WO2015094392A1

WO2015094392A1 - Compositions and methods for treatment of glaucoma

Info

Publication number: WO2015094392A1
Application number: PCT/US2014/015797
Authority: WO
Inventors: Gerald Horn
Original assignee: GNT LLC
Current assignee: GNT LLC
Priority date: 2013-12-18
Filing date: 2014-02-11
Publication date: 2015-06-25
Anticipated expiration: 2016-06-18
Also published as: BR112016014404A2; MX2016007902A; CN106455567A; CA2934453A1; EP3082427A1; JP2017501224A; EP3082427A4

Abstract

The invention provides a-2 adrenergic receptor agonist compositions and methods for treating glaucoma and other intraocular conditions. The preferred a-2 agonist used in the inventive compositions and methods is dexmedetomidine.

Description

COMPOSITIONS AND METHODS FOR TREATMENT OF GLAUCOMA Background of the Invention

[0001] Glaucoma is a multifactorial disease which encompasses a spectrum ranging from elevated intraocular pressure ("IOP") to reduced vascular perfusion of the optic nerve.

[0002] While many factors have been implicated as contributing causes of glaucoma, currently existing treatments for glaucoma have limited effectiveness in lowering IOP and/or are accompanied by a number of side effects, such as fatigue, sedation, lid allergy, topical allergy, and/or redness.

[0003] Because of the side effects, an additional major problem in glaucoma therapy is patient compliance in taking medications as prescribed. It is believed that many of these side effects and suboptimal efficacy of the existing treatments are unintended consequences of alpha- 1 ("a-1") receptor induction from treatment with alpha agonists.

[0004] Over 40% of glaucoma patients require two or more drugs for satisfactory control of their intraocular pressure. Of these, the prostaglandins/prostanoids, including Xalatan^® (latanoprost; Xalatan is a registered trademark of Pfizer Health AB), Travatan^® (travoprost; Travatan is a registered trademark of Novartis AG) and Lumigan^® (bimatoprost; Lumigan is a registered trademark of Allergan, Inc.), are the leading drugs due to their profound reduction of IOP, typically above 30% in ocular hypertensive eyes (21 mm Hg or greater), and long duration improvement in uveoscleral outflow. To have the greatest effect, the two drugs should have different mechanisms of action.

[0005] Brimonidine, a known alpha-2 (a-2) adrenergic receptor agonist, typically causes moderate peak IOP reduction of about 20-25% in ocular hypertensive eyes and 6-18% in normotensive eyes (less than 21 mm Hg). Its peak effect is within 2 hours of instillation, its duration of effect is typically less than 12 hours, and its moderate efficacy usually requires dosing of 2-3 times a day. It is one of the leading secondary drugs, with a mechanism of action of aqueous suppression that complements the prostaglandin/prostanoids uveal scleral outflow enhancement for significant additive benefit, but about equal to other second line glaucoma drugs such as beta-blockers and carbonic anhydrase inhibitors. Currently, brimonidine is the only commercially available a-2 agonist, proving safer and/or more effective than predecessors agonist which it has been compared, including clonidine (i.e. fewer instances of systemic hypotension and/or bradycardia), apraclonidine (i.e. fewer instances of tachyphylaxis), and dexmedetomidine (i.e. less systemic sedation, greater IOP reduction efficacy). However, brimonidine may induce substantial local side effects in 10-25% of users, such as conjunctival hyperemia (i.e. redness), blepharitis, allergy, conjunctival edema, conjunctival follicles, foreign body sensation, burning, or blurring. These side effects were only modestly improved by recent brimonidine formulations, resulting in somewhat reduced concentrations with increased intraocular absorption at more alkaline pH (Alphagan^® P, Alphagan is a registerd trademark of Allergan, Inc.). In general, a-2 agonists, including brimonidine, clonidine and dexmedetomidine, induce substantial systemic effects if absorbed into the circulation, and are specifically known to increase fatigue, decrease blood pressure (i.e. hypotension) and lower the heart rate (i.e. bradycardia). Further, many a-2 agonists, particularly the more lipophilic drugs such as clonidine and dexmedetomidine readily cross the blood brain barrier and thereby induce potent sedative effects. Dexmedetomidine, in particular, is a potent intravenous sedative, and side effects such as drowsiness, shortness of breath, dizziness, headache, hypotension, bradycardia, and mood depression are common to all a-2 agonists depending on their degree of systemic absorption. Brimonidine in particular produces topical lid and conjunctival allergy, dryness, and redness in well over 10% of patients. These side effects contribute to suboptimal compliance with brimonidine, which also negatively affects treatment.

[0006] Dexmedetomidine in phosphate buffer at pH 6.4-6.5 has been studied in rabbits with normotensive and artificially elevated eye pressure. U.S. Patent No. 5,304,569 (Lammintausta) describes the use of 0.02% dexmedetomidine in normotensive rabbits resulted in equal pressure reduction (100%) in the nontreated (contralateral) eye and the treated eye, a known side effect indicative of high systemic absorption. Vartiainen et al. demonstrated that dexmedetomidine at 0.05% in normotensive rabbits results in a pressure reduction of 4.75 mm Hg, with a peak effect at about 2 hours. (Inv Oph. & Vis Sci., Vol. 33, No. 6, May 1992, Dexmedetomidine-Induced Ocular Hypotension in Rabbits with Normal or Elevated Intraocular Pressures Vartiainen et. al). The comparison of the use of brimonidine tartrate 0.10% solution vs. dexmedetomidine in normotensive rabbits demonstrates a higher peak of about 6.2 mm Hg with brimonidine, a longer duration with peak of about 3 hours vs. 2 hours for dexmedetomidine, and lower systemic absorption with brimonidine, with contralateral (i.e. untreated eye) IOP reduction of only about 10% vs. about 100% for dexmedetomidine compared to the treated eye (Center for Drug Evaluation and Research Number 21-770, Pharmacology Review, brimonidine tartrate 0.1%, Allergan Pharmaceuticals). For over two decades, brimonidine has been the only commercially available a-2 agonist, due to its demonstrated combination of superior IOP reduction with greatly reduced risk of systemic side effects versus all other a-2 agonists attempted for this purpose, despite its less than optimal side effect profile and modest efficacy relative to prostaglandins/prostanoids.

[0007] Accordingly, there is a need for novel formulations of a-2 agonists for the treatment of glaucoma, which would have less systemic absorption, minimal, if any, cross- activation of a-1 receptors, improved intraocular retention with more effective IOP lowering and duration, and with significantly reduced or eliminated side effects of conventional a-2 agonists, such as burning, stinging, sedation and redness. In addition, an improved cosmetic appearance via both reduced redness and a cosmetically pleasing whiter shading of the eye may be important in reducing the rate of patients' noncompliance.

Summary of the Invention

[0008] The present invention provides compositions and methods effective for the treatment of glaucoma in a patient in need thereof. Preferably, the compositions of the invention are formulated to prevent sedation, eliminate or reduce redness, eliminate or reduce ocular allergy, as well as significantly reduce intraocular pressure.

[0009] In some embodiments, the provided compositions may also have an eye whitening effect. Most preferably, the compositions include all of the above benefits and also have neuroprotective benefits and may be used for optic nerve protection, including the treatment of neurodegenerative conditions, such as ischemic optic neuropathy, diabetic retinopathy, optic ischemia, retinal vascular ischemia, and other optic neuropathies, particularly those involving retinal ganglion cells and/or axons at or near the optic nerve lamina.

[00010] The present invention optimizes a-2 agonist corneal permeation utilizing a highly selective a-2 agonist which is formulated to optimize intraocular penetration at a lipophilicity of preferably Log P 2.5 or greater and range of topical lipophilicity based on the pH and optional buffering of the formulation that may range from 0.73 to 3.08 (measured relative to pH as the Log D value). Further, the improved formulations allow for reduced a-1 agonist activity and reduced systemic absorption, allowing for a more lipophilic a-2 agonist for topical use. [00011] The preferred compositions of the invention employ selective a-2 adrenergic receptor agonists.

[00012] It was found that certain rheological properties of a preferred embodiment were important for the safety and efficacy for the present invention. Particularly, it was discovered that the inventive formulations create and maintain over each blink cycle during which the drug is topically present, a very high ratio of low shear force - high viscosity and elastic modulus between blinks occurring within seconds, yet rapidly transition to very high shear force blink phase - low viscosity and elastic modulus within a fraction of a second.

[00013] Further, between blinks, once applied, the surface thickness of the tear film/formulation must be maintained at an equilibrium thin enough to prevent blurred vision.

