Abstract:
Pharmaceutical compositions useful in the treatment of ophthalmic inflammation and methods of treating ophthalmic inflammation with those compositions are disclosed. The compositions contain a combination of a glucocorticoid and tetrahydrocortisol. The tetrahydrocortisol serves to substantially prevent any significant increases in intraocular pressure which might otherwise be experienced by the patient as a side effect of the glucocorticoid component of the compositions. The therapeutic interaction of the two components therefore allows the potent antiinflammatory properties of the glucocorticoids to be utilized without fear of elevating intraocular pressure. A method of preventing increases in intraocular pressure attributable to systemic or topical corticosteroid therapy is also disclosed. That method involves the administration of a pharmaceutical composition containing tetrahydrocortisol to a patient receiving such therapy.

Description:
This is a continuation of application Ser. No. 07/399,349, filed Aug. 28, 1989 now abandoned, which is a continuation of Ser. No. 07/139,227, filed Dec. 29, 1987 now abandoned. 
    
    
     BACKGROUND OF THE INVENTION 
     The present invention relates to the field of ophthalmology. More particularly, this invention relates to the treatment of inflamed ocular tissue. 
     Many compounds classified as glucocorticoids, such as dexamethasone and prednisolone, are very effective in the treatment of inflamed tissues, but in certain patients, these compounds cause elevations in intraocular pressure. Patients who experience elevations in intraocular pressure when treated with glucocorticoids are generally referred to as &#34;steroid responders&#34;. The elevations in intraocular pressure are of particular concern in patients who are already suffering from elevated intraocular pressures, such as glaucoma patients. Moreover, there is always a risk that the use of glucocorticoids in patients who have normal intraocular pressures will cause elevations in pressure that result in damage to ocular tissue. Since therapy with glucocorticoids is frequently long term (i.e., several days or more), there is potential for significant damage to ocular tissue as a result of prolonged elevations in intraocular pressure attributable to that therapy. 
     The following articles may be referred to for further background information concerning the well recognized association between ophthalmic glucocorticoid therapy and elevations in intraocular pressure: Kitazawa, &#34;Increased Intraocular Pressure Induced by Corticosteroids&#34;, American Journal of Ophthalmology, Vol. 82, pages 492-495 (1976); Cantrill et al., &#34;Comparison of In Vitro Potentcy of Corticosteroids with Ability to Raise Intraocular Pressure&#34;, American Journal of Ophthalmology, Vol. 79, pages 1012-1016 (1975); and Mindel et al., &#34;Comparative Ocular Pressure Elevation by Medrysone, Fluorometholone, and Dexamethasone Phosphate&#34;, Archives of Ophthalmology, Vol. 98, pages 1577-1578 (1980). 
     One approach to solving the foregoing problems has been to search for compounds which are capable of alleviating ophthalmic inflammation without elevating intraocular pressure. The inventions described in U.S. Pat. No. 4,686,214 and in copending U.S. patent application Ser. No. 864,610, filed May 19, 1986, represent two examples of this approach. Notwithstanding the success of the therapies described in the above-cited patent and patent application, there continues to be a need for still further improvements in the treatment of ophthalmic inflammation, such as an improvement which would allow potent glucocorticoids to be utilized to treat inflamed ocular tissue without fear of elevating intraocular pressure. 
     SUMMARY OF THE INVENTION 
     A principal objective of the present invention is the provision of a therapy for ophthalmic inflammation which allows the potent antiinflammatory activity of the glucocorticoids to be employed without fear of elevating intraocular pressure. A further objective of the invention is the provision of methods of treatment and ophthalmic compositions useful in that therapy. 
     Another objective of the present invention is the provision of a prophylactic method of treatment wherein the elevations in intraocular pressure sometimes associated with corticosteroid therapy are substantially prevented. 
     The foregoing objectives and other general objectives of the present invention are met by the provision of a therapy for ophthalmic inflammation wherein the elevations in intraocular pressure caused by glucocorticoids are substantially prevented. The therapy involves the combination of a glucocorticoid with a second compound which prevents or antagonizes the intraocular pressure elevating effect of the glucocorticoid. The second compound is tetrahydrocortisol. It has been discovered that the intraocular pressure (&#34;IOP&#34;) elevating effect of glucocorticoids can be eliminated without adversely affecting the antiinflammatory activity of the glucocorticoids. Thus, the therapy of the present invention makes it possible to employ the potent topical antiinflammatory properties of the glucocorticoids without causing any significant elevations in intraocular pressure. 
     DESCRIPTION OF PREFERRED EMBODIMENTS 
     The present invention is based on the combination of one or more potent glucocorticoids with tetrahydrocortisol. It has been discovered that tetrahydrocortisol antagonizes the IOP elevating effect of glucocorticoids. It was previously discovered that tetrahydrocortisol is effective in controlling intraocular pressure; that discovery is the subject of U.S. patent application Ser. No. 864,610, filed May 19, 1986, the entire contents of which are hereby incorporated in the present specification by reference. The intraocular hypotensive effect of tetrahydrocortisol is reported by A. Louis Southren et al. in Investigative Ophthalmology &amp; Visual Science, Vol. 28, pages 901-903 (May 1987); the entire contents of that report are also incorporated herein by reference. 
