Methods and pharmaceutical compositions for treatment of respiratory dysfunction in neurodegenerative diseases

Abstract

This invention relates to pharmaceutical compositions, including compositions adapted for intranasal administration, comprising an active ingredient, including phosphodiesterase inhibitors, useful in the treatment of respiratory dysfunction associated with motor neuron diseases and lysosomal storage diseases, including amyotrophic lateral sclerosis and other adult and pediatric neurodegenerative diseases characterized by central apnea and protein misfolding involving brainstem nuclei.

Description

DOCKET NO.: 267181.000102 PATENTMETHODS AND PHARMACEUTICAL COMPOSITIONS FOR TREATMENT OF RESPIRATORY DYSFUNCTION IN NEURODEGENERATIVE DISEASESCROSS REFERENCE TO RELATED APPLICATIONS[0001 j This application claims the benefit of priority of US Provisional Patent Application Serial No. 63 / 690,618, filed on September 4, 2024, the entire contents of which is hereby incorporated by reference herein.FIELD OF THE INVENTION

[0002] This invention relates to compositions useful in the treatment of respiratory dysfunction associated with motor neuron diseases and lysosomal storage diseases. These diseases include amyotrophic lateral sclerosis and other adult and pediatric neurodegenerative diseases characterized by central apnea and protein misfolding involving brainstern nuclei. BACKGROUND OF THE INVENTION

[0003] Amyotrophic lateral sclerosis (ALS) is a degenerative motor neuron disease, causing progressive muscle paralysis and death from respiratory failure. While there is a high degree of vanability in ALS onset, site, and progression, survival is 3-5 years after symptom onset in most patients with death primarily attributed to respiratory failure. In addition to ALS patients, respiratory' failure is a major cause of morbidity and mortality in a significant number of adult and pediatric orphan diseases stemming from bulbar dysfunction. Individuals with other motor neuron diseases and those with lysosomal storage diseases also suffer from respiratory dysfunction stemming from bulbar dysfunction. Collectively, over one hundred conditions may be characterized as diseases of Bulbar Mediated Respiratory Dysfunction (BMRD). These include Gaucher’s disease, Pompe disease, adult and pediatric motor neuron disease and numerous other conditions that are variously referred to as orphan diseases, pediatric orphan diseases and adult orphan diseases.

[0004] Clinically, the leading cause of death in ALS, as well as a number of other motor neuron and lysosomal storage diseases, is respiratory' involvement due to bulbar dysfunction. Bulbar onset ALS for example, has a significantly worse prognosis than limb onset where degeneration of motor neurons in the anterior medulla reduces respiratory drive. On an anatomical basis, lesions m the pre-Botzinger complex in the lower brainstem lead to centrally mediated respiratory dysfunction. The pre-Botzinger complex, as the central inspiratory rhythm generator, has been implicated as the primary etiology of central mediated apnea. Brain 2011 Jan;134(Pt l):24-35. Centrally mediated respiratory dysfunction involving loss of brainstem neurons in the pre-Botzinger complex and phrenic motor-neurons isDOCKET NO.: 267181.000102 PATENT characteristic of both adult and pediatric orphan diseases, including Pompe disease. Proc.Natl. Acad Sci. USA. 2009:106:9419-9424.

[0005] Symptomatically, degeneration w ithin the nuclei of the pre-Botzinger complex in the ventral medulla results in cessation of phrenic nerve, hypoglossal nerve and vagal nerve activity. Respir Physiol Neurobiol 2024 Feb:320: 104202. In ALS, loss of respiratory drive has been directly associated with degeneration of the pre-Botzinger complex. However, to date the current disease modifying therapies do not address respiratory dysfunction despite it being the leading cause of morbidity7and mortality. Muscle Nerve 2017 Aug:56(2): 197-201. Assessment of respiratory dysfunction

[0006] Forced vital capacity (FVC) is a non-invasive respiratory test that has long been used in ALS. It assesses both the inspiratory and expiratoty loops, requiring expiration done forcefully after a maximal inspiration, as opposed to slow vital capacity (SVC). This test is sensitive to change and predictive of hypoventilation and survival in ALS. FVC can be an unreliable measure of ventilatory function in patients with bulbar involvement due to orofacial weakness, and due to air leakage around the mouthpiece. This pulmonary function test is not a very7sensitive test to detect hypercapnia, since gas exchange is well maintained until FVC values are very low. Further, Dysfunction in central control of breathing in ALS patients is not adequately detected with standard evaluation

[0007] An alternative non-invasive respiratory test to FV C is the sniff nasal inspiratory pressure (SNIP) test. The measurements produced by this test allow the assessment of diaphragmatic weakness in patients with neuromuscular disease (Is sniff inspiratory nasal pressure a useful test in the evaluation of patients with neuromuscular diseases? | European Respiratory7Society. https: / / erj.ersjoumals.com / content / 48 / suppl_60 / PA2167). One example of such anon-invasive test device is the Pneumotrac with RMS made by MD Spiro (https: / / mdspiro.com / product / pneumotrac-with-rms / ).Ventilation Methods

[0008] Effective means to preserve / restore ventilation are necessary to increase the quality and duration of life in patients with these conditions. Currently, breathing dysfunction in ALS and other BMRDs is managed primarily through non-invasive ventilation (NIV), including noninvasive supplemental oxygenation, cough assists and Bi-Pap devices. The US Centers for Medicare and Medicaid Services (CMS) criteria for initiating non- invasive ventilation (NIV) is a forced vital capacity (FVC) of less than 50% of predicted normal. In bulbar mediated respiratory dysfunction, apnea and retention of CO2 are managedDOCKET NO.: 267181.000102 PATENT primarily through noninvasive supplemental oxygenation, cough assists, and Bi-Pap devices. htps: / / www.ncbi.nlm.nih.gov / pmc / articles / PMC10214054 /

[0009] While B1PAP is effective in reducing the work of breathing, it can potentially reduce diaphragm loading, reduced motor unit recruitment and less phrenic motor neuron activity. BIPAP may be a useful therapeutic tool, but administering BIPAP too early may do more harm than good. Mechanical support of minute ventilation provides only sy mptomatic relief and is usually associated with deterioration to the point of complete ventilator dependency for survival. Respir Physiol Neurobiol. 2013 Nov 1; 189(2): 429-437. Requirements for Effective Therapy

[0010] There is a high unmet need to develop alternative therapies for orphan diseases like ALS that simultaneously target the underlying pathophysiological mechanisms and correction of the disease phenotype.