[00014] It has been discovered that the formulation preferably has the following non-

Newtonian characteristics:

1) creating an initial viscosity on instillation of at or about 150 cps or greater, with transient equilibration, whereby blurring of vision lasts only tens of seconds, after which viscosity equilibrates to a non-newtonian low shear force to high shear force differential such that the highest viscosity is at least 2 fold less than the initial instillation viscosity;

2) creating a viscosity increase differential as in 1) above after transient equilibration on instillation wherein a ratio of about 6 : 1 or greater within 1-2 seconds at the low shear force between blinks and drops within the fraction of a second of the start of the high shear force of each blink, in a preferred embodiment, from at least 70 cps to 10 cps or less for each blink cycle;

3) the elastic modulus increases about 200 to 1000 fold within 1-2 seconds during the low shear force interblink period of each cycle, more preferably at least 2000 fold, and still more preferably at least 4000 fold, and where during the blink phase such modulus is less than 100, preferably less than 10, and more preferably about 0;

4) on instillation create a tear film thickness approximating normal tear film within a minute, and preferably within 30 seconds, where the between blink thickening at low shear force of each cycle is thereafter about 10 μ or less, and preferably about 5 μ;

5) the formulation must not cause excessive stinging or discomfort, reducing compliance or causing unacceptable ocular surface toxicity; and

6) where selected incipients do not otherwise interfere with drug absorption, or otherwise reduce the activity of the active ingredient.

[00015] In a preferred embodiment, the invention provides novel formulations of dexmedetomidine, which are surprisingly found to be much more effective for the treatment of glaucoma than brimonidine. These novel inventive formulations share some or all of the following characteristics: a) a high selectivity for a-2 over a-1 adrenergic receptors, such as 1000: 1 or greater; more preferably 1500: 1 or greater; and even more preferably 2000: 1 or greater;

b) a high degree of intraocular lipophilicity as measured by the Log P, the equilibrated intraocular pH at 7.4, with an octanol-water partition coefficient Log P of between about 1.5 and 4.0; and more preferably between about 2.50 and 3.50 at physiologic pH; and

c) include an anionic cyclodextrin such as Captisol^® (Captisol is a registered trademark of Cydex Pharmaceuticals), other cyclodextrins, or other nonionic surfactants such as poloxamer or a polyoxyl alkyl at specified concentration range, and one or more specific viscosity enhancers (also interchangeably referred to as a "gelling agents"). [00016] In one embodiment, the invention provides a pharmaceutical composition comprising: an a-2 adrenergic receptor agonist at a concentration from between about 0.0125% to about 0.125%) weight by volume, wherein said a-2 adrenergic receptor has a Log P value of 2.0 or greater and has a binding affinity of 950 fold or greater for a-2 over a-1 adrenergic receptors;

11. a hypotonic salt or sterile water;

in. a cyclodextrin or a poloxamer or a polyoxyl alkyl at a concentration of between 2%> and 12% weight by volume or less; and

IV. a viscosity enhancer,

wherein said pharmaceutical composition has a viscosity of between 25 and 500 cps, and

wherein said pharmaceutical composition is effective for the treatment of glaucoma in a patient in need thereof.

[00017] A preferred a-2 adrenergic receptor agonist is dexmedetomidine.

[00018] Preferably, dexmedetomidine is at a concentration from between about 0.035% and 0.12% weight by volume, more preferably at a concentration from about 0.035% to about 0.10% and more preferably between about 0.050% and 0.10% and even more preferably between about 0.060% and 0.087%.

[00019] In one embodiment, the salt selected from the group consisting of sodium chloride, citrate, mesylate, hydrobromide/bromide, acetate, fumarate, sulfate/bisulfate, succinate, phosphate, maleate, nitrate, tartrate, benzoate, carbonate, and pamoate.

[00020] Preferably, the salt is sodium chloride (e.g., a saline solution). [00021] In one embodiment, the viscosity enhancer is selected from carboxymethyl cellulose, methylcellulose, hydroxymethyl cellulose, hydroxypropylmethyl cellulose, hydroxyethyl cellulose, polyethylene glycol, dextran, povidone, alginic acid, guar gum, acacia, Veegum^® (Veegum is a registered trademark of Vanderbilt Minerals, LLC), gelatin, chitosan, Carbopol^® (Carbopol is a registered trademark of Lubrizol Advanced Materials, Inc.), locust bean gum, acidic polycarbophil, dextran, pectin, glycerin, polysorbate, polyvinylpyrridone, polyvinyl alcohol, hyaluronic acid and combinations thereof.

[00022] In a preferred embodiment, the viscosity enhancer is carboxymethyl cellulose.

More preferably the carboxymethyl cellulose is of a high blend at a concentration of between 0.1% and 1.25% weight by volume.

[00023] Preferably, the cyclodextrin, poloxamer or polyoxyl alkyl is present at concentration range of 3% to 10%> by weight; and more preferably, at 5% to 6%> by weight.

[00024] Preferably, the cyclodextrin is selected from alpha, beta or gamma chain cyclodextrins, and is selected from the group consisting of 2 hydroxypropyl beta cyclodextrin and and more preferably the sulfobutyl ether derivative of β-cyclodextrin (Captisol^®); poloxamer is selected from the group consisting of poloxamer 407, poloxamer 188, and combinations thereof and the polyoxyl alkyl is selected from the group consisting of polyoxyl 40 stearate, polyoxyl 35 castor oil, and or polyoxyl dehydrogenated 40 castor oil.

[00025] In one embodiment, the pharmaceutical composition may further comprise a buffer which may be selected from, but is not limited to, the group consisting of citrate buffer, borate buffer, maleate buffer, succinate buffer, phosphate buffer, acetate buffer, sorbate buffer and carbonate buffer. [00026] In one embodiment, the buffer is at a concentration between 1 mM and 100 mM, preferably between 4 millimolar and 10 millimolar.

[00027] In one embodiment, the a-2 agonist of the pharmaceutical composition has an octanol-water partition coefficient Log D of between about 0.70 and about 2.98, or preferably between about 1.25 and 2.50.

[00028] In one embodiment, the pharmaceutical compositions of the invention may further comprise a mucoadhesive, which may be present at a concentration from between about 0.05% and about 10% weight by volume.

[00029] In one embodiment, the mucoadhesive is selected from the group consisting of

Carbopol^®, xanthan gums, and cellulose derivatives.

[00030] The invention also provides methods of treating glaucoma and/or posterior pole ocular neurodegenerative conditions and/or dry eye in a patient in need thereof comprising administering to said patient the pharmaceutical compositions of the invention.

[00031] Surprisingly, despite the use of very high viscosities of the non-newtonian viscosity enhancer, carboxymethyl cellulose, where 1% in water = 2,500 cps, highly preferred viscosity ranges are, on initial application viscosities are only about 150 cps on instillation, and further equilibrate in tens of seconds to about 50 to 100 such that at the end of this transient equilibration period a non-newtonian state whereby a high shear less than 30 cps and in most cases less than 20 cps resulted; with low shear higher than 30 cps and in most cases higher than 50 to 70 cps. Detailed Description of the Invention

Definitions

[00032] The term "a-1 adrenergic receptor" refers to a G-protein-coupled receptor

("GPCR") associated with the G_q heterotrimeric G-protein.

[00033] The term "a-2 adrenergic receptor" refers to a GPCR associated with the Gi heterotrimeric G-protein.

[00034] The term "selective a-2 adrenergic receptor agonists" encompasses all a-2 adrenergic receptor agonists which have a binding affinity of 1000 fold or greater for a-2 over a- 1 adrenergic receptors , and more preferably 1500 fold or greater. The term also encompasses pharmaceutically acceptable salts, esters, prodrugs, and other derivatives of selective a-2 adrenergic receptor agonists.

[00035] The term "dexmedetomidine" encompasses, without limitation, dexmedetomidine salts, esters, prodrugs and other derivatives.

[00036] The term "prodrug" refers to a compound that may be converted under physiological conditions to a biologically active compound.

[00037] As used herein, the term "composition" is intended to encompass a product comprising the specified ingredients in the specified amounts, as well as any product which results, directly or indirectly, from a combination of the specified ingredients in the specified amounts.

[00038] The terms "treating" and "treatment" refer to reversing, alleviating, inhibiting, or slowing the progress of the disease, disorder, or condition to which such terms apply, or one or more symptoms of such disease, disorder, or condition. [00039] The terms "preventing" and "prevention" refer to prophylactic use to reduce the likelihood of a disease, disorder, or condition to which such term applies, or one or more symptoms of such disease, disorder, or condition. It is not necessary to achieve a 100% likelihood of prevention; it is sufficient to achieve at least a partial effect of reducing the risk of acquiring such disease, disorder, or condition.

[00040] The term "significant side effects" refers to substantial side effects of the treatment which include at least: a) sedation of a patient such that the patient feels sedated and becomes impaired or b) visually noticeable increase in redness of a patient's eye due to hyperemia.

[00041] The term "medicamentosa" refers to the inflammatory sequelae of a-1 agonist topical medications, particularly following topical ocular or nasal delivery, such as the development of increased vasodilation and hyperemia, in its less severe form referred to as "rebound".

[00042] The terms Poloxamer 407 and Pluronic^® F127 (Pluronic is a registered trademark of BASF Corporation) are used interchangeably.

[00043] All percentages are based on weight by volume unless otherwise noted.

