other immunosuppressants include azathioprine (AZ), mycophenolate mofetil (MMF), and / or corticosteroids.

[0131] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure comprising an immunosuppressive agent can be administered in a dosing regimen or treatment method comprising orally administering the ready-to-use suspension formulations to a subject who has received an organ or stem cell transplant, including, without limitation, liver, kidney, small bowel, skin, heart, lung, trachea, cornea, bone marrow, limb, intestine, and pancreas. In certain embodiments, the treatment regimen can be applied to composite tissue transplantation. In certain embodiments, the composite tissue can be hand, face, or any other anatomical part. In certain embodiments, the ready-to-use suspension formulationincludes anhydrous tacrolimus. In certain embodiments, the ready-to-use suspension formulation includes tacrolimus monohydrate.

[0132] In certain embodiments, the ready-to-use surfactant free, oral, aqueous liquid, suspension formulations of the disclosure comprising an immunosuppressive agent can be administered in a dosing regimen for the treatment of toxic liver injury such as acetaminophen or fulminant hepatitis. In certain embodiments, the ready-to-use, oral, aqueous suspension formulations comprising immunosuppressive agents can be useful in the prophylaxis / treatment of patients with ischemic injury and / or shock. In certain embodiments, the immunosuppressive agent is anhydrous tacrolimus. In certain embodiments, the immunosuppressive agent is tacrolimus monohydrate. Although much of the present disclosure is made in the context of organ or stem cell transplantation, it should be recognized that the treatment regimens are broadly applicable, as noted above, and should not be construed as limited to organ or stem cell transplantation.

[0133] In certain embodiments, the treatment regimen of the present disclosure can recruit regulatory T-cells to the organ transplant site. Because regulatory T-cells are involved in controlling autoimmune diseases including, but not limited to, type 1 diabetes, experimental autoimmune encephalomyelitis, and inflammatory bowel disease, the mobilization of stem cells may have broader clinical applications rather than transplantation. In certain embodiments, the ready-to-use oral, liquid, suspension formulations of the disclosure comprising an immunosuppressive agent can be used to treat various T-cell mediated autoimmune diseases. In certain embodiments, the suspension formulations of the present disclosure can be used to treat atopic dermatitis, or other dermatologic conditions. In certain embodiments, the immunosuppressive agent is anhydrous tacrolimus. In certain embodiments, the immunosuppressive agent is tacrolimus monohydrate.

[0134] In certain embodiments, the ready-to-use, oral, aqueous suspension formulations of the present disclosure may be formulated neat with immunosuppressive agent alone or with an immunosuppressive agent and one or more pharmaceutically acceptable excipients for administration. The amount of the pharmaceutically acceptable excipients(s) is determined by a number of factors and considerations including the solubility and chemical nature of the active ingredient (e.g., immunosuppressive agent), chosen route of administration and standard pharmacological practice. The excipients may be in dry or aqueous form and must be pharmaceutically acceptable.

[0135] In certain embodiments, the ready-to-use, surfactant free, oral, aqueous suspension formulations of the disclosure are sub-divided to contain appropriate quantities of the immunosuppressive agent. For example, the unit dosage can be packaged formulations, e.g., vials, ampoules, prefdled syringes, bottles or sachets containing liquids. In certain embodiments, the ready-to-use suspension formulation is packaged in any suitable container, e.g., an amber glass bottle with a child resistant closure. In certain embodiments, the amber glass bottler may further comprise a press in bottle adapter, with or without a dip tube that will allow a user to withdraw the appropriate amount of the aqueous suspension into a dosing syringe. The packaged formulations may further include printed instructions describing the use and administration of the dosage form as well as dosing materials such as one or more dosing cups or one or more oral dosing syringes, with or without graduated volume markings. In certain embodiments the dosing cup or oral dosing syringe include markings indicating the volume of the dosage form in the dosing cup or oral dosing syringe, preferably in increments of 0.1 ml, 0.25 ml, 0.5 ml, 1 ml, or any intermediate volumes therein.

[0136] In certain embodiments, the injury which triggers administration of the first dose of the ready-to-use, surfactant free, oral, aqueous suspension formulation of the disclosure comprising an immunosuppressive agent can be any tissue injury that signals or indicates that a particular treatment is necessary. In certain embodiments, the tissue injury can be an organ transplant (including liver, kidney, small bowel, skin, heart, lung, trachea, cornea, bone marrow, limb, intestine, and pancreas) or the diagnosis of a T-cell mediated disease or other autoimmune or inflammatory disease or the occurrence of an episode of a T-cell mediated disease or other autoimmune or inflammatory disease. In certain embodiments, the administration of first dose is immediately upon occurrence of the tissue injury, or as soon thereafter as is practical or medically feasible, for example on the same day that the tissue injury occurred or was observed, such as within about one minute, five minutes, thirty minutes, sixty minutes, ninety minutes, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours, 12 hours, 13 hours, 14 hours, 15 hours, 16 hours, 17 hours, 18 hours, or intermediate periods therein, after occurrence of the tissue injury. In some embodiments, administration of the first dose can be delayed from the occurrence of the tissue injury, for example by about one day, 2 days, 3 days, 4 days, 5 days, 6 days or 7 days.

[0137] In certain embodiments, the disclosure provides therapeutic methods comprising administering to a subject in need of a ready -to-use, surfactant free, oral, aqueous suspension formulation comprising tacrolimus or a polymorph thereof, wherein administration of the formulation achieves a reduction in adverse events as compared to other marketed tacrolimus formulations (e.g., PROGRAF® (oral granules for suspension); ASTAGRAF®XL (oral capsules); ENVARSUS®XR (extended release oral tablet); and PROTOPIC® (topical formulation)). In certain embodiments, the adverse events being reduced can comprise cardiac damage, hypertension, blurred vision, liver problems, tacrolimus nephrotoxicity, hyperkalemia, loss of appetite, insomnia, seizures, and catatonia (among other things). In certain embodiments, reduction in adverse events comprises a reduction in the duration of a subject’s pain, discomfort, inflammation and / or weakness (among other things). In certain embodiments, the disclosure provides methods for improving patient / subject compliance comprising administering to said patient / subject in need thereof a ready -to-use, oral, aqueous suspension formulation comprising tacrolimus or a polymorph thereof.