[0011] An ideal therapeutic to manage respiratory dysfunction in ALS and other BMRDs has several important criteria. One, the agent or group of agents must readily cross the blood brain barrier and avoid off-target effects. The vast majority of potentially effective neurotherapeutics for ALS and other BRMDs fail to reach clinical trials. The most common reason for these failures is poor bioavailability of the drug, which is related to poor aqueous solubility, limited permeability through biological membranes, and hepatic first-pass metabolism, as well as an inability to cross the blood-brain barrier. The blood-brain barrier is the bottleneck in bram drug development and is the single most important factor limiting the future growth of neurotherapeutics. For a small-molecule drug to cross the BBB in pharmacologically significant amounts, a molecular mass under a 400- to 600-Da threshold is highly preferred, and they must demonstrate high lipid solubility forming less than 8-10 hydrogen bonds with solvent water. Once the total number of hydrogen bonds on the drug exceeds a threshold of 8-10, there is minimal transport of the drug across the BBB in pharmacologically active amounts. Moreover, large-molecule products of biotechnology, such as monoclonal antibodies, recombinant proteins, antisense, or gene therapeutics, generally do not cross the BBB.

[0012] In addition, in an effective therapeutic the active pharmaceutical ingredient(s) (API(s)) must be able to demonstrate an in v iv o effect on respiratory parameters including improvement of hypoxia and hypercapnia, improvement of respiratory muscle activity and reduction of motor fatigue.DOCKET NO.: 267181.000102 PATENT

[0013] In summary, in order to extend the survival time and improve the quality of life of patients with Bulbar Mediated Respiratory Dysfunction, including those with motor neuron diseases and lysosomal storage diseases, more effective means are needed to treat the respirator)' dysfunction associated with these conditions in tandem with addressing the primary genetic pathogenic mechanisms.SUMMARY OF THE INVENTION

[0014] Provided herein are methods and pharmaceutical compositions useful for treating respiratory dysfunction associated with motor neuron diseases and lysosomal storage diseases. One aspect of the invention relates to a method of intranasal administration of a selective phosphodiesterase (PDE) inhibitor. In a particular preferred embodiment, the phosphodiesterase inhibitor is amlexanox. In another aspect of the invention, the phosphodiesterase inhibitor is one of theophylline, aminophylline, ibudilast, roflumilast or ensifentrine. The formulation for intranasal administration may be aqueous, dry pow der, or a gel. delivered respectively by aqueous spray, dry powder spray, or nasal applicator device. DETAILED DESCRIPTION OF THE INVENTION

[0015] While certain descriptions of disease pathology in this disclosure relate to ALS, the methods of use are equally applicable to other orphan diseases characterized by respiratory dysfunction due to neurodegeneration and protein misfolding involving the brainstem. Other diseases relevant to the present invention include but are not limited to Alzheimer’s disease, multi -infarct dementia, Parkinson’s disease, corticobasal degeneration, multiple sclerosis (MS) and other demyelinating diseases, major depression, Lewy body dementia, multiple system atrophy, and frontotemporal dementia (FTD).

[0016] In one aspect, the present invention is a therapeutic formulated for intranasal delivery on a chronic basis consisting of a selective phosphodiesterase (PDE) inhibitor and ingredients that facilitate the transfer of the active API into the brainstem as the primary site of pathology. In a preferred embodiment, the active ingredient is amlexanox, a selective PDE4 inhibitor and the formulation is comprised of excipients that increase the solubility' and stability of the API, as well as improving its ability to cross the blood brain barrier through nasal delivery. In a further preferred embodiment, the active ingredient is ensifentrine, a selective PDE3 inhibitor with modest inhibitory effects on PDE4. A third contemplated embodiment is the combination of two or more members of a select group of PDE inhibitors that can both target central causes of apnea while simultaneously improving peripheral lung function by relaxing the smooth muscle of the pulmonary vasculature with pharmacologicalDOCKET NO.: 267181.000102 PATENT effects as bronchodilators. For example, a combination of selective PDE4A and PDE4B inhibitors particularly targeting central nervous system astrocytes and peripheral macrophages is envisioned. In another example, combining a selective PDE3 inhibitor and a selective PDE4 inhibitor as a dual agonist to treat respiratory dysfunction associated with neurodegeneration in envisioned.

[0017] Administration of a relatively low dose of these drugs acts to produce improvement in respiratory function, while avoiding the side effects associated with higher doses. By employing the intranasal route of administration, the present invention avoids the problematic side effects associated with the dosing levels of conventional IV or oral administration of these drugs.

[0018] Mechanistically, overexpression of phosphodiesterases has been implicated in the development of various neurological diseases, including ALS. owing to the importance of phosphorylation / dephosphorylation in regulating RNA transcription. In ALS, the phosphorylation of TDP-43 is the principal mutation in over 97% cases, which results in reduced RNA transcription and the formation of cryptic exons. Chemical modifications of 5',3'-phosphodiester bonds in the niRNA body and poly(A) are dependent on its ATPase, suggesting targeted pharmacological inhibition of phosphodiesterases as a mechanism to reduce protein aggregation in ALS.

[0019] Phosphorylation is regulated by phosphodiesterases (PDFs), negative regulators of cyclic AMP and GMP comprised of a large family of enzymes that degrade the second messenger cyclic AMP and cyclic GMP Phosphodiesterases are divided into 1 1 families of proteins which van' in distribution and sub cellular receptor binding.

[0020] The primary' isoforms of phosphodiesterase in the mammalian brain include PD3, PD4 and PDI0. Phosphodiesterase 3 is a dual esterase that hydrolyses both cAMP and cGMP and is highly expressed in the CNS, particularly in the olfactory bulb which may account for the loss of smell as a common feature in neurodegenerative disease. While PDE4A, B, and D subtypes are expressed in the brain, the strict amino acid sequence conservation of the active site across the four subtypes of PDE4 has made it difficult to discover subtype-specific inhibitors. Neurotherapeutics. 2015 Jan; 12.(1): 49 -56.

[0021] Both PDE3 and PDE4 are significant targets for select phosphodiesterase inhibitors to treat neurological disease PDE4 isoforms are in many structures of the medulla, but to date, have not been studied in the CNS. While inhibitors of cAMP-phosphodiesterase exert a number of promising therapeutic benefits, non-selective peripheral inhibitionDOCKET NO.: 267181.000102 PATENT frequently results in adverse effects, in particular emesis and nausea, have curbed their clinical utility. FASEB J. 2020 Sep; 34(9): 12533-12548. For example, roflumilast (N-(3,5- dichloropyridin-4-yl)-3-cyclopropylmethoxy-4-difluoromethoxybenzamide) is an oral PDE4 inhibitor approved for the treatment of COPD. The incidence of adverse effects of roflnailast was 38.2% in the 500 pg group and 25.3% in the 250 pg group (p=0.034) in one study. In another study, the discontinuation rate of roflumilast was 41 .6% (n=74) in the 500 pg group and 23. 1% (n=21) in the 250 pg group (p=:0.003 ). When adjusted by age. sex, smoking status, and lung function, 500 pg dose was significantly associated with the discontinuation of roflumilast (odds ratio, 2.87; p<0.001). Tuberc Respir Dis (Seoul). 2018 Oct; 81(4): 299-304.

[0022] Ibudilast is a phosphodiesterase inhibitor approved for the treatment of asthma inJapan that has been studied in ALS and MS. In an ALS study, 86% of participants experienced at least one, possibly study drug related adverse event. 37% of participants could not tolerate 100 mg / day and underwent dose reduction to 60-80 mg / day and 31% of participants discontinued study drug early due to drug related adverse events. Neuroimage Clin. 2021 ; 30: 102672.