[00044] Nonionic surfactants suitable for the present invention include cyclodextrins, polyoxyl alkyls, poloxamers or combinations thereof, and may include in addition combinations with other nonionic surfactants such as polysorbates. Preferred embodiments include polyoxyl 40 stearate; and optionally Poloxamer 188, Poloxamer 407, Polysorbate 20, Polysorbate 80, ionically charged (e.g. anionic) beta - cyclodextrins with or without a butyrated salt (Captisol^®), 2-hydroxypropyl beta cyclodextrin ("HPpCD"), Polyoxyl 35 castor oil, and Polyoxyl 40 hydrogenated castor oil or combinations thereof. Further, substitution of other nonionic surfactants compatible with ophthalmic use allows for similar formulation advantages, which may included but is not limited to one or more of a nonionizing surfactant such as poloxamer, poloxamer 103, poloxamer 123, and poloxamer 124, poloxamer 407, poloxamer 188, and poloxamer 338, any poloxamer analogue or derivative, polysorbate, polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80, any polysorbate analogue or derivative, cyclodextrin, hydroxypropyl-β- cyclodextrin, hydroxypropyl- γ-cyclodextrin, randomly methylated β- cyclodextrin, β-cyclodextrin sulfobutyl ether, γ-cyclodextrin sulfobutyl ether or glucosyl- β- cyclodextrin, any cyclodextrin analogue or derivative, polyoxyethylene, polyoxypropylene glycol, an polysorbate analogue or derivative, polyoxyethylene hydrogenated castor oil 60, polyoxyethylene (200) , polyoxypropylene glycol (70), polyoxyethylene hydrogenated castor oil, polyoxyethylene hydrogenated castor oil 60, polyoxol, polyoxyl stearate, nonoxynol, octyphenol ethoxylates, nonyl phenol ethoxylates, capryols, lauroglycol, PEG, Brij 35, glyceryl laurate, lauryl glucoside, decyl glucoside, or cetyl alcohol; or zwitterion surfactants such as palmitoyl carnitine, cocamide DEA, cocamide DEA derivatives cocamidopropyl betaine ("CAPB"), or trimethyl glycine betaine, N-2(2-acetamido)-2-aminoethane sulfonic acid (ACES), N-2-acetamido iminodiacetic acid (ADA), N,N-bis(2-hydroxyethyl)-2-aminoethane sulfonic acid (BES), 2-[Bis-(2-hydroxyethyl)-amino]-2-hydroxymethyl-propane-l,3-diol (Bis-Tris), 3- cyclohexylamino-1 -propane sulfonic acid (CAPS), 2-cyclohexylamino-l -ethane sulfonic acid (CHES), N,N-bis(2-hydroxyethyl)-3-amino-2-hydroxypropane sulfonic acid (DIPSO), 4-(2- hydroxyethyl)-l-piperazine propane sulfonic acid (EPPS), N-2-hydroxyethylpiperazine-N'-2- ethane sulfonic acid (HEPES), 2-(N-morpholino)-ethane sulfonic acid (MES), 4-(N- morpholino)-butane sulfonic acid (MOBS), 2-(N-morpholino)-propane sulfonic acid (MOPS), 3- morpholino-2-hydroxypropanesulfonic acid (MOPSO), 1 ,4-piperazine-bis-(ethane sulfonic acid) (PIPES), piperazine-N,N'-bis(2-hydroxypropane sulfonic acid) (POPSO), N- tris(hydroxymethyl)methyl-2-aminopropane sulfonic acid (TAPS), N-

[tris(hydroxymethyl)methyl]-3-amino-2-hydroxypropane sulfonic acid (TAPSO), N- tris(hydroxymethyl) methyl-2-aminoethane sulfonic acid (TES), 2-Amino-2-hydroxymethyl- propane-l,3-diol (Tris), tyloxapol, and Span^® 20-80, (Span is a registered trademark of Uniqema Americas Inc.). In certain embodiments, the addition of an anionic surfactant such as sodium lauryl ether sulfate, sodium lauryl sulfate ("SLS") or a combination thereof is preferred.

Embodiments of the Invention

[00045] The present invention provides compositions and methods effective for the treatment of glaucoma in a patient in need thereof. Preferably, the compositions of the invention are formulated to prevent sedation, eliminate or reduce redness, eliminate or reduce ocular allergy, as well as significantly reduce intraocular pressure.

[00046] In one embodiment, the salt selected from the group consisting of sodium chloride, citrate, mesylate, hydrobromide/bromide, acetate, fumarate, sulfate/bisulfate, succinate, phosphate, maleate, nitrate, tartrate, benzoate, carbonate, and pamoate.

[00047] Preferably, the salt is sodium chloride (e.g., a saline solution).

[00048] In one embodiment, the viscosity enhancer is selected from carboxymethyl cellulose, methylcellulose, hydroxymethyl cellulose, hydroxypropylmethyl cellulose, hydroxyethyl cellulose, polyethylene glycol, dextran, povidone, alginic acid, guar gum, acacia, Veegum^®, gelatin, chitosan, Carbopol^®, locust bean gum, acidic polycarbophil, dextran, pectin, povidone, polyvinylpyrridone, polyvinyl alcohol, and hyaluronic acid. [00049] In a preferred embodiment, the viscosity enhancer is carboxymethyl cellulose.

[00050] Preferably, the cyclodextrin, poloxamer or polyoxyl alkyl is present at concentration range of 3% to 10% by weight; and more preferably, at 5% to 6% by weight.

[00051] Preferably, the cyclodextrin is selected from the group consisting of alpha, beta or gamma chain cyclodextrin, more preferably 2 hydroxypropyl beta cyclodextrin, and still more preferably the sulfobutyl ether derivative of β-cyclodextrin such as Captisol^®; poloxamer is selected from the group consisting of poloxamer 407, poloxamer 188; and the polyoxyl alkyl is selected from the group consisting polyoxyl 40 stearate, polyoxyl 35 castor oil, and or polyoxyl dehydrogenated 40 castor oil. However, other poloxamers, polyoxyl alkyls and/or combinations thereof can be used for the purposes of the present invention.

[00052] It should be understood that part of the invention and optimal formulation herein has as its goal to maximize the corneal residence time and permeability of dexmedetomidme to achieve the greatest intraocular absorption while minimizing systemic circulation and side effects. These side effects include but are not limited to sedation, blurred vision and/or discomfort (e.g., stinging).

[00053] Although the prior art has shown dexmedetomidme can reduce IOP, there has been no showing to the Applicant's knowledge of dexmedetomidme at concentrations and formulations without side effects such as sedation.

[00054] Critical to the invention are the viscosity transitions of the formulation during high and low shear force of a blink, since it needs to provide sufficient corneal release and retention without systemic absorption. The ingredients and concentrations of the formulations exemplified herein are the best known examples but are not intended to be all inclusive. [00055] It has been discovered that the inventive formulations preferably have the following non-Newtonian characteristics:

1) creating a viscosity increase in ratio of at least about 5 to 20 : 1 within 1-2 seconds at the low shear force between blinks and drops within the fraction of a second of each blink, in a preferred embodiment, from at least 50 cps to 10 cps or less for each blink cycle;

2) the elastic modulus increases about 100 to 1000 fold within 1-2 seconds during the low shear force interblink period of each cycle, more preferably at least 2000 fold, and where during the blink phase such modulus is less than 100, preferably less than 10, and more preferably about 0;

3) on instillation create a tear film thickness approximating normal tear film within a minute, and preferably within 30 seconds, where the between blink thickening at low shear force of each cycle is thereafter about 10 μ or less, and preferably about 5 μ;

4) the formulation must not cause excessive stinging or discomfort, reducing compliance or causing unacceptable ocular surface toxicity;

5) where selected incipients do not otherwise interfere with drug absorption, or otherwise reduce the activity of the active ingredient; and

6) in a preferred embodiment, a solution consisting of Captisol^®, poloxamer 407 or polyoxyl 40 stearate between about 3% and about 10%; preferably at about 5-6%, NaCl 0.025%), high blend carboxymethylcellulose (CMC) 0.75%> to 1.25%, created the rheological conditions necessary for both corneal retention, corneal drug release, and inhibition of systemic absorption to allow for much greater IOP reduction at lower concentration than any previous alpha 2 agonist without the local or systemic previously found adverse events. [00056] It is particularly surprising the above formulations create both high viscosity on instillation, equilibrated viscosity in tens of seconds to below 30 cps at high shear and well above 30 cps at low shear. The result is reduced nasolacrimal drainage on instillation as well as decreased nasolacrimal pump and drainage between and during each blink where the viscosity agent in a preferred embodiment, CMC is actually 1% = 2,500 cps and at about 0.80% w/v.

[00057] It is also surprising, unexpected, and important for optimal corneal absorption and reduction of systemic absorption that when using Captisol^® the CMC is preferably increased to a range from about 0.90% to about 1.2% w/v to retain similar rheological properties found at 0.80%) w/v when used with poloxamers or polyoxyl alkyls.

