# Patent

## Title
Methods and compositions for safe and effective treatment of telangiectasia

## Abstract

Improved methods and compositions for safe and effective treatment of telangiectasia or a symptom associated with telangiectasia in a subject are described. The methods involve topically applying to an affected skin area a topical composition comprising about 0.3% to about 10% by weight of brimonidine and a pharmaceutically acceptable carrier.

## Background
CROSS-REFERENCE TO RELATED APPLICATION
This application is a Section 371 of International Application No. PCT/EP2011/054597, filed Mar. 25, 2011, which was published in the English language on Sep. 29, 2011, under International Publication No. WO 2011/117378 A2, and the disclosure of which is incorporated herein by reference.
BACKGROUND OF THE INVENTION
Telangiectasias are highly prevalent skin disorders. Telangiectasias are visible small, red, purple or blue surface blood vessels that can be located on the face, upper chest, neck or other parts of the body. Telangiectatic blood vessels, which can include swollen blood vessels, spider veins, red dermal patches, purple dermal patches, or blue dermal patches are abnormal and are not necessary for any essential body function.
Telangiectatic blood vessels can appear with or without a preceding or concurrent skin or internal disease. Telangiectasias can develop anywhere within the body, but can be most easily seen in the skin. Telangiectasias include essential or primary telangiectasias, which include blood vessel dilations of unknown etiology. Generalized essential telangiectasias (GET) exhibit a widespread distribution pattern over the body. Other primary telangiectasias include angioma serpiginosum, ataxia telangiectasia, varicose of smaller veins, such as starburst veins, angiomas and spider naevi. Some other examples of conditions, syndromes, diseases and disorders which can include telangiectasia are CREST Syndrome (acronym for Calcinosis, Raynaud's phenomenon, Esophageal dysfunction, Sclerodactyl), and Telangiextasis), hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome), ataxia-telangiectasia, rosacea (also known as acne rosacea), basal cell carcinoma, scleroderma, telangiectatic nevus, unilateral nevoid telangiectasia, cutis marmorata telangiectatica congenita, hereditary hemorrhagic telangiectasia. Secondary telangiectasia can develop after actinic damage (such as in erythrosis interfollicularis colli), radiation therapy and as well steroid therapies including chronic corticosteroid treatment. Chronic hepatic and collagen-vascular disorders can also induce telangiectasia.
Telangiectasia can be a symptom of rosacea. However, rosacea also encompasses erythema, and is, accordingly, a phenomenon distinct from a telangiectasia.
Current treatments for ameliorating telangiectasias include laser therapy, light therapy including IPL intense pulsed light, electrocoagulation and electro-optical synergy (ELOS), which combines intense pulsed optical energy and conducted bipolar radiofrequency (RF) energy into a single pulse (Sadick, N S et al., J. Drugs Dermatolog. 4: 181-186, 2005).
Brimonidine, a selective α2-adrenergic agonist, has been used as either a monotherapy or an adjunctive therapy to lower intraocular pressure (IOP) in the treatment of glaucoma and ocular hypertension (OHT) since its approval in 1996. The most common side effects associated with brimonidine therapy are dry mouth, fatigue/drowsiness, headache, mild hyperemia, blurred vision and foreign body sensation. Hypertension, palpitations and syncope have been reported by less than 3% patients in clinical trials involving brimonidine ophthalmic treatment. See McGhie, Journal of the Pharmacy Society of Wisconsin, May/June 2001, at World Wide Web: pswi.org/professional/pharmaco/brimonidine.pdf, and references therein. Results from the dose-ranging study in patients with glaucoma or ocular hypertension showed that although 0.5% (w/w) had higher efficacy in the early phase of treatment, the 0.5% (w/w) and 0.2% (w/w) had similar efficacy after two weeks of treatment, and that 0.5% (w/w) had more systemic and ocular side effects than 0.2% (w/w). See, e.g., Walters, Survey of Ophthalmology, 1996, 41: S19-S26). Ophthalmic formulations containing 0.2% (w/w) brimonidine have been used for chronic applications to treat glaucoma and ocular hypertension, while that containing 0.5% (w/w) brimonidine has been only used for acute therapy for the prevention of postoperative intraocular pressure spikes. In order to reduce a variety of ocular and systemic side-effects associated with the ophthalmic application of 0.2% (w/w) brimonidine, ophthalmic formulations containing lower concentrations of brimonidine, e.g., 0.15% (w/w) or 0.1% (w/w), have been subsequently developed and used for chronic ophthalmic applications.
Brimonidine has been reported to be useful in treating telangiectasias. See, e.g., U.S. Pat. No. 7,838,563 to DeJovin et al. Brimonidine has also been reported to be useful in treating erythema caused by rosacea. See, e.g., U.S. Ser. No. 10/853,585 to DeJovin et al. To ensure the safety and avoid unacceptable side effects, a previous clinical study used 0.2% (w/w) brimonidine tartrate as the “high” dosage for treating erythema. See US 2009/0061020 to Theobald et al.
In the present invention, it has been surprisingly discovered that topical administration of brimonidine to an affected skin area resulted in significantly less systemic exposure to brimonidine than topical ophthalmic application of brimonidine. It has been found that although systemic exposure increased with the applied dose of brimonidine, statistical analysis showed that the increase in systemic exposure (Cmax) was not dose proportional, e.g., the increase in the mean Cmax was much less than the increase in the dose. It has also been discovered that, unlike the topical ophthalmic application of brimonidine, topical administration of higher than 0.2% (w/w) brimonidine to a skin area affected by telangiectasias or a related symptom resulted in increased efficacy without observable loss of effectiveness over time. No unacceptable drug related adverse events was observed with the treatment of higher concentration of brimonidine tested.
Accordingly, a higher concentration of brimonidine, such as about 0.3% (w/w) to about 10% (w/w), can now be used in improved methods and compositions for safe and effective treatment of telangiectasias or a symptom associated therewith.
BRIEF SUMMARY OF THE INVENTION
In one general aspect, embodiments of the present invention relate to a method of providing a safe and effective treatment of telangiectasia or a symptom associated therewith in a subject. The method comprises topically administering to a skin area affected by the telangiectasia or the symptom a topical composition comprising about 0.3% to about 10% by weight brimonidine and a pharmaceutically acceptable carrier, wherein the topical administration effects a serum or plasma profile of brimonidine having a mean Cmax of about 54±28 pg/mL or less and a mean AUC0-24 hr of about 568±277 pg.hr/mL or less.
In another general aspect, embodiments of the present invention relate to a method of producing a packaged product for providing a safe and effective treatment of telangiectasia or a symptom associated therewith in a subject, comprising:
(1) obtaining a topical composition comprising about 0.3% to about 10% by weight brimonidine and a pharmaceutically acceptable carrier;
(2) devising instructions for topically administering the topical composition to a skin area affected by the telangiectasia or the symptom to obtain the safe and effective treatment, and
(3) providing the topical composition and the instructions in a unified package, wherein the topical administration effects a serum or plasma profile of brimonidine having a mean Cmax of about 54±28 pg/mL or less and a mean AUC0-24 hr of about 568±277 pg.hr/mL or less.
In a preferred embodiment, the topical composition used in or encompassed by embodiments of the present invention comprises about 0.4% (w/w) to about 0.6% (w/w) brimonidine tartrate.
In another preferred embodiment, the telangiectasia is telangiectasia associated with rosacea.
Other aspects, features and advantages of the invention will be apparent from the following disclosure, including the detailed description of the invention and its preferred embodiments and the appended claims.



BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS
The foregoing summary, as well as the following detailed description of the invention, will be better understood when read in conjunction with the appended drawings. For the purpose of illustrating the invention, there are shown in the drawings embodiments which are presently preferred. It should be understood, however, that the invention is not limited by the drawings.
In the drawings:
FIG. 1 is a picture of the face of a subject taken under RBX RedTM pretreatment, baseline, red score of full face was 126.29;
FIG. 2 is a picture of the face of the subject in FIG. 1 taken under RBX RedTM 30 minutes post pretreatment with 0.5% (w/w) brimonidine tartrate, red score of full face 88.15, 30.20% reduction compared to the baseline;
FIG. 3 is a picture of the face of the subject in FIG. 1 taken under RBX RedTM 3 hours post pretreatment with 0.5% (w/w) brimonidine tartrate, red score of full face 78.03, 38.22% reduction compared to the baseline;
FIG. 4 is a picture of the face of the subject in FIG. 1 taken under RBX RedTM 6 hours post pretreatment with 0.5% (w/w) brimonidine tartrate, red score of full face 84.90, 32.77% reduction compared to the baseline;
FIG. 5 is a picture of the face of the subject in FIG. 1 taken under RBX RedTM 9 hours post pretreatment with 0.5% (w/w) brimonidine tartrate, red score of full face 97.93, 22.46% reduction compared to the baseline; and
FIG. 6 is a picture of the face of the subject in FIG. 1 taken under RBX RedTM 12 hours post pretreatment with 0.5% (w/w) brimonidine tartrate, red score of full face 104.15, 17.53% reduction compared to the baseline.



DETAILED DESCRIPTION OF THE INVENTION
Various publications, articles and patents are cited or described in the background and throughout the specification; each of these references is herein incorporated by reference in its entirety. Discussion of documents, acts, materials, devices, articles or the like which have been included in the present specification is for the purpose of providing context for the present invention. Such discussion is not an admission that any or all of these matters form part of the prior art with respect to any inventions disclosed or claimed.
Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood to one of ordinary skill in the art to which this invention pertains. Otherwise, certain terms used herein have the meanings as set in the specification. All patents, published patent applications and publications cited herein are incorporated by reference as if set forth fully herein. It must be noted that, as used herein and in the appended claims, the singular forms “a,” “an,” and “the” include plural reference unless the context clearly dictates otherwise.
As used herein, “telangiectasia or a symptom associated therewith” refers to a visible, permanent abnormal dilation of blood vessels, such as arterioles and venules. A visible blood vessel is a blood vessel visually discernable as a line to an observer without the aid of magnifying equipment (other than spectacles normally used by the observer. Telangiectasias can be associated with numerous conditions, syndromes, diseases and disorders. For example, a facial telangiectasia can be associated with age, sun exposure, and alcohol use. Other diseases, disorders, conditions and syndromes associated with telangiectasias include, in non-limiting example, scleroderma, hereditary hemorrhagic telangiectasia (Olser-Rendu syndrome), Ataxia-Telangiectasia, spider angioma, cutis marmorata telangiectasia congenita, Bloom syndrome, Klippel-Trenaunay-Weber syndrome, Sturge-Weber disease, Xeroderma pigmentosa, Nevus flammeus, Generalized essential telangiectasias (GET), angioma serpiginosum, ataxia telangiectasia, spider naevi, CREST Syndrome, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome), ataxia-telangiectasia, basal cell carcinoma, scleroderma, unilateral nevoid telangiectasia, and cutis marmorata telangiectatica congenita.
In one particular embodiment of the present invention, the term “telangiectasia or a symptom associated therewith” includes telangiectasia associated with or resulting from rosacea, i.e., telangiectasia or a symptom associated therewith in a patient with rosacea.
In another particular embodiment of the present invention, the term “telangiectasia or a symptom associated therewith” includes suninduced/photodamage telangiectasia.
The term “telangiectasia or a symptom associated therewith” encompasses different degrees or grades of telangiectasia or symptoms associated therewith, from mild to severe. Such degrees or grades can be measured using methods known in the art, such as by the scale of Telangiectasia Global Assessment (TGA).
In view of the present disclosure, a skin area that is affected by telangiectasia or that is prone to be affected by telangiectasia can be identified using any diagnostic signs or means known in the art, and can be treated by methods according to embodiments of the present invention.
The efficacy of the treatment can be measured using method known in the art. For example, the efficacy can be measured by the grades of improvement as evaluated by TGA and the duration of the improvement.
As used herein, the term “brimonidine” refers to the compound (5-bromo-quinoxalin-6-yl)-(4,5-dihydro-1H-imidazol-2-yl)-amine having the structure of formula (I):




and any pharmaceutically acceptable salt of the compound, including, but not limited to, brimonidine tartrate.