[0023] Ensifentrme, a dual PDE3 / PDE4 inhibitor recently approved for the treatment of COPD, regulates cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP) concentrations in airway smooth muscle, and has been reported to result in vomiting, headache and nausea Am J Respir Crit Care Med. 2023 Aug 15; 208(4): 406-416.

[0024] Given these adverse effects, there is an urgent need to develop novel delivery systems that can target the primary sites of pathology in the CNS through alternative routes of administration to improve efficacy while greatly reducing or eliminating adverse drug reactions.

[0025] Dosing levels required to achieve therapeutic effect, when utilizing the intranasal route of the present invention, are substantially lower than dose levels found in products utilizing other delivery routes. Table 1 contains information on the dosing levels of active ingredients used in differing routes of administration, as well as anticipated dosing levels for various embodiments of the invention. The intranasal routes provide significantly lower dosing. Should nano formulation be utilized in the intranasal formulations, these doses may be further reduced.DOCKET NO.: 267181.000102 PATENTTable 1 : Relative Dosing Levels by Route of Delivery (daily dose)

[0026] In a preferred embodiment of the present invention, amlexanox is utilized as the active ingredient in an intranasally administrated therapeutic formulation for the treatment of respiratory dysfunction in patients with motor neuron and pediatric orphan diseases of bulbar etiology. In some aspects of the present invention, the formulation of amlexanox is administered to patients having bulbar mediated respiratory dysfunction attributed to adult or pediatric onset orphan disease.

[0027] Amlexanox (C16H14N2O4) is a topical anti-inflammatory, anti-allergic oral paste that was approved by the FDA in 1996 for the treatment of patients with recurrent aphthous stomatitis, and later withdrawn from the US market. The product for treatment of aphthous stomatitis was reportedly withdrawn due to side effects caused bv an excipient in its formulation. Amlexanox has also been approved in Japan as a treatment for asthma in either 25 mg or 50 mg oral tablets. Amlexanox is a monocarboxylic acid derivative having an amino substituent at the 2-position, an oxo substituent at the 5-position and an isopropyl substituent at the 7-position that directly inhibits the activities of PDE4, 3A, and 3B, which likely’ accounts for its anti-inflammatory effects In mouse brain, amlexanox reduces inflammatory infiltration and demyelination in the spinal cords, accompanied by reduced frequency of pathogenic Thl and Th 17 cells and increased Tregs.Amlexanox

[0028] In protein misfolding disorders such as AI..S, amlexanox can promote the degradation of nonsense-carry ing transcripts prior to translation when the ribosome encounters termination codons following GTP hydrolysis mediated by its effects as a phosphodiesterase inhibitor. Amlexanox was demonstrated to stabilize premature codons viaDOCKET NO.: 267181.000102 PATENT the inhibition of phosphorylation status of eIF2«-containing mRNAs. Orphanet J Rare Dis. 2012; 7: 58.

[0029] In this regard, amlexanox may have dual beneficial effects, including symptomatic respirator)' enhancing effects, through selective phosphodiesterase inhibition and gene stabilizing effects by inhibiting premature termination codon (PTC). Amlexanox is a stable orally available compound as a powder stored at -20 °C with a shelf life of 3 years. A 6- month toxicology study using dogs determined that the dosage of oral amlexanox at which no side effects were observed was demonstrated at 10 mg / kg / day. Its respiratory stimulatory effects likely resemble other phosphodiesterase inhibitors that stimulate respiratory activity through distinct activation of neurons in the nucleus hypoglossus and the pre-Botzinger complex. J Neurophysiol. 2019 Apr 1;121(4): 1 102-1 1 10.

[0030] However, the clinical utility of amlexanox as a respiratory stimulant has been hampered by its limited solubility, with the drug being originally formulated as a topical paste. In the present invention, solubility of amlexanox is enhanced through the novel formulations discussed below.

[0031] In alternative embodiments of the invention, other phosphodiesterase inhibitors may be utilized. In one embodiment of the invention, the active ingredient is ensifentrine. Ensifen trine is a selective, dual phosphodiesterase (PDE)3 and PDE4 inhibitor with bronchodilator and anti-inflammatory effects that has recently been approved as an inhalation-based treatment for COPD at doses between 0.75 to 6 mg.

[0032] Ensifentrine is an inhaled first-in-class dual inhibitor of phosphodiesterase (PDF.) 3 and 4 in patients with chronic obstructive pulmonary disease. Nebulized ensifentrine 0.75 to 6 mg twice daily significantly improved bronchodilation and symptoms. The purported mechanism in COPD is related to the activation of purinergic receptors in airway epithelia by cyclic AMP and cyclic GMP nucleotides.EnsifentrineDOCKET NO.: 267181.000102 PATENT[0033 [ The pharmacological characteristics of ensifen trine indicate that the affinity for PDE3 is ^3, 700-fold higher than that for PDE4. In the CNS, there is higher expression of PDE4, whereas PD3 isoforms have been shown to reduce systemic inflammation with a greater capacity to act as a bronchodilator.

[0034] Roflumilast is a PDE4 inhibitor used to manage COPD. It functions to reduce inflammation and relax the airways. The standard dosing for roflumilast is 500 micrograms (mcg) once daily as an oral tablet. The mechanism of action of roflumilast is inhibition of PDE4 causing an increase in cAMP levels. In the brain, smooth muscle receptors are responsive to phosphodiesterase inhibition. By dilating these receptors there is increased blood vessel supply to the cerebral vascular tree.Roflumilast

[0035] Ibudilast is a selective PDE inhibitor. Ibudilast is a drug with a multifaceted mechanism of action, primarily used for its anti-inflammatory' and neuroprotective effects. Its precise mechanisms are complex and not fully understood, but several key actions have been identified including PDE inhibition, anti-inflammatory effects, neuroprotective action, antiamyloid effects, and vasodilatory effects. Ibudilast is an oral medication ty pically dosed at 10 to 100 mg per day.Ibudilast

[0036] Aminophylline is a methylxanthine known for stimulatory effects on the central nervous system, through antagonism of adenosine receptors in the brainstem respiratory control centers leading to increased respiratory drive, improved diaphragmatic function andDOCKET NO.: 267181.000102 PATENT greater minute ventilation. Aminophylline is a complex of theophylline and ethylenediamine. Aminophylline is a nonspecific adenosine receptor antagonist. Aminophylline inhibits phosphodiesterases (PDEs), such as PDE4, in rhythmogenic neurons of the medulla and pons, which increases cyclic AMP (cAMP) levels and further stimulates respiratory neural activity to mitigate hypoxic ventilatory depression.