[00058] Not wishing to be held or restricted to a particular theory, it is believed that the high viscosity of 150 cps or higher on instillation equilibrating in tens of seconds to below lOOcps, followed by the non-newtonian properties whereby between blink and blink properties are inverse of each other from relatively high to relatively low; whereby sudden high increase in viscosity and elastic modulus between blinks and the sudden and extremely low reduction during the fraction of a second of high shear force during a blink: 1) creates an optimal residence time on the cornea; 2) results in a thin tear film thickness allowing excellent vision; 3) allows for a viscosity of about 20 cps or less during each blink allowing excellent vision; and 4) creates an initial high viscosity on instillation suppressing the normal high nasolacrimal absorption on instillation, as well as a non-newtonian higher multiple of viscosity increase between blinks that follows further retarding nasolacrimal pumping during the blink cycle and reduced nasolacrimal absorption. The low shear force rapid transition in seconds to very high viscosity and high elastic modulus, in addition to increasing corneal residence time, is sufficient to impede drug delivery through the nasolacrimal duct to the nasal turbinates and return to circulation without compromising vision during the blink cycle. Not wishing to be held to particularly theory it is further held that highly lipophilic drugs such as dexmedetomidine or other similar a-2 agonists are embedded within a nonpolar inner cell within micelles of a micellar equilibrium of the inventive formulations and thereby shielded by a polar outer shell in such configurations reducing the absorption by the lipophilic vascular endothelium relative to free floating drug in solution. These characteristics of an ophthalmic drug delivery vehicle should be suitable for any soluble therapeutic or palliative ophthalmic active drug to achieve optimal vision, comfort, efficacy and safety.

[00059] In a preferred embodiment the present invention is directed to a pharmaceutical composition comprising: i. dexmedetomidine at a concentration from about 0.0125% to about 0.125% w/v, more preferably from about 0.035% to about 0.10% w/v, most preferably from about 0.060% to about 0.087% w/v;

ii. a surfactant selected from polyoxyl 40 stearate, a cyclodextrin, gamma cyclodextrin and Captisol^® at a concentration from about 1% to about 15% w/v, more preferably polyoxyl 40 stearate or Captisol^® at a concentration of about 5.5% w/v;

iii. carboxymethyl cellulose ((1% = 2,500 centipoise)), at a concentration from about 0.10%) to about 1.25%) w/v, more preferably at about 0.80%> w/v if the surfactant is polyoxyl 40 stearate or from 0.90% to about 1.2% w/v if the surfactant is Captisol^®; iv. sodium chloride at a concentration from about 0.025% to about 0.90% w/v, more preferably from about 0.25%> to about 0.50%> w/v, most preferably at about 0.037%) w/v; v. benzalkonium chloride ("BAK") at a concentration from about 0.007% to about 0.02% w/v; preferably at 0.02% w/v;

vi. optionally an antioxidant at a concentration from about 0.005% to about 0.05% w/v, preferaby at 0.015% w/v, preferably the antioxidant is sodium

ethylenediaminetetraacetic acid at a concentration of about 0.015% w/v; vii. optionally a buffer at a concentration from about 1 millimolar to about 100

millimolar; preferably a phosphate or borate buffer from about 1 to about 5 millimolar, more preferably a phosphate buffer at a concentration from about 2 to about 4 millimolar; and

viii. a pH from about 4.0 to about 8.0, preferably from about 6.0 to about 7.0.

[00060] In another preferred embodiment the present invention is directed to a pharmaceutical composition comprising: i. dexmedetomidine at a concentration from about 0.060% to about 0.087% w/v; ii. polyoxyl 40 stearate at a concentration of about 5.5% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) at a concentration of about 0.80% w/v;

iv. sodium chloride at a concentration of about 0.037%) w/v;

v. benzalkonium chloride at a concentration of about 0.02% w/v; vi. sodium lauryl sulfate at a concentration from about 0.01% to about 5.0% w/v, preferably at 0.50%> w/v;

vii. optionally EDTA at a concentration of about 0.015% w/v; and viii. optionally a phosphate buffer at a concentration from about 1 to about 5

millimolar,

wherein the pH of the composition is from about 6.0 to about 7.0.

[00061] In another preferred embodiment the present invention is directed to a pharmaceutical composition comprising:

i. dexmedetomidine at a concentration from about 0.06% to 0.087% w/v;

ii. Captisol^® at a concentration of about 5.5% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) at a concentration from about 0.90% to about 1.1% w/v;

iv. sodium chloride at a concentration of about 0.037%) w/v;

v. benzalkonium chloride at a concentration of about 0.02% w/v; v. sodium lauryl sulfate at a concentration from about 0.1% to about 1.0% w/v, preferably at 0.50%> w/v;

vi. optionally an antioxidant is at a concentration of about 0.015% w/v; and vii. optionally a phosphate buffer at a concentration from about 1 to about 5

millimolar;

wherein the pH of the composition is from about 6.0 to about 7.0.

[00062] In another preferred embodiment the present invention is directed to a pharmaceutical composition comprising: i. dexmedetomidine at a concentration of about 0.080% w/v;

ii. Captisol^® at a concentration of about 5.5% w/v;

ii. sodium lauryl sulfate at a concentration of about 0.5% w/v; iii. cocamidopropyl betaine at a concentration from about 0.05% to about 0.5% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) at a concentration from

about 0.90% to about 1.1% w/v, preferably 1.05% w/v;

iv. sodium chloride at a concentration of about 0.037%) w/v;

v. sodium ethylenediaminetetraacetic acid at a concentration of about 0.015% w/v;

vi. benzalkonium chloride at a concentration of about 0.02% w/v; and wherein w/v denotes weight by volume and wherein said pharmaceutical composition is effective for the treatment of glaucoma in a patient in need thereof.

[00063] In one embodiment, the pharmaceutical composition may further comprise a buffer at a concentration from about 1 miUimolar to about 5 miUimolar, which may be selected from the group consisting of citrate buffer, borate buffer, maleate buffer, succinate buffer, phosphate buffer, acetate buffer, sorbate buffer and carbonate buffer, preferably from about 2 miUimolar to about 4 miUimolar and at a pH from about 5.5 to about 7.5.

[00064] In one embodiment, the overall pH of the pharmaceutical composition is from about 6.0 to 7.0.

[00065] In one embodiment, the a-2 agonist of the pharmaceutical composition has an octanol-water partition coefficient Log D of between about 0.70 and about 2.20, and preferably between about 1.25 and 2.00.

[00066] In one embodiment, the pharmaceutical compositions of the invention may further comprise a mucoadhesive, which may be selected from the group consisting of Carbopol^®, xanthan gums, and cellulose derivatives. However, other gums and/or gels, and/or viscosity enhancers can also be used for the purposes of the present invention.

[00067] In one embodiment, the mucoadhesive is at a concentration from between about

0.5% and about 1.0% weight by volume.

[00068] The inventive formulations may also optionally include other ingredients, such as corneal penetration enhancers and others.

[00069] The invention also provides a method of treating glaucoma and/or posterior pole ocular neurodegenerative conditions in a patient in need thereof comprising administering to said patient the pharmaceutical compositions of the invention.

[00070] Additionally, the inventive compositions may provide optic nerve protection, retinal ganglion cell neuroprotection, an increase in a-2 agonist concentration in the inner retinal plexiform, and additional neuroprotective benefits. They may also increase the outfiow at the trabecular meshwork which is populated with endothelial cells and believed to be populated with a-2a receptors in humans.

[00071] In addition, the methods and compositions of the invention may be used to reduce eye redness and/or increase eye whiteness in subjects in need thereof.

Unexpected Results of Using the Specific Combinations of the Ingredients

[00072] It was surprising that the discovered ranges and combinations were found to be most effective. Based on prior art, one would expect that dexmedetomidine would be an inferior glaucoma drug than the less lipophilic brimonidine or apraclonidine, much as was found for the similarly lipophilic to dexmedetomidine a-2 agonist, clonidine. [00073] Further, it has been found that a poloxamer alone, regardless of concentration, is not only ineffective for the purposes of the present invention in terms of increased efficacy, but it also creates moderate to severe stinging on topical application, whether it is buffered or non- buffered, and regardless of pH.

[00074] It would have been expected that the concentration of a poloxamer, a polyoxyl alkyl, or a cyclodextrin should be within the 15% to 25% range, at which gelling effect at room temperature is known to occur by which corneal retention is prolonged but with substantial prolonged blurring on instillation of minutes or more, and/or at the physiologic range of tonicity enhancers. However, it has been discovered that a poloxamer, a polyoxyl alkyl, or a cyclodextrin is effective in the provided combinations when it is present at 12% or less, and preferably at more than 3% but less than 10%. When a poloxamer, a polyoxyl alkyl, or a cyclodextrin is present at a concentration of 15% or greater or much less than 2%, the compositions are surprisingly less effective or ineffective.

[00075] It was also surprising and unexpected that in tested embodiments, other gelling agents, such as Carbopol^® 954 and/or xanthan gums, could not be used instead of a poloxamer, a polyoxyl alkyl or a cyclodextrin. One would have expected that these agents be interchangeable.

[00076] Further, the use of viscosity enhancers at too low concentrations resulted in surprisingly more side effects and reduced efficacy, and that viscosities are reduced up to or more than 100 fold within the inventive formulations, such that a 1% CMC solution in water of 2,500 cps will be about 100 to 250 cps on initial instillation of a preferred embodiment. It has also been found that the use of viscosity enhancers by themselves (i.e., without a poloxamer, a polyoxyl alkyl or a cyclodextrin) results in much less effective formulations with prolonged blurring on instillation, greater systemic absorption, and in general less efficacy and more side effects. Most surprising is that such high viscosities of preferred viscosity agents such as CMC 0.80% w/v (where 1% = 2,500 cps) resulted in such dramatic equilibration and non-newtonian benefits to enhanced residence time with reduced nasolacrimal drainage from about 100 cps for the formulation on instillation to about 15 cps after tens of seconds at high shear (blink) and about 50-70 cps at low shear (between blinks).