     It has been postulated that tetrahydrocortisol controls intraocular pressure by antagonizing the action of 5-alpha and/or 5-beta-dihydrocortisol, which are two substances that are believed to play a significant role in a metabolic imbalance involving the trabecular meshwork cells of the eye and, ultimately, elevations in intraocular pressure. The present invention is based on the finding that tetrahydrocortisol somehow antagonizes the IOP elevating effect of glucocorticoids. The mechanism by which tetrahydrocortisol prevents or antagonizes the IOP elevating effect of glucocorticoids is not totally understood at this point. While applicants do not wish to be bound by any theory, one possible explanation is that tetrahydrocortisol interferes with the action of glucocorticoids on trabecular meshwork cells, thereby blocking or reversing the IOP elevating effect of the glucocorticoids. 
     Tetrahydrocortisol is a known compound. It has a molecular weight of 366.5, and an empirical formula of C 21  H 34  O 5 . The compound is commercially available and may, for example, be obtained from Research Plus, Inc., Post Office Box 324, Bayonne, N.J., or Steraloids, Inc., P.O. Box 310, Wilton, N.H. 03086. It may also be synthesized if desired. The general approach to synthesis involves treating tetrahydrocortisol acetate with semicarbazide to form 20-semi-carbazone. This is dissolved in solution and reduced with potassium borohydride. It is then suspended in methylene chloride and treated with hydrochloric acid. The product is stable at room temperature and requires no extraordinary storage precautions. Tetrahydrocortisol has the following formula: ##STR1## 
     Tetrahydrocortisol may exist in several stereoisomeric forms. Specifically, with regard to stereoisometry, for tetrahydrocortisol it refers to relative positions of the hydroxyl and hydrogen groups at the 3,5 positions, as to whether or not they are above or below the plane of the ring structure. Alpha position refers to below the plane of the ring structure, and beta refers to above the ring structure. Thus, tetrahydrocortisol may exist as 3-alpha, 5-beta; 3-alpha, 5alpha; 3-beta, 5-alpha; and 3-beta, 5-beta. The preferred isomer for use in this invention is 3-alpha, 5-beta-tetrahydrocortisol. The ring containing the 1-5 positions is referred to as the &#34;A-ring.&#34; 
     The glucocorticoids which may be employed in the present invention include all pharmaceutically acceptable compounds which are effective in the treatment of inflamed ocular tissue. The preferred glucocorticoids include dexamethasone, fluorometholone, medrysone, betamethasone, triamcinolone, prednisone, prednisolone, hydrocortisone, and pharmaceutically acceptable salts thereof. Further examples of glucocorticoids include prednicarbate; deflazacort; halomethasone; tixocortol; prednylidene (21-diethylaminoacetate); prednival; paramethasone; methylprednisolone; meprednisone; maztpredone; isoflupredone; halopredone acetate; halcinonide; formocortal; flurandrenolide; fluprednisolone; flurprednidine acetate; fluperolone acetate; fluocortolone; fluocortin butyl; fluocinonide; fluocinolone acetonide; flunisolide; flumethasone; fludrocortisone; fluclorinide; enoxolone; difluprednate; diflucortolone; diflorasone diacetate; desoximetasone (desoxymethasone); desonide; descinolone; cortivazol; corticosterone; cortisone; cloprednol; clocortolone; clobetasone; clobetasol; chloroprednisone; cafestol; budesonide; beclomethasone; amcinonide; allopregnane acetonide; alclometasone; 21-acetoxypregnenolone; tralonide; diflorasone acetate; deacylcortivazol; RU-26988; budesonide; and deacylcortivazol oxetanone. All of the above-cited glucocorticoids are known compounds. Further information about the compounds may be found, for example, in The Merck Index, Tenth Edition (1983), and the publications cited therein, the entire contents of which are hereby incorporated in the present specification by reference. 
     In accordance with the invention, topical ophthalmic compositions containing one or more glucocorticoids and a second component comprising tetrahydrocortisol are provided. The compositions will contain the one or more glucocorticoids in an antiinflammatory effective amount and will contain an amount of tetrahydrocortisol effective to inhibit the IOP elevating effect of the glucocorticoids. The amount of each component will depend on various factors, such as the relative tendency of certain glucocorticoids to cause IOP elevations, the severity and type of ocular inflammation being treated, the estimated duration of the treatment, and so on. In general, the ratio of the amount of glucocorticoid to tetrahydrocortisol will be in the range of 10:1 to 1:20. The concentration of the glucocorticoid component will typically be in the range of from about 0.01% to about 2.0% by weight. The concentration of tetrahydrocortisol will typically be in the range of from about 0.05% to about 5.0% by weight. 
     The above-described active ingredients may be incorporated into various types of ophthalmic formulations for delivery to the eye. For example, the active ingredients may be combined with ophthalmologically acceptable preservatives, surfactants, viscosity enhancers, buffers, toxicity agents and water to form an aqueous, sterile ophthalmic suspension. In order to prepare sterile ophthalmic ointment formulations, the active ingredients are combined with a preservative in an appropriate vehicle, such as mineral oil, liquid lanolin, or white petrolatum. Sterile ophthalmic gel formulations may be prepared by suspending the active ingredient in a hydrophilic base prepared from the combination of Carbopol-940 (a carboxy vinyl polymer available from the B. F. Goodrich Company) according to published formulations for analogous ophthalmic preparations; preservatives and tonicity agents can be incorporated. The specific type of formulation selected will depend on various factors, such as the severity and type of ophthalmic inflammation being treated, and dosage frequency. Ophthalmic solutions, suspensions, ointments and gels are the preferred dosage forms. 
    