[0138] In certain embodiments, the disclosure provides ready -to-use, surfactant free, oral, aqueous suspension formulations comprising an immunosuppressive agent for inhibiting calcineurin. In certain embodiments, the suspension formulation for inhibiting calcineurin comprises tacrolimus or a polymorph thereof. In certain embodiments, the disclosure provides ready-to-use, surfactant free, oral, aqueous suspension formulations comprising tacrolimus or a polymorph thereof for targeting FKBP12.

[0139] In certain embodiments, the disclosure provides therapeutic methods for inhibiting calcineurin. In certain embodiments, the therapeutic methods of inhibiting calcineurin comprise administering to a subject in need a ready-to-use, surfactant free, oral, aqueous suspension formulation comprising tacrolimus. In certain embodiments, the disclosure provides therapeutic methods of targeting FKBP12. In certain embodiments, the therapeutic methods of targeting FKBP12 comprise administering to a subject in need a ready-to-use, oral, aqueous suspension formulation comprising tacrolimus.

[0140] In certain embodiments, the disclosure provides methods of increasing the bioavailability of an immunosuppressive agent in a patient, the method comprising administering to the patient a ready-to-use, surfactant free, oral, aqueous suspension formulation comprising the immunosuppressive agent and at least one suspending agent. In certain embodiments, theimmunosuppressive agent is tacrolimus or a polymorph thereof. Tn certain embodiments, the immunosuppressive agent is anhydrous tacrolimus. In certain embodiments, the immunosuppressive agent is tacrolimus monohydrate.STORAGE STABILITY OF READY TO USE AQUEOUS SUSPENSION FORMULATIONS

[0141] The pharmaceutical formulations disclosed herein comprise ready-to-use, surfactant free, oral, aqueous suspension formulations of tacrolimus or a polymorph thereof (ready-to-use, surfactant free tacrolimus suspension formulations) having improved stability profiles. The suspension formulations of the disclosure are stable under standard storage conditions and accelerated conditions. The total amount of impurities in the formulations may be not more than about 0.1 to 3%, and standard storage conditions may comprise a temperature of about 20 to 25°C (i.e., room temperature) and no more than about 40% Relative Humidity (RH). In one embodiment, the formulations disclosed herein are stable at room temperature for 18 to 24 months or longer. The stability of the suspension formulations of the disclosure is determined, for example, by measuring the physical state of the formulation, including the viscosity and presence of any discoloration and chemical stability by measuring assay of API & related compound.

[0142] In certain embodiments, the ready-to-use, surfactant free tacrolimus suspension formulations of the disclosure are stable when subject to predetermined conditions for predetermined times. For example, suspension formulations of the disclosure can be stored at various predetermined temperatures and relative humidities for defined or predetermined time periods, for example in an open or closed container. In certain embodiments, ready-to-use, oral, aqueous suspension formulations of the disclosure comprising tacrolimus or a polymorph thereof are stable upon storage at about 0, 2, 5, 8, 10, 15, 20, 25, 30, 37, 40 or 45 degrees Celsius and about 0%, 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95% or 100% relative humidity for a period of at least about 0.5, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5,9, 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 13.5, 14, 14.5, 15, 20, 25, 30, 35, 40, 45, 48, 50, 51, 52, 53, 55 or 60 hours 1 week, 2 weeks, 3 weeks or 4 week; 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, one year, 18 months, or 24 months.

[0143] In certain embodiments, the disclosure provides ready-to-use, surfactant free tacrolimus suspension formulations, wherein the formulations are stable upon storage in an open or closed container for 12 months at room temperature (CRT) conditions of 25°C and 60% RH; 6 month storage under interim storage conditions (ISC) of 30°C and 65% RH; or 6 month storage under accelerated (ACC) storage conditions of 40°C and 75% RH. In certain embodiments, “storage in an open container” means that the container was opened twice a day for a given period of time, for example up to four weeks, but was otherwise left closed.

[0144] In certain embodiments, the disclosure provides storage stability of the ready-to-use, surfactant free tacrolimus suspension formulations, following a 12 month storage in amber colored glass bottles with a tightly sealed child resistant closure under controlled room temperature (CRT) conditions of 25°C and 60% RH; 6 month storage under interim storage conditions (ISC) of 30°C and 65% RH; and 6 month storage under accelerated (ACC) storage conditions of 40°C and 75% RH. Table 3 provides 6-month and 12-month storage stability of the ready-to-use suspension formulation comprising anhydrous tacrolimus, at least one suspending agent, and at least one pH adjusting agent, wherein the suspension is free of surfactant. The suspension was packed in a 60 mL amber colored glass bottle with a tightly sealed child resistant closure and placed on stability.Table 3

[0145] Data from Table 3 clearly demonstrates that the ready-to-use tacrolimus suspension formulation exhibits excellent storage stability under CRT conditions, ISC, and ACC conditions. The ready-to-use suspension formulation on storage under various storage conditions includes the tacrolimus 8 epimer impurity in an amount of 0.11% or less, which is substantially lower than theimpurity specification of 0.5%. Similarly, the ready-to-use tacrolimus suspension formulation on storage under various storage conditions includes the individual highest unknown impurity in an amount of 0.086% or less, which is less than half of the impurity specification of 0.2%.