[0037] Aminophylline acts to improve smooth muscle activity, promote bronchodilation and mucociliary clearance, enhance respiratory drive by increasing the mitochondrial respiration rate, reduce PaCCh and pulmonary oxygen tension, and it has been reported to increase the synaptic drive of motoneurons as they stimulate the respiratory' centers within the brainstem. Aminophylline is currently delivered in oral form and via IV.Aminophylline

[0038] In another embodiment of the invention, the active ingredient is chosen from a generalized PDE inhibitor class, including but not limited io theophylline, aminophylline, tadalafil, sildenafil, caffeine, enoximone, or levosimendan. Levosimendan. while classified as a PDE inhibitor indicated for congestive heart failure, has a mechanism of action based upon its effects in mediating the opening of ATP-dependent potassium channels (KATP channels) in vascular smooth muscle cells. A trial investigating oral levosimendan 1 mg once daily and 1 mg two times a day was previously conducted in ALS patients, but the trial was terminated due to adverse drug reactions and failure to meet its primary' end points. J Neurol Neurosurg Psychiatry 2019 0ct;90(10): 1165-1170. In another embodiment of the invention, the active ingredient is combined with a disease modifying therapy such as riluzole, edaravone. antisense oligonucleotides or monoclonal antibodies in development for ALS.Formulation of Pharmaceutical Compositions

[0039] In the present invention, various pharmaceutical compositions and nasal delivery systems are conceived of and optimized to enhance solubility and stability for the APIs, while certain excipients may also act as functionally active ingredients. An aerosol spray comprised of a saline solution containing oxygenated nanobubbles, for example, may exert a range ofDOCKET NO.: 267181.000102 PATENT beneficial physiologic and pharmacologic effects that include tissue oxygenation as a treatment for patients with hypoxemic respiratory failure,

[0040] Active ingredients in some embodiments of the invention are not highly soluble, and this characteristic must be addressed if they are to be successfully delivered via the intranasal route. Amlexanox, the active ingredient in a preferred embodiment of the invention, is not highly soluble. In one aspect of the present invention, excipients are introduced to increase solubility and absorption. This has several advantages over other nasal formulations as the nasal mucosa is negatively charged and otherwise will repel the negatively charged carboxy terminus of amlexanox.

[0041] In another aspect of the present invention, intranasal delivery of amlexanox or other PDE inhibitors is enhanced by means of increasing the binding of the API to the olfactory' neuroepithelium, a form of molecular ‘‘hitch hiking'’ across biological membranes for drug delivery. This is achieved by co-formulation of amlexanox (C16H14N2O4) with cyclodextrins a-l,4-linked D-glucopyranose units where the later consists of six to eight glucopyranose units. In a preferred embodiment, this excipient is dimethyl-beta-cyclodextrin (D1MEB). The ratio between API and D1MEB can be in any integer ratio from 1 : 1 to 1 : 10,000.

[0042] The choice of excipients in the design of a pharmaceutical formulation is generally made based on their function, as well as chemical compatibility with the drug substance. Typical drug- excipient formulations influence environmental conditions (microenvironmental pH, temperature, water content, and / or water activity (RH), and oxygen).

[0043] The majority of excipients are classified as synthetic, including poly ethylene glycols, polysorbates, Cremophor EL and Pluronics* Excipients such as Cremophor EL-35, Pluronic block copolymer F68, PEG-400, Tween-80 and Labrasol, associated with genotoxicity’ and very small dose limits before reaching toxicity7. Pharmaceutics. 2022 Dec; 14(12): 2575. Microcrystailine cellulose, hydroxypropyl cellulose, stearic acid, and silicon dioxide excipients have been associated with the production of formaldehyde, acetaldehyde, furfuraldehyde (and possibly’ other aldehydes), and polyethylene glycol. Formaldehyde may also be formed as a degradation product of misfolded proteins prone to oxidation and susceptible to interactions with hydroperoxide containing excipients.

[0044] While synthetic permeation enhancers such as Poloxamer 407, Poloxamer 188, and hydroxypropyl methylcellulose (HPMC) can be employed for gel preparation,DOCKET NO.: 267181.000102 PATENT augmentation nasal absorption, and reduction of mucus viscosity, at higher dose they can have toxicity

[0045] Numerous reactive excipient impurities have been reported to cause drag degradation, including toxic reducing sugars, aldehydes, hydroperoxides, organic acids and esters, heavy metals and trace metals, nitrates / nitrites, and free radicals. Polysorbates (PSs) are the most prevalently used family of non-ionic surfactants for protein stabilization and is also associated with excipient reported toxicity. In situ gels composed of 15% Poioxamer 407, 12% Poioxamer 188, and 1% HPMC are exemplary.

[0046] As a potential alternative to synthetic ingredients, organic or natural excipients may be employed that avoid the aforementioned concerns.

[0047] Beta cyclodextrins are GRAS (generally regarded as safe) and are cited in the FDA’s list of Inactive Pharmaceuticals. These are preferred absorption enhancers for nasal drug formulations.[004§| Allergy Asthma Immunol Res. 2019 May; 11(3): 306 -319. The most common cyclodextrin excipients are 2-hydroxypropyl-beta-cyclodextrin Beta hydroxy-cyclodextrin which improve solubility' but are only' weak P-gp inhibitor to improve nasal-brain delivery' AAPS J. 2021 Sep 15; 23(5): 106. Alternatively, methylated P-cyclodextnns, in particular (2,6-di-O-methyl)-P-cyclodextrin (DM-p-CD), is chosen as a preferred excipient to increase nose brain delivery selectively,[00491 In a preferred embodiment of the invention, cyclodextrins are utilized as excipients that have putative beneficial effects beyond enhanced solubility. These benefits include promotion of autophagy, inhibition of the p-glycoprotein (MDR inhibition), and facilitation of transit of the API across the blood-brain-barriers.[0050j Cyclodextrins have been used medically to treat Neimann-Pick disease for example based upon their ability to promote autophagy Cyclodextrins are compatible with nasal delivery' and well tolerated by the nasal mucosa. Two excipient-based products have been approved by FDA and EMA in 2019 for nasal administration.

[0051] Cyclodextrins are cyclic oligosaccharides consisting of (a-l,4-linked) D- glucopyranose units: a-CD, 0-CD and y-CD, consisting of six, seven, and eight glucopyranose units, respectively. Cyclodextrins consist of a hydrophilic shell and a hydrophobic cavity, where poorly water-soluble drugs like amlexanox can become more soluble The hydroxyl groups of cy clodextrins are responsible for the hydrophilic character that improves solubility of compounds commonly used in drug development. a-CDDOCKET NO.: 267181.000102 PATENT(alfadex), p-CD (betadex), and y-CD (gammadex) are listed in the European Pharmacopoeia, the United Slates Pharmacopeia / Nalional Formulary (USP-NF) and the Japanese Pharmaceutical Codex (JPC ) as GRAS (generally regarded as safe) and are cited in the FDA A list of Inactive Pharmaceutical Ingredients.

