Abstract:
A pharmaceutical composition comprising in admixture a hyaluronic acid related component (HARC) and a pharmaceutically effective amount of triamcinolone hexacetonide (TAH). The composition is stable in an accelerated shelf life test in which the composition is heated to 80° C. for 24 hours.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is a divisional application of and claims priority to U.S. application Ser. No. 12/556,869, filed on Sep. 10, 2009. 
     
    
     TECHNICAL FIELD 
       [0002]    This invention is in the general field of compositions and methods comprising hyaluronic acid (HA) or an HA-related component (collectively “HARC”), for example pharmaceutical compositions, devices and methods for treating various medical conditions. 
       BACKGROUND 
       [0003]    Hyaluronic acid has many medical uses, and various HARCs have been developed. The term HARC includes hyaluronic acid itself (including HA from living sources such as avian or bacterial sources), as well as hyaluronic acid salts and derivatives of the foregoing, including polymerized gels, cross-linked gels, and derivatized hyaluronic acid. 
         [0004]    HARCs may be administered by themselves, for example to provide relief from arthritis. They also may be mixed with anti-inflammatory steroids. Lyons US2006/0141049 discloses pharmaceutical compositions containing triamcinolone acetonide and hyaluronate. Yu et al.,  Osteoarthritis and Cartilage  vol. 12, Supp. B, P350 at page S144 (2004) discloses an in vitro evaluation of hylan G-F 20 diluted with a corticosteroid (triamcinolone acetonide) suspension. 
         [0005]    When used in a medical product HARCs typically are sterilized by heating, autoclaving, chemical treatment or filtration. Often it is important to maintain the viscoelastic properties of the HARC. Sterilization techniques may alter viscoelastic properties or make it difficult to control or maintain the stability of those properties. Sterilization may decrease the shelf life of the product. 
         [0006]    In some cases, HARCs are heat sterilized before forming a steroid/HARC mixture. Sterility of the final mixture may be achieved by filtration of the steroid solution before it is mixed with the HARC. 
       SUMMARY 
       [0007]    We have discovered that, when mixed with an HARC, one particular steroid salt, triamcinolone hexacetonide (TAH), retains its chemical integrity and provides a stable pharmaceutical composition with suitable shelf life and stability (particularly viscoelastic stability after sterilization) as compared to the original HARC (without the TAH). These and other properties provide a more efficient and convenient formulation. The combined composition shows good stability during and after heat sterilization in comparison to controls. 
         [0008]    Accordingly one aspect of the invention can be generally stated as a pharmaceutical composition comprising in admixture a hyaluronic acid related component (HARC) and a pharmaceutically effective amount of triamcinolone hexacetonide (TAH). The composition is stable in an accelerated shelf life test in which the composition is heated to 80° C. for 24 hours. Preferably, after this shelf life test, a) the % change of one or more viscoelastic properties (elastic modulus ΔG′, viscosity Δη, and/or phase angle Δδ) should be no more than ∀10% as compared to the comparable change in the control HARC (without TAH); b) the change in the composition pH should be no more than 0.5 pH unit; c) the change in osmolarity should be less than 10% (more preferably less than 5%) different from the change in osmolarity of the control HARC; d) the steroid should retain at least 90% (more preferably at least 95%) of its chemical integrity—i.e., there is less than 10% (more preferably less than 5%) chemical degradation—as determined by recovery data. Examples of suitable protocols for shelf-life and other tests are provided below. 
         [0009]    Preferably the composition can be heat sterilized. For example, the composition is stable in a simulated autoclave conditions with approximate 30 F o , in which the composition is heated at 121° C. for 30 min in a oil bath. Preferably, after the heat sterilization, the % change of G′, viscosity (η) or phase angle (δ) should be no more than 20% different (more preferably no more than 15% different) from the control (HARC without TAH); 
         [0010]    While the invention includes HARCs that are 100% gel or fluid, in preferred embodiments of this aspect of the invention, the HARC component includes both a cross-linked HARC gel and an HARC fluid component. The combination has a gel:fluid ratio between 80% and 20%, more preferably between 65% and 35%. Other HARCs may be used, including Orthovisc®, Monovisc™, Cingal™, and Elevess™ dermal filler (all from Anika Therapeutics), Adant, Arthrease, Arthrum, Durolane, Fermathron, Go-on, Hya-ject, Hyalgan/Hyalart, Hyalubrix, Hy-GAG, Ostenil, Sinovial, Supartz/Artz, Suplasyn, Synochrom, Viscorneal, Enflexxa, and Gel-eo. 
         [0011]    Preferably one ml of the composition includes at least 5 mg HA, when measured by standard procedures such as acid degradation followed by a determination of the HA free acid. 
         [0012]    The composition has a viscosity and an extrusion force that enable its use in a syringe. For example, it is delivered from a 5 cc syringe with a needle size of 20G-1.5″ with an extrusion force of less than 30 Newtons. The viscosity is between 20 Pas and 100 Pas. 
         [0013]    The gel component may be divinyl sulfone (DVS) cross-linked hyaluronic acid. 
         [0014]    The composition may be packaged in a syringe for delivery to a patient and it has a sterility assurance level (SAL) suitable for human administration. 
         [0015]    In some embodiments, the composition includes a surfactant, such as Polysorbate 80, Polysorbate 20, Pluronic F-127, Pluronic F-68 or other physiologically suitable surfactants. 
         [0016]    The stability provided by the invention enables a longer shelf life at room temperature so that the mixture may be stored after heat sterilization. The sterilized mixture can be packaged and stored (e.g., in a syringe) for later use. Accordingly, another aspect of the invention features a package containing a syringe filled with the sterilized pharmaceutical composition. 
         [0017]    The invention also provides more efficient manufacturing methods, and another aspect of the invention can be generally stated as a method of making the above described sterilized pharmaceutical composition by mixing the HARC with the TAH, and subjecting the mixture to heat sterilization. The sterilized mixture is then stored under sterile conditions. 
         [0018]    The invention may be used in a method of treating a patient for joint disease by using the syringe to administer the pharmaceutical composition into a joint of the patient. Administration may be by standard injection, by introduction on-site during arthroscopic surgery or open-knee surgery. 
         [0019]    The details of one or more embodiments of the invention are set forth in the accompanying drawings and the description below. Other features, objects, and advantages of the invention will be apparent from the description and drawings, and from the claims. 
     