[0146] Table 4 provides purity assay of the active pharmaceutical ingredient (anhydrous tacrolimus) from the surfactant free aqueous suspension composition of the disclosure comprising annhydrous tacrolimus, at least one suspending agent, and at least one pH adjusting agent, at 12 M storage at room temperature (CRT), 6M storage in Intermediate storage conditions (ISC), and 6M storage in accelerated storage conditions. The data from Table 4 clearly demonstrates that the surfactant free aqueous suspension compositions of the disclosure exhibit good stability whereby the assay value is greater than 99%.Table 4

[0147] In certain embodiments, the ready-to-use, surfactant free tacrolimus suspension formulations can be stored for at least three months, four months, five months, six months, or longer under refrigerated conditions, preferably at a temperature between about 0°C and about 10°C and more preferably between about 2°C and about 8°C when packaged in a single or multiple dose amber glass bottle with a conventional child resistant screw cap and with or without a pressin bottle adapter / orifice reducer with a dip tube. In certain embodiments the suspension formulations will exhibit the following impurity profiles as determined by High Performance Liquid Chromatography (HPLC) analysis when stored under refrigerated conditions in an amber glass bottle with a conventional child resistant screw cap:Table 5

[0148] Table 6 provides preferred and most preferred impurity profiles of the ready-to-use, oral, aqueous suspension formulations of disclosure comprising tacrolimus or a polymorph thereof.Table 6

[0149] In certain embodiments, the disclosure provides ready-to-use, surfactant free tacrolimus suspension formulations that are free of any surfactant. In certain embodiments, the ready-to-use, surfactant free tacrolimus suspension formulations can be stored for at least three months, four months, five months, six months, or longer at ambient conditions or room temperature, i.e., without the need for refrigeration, or under CRT conditions, when packaged in a single or multiple dose amber glass bottle with a conventional child resistant screw cap as described above. In certain embodiments the ready-to-use, surfactant free tacrolimus suspension formulations of the disclosure exhibit the following impurity profiles as determined by HPLC analysis when stored at ambient conditions in an amber glass bottle with a conventional child resistant screw cap:Table 7

[0150] In certain embodiments, the disclosure provides suitable packages or containers that can be used to hold and dispense the ready -to-use, surfactant free tacrolimus suspension formulations. In certain embodiments, the package comprises labeled ampules, dial dispenser package, or bottle. In certain embodiments, the bottle can be an amber glass bottle as previously described. In certain embodiments, the package can be a single dose package or can contain multiple doses of the suspension formulation.

[0151] In certain embodiments, the disclosure provides kits comprising a means for containing any type of packaging that houses the unit dosage forms, for example bottles or vials, which can (for example) be held in close confinement for commercial sales such as, e.g., injection or blow- molded plastic containers into which the bottles or vials are retained.METHOD OF MANUFACTURE

[0152] In certain embodiments, the disclosure provides methods for manufacturing ready -to-use, surfactant free, oral, aqueous suspension formulations comprising at least one immunosuppressive agent. The method comprises adding purified water and one or more excipients selected from the group comprising suspending agent, sweetener, pH adjusting agent / buffering agent, and preservative in a stainless steel container and mixing to obtain a solution; adding an immunosuppressive agent to the solution with homogenization to obtain a uniform suspension; adding flavoring agent to the suspension; and finally diluting the suspension to a desired final volume. The ready-to-use, suspension formulations of the disclosure are made under continuous inert gas purging and / or sparging.

[0153] In certain embodiments, the inert gas is selected from the group comprising nitrogen, argon, helium, and mixtures thereof.

[0154] In certain embodiments, the immunosuppressive agent is selected from the group comprising cyclosporine, tacrolimus, sirolimus, everolimus and mixtures thereof. In certain embodiments, the immunosuppressive agent is tacrolimus or a polymorph thereof. In certain embodiments, the immunosuppressive agent is anhydrous tacrolimus.

[0155] In certain embodiments, the aqueous suspension formulation of the disclosure can be filled into single or multiple dose container such as amber glass bottles with continuous nitrogen purging / sparging and sealed with a screw cap.METHOD OF ADMINISTRATION

[0156] In certain embodiments, the disclosure provides a method of administering ready-to-use, surfactant free, oral, liquid, suspension formulations of the disclosure comprising at least one immunosuppressive agent, stored in single or multiple dose amber glass bottles, the method comprising: determining the desired dose to be administered to a patient in need thereof; calculating suspension volume containing the desired dose; measuring the suspension volume using a dosing device; and administering the suspension to the patient.

[0157] In certain embodiments, the desired dose amount can be determined by the attending physician and may depend on the target therapeutic blood level to achieve immunosuppression without inducing toxicity, as well as the condition treated, the compound administered, the route of delivery, the age, weight, severity of the patient's symptoms and response pattern of the patient.

[0158] In certain embodiments, the immunosuppressive agent may be administered in an amount that achieves immunosuppression without inducing negative effects of a low therapeutic blood level (e.g., rejection of an organ) or a high therapeutic blood level (e.g., toxicity). In certain embodiments, the dosing device is a cup, spoon or syringe. The ready-to-use suspension formulation can be administered without further manipulation of the suspension formulation such as suspending, diluting, or combining with additional components.

[0159] In certain embodiments, the dosing should be titrated based on clinical assessments of rejections and tolerability. A lower dose than the recommended initial dose may be sufficient as maintenance therapy. Adjunct therapy with adrenal corticosteroids is recommended early posttransplant. The above dose may be adjusted based on other conditions such as renal or hepatic impairment levels.

[0160] In certain embodiments, pediatric patients require a higher tacrolimus dose compared to adults. The higher dose requirement may decrease as the child grows older. Table 2 lists recommended initial dosing for pediatric transplant patients along with the whole blood concentration range.

[0161] In certain embodiments, patients with lung transplantation or cystic fibrosis may have a reduced bioavailability of orally administered tacrolimus resulting in need for higher doses to achieve target trough concentrations. The tacrolimus trough concentrations are monitored to adjust the dose accordingly.