[00077] Further, it has been surprisingly found that when the tonicity of the provided formulations is at 0 to 200 mOsm/kg, and preferably at 50 to 150 mOsm/kg, a sustained wetting/lubricating effect will result with minimal blurring and the greater comfort for the patients. Typically, an ophthalmic vehicle requires 280-310 mOsm/kg, which is achieved through the use of electrolytes or polyols (e.g. mannitol).

[00078] Further, it has been surprisingly found that cyclodextrins, and more preferably the sulfobutyl ether derivative of β-cyclodextrin (Captisol^®) enhance the topical redness reduction whitening effect of the a-2 agonist, particularly dexmedetomidine; and whereby such preferred cyclodextrins further enhance intraocular pressure reduction.

[00079] Further, it has been surprisingly discovered that addition of sodium lauryl ether sulfate and or similar anionic surfactants including but not limited to sodium lauryl sulfate, still further enhance the intraocular pressure reduction of the inventive formulations. It is an unexpected discovery that the inventive formulations greatly minimize any stinging typically found with such anionic surfactants; and where such stinging as may still occur was completely and unexpectedly found to be reduced or essentially eliminated by addition of a small concentration of cationic surfactant such as cocamidopropyl betaine. Advantages of the Provided Compositions and Methods

[00080] The provided compositions and methods are effective for the treatment of glaucoma. Preferably, the compositions of the invention are formulated to prevent sedation, eliminate or reduce redness, may increase duration of therapeutic action and reduce the incidence of rebound hyperemia and/or other allergic reaction, as well as more significantly reduce intraocular pressure than prior art formulations of a-2 agonists.

[00081] It has been surprisingly found that the provided combinations of the ingredients result in up to a two-fold increased duration effect, and about a two- fold or greater peak IOP reduction for dexmedetomidine versus similar dexmedetomidine formulations (e.g., dexmedetomidine in phosphate buffer pH 6.4 - 6.5). They also provide a five to six-fold decrease in contra-lateral (non-treated eye) IOP reduction vs. ipsilateral (treated eye effect), reflecting greatly reduced systemic absorption affecting the non-treated eye. In non-inventive dexmedetomidine formulations (dexmedetomidine at 0.025% to 0.05% in phosphate buffer at pH 6.4 - 6.5), contralateral eye IOP is 90-100% of the IOP of the treated eye, due to very high systemic absorption (vs. about 10%> systemic absorption with the compositions of the present invention).

[00082] In a preferred embodiment, the formulations of the present invention provide the

IOP reduction of about 40% at 4 hours in a treated eye. The IOP reduction in the treated eye is greater than that found for the most optimized formulation of brimonidine (Alphagan^® P at 0.1%, pH 7.4 or greater), which is about 20%> in a treated eye.

[00083] Every 1 mm Hg reduction in IOP may result in substantial prevention of visual field loss. The longer duration of effect of the present invention creates a substantial effect over a 24 hour period, while a single dose of the conventional brimonidine formulations provides the IOP reduction effect for only about 12 hours or less.

[00084] A common side effect of glaucoma drugs and, particularly, brimonidine, is eye redness (20-25% rebound redness with long term use of brimonidine), and compliance is a key problem. For this reason, it is believed that reduction of redness, and/or cosmetic whitening achieved with the provided compositions are likely to substantially improve compliance. The invention also provides improved wetting and comfort, lasting up to an hour after instillation.

[00085] In addition, it has been surprisingly discovered that novel formulations provide a much greater comfort, a greater eye wetting and lubrication action, significantly fewer topical side effects than brimonidine, and result in few, if any, systemic effects. Thus, the provided formulations are significantly superior to conventional brimonidine or dexmedetomidine formulations. This surprising discovery was contrary to over 20 years of prior art findings that brimonidine was more effective than dexmedetomidine.

[00086] Thus, in some embodiments, the beneficial effects of the provided compositions include:

1) onset within one hour;

2) peak effects of over 30%, and as great as 42% in normotensive eyes;

3) reduction over normotensive baseline mean IOP of about 15.5 to a mean IOP of about 8.66;

4) peak effects at about 3.5 to 4 hours, compared to 2 to 2.5 hours for brimonidine;

5) prolonged action with great comfort and minimal to absent stinging, eye ache, or lid irritation; 6) a strong lubricating-wetting effect for nearly one hour after instillation with only transient blurring up to one minute;

7) improved cosmetic appearance via reduction of redness and in some cases cosmetic whitening;

8) less systemic absorption (only about 16% contralateral (non-treated) eye IOP reduction with inventive formulations versus much higher systemic absorption with prior art formulations of dexmedetomidine;

9) reduction of topical and systemic side effects associated with conventional formulations of a-2 agonists (such as apraclonidine and brimonidine), including but not limited to reduced incidence of: oral dryness, ocular hyperemia, burning and stinging, headache, blurring, foreign body sensation, conjunctival follicles, ocular allergic reactions, ocular pruritus, corneal staining/erosion, photophobia, eyelid erythema, ocular ache/pain, ocular dryness, tearing, upper respiratory symptoms, eyelid edema, conjunctival edema, dizziness, blepharitis, ocular irritation, gastrointestinal symptoms, asthenia, abnormal vision, muscular pain, lid crusting, conjunctival hemorrhage, abnormal taste, insomnia, conjunctival discharge, depression, hypertension, anxiety, palpitations/arrhythmias, nasal dryness and syncope.

[00087] Some of the characteristics which are important for the provided compositions include selectivity for a-2 versus a-1 adrenergic receptors, lipophilicity, tonicity and solubility.

Selectivity for a-2 versus a-1 adrenergic receptors

[00088] The selective a-2 adrenergic receptor agonists have binding affinities (Kj) for a-2 over a-1 receptors of 1000:1 or greater; more preferably 1500: 1 or greater; and even more preferably 2000:1 or greater. It is well within a skill in the art to design an assay to determine a- 2/α-1 functional selectivity. For example, potency, activity or EC50 at an a-2 A receptor can be determined by assaying for inhibition of adenylate cyclase activity. Furthermore, inhibition of adenylate cyclase activity can be assayed, without limitation, in PC 12 cells stably expressing an a-2 A receptor such as a human a-2 A receptor. Additionally, potency, activity or EC50 at an a-1 A receptor can be determined by assaying for intracellular calcium. Intracellular calcium can be assayed, without limitation, in HEK293 cells stably expressing an a-1 A receptor, such as a bovine a-1 A receptor.

[00089] For the purposes of the present invention, it is desired to avoid or minimize triggering of a-1 receptors. Even a small critical threshold achieved of undesired a-1 receptor recruitment creates sufficient generalized vasoconstriction, micro-inflammatory change, and/or pro-inflammatory cytokine release to reduce effectiveness of the a-2 receptor induced positive treatment effects. As all a-2 agonists known have a relative affinity for a-2 vs. a-1, this partial affinity is measure by the ratio of a-2 to a-1 receptor induction, where the multiplied product of the degree of selective a-2 affinity - the α-2/α-Ι ratio x the concentration C% determines that actual total pool of both a-2 and a-1 receptors induced.

[00090] The discovered range of necessary high selectivity, high lipophilicity and relatively low concentration of induced a-1 effects completely alters the IOP efficacy and side effect profile of a-2 agonist drugs. Accordingly, when these a-2 agonists are used for the treatment of glaucoma, they greatly reduce IOP without significant side effects believed to be associated with a-1 receptors, such as rebound hyperemia.

[00091] In some embodiments, compositions and methods of the invention include selective a-2 adrenergic receptor agonists which have K; for a-2 over a-1 receptors of 1500 fold or greater and have an octanol-water partition coefficient of about Log P 2.50 - 3.0 adjusted however for topical pH (Log D) to be between 0.75 and 3.08. Tears and intraocular fluids are physiologic at pH 7.4, which is equal to pH at Log P and, according to the precepts of the present invention, confers IOP reduction benefits. Corneal physiology requires a delicate and different octanol-water Log value (called Log D, determined by the pH of the formulation), so that the formulations are able to not only penetrate the lipophilic corneal epithelium and inner endothelium, but also penetrate the hydrophilic middle stromal layer.

[00092] In yet other embodiments, compositions and methods of the invention include selective a-2 adrenergic receptor agonists which have IQ for a-2 over a-1 receptors of 1000 fold or greater and are at a concentration from between about 0.0035% to about 0.035% weight by volume.

[00093] Brimonidine, guanfacine, guanabenz, dexmedetomidine and fadolmidine are some of the sufficiently highly selective a-2 agonists to satisfy the selectivity requirement. However, of these highly selective a-2 agonists, only dexmedetomidine satisfies other additional preferred formulation characteristics of the present invention, such as lipophilicity. Other a-2 agonists, such as clonidine, may be sufficiently lipophilic but lack sufficient selectivity.