    
     
       DESCRIPTION OF DRAWINGS 
         [0020]      FIG. 1  shows the structure of TAH. 
           [0021]      FIGS. 2   a  and  2   b  plot the change in elastic modulus after an accelerated shelf-life test ( 2   a ) and after sterilization ( 2   b ) for various HA/steroid formulations. 
           [0022]      FIGS. 3   a  and  3   b  show the relative % of steroid recovery after heat treatment of various formulations. 
       
    
    
     DETAILED DESCRIPTION 
       [0023]    One embodiment of the invention combines: a) a cross linked HA-gel; b) a modified or unmodified HA fluid and c) the insoluble steroid triamcinolone hexacetonide (TAH). 
         [0024]    Various procedures for HA cross linking are known, for example divinyl sulfone cross-linked HA as described in US2005 0142152, U.S. Pat. No. 5,143,724 and U.S. Pat. No. 4,582,865, each of which is hereby incorporated by reference. Other suitable cross linking agents may be used in place of DVS. For example, formaldehyde, glutaraldehyde, glyoxal, (U.S. Pat. No. 4,713,448); 1,4 butane diol diglycidylether (BDDE) 1,4-butane diol diglycidylether (BDDE), 1,2-ethandioldiglycidylether (EDDE), 1-(2,3-epoxypropyl)-2,3,epoxycyclohexane, N,N-diglycidylaniline, epoxysubstituted pentaerythritol (U.S. Pat. No. 4,772,419); biscarbodiimides such as p-phenylene-bis(ethylcarbodiimide) (U.S. Pat. No. 6,548,081); epichlorohydrin (WO8600079); polyaziridines, such as pentaerythritol tris(3-aziridinopropionate) (XAMA-7) (U.S. Pat. No. 5,827,937 and US2005-0222081). Each of the above references is hereby incorporated by reference. 
         [0025]    Formulations according to the invention are stable to an autoclave sterilization process. Additionally, the formulations are stable when subjected to accelerated stability tests such as a simulated two-year room temperature storage condition. Stability (as determined by rheology) of triamcinolone hexacetonide/viscosupplement combinational formulations compare favorably with formulations that replace the triamcinolone hexacetonide with a very similar steroid, triamcinolone acetonide (TAA). These two steroids are very similar chemically and a significant difference in stability would not be predicted. 
         [0026]    We conducted various experiments in which a number of steroids, both soluble and insoluble, were mixed with HA-based viscosupplements, and the heat stability of the HA/steroid formulations were evaluated at 121° C. for 30 min (simulated autoclave conditions), to achieve a bioburden inactivation of approximate 30 F o , where F o  is the total heat applied during the cycle to achieve a desired probable inactivation ratio). Formulations were also evaluated after heating at 80° C. for 24 hours (simulated two year room temperature shelf-life). 
         [0027]    Viscosupplements containing triamcinolone hexacetonide (TAH) generally exhibited stability comparable to a viscosupplement control (the same formulation with no steroid) within the limits described. Other steroid/viscosupplement combinations we tested demonstrated a decrease in HA stability as determined by rheology. 
       Rheological Properties 
       [0028]    Specifically we tested the TAH mixtures with SYNVISC® and hylastan products of Genzyme Corporation, Framingham Mass. 1  The rheological properties of the heat treated SYNVISC®/steroid and hylastan SGL-80/steroid formulations plus their controls are listed in Tables 1a and 1b, respectively, set out below. 1 Synvisc is a gel-like mixture that is made up of hylan A fluid, hylan B gel, and salt water. Hylan A and hylan B are made from a substance called hyaluronan (also known as sodium hyaluronate) from chicken combs. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 1a 
               