[0162] In certain embodiments, due to potential of tacrolimus for nephrotoxicity, patients who have received a liver, heart, or lung transplant, and have pre-existing renal impairment, require lower end of the therapeutic dose range. In kidney transplant patients with post-operative oliguria, the initial dose of tacrolimus suspension composition of the disclosure should be administered no sooner than 6 hours and within 24 hours of transplantation but may be delayed until renal function shows evidence of recovery.

[0163] In certain embodiment, due to potential of reduced clearance and prolonged half-life of tacrolimus, patients with severe hepatic impairment may require low doses of tacrolimus suspension composition of the disclosure. In such cases, close monitoring of blood pressure is warranted. The use of tacrolimus suspension composition of the disclosure in liver transplant recipients experiencing post-transplant hepatic impairment may be associated with increased risk of developing renal insufficiency related to high whole blood concentrations of tacrolimus. These patients should be monitored closely, and dosage adjustment should be considered. In certain embodiments, the patients with hepatic impairment are dose adjusted to lower doses (lower than the standard prescribing dose).

[0164] In certain embodiments, the factors influencing frequency of monitoring include but are not limited to hepatic or renal dysfunction, the addition or discontinuation of potentially interacting drugs and the post-transplant time. In certain embodiments, blood concentration monitoring is not a replacement for renal and liver function monitoring and tissue biopsies. In certain embodiments, whole blood concentrations are most variable during the first week of post-transplantation.

[0165] In certain embodiments, the relative risks of toxicity and efficacy failure are related to tacrolimus whole blood trough concentration. Therefore, monitoring of whole blood trough concentration is recommended to assist in the clinical evaluation of toxicity and efficacy failure.

[0166] Once the appropriate amount volume of the suspension formulation is in the dosing device, the patient or care provider may administer the formulation. In the case of a single dose bottle or syringe, the patient or care provider will not be required to measure the appropriate volume into a dosing device but may orally administer the oral aqueous suspension formulation directly from the single dose bottle or dosing syringe to the patient. The ready-to-use, suspension formulations of the disclosure do not require any reconstitution (mixing with water for reconstitution) prior to use or administration.

[0167] Further included herein are embodiments comprising methods of manufacturing and / or stabilizing the pharmaceutical formulation embodiments described herein. Also included are methods for prophylaxis of organ rejection in patients receiving allogeneic liver, kidney, or heart transplants, in combination with other immunosuppressants; and methods for treating an organ or stem cell transplant recipient, for preventing or lowering the risk of organ rejection, or for treating a T-cell mediated disease, comprising administering to a subject in need a pharmaceutical formulation according to the present disclosure. The disclosure further includes methods for inhibiting the effects of interleukin-2 (lowering the risk of organ rejection in a transplant patient / subject) comprising administering to the subject in need a pharmaceutical formulation according to the present disclosure.

[0168] Further included herein are embodiments comprising a dosage form or a kit comprising one or more dosage forms and instructions for administering the dosage forms to a subject in need, wherein the dosage forms comprise a ready-to-use, aqueous suspension formulation of the present disclosure, for a) prophylaxis of organ rejection in patients receiving allogeneic liver, kidney, or heart transplants, in combination with other immunosuppressants, and / or b) treating an organ or stem cell transplant recipient or a T-cell mediated disease.EXAMPLES

[0169] Below are examples of formulations of Tacrolimus oral suspensions according to embodiments of the present disclosure.Example 1: Formulation Composition of Tacrolimus Oral Suspension 1.0 mg / mLTable 8*QS = Quantity Sufficient.

[0170] Suspensions 1 and 2 were manufactured according to the following procedure.1. Purified water was taken in a stainless-steel container.2. Xanthan gum, sucralose, sorbitol solution, glycerin, sodium benzoate, and citric acid were added to the stainless-steel container from step #1 and stirred to obtain a solution.3. A portion of the solution from step #2 was taken in a separate stainless-steel container.4. Anhydrous Tacrolimus was added into the solution from step #3, dispersed and homogenized to obtain a uniform dispersion.5. The uniform dispersion from step #4 was added to the remaining solution from step #2 and mixed to obtain a uniform dispersion.6. Strawberry flavor was added into the dispersion from step #5.Purified water was added to the dispersion from step #6 in QS to 100%.Example 2: Storage Stability of Tacrolimus Suspensions with and without Surfactant

[0171] Storage stability of Suspension 1 (without surfactant) was determined with 12 month storage in amber colored glass bottles with a tightly sealed child resistant closure under controlled room temperature (CRT) conditions of 25°C and 60% relative humidity (RH); 6 month storage under interim storage conditions (ISC) of 30°C and 65% relative humidity (RH); and 6 month storage under accelerated (ACC) storage conditions of 40°C and 75% RH. Storage stability of Suspension 2 (with surfactant) was determined with 12-month storage in amber colored glass bottles with a tightly sealed child resistant closure under CRT storage conditions. Table 9 compares 6-month and 12-month storage stability of Suspensions 1 and 2, under various storage conditions. The suspensions were packed individually in 60 mL amber colored glass bottles with a tightly sealed child resistant closure and placed on stability.Table 9

[0172] Data from Table 2 clearly demonstrates that Suspension 1 without a surfactant exhibits excellent storage stability under CRT conditions, ISC, and ACC conditions.Example 3: Effect of Particle Size Distribution on Dissolution of Anhydrous Tacrolimus

