Dry powder inhalation compositions and methods for treating or preventing pulmonary arterial hypertension

Abstract

The present disclosure relates generally to dry powder inhalation compositions and methods for preventing, ameliorating or treating pulmonary arterial hypertension and / or reducing the severity of one or more risk factors, signs, or symptoms associated with pulmonary arterial hypertension.

Description

Atty. Dkt. No.: 126842-0117 DRY POWDER INHALATION COMPOSITIONS AND METHODS FOR TREATING OR PREVENTING PULMONARY ARTERIAL HYPERTENSION CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of and priority to U.S. Provisional Appl. No. 63 / 670,300, filed July 12, 2024, the contents of which are incorporated herein by reference in their entirety for any and all purposes. TECHNICAL FIELD

[0002] The present technology relates generally to dry powder inhalation compositions and methods for preventing, ameliorating or treating pulmonary arterial hypertension and / or reducing the severity of one or more risk factors, signs, or symptoms associated with pulmonary arterial hypertension. BACKGROUND

[0003] The following description of the background of the present technology is provided simply as an aid in understanding the present technology and is not admitted to describe or constitute prior art to the present technology.

[0004] Pulmonary hypertension (PH) is a lung disorder in which mean pulmonary arterial pressure rises above normal levels (25 mm Hg at rest and 30 mm Hg during exercise) and is classified into arterial, venous, hypoxic, thromboembolitic, and miscellaneous varieties. Pulmonary arterial hypertension (PAH)), also known as Group 1 Pulmonary Hypertension, is typically associated with the worst prognosis. PAH is subclassified as idiopathic PAH (IPAH), familial PAH (FPAH), and associated PAH (APAH) varieties. Gérald Simonneau et al., Updated Clinical Classification of Pulmonary Hypertension, J Am Coll Cardiol. Volume 54(Suppl): S43–S54 (2009) at Table 1. Pulmonary arterial hypertension (PAH) is a chronic and progressive disease of the lung vascular system in which endothelial dysfunction and vascular remodeling of endothelial and smooth muscle cells lead to the obstruction of pulmonary arteries, resulting in increased pulmonary vascular resistance and pulmonary arterial pressures. This leads to reduced cardiac output, right ventricular failure (cor pulmonale), and ultimately death within two to three years of diagnosis, if untreated. -1- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0005] In the United States, the estimated incidence and prevalence of PAH are 2.3 and 12.4 cases per million adults, respectively. PAH can develop in men and women at any age, but the disorder is nearly twice as common in females as in males. Despite recent advances in elucidating potential molecular pathways implicated in PAH and therapeutic approaches that appear to prolong survival in some PAH patients, the prognosis of PAH remains poor and there is no cure for this disorder. SUMMARY OF THE PRESENT TECHNOLOGY

[0006] In one aspect, the present disclosure provides a dry powder inhalation (DPI) formulation comprising (a) about 30% w / w to about 50% w / w of quinacrine or a pharmaceutical salt thereof; (b) about 2.5% w / w to about 35%w / w of L-leucine and (c) about 25% w / w to about 52.5% w / w of trehalose. In some embodiments of the DPI formulation disclosed herein, the ratio of L-leucine to trehalose is about 1:1 to about 1:19.

[0007] Additionally or alternatively, in some embodiments, the DPI formulation comprises 50% w / w of quinacrine or the pharmaceutical salt thereof. In any of the preceding embodiments of the DPI formulation disclosed herein, the ratio of L-leucine to trehalose is 1:1. Additionally or alternatively, in certain embodiments, the DPI formulation comprises 25% w / w of L-leucine and 25% w / w of trehalose.

[0008] Additionally or alternatively, in certain embodiments, the DPI formulation further includes one or more excipients chosen from 1,2-distearoyl-sn-glycero-3-phosphocholine, alcohol, anhydrous citric acid, anhydrous trisodium citrate, apaflurane, ascorbic acid, benzalkonium chloride, black ink, calcium carbonate, calcium chloride, carrageenan, cetylpyridinium chloride, chlorobutanol, citric acid monohydrate, dichlorodifluoromethane, dichlorotetrafluoroethane, edetate disodium, ferric oxide yellow, fluorochlorohydrocarbons, gelatin, glycerin, glycine, hydrochloric acid, hypromellose 2906 (4 mPa.S), lactose, lactose monohydrate, lecithin (soybean), magnesium stearate, mannitol, menthol, methylparaben, nitric acid, norflurane, N-phenyl-1-napthylamine, nutmeg oil, oleic acid, petrolatum, phenylethyl alcohol, polysorbate 80, potassium chloride, propylene glycol, propylparaben, saccharin, saccharin sodium, silicon dioxide, sodium bicarbonate, sodium bisulfite, sodium chloride, sodium hydroxide, sodium lauryl sulfate, sodium metabisulfite, sodium sulfate anhydrous, sorbitan trioleate, sulfuric acid, thymol, titanium dioxide, -2- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 trichloromonofluoromethane, trisodium citrate dihydrate, tromethamine, turpentine oil, and zinc oxide.

[0009] Additionally or alternatively, in certain embodiments, the DPI formulation has a solid content of 2-5% w / v. In any and all embodiments of the DPI formulation disclosed here, the DPI formulation is amorphous. In any of the above embodiments, the DPI formulation comprises about 0.3 mg to about 0.5 mg of quinacrine or the pharmaceutical salt thereof per mg of the DPI formulation.

[0010] Additionally or alternatively, in some embodiments, the DPI formulation has a Mass Median Aerodynamic Diameter (MMAD) of about 1-5 µm. In certain embodiments, the DPI formulation has a Fine Particle Fraction (FPF) of about 70%-100%.

[0011] In any and all embodiments of the DPI formulation disclosed herein, the DPI formulation is configured to be aerosolized with an inhaler device (e.g., RS01) and tested for aerosolization properties using a cascade impactor and a throat adapter, and the cascade impactor is configured to operate at an inlet flow rate between 30-100 L / min. Additionally or alternatively, in certain embodiments, the DPI formulation comprises particles having an effective cut-off diameter of about 4-8 µm.

[0012] In another aspect, the present disclosure provides methods for preparing the DPI formulation disclosed herein, comprising combining quinacrine or a pharmaceutical salt thereof, L-leucine and trehalose with an aqueous solvent to form a mixture and feeding the mixture through a spray dryer.

[0013] In some embodiments of the methods for preparing the DPI formulation disclosed herein, the spray dryer has an inlet temperature of about 150 ºC and / or an atomizing airflow of about 400 L / hr. Additionally or alternatively, in some embodiments of the methods for preparing the DPI formulation disclosed herein, the spray dryer has a nozzle orifice of about 0.7 mm. In any and all embodiments of the methods for preparing the DPI formulation disclosed herein, the mixture is fed through the spray dryer at a feed rate of about 5%-10%.

[0014] In yet another aspect, the present disclosure provides methods for treating or preventing pulmonary arterial hypertension in a subject in need thereof comprising administering to the subject a therapeutically effective amount of the DPI formulation disclosed herein. -3- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0015] Additionally or alternatively, in some embodiments of the methods for treating or preventing pulmonary arterial hypertension disclosed herein, the pulmonary arterial hypertension is idiopathic PAH (IPAH), familial PAH (FPAH), or associated PAH (APAH). Examples of APAH include PAH associated with Collagen vascular disease, PAH associated with Congenital systemic-to-pulmonary shunts, PAH associated with Portal hypertension, PAH associated with HIV infection, PAH associated with drugs and toxins, PAH associated with other disorders (e.g., thyroid disorders, glycogen storage disease, Gaucher disease, hereditary hemorrhagic telangiectasia, hemoglobinopathies, myeloproliferative disorders, splenectomy).

[0016] In any of the forgoing embodiments of the methods for treating or preventing pulmonary arterial hypertension disclosed herein, the subject is a pediatric patient, a geriatric patient, an immunocompromised patient, a female patient, or a male patient. BRIEF DESCRIPTION OF THE DRAWINGS

[0017] FIG.1 shows the chemical structure of quinacrine (QA), a.k.a., mepacrine. As used herein, the term PT001 is interchangeable with quinacrine.

[0018] FIG.2 shows a differential scanning calorimetry (DSC) thermogram of QA dry powder inhaled (DPI) formulations containing 15% w / w drug loading (drug weight / mixture weight) with 2 different ratios of carriers at feed rate (FR) of 5 and 10. T, trehalose; L, leucine; DL, drug load; FR, feed rate. (1) corresponds to T:L (75:25), 15% DL, 10 FR. (2) corresponds to T:L (50:50), 15% DL, 10 FR. (3) corresponds to T:L (75:25), 15% DL, 5 FR. (4) corresponds to T:L (50:50), 15% DL, 5 FR. (5) corresponds to amorphous form drug.

[0019] FIG.3 shows a DSC thermogram of QA DPI formulations containing 30% w / w drug loading with 2 different ratios of carriers at feed rate of 5 and 10. T, trehalose; L, leucine; DL, drug load; FR, feed rate. (1) corresponds to T:L (75:25), 30% DL, 10 FR. (2) corresponds to T:L (50:50), 30% DL, 10 FR. (3) corresponds to T:L (75:25), 30% DL, 5 FR. (4) corresponds to T:L (50:50), 30% DL, 5 FR. (5) corresponds to amorphous form drug.

[0020] FIG.4 shows a DSC thermogram of the optimized QA DPI formulation with 50% w / w drug load containing carrier ratio 1:1 (25%T: 25%L) at feed rate 10. T, trehalose; L, leucine; DL, drug load; FR, feed rate. -4- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0021] FIG.5 shows a powder X-ray diffraction (PXRD) graph of the optimized QA DPI formulation. (1) corresponds to DPI formulation. (2) corresponds to D-Trehalose. (3) corresponds to L-Leucine. (4) corresponds to PT001.

[0022] FIGs.6A-6D show percent deposition of QA dry powder in different stages of a Next Generation Impactor (NGI; FIG.6A), a cumulative distribution plot of deposited particles’ effective cut-off diameter (FIG.6B), a visual representation of QA dry powder deposition in different stages of the NGI (FIG.6C), and Scanning Electron Microscopy images of the QA dry powder formulation (FIG.6D).

[0023] FIG.7 shows a thermogravimetric analysis for QA dry powder formulations F1- F3, and unformulated QA. (1) corresponds to pure drug (PT001). (2) corresponds to Formulation F1. (3) corresponds to Formulation F2. (4) corresponds to Formulation F3.

[0024] FIG.8 shows the cytotoxicity of unformulated QA and a QA DPI formulation in primary pulmonary artery smooth muscle cells (PASMCs) at 6 and 24 hours after treatment.