             
             
               
                   
               
               
                 Rheology Results of Synvisc/Steroid Formulations by Heat Treatment 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                 G′ 
                 St. 
                 % G′ 
                 DG′ 
                 h 
                 St. 
                 % h 
                 Dh 
               
               
                 Sample ID 
                 Steroid 
                 Treatment 
                 (Pa) 
                 Dev 
                 heat 
                 (%) 
                 (Pas) 
                 Dev 
                 heat 
                 (%) 
               
               
                   
               
             
          
           
               
                 Synvisc Ctrl 
                 No Steroid 
                 No Heat 
                 126 
                 6.4 
                   
                   
                 60 
                 0.7 
                   
                   
               
               
                   
                   
                 80° C./24 hr 
                 101 
                 0.0 
                 80.5% 
                 0.0% 
                 38 
                 0.0 
                 63.9% 
                 0.0% 
               
               
                 Synvisc - S 
                 Betamethasone 
                 No Heat 
                 121 
                 2.8 
                   
                   
                 59 
                 1.4 
                   
                   
               
               
                   
                 Phosphate 
                 80° C./24 hr 
                 18 
                 0.0 
                 14.9% 
                 −65.6% 
                 2 
                 0.1 
                 3.4% 
                 −60.5% 
               
               
                 Synvisc - K 
                 Triamcinolone 
                 No Heat 
                 112 
                 0.7 
                   
                   
                 61 
                 0.0 
                   
                   
               
               
                   
                 Acetonide 
                 80° C./24 hr 
                 9 
                 1.1 
                 7.8% 
                 −72.7% 
                 0.9 
                 0.1 
                 1.4% 
                 −62.5% 
               
               
                 Synvisc - D 
                 Methylprednisolone 
                 No Heat 
                 118 
                 9.9 
                   
                   
                 61 
                 2.8 
                   
                   
               
               
                   
                 Acetate 
                 80° C./24 hr 
                 22 
                 1.4 
                 18.6% 
                 −61.9% 
                 2.8 
                 0.1 
                 4.6% 
                 −59.3% 
               
               
                 Synvisc - C 
                 Betamethasone 
                 No Heat 
                 129 
                 4.9 
                   
                   
                 63 
                 2.1 
                   
                   
               
               
                   
                 Acetate 
                 80° C./24 hr 
                 1111 
                 211 
                 864.6% 
                 784.1% 
                 69 
                 2.1 
                 109.6% 
                 45.7% 
               
               
                 Synvisc - A 
                 Triamcinolone 
                 No Heat 
                 120 
                 7.1 
                   
                   
                 65 
                 0.7 
                   
                   
               
               
                   
                 Hexacetonide 
                 80° C./24 hr 
                 100 
                 1.4 
                 83.3% 
                 2.8% 
                 37 
                 0.7 
                 56.6% 
                 −7.3% 
               
               
                   
               
               
                 % X heat  = 100% * X(post-heat)/X(pre-heat); 
               
               
                 ΔX = % X heat (HARC/Steroid) − % X heat (HARC/Ctrl); 
               
               
                 In which X = G′ or η 
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 1b 
               
             
             
               
                   
               
               
                 Rheology Results of hylastan SGL-80/Steroid Formulations by Heat Treatments 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                 G′ 
                 St. 
                 % G′ 
                 DG′ 
                   
                 St. 
                 % d 
                 Dd 
                 h 
                 St. 
                 % h 
                 Dη 
               
               
                 Sample ID 
                 Steroid 
                 treatment 
                 (Pa) 
                 Dev 
                 heat 
                 % 
                 d(°) 
                 Dev 
                 heat 
                 (%) 
                 (Pas) 
                 Dev 
                 heat 
                 (%) 
               
               
                   
               
             
          
           