[0052] AH cyclodextrins are not created equal in regard to their possible beneficial or rate limiting effects. Hydroxypropyl-p-cyclodextrin (HP-p-CD), a cyclic oligosaccharide derivative, is being developed to treat Neimann-Pick Disease (NPC). However, HP-p-CD has been shown to reduce the production of sphingomyelins, and would potentially be contraindicated in ALS, where significant disturbances in sphingomyelin metabolism have been reported. Further, (hydropropyl)-p-cyciodextrin has been shown to decrease drug uptake by the striatum. Peptides. 2012 Aug: 36(2): 168-175)

[0053] In a preferred embodiment of the present invention, dimethyl-beta-cyclodextrin (DIMES) is used as an excipient. Limitations of other excipients are overcome by DIMEB. It can be shown that dimethyl-beta-cyclodextrm (DIMES) can inhibit P-gp level in the apical membranes of brainstem monolayers. Unlike all other excipients used in drug delivery'. DIMEB is distinguished by its ability' to inhibit P-gp and increase the deposition of an active API into affected brain areas.Stabilizing agents

[0054] In one embodiment of the invention, disaccharide trehalose is used as an excipient with stabilizing properties. Trehalose is a naturally occurring homodisaccharide composed of two D-glucose units linked at their anomeric positions by an a,a'-l J '-glycosidic bond.Several studies have shown that trehalose can directly' maintain the APIs structural integrity and limit the aggregation of pathologically misfolded proteins. Trehalose acts as anon-ionic surfactant as the backbone hydrophilic group atached to a hydrophobic moiety having a maximum of eight fatly acids per molecule. The hydrophobic fatty' acids of the excipient may constitute lauric, myristic, palmitic, stearic, erucic, and / or oleic acid.

[0055] In another embodiment of the invention, the formulation includes a vasoconstrictor. By adding a vasoconstrictor, systemic absorption in the respiratory region is limited through constriction of blood vessels in this region. By limiting drug absorption in the respiratory region, higher concentrations of the drug are allowed to reach the olfactory region therefore allow ing higher concentrations of the active ingredient to reach the CNS. Vasoconstrictors that may be utilized include but are not limited to phenylephrine, epinephrine, ephedrine, vasopressin, dopamine, angiotensin II, oxymetazoline.DOCKET NO.: 267181.000102 PATENT xylometazoline, midodrine, norepinephrine, phenylpropanolamine, methoxamine, pseudoephedrine, and mephentermine.P-gp inhibitors

[0056] In another embodiment of the invention, the formulation includes the addition of a P-glycoprotein (P-gp) efflux inhibitor. P-gly coprotein transporters are responsible for drug removal from the CNS. Administration of a P-gp inhibitor may therefore lead to increased drug levels in the CNS. In a preferred embodiment of the invention, dimethyl -betacycl odextrin (DIMES) is used Other P-gp inhibitors that may be utilized include but are not limited to verapamil, rifampin, diltiazem, cyclosporin, proton-pump inhibitors (e.g., pantoprazole), elacridar, amiodarone, quinidine, tamoxifen, erythromycin, and ketoconazole.

[9057] Intranasal (IN) administration for nose-to-brain transport volume for each nostril is limited (<200 pL) Particle size is a pivotal requirement (<200 nm) The API must be protected from enzymatic degradation with formulations with pH values compatible with the nasal mucosa.Description of aqueous formulations

[0058] As used herein, the term ‘'aerosol’’ refers to suspension in the air. In particular, aerosol refers to the particlization or atomization of a formulation of the invention and its suspension in the air. According to the present invention, an aerosol formulation is a formulation comprising an API, such as amlexanox or another PDE, for nasal inhalation.

[0059] As used herein, the term '‘inhaler’’ refers to a device for nasal administration of a drug, e g., in solution, powder and the like delivery via handheld devices, such as plastic spray bottles commonly used to administer decongestants.

[9060] As used herein, the term “dispersant" refers to an agent that assists aerosohzation in mucosal tissue. In a specific aspect of the invention, the dispersant can be a mucosal penetration enhancer Preferably, the dispersant is pharmaceutically acceptable. "Pharmaceutically acceptable” refers to those compounds, materials, compositions, and dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation. or other problem or complication, commensurate with a reasonable benefit / risk ratio. Often, pharmaceutically acceptable compounds are those that are approved by a regulatory' agency of the Federal or a state government or listed in the U S Pharmacopeia or other generally recognized pharmacopeia for use in humans.DOCKET NO.: 267181.000102 PATENT

[0061] Suitable dispersing agents are well known in the art arid include, but are not limited to, surfactants and the like. Such surfactants are generally used in the art to reduce surface induced aggregation caused by atomization of the solution forming the liquid aerosol and may be used in the methods and devices of the present invention. Examples of such surfactants include, but are not limited to, surfactants such as polyoxyethylene fatty acid esters and alcohols, and polyoxyethylene sorbitan fatty acid esters. Amounts of surfactants used will vary; being generally within the range of 0.001 and 4% by weight of the formulation. Suitable surfactants are well known in the art, and can be selected on the basis of desired properties, depending on the specific formulation, concentration of the desired API, diluent (m a liquid formulation) etc.

[0062] In a preferred embodiment, the designation of an API compound is meant to designate the compound per se, as well as any’ pharmaceutically acceptable salt, hydrate, isomer or racemate of that compound.

[0063] Table 2 below provides active ingredient compounds for use in the invention. The active ingredients may take various compound forms, including various salt(s). derivative(s), metabolite(s), and / or prodrug(s).Table 2: Active Ingredients

[0064] Selective PDE inhibitors prescribed for asthma and COPD act as smooth muscle agonists, and act to inhibit astrocytic phosphodiesterase in the central nervous system. The APIs identified in Table 2 were selectively considered based upon their antagonist properties of PDE3, PDE4, PDE7 and PDE10 as being the predominant up regulated phosphodiesterases in the CNS. This does not exclude other PDE inhibitors from this disclosure.DOCKET NO.: 267181.000102 PATENTTable 3: Excipients for Intranasal FormulationDOCKET NO.: 267181.000102 PATENT

[0065] In a preferred embodiment, the active ingredient, such as amlexanox, is coformulated with dimethyl-beta-cyclodextrin on average between 1-10% weight of formulation as CD microspheres, sodium chloride and sodium citrate to maintain pH compatible with nasal mucosal tissue (6-6.5), methylparaben 0.1%, glycerin as an emulsifier, alginate or chitosan as a mucoadhesive polymer, and peppermint for flavoring and taste masking. Physical requirements for the spray include spray patterns between 3-7 cm. 0.05 mg / 1 ccl of API. droplet size distribution between 10-120 cm, and osmolality 300-700 mOsm / kg.Tables 4 and 5 through 8 provide illustrative examples of formulations of the invention and dose ranges for active and inactive ingredients.Table 4Example FormulationsDOCKET NO.: 267181.000102 PATENTTable 5: Example active and inactive ingredient formulation dose rangesTable 6: Example active and inactive ingredient formulation dose rangesTable 7: Example active and inactive ingredient formulation dose rangesDOCKET NO.: 267181.000102 PATENTTable 8: Example active and inactive ingredient formulation dose ranges