[0025] FIG.9 shows a Fulton index comparison for QA and QA DPI. PAH symptoms were induced and rats were administered indicated doses of unformulated QA intratracheally (IT) or intraperitoneally (IP), and formulated QA (DPI) intratracheally. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0026] FIG.10 shows a right ventricular systolic pressure (RVSP) comparison for QA and QA DPI. PAH symptoms were induced and rats were administered indicated doses of unformulated QA intratracheally (IT) or intraperitoneally (IP), and formulated QA (DPI) intratracheally. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0027] FIG.11 shows a cardiac output comparison for QA and QA DPI. PAH symptoms were induced and rats were administered indicated doses of unformulated QA intratracheally (IT) or intraperitoneally (IP), and formulated QA (DPI) intratracheally. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0028] FIG.12 shows a pulmonary vascular resistance (PVR) comparison for QA and QA DPI. PAH symptoms were induced and rats were administered indicated doses of unformulated QA intratracheally (IT) or intraperitoneally (IP), and formulated QA (DPI) intratracheally. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001. -5- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0029] FIG.13 shows a heart rate comparison for QA and QA DPI. PAH symptoms were induced and rats were administered indicated doses of unformulated QA intratracheally (IT) or intraperitoneally (IP), and formulated QA (DPI) intratracheally. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0030] FIGs.14A-14C show a comparison of orally administered FDA approved anti- PAH medications ambrisentan and riociguat with intratracheally administered unformulated QA (DPI). PAH symptoms were induced and rats were administered indicated doses. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001.

[0031] FIG.15 shows physical appearance of Formulations 16-19.

[0032] FIG.16 shows XRD Analysis of Formulations 16-19. (1) corresponds to PT001. (2) corresponds to L-Leucine. (3) corresponds to D-Trehalose. (4) corresponds to T100. (5) corresponds to PTL 50:47.5:2.5 (Formulation 16). (6) corresponds to PTL 50:45:5 (Formulation 17). (7) corresponds to PTL 50:40:10 (Formulation 18). (8) corresponds to PTL 50:30:20 (Formulation 19). (9) corresponds to PTL 50:25:25.

[0033] FIGs.17A-17D show SEM images of Formulation 16 (FIG.17A), Formulation 17 (FIG.17B), Formulation 18 (FIG.17C), and Formulation 19 (FIG.17D). DETAILED DESCRIPTION

[0034] It is to be appreciated that certain aspects, modes, embodiments, variations and features of the present methods are described below in various levels of detail in order to provide a substantial understanding of the present technology.

[0035] In practicing the present methods, many conventional techniques in molecular biology, protein biochemistry, cell biology, immunology, microbiology and recombinant DNA are used. See, e.g., Sambrook and Russell eds. (2001) Molecular Cloning: A Laboratory Manual, 3rd edition; the series Ausubel et al. eds. (2007) Current Protocols in Molecular Biology; the series Methods in Enzymology (Academic Press, Inc., N.Y.); MacPherson et al. (1991) PCR 1: A Practical Approach (IRL Press at Oxford University Press); MacPherson et al. (1995) PCR 2: A Practical Approach; Harlow and Lane eds. (1999) Antibodies, A Laboratory Manual; Freshney (2005) Culture of Animal Cells: A Manual of Basic Technique, 5th edition; Gait ed. (1984) Oligonucleotide Synthesis; U.S. Patent No. -6- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 4,683,195; Hames and Higgins eds. (1984) Nucleic Acid Hybridization; Anderson (1999) Nucleic Acid Hybridization; Hames and Higgins eds. (1984) Transcription and Translation; Immobilized Cells and Enzymes (IRL Press (1986)); Perbal (1984) A Practical Guide to Molecular Cloning; Miller and Calos eds. (1987) Gene Transfer Vectors for Mammalian Cells (Cold Spring Harbor Laboratory); Makrides ed. (2003) Gene Transfer and Expression in Mammalian Cells; Mayer and Walker eds. (1987) Immunochemical Methods in Cell and Molecular Biology (Academic Press, London); and Herzenberg et al. eds (1996) Weir’s Handbook of Experimental Immunology. Methods to detect and measure levels of polypeptide gene expression products (i.e., gene translation level) are well-known in the art and include the use of polypeptide detection methods such as antibody detection and quantification techniques. (See also, Strachan & Read, Human Molecular Genetics, Second Edition. (John Wiley and Sons, Inc., NY, 1999)).

[0036] Ultrasonic nebulizers use flat or concave piezoelectric discs immersed under a reservoir of liquid to resonate the surface of the reservoir of liquid, forming a liquid cone that spews aerosol particles from its surface (US 2006 / 0249144 and US documents 5,551,416). Since no airflow is required in the aerosol formation process, high aerosol concentrations can be achieved, however piezoelectric components are relatively expensive to produce and are ineffective in aerosol-forming suspensions, which require the active drug dissolves at low concentrations in water or saline solutions. Newer liquid aerosol technologies involve generating smaller and more uniform liquid respirable dry particles by passing the aerosolized liquid through micrometer-sized holes. See, for example, US Patent No. 6,131,570, US Patent No.5,724,957, and US Patent No.6,098,620. Disadvantages of this technique include relatively expensive piezoelectric and fine mesh components as well as scale formation in the holes from residual salts and solid suspensions.

[0037] Dry powder inhalers (DPIs) represent one of the most underutilized forms of inhaled drug delivery devices. While the efficacy of delivered dose seems to be equivalent between DPIs and nebulizers, DPI formulations are more stable. Some of the benefits that DPIs have over nebulizers and metered dose inhaler include long-term stability, ease of handling, low cost, ease of maintaining sterility, lack of propellant, compatibility with drugs having low water solubility, lung deposition that can be modulated based on powder -7- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 properties, and being less error prone in dose delivery due to reliance on patients’ breathing pattern.

[0038] Historically, dry powder inhalation has relied on lactose mixing to allow dosing of particles that are small enough to be inhaled, but the particles are not sufficiently dispersed on their own. This process is known to be ineffective and does not work for some drugs. Some groups have tried to improve these drawbacks by developing breathable and dispersible dry powder inhaler (DPI) formulations, thus requiring no lactose mixing. Formulations in dry powder form for inhalation therapy are described, for example, in US Patent No.5,993,805 to Sutton et al.; US Patent No.6,921,527 to Platz et al.; WO 0000176 to Robinson et al.; WO 9916419 to Tarara et al.; WO 0000215 to Bot et al.; US Patent No.5,855,913 to Hanes et al.; and US Patent Nos.6,136,295 and 5,874,064 to Edwards et al. Formation of highly dispersible small particle size aerosols is necessary for efficient and consistent deep lung delivery. In addition, methods are required that produce aerosols comprising suitable amounts of drug relative to non-pharmacological material. Finally, there is an urgent need for methods that allow a patient to be given a unit dose with one or two small-volume inspirations.

[0039] The present disclosure provides for QA compositions suitable for administration by inhalation, methods of preparing said respirable QA compositions, and methods of using said respirable QA compositions for preventing, ameliorating or treating pulmonary arterial hypertension and / or reducing the severity of one or more risk factors, signs, or symptoms associated with pulmonary arterial hypertension in a subject in need thereof. As demonstrated in the Examples described herein, dry powder QA (i) is amorphous (unlike unformulated QA which is crystalline), a property associated with improved solubility and bioavailability of the drug; (ii) is aerosolizable; (iii) is not cytotoxic, and (iv) improves PAH symptoms in vivo. Accordingly, the respirable QA compositions of the present disclosure are useful in methods for preventing, ameliorating or treating pulmonary arterial hypertension, in particular, PAH. Definitions

[0040] Unless defined otherwise, all technical and scientific terms used herein generally have the same meaning as commonly understood by one of ordinary skill in the art to which this technology belongs. As used in this specification and the appended claims, the singular -8- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 forms “a”, “an” and “the” include plural referents unless the content clearly dictates otherwise. For example, reference to “a cell” includes a combination of two or more cells, and the like. Generally, the nomenclature used herein and the laboratory procedures in cell culture, molecular genetics, organic chemistry, analytical chemistry and nucleic acid chemistry and hybridization described below are those well-known and commonly employed in the art.

[0041] As used herein, the term “about” in reference to a number is generally taken to include numbers that fall within a range of 1%, 5%, or 10% in either direction (greater than or less than) of the number unless otherwise stated or otherwise evident from the context (except where such number would be less than 0% or exceed 100% of a possible value).

[0042] As used herein, the term “feed rate” in reference to spray drying refers to the rate at which an aqueous composition is fed into the spray drying chamber. For example, using a Buchi B-290 spray dryer, “100% feed rate” as used herein corresponds to a rate of 30 mL per minute, and a “10% feed rate” corresponds to a rate of 3 mL per minute.

[0043] As used herein, the “administration” of an agent or drug to a subject includes any route of introducing or delivering to a subject a compound to perform its intended function. Administration can be carried out by any suitable route, including but not limited to, orally, intranasally, via inhalation, intrapleurally, parenterally (intravenously, intramuscularly, intraperitoneally, or subcutaneously), rectally, intrathecally, or topically. Administration includes self-administration and the administration by another.

[0044] As used herein, a "control" is an alternative sample used in an experiment for comparison purpose. A control can be "positive" or "negative." For example, where the purpose of the experiment is to determine a correlation of the efficacy of a therapeutic agent for the treatment for a particular type of disease, a positive control (a compound or composition known to exhibit the desired therapeutic effect) and a negative control (a subject or a sample that does not receive the therapy or receives a placebo) are typically employed.

[0045] As used herein, the term “effective amount” refers to a quantity sufficient to achieve a desired therapeutic and / or prophylactic effect, e.g., an amount which results in the prevention of, or a decrease in a disease or condition described herein or one or more signs or symptoms associated with a disease or condition described herein. In the context of -9- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 therapeutic or prophylactic applications, the amount of a composition administered to the subject will vary depending on the composition, the degree, type, and severity of the disease and on the characteristics of the individual, such as general health, age, sex, body weight and tolerance to drugs. The skilled artisan will be able to determine appropriate dosages depending on these and other factors. The compositions can also be administered in combination with one or more additional therapeutic compounds. In the methods described herein, the therapeutic compositions may be administered to a subject having one or more signs or symptoms of a disease or condition described herein. As used herein, a "therapeutically effective amount" of a composition refers to composition levels in which the physiological effects of a disease or condition are ameliorated or eliminated. A therapeutically effective amount can be given in one or more administrations.

[0046] As used herein, the terms “individual”, “patient”, or “subject” can be an individual organism, a vertebrate, a mammal, or a human. In some embodiments, the individual, patient or subject is a human.

[0047] As used herein, the term “pharmaceutically-acceptable carrier” is intended to include any and all solvents, dispersion media, coatings, antibacterial and antifungal compounds, isotonic and absorption delaying compounds, and the like, compatible with pharmaceutical administration. Pharmaceutically-acceptable carriers and their formulations are known to one skilled in the art and are described, for example, in Remington's Pharmaceutical Sciences (20thedition, ed. A. Gennaro, 2000, Lippincott, Williams & Wilkins, Philadelphia, Pa.).