               
                 Hylastan Ctrl 
                 No Steroid 
                 No Heat 
                 126 
                 4.9 
                   
                   
                 16 
                 0.7 
                   
                   
                 102 
                 0.7 
                   
                   
               
               
                   
                   
                 121° C./30 min 
                 74 
                 0.7 
                 58.6% 
                 0.0% 
                 24 
                 0.0 
                 154.8% 
                 0.0% 
                 57 
                 0.7 
                 56.1% 
                 0.0% 
               
               
                   
                   
                 121° C./30 min 
                 57 
                 1.4 
                 77.6% 
                 0.0% 
                 28 
                 1.4 
                 116.7% 
                 0.0% 
                 47 
                 4.2 
                 76.5% 
                 0.0% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - S 
                 Betamethasone 
                 No Heat 
                 123 
                 4.9 
                   
                   
                 16 
                 0.7 
                   
                   
                 92 
                 5.7 
                   
                   
               
               
                   
                 Phosphate 
                 121° C./30 min 
                 21 
                 7.1 
                 17.1% 
                 −41.5% 
                 39 
                 3.5 
                 248.4% 
                 93.6% 
                 20 
                 7.9 
                 16.4% 
                 −39.7% 
               
               
                   
                   
                 121° C./30 min 
                 4.1 
                 0.1 
                 19.3% 
                 −58.3% 
                 50 
                 0.0 
                 129.9% 
                 13.2% 
                 1.4 
                 0.1 
                 9.0% 
                 −67.5% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - K 
                 Triamcinolone 
                 No Heat 
                 129 
                 0.0 
                   
                   
                 15 
                 0.0 
                   
                   
                 98 
                 0.7 
                   
                   
               
               
                   
                 Acetonide 
                 121° C./30 min 
                 2.5 
                 1.0 
                 1.9% 
                 −56.7% 
                 53 
                 4.9 
                 350.0% 
                 195.2% 
                 0.8 
                 0.3 
                 0.6% 
                 −55.5% 
               
               
                   
                   
                 121° C./30 min 
                 1.6 
                 0.1 
                 62.0% 
                 −15.6% 
                 47 
                 2.8 
                 89.5% 
                 −27.2% 
                 0.1 
                 0.0 
                 13.3% 
                 −63.2% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - D 
                 Methyl 
                 No Heat 
                 134 
                 2.1 
                   
                   
                 16 
                 0.7 
                   
                   
                 114 
                 10.6 
                   
                   
               
               
                   
                 prednisolone 
                 121° C./30 min 
                 8.9 
                 0.8 
                 6.7% 
                 −51.9% 
                 45 
                 0.7 
                 287.1% 
                 132.3% 
                 3.4 
                 0.2 
                 3.3% 
                 −52.8% 
               
               
                   
                 Acetate 
                 121° C./30 min 
                 3.5 
                 0.4 
                 39.3% 
                 −38.3% 
                 53 
                 3.5 
                 118.0% 
                 1.3% 
                 1.3 
                 0.3 
                 42.3% 
                 −34.2% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - C 
                 Betamethasone 
                 No Heat 
                 139 
                 0.0 
                   
                   
                 15 
                 0.0 
                   
                   
                 117 
                 0.7 
                   
                   
               
               
                   
                 Acetate 
                 121° C./30 min 
                 107 
                 11.3 
                 77.0% 
                 18.4% 
                 23 
                 0.7 
                 150.0% 
                 −4.8% 
                 77 
                 2.1 
                 67.4% 
                 11.3% 
               
               
                   
                   
                 121° C./30 min 
                 104 
                 2.8 
                 97.2% 
                 19.6% 
                 22 
                 0.0 
                 97.8% 
                 −18.9% 
                 41 
                 3.5 
                 55.4% 
                 −21.1% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - A 
                 Triamcinolone 
                 No Heat 
                 145 
                 5.7 
                   
                   
                 16 
                 0.7 
                   
                   
                 111 
                 2.1 
                   
                   
               
               
                   
                 Hexacetonide 
                 121° C./30 min 
                 86 
                 2.8 
                 59.3% 
                 0.7% 
                 23 
                 0.7 
                 145.2% 
                 −9.6% 
                 79 
                 2.8 
                 68.4% 
                 12.3% 
               
               
                   
                   
                 121° C./30 min 
                 65 
                 1.4 
                 75.6% 
                 −2.0% 
                 27 
                 0.0 
                 120.0% 
                 3.3% 
                 57 
                 0.7 
                 74.7% 
                 −1.8% 
               
               
                   
                   
                 &amp; 80° C./24 h 
               
               
                   
               
               