    
     The following Example is presented to further illustrate the compositions of the present invention. 
     EXAMPLE 
     The following formulation is representative of the compositions of the present invention. 
     
         ______________________________________Ingredient       Amount (wt. %)______________________________________THF              1.0Dexamethasone    0.1Tyloxapol        0.01 to 0.05HPMC             0.5Benzalkonium chloride             0.01Sodium chloride  0.8Edetate Disodium  0.01NaOH/HCl         q.s. pH 7.4.sup.Purified water   q.s. 100 mL______________________________________ 
    
     The formulation is prepared by first placing a portion of the purified water into a beaker and heating to 90° C. The hydroxypropylmethylcellulose (HPMC) is then added to the heated water and mixed by means of vigorous vortex stirring until all of the HPMC is dispersed. The resulting mixture is then allowed to cool while undergoing mixing in order to hydrate the HPMC. The resulting solution is then sterilized by means of autoclaving in a vessel having a liquid inlet and a hydrophobic, sterile air vent filter. 
     The sodium chloride and the edetate disodium are then added to a second portion of the purified water and dissolved. The benzalkonium chloride is then added to the solution, and the pH of the solution is adjusted to 7.4 with 0.1M NaOH/HCl. The solution is then sterilized by means of filtration. 
     The tetrahydrocortisol (THF) and dexamethasone are sterilized by either dry heat or ethylene oxide. If ethylene oxide sterilization is selected, aeration for at least 72 hours at 50° C. is necessary. The sterilized THF and dexamethasone are weighed aseptically and placed into a pressurized ballmill container. The tyloxapol, in sterilized aqueous solution form, is then added to the ballmill container. Sterilized glass balls are then added to the container and the contents of the container are milled aseptically at 225 rpm for 16 hours, or until all particles are in the range of approximately 5 microns. 
     Under aseptic conditions, the micronized drug suspension formed by means of the preceding step is then poured into the HPMC solution with mixing. The ballmill container and balls contained therein are then rinsed with a portion of the solution containing the sodium chloride, the edetate disodium and benzalkonium chloride. The rinse is then added aseptically to the HPMC solution. The final volume of the solution is then adjusted with purified water and, if necessary, the pH of the solution is adjusted to pH 7.4 with NaOH/HCl. 
     The treatment method of the present invention comprises application of an effective amount of the above-described compositions to the eye. The dosage regimen utilized will depend on the severity and type of inflammation being treated, as well as various clinical factors, such as, the patient&#39;s age, sex, weight and medical history. In general, the above-described compositions may be topically applied, for example, as drops to the upper globe, or as a 0.5-1 cm strip of ointment or gel to the lower conjunctival sac of the eye. Suspensions will generally be applied 1 to 4 times daily, while ointments or gels will generally be applied once or twice daily. The application of sustained release formulations (e.g., polymer based gels) once daily at bedtime will be preferred in some conditions. 
     The present invention primarily concerns a new and useful therapeutic approach to treating ophthalmic inflammation. A different, but related aspect of the present invention involves the use of tetrahydrocortisol in connection with the systemic use of corticosteroids. More specifically, the present invention is also directed to the provision of a method of preventing elevations of intraocular pressure in patients receiving corticosteroids systemically or topically at a site other than the eye. This other aspect of the invention might therefore be described as a prophylactic therapy designed to protect patients from an ophthalmic side effect of systemic and topical corticosteroid therapy. The therapy comprises the administration of a pharmaceutical composition containing a therapeutically effective amount of tetrahydrocortisol. In this instance, the phrase &#34;therapeutically effective amount&#34; means an amount which is sufficient to substantially prevent or reverse any increases in intraocular pressure attributable to the corticosteroid therapy. The dosage regimen utilized will depend on the nature of the corticosteroid therapy and the general predisposition of the patient to elevations in intraocular pressure, as well as various other factors such as the patients age, sex, weight and medical history. The therapy will generally comprise topical administration of compositions which are essentially the same as those described above, except for the absence of a glucocorticoid.