[0048] As used herein, “prevention” or “preventing” of a disorder or condition refers to a compound that, in a statistical sample, reduces the occurrence of the disorder or condition in the treated sample relative to an untreated control sample, or delays the onset of one or more symptoms of the disorder or condition relative to the untreated control sample. As used herein, preventing pulmonary arterial hypertension includes preventing or delaying the initiation of pulmonary arterial hypertension. As used herein, prevention of pulmonary arterial hypertension also includes preventing a recurrence of one or more signs or symptoms of pulmonary arterial hypertension. -10- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0049] The term “spray-drying” is intended to encompass any process in which a solution of one or more solutes or suspension is formed in a liquid, whereby the liquid is physically atomized into individual droplets which are then dried to form a dry particulate powder. It may encompass any form of a droplet to particle formation process and may encompass related processes such as spray-freeze drying, spray chilling and spray flash drying. The droplets may be formed by any known atomization process, including but not limited to pressure atomization, pneumatic atomization, two or multiple fluid atomization, rotary disc atomization, electrohydrodynamic atomization, ultrasonic atomization, and any variant of such atomization processes. The atomization may occur from one spray source or multiple sources. The liquid vehicle spray may or may not be aqueous and may optionally comprise co-solvents plus additional components dissolved or suspended. The liquid may include a material that is a vapor or solid at ambient conditions but exists as a liquid under the selected process conditions. The droplets formed may be dried by applying heat in the form of a heated drying gas, or heat may be applied in other ways, for example radiatively from the walls of the drying chamber or as microwaves. Once collected from this drying process, the particles may be further dried or conditioned to a controlled moisture level via a process such as vacuum drying or freeze drying. Alternatively drying may be achieved by freezing followed by drying or by application of vacuum.

[0050] It will be recognized that any other means of obtaining such particles are also contemplated herein, for example super critical fluid synthesis, synthesis from emulsions and any other form of controlled precipitation that forms substantially spherical particles. Alternatively, any forms of size reduction, attrition, milling and co-milling may be used to obtain suitably sized particles.

[0051] As used herein, the term “therapeutic agent” is intended to mean a compound that, when present in an effective amount, produces a desired therapeutic effect on a subject in need thereof.

[0052] “Treating” or “treatment” as used herein covers the treatment of a disease or disorder described herein, in a subject, such as a human, and includes: (i) inhibiting a disease or disorder, i.e., arresting its development; (ii) relieving a disease or disorder, i.e., causing regression of the disorder; (iii) slowing progression of the disorder; and / or (iv) inhibiting, relieving, or slowing progression of one or more symptoms of the disease or disorder. In -11- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 some embodiments, treatment means that the symptoms associated with the disease are, e.g., alleviated, reduced, cured, or placed in a state of remission.

[0053] It is also to be appreciated that the various modes of treatment or prevention of disorders as described herein are intended to mean “substantial,” which includes total but also less than total treatment, and wherein some biologically or medically relevant result is achieved. The treatment may be a continuous prolonged treatment for a chronic disease or a single, or few time administrations for the treatment of an acute condition. Pulmonary Arterial Hypertension (PAH)

[0054] PAH is a progressive disorder characterized by abnormally high blood pressure (hypertension) in the pulmonary artery, the blood vessel that carries blood from the heart to the lungs.

[0055] PAH is characterized by vasoconstriction, medial hypertrophy, cell proliferation and fibrosis, complex lesions (plexiform lesions), and thrombosis in situ. Pulmonary arterial changes occur in all three layers of the pulmonary artery: the tunica adventitia, tunica media, and tunica intima. Some key pathobiologic changes in PAH include vasoconstriction, arterial remodeling / inflammation, plexiform lesion, and thrombotic lesion. Vasoconstriction results in the narrowing of the lumen and tightly folded internal elastic lamina with endothelial cells pinched between the folds. Arterial remodeling and inflammation causes thickening of the adventitia and media with neointima formation due to smooth cell and fibroblast proliferation and migration, and lymphoid neogenesis. Prolonged pulmonary vasoconstriction leads to endothelial dysfunction, which is characterized by increased levels of vasoconstrictors (endothelin) and reduced production of vasodilators (nitric oxide and prostacyclin). These mechanisms have led to the development of pharmacologic agents that counteract factors involved in the pathogenesis of PAH. PAH are rare and have been associated with predisposing genetic factors such as mutations in BMPR2, 5-HTT, and Activin-Like Kinase Type-1 Receptor.

[0056] Signs and / or symptoms of PAH include, but are not limited to, persistent dyspnea on exertion, chest pain, light-headedness, exertional presyncope / syncope, palpitations, fatigue, weakness, hoarseness in the voice due to compression of the left laryngeal nerve by the dilated pulmonary artery, venous jugular distension, hepato-jugular reflux, hepatomegaly, -12- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 hepatalgia, lower limb edema, ascites, generalized edema, intimal fibrosis of pulmonary arteries, increased medial thickness of pulmonary arteries, intimal hyperplasia of muscular pulmonary arteries, pulmonary artery thrombotic lesions, pulmonary arteriolar occlusion, pulmonary vascular pruning, plexiform lesions in pulmonary arteries, increased right ventricular systolic pressure, increased right ventricular hypertrophy, pulmonary vasculature hyper-proliferation, elevated serum or plasma brain natriuretic peptide (BNP) (> 180 pg / mL), and elevated serum or plasma N-terminal fragment of proBNP (NT-proBNP) (≥ 1400 pg / mL).

[0057] Diagnosis of PAH, which results from various pathophysiologic and hemodynamic mechanisms with nonspecific symptoms usually due to other underlying comorbid conditions, is particularly challenging, thus necessitating a stepwise approach. History and physical examination are usually evaluated first. The tests that are commonly performed to diagnose PAH and rule out other diseases are echocardiography, blood tests, pulmonary function tests, X-rays of the chest, lung blood flow scans, electrocardiography (ECG), and the “6-minute walk test”, which measures how far an individual can walk in that time period. Ultimately, the majority of subjects undergo confirmation by cardiac catheterization with and without vasodilator testing.

[0058] At-Risk Populations. Individuals with multiple affected family members, who have a known BMPR2 mutation or other mutations that may cause PAH, or those with connective tissue disease (CTD) or HIV is recommended for screening by methods including Doppler echocardiography.

[0059] Physical Examination. A history of angina, dyspnea on exertion, exercise intolerance, fatigue, and syncope are among some of the signs that, although not exclusively related, can help support differential diagnosis. Upon physical examination, abnormal pulse oximetry, tricuspid regurgitation, lower-extremity edema, and signs of right-heart failure can be a few of the signs suggestive of PAH. Initially, a noninvasive test such as an echocardiograph can be performed in patients presenting with any of these signs.

[0060] Right-heart catheterization (RHC) and Vasodilator Testing. Right heart catheterization remains the standard by which the diagnosis of PAH is made. Right heart catheterization provides important prognostic information and is essential to exclude pulmonary venous hypertension by measuring the pulmonary capillary wedge pressure -13- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 (PCWP). If an adequate PCWP tracing cannot be obtained, the left ventricular end-diastolic pressure should be measured. In addition, the mixed venous saturation should be sampled, and measurements of cardiac output should be obtained. The hemodynamic definition of PAH is a mean pulmonary arterial pressure (mPAP) ≥25 mm Hg with a PCWP of ≤15 mm Hg and a pulmonary vascular resistance of >3 Wood units.

[0061] The degree to which mPAP and pulmonary vascular resistance can be decreased acutely by the administration of fast-acting, short-duration vasodilators reflects the extent to which vascular smooth muscle constriction is contributing to the hypertensive state. Because the vasodilator response has considerable therapeutic implications in IPAH, most patients should undergo a vasodilator trial at the time of initial cardiac catheterization. Intravenous epoprostenol, intravenous adenosine, and inhaled NO are commonly used for acute vasodilator testing. On the basis of retrospective data, the consensus definition of a positive response is defined as a reduction of mPAP by at least 10 mm Hg to a value of 40 mm Hg or less, given the observation that patients with this response are most likely to have a beneficial hemodynamic and clinical response to treatment with calcium channel blockers. Those failing to achieve this response are unlikely to improve with calcium channel blocker therapy, whereas those achieving this response may be treated with calcium channel blockers and followed up closely for both safety and efficacy of therapy. A significant vasodilator response may reflect an earlier stage of disease or a qualitatively different disease process.

[0062] Current treatment options for PAH includes supportive therapy and disease- specific therapies.

[0063] Supportive Therapy

[0064] Oral anticoagulation, diuretics, oxygen, digoxin, and management of anemia may be necessary in supportive management of patients with PAH. Venous thromboembolism in certain forms of PAH is a possibility because of abnormalities in coagulation and fibrinolytic pathways along with right-heart failure and immobility. Diuretic therapy may be considered in patients with symptoms of decompensated right-heart failure resulting in fluid retention, ascites, peripheral edema, and other related symptoms. Oxygen has been shown to reduce peripheral vascular resistance, but long-term therapy has not been shown to be beneficial. Oxygen may be recommended in patients with chronic obstructive pulmonary disease, low -14- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 arterial blood-oxygen pressure, evidence of symptomatic benefit, and correctable desaturation on exercise. Digoxin may improve cardiac output in IPAH and slow ventricular rate in patients with arterial tachyarrhythmias. Evidence of efficacy for chronic use in PAH is lacking. Since iron deficiency is common in this population, iron supplementation can be recommended once evaluation is completed. Theoretically, IV iron replacement is usually preferred over oral therapy because oral therapy is associated with impaired absorption in these patients.

[0065] Targeted / Specific Drug Therapy

[0066] Current PAH specific therapies target components of PAH relevant molecular pathways such as voltage gated, L type calcium channels, nitric oxide cyclic guanosine monophosphate (cGMP), endothelin, and prostacyclin.

[0067] Calcium channel blockers. CCBs are indicated only in PAH patients with a documented, positive vasodilator test (e.g., responding to acute vasodilatory challenge during RHC with a drop in mPAP by between 10 and 40 mm Hg, with no drop in cardiac output). These patients are uncommon (5-10% of all cases) and have a different natural history with a five year survival rate of 90% with CCB monotherapy. Patients treated with CCBs should be closely monitored for adequate response and transitioned to PAH specific therapies if symptoms progress. Adequate long term response to CCBs in patients with APAH is rare

[0068] Drugs targeting the nitric oxide pathway. Nitric oxide is a potent pulmonary vasodilator that activates soluble guanylate cyclase (sGC) to generate cGMP. cGMP causes pulmonary artery smooth muscle cell (PASMC) relaxation through cGMP dependent protein kinases, which activate downstream targets, including the large conductance, calcium sensitive potassium channel BKca. Patients with PAH have reduced lung expression of endothelial nitric oxide synthase (eNOS), which synthesizes nitric oxide, and increased expression of phosphodiesterase 5 (PDE5), which degrades cGMP to 5′-GMP. The resulting decrease in cGMP is implicated in adverse pulmonary vascular remodeling in PAH. PDE5 inhibitors and sGC stimulators augment the nitric oxide-cGMP pathway and are approved for treating PAH. A phase III trial is evaluating the safety and efficacy of long term inhaled nitric oxide in PAH (NCT02725372). -15- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0069] PDE5 inhibitors sildenafil and tadalafil are approved for treatment of PAH. The major side effects of PDE5 inhibitors include headache, flushing, dyspepsia, and epistaxis.

[0070] sGC stimulator riociguat directly stimulates sGC independent of nitric oxide, resulting in increased cGMP and pulmonary vasodilation. GC stimulators and PDE5 inhibitors should not be given concurrently owing to the risk of hypotension. However, transition to sGC stimulators from PDE5 inhibitors improves exercise capacity and hemodynamics in patients who have inadequate responses to PDE5 inhibitors. Headache, dizziness, hypotension, dyspepsia, and gastroesophageal reflux are the most common adverse effects of riociguat.

[0071] Endothelin receptors antagonists. Endothelin is a potent vasoconstrictor and smooth muscle mitogen. It acts through endothelin A and endothelin B receptors. Endothelin is overexpressed in the lungs and plasma of patients with PAH. The endothelial receptor antagonists (ERAs) bosentan, ambrisentan, and macitentan are beneficial in PAH. The major adverse effects of ERAs include hepatotoxicity, peripheral edema, anemia, and nasal congestion.