                 % X heat  = 100% * X(post-heat)/X(pre-heat); 
               
               
                 ΔX = % X heat (HARC/Steroid) − % X heat (HARC/Ctrl); 
               
               
                 In which X = G′ or δ or η 
               
             
          
         
       
     
         [0029]    Of the formulations made with various steroids, TAH formulations behaved to comparably to control formulations having no steroid. Other steroid formulations we tested either: a) (in the case of triamcinolone acetonide, methyl prednisolone acetate, and betamethasone phosphate) exacerbated degradation of HARC properties after heat treatment, or b) (in the case of betamethasone acetate) interacted with HARC. The change in elastic modulus for different HA viscosupplement/steroid formulations are plotted in  FIGS. 2   a  &amp;  2   b . Based on these experiments, we conclude that the TAH/HARC composition generally maintains a suitable level of stability when compared to the non-steroidal control. 
       pH and Osmolality 
       [0030]    The pH and osmolality were measured and are listed in Tables 2a &amp; 2b. Results also showed no significant change in pH and osmolality after mixing the TAH into the HA-based viscosupplements. Compositions retained suitable pH and osmolarity. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 2a 
               
             
             
               
                   
               
               
                 Osmolality and pH of Synvisc/Steroid Formulations 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                   
                 St. 
                 % 
                 ΔpH 
                 Osmolality 
                 St. 
                 (%) 
                 ΔOsm 
               
               
                 Sample ID 
                 Steroid 
                 Treatment 
                 pH 
                 Dev 
                 pH heat   
                 (%) 
                 (mOsm) 
                 Dev 
                 Osm heat   
                 (%) 
               
               
                   
               
             
          
           
               
                 Synvisc Ctrl 
                 No Steroid 
                 No Heat 
                 7.10 
                 0.04 
                   
                   
                 311 
                 0 
                   
                   
               
               
                   
                   
                 80° C./24 hr 
                 7.19 
                 0.01 
                 101% 
                 0.0% 
                 315 
                 2 
                 101% 
                 0.0% 
               
               
                 Synvisc - S 
                 Betamethasone 
                 No Heat 
                 7.62 
                 0.01 
                   
                   
                 358 
                 1 
                   
                   
               
               
                   
                 Phosphate 
                 80° C./24 hr 
                 7.51 
                 0.01 
                  99% 
                 −2.7% 
                 367 
                 7 
                 103% 
                 1.4% 
               
               
                 Synvisc - K 
                 Triamcinolone 
                 No Heat 
                 7.23 
                 0.01 
                   
                   
                 316 
                 1 
                   
                   
               
               
                   
                 Acetonide 
                 80° C./24 hr 
                 7.33 
                 0.04 
                 101% 
                 0.1% 
                 314 
                 1 
                  99% 
                 −1.7% 
               
               
                 Synvisc - D 
                 Methylprednisolone 
                 No Heat 
                 7.21 
                 0.03 
                   
                   
                 317 
                 4 
                   
                   
               
               
                   
                 Acetate 
                 80° C./24 hr 
                 6.58 
                 0.03 
                  91% 
                 −10.0% 
                 318 
                 1 
                 100% 
                 −0.9% 
               
               
                 Synvisc - C 
                 Betamethasone 
                 No Heat 
                 7.15 
                 0.02 
                   
                   
                 318 
                 0 
                   
                   
               
               
                   
                 Acetate 
                 80° C./24 hr 
                 6.38 
                 0.04 
                  89% 
                 −12.1% 
                 322 
                 2 
                 101% 
                 0.0% 
               
               
                 Synvisc - A 
                 Triamcinolone 
                 No Heat 
                 7.25 
                 0.03 
                   
                   
                 318 
                 5 
                   
                   
               
               
                   
                 Hexacetonide 
                 80° C./24 hr 
                 7.28 
                 0.00 
                 100% 
                 −0.9% 
                 313 
                 1 
                  99% 
                 −2.5% 
               
               
                   
               
               
                 % X heat  = 100% * X(post-heat)/X(pre-heat); 
               
               
                 ΔX = % X heat (HARC/Steroid) − % X heat (HARC/Ctrl) 
               
               
                 In which X = pH or Osmolality 
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 2b 
               
             
             
               
                   
               
               
                 Osmolality and pH of Hylastan/Steroid Formulations 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                   
                 St. 
                 % 
                 ΔpH 
                 Osmolality 
                 St. 
                 % 
                 ΔOsm 
               
               
                 Sample ID 
                 Steroid 
                 treatment 
                 pH 
                 Dev 
                 pH heat   
                 (%) 
                 (mOsm) 
                 Dev 
                 Osm heat   
                 (%) 
               