[0066] The example formulations provided in tables 5-8 allow for a variety of beta cyclodextrins to be employed. Preferred beta cyclodextrins include dimethyl-beta- cyclodexlnn and 2-hydroxypropyl-beta-cyclodextrin.Intranasal delivery

[0067] Pharmaceutical formulations and treatment methods of the present invention utilize characteristics of the nasal route in order to achieve deli very7of levels of drug to target sites necessary to obtain a therapeutic effect. Intranasal (IN) delivery is a developing area for delivery of CNS therapies and holds great potential for the treatment of ALS or pediatric orphan diseases particularly in patients with bulbar mediated respiratory dysfunction. There is a direct anatomic pathway between the olfactory / trigeminal neuroepithelium of the nasal mucosa and the brain, allowing for more targeted delivery to specific regions, e.g., the olfactory region in the nasal cavity, while achieving less off-target drug loss. Olfactory dysfunction is an early sign of most neurodegenerative diseases as several lines of research indicates that the olfactory pathway may be one of the initially affected areas in patients with brainstem pathology7in ALS, suggesting that novel therapeutics can be delivered intranasally for targeted therapeutics.[00681 APIs that are delivered intranasally must overcome rapid mucociliary clearance and make their way across the respiratory' epithelium, where they are absorbed into the small blood vessels within the lamina propria, thus avoiding first-pass metabolism encountered with orally delivered agents.Nanosuspensions

[0069] In one embodiment of the invention, the API can be formulated as a nano formulation. More than 98% of the small-molecule and macromolecular drugs and newDOCKET NO.: 267181.000102 PATENT neurotherapeutics under preclinical and clinical investigation fail in crossing the BBB because of their large size. Only molecules that are highly concentrated (<20 mg per dose), can be delivered through nasal delivery’ and must be administered in a 100-200 pL spray or solution.

[0070] Nanoparticle size is typically between ~ 100-300 nm. Currently, the spectrum of nanoparticles used for targeted drug delivery is quite wide and can be divided into three main groups: polymeric nanoparticles (NPs), lipid-based NPs and inorganic NPs. Nanoparticles based on polylactide acid (PLA) and poly (lactic-co-glycolic acid) (PLGA) har e uncomplicated synthesis methods (emulsification, evaporation, solvent replacement method (deposition), solvent diffusion method) and are metabolized into lactic and glycolic acids. Thus, they are biodegradable, with optimal sizes ranging from 100 to 200 nm. Surface changes of nanocarriers enhance their efficacy in delivering drugs from the nose to the brain by using zeta potential-shifting ability or high charge density Nanoparticles’ diminutive dimensions result in improved medication penetration across mucosal barriers, boosting their transportation to the brain. Nanoscale carriers have an ideal range of zeta potential -16.3 ± 3.7 mV.Intranasal Delivery Devices

[0071] Intranasal Mucosal Atomization Devices are contemplated as a nasal delivery' device as disclosed in Chem Eng Sei. 2015 Mar 24; 125: 32-57. Intranasal mucosal atomization refers to improving fluid dynamics of nasal formulations where atomization transforms bulk liquid into fine droplets, a process where a liquid jet breaks up into fine droplets under influence of an external electrical field. The select API can be delivered through mucosal atomization devices to enhance the deposition in the nasal mucosa.

[0072] In one aspect of the invention, a nasal spray device is used to deliver the therapeutic formulation to the nasal cavity, such as the VP3 Multi-dose Spray Pump manufactured by Aptar Pharma. https: / / aptar.com / wp-content / uploads / 2020 / 07 / Brochure- Nasal-spray-pump-Vp3.pdf https: / / aptar.com / products / pharmaceutical / vp3-technology- platform /

[0073] The targeting of drug deposition and subsequent absorption within the nasal cavity is affected by the geometry' of the spray plume as influenced by drug formulation and device mechanics. Droplet size also affects deposition, with droplets > 10 pm retained in the nasal cavity . Narrower plume angles have been associated with better deposition in the olfactory regions of the cavity, while wider angles result in more deposition on the nasal valveDOCKET NO.: 267181.000102 PATENTMinimizing off-target deposition is important so as to avoid loss of dose through leaking out of the nostrils.Methods of Validation

[0074] Formulation development and efficacy can be validated pre-clinically. Current drug development is a highly laborious process where the high clinical failure rate is based in part on the inability to adequately model human neurological disorders in vivo. The formulation of the present invention will utilize the availability of human induced pluripotent stem cells (iPSCs) with their ability to differentiate into different types of neural cells and astrocytes, which provides unprecedented opportunities to validate the efficacy of selective PDE4 inhibitors in cell cultures. Human iPSCs are reprogrammed from a small sample of fibroblasts in a culture dish through the combined expression of pluripotency-associated transcription factors. Several ALS-associaled genes that are expressed in astrocytes are implicated in hyperactive neuroinflammatory responses in ALS patients. Motor neuron death may be initiated in anon-cell autonomous astrocyte-dependent manner. Astrocytes actively participate in inflammatory signaling cascades and involves the rapid induction of gene expression that results in complex morphological and functional changes. The significance of astrocytes in motor neuron disease has led to a number of iPSC-derived astrocy te protocols attempting to replicate the physical and functional properties of in vivo astrocy tes. iPSC- astrocyte monocultures are used to investigate astrocytic pathology and the effects of select phosphodiesterase inhibitors to probe their effects on motor neuron pathology.

[0075] Selective expression of mutant TDP-43 (Q331K) in glial cells promotes an increased level of age-dependent astrocyte activation, Acta Neuropathol 133, 907-922. 10. 1007 / s00401-017-1698-6. is the preferred method of IPSC validation in NSC-34 cells overly expressing TDP-43 WT / Q331K. Human-induced pluripotent stem cell lines generate highly enriched (>90%) populations of hiPSC-derived astrocytes. Human-induced pluripotent stem cell lines (can be obtained by STEMCELL Technologies, Canada Inc.) are usually plated at 20,000 ceils per cm2onto a Greiner uClear 96-well plate (Greiner Bio-One cat. no. 655087). Astrocytic maintenance medium (AMM), which promotes the generation of astrocyte progenitor cells (APCs). The employment of immunohistochemistry can be used to identity and differentiate astrocytes primary antibodies against GFAP (ThermoFisher Scientific cat. no. PAI-10019),

[0076] Various doses of active API can be introduced into well plates in diseased cell cultures and compared to non-treated controls. RNAseq canonical pathway analysis can beDOCKET NO.: 267181.000102 PATENT performed with Ingenuity Pathway Analysis (IPA) (Qiagen Inc.) using the Illumina TruSeq® Stranded mRNA Sample Prep Kit to detect changes in gene expression as a result of drug administration.Mouse model validation:TDP-43 mouse model:

[0077] Doxycycline (Dox)-suppressible expression of human TDP-43 (hTDP-43) harboring a defective nuclear localization signal ( / XNLS) under the control of the neurofilament heavy chain promoter mice resulted m the accumulation of insoluble, phosphorylated cy toplasmic TDP-43 in brain and spinal cord. Acta Neuropathol 2015 Nov;130(5):643-60.