[0072] Drugs targeting the prostacyclin pathway. Prostacyclin and prostanoids bind prostacyclin (IP) receptors, which increases cyclic adenosine monophosphate concentrations causing non-selective pulmonary vasodilatation. They also have antiplatelet, antithrombotic, antiproliferative, and anti-inflammatory properties. Prostacyclin expression is reduced in the lungs of patients with PAH. Prostanoids include but not limited to epoprostenol, treprostinil, iloprost, and beraprost. Selexipag is an orally available, non-prostanoid activator of IP receptors.

[0073] Atrial septostomy and lung transplantation. Atrial septostomy involves the creation of a right-to-left interatrial shunt to increase cardiac output, which, despite reduction in systemic arterial oxygen saturation, may increase systemic oxygen transport, thus reducing the signs and symptoms of right heart failure. Where advanced medical therapies are available, atrial septostomy is used as a palliative measure or a bridge to lung transplantation in appropriately selected patients with refractory right heart failure or syncope / near syncope despite therapy. In regions of the world without access to current medical therapies, atrial septostomy is sometimes used as primary therapy. The procedure carries substantial risk and -16- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 should only be performed by experienced operators. Lung transplantation is generally reserved for those failing the best available medical therapy. Survival in patients with PAH who undergo lung transplantation is ≈66% to 75% at 1 year. Most centers prefer double lung transplantation. Heart and lung transplantation is generally reserved for those with complex congenital heart disease.

[0074] Despite the current available treatments, the prognosis of PAH remains poor and there is no cure for this disorder. Traditional PAH therapies are limited because these conventional medications target and act on downstream pathways directly responsible for cellular functions. Such strategies only provide symptomatic relief, and are not capable of disease reversal / sustained clinical response. Moreover, the targeted downstream pathways are saturable, which generally leads to a build-up of acquired resistance and most non- responsive patients must opt for invasive lung transplantation. Formulations of the Present Technology

[0075] The present disclosure relates to respirable dry powders containing quinacrine (QA), or a pharmaceutically acceptable salt thereof, as an active ingredient. In one aspect, the respirable QA dry powder particles are small and highly dispersible.

[0076] In one aspect, the present disclosure provides a dry powder inhalation (DPI) formulation comprising (a) about 30% w / w to about 50% w / w of quinacrine or a pharmaceutical salt thereof; (b) about 2.5% w / w to about 35%w / w of L-leucine and (c) about 25% w / w to about 52.5% w / w of trehalose. In some embodiments, the DPI formulation comprises about 30% w / w, about 31% w / w, about 32% w / w, about 33% w / w, about 34% w / w, about 35% w / w, about 36% w / w, about 37% w / w, about 38% w / w, about 39% w / w, about 40% w / w, about 41% w / w, about 42% w / w, about 43% w / w, about 44% w / w, about 45% w / w, about 46% w / w, about 47% w / w, about 48% w / w, about 49% w / w, or about 50% w / w of QA or the pharmaceutical salt thereof.

[0077] In any of the above embodiments, the DPI formulation comprises about 0.3 mg to about 0.5 mg of quinacrine or the pharmaceutical salt thereof per mg of the DPI formulation. In certain embodiments, the DPI formulations described herein comprise about 0.3 mg, about 0.31 mg, about 0.32 mg, about 0.33 mg, about 0.34 mg, about 0.35 mg, about 0.36 mg, about 0.37 mg, about 0.38 mg, about 0.39 mg, 0.4 mg, about 0.41 mg, about 0.42 mg, about 0.43 mg, about 0.44 mg, about 0.45 mg, about 0.46 mg, about 0.47 mg, about 0.48 mg, about 0.49 mg, or about 0.5 mg of quinacrine or the pharmaceutical salt thereof per mg of formulation. -17- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0078] Additionally or alternatively, in some embodiments, the DPI formulation comprises about 2.5% w / w, about 3.0% w / w, about 3.5% w / w, about 4.0% w / w, about 4.5% w / w, about 5.0% w / w, about 5.5% w / w, about 6.0% w / w, about 6.5% w / w, about 7.0% w / w, about 7.5% w / w, about 8.0% w / w, about 8.5% w / w, about 9.0% w / w, about 9.5% w / w, about 10.0% w / w, about 10.5% w / w, about 11.0% w / w, about 11.5% w / w, about 12.0% w / w, about 12.5% w / w, about 13.0% w / w, about 13.5% w / w, about 14.0% w / w, about 14.5% w / w, about 15.0% w / w, about 15.5% w / w, about 16.0% w / w, about 16.5% w / w, about 17.0% w / w, about 17.5% w / w, about 18.0% w / w, about 18.5% w / w, about 19.0% w / w, about 19.5% w / w, about 20.0% w / w, about 20.5% w / w, about 21.0% w / w, about 21.5% w / w, about 22.0% w / w, about 22.5% w / w, about 23.0% w / w, about 23.5% w / w, about 24.0% w / w, about 24.5% w / w, about 25.0% w / w, about 25.5% w / w, about 26.0% w / w, about 26.5% w / w, about 27.0% w / w, about 27.5% w / w, about 28.0% w / w, about 28.5% w / w, about 29.0% w / w, about 29.5% w / w, about 30.0% w / w, about 30.5% w / w, about 31.0% w / w, about 31.5% w / w, about 32.0% w / w, about 32.5% w / w, about 33.0% w / w, about 33.5% w / w, about 34.0% w / w, about 34.5% w / w, or about 35.0% w / w of L-leucine.

[0079] Additionally or alternatively, in certain embodiments, the DPI formulation comprises about 25.0% w / w, about 25.5% w / w, about 26.0% w / w, about 26.5% w / w, about 27.0% w / w, about 27.5% w / w, about 28.0% w / w, about 28.5% w / w, about 29.0% w / w, about 29.5% w / w, about 30.0% w / w, about 30.5% w / w, about 31.0% w / w, about 31.5% w / w, about 32.0% w / w, about 32.5% w / w, about 33.0% w / w, about 33.5% w / w, about 34.0% w / w, about 34.5% w / w, about 35.0% w / w, about 35.5% w / w, about 36.0% w / w, about 36.5% w / w, about 37.0% w / w, about 37.5% w / w, about 38.0% w / w, about 38.5% w / w, about 39.0% w / w, about 39.5% w / w, about 40.0% w / w, about 40.5% w / w, about 41.0% w / w, about 41.5% w / w, about 42.0% w / w, about 42.5% w / w, about 43.0% w / w, about 43.5% w / w, about 44.0% w / w, about 44.5% w / w, about 45.0% w / w, about 45.5% w / w, about 46.0% w / w, about 46.5% w / w, about 47.0% w / w, about 47.5% w / w, about 48.0% w / w, about 48.5% w / w, about 49.0% w / w, about 49.5% w / w, about 50.0% w / w, about 50.5% w / w, about 51.0% w / w, about 51.5% w / w, about 52.0% w / w, or about 52.5% w / w of trehalose.

[0080] In any of the preceding embodiments of the DPI formulations described herein, the ratio of L-leucine to trehalose is about 1:1 to about 1:19. In certain embodiments, the ratio of L-leucine to trehalose is about 1:1, about 1:1.25, about 1:1.5, about 1:1.75, about 1:2, -18- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 about 1:2.25, about 1:2.5, about 1:2.75, about 1:3, about 1:3.25, about 1:3.5, about 1:3.75, about 1:4, about 1:4.25, about 1:4.5, about 1:4.75, about 1:5, about 1:5.25, about 1:5.5, about 1:5.75, about 1:6, about 1:6.25, about 1:6.5, about 1:6.75, about 1:7, about 1:7.25, about 1:7.5, about 1:7.75, about 1:8, about 1:8.25, about 1:8.5, about 1:8.75, about 1:9, about 1:9.25, about 1:9.5, about 1:9.75, about 1:10, about 1:10.25, about 1:10.5, about 1:10.75, about 1:11, about 1:11.25, about 1:11.5, about 1:11.75, about 1:12, about 1:12.25, about 1:12.5, about 1:12.75, about 1:13, about 1:13.25, about 1:13.5, about 1:13.75, about 1:14, about 1:14.25, about 1:14.5, about 1:14.75, about 1:15, about 1:15.25, about 1:15.5, about 1:15.75, about 1:16, about 1:16.25, about 1:16.5, about 1:16.75, about 1:17, about 1:17.25, about 1:17.5, about 1:17.75, about 1:18, about 1:18.25, about 1:18.5, about 1:18.75, or about 1:19.

[0081] In certain embodiments, the DPI formulation comprises 50% w / w of quinacrine or the pharmaceutical salt thereof. Additionally or alternatively, in certain embodiments, the ratio of L-leucine to trehalose is 1:1. In some embodiments, the DPI formulation comprises 25% w / w of L-leucine and 25% w / w of trehalose.

[0082] Additionally or alternatively, in any of the above embodiments, the DPI formulations further comprise one or more excipients chosen from 1,2-distearoyl-sn-glycero- 3-phosphocholine, alcohol, anhydrous citric acid, anhydrous trisodium citrate, apaflurane, ascorbic acid, benzalkonium chloride, black ink, calcium carbonate, calcium chloride, carrageenan, cetylpyridinium chloride, chlorobutanol, citric acid monohydrate, dichlorodifluoromethane, dichlorotetrafluoroethane, edetate disodium, ferric oxide yellow, fluorochlorohydrocarbons, gelatin, glycerin, glycine, hydrochloric acid, hypromellose 2906 (4 mPa.S), lactose, lactose monohydrate, lecithin (soybean), magnesium stearate, mannitol, menthol, methylparaben, nitric acid, norflurane, N-phenyl-1-napthylamine, nutmeg oil, oleic acid, petrolatum, phenylethyl alcohol, polysorbate 80, potassium chloride, propylene glycol, propylparaben, saccharin, saccharin sodium, silicon dioxide, sodium bicarbonate, sodium bisulfite, sodium chloride, sodium hydroxide, sodium lauryl sulfate, sodium metabisulfite, sodium sulfate anhydrous, sorbitan trioleate, sulfuric acid, thymol, titanium dioxide, trichloromonofluoromethane, trisodium citrate dihydrate, tromethamine, turpentine oil, and zinc oxide. -19- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0083] In any of the above embodiments, the DPI formulations described herein have a solid content of about 2-5% w / v. In certain embodiments, the solid content is about 2% w / v, 2.5% w / v, about 3% w / v, about 3.5% w / v, about 4% w / v, about 4.5% w / v, or about 5% w / v. Additionally or alternatively, in some embodiments, the DPI formulations of the present technology are amorphous.