The phrase “pharmaceutically acceptable salt(s)”, as used herein, means those salts of a compound of interest that are safe and effective for topical use in mammals and that possess the desired biological activity. Pharmaceutically acceptable salts include salts of acidic or basic groups present in the specified compounds. Pharmaceutically acceptable acid addition salts include, but are not limited to, hydrochloride, hydrobromide, hydroiodide, nitrate, sulfate, bisulfate, phosphate, acid phosphate, isonicotinate, acetate, lactate, salicylate, citrate, tartrate, pantothenate, bitartrate, ascorbate, succinate, maleate, gentisinate, fumarate, gluconate, glucaronate, saccharate, formate, benzoate, glutamate, methanesulfonate, ethanesulfonate, benzensulfonate, p-toluenesulfonate and pamoate (i.e., 1,1′-methylene-bis-(2-hydroxy-3-naphthoate)) salts. Certain compounds used in the present invention can form pharmaceutically acceptable salts with various amino acids. Suitable base salts include, but are not limited to, aluminum, calcium, lithium, magnesium, potassium, sodium, zinc, and diethanolamine salts. For a review on pharmaceutically acceptable salts see BERGE ET AL., 66 J. PHARM. SCI. 1-19 (1977), incorporated herein by reference.
The term “topically administrable composition,” a “topical composition,” or a “topical formulation,” as used herein, means any formulation or composition which is pharmaceutically and/or cosmetically acceptable for topical delivery of the specified compounds according to embodiments of the invention. Exemplary forms of formulation that can be used for topical administration in embodiments of the present invention include, but are not limited to, sprays, mists, aerosols, solutions, lotions, gels, creams, ointments, pastes, unguents, emulsions and suspensions.
The term “topically administrable composition” as used herein, also encompasses locally applied and locally acting formulations such as formulations for use with implants, injections, or patches.
The choice of topically administrable composition will depend on several factors, including, but not limited to, the nature of the symptoms to be treated or prevented, the physiochemical characteristics of the particular compound to be administered and of other excipients present, their stability in the formulation, the aesthetics of any given formulation, available manufacturing equipment, and cost constraints.
As used herein, the term “composition” is intended to encompass a product comprising the specified ingredient in the specified amount, as well as any product which results, directly or indirectly, from combinations of the specified ingredient in the specified amount.
As used herein, the term “subject” means any animal, preferably a mammal, most preferably a human, to whom will be or has been administered compounds or topical formulations according to embodiments of the invention. Preferably, a subject is in need of, or has been the object of observation or experiment of, treatment or prevention of telangiectasia or a symptom associated therewith.
As used herein, the term “instructions” when used in the context of a packaged product includes a publication, a recording, a diagram or any other medium of expression which can be used to communicate the usefulness of the packaged product for its designated use. The instructions can, for example, be affixed to or included within a container for the packaged product.
As used herein, the term “treatment” or “treating” refers to an amelioration, prophylaxis, or reversal of telangiectasia or a symptom associated therewith, for example, by lessening or delaying the onset of the visibility of small, red, purple or blue surface blood vessels on the skin surface affected by the telangiectasia or the symptom.
As used herein, a “safe and effective amount of brimonidine” means the amount of brimonidine that is effective to treat telangiectasia or a symptom associated therewith, without causing unacceptable drug related adverse events, when administered to a subject.
As used herein, the phrase “unacceptable drug related adverse events,” “unacceptable adverse drug events,” and “unacceptable adverse drug reaction,” shall all mean harm or undesired outcome associated with or caused by a proposed use of a drug, and the harm or undesired outcome reaches such a severity that a regulatory agency deems the drug unacceptable for the proposed use.
It has been discovered in the present invention that topical administration of a safe and effective amount of brimonidine, such as a topical composition comprising about 0.3% to about 10% by weight of brimonidine, to a skin area affected by telangiectasia or a symptom associated therewith, provides effective treatment of telangiectasia or a symptom associated therewith, without causing unacceptable drug related adverse events. For example, it was discovered that topical administration of a topical composition comprising increasing concentration of brimonidine to a skin area affected by erythema or a symptom associated therewith resulted in a clear dosage responsive increase in the efficacy and an increase in the systemic exposure. However, statistical analysis showed that the increase in systemic exposure (Cmax) was not dose proportional, e.g., the increase in mean Cmax was much less than the increase in dose. No unacceptable adverse event was observed with the treatment of higher concentration of brimonidine tested. Topical skin treatments with all concentrations and regimens tested resulted in significantly lower systemic exposure to brimonidine than the treatment with eye drops applied as recommended in the label of the ophthalmic products.
Such superior clinical activities of the higher concentrations of brimonidine, e.g., about 0.3% to about 10% by weight, have not been previously reported. The present discovery is surprising and unexpected, particularly in view of the previously reported efficacy and safety profiles of brimonidine in ophthalmic applications, where a significant loss of effectiveness over time was seen with the brimonidine 0.5% (w/w) formulation and the chronic use of much lower concentrations of brimonidine, e.g., 0.1% or 0.15% by weight, is preferred, because the lower concentrations provide improved tolerability while maintaining IOP-lowering efficacy.
Accordingly, in one general aspect, embodiments of the present invention relate to a method of providing a safe and effective treatment of telangiectasia or a symptom associated therewith in a subject, comprising topically administering to a skin area affected by the telangiectasia or the symptom a topical composition comprising about 0.3% to about 10% by weight brimonidine and a pharmaceutically acceptable carrier, wherein the topical administration effects a serum or plasma profile of brimonidine having a mean Cmax of about 54±28 pg/mL or less and a mean AUC0-24 hr of about 568±277 pg.hr/mL or less. The mean Cmax and the mean AUC0-24 hr correspond to the serum or plasma profile of brimonidine after ophthalmic treatment with 0.2% (w/w) brimonidine tartrate eye drops as recommended in the label of the ophthalmic product.