[0078] Commercially available mouse models that are selective to the TDP43 mutation can be employed in formulation testing.

[0079] Methods of validation through select biomarkers employed through the use of atomic flow cy tometry

[9080] Diagnostically, single cell RBC (red blood cell) morphology' can detect changes in the balance of hydrophobic and hydrophilic domains on surface membranes. RBC undergo passive deformations for efficient exchange of oxygen and carbon dioxide, where the efficacy of this diffusive exchange depends upon high surface-to-volurne ratio that affect microcirculatory efficiency, where the densification of RBC results in reduced diffusion of oxygen. (Crit Rev Biomed Eng. 1 S>89; 17(3): 257-321). Atomic flow microscopy, an emerging flow cytometry' method, has been employed as a measure of uniform refractive index used to determine RBC morphology’, elasticity and surface roughness. The utilization of AFM has been used to determine RBC morphology and, hence, a deformation index, also known as elongation index, has been reported to efficiently assess RBC stiffness. Biosensors (Basel). 2023 Jan; 130): 117. Retrospective studies have confirmed consistent abnormalities in RBC morphology in neurodegeneration. Several research groups have found significant differences in the shape distribution of RBCs derived from patients with ALS compared to healthy controls suggesting that morphological analysis of RBC can be applied as a sensitive biomarker of neurodegeneration, especially when measuring the rate of decline of RBC shape longitudinally. In TDP-43 knock out mutations, there is reduced plasticity of RBC in tandem with impaired angiogenesis and endothelial function, JCI Insight. 2024 Mar 8; 9(5): e!77819. Similar findings of reduced conformational plasticity of red blood cells have been demonstrated in ApoE null cells, Biochim Biophys Acta Mol Basis Dis 2020.DOCKET NO.: 267181.000102 PATENT

[0081] The utilizations of microfluidic chips for single RBC (red blood cell) analysis including integrated sensors and microfluidic platforms can be used to determine the aggregation index and the movement of dielectric particles when subjected to a non-uniform electric field as a discriminatory analysis between affected and non-affected patients or to measure the trajectory of disease or to track therapy. Dissipative Particle Dynamics (DPD) methods through atomic flow microscopy can aid in the prediction of the RBC trajectories in the presence of dielectrophoretic force. RBCs move toward high electric field gradients and undergo morphological deformation under the influence of dielectrophoretic forces Biosensors (Basel). 2023 Jan; 13(1 ): 117.

[0082] Therapeutical applications using atomic flow cytometry are also contemplated. Interactions between biomolecules, such as between a receptor and a ligand, are fundamental events in drug discover}' because a drug must bind to and recognize its receptor for signal transduction. The strength of this interaction is characterized by the binding affinity’ between the receptor and the ligand. Quantitative relationships between chemical structure and properties (QSAR), starting with intuitive physicochemical descriptors such as molecular weight (MW) and logP, and topological descriptors, are computationally’ demanding. Unlike drug molecules that target folded proteins, those targeting IDPs (Intrinsically' Disordered Proteins) such as TDP-43 demonstrate restraining or broadening of the IDP conformational ensemble as a mechanism of acti on. Drug candidates targeting TDP-43 must show affinity toward hydrophobic residues and regions along the sequence, resulting m entropically driven binding. Drug-IDP / IDR (Intrinsically Disordered Proteins / Intrinsically Disordered Reactions) interactions can be studied using fluorescence polarization, a technique based on the excitation of diug-fluorophore conjugates with polarized light for measuring-specific displacement of fluorescent cAMP / cGMP analogs. Schmidt, H. B. and Rohatgi, R. (2020). High-throughput Flow Cytometry’ Assay to Investigate TDP43 Splicing Function. Bioprotocol 10(8): e3594. DOI: 10.21769 / BioProtoc.3594.Methods of Treatment

[0083] Method of treatment according to the invention may be provided in the patient's home, clinic, or any other location.

[0084] The frequency of therapy may be prescribed by a healthcare practitioner for the individual patient and may be daily, BID, or another interval, with one to four aqueous or dry' powder sprays or intranasal gel applications, likely one to two per nostril. By way of example, in the case of a homebound ALS patient who is utilizing non-invasive respiratoryDOCKET NO.: 267181.000102 PATENT modalities such as C-PAP and cough assist, the patient notices he is breathing more shallowly and complains of orthopnea. For this patient, as needed (PRN) dose administrations might be initiated to gain symptomatic improvement.

[0085] Duration of therapy will be determined by patient age, condition, stage of disease, performance in pulmonary function tests, and response to treatment.

[0086] In another aspect of the present invention, the therapeutics described herein are utilized to treat patients having BMRD in conjunction with clinical measures to track patient progression and modify treatment frequency and dosing.

[0087] Preferably, the effective dose of the API is titrated under the supervision of a physician or medical care provider, so that the optimum dose for the particular application is accurately determined. Once the dosage range is established, a further advantage of the invention is that the patient can administer the formulation on an as-needed, dose-to-effect basis. By way of example, in a formulation utilizing amlexanox as the API, nasal administration might be of dose between 1 mg and 60 mg per nostril, with an expected range between 0.5 mg and 5 mg per nostril. By way of example, in a formulation utilizing ensifentrine as the API, nasal administration might be of dose between 0.5 mg and 20 mg per nostril, with an expected range between 1 mg and 6 mg per nostril.

[0088] Monitoring pulmonary function at frequent intervals is the current standard of care of ALS patients. However, the most appropriate method of screening with a high pre-test probability to detect early respiratory insufficiency is still uncertain. Forced vital capacity (FVC) is one of the main parameters used in clinical practice, although it varies between countries, being the indication of NIV when FVC is between 80% and 50% of predicted. In progressive neuromuscular disease, hypoventilation in tandem with hypercapnia (the retention of CO2) can occur even when the FVC is borderline or inconclusive. To directly measure carbon dioxide tensions, the arterial blood gas (ABG) has long been established as the gold standard; however, ABGs are impractical for the outpatient setting. Alternatively, transcutaneous carbon dioxide (TCO2) monitoring offers several advantages over arterial blood gases and avoids the bulbar limitations of accurate FVC. Select home ventilators now' directly connect to TCO? monitors to provide a reliable estimate of carbon dioxide (PaCOz).

Claims

DOCKET NO.: 267181.000102 PATENTCLAIMSWe claim:

1. A method of treatment of respiratory dysfunction associated with a motor neuron disease comprising administering intranasally to a human in need thereof a composition comprising a phosphodiesterase inhibitor.

2. Tire method according to claim 1 wherein the phosphodiesterase inhibitor is capable of inhibiting at least one of PDE3, PDE4, PDE7, PDE10, and PDE11.