[0084] Additionally or alternatively, in some embodiments, the DPI formulation has a Mass Median Aerodynamic Diameter (MMAD) of about 0.5-10 µm or about 1-5 µm. In certain embodiments, the DPI formulation has a MMAD of about 1 µm, about 1.1 µm, about 1.2 µm, about 1.3 µm, about 1.4 µm, about 1.5 µm, about 1.6 µm, about 1.7 µm, about 1.8 µm, about 1.9 µm, about 2 µm, about 2.1 µm, about 2.2 µm, about 2.3 µm, about 2.4 µm, about 2.5 µm, about 2.6 µm, about 2.7 µm, about 2.8 µm, about 2.9 µm, about 3 µm, about 3.1 µm, about 3.2 µm, about 3.3 µm, about 3.4 µm, about 3.5 µm, about 3.6 µm, about 3.7 µm, about 3.8 µm, about 3.9 µm, about 4 µm, about 4.1 µm, about 4.2 µm, about 4.3 µm, about 4.4 µm, about 4.5 µm, about 4.6 µm, about 4.7 µm, about 4.8 µm, about 4.9 µm, or 5 µm.

[0085] In any of the above embodiments, the DPI formulations described herein have a Fine Particle Fraction (FPF) of about 70%-100% or about 82%-88%. In certain embodiments, the DPI formulations described herein have a FPF of about 70%, about 71%, about 72%, about 73%, about 74%, about 75%, about 76%, about 77%, about 78%, about 79%, about 80%, about 81%, about 82%, about 83%, about 84%, about 85%, about 86%, about 87%, about 88%, about 89%, about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, or about 100%.

[0086] In any and all embodiments, the DPI formulations comprise particles having an effective cut-off diameter of about 4-8 µm. In certain embodiments, the DPI formulations comprise particles having an effective cut-off diameter of about 4 µm, about 4.25 µm, about 4.5 µm, about 4.75 µm, about 5 µm, about 5.25 µm, about 5.5 µm, about 5.75 µm, about 6 µm, about 6.25 µm, about 6.5 µm, about 6.75 µm, about 7 µm, about 7.25 µm, about 7.5 µm, about 7.75 µm, or about 8 µm.

[0087] Additionally or alternatively, in some embodiments, the DPI formulation is configured to be aerosolized with an inhaler device (e.g., RS01) and tested for aerosolization properties using a cascade impactor and a throat adapter, and the cascade impactor is -20- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 configured to operate at an inlet flow rate between 30-100 L / min. In certain embodiments, the cascade impactor is configured to operate at an inlet flow rate of 30 L / min, 40 L / min, 50 L / min, 60 L / min, 70 L / min, 80 L / min, 90 L / min, or 100 L / min.

[0088] The present disclosure also relates to the preparation of the QA DPI formulations disclosed herein comprising combining quinacrine or a pharmaceutical salt thereof, L-leucine and trehalose with an aqueous solvent to form a mixture and feeding the mixture through a spray dryer. In some embodiments, the spray dryer has an inlet temperature of about 150 ºC and / or an atomizing airflow of about 400 L / hr. Additionally or alternatively, in some embodiments, the mixture is fed through the spray dryer at a feed rate of about 5%-10%. In certain embodiments, the spray dryer has a nozzle orifice of about 0.7 mm. Methods of Treating PAH Using the DPI Compositions of the Present Technology

[0089] In one aspect, the present disclosure provides a method for treating or preventing pulmonary arterial hypertension in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of the respirable compositions of the present technology (i.e., dry powder quinacrine). The chemical structure of quinacrine is shown in FIG.1. In some embodiments, the subject has been diagnosed as having pulmonary arterial hypertension (PAH). In some embodiments, the subject has been diagnosed as having an idiopathic PAH (IPAH), familial PAH (FPAH), or associated PAH (APAH).

[0090] Examples of APAH include PAH associated with Collagen vascular disease, PAH associated with Congenital systemic-to-pulmonary shunts, PAH associated with Portal hypertension, PAH associated with HIV infection, PAH associated with drugs and toxins, PAH associated with other disorders (e.g., thyroid disorders, glycogen storage disease, Gaucher disease, hereditary hemorrhagic telangiectasia, hemoglobinopathies, myeloproliferative disorders, splenectomy).

[0091] Additionally or alternatively, in some embodiments, the subject harbors a mutation selected from the group consisting of bone morphogenetic protein receptor type II (BMPR2), Serotonin (5-HTT) transporter, and Activin-Like Kinase Type-1 Receptor (ALK- 1). Additionally or alternatively, in certain embodiments, the subject is a pediatric patient, a geriatric patient, an immunocompromised patient, a female patient, or a male patient, and / or is of Caucasian, South Asian, Southeastern Asian, or Middle-eastern descent.

[0092] In any and all embodiments of the methods disclosed herein, administration of dry powder QA prevents, delays the onset of, or reduces the signs or symptoms of PAH. In some -21- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 embodiments, the signs or symptoms of PAH comprise one or more of persistent dyspnea on exertion, chest pain, light-headedness, exertional presyncope / syncope, palpitations, fatigue, weakness, hoarseness in the voice due to compression of the left laryngeal nerve by the dilated pulmonary artery, venous jugular distension, hepato-jugular reflux, hepatomegaly, hepatalgia, lower limb edema, ascites, generalized edema, intimal fibrosis of pulmonary arteries, increased medial thickness of pulmonary arteries, intimal hyperplasia of muscular pulmonary arteries, pulmonary artery thrombotic lesions, pulmonary arteriolar occlusion, pulmonary vascular pruning, plexiform lesions in pulmonary arteries, increased right ventricular systolic pressure, increased right ventricular hypertrophy, pulmonary vasculature hyper-proliferation, elevated serum or plasma brain natriuretic peptide (BNP) (> 180 pg / mL), and elevated serum or plasma N-terminal fragment of proBNP (NT-proBNP) (≥ 1400 pg / mL).

[0093] Additionally or alternatively, in some embodiments, the subject exhibits a decrease in right ventricular systolic pressure (RVSP) and / or a reduction in right ventricular hypertrophy (RVH) following administration of quinacrine. RVSP is generally determined using right heart catheterization (see supra), which is known to a skilled in the art. In some embodiments, the subject exhibits at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, or at least 95% reduction in RVSP following administration of quinacrine. In certain embodiments, the subject exhibits at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, or at least 95% reduction in RVH following administration of quinacrine.

[0094] Additionally or alternatively, the subject exhibits a decrease in vessel muscularization and / or a reduction in medial wall thickness in pulmonary arterioles following administration of quinacrine. In some embodiments, the subject exhibits at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 90%, at least 100%, at least 110%, at least 120%, at least 130%, at least 140%, at least 150%, at least 160%, at least 170%, at least 180%, at least 190%, at least 200%, at least 210%, at least 220%, at least 230%, at least 240%, at least 250%, at least 260%, at least -22- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 270%, at least 280%, at least 290%, at least 300%, at least 310%, at least 320%, at least 330%, at least 340%, at least 350%, at least 360%, at least 370%, at least 380%, at least 390%, at least 400% reduction in the medial wall thickness following administration of quinacrine.

[0095] Additionally or alternatively, the subject exhibits decreased expression of hyper- proliferating biomarkers such as Ki67, Proliferating Cell Nuclear Antigen (PCNA), and serpine1 following administration of QA. Additionally or alternatively, the subject exhibits reduced expression of IL-6, and / or Acta2 following administration of QA.

[0096] Additionally or alternatively, in some embodiments, the methods of the present technology further comprise separately, sequentially or simultaneously administering one or more additional therapeutic agents to the subject. In some embodiments, the additional therapeutic agents are selected from the group consisting of: endothelin receptor antagonists (ETRAs), guanylate cyclase stimulators, prostacyclin analogues, phosphodiesterase (PDE)-5 inhibitors, dehydroepiandrosterone (DHEA), cyclosporine, tacrolimus, bestatin, imatinib, calcium-channel blockers (CCBs), dichloroacetate (DCA), trimetazidine, ranolazine, 4- phenylbutyrate, tauroursodeoxycholic acid, and salubrinal.

[0097] In any embodiments of the methods disclosed herein, the subject may be a human. Modes of Administration and Effective Dosages

[0098] Any method known to those in the art for contacting a cell, organ or tissue with dry powder compositions may be employed. Suitable methods include in vitro, ex vivo, or in vivo methods. In vivo methods include the administration of dry powder QA to a mammal, suitably a human. When used in vivo for therapy, dry powder QA is administered to the subject in effective amounts (i.e., amounts that have desired therapeutic effect). The dose and dosage regimen will depend upon the degree of the disease state of the subject, the characteristics of the particular DPI composition used, e.g., its therapeutic index, the subject, and the subject’s history.

[0099] The effective amount may be determined during pre-clinical trials and clinical trials by methods familiar to physicians and clinicians. An effective amount of dry powder QA useful in the methods may be administered to a mammal in need thereof by any of a number of well-known methods for administering dry powder compositions. The composition including dry powder QA may be administered systemically or locally. In any -23- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 and all embodiments of the methods disclosed herein, QA or pharmaceutically acceptable salt thereof is administered via inhalation, orally, topically, intranasally, intrapleurally, systemically, intravenously, subcutaneously, intraperitoneally, intradermally, intraocularly, iontophoretically, transmucosally, or intramuscularly.

[0100] Dry powder QA may be formulated as a pharmaceutically acceptable salt. The term “pharmaceutically acceptable salt” means a salt prepared from a base or an acid which is acceptable for administration to a patient, such as a mammal (e.g., salts having acceptable mammalian safety for a given dosage regime). However, it is understood that the salts are not required to be pharmaceutically acceptable salts, such as salts of intermediate compositions that are not intended for administration to a patient. Pharmaceutically acceptable salts can be derived from pharmaceutically acceptable inorganic or organic bases and from pharmaceutically acceptable inorganic or organic acids. In addition, when a composition contains both a basic moiety, such as an amine, pyridine or imidazole, and an acidic moiety such as a carboxylic acid or tetrazole, zwitterions may be formed and are included within the term "salt" as used herein. Salts derived from pharmaceutically acceptable inorganic bases include ammonium, calcium, copper, ferric, ferrous, lithium, magnesium, manganic, manganous, potassium, sodium, and zinc salts, and the like. Salts derived from pharmaceutically acceptable organic bases include salts of primary, secondary and tertiary amines, including substituted amines, cyclic amines, naturally-occurring amines and the like, such as arginine, betaine, caffeine, choline, N,N'-dibenzylethylenediamine, diethylamine, 2-diethylaminoethanol, 2-dimethylaminoethanol, ethanolamine, ethylenediamine, N-ethylmorpholine, N-ethylpiperidine, glucamine, glucosamine, histidine, hydrabamine, isopropylamine, lysine, methylglucamine, morpholine, piperazine, piperadine, polyamine resins, procaine, purines, theobromine, triethylamine, trimethylamine, tripropylamine, tromethamine and the like. Salts derived from pharmaceutically acceptable inorganic acids include salts of boric, carbonic, hydrohalic (hydrobromic, hydrochloric, hydrofluoric or hydroiodic), nitric, phosphoric, sulfamic and sulfuric acids. Salts derived from pharmaceutically acceptable organic acids include salts of aliphatic hydroxyl acids (e.g., citric, gluconic, glycolic, lactic, lactobionic, malic, and tartaric acids), aliphatic monocarboxylic acids (e.g., acetic, butyric, formic, propionic and trifluoroacetic acids), amino acids (e.g., aspartic and glutamic acids), aromatic carboxylic acids (e.g., benzoic, p- -24- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 chlorobenzoic, diphenylacetic, gentisic, hippuric, and triphenylacetic acids), aromatic hydroxyl acids (e.g., o-hydroxybenzoic, p-hydroxybenzoic, 1-hydroxynaphthalene-2- carboxylic and 3-hydroxynaphthalene-2-carboxylic acids), ascorbic, dicarboxylic acids (e.g., fumaric, maleic, oxalic and succinic acids), glucuronic, mandelic, mucic, nicotinic, orotic, pamoic, pantothenic, sulfonic acids (e.g., benzenesulfonic, camphosulfonic, edisylic, ethanesulfonic, isethionic, methanesulfonic, naphthalenesulfonic, naphthalene-1,5-disulfonic, naphthalene-2,6-disulfonic and p-toluenesulfonic acids), xinafoic acid, and the like.