[0173] Dissolution of Tacrolimus suspension compositions of the disclosure (Suspension 1) with D90 particle size of ~ 44pm, 24pm, 7pm, and 5.5pm; and PROGRAF® granules (marketed tacrolimus oral granules for suspension) were conducted using USP Apparatus II (Paddle method) at 50 rpm and 37°C, in a pH 4.5 dissolution medium comprising 0.005% hydroxypropyl cellulose (HPC) and phosphoric acid. Dissolution of PROGRAF® capsule composition was conducted using USP Apparatus II (Paddle method) at 100 rpm and 37°C, in a pH 4.5 dissolution medium comprising 0.005% hydroxypropyl cellulose (HPC), 0.5% sodium lauryl sulfate (SLS) surfactant, and phosphoric acid. Table 10 / Figure 1 compares dissolution time of Tacrolimus from suspension compositions with different particle sizes, PROGRAF® granules, and PROGRAF® Capsule.Table 10

[0174] The data from Table 10 / Figure 1 clearly demonstrates that the drug (Tacrolimus) dissolution increases with reduction in D90 particle size (particle size is inversely proportional to drug dissolution).Example 4: Single-dose Oral Bioavailability under Fed Condition (High-Fat High-Calorie) with T1 (Suspension 1-un-micronized), T2 (Suspension 1-micronized), R1 (PROGRAF® Granules), and R2 (PROGRAF® Capsules)

[0175] Suspension 1 described in Example 1 was administered to 24 healthy, adult, male human subjects in an open label, balanced, randomized, four-treatment, four sequence, four-period, single dose, four-way crossover oral comparative bioavailability study under fed conditions. The subjects were randomized into 1 of the 4 dosing sequences receiving Test Product T1 (Tacrolimus Oral Suspension 1 mg / ml (un-micronized)), Test Product T2 (Tacrolimus Oral Suspension 1 mg / ml (micronized-D90 5-6 pm)), commercially available PROGRAF® granules (Tacrolimus oral suspension) 1 mg / packet (Rl), and commercially available PROGRAF® CAPSULE (R2). After overnight fasting of at least 10 hours before the scheduled time of high-fat high calorie breakfast, a single dose of either reference product (Rl or R2) or Test product (T1 or T2) was administered orally at scheduled dosing time exactly 30 minutes after the high-fat high-calorie breakfast in sitting posture with 240 ±2 ml of water. The washout period of 14 days was maintained between each dosing period.

[0176] For tacrolimus, based on the statistical results, of 90% confidence intervals for the geometric least square mean ratio (Tl / Rl and / or T2 / R2 and / or T1 / R2 and / or T2 / R1) for the pharmacokinetic parameters Cmax, AUCO-t, and AUC0-co, conclusions were drawn whether the test formulation (T1 and / or T2) was bioequivalent to the reference formulation (Rl and / or R2) under fed conditions. Acceptance range for comparative bioavailability was 80.00% -125.00% for 90% confidence intervals of the geometric least square means ratio (Tl / Rl or T2 / R2 or T1 / R2 or T2 / R1) for Cmax, AUCO-t and AUCO-oo. Interest for comparisons were (i) T1 Vs. Rl; (ii) T1 Vs. R2; (iii) T2 Vs. Rl; and T2 Vs. R2.

[0177] Twenty -two subjects completed at least two study periods with one test formulation and one reference formulation as per the approved protocol. Hence 22 subjects were used for pharmacokinetic and statistical analysis.

[0178] Table 11 provides a summary of measured pharmacokinetic parameters of the Test Product (T1 and T2) and Reference Product (Rl and R2).Table 11

[0179] Statistical results for the primary pharmacokinetic parameters are summarized below:Table 12-T1 Vs. R1Table 13-T2 Vs. R1Table 14-T1 Vs. R2Table 15-T2 Vs. R2

[0180] Data from Tables 11-15 confirms that T1 and T2 test products exhibit comparable bioavailability to the reference product Rl. Data shows that 90% CI for geometric least square mean ratio of Tl / Rl and T2 / R1 is within the acceptance range of 80.00% to 125.00% for the Intransformed primary pharmacokinetic parameter Cmax, AUCO-t and AUC0-co required for concluding comparative bioavailability between the test and reference formulations.

[0181] The data further demonstrates that the Cmax for T1 and T2 is higher than the reference product R2 (capsule formulation; and there is no significant difference in the PK data of T1 and T2.

[0182] There is no significant difference in the PK parameters of the two test prototypes T1 and T2.Example 5: Single-dose Oral Bioavailability under Fasted Condition with T1 (Suspension 1-un-micronized), T2 (Suspension 1-micronized), Rl (PROGRAF® Granules), and R2 (PROGRAF® Capsules)

[0183] Suspension 1 described in Example 1 was administered to 24 healthy, adult, male human subjects in an open label, balanced, randomized, four-treatment, four sequence, four-period, singledose, four-way crossover oral comparative bioavailability study under fasted conditions. The subjects were randomized into 1 of the 4 dosing sequences receiving Test Product T1 (Tacrolimus oral suspension 1 mg / ml (un-micronized)), Test Product T2 (Tacrolimus Oral Suspension 1 mg / ml (micronized-D90 5-6 pm)), commercially available PROGRAF® granules (Tacrolimus oral suspension) 1 mg / packet (Rl), and commercially available PROGRAF® CAPSULE (R2). After overnight fasting of at least 10 hours before scheduled dosing time, a single dose of either reference product (Rl or R2) or Test product (T1 or T2) was administered orally in sitting posture with 240 ±2 ml of water as per randomization schedule. The washout period of 14 days was maintained between each dosing period.

[0184] For tacrolimus, based on the statistical results, of 90% confidence intervals for the geometric least square mean ratio (Tl / Rl and / or T2 / R2 and / or T1 / R2 and / or T2 / R1) for the pharmacokinetic parameters Cmax, AUCO-t, and AUCO-co, conclusions were drawn whether the test formulation (T1 and / or T2) was bioequivalent to the reference formulation (Rl and / or R2) under fasted conditions. Acceptance range for comparative bioavailability was 80.00% -125.00% for 90% confidence intervals of the geometric least square means ratio (Tl / Rl or T2 / R2 or T1 / R2 or T2 / R1) for Cmax, AUCO-t and AUC0-co. Interest for comparisons were (i) T1 Vs. Rl; (ii) T1 Vs. R2; (iii) T2 Vs. Rl; and T2 Vs. R2.