In an embodiment of the present invention, the topically administrable composition comprises about 0.3%, 0.5%, 1.0%, 1.5%, 2.0%, 2.5%, 3.0%, 3.5%, 4.0%, 4.5%, 5.0%, 5.5%, 6.0%, 6.5%, 7.0%, 7.5%, 8.0%, 8.5%, 9.0%, 9.5% or 10.0%, by weight of brimonidine, such as brimonidine tartrate.
In another embodiment of the present invention, the topically administrable composition comprises about 0.4%, about 0.45%, about 0.5%, about 0.55% or about 0.6%, by weight of brimonidine, such as brimonidine tartrate.
In a preferred embodiment, the topical composition comprises about 0.5% by weight of brimonidine, such as about 0.5% by weight of brimonidine tartrate.
To treat or prevent telangiectasia or a symptom associated therewith, in view of the present disclosure, the topically administrable compositions of the invention can be topically applied directly to the affected area in any conventional manner known in the art, e.g., by dropper, applicator stick, or cotton swab, as a mist via an aerosol applicator, via an intradermal or transdermal patch, or by simply spreading a formulation of the invention onto the affected area with fingers, a sponge, a pad, or wipes. Generally the amount of a topical formulation of the invention applied to the affected skin area ranges from about 0.0001 g/cm2 of skin surface area to about 0.05 g/cm2, preferably, 0.002 g/cm2 to about 0.005 g/cm2 of skin surface area.
In various aspects, an application of a topical composition can noticeably ameliorate a telangiectasia within about 2 minutes following application, within about 5 minutes following application, or within about 10 minutes following application. In some aspects, a composition can be maximally effective at about 30 minutes after application, and the ameliorative effects can last up to about 2 hours, up to about 4 hours, up to about 8 hours, up to about 12 hours, up to about 18 hours, or up to about 24 hours, or longer. Accordingly, in some aspects, a composition can be topically applied to skin at a site of telangiectasia symptoms once per day, twice per day, or three or more times per day.
Methods of the present invention can be used in conjunction with one or more other treatments and/or medications to provide more effective treatment of a telangiectasia. In some aspects, a topical formulation can be used in combination with treatment regimens and medications for treatment of dermatologic disorders, such as those disclosed in THE MERCK MANUAL 811-830 (Keryn A. G. Lane et al. eds. 17th ed. 2001), hereby incorporated herein by reference.
In one aspect, the topical formulations can be used in combination with systemic administration of antibiotics or retinoids including, but not limited to, orally dosed antibiotics, such as tetracycline, minocin, minocycline, erythromycin, and doxycycline, and orally dosed retinoids such as isotretinoins (e.g., Accutane or Roaccutance).
In other aspects, the topical formulations disclosed herein can be used in combination with other topical treatments including, but not limited to, topical formulations consisting of metronidazole, hydrogen peroxide, benzoyl peroxide, lipoic acid, and azelaic acid, and sulfur preparations; topically dosed antibiotics, such as metronidazole, clindamycin, and erythromycin; antiparasitics such as permethrin and ivermectin; topical retinoids such as tretinoin, adapalene, tazarotene; or topical steroids.
In other aspects, topical formulations described herein can be used in combination with other therapies such as, for example, laser therapy, such as pulsed dye laser treatment; light therapy, such as mixed light pulse therapy (photoderm), IPL intense pulsed light; photodynamic therapy; electrocoagulation and electro-optical synergy (ELOS); or electrosurgery.
The other medicament or treatment can be administered to the subject simultaneously with, or in a sequence and within a time interval of, the administration of brimonidine, such that the active ingredients or agents can act together to treat or prevent telangiectasia and symptoms associated therewith. For example, the other medicament or treatment and brimonidine can be administered in the same or separate formulations at the same or different times, i.e., before or after. Any suitable route of administration can be employed to deliver the additional treatment or medication.
Another aspect of the invention relates to a method of producing a packaged product for providing a safe and effective treatment of telangiectasia or a symptom associated therewith in a subject. The method comprises:
(1) obtaining a topical composition comprising about 0.3% to about 10% by weight brimonidine and a pharmaceutically acceptable carrier;
(2) devising instructions for topically administering the topical composition to a skin area affected by the telangiectasia or the symptom to obtain the safe and effective treatment, and
(3) providing the topical composition and the instructions in a unified package, wherein the topical administration effects a serum or plasma profile of brimonidine having a mean Cmax of about 54±28 pg/mL or less and a mean AUC0-24 hr of about 568±277 pg.hr/mL or less.
In one embodiment of the invention, the topical composition is contained within one suitable container, such as a dropper, a jar, or a tube with a suitable small orifice size, such as an extended tip tube, made of any pharmaceutically suitable material. The topical formulations according to embodiments of the invention can be filled and packaged into a plastic squeeze bottle or tube. Suitable container-closure systems for packaging a topical formulations of the invention are commercially available for example, from Wheaton Plastic Products, 1101 Wheaton Avenue, Millville, N.J. 08332. Optionally, an applicator can be provided in or attached to the container, or separately from the container.
In one embodiment of the invention, the instructions are, for example, a pamphlet or package label. The instructions explain how to administer topical formulations of the invention, in an amount and for a period of time sufficient to provide a safe and effective treatment of telangiectasia or a symptom associated therewith. Preferably, the instructions include, for example, the dosage and administration instructions, the topical formulation's composition, the clinical pharmacology, drug resistance, pharmacokinetics, absorption, bioavailability, and contraindications.
In an embodiment of the present invention, the topical composition is a topical gel composition, which comprises:
about 0.3% (w/w) to about 10.0% (w/w) brimonidine;
about 0.20% (w/w) to about 4.0% (w/w) gelling agent; and
about 5.0% (w/w) to about 30.0% (w/w) at least one polyol,
The topically administrable composition are prepared by mixing a pharmaceutically acceptable carrier with the safe and effective amount of brimonidine according to known methods in the art, for example, methods provided by standard reference texts such as, REMINGTON: THE SCIENCE AND PRACTICE OF PHARMACY 1577-1591, 1672-1673, 866-885(Alfonso R. Gennaro ed. 19th ed. 1995); Ghosh, T. K.; et al. TRANSDERMAL AND TOPICAL DRUG DELIVERY SYSTEMS (1997), both of which are hereby incorporated herein by reference.