[0101] The dry powder QA compositions described herein can be incorporated into pharmaceutical compositions for administration, singly or in combination, to a subject for the treatment or prevention of PAH described herein. Such DPI compositions typically include the active agent and a pharmaceutically acceptable carrier. One or more tonicity adjusting agents may be added to provide the desired ionic strength. Tonicity adjusting agents for use herein include those which display no or only negligible pharmacological activity after administration. Both inorganic and organic tonicity adjusting agents may be used. Supplementary active compositions may also be incorporated into the DPI compositions.

[0102] Dosage, toxicity and therapeutic efficacy of any therapeutic agent can be determined by standard pharmaceutical procedures in cell cultures or experimental animals, e.g., for determining the LD50 (the dose lethal to 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index and it can be expressed as the ratio LD50 / ED50. Compositions that exhibit high therapeutic indices are advantageous. While DPI compositions that exhibit toxic side effects may be used, care should be taken to design a delivery system that targets such DPI compositions to the site of affected tissue in order to minimize potential damage to uninfected cells and, thereby, reduce side effects.

[0103] The data obtained from the cell culture assays and animal studies can be used in formulating a range of dosage for use in humans. The dosage of such DPI compositions may be within a range of circulating concentrations that include the ED50 with little or no toxicity. The dosage may vary within this range depending upon the dosage form employed and the route of administration utilized. For any DPI composition used in the methods, the therapeutically effective dose can be estimated initially from cell culture assays. A dose can be formulated in animal models to achieve a circulating plasma concentration range that -25- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 includes the IC50 (i.e., the concentration of the test compound which achieves a half- maximal inhibition of symptoms) as determined in cell culture. Such information can be used to determine useful doses in humans accurately. Levels in plasma may be measured, for example, by high performance liquid chromatography.

[0104] An exemplary treatment regime entails administration once per day or once a week. In therapeutic applications, a relatively high dosage at relatively short intervals is sometimes required until progression of the disease is reduced or terminated, or until the subject shows partial or complete amelioration of symptoms of disease. Thereafter, the patient can be administered a prophylactic regime.

[0105] Typically, an effective amount of the DPI composition, sufficient for achieving a therapeutic or prophylactic effect, range from about 0.000001 mg per kilogram body weight per day to about 10,000 mg per kilogram body weight per day. Suitably, the dosage ranges are from about 0.0001 mg per kilogram body weight per day to about 100 mg per kilogram body weight per day. For example, dosages can be 1 mg / kg body weight or 10 mg / kg body weight every day, every two days or every three days or within the range of 1-10 mg / kg every week, every two weeks or every three weeks. In one embodiment, a single dosage of the DPI composition ranges from 0.001-10,000 micrograms per kg body weight. In one embodiment, DPI composition concentrations in a carrier range from 0.2 to 2000 micrograms per delivered milliliter. An exemplary treatment regime entails administration once per day or once a week. In therapeutic applications, a relatively high dosage at relatively short intervals is sometimes required until progression of the disease is reduced or terminated, or until the subject shows partial or complete amelioration of symptoms of disease. Thereafter, the patient can be administered a prophylactic regime.

[0106] In some embodiments, a therapeutically effective amount of a DPI composition may be defined as a concentration of the DPI composition at the target tissue of 10-12to 10-6molar, e.g., approximately 10-7molar. This concentration may be delivered by systemic doses of 0.001 to 100 mg / kg or equivalent dose by body surface area. The schedule of doses would be optimized to maintain the therapeutic concentration at the target tissue, such as by single daily or weekly administration, but also including continuous administration (e.g., parenteral infusion or transdermal application). -26- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0107] The skilled artisan will appreciate that certain factors may influence the dosage and timing required to effectively treat a subject, including but not limited to, the severity of the disease or disorder, previous treatments, the general health and / or age of the subject, and other diseases present. Moreover, treatment of a subject with a therapeutically effective amount of the therapeutic DPI compositions described herein can include a single treatment or a series of treatments.

[0108] The mammal treated in accordance with the present methods can be any mammal, including, for example, farm animals, such as sheep, pigs, cows, and horses; pet animals, such as dogs and cats; laboratory animals, such as rats, mice and rabbits. In some embodiments, the mammal is a human.

[0109] For therapeutic and / or prophylactic applications, a composition comprising dry powder QA is administered to the subject. In some embodiments, the dry powder QA is administered in an effective amount between about 5 mg / kg to about 10 mg / kg. In certain embodiments, the QA or pharmaceutically acceptable salt thereof is administered in an effective amount of about 1 mg / kg, about 1.5 mg / kg, about 2 mg / kg, about 2.5 mg / kg, about 3 mg / kg, about 3.5 mg / kg, about 4 mg / kg, about 4.5 mg / kg, about 5 mg / kg, about 5.5 mg / kg, about 6 mg / kg, about 6.5 mg / kg, about 7 mg / kg, about 7.5 mg / kg, about 8 mg / kg, about 8.5 mg / kg, about 9 mg / kg, about 9.5 mg / kg, about 10 mg / kg, about 10.5 mg / kg, about 11 mg / kg, about 11.5 mg / kg, about 12 mg / kg, about 12.5 mg / kg, about 13 mg / kg, about 13.5 mg / kg, about 14 mg / kg, about 14.5 mg / kg, or about 15 mg / kg. Additionally or alternatively, in some embodiments, the dry powder QA is administered in an effective amount between about 1 µM to about 10 µM. In certain embodiments, the dry powder QA is administered in an effective amount of about 1 µM, about 1.5 µM, about 2 µM, about 2.5 µM, about 3 µM, about 3.5 µM, about 4 µM, about 4.5 µM, about 5 µM, about 5.5 µM, about 6 µM, about 6.5 µM, about 7 µM, about 7.5 µM, about 8 µM, about 8.5 µM, about 9 µM, about 9.5 µM, or about 10 µM. Values and ranges intermediate to the recited values are also contemplated as part of the present disclosure.

[0110] In some embodiments, administering dry powder QA comprises the delivery of dry powder QA to the patient through a dry powder inhaler (DPI). In some embodiments, the DPI comprises a container for storing dry powder QA; a metering member having a dosing recess to be filled with a dose of the dry powder QA from the container; and a mouthpiece -27- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 being in communication with an inhalation channel for enabling inhalation of the dose of the powdered medicament contained in the dosing recess of the metering member. In some embodiments, delivery comprises the patient exhaling; placing mouthpiece in mouth; inhaling; and holding breath for 5-10 seconds.

[0111] In some embodiments, the dry powder QA is administered one, two, three, four, or five times per day. In some embodiments, the QA or pharmaceutically acceptable salt thereof is administered more than five times per day. Additionally or alternatively, in some embodiments, the dry powder QA is administered every day, every other day, every third day, every fourth day, every fifth day, or every sixth day. In some embodiments, the dry powder QA is administered weekly, bi-weekly, tri-weekly, or monthly. In some embodiments, the dry powder QA is administered for a period of one, two, three, four, or five weeks. In some embodiments, the dry powder QA is administered for six weeks or more. In some embodiments, the dry powder QA is administered for twelve weeks or more. In some embodiments, the dry powder QA is administered for a period of less than one year. In some embodiments, the dry powder QA is administered for a period of more than one year. In some embodiments, the dry powder QA is administered throughout the subject’s life.

[0112] In some embodiments, the dry powder QA is administered daily for 1 week or more. In some embodiments of the methods of the present technology, the dry powder QA is administered daily for 2 weeks or more. In some embodiments of the methods of the present technology, the dry powder QA is administered daily for 3 weeks or more. In some embodiments of the methods of the present technology, the dry powder QA is administered daily for 4 weeks or more. In some embodiments of the methods of the present technology, the dry powder QA is administered daily for 6 weeks or more. In some embodiments of the methods of the present technology, the dry powder QA is administered daily for 12 weeks or more. In some embodiments, the dry powder QA is administered daily throughout the subject’s life. Values and ranges intermediate to the recited values are also contemplated as part of the present disclosure. EXAMPLES

[0113] The present technology is further illustrated by the following Examples, which should not be construed as limiting in any way. -28- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 Example 1: QA dry powder formulations

[0114] Dry powder QA formulations were prepared by traditional spray drying using Buchi B-290 spray dryer. The spray drying of QA involved various carriers. All formulations had a consistent solid content of 2% w / v or 2 g / 100 mL (2 g total solids of which 15-50% is QA and rest are excipients). Batch size for all the formulations was 20ml. A Buchi mini- spray dryer B-290, equipped with a 0.7mm nozzle orifice and a nozzle atomizer, was used for the spray drying process, with the atomizing airflow was adjusted to 400L / hr.

[0115] Various drug loadings were tested in all the batches produced by the spray dryer, starting with a 15%w / w drug loading. Mannitol was selected as the primary carrier for the formulation development due to its lower inlet temperature requirement than trehalose. A batch using 100% mannitol as the carrier yielded 77.96% at 20% feed rate with an inlet temperature of 100oC (Table 1, Formulation 1 “F1”). Lactohale, an inhalable grade of lactose, was also considered as a carrier and spray-dried at 100oC with a feed rate of 20%, yielding 48.87% (Table 1, F2). Additionally, leucine was explored as a carrier based on numerous studies suggesting that its incorporation enhances the yield of spray drying batches. This batch resulted in a yield of 79.69% (Table 1, F3).

[0116] After observing that mannitol and leucine resulted in a higher % yield, the next formulation trial involved using these both carriers in a 1:1 ratio with a 15% drug load. The % yield for this batch was 83.29% with the feed rate of 20% (Table 1, F4). In-vitro aerosolization performance testing was conducted on this batch using a RS01 DPI device. Mannitol was replaced with Trehalose to determine if similar results could be obtained. Trehalose is a non-reducing sugar that does not induce the Maillard reaction and, therefore, does not contribute to potential product degradation. Additionally, trehalose has a higher glass transition temperature than mannitol, which helps reduce the hygroscopic nature of the spray-dried powder.

[0117] Trehalose with a 15% drug load, similar to other carriers tested, was used. The inlet temperature was adjusted to 150oC with a feed rate of 10% (Table 1, F5). However, all the powder became stuck in the cyclone separator. To enhance powder flowability, leucine was combined with trehalose at two different proportions. All the formulations containing trehalose were conducted at 150oC as the inlet temperature. Initially, an equal ratio of both -29- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 carriers, i.e., 1:1, was used. The feed rate for this batch was 10%, and the yield was 77.18% (Table 1, F6). A different ratio of trehalose to leucine (3:1) was also tested. This batch was also processed at a feed rate of 10%, resulting in a yield of 70.97% (Table 1, F7). Differential scanning chromatography (DSC) was performed using standard techniques to determine if the QA is properly coated with carriers and changed to amorphous form (FIG.2), as evidenced by the lack of peak at 250ºC.