[00094] It is currently believed that the most preferred selective a-2 adrenergic receptor agonist suitable for purposes of the invention is dexmedetomidine as either the HC1 salt, or as the citrate salt. Other salts may similarly be substituted for the HC1.

[00095] Accordingly, in some embodiments, compositions and methods of the invention include dexmedetomidine, or another selective a-2 adrenergic receptor agonist, at a concentration from between about 0.0125%) to about 0.125%) weight by volume; preferably, between about 0.025%> to about 0.125% weight by volume; more preferably between about 0.045% and about 0.10% weight by volume and even more preferably between about 0.060%) and about 0.087%.

[00096] It is believed that new a-2 agonists can be synthesized to meet the requirements of the present invention.

Lipophilicity

[00097] For any given ophthalmic drug, an optimal lipophilicity exists to maximize requisite penetration into the lipophilic cornea surface epithelium and, to a lesser extent, inner layer endothelium. If a drug is too hydrophilic, the epithelium becomes an impenetrable barrier. If a drug is too lipophilic, the drug cannot pass through the more hydrophilic stroma.

[00098] Lipophilicity may be measured, for example, using known measurements, such as

Log P (log Kow) derivation of the octanol-water partition coefficient and/or, a closely related coefficient, XLogP3-AA. See, for example, Tiejun Cheng et al, Computation of Octanol-Water Partition Coefficients by Guiding an Additive Model with Knowledge, J. Chem. Inf. Model., 2007, 47 (6), pp 2140-2148. These measurements represent the intraocular lipophilicity value of topical drugs for intraocular delivery (i.e., once the drug permeates into the anterior chamber and is at a pH of 7.4). A person of ordinary skill in the art is well familiar with these measurements. Thus, the Log P value is the octanol-water coefficient at pH 7.4, i.e., physiologic pH.

[00099] It was discovered in prior art that increasing the pH results in a better lipophilicity profile, making brimonidine mildly lipophilic on topical instillation and resulting in a better corneal penetration. For weak base a-2 agonists, such as brimonidine and dexmedetomidine, the more alkaline pH, the more the equilibrium between ionized base releasing H+ and non-ionized base shifts to the left (non-ionized), resulting in a more lipophilic compound. This is particularly true for a-2 agonists with pKa values of near or greater than 7.0, as is the case for brimonidine and dexmedetomidine. This is because at a more alkaline pH, more of the compound is present in a non-ionized form, and conversely therefore, at more acidic pH more of a drug is ionized and less lipophilic. Usually, Log P and/or XLogP3-AA are measured when the formulation at issue is or will be at the physiologic pH of about 7.4.

[000100] For a majority of drugs a general trend of Log P values from 2.0 to 3.0 is thought to be the best range of lipophilicity, though some of the best absorbing drugs range from 1.00 to about 2.50. Since each drug has its own Log P, and is not always amenable to stable Log D/pH manipulation, little is known about how each drug might be further optimized for topical delivery. The Log P value is highly drug/drug subclass specific, and while predictive software algorithms have been developed, there is no completely accurate means for determining the ideal Log P value for a proposed drug formulation to optimize intraocular penetration.

[000101] The range between +2.0 and +3.0 typically allows for the best compromise between: a) the need for a highly lipophilic drug to penetrate the lipophilic corneal epithelium, and to a lesser extent, the very thin inner corneal membrane called Descemet's membrane, and b) a highly hydrophilic drug to penetrate the stroma, which is the middle layer of the corneal "sandwich" that must be penetrated for effective ophthalmic absorption.

[000102] The disclosed combination of a poloxamer, a viscosity enhancer and a hypotonic solution at the disclosed concentration ranges provides a delivery vehicle for dexmedetomidine (and, it is believed, for other mild to highly lipophilic drugs) that is independent of pH and largely independent of the individual drug's lipophilicity.

[000103] The optimal pH of the provided formulations (i.e., the topically delivered pH of the formulation before physiologic equilibration to pH 7.4) is such pH that results in a Log "D" value for the drug (the initial topical lipophilicity) of between 0.75 and 3.08, and more preferably between 0.92 and 2.98, representing the maximum pH range of 4.0 to 8.0, and the preferred pH range of 4.5 to 7.0 for optimal comfort and stability.

[000104] Noticeably, for some dexmedetomidine formulations, increased stinging has been observed, particularly at pH of 4.0 to 7.0, and particularly pH 4.0 to 4.5. Further, it has been discovered that certain buffers added to dexmedetomidine in 0.9% NaCl render the drug less effective: particularly, phosphate buffer in its pH range of 6.0 to about 6.4.

[000105] However, it has been discovered that the topical application of the inventive formulations (i.e., those formulations including all of the required ingredients at the required concentrations), is not pH sensitive. Further, the efficacy of the inventive formulations no longer appears to be reduced by any particular buffers, including phosphate buffer. It is believed that the specific combination of the ingredients in the inventive formulations confers this pH independence and increased solubility range on a variety of active drugs, both for glaucoma and other purposes, as well as provides increased absorption and reduced systemic side effects; including but not limited to steroidals, nonsteroidals, anti-infectives (antivirals and antimicrobials), and macular degeneration drug treatments such as anti-VEGF.

[000106] The preferred Log P (and XLogP3-AA) values - those that define intraocular performance according to the present invention - that are suitable for the purposes of the invention are between about 1.00 and 4.50; and more preferably, between about 2.0 and 3.50. If the selectivity of a specific a-2 agonist is substantially above 1000: 1 (for example, 1500: 1), additional advantages are believed to be conferred via greater a-2 agonist binding and reduced a- 1 agonist induced ischemia. For example, optic nerve damage progression is known to be highly sensitive to circulation change and ischemia. Because the drug is used over an extended period of time, even small reductions in unintended a-1 agonist-induced ischemia may be beneficial. Thus it is a discovery of the present invention that the a-2 agonist intraocular lipophilicity as represented by Log P, and selectivity as represented by the α-2:α-1 receptor recruitment ratio, appear to be very important for greater efficacy of an a-2 agonist glaucoma drug. If the selectivity is above, for example, 2000: 1, then it is possible that this agonist may be effective for the purposes of the invention at slightly reduced lipophilicity, and vice versa.

[000107] Table 1 provides known XLogP3-AA values (a more accurate Log P) and a2/al binding affinities for several a-2 agonists.

TABLE 1

Methyl Dopa -1.9

Lofexidine 2.6 <300

[000108] Table 1 demonstrates that among the listed a-2 agonists, only dexmedetomidine has an optimal combination of high lipophilicity (XLogP3-AA) and highly selective a2:al coefficient. However, it is possible that formulations including other a-2 agonists can be achieved which meet the defined requirements of the present invention in both selectivity and lipophilicity categories.

[000109] In some embodiments, dexmedetomidine, or another selective a-2 adrenergic receptor agonist, has Log P at an intraocular pH 7.4 of about 3.10; preferably, between about 2.0 and 5.00; and more preferably between about 2.75 and 3.50.

[000110] As Log D refers to a lipophilicity value at a given pH, this measurement is especially useful to determine the level of topical lipophilicity and resultant corneal permeability of a topical composition through the highly lipophilic corneal epithelium.

[000111] Normally, higher Log P values, such as 3.0 or greater, are constrained by the highly hydrophilic stroma, and therefore a compromise lipophilicity of 1.0 to 3.0 and more preferably 1.5 to 2.5 is preferred for most ophthalmic topical drugs. Corneal permeability is a complex event, which may be affected by polar surface area, H⁺ donor activity, bond rotation, and active transport phenomenon.

[000112] It is a discovery of the present invention that the Log D values of between about

0.75 and about 2.20, and more particularly between about 1.00 and about 1.50, are preferred for increased corneal permeation of dexmedetomidine and other similar a-2 agonists in normal saline, preferably below the pH of 6.4 to 6.5, and that the "vehicle" of the present invention including poloxamer, viscosity enhancer and hypotonic saline or sterile water greatly reduces and likely totally eliminates such pH limitations.

[000113] When the selective a-2 agonist is dexmedetomidme, the optimal Log D value is from 0.75 to 2.2, and more preferably is about 1.00 to 2.00 at a topical pH of about 4.7 to 6.0.

Tonicity

[000114] For purposes of comfort topical delivery, ophthalmic drugs typically require about

275 to 320 mOsm/kg tonicity. A variety of tonicity enhancers, including but not limited to electrolytes, particularly 0.9% NaCl, and polyols, such as mannitol, may be used to achieve the desired range.

[000115] It is a surprising discovery of the present invention that such comfort is enhanced when poloxamer, a polyoxyl alkyl or a cyclodextrin at a concentration of about 3% or above is combined with a viscosity enhancer with no or reduced tonicity enhancement of about 25 - 150 mOsm/kg, and that poloxamer alone is highly irritating topically at a 3% or greater concentration.