               
                   
               
             
          
           
               
                 Hylastan Ctrl 
                 No Steroid 
                 No Heat 
                 7.27 
                 0.01 
                   
                   
                 339 
                 3 
                   
                   
               
               
                   
                   
                 121° C./30 min 
                 7.34 
                 0.01 
                 101% 
                 0.0% 
                 341 
                 1 
                 100% 
                 0.0% 
               
               
                   
                   
                 121° C./30 min 
                 7.34 
                 0.01 
                 100% 
                 0.0% 
                 340 
                 1 
                 100% 
                 0.0% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - S 
                 Betamethasone 
                 No Heat 
                 7.49 
                 0.01 
                   
                   
                 393 
                 1 
                   
                   
               
               
                   
                 Phosphate 
                 121° C./ 30 min 
                 7.43 
                 0.01 
                  99% 
                 −1.7% 
                 380 
                 3 
                  97% 
                 −3.7% 
               
               
                   
                   
                 121° C./30 min 
                 7.36 
                 0.01 
                  99% 
                 −0.9% 
                 383 
                 3 
                 101% 
                 1.1% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - K 
                 Triamcinolone 
                 No Heat 
                 7.28 
                 0.01 
                   
                   
                 344 
                 4 
                   
                   
               
               
                   
                 Acetonide 
                 121° C./30 min 
                 7.26 
                 0.00 
                 100% 
                 −1.2% 
                 333 
                 1 
                  97% 
                 −3.5% 
               
               
                   
                   
                 121° C./30 min 
                 7.26 
                 0.00 
                 100% 
                 0.0% 
                 331 
                 3 
                  99% 
                 −0.3% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - D 
                 Methyl 
                 No Heat 
                 7.31 
                 0.01 
                   
                   
                 342 
                 0 
                   
                   
               
               
                   
                 prednisolone 
                 121° C./30 min 
                 6.52 
                 0.02 
                  89% 
                 −11.7% 
                 342 
                 2 
                 100% 
                 −0.5% 
               
               
                   
                 Acetate 
                 121° C./30 min 
                 6.39 
                 0.01 
                  98% 
                 −1.9% 
                 344 
                 2 
                 101% 
                 0.9% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - C 
                 Betamethasone 
                 No Heat 
                 7.33 
                 0.01 
                   
                   
                 346 
                 4 
                   
                   
               
               
                   
                 Acetate 
                 121° C./30 min 
                 6.74 
                 0.01 
                  92% 
                 −8.9% 
                 346 
                 6 
                 100% 
                 −0.3% 
               
               
                   
                   
                 121° C./30 min 
                 6.66 
                 0.01 
                  99% 
                 −1.3% 
                 344 
                 0 
                  99% 
                 −0.3% 
               
               
                   
                   
                 &amp; 80° C./24 h 
                   
                   
                   
                   
                   
                   
                   
                   
               
               
                 Hylastan - A 
                 Triamcinolone 
                 No Heat 
                 7.31 
                 0.01 
                   
                   
                 341 
                 1 
                   
                   
               
               
                   
                 Hexacetonide 
                 121° C./30 min 
                 7.32 
                 0.02 
                 100% 
                 −0.8% 
                 333 
                 3 
                  98% 
                 −2.6% 
               
               
                   
                   
                 121° C./30 min 
                 7.33 
                 0.01 
                 100% 
                 0.1% 
                 334 
                 3 
                 100% 
                 0.6% 
               
               
                   
                   
                 &amp; 80° C./24 h 
               
               
                   
               
               
                 % X heat  = 100% * X(post-heat)/X(pre-heat); 
               
               
                 ΔX = % X heat (HARC/Steroid) − % X heat (HARC/Ctrl) 
               
               
                 In which X = pH or Osmolality 
               
             
          
         
       
     
         [0031]    An HPLC assay was employed to assess the stability of the incorporated steroids. All steroid/viscosupplement formulations without heat treatment served as controls. After an 80° C./24 hr heat treatment (simulating two years of room temperature storage), compositions according to the invention showed suitable chemical integrity after this heat treatment. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
             
           
               
                 TABLE 3a 
               
             
             
               
                   
               
               
                 Steroids&#39; stability study for Synvisc/steroid formulations (heat treatment) 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                 Conc. of 
                 St. 
                 Rel. % 
                 Std. 
               