[0118] The impact of flow rate on % yield and powder characteristics was further investigated. To observe the same, F6 and F7 (Table 1) formulations were produced with different ratios of trehalose and leucine at feed rate of 5%. The formulation with a trehalose- to-leucine ratio of 1:1 resulted in a yield of 75.67% (Table 1, F8), while the formulation with a ratio of 3:1 yielded 68.5% powder (Table 1, F9). It was observed that both feed rates produced a high percentage yield in the formulation containing an equal ratio of both carriers.

[0119] After establishing the ratio of carriers and spray dry parameters, the aim shifted to enhancing the drug load in the formulation. A higher drug load results in a reduced dosing frequency for the patient. Further formulations aimed at increasing the drug load to 30% w / w. Both the formulations were produced with the feed rate of 5% and 10%. At a 10% feed rate, the yield was 80.74% for 1:1 carrier ratio (Table 1, F10) while the yield was 80.39% for 3:1 carrier ratio (Table 1, F11). On the other hand, at a 5% feed rate, a 1:1 carrier ratio yielded 75.87% (Table 1, F12), and a 3:1 carrier ratio yielded 74.89% powder (Table 1, F13). Solid- state characterization tests were conducted on these formulations to assess the drug's crystallinity (FIG.3), as evidenced by the lack of peak at 250ºC.

[0120] It was observed that the crystallinity of the drug changes to an amorphous form, and the % yield remains unchanged despite an increase in the drug load. Based on these findings, the 1:1 carrier ratio was selected as it consistently demonstrated a high % yield across varying feed rates and drug loads. Following this, the feasibility of increasing the drug load to 50% was evaluated within the established formulation. Upon increasing the drug load to 50% w / w and testing it at feed rates of 5 and 10, % yields of 71.42% (Table 1, F14) and 74.62% (Table 1, F15) were obtained, respectively. Although the % yield did not significantly differ, variations in the flow properties of the final spray dry formulations between the two batches were observed. Visual inspection revealed superior flow properties in the powder produced at a feed rate of 10% compared to 5%. Consequently, a formulation -30- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 with a 50% drug load, 1:1 carrier ratio, and a feed rate of 10% was selected for further characterization. Solid-state characterization tests were conducted to assess the drug's crystallinity (FIG. 4), as evidenced by the lack of peak at 250ºC. A powder X-ray diffraction (PXRD) analysis, using standard techniques, further revealed that both the carriers and the drug exhibit a high degree of crystallinity (FIG. 5). However, in the formulated product, the absence of crystalline peaks indicates that the spray drying process transformed the drug and carriers into an amorphous form.

[0121] A particularly preferred formulation is optimized formula F15, comprising 0.51±0.02 mg QA / mg formulation, a trehalose to leucine ratio of 25%:25%, and solid content of about 2% w / v, produced with a batch size of 20ml fed through a Buchi mini spray dryer at a 10% feed rate with a B-290 Nozzle orifice (0.7 mm), the aspirator set to 100%, the temperature set to 150 ºC, and atomizing airflow set to 400 L / hr.

[0122] Table 1: Formulation Optimization Based on Excipients and Drug Load-31- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117

[0123] Formulations #16-19 were prepared by sequentially changing the amount of L- Leucine in the formulation mixture.

[0124] Table 2: Formulation Optimization with modulating L-Leucine Content

[0125] As can be seen in Table 2, formulation yield increased with increasing leucine concentrations from 71.1% for F16 with 2.5% Leucine, to 77.9% for F19 with 20% leucine. The drug content of QA remained consistently about 0.5 mg QA per 1 mg of DPI formulation.

[0126] Images of formulation appearance (FIG. 15) clearly show the differences in appearances for all 4 formulations. As with increase in L-leucine concentration, the formulations became more free flowing and homogeneously dispersed. A powder X-ray diffraction (PXRD) analysis, using standard techniques, further revealed that both the carriers and the drug exhibit a high degree of crystallinity (FIG. 16). However, in the formulated product, the absence of crystalline peaks indicates that the spray drying process transformed the drug and carriers into an amorphous form.

[0127] The SEM images (FIGs. 17A-17D) pertaining to F16-F19 revealed particle aggregation in F16, referring to possible higher moisture content. F17-F19 showed regularly shaped particles with the absence of particle aggregation caused by moisture residual or temperature effects. These findings suggest that F17-F19 formulation powders are likely to demonstrate favorable aerodynamic behavior. -32- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 Example 2: In-vitro aerosolization test

[0128] For the in-vitro aerosolization test, a Next Generation Impactor (NGI), an eight stage cascade impactor designed specifically for pharmaceutical inhaler testing, was used with a throat adaptor. QA formulations (2 capsules, each containing 10 mg of spray-dried powder) were weighed and manually filled into size 3 hydroxypropylmethylcellulose (HPMC) capsules. Each capsule was loaded into an RS01 dry powder inhaler, and the powder was drawn into the NGI through the induction port using an HCP5 Vacuum Pump operated at a flow rate of 60 L / min for 4 s. The sample deposited in each stage was collected using 1 mL of solvent (for preseparator, solvent used was 10 ml) and drug content analyzed with ultra- performance liquid chromatography (UPLC), using standard techniques. The aerosolization performance parameters were then calculated by analyzing QA deposition in the NGI (FIGs. 6A-6C). The Mass Median Aerodynamic Diameter (MMAD) of the finalized formulation was measured at 1.18 ± 0.09 µm, falling within the recommended range of 1-5 µm. Moreover, the Fine Particle Fraction (FPF) of the formulation was determined to be 85.06 ± 2.48%, signifying its suitability for inhalation.

[0129] Scanning Electron Microscopy analysis revealed that the QA spray dry powder formulation exhibited irregularly shaped particles (FIG.6D). The absence of particle aggregation caused by residual moisture or temperature effects further supports that the QA dry powder formulation has favorable aerodynamic properties.

[0130] Thermogravimetric analysis was also conducted, using standard techniques, to assess the residual moisture in the spray-dried formulation. The analysis revealed that the residual moisture in the spray-dried formulation was 1.84 ± 0.01% (FIG.7). Previous studies have indicated that moisture content in crystalline powders exists as adsorbed water, while in amorphous powders, it is present in the absorbed form. See Bronlund, J., & Paterson, T. (2004). Moisture sorption isotherms for crystalline, amorphous and predominantly crystalline lactose powders. International Dairy Journal, 14(3), 247-254. Since DSC and PXRD analysis (see supra) showed that the prepared formulation exhibited an amorphous nature, the residual moisture content exists in the absorbed form. -33- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 Example 3: QA dry powder safety in primary pulmonary artery smooth muscle cells (PASMC)

[0131] Safety of QA inhaled dry powder was tested in primary PASMCs isolated from PAH patients. Briefly, the cells were plated in 96 well plates using standard techniques, and after overnight attachment, were treated with varying concentrations of QA dry powder for 6- 24 hours. Cytotoxicity was assessed using Cell Titer Blue assay kit. No significant reduction in cell viability was seen that confirms safety of the developed inhaled dry powder formulation of QA (FIG.8). Example 4: QA dry powder pharmacodynamic studies

[0132] Pharmacodynamic testing of QA dry powder inhaled formulation was tested in adult male rate (175-200 mg) following once-a-day administration for 10 days after disease development.

[0133] Briefly, PAH symptoms were induced in animals by injecting SU5416 (20 mg / kg) once in the beginning, following which animals were kept in hypoxia (10% O2) for 21 days. After 21 days, animals were taken out of the hypoxia chamber, and were administered intratracheally (non-invasive, directly into the lungs) with QA dry powder formulation once- a-day for 10 days at 5- and 10-mg / kg dose. After 10 days, animals were catheterized to measure hemodynamic parameters including right ventricular systolic pressure (RVSP), right ventricular hypertrophy (Fulton Index), cardiac output, pulmonary vascular resistance, and heart rate. Similar experiments were performed with control animals for following groups: 1. Sham animals (no PAH) 2. SU5416 / Hypoxia (PAH symptoms, sham treatment) 3. Ambrisentan (FDA-approved PAH drug, 10 mg / kg once a day orally) 4. Riociguat (FDA-approved PAH drug, 10 mg / kg once a day orally) 5. Unformulated QA Active Pharmaceutical Ingredient (API) (5 and 10 mg / kg Intratracheally) 6. Unformulated QA API (5 and 10 mg / kg intraperitoneally)

[0134] A substantial reduction in the right ventricle systolic pressure (RVSP) was observed in both 5 and 10mg / kg group for QA dry powder (IT DPI group), corresponding to 49.1±3.4 mmHg and 27.8±2.6 mmHg respectively, compared to 67.7±5.7 mmHg mm Hg for -34- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 SU5416 control SU5416 / Hypoxia animals (FIG.10). Similar modulation in other parameters were seen as well, including a significant reduction in Fulton index (RV / (LV+S)) (FIG.9), a significant increase in cardiac output (FIG.11), a decrease in pulmonary vascular resistance (PVR) (FIG.12), and a reduction in heart rate (FIG.13). The efficacy of QA inhaled dry powder was comparable to unformulated QA API administration, which highlights efficacy of the delivery system.

[0135] Experimental control groups performed with ambrisentan and riociguat administration demonstrated that unformulated QA at the same dosage (10 mg / kg) have superior therapeutic outcomes in the preclinical PAH model (FIGs.14A-14C). Taken together, these results demonstrate that QA as an API and as an inhaled dosage form have superior therapeutic outcomes in preclinical PAH model compared to other approved PAH drugs. EQUIVALENTS

[0136] The present technology is not to be limited in terms of the particular embodiments described in this application, which are intended as single illustrations of individual aspects of the present technology. Many modifications and variations of this present technology can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. Functionally equivalent methods and apparatuses within the scope of the present technology, in addition to those enumerated herein, will be apparent to those skilled in the art from the foregoing descriptions. Such modifications and variations are intended to fall within the scope of the present technology. It is to be understood that this present technology is not limited to particular methods, reagents, compounds compositions or biological systems, which can, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.

[0137] In addition, where features or aspects of the disclosure are described in terms of Markush groups, those skilled in the art will recognize that the disclosure is also thereby described in terms of any individual member or subgroup of members of the Markush group.

[0138] As will be understood by one skilled in the art, for any and all purposes, particularly in terms of providing a written description, all ranges disclosed herein also encompass any and all possible subranges and combinations of subranges thereof. Any listed -35- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 range can be easily recognized as sufficiently describing and enabling the same range being broken down into at least equal halves, thirds, quarters, fifths, tenths, etc. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third and upper third, etc. As will also be understood by one skilled in the art all language such as “up to,” “at least,” “greater than,” “less than,” and the like, include the number recited and refer to ranges which can be subsequently broken down into subranges as discussed above. Finally, as will be understood by one skilled in the art, a range includes each individual member. Thus, for example, a group having 1-3 cells refers to groups having 1, 2, or 3 cells. Similarly, a group having 1-5 cells refers to groups having 1, 2, 3, 4, or 5 cells, and so forth.

[0139] All patents, patent applications, provisional applications, and publications referred to or cited herein are incorporated by reference in their entirety, including all figures and tables, to the extent they are not inconsistent with the explicit teachings of this specification.