Solubility

[000116] The solubility of a-2 agonists decreases exponentially at an increased pH. Table 2 illustrates the relationship between pH and solubility in water for dexmedetomidme. It shows that the soluble concentration of dexmedetomidme falls exponentially with higher pH. For pH of 4.0 - 6.0 a very high degree of solubility exists. TABLE 2

[000117] To achieve the greatest solubility while retaining the activity, the inventive compositions should include a salt; a poloxamer at a concentration of 12% weight by volume or less; and a viscosity enhancer. For example, using the provided compositions, dexmedetomidme is rendered soluble up to or beyond 0.15%.

[000118] Solubility for dexmedetomidme and other similar drugs in its subclass is typically reduced exponentially with increasing pH. For example, dexmedetomidme is only soluble in physiologic saline to about 0.025% at a highly alkaline pH. It is believed that the inventive formulations result in enhancement of solubility of dexmedetomidme, and by extension other members of its subclass, well above the 0.125% at alkaline pH.

[000119] It is believed the activity of the a-2 agonists, and dexmedetomidme in particular, in physiologic saline may be negatively affected by excipients of certain hydrophilicity or polarity, including citrate, various viscosity enhancing agents such as polyvinyl alcohol, various buffers such as phosphate buffer, and various gelling agents such as xanthan gum. [000120] Thus, it is inventive and not trivial that only a very limited number of specific combinations of the ingredients lead to a greater activity and stability, and is therefore unexpectedly superior to other similar formulations. This result was not at all predictable and is not likely to be due to simply gelling or enhancing viscosity: for example, neither Xanthan gum, Carbopol^® 954, nor carboxymethylcellulose alone or in combination conferred the effectiveness equal to that of brimonidine.

[000121] It is therefore very unexpected and surprising that the ingredients of the provided formulations not only offer an improved efficacy compared to dexmedetomidine formulations in physiologic saline, but also make the formulations superior to brimonidine formulations. This is surprising because prior art comparisons of dexmedetomidine and brimonidine under similar conditions demonstrated brimonidine to be the preferred a-2 agonist. Such prior art testing demonstrated that dexmedetomidine (and clonidine) resulted in less IOP reduction with greater systemic absorption than brimonidine. It is therefore surprising and unexpected that under specific and very limited formulation conditions, dexmedetomidine is more effective than prior art formulations of dexmedetomidine and more effective than brimonidine by about 200% (IOP reduction vs. time, which is the key measure of the effectiveness of IOP reduction).

[000122] Other agents that improve solubility which may be used for the purposes of the present invention (as long as a salt, a poloxamer, a polyoxyl alkyl or a cyclodextrin and a viscosity enhancers are included in the compositions) include, but are not limited to, polyanionic (multiple negatively charged) compounds, such as methylcellulose and derivatives, particularly carboxymethyl cellulose or other cellulose derivatives; hypotonic saline; sodium acetate, calcium salt, methanesulfonate (mesylate), hydrobromide/bromide, acetate, fumarate, sulfate/bisulfate, succinate, citrate, phosphate, maleate, nitrate, tartrate, benzoate, carbonate, pamoate, borate, glycolate, pivylate, sodium citrate monohydrate, sodium citrate trihydrate, sodium carbonate, sodium ethylenediaminetetraacetic acid ("EDTA"), phosphoric acid, pentasodium pentetate, tetrasodium etidronate, tetrasodium pyrophosphate, diammonium ethylenediamine triacetate, hydroxyethyl-ethylenediamine triacetic acid, diethylenetriamine pentaacetic acid, nitriloacetic acid, and various other alkaline buffering salts, and/or addition of cyclodextrins and/or their derivatives, particularly (2-Hydroxypropyl)~beta-cyclodextrin; certain solvents such as Tween^® 20 (Tween is a registered trademark of Uniqema Americas LLC), Tween^® 80, polyvinyl alcohol, propylene glycol and analogues or derivatives thereof; certain osmotic agents, such as mannitol or sucrose, hydroxypropylmethylcellulose ("HPMC") or analogues and/or derivatives thereof, or certain chelating agents.

[000123] In some preferred embodiments, the composition includes sodium citrate dehydrate at about 0.17%, and/or sodium acetate at about 0.39%; and/or calcium salt at about 0.048%.

Compositions and Methods of the Present Invention

[000124] Compositions and methods of the invention encompass all isomeric forms of the described a-2 adrenergic receptor agonists, their racemic mixtures, enol forms, solvated and unsolvated forms, analogs, prodrugs, derivatives, including but not limited to esters and ethers, and pharmaceutically acceptable salts, including acid addition salts. Examples of suitable acids for salt formation are hydrochloric, sulfuric, phosphoric, acetic, citric, oxalic, malonic, salicylic, malic, furmaric, succinic, ascorbic, maleic, methanesulfonic, tartaric, and other mineral carboxylic acids well known to those in the art. The salts may be prepared by contacting the free base form with a sufficient amount of the desired acid to produce a salt in the conventional manner. The free base forms may be regenerated by treating the salt with a suitable dilute aqueous base solution such as dilute aqueous hydroxide potassium carbonate, ammonia, and sodium bicarbonate. The free base forms differ from their respective salt forms somewhat in certain physical properties, such as solubility in polar solvents, but the acid salts are equivalent to their respective free base forms for purposes of the invention. (See, for example S. M. Berge, et al, "Pharmaceutical Salts," J. Pharm. Sci., 66: 1-19 (1977) which is incorporated herein by reference).

[000125] As long as a particular isomer, salt, analog, prodrug or other derivative of a suitable selective a-2 adrenergic receptor agonist functions as a suitable selective a-2 agonist, it may be used for the purposes of the present invention.

[000126] In some embodiments, compositions and methods of the invention include selective a-2 adrenergic receptor agonists which have binding affinities (Kj) for a-2 over a-1 receptors of 1000 fold or greater and are highly lipophilic, having an octanol-water partition coefficient of about 2.00 or greater. Brimonidine, by comparison, has a binding affinity for a-2 over a-1 receptors of about 976 and its lipophilicity range, even when optimized by pH, is about three hundred fold less than that of dexmedetomidine, a preferred embodiment.

[000127] In yet other embodiments, compositions and methods of the invention include selective a-2 adrenergic receptor agonists which have IQ for a-2 over a-1 receptors of 1000 fold or greater and are at a concentration from between about 0.001% to about 0.035% weight by volume.

[000128] In some embodiments, compositions and methods of the invention include selective a-2 adrenergic receptor agonists which have K; for a-2 over a-1 receptors of 1500 fold or greater, are present at a concentration from between about 0.010% to about 0.040% weight by volume, and have pH of about 6.2 or less. [000129] In some embodiments, the compositions of the invention may also include other therapeutic agents; however, the compositions are intended to be effective without the need for any other therapeutic agents, specifically including, but not limited to, a-1 antagonists.

[000130] The invention also provides methods of treating and/or preventing glaucoma with the provided compositions. The provided methods lower IOP in glaucoma patients, reduce redness, and provide eye whitening. The provided methods may also treat ischemic optic neuropathy and other neuropathies of various etiologies due to neuroprotective effects of the provided compositions.

[000131] The compositions of the present invention are preferably formulated for a mammal, and more preferably, for a human. In one embodiment of the invention, the compositions are delivered as ophthalmic solutions into the eyes. The invention also contemplates topical compositions which include, but are not limited to, gels and creams. They may also include additional non-therapeutic components, which include, but are not limited to, preservatives, delivery vehicles, tonicity adjustors, buffers, pH adjustors, antioxidants, tenacity adjusting agents, mucoadhesive agents, viscosity adjusting agents, and water.

[000132] To make the topical compositions of the present invention, one can simply dilute more concentrated solutions of selective a-2 agonists, using methods known in the art with diluent of particular gelling agents in solution, being in a preferred embodiment polyoxyl 40 stearate. In addition, the inventive formulations may optionally include one or more of electrolytes or tonicity enhancing agents, and preferably one or more of the weak acids and/or their salts to achieve a formulated pH of 4.0 to 8.0, and more preferably 5.5 - 6.5.

[000133] One preferred method of carrying out the dilutions involves overnight refrigeration, solubilizing both the active drug and the other excipients. This is a well known technique for solubilizing drugs for use with poloxamers. However, other methods can also be used. The compositions of the invention may include various inactive ingredients commonly used in formulating topical compositions and that may improve stability of the formulation. For example, the compositions of the invention may include alcohols and/or surface active agents, including but not limited to polyglycol ether, polyethylene glycol-nonphenol ether, polyethylene glycol sorbitan monolaurate, polyethylene glycol sorbitan monooleate, polyethylene glycol sorbitanmonooleate, polyethylene glycol sterarate, polyethylene glycol polypropylene glycol ether, polyvinyl alcohol, polyvinyl pyrrolidine, PEG and its derivatives, including but not limited to PEG 4000 or PEG 6000, in a total amount of 0.05% to 5% by mass of the composition.

[000134] In some embodiments, the compositions of the invention may include acids or monoglycerides of fatty acids having 8 to 12 carbon atoms, which when in 0.5 - 1.5 M, and preferably equimolar concentration to the alpha 2 agonist may improve corneal permeation via ion pair formation; or antioxidants such as ion-exchange/photooxidation stabilizing agents, including but not limited to citric acid, sorbic acid, boric acid, caprylic acid, glyceryl monocaprylate, glyceryl monocaproate, glycerol monolaurate, sodium metabisulfite.