               
                 Sample ID 
                 Steroid 
                 Treatment 
                 Steroid (mg/mL) 
                 Dev. 
                 recovery 
                 Dev 
               
               
                   
               
             
          
           
               
                 Synvisc-K 
                 Triamcinolone 
                 No Heat 
                 9.8 
                 0.45 
                 100 
                 4.6 
               
               
                   
                 Acetonide 
                 80° C./24 hr 
                 9.4 
                 0.13 
                 96.3 
                 1.4 
               
               
                 Synvisc-D 
                 Methylprednisolone 
                 No Heat 
                 6.4 
                 0.16 
                 100 
                 0.4 
               
               
                   
                 Acetate 
                 80° C./24 hr 
                 6.2 
                 0.61 
                 98.6 
                 0.9 
               
               
                 Synvisc-A 
                 Triamcinolone 
                 No Heat 
                 9.0 
                 0.36 
                 100 
                 4.0 
               
               
                   
                 Hexacetonide 
                 80° C./24 hr 
                 9.1 
                 0.23 
                 100.9 
                 2.5 
               
               
                   
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
             
           
               
                 TABLE 3b 
               
             
             
               
                   
               
               
                 Steroids&#39; stability study for hylastan SGL-80/steroid formulations (heat treatment) 
               
             
          
           
               
                   
                 Name of 
                 Heat 
                 Conc. of 
                 St. 
                 Rel. % 
                 Std. 
               
               
                 Sample ID 
                 Steroid 
                 Treatment 
                 Steroid (mg/mL) 
                 Dev. 
                 recovery 
                 Dev 
               
               
                   
               
             
          
           
               
                 hylastan-K 
                 Triamcinolone 
                 No Heat 
                 10.1 
                 0.02 
                 100 
                 0.2 
               
               
                   
                 Acetonide 
                 121° C./30 min 
                 10.5 
                 0.63 
                 103.3 
                 6.2 
               
               
                   
                   
                 121° C./30 min 
                 10.3 
                 0.25 
                 101.4 
                 2.5 
               
               
                   
                   
                 &amp; 80 C./24 hr 
                   
                   
                   
                   
               
               
                 hylastan-D 
                 Methylprednisolone 
                 No Heat 
                 8.2 
                 0.01 
                 100 
                 0.1 
               
               
                   
                 Acetate 
                 121° C./30 min 
                 8.1 
                 0.55 
                 89.9 
                 0.7 
               
               
                   
                   
                 121° C./30 min 
                 6.6 
                 0.23 
                 86.2 
                 0.4 
               
               
                   
                   
                 &amp; 80 C./24 hr 
                   
                   
                   
                   
               
               
                 hylastan-A 
                 Triamcinolone 
                 No Heat 
                 8.6 
                 0.64 
                 100 
                 7.5 
               
               
                   
                 Hexacetonide 
                 121° C./30 min 
                 9.2 
                 0.08 
                 106.4 
                 1.0 
               
               
                   
                   
                 121° C./30 min 
                 8.5 
                 0.04 
                 99.1 
                 0.5 
               
               
                   
                   
                 &amp; 80 C./24 hr 
               
               
                   
               
             
          
         
       
     
         [0032]    The relative % of steroid recovery for all steroid/viscosupplement formulations is shown in  FIGS. 3   a  and  3   b . It is unexpected the triamcinolone hexacetonide/viscosuplement combinational formulations are stable while the triamcinolone acetonide/viscosupplement formulations are not stable based on the rheology evaluation. These two steroids are very similar chemically and large difference in stability would not be predicted. 
         [0033]    The following examples illustrate the invention and those skilled in the art will readily understand that other embodiments may be made without departing from the spirit and scope of the invention. 
       Example 1 
       [0034]    The composition will be a homogeneous colloidal suspension of triamcinolone hexacetonide, USP combined with an HA-based viscosupplement. The physical appearance will be a milky white viscous fluid. Product will be supplied sterile in a prefilled syringe (e.g, 5 mL with a 5 mL product fill). 
         [0000]    
       
         
               
             
               
               
             
               
               
               
             
               
               
             
           
               
                   
               
               
                 Formulation of Product in Pre-filled Syringe 
               
             
          
           
               
                 Component 
                 Amount per mL 
               
               
                   
               
             
          
           
               
                 Triamcinolone hexacetonide, USP 
                 2 to 12 
                 mg 
               
               
                 Non-modified hyaluronic acid fluid (35% 
                 3.5 
                 mg 
               
               
                 polymer content) 
               
               
                 Cross linked hylastan gel (65% polymer content) 
                 6.5 
                 mg 
               
               
                 Polysorbate 80 
                 0.35 
                 mg 
               
               
                 Sodium chloride 
                 8.47 
                 mg 
               
               
                 Sodium phosphate monobasic•H 2 O 
                 0.26 
                 mg 
               
               
                 Sodium phosphate dibasic•7H 2 O 
                 2.17 
                 mg 
               
             
          