In a preferred embodiment, the topical gel composition comprises about 0.4% to about 0.6% by weight of brimonidine, more preferably, 0.5% by weight of brimonidine tartrate.
Suitable gelling agents known in the art, including those used in the two-phase or single-phase gel systems, can be used in the present invention. Some examples of suitable gelling agents are disclosed in REMINGTON: THE SCIENCE AND PRACTICE OF PHARMACY 1517-1518 (Alfonso R. Gennaro ed. 19th ed. 1995), which is hereby incorporated herein by reference. The gelling agents used in embodiments of the present invention, include, but are not limited to, one or more hydrophilic and hydroalcoholic gelling agents used in the cosmetic and pharmaceutical industries. Preferably, the hydrophilic or hydroalcoholic gelling agent comprises “CARBOPOL®” (B.F. Goodrich, Cleveland, Ohio), “HYPAN®” (Kingston Technologies, Dayton, N.J.), “NATROSOL®” (Aqualon, Wilmington, Del.), “KLUCEL®” (Aqualon, Wilmington, Del.), or “STABILEZE®” (ISP Technologies, Wayne, N.J.). The preferred compositional weight percent range for “CARBOPOL®” is between about 0.5% to about 2%, while the preferred weight percent range for “NATROLSOL®” and “KLUCEL®” is between about 0.5% to about 4%. The preferred compositional weight percent range for both “HYPAN®” and “STABILEZE®” is between 0.5% to about 4%. Other preferred gelling agents include hydroxyethylcellulose, cellulose gum, MVE/MA decadiene crosspolymer, PVM/MA copolymer, glycerine polyacrylate, or a combination thereof.
Examples of carbomers that can be used in the present invention include, but are not limited to, Carbomer 910, 934P, 940, 941, 980 and 1342, and Carbopol® 974P and Carbopol® 980. Preferably, the carbomer is Carbomer 934P or Carbopol® 974P, and Carbopol® 980.
According to embodiments of the present invention, the amount of the carbomer in the composition is about 0.5%, 0.6%, 0.7%, 0.8%, 0.85%, 0.95%, 1.05%, 1.15%, 1.25%, 1.35%, 1.45%, 1.5%, 1.6%, 1.7%, 1.8%, 1.9% or 2.0% (w/w).
Polyol gel formulations with various ingredients solubilized therein have been used to minimize irritation when applied to the skin of a subject, while ensuring bioavailability of the active agent in the formulation. See Ofher III et al. “Gels and Jellies,” pp. 1327-1344 of Encyclopedia of Pharmaceutical Technology, vol. 3 (ed. by Swarbrick, et al, pub. by Marcel Dekker, 2002); or Pena, “Gel Dosage Forms: Theory, Formulation, and Processing,” pp. 381-388 of Topical Drug Delivery Formulations, (ed. by Osborne et al., pub. by Marcel Dekker, Inc., 1990). Polyols in gel formulations can serve one or more functions such as solubilizing agents, moisturizers, emollients, skin humectant, skin-penetration agents, etc. Suitable polyols that can be used in embodiments of the present invention include, but are not limited to, glycerine, propylene glycol, dipropylene glycol, hexylene glycol, butylene glycol, and liquid polyethylene glycols, such as polyethylene glycol 200 to 600.
According to embodiments of the present invention, the amount of the total polyols in the composition is about 5.0% to 30.0% (w/w), for example, about 5.0%, 5.5%, 6.0%, 6.5%, 7.0%, 7.5%, 8.0%, 8.5%, 9.0%, 9.5%, 10.0%, 10.5%, 11.0%, 11.5%, 12.0%, 12.5%, 13.0%, 13.5%, 14.0%, 14.5%, 15.0%, 17%, 20%, 25% or 30% (w/w).
Preferably, the topical gel composition comprises a first polyol and a second polyol, such as propylene glycol and glycerine, respectively.
According to embodiments of the present invention, the amount of each of the first and second polyols in the composition is independently about 4 to 15%, such as 4.5% to 6.5% (w/w), for example, 4.5%, 5.0%, 5.5%, 6.0% or 6.5% (w/w).
The pH of the topical formulations of the invention are preferably within a physiologically acceptable pH, e.g., within the range of about 4 to about 8, preferably, of about 6 to about 7.5, and more preferably about 4.5 to 6.5. To stabilize the pH, preferably, an effective amount of a buffer is included. In one embodiment, the buffering agent is present in the aqueous topical formulation in an amount of from about 0.05 to about 1 weight percent of the formulation.
The topical gel composition of the present invention can include one or more other ingredients, such as a protective agent, a cosmetic agent, an adsorbent, a preservative, an antioxidant, a surfactant, a skin-penetration agent, local anesthetics, analgesics etc.
In a preferred embodiment, a topical gel composition according to embodiments of the invention further comprises water dispersible form of titanium dioxide (TiO2), preferably at an amount that is sufficient to mask the color of brimonidine or another colored ingredient in the formulation, but would not cause irritation to the skin. TiO2 may cause mild irritation and reddening to the eyes, thus eye contact with the TiO2-containing topically administrable composition should be avoided. Titanium dioxide imparts a whiteness to the topically administrable composition and helps to increase the opacity and reduce the transparency of the composition. Titanium dioxide absorbs, reflects, or scatters light (including ultraviolet radiation in light), which can help protect products from deterioration. Titanium dioxide can also be used as a sunscreen to protect the user from the harmful effects of ultraviolet radiation that is part of sunlight.
According to embodiments of the present invention, the amount of water dispersible form of titanium dioxide in the composition is about 0.04 to 0.2%, such as 0.04%, 0.0425%, 0.0525%, 0.0625%, 0.0725%, 0.0825%, 0.09%, 0.10%, 0.15%, or 0.20% (w/w).
Suitable preservatives include, but are not limited to, quaternary ammonium compounds, such as benzalkonium chloride, benzethonium chloride, cetrimide, dequalinium chloride, and cetylpyridinium chloride; alcoholic agents, for example, chlorobutanol, phenylethyl alcohol, and benzyl alcohol; parabens such as methylparaben, ethylparaben, propylparaben, and butylparaben; antibacterial esters, for example, esters of parahydroxybenzoic acid; and other anti-microbial agents such as chlorhexidine, chlorocresol, benzoic acid, polymyxin, and phenoxyethanol. Preferably, the preservative is selected from the group consisting of sodium benzoate, phenoxyethanol, benzyl alcohol, methylparaben, imidazolidinyl urea and diazolidinyl urea.
In addition to brimonidine, the topically administrable composition according to embodiments of the invention can optionally include one or more other pharmaceutically active ingredients, including, but not limited to, medications used to treat the underlying disease that causes telangiectasia, antihistamines to control itching, antibiotics, corticosteroids, intravenous immunoglobulins, acetaminophen, etc.
This invention will be better understood by reference to the non-limiting examples that follow, but those skilled in the art will readily appreciate that the examples are only illustrative of the invention as described more fully in the claims which follow thereafter.
Example 1
Gel Topical Formulations
This example illustrates gel topical formulations that can be used in the present invention.
A first group of gel formulations is described in Table 1 below.