[0185] Twenty-four subjects completed at least two study periods with one test formulation and one reference formulation as per the approved protocol. Hence 24 subjects were used for pharmacokinetic and statistical analysis.

[0186] Table 16 provides a summary of measured pharmacokinetic parameters of the Test Product (T1 and T2) and Reference Product (Rl and R2).Table 16

[0187] Statistical results for the primary pharmacokinetic parameters are summarized below:Table 17-T1 Vs. R1Table 18-T2 Vs. R1

[0188] Data from Tables 17-18 shows that 90% CI for geometric least square mean ratio of Tl / Rl and T2 / R1 is within the acceptance range of 80.00% to 125.00% for the In-transformed primary pharmacokinetic parameter AUCO-t and AUC0-co. There is no significant difference in the PK parameters of the two test prototypes T1 and T2.Example 6-Dissolution of Suspension 1 (T1 (un-micronized) and T2 (micronized)) in 0.1 N HC1

[0189] Figure 2 / Table 19 compares dissolution profiles of Test Products T1 (Suspension 1 containing un-micronized anhydrous tacrolimus), T2 (suspension 1 containing micronized (D90 5-6 pm) anhydrous tacrolimus), Reference Product R1 (granules), and Reference product R2 (capsule). Dissolution testing was conducted in about 900 ml of 0.1 N HC1, using USP Apparatus II, at 75 rpm and 37°C.Table 19

[0190] Figure 2 demonstrates that dissolution profiles of T1 and T2 are comparable to each other. Figure 2 further demonstrates that dissolution profiles of Tl, T2, and Rlare comparable as well.Example 7: Dissolution of Suspension 1 (Tl (un-micronized) and T2 (micronized)) in pH4.5 Buffer containing 0.005% Hydroxypropyl Cellulose

[0191] Figure 3 / Table 20 compares dissolution profiles of Test Products Tl (Suspension 1 containing un-micronized anhydrous tacrolimus), T2 (suspension 1 containing micronized anhydrous tacrolimus-D90 5-6 pm), Reference Product R1 (Granules), and Reference product R2 (capsule). Dissolution testing was conducted in about 900 ml of pH 4.5 phosphate buffer containing 0.005% hydroxypropyl cellulose, using USP Apparatus II, at 75 rpm and 37°C.Table 20

[0192] Figure 3 demonstrates that dissolution profiles of Tl and T2 are comparable to each other. Figure 3 further demonstrates that dissolution profiles of Tl, T2, and R1 are comparable as well.Example 8: Single-dose Oral Bioavailability under Fed Condition (High-Fat High-Calorie) with Tl (Suspension 1-micronized), T2 (Tacrolimus Solution), R1 (PROGRAF® Granules)

[0193] Suspension 1 described in Example 1 was administered to 23 healthy, adult, male human subjects in an open label, balanced, randomized, three-treatment, three sequence, three-period, single dose, three-way crossover oral comparative bioavailability study under fed conditions. The subjects were randomized into 1 of the 3 dosing sequences receiving Test Product Tl (Tacrolimusoral suspension 1 mg / ml (micronized-D90 of 2.53 pm)), Test Product T2 (Tacrolimus Oral Solution 1 mg / ml), and commercially available PROGRAF® granules (Tacrolimus for oral suspension) 1 mg / packet (R). After an overnight fasting of at least 10 hours before the scheduled time of high-fat high calorie breakfast, a single dose of reference product (R) or Test product (T1 or T2) was administered orally at scheduled dosing time exactly 30 minutes after the high-fat high- calorie breakfast in sitting posture with 240 ±2 ml of water. The washout period of 14 days was maintained between each dosing period.

[0194] For tacrolimus, based on the statistical results, of 90% confidence intervals for the geometric least square mean ratio (Tl / R and / or T2 / R) for the pharmacokinetic parameters Cmax, AUCO-t, and AUC0-co, conclusions were drawn whether the test formulation (T1 and / or T2) was bioequivalent to the reference formulation (R) under fed conditions. Acceptance range for comparative bioavailability was 80.00% -125.00% for 90% confidence intervals of the geometric least square means ratio (Tl / R or T2 / R) for Cmax, AUCO-t and AUC0-co. Interest for comparisons were (i) T1 Vs. R; (ii) T2 Vs. R.

[0195] Twenty -three subjects completed at least two study periods with one test formulation and one reference formulation as per the approved protocol. Hence 22 subjects were used for pharmacokinetic and statistical analysis.

[0196] Table 21 provides a summary of measured pharmacokinetic parameters of the Test Products (T1 & T2) and Reference Product (R).Table 21

[0197] Statistical results for the primary pharmacokinetic parameters are summarized below:Table 22-T1 (1 mg / mL Suspension) Vs. RTable 23-T2 (Solution) Vs. R

[0198] Data from Tables 21-23 confirms that T1 and T2 test products exhibit comparable bioavailability to the reference product R. Data shows that 90% CI for geometric least square mean ratio of Tl / R and T2 / R is within the acceptance range of 80.00% to 125.00% for the Intransformed primary pharmacokinetic parameter Cmax, AUCO-t and AUCO-co required for concluding comparative bioavailability between the test and reference formulations.