           
               
                 Water for injection 
                 QS to 1.0 ml 
               
               
                   
               
             
          
         
       
     
       Example 2 
       [0035]    Gen-S1023-75 is a mixture of TAH (Triamcinolone Hexacetonide) with a HA based viscosupplement. The viscosupplement was made with DVS modified HA gel (AVS-gel) and unmodified HA fluid at 65:35 ratio of gel:fluid. Gen-S1023-75 contained about 8 mg/ml TAH (1002196), 0.35 mg/ml Tween-80 (Lot #E35595), 6.5 mg/ml of HA/DVS gel (lot #EX0848) and 3.5 mg/ml of unmodified HA. 
         [0000]    
       
         
               
             
               
               
               
               
               
               
               
             
               
               
             
               
               
               
               
               
               
               
             
               
               
               
               
               
               
               
             
           
               
                   
               
               
                 Gen-S. Rheological Properties. 
               
             
          
           
               
                   
                 δ (5) 
                 St. 
                 G′(5) 
                 St. 
                 η(1) 
                 St. 
               
               
                   
                 (°) 
                 Dev 
                 (Pa) 
                 Dev 
                 (Pas) 
                 Dev 
               
             
          
           
               
                   
                 Specification 
               
             
          
           
               
                 Sample ID 
                 &lt;35° 
                   
                 20-150 Pa 
                   
                 30-100 Pas 
                   
               
               
                   
               
             
          
           
               
                 Gen-S 1023-75 
                 21 
                 0.7 
                 86 
                 2.8 
                 70 
                 8.5 
               
               
                 (post-autoc) 
                   
                   
                   
                   
                   
                   
               
               
                 Gen-S 1023-75 
                 34 
                 2.1 
                 36 
                 3.5 
                 43 
                 3.5 
               
               
                 24 hrs @ 80° C. 
                   
                   
                   
                   
                   
                   
               
               
                 Gen-S 1023-75 
                 16 
                 0.0 
                 108 
                 1.4 
                 81 
                 4.2 
               
               
                 (pre-autoc) 
               
               
                   
               
             
          
         
       
     
       Example 3 
       [0036]    Experiments comparing the extrusion force required to deliver the composition from a 5 cc and a 10 cc syringe (compared to a composition lacking TAH) are summarized in the following table. 
         [0000]    
       
         
               
             
               
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 Extrusion Data for Gen-S lots 
               
             
          
           
               
                 Gen-S 
                 Average extrusion force 
               
             
          
           
               
                 lot # 
                 Description 
                 Newtons 
                 Syringe 
                 Needles 
               
               
                   
               
             
          
           
               
                 Extrusion force from a 5 cc syringe 
               
             
          
           
               
                 MTS 
                 Gen-S + 0 mg/ml TAH 
                 15.4 
                 5 cc 
                 20G 1.5″ 
               
               
                 09020 
               
               
                 MTS 
                 Gen-S + 12 mg/ml TAH 
                 12.42 
                 5 cc 
                 20G 1.5″ 
               
               
                 09022 
               
               
                 1023-75 
                 Gen-S + 8 mg/ml TAH 
                 15.21 
                 5 cc 
                 20G 1.5″ 
               
               
                 5 ml 
               
             
          
           
               
                 Extrusion force from a 10 cc syringe 
               
             
          
           
               
                 1023-68 
                 Gen-S + 2 mg/ml TAH 
                 22.87 
                 10 cc  
                 20G 1.5″ 
               
               
                 1023-70 
                 Gen-S + 8 mg/ml TAH 
                 22.39 
                 10 cc  
                 20G 1.5″ 
               
               
                 1023-75 
                 Gen-S + 8 mg/ml TAH 
                 16.42 
                 10 cc  
                 20G 1.5″ 
               
               
                 5 ml 
               
               
                 1023-75 
                 Gen-S + 8 mg/ml TAH 
                 17.62 
                 10 cc  
                 20G 1.5″ 
               
               
                 6 ml 
               
             
          
           
               
                 Comparison to 80:20 formulation 
               
             
          
           
               
                 MTS 
                 hylastan SGL-80 
                 22.51 
                 5 cc 
                 20G 1.5″ 
               
               
                 03002-B 
                 (Jonexa) 80% gel 
               
               
                 MTS 
                 hylastan 65:35 w/PS 
                 15.4 
                 5 cc 
                 20G 1.5″ 
               
               
                 09020 
                 65% gel 
               
               
                   
               
             
          
         
       
     
         [0037]    Accordingly, these and other embodiments are within the scope of the following claims.