[0140] The present technology may include, but is not limited to, the features and combinations of features recited in the following lettered paragraphs, it being understood that the following paragraphs should not be interpreted as limiting the scope of the claims as appended hereto or mandating that all such features must necessarily be included in such claims: A. A dry powder inhalation (DPI) formulation comprising (a) about 30% w / w to about 50% w / w of quinacrine or a pharmaceutical salt thereof; (b) about 2.5% w / w to about 35%w / w of L-leucine and (c) about 25% w / w to about 52.5% w / w of trehalose. B. The DPI formulation of paragraph A, wherein the ratio of L-leucine to trehalose is about 1:1 to about 1:19. C. The DPI formulation of paragraph A or B, comprising 50% w / w of quinacrine or the pharmaceutical salt thereof. D. The DPI formulation of any one of paragraphs A-C, wherein the ratio of L-leucine to trehalose is 1:1. E. The DPI formulation of any one of paragraphs A-D, comprising 25% w / w of L-leucine and 25% w / w of trehalose. -36- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 F. The DPI formulation of any one of paragraphs A-E, further comprising one or more excipients chosen from 1,2-distearoyl-sn-glycero-3-phosphocholine, alcohol, anhydrous citric acid, anhydrous trisodium citrate, apaflurane, ascorbic acid, benzalkonium chloride, black ink, calcium carbonate, calcium chloride, carrageenan, cetylpyridinium chloride, chlorobutanol, citric acid monohydrate, dichlorodifluoromethane, dichlorotetrafluoroethane, edetate disodium, ferric oxide yellow, fluorochlorohydrocarbons, gelatin, glycerin, glycine, hydrochloric acid, hypromellose 2906 (4 mPa.S), lactose, lactose monohydrate, lecithin (soybean), magnesium stearate, mannitol, menthol, methylparaben, nitric acid, norflurane, N- phenyl-1-napthylamine, nutmeg oil, oleic acid, petrolatum, phenylethyl alcohol, polysorbate 80, potassium chloride, propylene glycol, propylparaben, saccharin, saccharin sodium, silicon dioxide, sodium bicarbonate, sodium bisulfite, sodium chloride, sodium hydroxide, sodium lauryl sulfate, sodium metabisulfite, sodium sulfate anhydrous, sorbitan trioleate, sulfuric acid, thymol, titanium dioxide, trichloromonofluoromethane, trisodium citrate dihydrate, tromethamine, turpentine oil, and zinc oxide.G. The DPI formulation of any one of paragraphs A-F, having a solid content of 2-5% w / v. G. The DPI formulation of any one of paragraphs A-F, having a solid content of 2-5% w / v. H. The DPI formulation of any one of paragraphs A-G, wherein the DPI formulation is amorphous. I. The DPI formulation of any one of paragraphs A-H, comprising about 0.3 mg to about 0.5 mg of quinacrine or the pharmaceutical salt thereof per mg of the DPI formulation. J. The DPI formulation of any one of paragraphs A-I, wherein the DPI formulation has a Mass Median Aerodynamic Diameter (MMAD) of about 1-5 µm. K. The DPI formulation of any one of paragraphs A-J, wherein the DPI formulation has a Fine Particle Fraction (FPF) of about 82%-88%. L. The DPI formulation of any one of paragraphs A-K, wherein the DPI formulation comprises particles having an effective cut-off diameter of about 4-8 µm. -37- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 M. The DPI formulation of any one of paragraphs A-L, wherein the DPI formulation is configured to be aerosolized with an inhaler device and tested for aerosolization properties using a cascade impactor and a throat adapter, wherein the cascade impactor is configured to operate at an inlet flow rate between 30-100 L / min. N. A method for preparing the DPI formulation of any one of paragraphs A-M comprising combining quinacrine or a pharmaceutical salt thereof, L-leucine and trehalose with an aqueous solvent to form a mixture and feeding the mixture through a spray dryer. O. The method of claim N, wherein the spray dryer has an inlet temperature of about 150 ºC and / or an atomizing airflow of about 400 L / hr. P. The method of paragraph N or O, wherein the spray dryer has a nozzle orifice of about 0.7 mm. Q. The method of any one of paragraphs N-P, wherein the mixture is fed through the spray dryer at a feed rate of about 5%-10%. R. A method for treating or preventing pulmonary arterial hypertension in a subject in need thereof comprising administering to the subject a therapeutically effective amount of the DPI formulation of any one of paragraphs A-M. S. The method of paragraph R, wherein the pulmonary arterial hypertension is idiopathic PAH (IPAH), familial PAH (FPAH), or associated PAH (APAH). T. The method of paragraph R or S, wherein the subject is a pediatric patient, a geriatric patient, an immunocompromised patient, a female patient, or a male patient. U. The method of any one of paragraphs R-T, wherein the signs or symptoms of PAH comprise one or more of persistent dyspnea on exertion, chest pain, light-headedness, exertional presyncope / syncope, palpitations, fatigue, weakness, hoarseness in the voice due to compression of the left laryngeal nerve by the dilated pulmonary artery, venous jugular distension, hepato-jugular reflux, hepatomegaly, hepatalgia, lower limb edema, ascites, generalized edema, intimal fibrosis of pulmonary arteries, increased medial thickness of pulmonary arteries, intimal hyperplasia of muscular pulmonary arteries, pulmonary artery thrombotic lesions, pulmonary arteriolar occlusion, pulmonary vascular pruning, plexiform lesions in pulmonary arteries, -38- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 increased right ventricular systolic pressure, increased right ventricular hypertrophy, pulmonary vasculature hyper-proliferation, elevated serum or plasma brain natriuretic peptide (BNP) (> 180 pg / mL), and elevated serum or plasma N-terminal fragment of proBNP (NT-proBNP) (≥ 1400 pg / mL).

[0141] Other embodiments are set forth in the following claims, along with the full scope of equivalents to which such claims are entitled. -39- 4930-4097-2883.2

Claims

Atty. Dkt. No.: 126842-0117 WHAT IS CLAIMED IS:

1. A dry powder inhalation (DPI) formulation comprising (a) about 30% w / w to about 50% w / w of quinacrine or a pharmaceutical salt thereof; (b) about 2.5% w / w to about 35%w / w of L-leucine and (c) about 25% w / w to about 52.5% w / w of trehalose.

2. The DPI formulation of claim 1, wherein the ratio of L-leucine to trehalose is about 1:1 to about 1:

19.

3. The DPI formulation of claim 1 or 2, comprising 50% w / w of quinacrine or the pharmaceutical salt thereof.

4. The DPI formulation of any one of claims 1-3, wherein the ratio of L-leucine to trehalose is 1:

1.

5. The DPI formulation of any one of claims 1-4, comprising 25% w / w of L-leucine and 25% w / w of trehalose.

6. The DPI formulation of any one of claims 1-5, further comprising one or more excipients chosen from 1,2-distearoyl-sn-glycero-3-phosphocholine, alcohol, anhydrous citric acid, anhydrous trisodium citrate, apaflurane, ascorbic acid, benzalkonium chloride, black ink, calcium carbonate, calcium chloride, carrageenan, cetylpyridinium chloride, chlorobutanol, citric acid monohydrate, dichlorodifluoromethane, dichlorotetrafluoroethane, edetate disodium, ferric oxide yellow, fluorochlorohydrocarbons, gelatin, glycerin, glycine, hydrochloric acid, hypromellose 2906 (4 mPa.S), lactose, lactose monohydrate, lecithin (soybean), magnesium stearate, mannitol, menthol, methylparaben, nitric acid, norflurane, N-phenyl-1- napthylamine, nutmeg oil, oleic acid, petrolatum, phenylethyl alcohol, polysorbate 80, potassium chloride, propylene glycol, propylparaben, saccharin, saccharin sodium, silicon dioxide, sodium bicarbonate, sodium bisulfite, sodium chloride, sodium hydroxide, sodium lauryl sulfate, sodium metabisulfite, sodium sulfate anhydrous, sorbitan trioleate, sulfuric acid, thymol, titanium dioxide, trichloromonofluoromethane, trisodium citrate dihydrate, tromethamine, turpentine oil, and zinc oxide.

7. The DPI formulation of any one of claims 1-6, having a solid content of 2-5% w / v. -40- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 8. The DPI formulation of any one of claims 1-7, wherein the DPI formulation is amorphous.

9. The DPI formulation of any one of claims 1-8, comprising about 0.3 mg to about 0.5 mg of quinacrine or the pharmaceutical salt thereof per mg of the DPI formulation.

10. The DPI formulation of any one of claims 1-9, wherein the DPI formulation has a Mass Median Aerodynamic Diameter (MMAD) of about 1-5 µm.

11. The DPI formulation of any one of claims 1-10, wherein the DPI formulation has a Fine Particle Fraction (FPF) of about 82%-88%.

12. The DPI formulation of any one of claims 1-11, wherein the DPI formulation comprises particles having an effective cut-off diameter of about 4-8 µm.

13. The DPI formulation of any one of claims 1-12, wherein the DPI formulation is configured to be aerosolized with an inhaler device and tested for aerosolization properties using a cascade impactor and a throat adapter, wherein the cascade impactor is configured to operate at an inlet flow rate between 30-100 L / min.

14. A method for preparing the DPI formulation of any one of claims 1-13 comprising combining quinacrine or a pharmaceutical salt thereof, L-leucine and trehalose with an aqueous solvent to form a mixture and feeding the mixture through a spray dryer.

15. The method of claim 14, wherein the spray dryer has an inlet temperature of about 150 ºC and / or an atomizing airflow of about 400 L / hr.

16. The method of claim 14 or 15, wherein the spray dryer has a nozzle orifice of about 0.7 mm.

17. The method of any one of claims 14-16, wherein the mixture is fed through the spray dryer at a feed rate of about 5%-10%.

18. A method for treating or preventing pulmonary arterial hypertension in a subject in need thereof comprising administering to the subject a therapeutically effective amount of the DPI formulation of any one of claims 1-13.

19. The method of claim 18, wherein the pulmonary arterial hypertension is idiopathic PAH (IPAH), familial PAH (FPAH), or associated PAH (APAH). -41- 4930-4097-2883.2Atty. Dkt. No.: 126842-0117 20. The method of claim 18 or 19, wherein the subject is a pediatric patient, a geriatric patient, an immunocompromised patient, a female patient, or a male patient.

21. The method of any one of claims 18-20, wherein the signs or symptoms of PAH comprise one or more of persistent dyspnea on exertion, chest pain, light-headedness, exertional presyncope / syncope, palpitations, fatigue, weakness, hoarseness in the voice due to compression of the left laryngeal nerve by the dilated pulmonary artery, venous jugular distension, hepato-jugular reflux, hepatomegaly, hepatalgia, lower limb edema, ascites, generalized edema, intimal fibrosis of pulmonary arteries, increased medial thickness of pulmonary arteries, intimal hyperplasia of muscular pulmonary arteries, pulmonary artery thrombotic lesions, pulmonary arteriolar occlusion, pulmonary vascular pruning, plexiform lesions in pulmonary arteries, increased right ventricular systolic pressure, increased right ventricular hypertrophy, pulmonary vasculature hyper-proliferation, elevated serum or plasma brain natriuretic peptide (BNP) (> 180 pg / mL), and elevated serum or plasma N-terminal fragment of proBNP (NT-proBNP) (≥ 1400 pg / mL). -42- 4930-4097-2883.2

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