[0199] The data further demonstrates that there is no significant difference in the PK data of T1 and T2.Example 9: Single-dose Oral Bioavailability under Fasted Condition with T1 (Suspension 1-micronized), T2 (Solution), R1 (PROGRAF® Granules)

[0200] Suspension 1 described in Example 1 was administered to 23 healthy, adult, male human subjects in an open label, balanced, randomized, three-treatment, three sequence, three-period, single dose, three-way crossover oral comparative bioavailability study under fasted conditions. The subjects were randomized into 1 of the 3 dosing sequences receiving Test Product T1 (Tacrolimus oral suspension 1 mg / ml (micronized-D90 particle size of -2.53 pm)), Test Product T2 (Tacrolimus Oral Solution 1 mg / ml), and commercially available PROGRAF® granules (Tacrolimus for oral suspension-D90 particle size of -2 pm) 1 mg / packet (R). After overnight fasting of at least 10 hours, a single dose of reference product (R) or Test product (T1 or T2) wasadministered orally at scheduled dosing time in sitting posture with 240 ±2 ml of water. The washout period of 14 days was maintained between each dosing period.

[0201] For tacrolimus, based on the statistical results, of 90% confidence intervals for the geometric least square mean ratio (Tl / R and / or T2 / R) for the pharmacokinetic parameters Cmax, AUCO-t, and AUCO-co, conclusions were drawn whether the test formulation (T1 and / or T2) was bioequivalent to the reference formulation (R) under fed conditions. Acceptance range for comparative bioavailability was 80.00% -125.00% for 90% confidence intervals of the geometric least square means ratio (Tl / R or T2 / R) for Cmax, AUCO-t and AUC0-co. Interest for comparisons were (i) T1 Vs. R; (ii) T2 Vs. R. 23 subjects were used for pharmacokinetic and statistical analysis.

[0202] Table 24 provides a summary of measured pharmacokinetic parameters under fasted conditions of the Test Products (T1 & T2) and Reference Product (R).Table 24

[0203] Statistical results for the primary pharmacokinetic parameters are summarized below:Table 25-T1 (1 mg / mL Suspension) Vs. RTable 26-T2 (Solution) Vs. R

[0204] Data from Tables 24-26 confirms that 90% CI for geometric least square mean ratio of Tl / R is within the acceptance range of 80.00% to 125.00% for the In-transformed primary pharmacokinetic parameter AUCO-t and AUCO-co.Example 10: Effect of Xanthan Gum on Viscosity of Tacrolimus Suspension

[0205] Viscosities of Suspensions 3-9 (1 mg / ml-un-micronized) were measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry at 25°C.Table 27

[0206] The data from Table 27 clearly demonstrates that tacrolimus suspensions containing from about 0.2-about 0.6% wt / vol of xanthan gum exhibit a viscosity from about 20 cp to about 13300 cp.Example 11: Effect of pH on Stability of Tacrolimus Suspension

[0207] Six-month storage stability of Suspension 1 (Un-micronized) at pH 2, 3, and 4 was determined under accelerated storage conditions (40°C and 75% RH). Table 28 provides 6-month storage stability for Suspension 1 under accelerated storage conditions.Table 28

[0208] The data Table 28 clearly demonstrates that tacrolimus Suspension 1 is stable under accelerated storage conditions at pH 2, 3, and 4.

[0209] The invention illustratively described herein suitably may be practiced in the absence of any element or elements, limitation or limitations which is not specifically disclosed herein. Thus, for example, in each instance herein, any of the terms “comprising,” “consisting essentially of’ and “consisting of’ may be replaced with either of the other two terms. The terms and expressions which have been employed are used as terms of description and not of limitation, and there is no intention in the use of such terms and expressions of excluding any equivalents of the features shown and described or portions thereof, but it is recognized that various modifications are possible within the scope of the invention claimed. Thus, it should be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the appended claims.

Claims

CLAIMS1. A ready -to-use oral suspension formulation comprising:(a) tacrolimus or a polymorph thereof; and(b) at least one pharmaceutically acceptable suspending agent, wherein the formulation comprises from 0.1% wt / vol-2 % wt / vol of the suspending agent, wherein the formulation is free of a pharmaceutical vehicle that can dissolve greater than 0.1 mg / ml of the tacrolimus or a polymorph thereof; and wherein the formulation is free of a surfactant, a wetting agent, and an emulsifying agent.

2. The formulation of claim 1, wherein the suspending agent is selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methylcellulose, hydroxyethyl cellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof.

3. The formulation of claim 1, wherein the suspending agent is a water-soluble suspending agent.

4. The formulation of claim 1, wherein the suspending agent is xanthan gum.

5. The formulation of claim 1, wherein the formulation comprises from 0.1% wt / vol-1% wt / vol of the suspending agent.

6. The formulation of claim 1, wherein the suspending agent is a viscosity enhancing agent.

7. The formulation of claim 1 comprising tacrolimus polymorph.

8. The formulation of claim 7, wherein the tacrolimus polymorph is anhydrous tacrolimus.

9. The formulation of claim 8, wherein the anhydrous tacrolimus has D90 particle size of from about 0.1 pm to about 10 pm.

10. The formulation of claim 9, wherein the anhydrous tacrolimus has D90 particle size of from about 1 pm to about 10 pm.

11. The formulation of claim 1, wherein the pharmaceutical vehicle is selected from the group consisting of polyethylene glycols, propylene glycols, triacetin, ethanol, polysorbates, oils, and mixtures thereof.

12. The formulation of claim 1 , wherein the 0.1% wt / vol-2 % wt / vol of the suspending agent provides a viscosity of between 20 cp and 20,000 cp, measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry.

13. The formulation of claim 8, wherein the concentration of anhydrous tacrolimus is about 0.1 mg / ml to about 1.5 mg / ml.

14. The formulation of claim 1, wherein the suspension exhibits a pH of between 2 and 6.

15. The formulation of claim 1, wherein the formulation on storage under accelerated storage conditions for 6 months, comprises a total impurity of less than 1% wt / vol.