3. The method according to claim J or claim 2 wherein the phosphodiesterase inhibitor is selected from the group consisting of amlexonox, theophylline, aminophylline, ibudilast, roflumilast. ensifentrine, tadalafil, sildenafil, caffeine, enoximone, and levosimendan.

4. The method according to any one of claims 1-3 wherein the phosphodiesterase inhibitor is ami exonox.

5. The method according to any one of claims 1-3 wherein the phosphodiesterase inhibitor is ensifentrine.

6. The method according to any one of claims 1-3 wherein the phosphodiesterase inhibitor is ibudilast.

7. The method according to any one of claims 1-3 wherein the phosphodiesterase inhibitor is roflumilast.

8. The method according to any one of claims 1-3 wherein the phosphodiesterase inhibitor is aminophylline.

9. The method according to any one of claims 1-8 wherein the composition further comprises a second phosphodiesterase inhibitor.DOCKET NO.: 267181.000102 PATENT10. The method according to claim 9 wherein the phosphodiesterase inhibitors are ami exonox and ibudilast11. The method according to any one of claims 1-8, wherein the phosphodiesterase inhibitor is administered at a dose of about 0.5 mg to about 30 mg.

12. The method according to any one of claims 1-1 1 , wherein the composition is administered once per day13. The method according to any one of claims 1-11, wherein the composition is administered twice per day.

14. The method according to any one of claims 1-13, wherein the composition is administered to a single nostril.

15. The method according to any one of claims 1 -13. wherein the composition is administered to each nostril16. The method according to any one of claims 1-15, wherein the motor neuron disease is amyotrophic lateral sclerosis.

17. The method according to any one of claims 1-15, wherein the motor neuron disease is selected from the group consisting of Alzheimer’s disease, multi-infarct dementia, Parkinson’s disease, corticobasal degeneration, multiple sclerosis, major depression, Lewy body dementia, multiple system atrophy, and frontotemporal dementia.

18. The method according to any one of claims 1-15, wherein the respiratory dysfunction associated with a motor neuron disease is Bulbar Mediated Respiratoiy Dysfunction.

19. The method according to claim 18. wherein the motor neuron disease is Gaucher’s disease.DOCKET NO.: 267181.000102 PATENT20. The method according to claim 18. wherein the motor neuron disease is Pompe disease.

21. The method according to any one of claims 1-20, wherein the composition further comprises a cyclodextrin.

22. The method according to claim 21, w herein the cyclodextrin is dimethyl-beta- cyclodextrin.

23. The method according to claim 21. wherein the cyclodextrin is 2-hydroxypropyl-beta- cyclodexlrin.

24. The method according to any one of claims 1-23, wherein the composition further comprises a mucoadhesive.

25. The method according to claim 24. wherein the mucoadhesive is alginate.

26. The method according to claim 24, wherein die mucoadhesive is chitosan.

27. The method according to any one of claims 1-26. wherein the composition further comprises trehalose.

28. The method according to any one of claims 1-27, wherein the composition is delivered in a micromzing pump.

29. A pharmaceutical composition for intranasal delivery comprising a phosphodiesterase inhibitor.

30. The pharmaceutical composition according to claim 29 wherein the phosphodiesterase inhibitor is capable of inhibiting at least one of PDE3, PDE4, PDE7, PDEI 0, PDE1 1 .

31. The pharmaceutical composition according to claim 29 or claim 30 wherein the phosphodiesterase inhibitor is selected from the group consisting of ami exonox,DOCKET NO.: 267181.000102 PATENT theophylline, aminophylline, ibudilast. rollumilast, ensifentrine, tadalatil, sildenafil, caffeine, enoximone. and levosimendan.

32. The pharmaceutical composition according io any one of claims 29-31 wherein the phosphodiesterase inhibitor is ami exonox.

33. The pharmaceutical composition according to any one of claims 29-31 wherein the phosphodiesterase inhibitor is ensifentrine34. The pharmaceutical composition according to any one of claims 29-31 wherein the phosphodiesterase inhibitor is ibudilast.

35. The pharmaceutical composition according to any one of claims 29- 31 wherein the phosphodiesterase inhibitor is rollumilast.

36. The pharmaceutical composition according to any one of claims 29-31 wherein the phosphodiesterase inhibitor is aminophylline.

37. The pharmaceutical composition according to any one of claims 29-36, further comprising a second phosphodiesterase inhibitor.

38. The pharmaceutical composition according to claim 37 wherein the phosphodiesterase inhibitors are amlexonox and ibudilast.

39. The pharmaceutical composition according to any one of claims 29-38, further comprising a cyclodextrin.

40. The pharmaceutical composition according to claim 39, wherein the cyclodextrin is dimethyl-beta-cyclodextrin.

41. The pharmaceutical composition according to claim 39, wherein the cyclodextrin is 2- hydroxypropyl-bela-cyclodextrin.DOCKET NO.: 267181.000102 PATENT42. The pharmaceutical composition according to any one of claims 29-41, further comprising a mucoadhesive.

43. The pharmaceutical composition according io claim 42. wherein the mucoadhesive is alginate.

44. The pharmaceutical composition according to claim 42. wherein the mucoadhesive is chitosan.

45. The pharmaceutical composition according to any one of claims 29-44, further comprising trehalose46. The pharmaceutical composition according to any one of claims 29-45 for use in the treatment of respirator}' dysfunction associated with a motor neuron disease.

47. The pharmaceutical composition for use according to claim 46, wherein the motor neuron disease is amyotrophic lateral sclerosis.

48. The pharmaceutical composition for use according to claim 46. wherein the motor neuron disease is selected from the group consisting of Alzheimer’s disease, multiinfarct dementia, Parkinson’s disease, corticobasal degeneration, multiple sclerosis, major depression, Lewy body dementia, multiple system atrophy, and frontotemporal dementia.

49. The pharmaceutical composition for use according to claim 46, wherein the respiratory dysfunction associated with a motor neuron disease is Bulbar Mediated Respiratory Dysfunction.

50. The pharmaceutical composition for use according to claim 49, wherein the motor neuron disease is Gaucher’s disease.

51. The pharmaceutical composition for use according to claim 49. wherein the motor neuron disease is Pompe disease.DOCKET NO.: 267181.000102 PATENT52. Use of the pharmaceutical composition according to any one of claims 29-45 in the manufacture of a medicament for use tn the treatment of respiratory dysfunction associated with a motor neuron disease.

53. The use according to claim 52, wherein the motor neuron disease is amyotrophic lateral sclerosis.

54. The use according to claim 52, wherein the motor neuron disease is selected from the group consisting of Alzheimer’s disease, multi-infarct dementia, Parkinson’s disease, corticobasal degeneration, multiple sclerosis, major depression, Lewy body dementia, multiple system atrophy, and frontotemporal dementia.

55. The use according to claim 52, wherein the respiratory dysfunction associated with a motor neuron disease is Bulbar Mediated Respiratory Dysfunction.

56. The use according to claim 55, wherein the motor neuron disease is Gaucher's disease.

57. The use according to claim 55. wherein the motor neuron disease is Pompe disease

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