TABLE 1





Ingredients
% (w/w)
% (w/w)
% (w/w)







Brimonidine tartrate
0.3-0.6%  
0.6-3% 
3-10%


Methylparaben NF
0.15%
0.20%
0.10%


Propylparaben NF
0.03%
0.02%
0.04%


Hydroxyethylcellulose NF
 1.0%
1.25%
 1.5%


Butylene glycol 1,3
 3.0%
 6.0%
18.0%


Glycerine
 2.0%
 4.0%
12.0%


Disodium Edetate USP
0.05%
0.05%
0.05%


Purified Water, USP
QS
QS
QS


TOTAL
 100%
 100%
 100%









The pH of the formulation is adjusted to about 4.5 to 7.0.
A second group of gel formulations is described in Table 2 below.










TABLE 2





Ingredients
% (w/w)
% (w/w)
% (w/w)







Brimonidine tartrate
0.3-0.6%  
0.6-3.0%  
3.0-10%   


Methylparaben
0.20%
0.20%
0.20% 


Propylparaben
0.05%
0.05%
0.05% 


KLUCEL ®
 2.0%
 2.5%
1.0%


Propylene glycol
  3%
  6%
 15%


Glycerine, USP
  3%
  6%
 15%


10% Titanium dioxide
 0.5%
 0.6%
0.7%


Purified Water, USP
QS
QS
QS


TOTAL
 100%
 100%
100% 









The ingredients are mixed together and aqueous sodium hydroxide is slowly added to the mixture until a pH of about 4.5 to 6.5 is reached and the gel is formed.
A third group of gel formulations is described in Table 3 below.










TABLE 3





Ingredient
% (w/w)
% (w/w)
% (w/w)







Brimonidine tartrate
0.3-0.6%    
0.6-3.0%  
3.0-10%   


Carbomer 934P
1.25% 
 1.0%
1.5%


Methylparaben
0.2%
0.15%
0.20% 


Phenoxyethanol
0.4%
0.35%
0.4%


Glycerol
5.5%
 10%
 15%


Kowet titanium dioxide
0.0625%  
0.0725% 
0.0825%  


Propylene glycol
5.5%
 10%
 15%


DI Water
QS
QS
QS


TOTAL
100% 
 100%
100% 









The ingredients are mixed together and aqueous sodium hydroxide is slowly added to the mixture until a pH of about 4.5 to 6.5 is reached and the gel is formed.
A fourth group of gel formulations is described in Table 4 below.










TABLE 4





Ingredients
% (w/w)
% (w/w)
% (w/w)







Brimonidine tartrate
0.3-0.6%    
0.6-3.0%  
3.0-10%   


Methylparaben
0.15% 
0.125%
0.1%


Propylparaben
0.05% 
 0.05%
0.06% 


Carbopol ® 980
1.0%
 0.8%
1.5%


Glycerin
5.5%
  10%
 15%


10% Titanium dioxide
0.575% 
0.675%
0.775% 


Polyethylene glycol
4.5%
   8%
 12%


Water
QS
QS
QS


TOTAL
100% 
 100%
100% 









The ingredients are mixed together and stirred. Triethanolamine is added until a pH of about 5.5 to 7.0 is attained.
Example 2
Comparative Bioavailability and Pharmacokinetics Study of Brimonidine Compositions
This study was a randomized, evaluator-blinded, intra-individual comparative pharmacokinetic study of brimonidine tartrate, ophthalmic solution (0.2%) and topical gel (0.07%, 0.18% and 0.50%) applied under maximal use conditions for 29 days in subjects with moderate to severe erythema associated with rosacea. Major entrance criteria included clinical diagnosis of moderate to severe facial erythema associated with rosacea, CEA score ≧3, and IOP level 11-21 mmHg. Intra-subject comparison of topical to ophthalmic exposure following one day treatment with brimonidine tartrate ophthalmic solution 0.2% was performed.
A total of 102 subjects were randomized: 24, 26, 25, and 27 subjects in 0.5% Gel QD, 0.18% Gel BID, 0.18% Gel QD, and 0.07% Gel BID, respectively. On the Day 1 visit, one drop of brimonidine tartrate ophthalmic solution 0.2% was administered to each eye every 8 hours over a 24 hour period. After a 2-day wash-out period, one gram of topical gel (0.07%, 0.18%, or 0.50% of brimonidine tartrate) was applied once (QD) or twice daily (BID) to the face of subjects for 4 weeks.
Blood samples for complete PK profiling were taken during the 24-hour ocular treatment (study Day 1) and during the first day of topical application (study Day 4), fifteen days of topical application (study Day 18) and after the last topical application up to 72 hours post-dose (study Day 32). Additional blood samples were collected before application (Day 10, Day 24). Brimonidine plasma concentrations were determined by using a validated LC-MS/MS method with a lower limit of quantification (LOQ) of 10 pg/mL.
The PK parameters for brimonidine were calculated using standard non-compartmental method and Cmax, AUC0-24 hr were analyzed statistically using log-transformed data. For both the differences between times administration routes and between treatment groups, the limits of the intervals were back-transformed into exponential to obtain 90% confidence intervals (90% CI) of the ratios of geometric means on the original scale. The statistical analysis was performed using all Cmax (BLQ values being replaced by the LOQ) and using only quantifiable AUC0-24 hr.
PK results demonstrated that:
(1) Ocular treatment: Administration of brimonidine tartrate 0.2% by ophthalmic route resulted in quantifiable exposure (>10 pg/mL) in all patients receiving TID treatment. The pharmacokinetic (PK) parameters of the ophthalmic solution have a mean Cmax of 54±28 pg/mL (range: 16-134 pg/mL) and a mean AUC0-24 hr of 568±277 pg.hr/mL (range: 124-1490 pg.hr/mL). These were consistent with the known data of brimonidine tartrate 0.2% (w/w) ophthalmic solution, e.g., NDA:21-262, 0.2% Brimonidine Purite Multiple dose TID, Cmax 65±38 pg/mL.
(2) Topical treatments: Daily topical application of brimonidine Gel for 29 days resulted in quantifiable (>10 pg/mL) systemic exposure in 24%, 48%, 68% and 75% of subjects receiving brimonidine Gel 0.07% BID, 0.18% QD, 0.18% BID or 0.5% QD, respectively. At the end of the treatment period, the mean (±SD) Cmax were 13±9 pg/mL 17±20 pg/mL, 17±10 pg/mL, 25±24 pg/mL for brimonidine Gel 0.07% BID, 0.18% QD, 0.18% BID or 0.5% QD, respectively. Quantifiable AUC0-24 hr were 172±87 pg.hr/mL, 183±113 pg.hr/mL, 267±119 pg.hr/mL, 364±216 pg.hr/mL for brimonidine Gel 0.07% BID, 0.18% QD, 0.18% BID or 0.5% QD, respectively.
The effect of multiple dose of brimonidine gel on PK profile (Time effect: Day 4/Day 18/Day 32) was assessed for each topical treatment groups. Systemic exposures of the first day of topical application were comparable to those observed after 29 days topical applications in all treatment groups, thus suggesting that there is no drug accumulation throughout the treatment duration (i.e. 4 weeks) whatever the dose and the dose regimen. Whatever the dose and dose regimen tested, the Ocular/Topical ratios calculated over the entire topical treatment period (Day 4, Day 18 and Day 32) was significantly lower than 1.
After topical application of brimonidine gel, systemic exposure increases with applied dose. However, statistical analysis showed that systemic exposure (Cmax) is not dose proportional. The mean Cmax increased lower than dose proportionality.
The topical systemic exposure (expressed as Cmax or AUC0-24 hr) from the skin treatment was compared to the one obtained after ocular treatment. See Table 5.