16. The formulation of claim 13, wherein the accelerated storage conditions comprise storage at 40°C and 75% relative humidity.

17. The formulation of claim 14, wherein the suspension on storage under accelerated storage conditions for 6 months maintains the pH of between 2 and 6.

18. The formulation of claim 8 wherein the concentration of anhydrous tacrolimus is about 0.5 mg / ml to about 1.0 mg / ml.

19. A ready -to-use suspension formulation comprising:(a) anhydrous tacrolimus, and(b) one or more pharmaceutically acceptable suspending agents selected from the group consisting of selected from the group consisting of xanthan gum, cellulose, sodium carboxymethyl cellulose, carboxymethyl cellulose, hydroxypropyl methylcellulose, hydroxyethyl cellulose, microcrystalline cellulose, magnesium aluminum silicate, bentonite, colloidal silicon dioxide, carrageenan, carbomers, propylene glycol alginate, sodium alginate, guar gum, tragacanth gum, acacia gum, hydroxypropyl guar, starch and its derivatives, and mixtures thereof; wherein the formulation is free of a pharmaceutical vehicle selected from the group consisting of polyethylene glycols, propylene glycols, triacetin, ethanol, polysorbates, oils, and mixtures thereof; wherein the formulation is free of a surfactant, a wetting agent, and / or an emulsifying agent; and wherein the suspension comprises 0.1-2% wt / vol of the suspending agent.

20. The of claim 19, wherein the suspending agent is xanthan gum.

21. The formulation of claim 19, wherein the anhydrous tacrolimus has D90 particle size of from about 0.1 pm to about 10 pm.

22. The formulation of claim 21, wherein the D90 particle size is from about 1 pm to about 10 pm.

23. The formulation of claim 19, wherein the 0.1% wt / vol-2 % wt / vol of the suspending agent provides a suspension viscosity of between 20 cp and 20,000 cp, measured using Rheometer at ~ 0.1 1 / s and 40 mm stainless steel plate geometry.

24. The formulation of claim 19 comprising from about 0.1 mg / ml to about 1.5 mg / ml of anhydrous tacrolimus.

25. The formulation of claim 19, wherein the suspension exhibits a pH of between 2 and 6.

26. The formulation of claim 19, wherein the formulation on storage under accelerated storage conditions for 6 months, comprises a total impurity of less than 1% wt / vol.

27. The formulation of claim 26, wherein the accelerated storage conditions comprise storage at 40°C and 75% relative humidity.

28. The suspension formulation of claim 19, wherein the suspension on storage under accelerated storage conditions for 6 months maintains the pH of between 2 and 6.

29. The suspension formulation of claim 24 comprising from about 0.5 mg / ml to about 1.5 mg / ml of anhydrous tacrolimus.

30. A method for prophylaxis of organ rejection in patients receiving allogeneic kidney transplant, the method comprising orally administering to the patient, a ready-to-use aqueous suspension formulation comprising anhydrous tacrolimus and at least one suspending agent, wherein the formulation comprises 0.1-2% wt / vol of the suspending agent; wherein the formulation is free of a surfactant, a wetting agent, and / or an emulsifying agent; the suspension is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof; and wherein the formulation is administered in combination with azathioprine, mycophenolate mofetil (MMF), and / or corticosteroids.

31. A method for prophylaxis of organ rejection in patients receiving allogeneic heart transplant, the method comprising orally administering to the patient, a ready-to-use aqueous suspension formulation comprising anhydrous tacrolimus and at least one suspending agent, wherein the formulation comprises 0.1-2% wt / vol of the suspending agent; wherein the formulation is free of a surfactant, a wetting agent, and / or an emulsifying agent;the suspension is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof; and wherein the formulation is administered in combination with azathioprine, mycophenolate mofetil (MMF), and / or corticosteroids.

32. A method for prophylaxis of organ rejection in patients receiving allogeneic liver transplant, the method comprising orally administering to the patient, a ready-to-use aqueous suspension formulation comprising anhydrous tacrolimus and at least one suspending agent, wherein the formulation comprises 0.1-2% wt / vol of the suspending agent; wherein the formulation is free of a surfactant, a wetting agent, and / or an emulsifying agent; the suspension is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof; and wherein the formulation is administered in combination with azathioprine, mycophenolate mofetil (MMF), and / or corticosteroids.

33. A method for prophylaxis of organ rejection in patients receiving allogeneic lung transplant, the method comprising orally administering to the patient, a ready-to-use aqueous suspension formulation comprising anhydrous tacrolimus and at least one suspending agent, wherein the formulation comprises 0.1-2% wt / vol of the suspending agent; wherein the formulation is free of a surfactant, a wetting agent, and / or an emulsifying agent; the suspension is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof; and wherein the formulation is administered in combination with azathioprine, mycophenolate mofetil (MMF), and / or corticosteroids.

34. The method of any one of preceding claims 31-33, wherein the dosage is based on whole blood trough concentration of the patient.

35. The method of any one of preceding claims 31-34, wherein the suspension comprises 0.5 mg / ml or 1 mg / ml of anhydrous tacrolimus.

36. A method for making a ready-to-use aqueous suspension formulation comprising tacrolimus or a polymorph thereof, the method comprising adding purified water and one or more excipients selected from the group comprising suspending agent, sweetener, pH adjusting agent / buffering agent, and preservative in a stainless-steel container and mixing to obtain a solution; adding an immunosuppressive agent to the solution with homogenization to obtain a uniform suspension;adding flavoring agent to the suspension; and finally diluting the suspension to a desired final volume; wherein the suspension is free of free of a surfactant, a wetting agent, and / or an emulsifying agent; and wherein the suspension is free of polyethylene glycol, propylene glycol, triacetin, ethanol, polysorbates, oils and mixtures thereof.

36. The method of claim 36, wherein the suspension is made under continuous inert gas purging and / or sparging.

Images