TABLE 5







statistical comparison of the ocular and topical treatments












CD07805/
CD07805/
CD07805/
CD07805/



47 Gel
47 Gel
47 Gel
47 Gel



0.5% QD
0.18% BID
0.18% QD
0.07% BID



Estimate
Estimate
Estimate
Estimate


Parameter
(90% CI)
(90% CI)
(90% CI)
(90% CI)










Cmax


Ratio between Topical Administration Visit and Day 1


(Ophthalmic administration)











Day 4/Day 1
0.3 (0.3, 0.3)
0.3 (0.2, 0.3)
0.2 (0.2, 0.3)
0.2 (0.2, 0.2)


Day 18/
0.6 (0.5, 0.7)
0.3 (0.3, 0.4)
0.2 (0.2, 0.3)
0.2 (0.2, 0.2)


Day 1


Day 32/
0.4 (0.3, 0.4)
0.3 (0.3, 0.4)
0.3 (0.2, 0.3)
0.2 (0.2, 0.3)


Day 1







Quantifiable AUC0-24 hr


Ratio between Topical Administration Visit and Day 1


(Ophthalmic administration)











Day 4/Day 1
0.6 (0.4, 0.7)
0.4 (0.3, 0.5)
0.3 (0.2, 0.4)
0.1 (0.1, 0.3)a


Day 18/
0.7 (0.6, 0.9)
0.5 (0.4, 0.6)
0.3 (0.2, 0.4)
0.5 (0.2, 0.8)a


Day 1


Day 32/
0.5 (0.4, 0.7)
0.5 (0.4, 0.6)
0.3 (0.2, 0.4)
0.4 (0.3, 0.7)a


Day 1





ashould be taken with care due to the limited number of quantifiable AUC0-24 hr (2 to 6)


N.B.: Day 4 → first topical administration; Day 18 → 15th topical administration; Day 32 → 29th and last topical administration






In all the dosages and dose regimens tested the Ocular/Topical ratios calculated over the entire duration of the topical treatment period (Day 4, Day 18 and Day 32) were significantly lower than 1. The Cmax mean ratio was 0.2 for 0.07% BID group, ranged from 0.2 to 0.3 for 0.18% QD and BID groups and ranged from 0.3 to 0.6 for 0.5% QD group. For Cmax, the upper limit of the 90% confidence interval did not include 0.8 whatever the dose and dose regimen tested. The highest ratio was observed in the 0.5% QD group (mean ratio 0.6, 90% CI [0.5-0.7]) after 15 days of application, but not confirmed at the end of the 29-day of topical treatment (mean ratio 0.4, 90% CI [0.3-0.4]). The same tendency was observed with the quantifiable AUC0-24 hr. The clinical study results demonstrated that the systemic exposure obtained after topical treatment with all concentrations and regimens tested in the study is significantly lower compared to the systemic exposure obtained with the eye drops applied as recommended in the label of the ophthalmic products.
In conclusion, quantifiable PK profiles (at least Cmax) were observed in all treatment groups. It has been found that although systemic exposure increased with the applied dose of brimonidine, statistical analysis showed that the increase in systemic exposure (Cmax) was not dose proportional, e.g., the increase in the mean Cmax was much less than the increase in the dose. No evidence for systemic accumulation was observed.
All evaluated concentrations and regimens were well tolerate and safe. No clinically meaningful reductions in mean IOP, vital signs or routine laboratory parameters were observed with any of the topical gel treatment groups. Increasing drug concentration or regimen had no effect on the incidence of related cardiac/vascular AEs. There is no identifiable relationship between any PK parameter and the incidence or severity of any AEs related to the topical gel. There were no SAEs reported during the treatment period with the topical gel for skin application (DAY 4 through study completion). Two SAEs were reported during the ophthalmic solution treatment period (DAYS 1-3) in two subjects, with one SAE (Acute Hypotensive Event) considered related to the ophthalmic solution. Both subjects with SAEs were discontinued from the study prior to any exposure to the topical gel.
The study results demonstrated that the systemic exposure obtained after topical treatment of the affected skin areas with all concentrations of brimonidine and regimens tested is significantly lower compared to the systemic exposure obtained with the eye drops (0.2% by weight brimonidine tartrate) applied as recommended in the label of the ophthalmic products.
Based on this comparative bioavailability and pharmacokinetics study, concentrations of brimonidine higher than 0.2% (w/w) can be used for topical administration to an affected skin area for safe and effective treatment of a skin disorder.
Example 3
Clinical Study of Brimonidine Tartrate Gel Compositions
Clinical Study
A single-dose, randomized, double-blind, parallel-group, vehicle-controlled, dose-finding study was conducted to evaluate the pharmacodynamics and safety of three gel formulations containing three concentrations of brimonidine tartrate, i.e., 0.07%, 0.18% and 0.50%, by weight in subjects with stable moderate to severe erythematotelangiectatic rosacea.
A total of 122 subjects were randomized to receive one application of one of the three topical gel formulations (N=31, N=31, N=28, for the 0.5%, 0.18%, 0.07%, respectively) or vehicle gel (N=32). A single application was applied to the face in the morning. Subjects remained at the site for a mandatory 12-hour post-dose observation period. All 122 subjects completed the study and were included in the intent to treat (ITT) and Safety population. A total of 117 subjects (96%) were included in the population point (PP) population.
Each patient's telangiectasia was graded on a scale from 0 to 4 by Telangiectasia Global Assessment (TGA), with 0 being the rating for no signs of telangiectasia and 4 being the rating for severe telangiectasia, with the presence of many clearly visible telangiectasias. The TGA score was recorded pretreatment or pre-dose and at various time points after the treatment.
Changes in TGA score were analyzed using an analysis of covariance model (ANCOVA) with analysis center, treatment as factors and the corresponding baseline value as covariate.
Efficacy of the Treatment
Table 6 provides the summary of average mean change and the average minimum (min) and maximum (max) change of TGA from the pre-dose baseline over a 12-hour interval. The treatment with 0.5% (w/w) brimonidine has resulted in more reduction in TGA compared to that with vehicle or lower concentration of brimonidine, e.g., at 018% (w/w) or 0.07% (w/w).







TABLE 6







Average Changes of the TGA from the Pre-dose












0.5%
0.18%
0.07%




Brimonidine
Brimonidine
Brimonidine
Vehicle



(N = 31)
(N = 31)
(N = 28)
(N = 32)















Average Mean
−0.28
−0.16
−0.21
0.03


Change


Average Min,
−2.4, 1.5
−1.7, 0.5
−1.7, 0.1
−1.7, 0.9


Max Change









Also as shown in FIGS. 1-6, significant reduction in telangiectasia was observed with the treatment of 0.5% (w/w) brimonidine, e.g., 30 minutes post treatment, which lasted even 12 hours post treatment.
The more effective and long lasting treatment of telangiectasia by 0.5% (w/w) brimonidine observed from the clinical study is unexpected in view of the ophthalmic applications of brimonidine, where increasing the concentration of brimonidine does not appear to significantly increase its efficacy and lowering the concentration of brimonidine, e.g., to 0.1% (w/w), maintains its IOP-lowering efficacy.
Safety of the Treatment
Intraocular pressure (IOP) was measured at pre-dose (T0) and Hour 12 on the treatment day. Slight reductions were observed in all treatment groups. However, no clear pattern relating to the dosage level of brimonidine could be identified. The result indicates that topical application of increasing concentrations of brimonidine up to 0.5% (w/w) to the skin area affected with telangiectasia did not increase the effect on IOP.
No serious adverse event (SAE) and no adverse event (AE) leading to discontinuation of the study were reported. The number of AEs is comparable between the groups. There is no increase in the number of AEs with the increase in the dose level. No unacceptable drug related adverse event was observed.
Unlike ophthalmic applications of brimonidine, where the chronic use of lower concentration of brimonidine, e.g., 0.1% (w/w), provides improved tolerability while maintaining IOP-lowering efficacy, the present clinical studies unexpectedly discovered that higher concentrations of brimonidine provide significantly improved clinical efficacy in treating telangiectasia or related symptoms, while not causing any observable change in patient safety and tolerability as compared to lower concentrations of brimonidine.
It will be appreciated by those skilled in the art that changes could be made to the embodiments described above without departing from the broad inventive concept thereof. It is understood, therefore, that this invention is not limited to the particular embodiments disclosed, but it is intended to cover modifications within the spirit and scope of the present invention as defined by the appended claims.

## Claims

1. A method of providing a safe and effective treatment of telangiectasia in a subject, comprising topically administering to a skin area affected by the telangiectasia or the symptom a topical composition comprising about 0.4% to about 0.6% by weight brimonidine tartrate and a pharmaceutically acceptable carrier, wherein the topical administration effects a serum or plasma profile of brimonidine having a mean Cmax of about 54±28 pg/mL or less and a mean AUC0-24 hr of about 568±277 pg.hr/mL or less.

2. The method of claim 1, wherein the telangiectasia is a telangiectasia associated with at least one of age, sun exposure, alcohol use, scleroderma, spider angioma, cutis marmorata telangiectasia congenita, Bloom syndrome, Klippel-Trenaunay-Weber syndrome, Sturge-Weber disease, Xeroderma pigmentosa, Nevus flammeus, Generalized essential telangiectasias (GET), angioma serpiginosum, ataxia telangiectasia, spider naevi, CREST Syndrome, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome), basal cell carcinoma, and unilateral nevoid telangiectasia.

3. The method of claim 1, wherein the telangiectasia is telangiectasia of rosacea.

4. The method of claim 1, wherein the symptom associated with telangiectasia is selected from the group consisting of a swelling of blood vessels, enlarged, dilated and/or visible spider veins, and red, purple or blue patches on the skin resulting from dilated blood vessels associated with telangiectasia.

5. The method of claim 1, wherein the topical composition is administered to the skin area once daily.

6. The method of claim 1, further comprising administering to the subject at least one additional treatment or active agent for telangiectasia.

7. The method of claim 6, wherein the additional active agent is selected from the group consisting of azelaic acid, benzoyl peroxide, isotretinoin, an antibiotic, a pharmaceutically acceptable salt thereof and a combination thereof.

8. The method of claim 1, wherein the topical composition further comprises about 0.20% (w/w) to about 4.0% (w/w) gelling agent; and about 5.0% (w/w) to about 30.0% (w/w) at least one polyol.

9. The method of claim 1, wherein the topical composition comprises about 0.5% by weight of brimonidine tartrate.

10. The method of claim 8, wherein the topical composition comprises about 0.50% (w/w) to about 2.0% (w/w) carbomer.

11. The method of claim 8, wherein the topical composition further comprises about 0.04% to about 0.08% (w/w) water dispersible form of titanium dioxide.

12. The method of claim 8, wherein the topical composition further comprises a preservative selected from the group consisting of sodium benzoate, phenoxyethanol, benzyl alcohol, methylparaben, imidazolidinyl urea and diazolidinyl urea.

13. The method of claim 8, wherein the topical composition comprises at least one of glycerin and propylene glycol.