[000135] In some embodiments, the compositions and methods of the present invention may include chelating agents that further improve stability, including but not limited to ethylenediaminetetraacetic acid ("EDTA") and structurally related acids and even more preferably citric acid or its salt. In some embodiments, the chelating agents are present at a concentration of between 0.005% and 0.2%> weight/vol.

[000136] Preservatives include, but are not limited to, benzalkonium chloride ("BAK"), methylparaben, polypropylparaben, chlorobutanol, thimerosal, phenylmercuric acetate, perborate, or phenylmercuric nitrate. BAK, in particular, has been found to be effective with preferred embodiments.

[000137] Delivery vehicles include, but are not limited to, polyvinyl alcohol, polyethylene glycol ("PEG") and its analogues, povidone, hydroxypropyl methyl cellulose, poloxamers, carboxymethyl cellulose ("CMC"), hydroxyethyl cellulose and purified water. It is also possible to use a physiological saline solution as a major vehicle.

[000138] Tonicity adjusters include, but are not limited to, a salt such as sodium chloride, potassium chloride, dextran, cyclodextrins, mannitol, dextrose, glycerin, or another pharmaceutically or ophthalmically acceptable tonicity adjustor. In some embodiments, the tonicity modifying agents are present at a concentration of between 0.1% and 1% weight by volume.

[000139] The compositions of the present invention may comprise corneal permeation enhancing agents which include, but are not limited to, preservatives, cyclodextrins, viscosity enhancers, and ion-channel enhancing agents. In some embodiments, corneal permeation enhancing agents include citrate, a citrate salt and/or other salts which increase solubility, chelating agents such as EDTA, preservatives, ion-channeling agents, cyclodextrin, or other additives which increase corneal permeability.

[000140] In some embodiments of the invention, a corneal permeation enhancing agent may be selected from the group consisting of BAK at 0.007%) to 0.02%> weight by volume, EDTA at 0.015%) weight by volume, caprylic acid, citric acid, boric acid, sorbic acid and/or salts, derivatives, and analogues thereof, where citric acid or its salt is a preferred embodiment. [000141] In some embodiments, the compositions and methods of the present invention may include additional viscosity enhancers and/or agents increasing solubility and/or stability, including but not limited to polyvinylpyrrolidone, polyethylene glycol ("PEG"), cellulose or cellulose derivatives of various molecular weights, including methylcellulose, cellulose glycolate, hydroxypropylcellulose, CMC and its salts, gelatin, sorbitol, alpha-cyclodextrin and/or other cyclodextrin derivatives, niacinamide, carbomers of various molecular weights including carbomer 934 P and 974 P, xanthan gums, alginic acid, guar gums, locust bean gum, chitosan, propylene glycol, polyvinyl alcohol, polysorbate including polysorbate 80, glycerin, mannitol, benzyl alcohol, phenylethyl alcohol, povidone, borate, acetate, phosphate or other similar buffering salts or agents, BAK, methyl paraben, sodium bisulfite, or peroxide preservative systems, surfactants, etc. In some embodiments, these agents are present at a total amount of 0.05% to 5% by w/v.

[000142] Many of the listed additives (for example, BAK, EDTA, etc.) may serve more than one purpose: for example, they can serve as both preservatives and corneal permeation enhancing agents (e.g. BAK), or solubilizing, preservative, and corneal permeation enhancing agents (e.g. citrate).

[000143] Buffers and pH adjusters include, but are not limited to, acetate buffers, carbonate buffers, citrate buffers, phosphate buffers and borate buffers. It is understood that various acids or bases can be used to adjust the pH of the composition as needed. pH adjusting agents include, but are not limited to, sodium hydroxide and hydrochloric acid. Antioxidants include, but are not limited to, sodium metabisulfite, sodium thiosulfate, acetylcysteine, butylated hydroxyanisole and butylated hydroxytoluene. EXAMPLE 1 Intraocular Pressure (ΊΟΡ), Redness and Burning/Stinging

Experimental Design

[000144] Various formulations of a-2 agonists were unilaterally administered to a normotensive (< 21 mm Hg) human subject. The subject first underwent baseline IOP testing using standard applanation tonometry via slit lamp. After fluorescein instillation, the drug was instilled as a morning dose at between about 7:00 and 9:00 AM. Preliminary measurements at 2, 3, 3.5, 4 and 4.5 hours demonstrated a substantial peak effect between about 3.45 and 4.15 hours for a preferred formulation of the invention. Follow up IOP checks were designed to be about 4 hours after initial instillation, where instillation consisted of 1-2 drops.

Experimental Results

[000145] The comparative human studies of: a) a preferred embodiment of the present invention versus; b) a dexmedetomidine formulation without poloxamer; and c) brimonidine demonstrate significant therapeutic advantages of the inventive composition over prior art.

[000146] In particular, testing of prior art formulations of dexmedetomidine (in phosphate buffer 6.4) and brimonidine (Alphagan^® P) were consistent with published data showing 30-35% IOP reduction in normotensive rabbits (equivalent to about 20% reduction in normotensive human eyes which have thicker corneas and less intraocular penetration). In contrast, the present invention demonstrates a surprising increase in IOP reduction, peaking at about 4 hours (versus 2 hours for brimonidine), nearly two-fold greater IOP reduction versus brimonidine, greater topical comfort, greater redness reduction, reduced topical side effects, and reduced systemic side effects. Table 3 demonstrates the results of this experiment.

TABLE 3

[000147] Tables 4-8 summarize studies of various formulations and excipients with dexmedetomidme. In particular, Table 4 demonstrates that there are significant side effects, such as sedation, when dexmedetomidme concentration is at or greater than about 0.02%, Table 5 demonstrates substantial and surprising improvements over Table 4 and prior art studies with the preferred embodiment of dexmedetomidme. TABLE 4

Poloxamer, Normal Saline

* different source TABLE 5

CMC, Poloxamer, Normal Saline

Formulations

Components 8 9 10 11 12 13 14

Rate ("-" bad,

"+++++" best) + + + ++ + ++ +++

* phosphate buffered

TABLE 6

Poloxamer, CMC, Hypotonic NaCl, pH

Formulations

Components 15 16 16A 16b 16b2 17 18 19

Effects

Peak IOP reduction 30% 40% 40% 40% 40% 40% 35% 35%

Side effects (0-4)

Bradycardia 0 0 0 0.5 0.5 0 0 0

Stinging 2 0.5 0.5 0.5 0 0.5 0.5 0.5

Dry Mouth 1.5 0.5 0.5 0.5 0.5 0.5 0.5 0.5

Sedation 0 0 0 1 0-1 * 0 0 0

+++++ Dest ) +++

* alternate source

** 0 with 30 sec punctal occlusion

TABLE 7

Other Viscosity Enhancers, Xanthan Gums, Poloxamer, pH

Formulations

Components 20 21 22 23 24

EDTA 0.01% - - 0.01% 0.01%

PVA 0.30% - - - -

PVP 0.30% - - - - citric acid 0.03% - - - - pH 7.0-7.5 4.5 5.2 4.5 5.2

Effects

IOP j,peak 20-25% 15% 20% 25% 25%

Side effects (0-4)

Bradycardia 1 1 1 1 1

Stinging 0-1 0-1 0-1 0-1 0-1

Dry Mouth 1.5x 0 0 0 0

Sedation

Rate ("-" bad, "+++++"

best) +½ ½ ½ ½ ½

* phosphate buffered

TABLE 8 Xanthan Gums, NaCl, Polysorbate 80

NaCl 0.250% 0.250% 0.250% 0.250% 0.250% 0.250% 0.250% 0.250%

Polysorbate 80 0.050% 0.050% 0.050% 0.050% 0.050% 0.050% 0.050% 0.050%

BAK 0.010% 0.010% 0.010% 0.010% 0.010% 0.010% 0.010% 0.010% mannitol - - - - - - - -

EDTA - - - - 0.01% 0.01% 0.01% 0.01% citric acid - - - - - - - - pH 5.2 4.5 5.2 4.5 5.2 4.5 4.5 4.5

Effects

20% 18% 25% 22% 28% 25% 25% 25%

IOP Reduction

Sedation 2.00 2.00 2.50 2.50 2.75 2.75 2.75 2.75

Rate ("-" bad,

+ + + + + + + + "+++++" best)

[000148] As Tables 4-8 demonstrate, the most effective compositions with lowest side effect profile are those which contain poloxamer at about 5-6%, CMC, sodium chloride and BAK. The peak dose response IOP reduction for preferred embodiments of the present invention appeared to be between about 0.070% - 0.10%.

EXAMPLE 2 Intraocular pressure (IOP) Utilizing Polyoxyl 40 Stearate Experimental Design

[000149] A formulation comprising 0.08% dexmedetomidine, 5.5% polyoxyl 40 stearate,

0.80% carboxymethyl cellulose (1% = 2,500 centipoise), 0.015% sodium ethylenediaminetetraacetic acid, 0.037% sodium chloride, 0.02% benzalkonium chloride and 5 mM phosphate buffer at a pH of 6.0 was unilaterally administered to a normotensive (< 21 mm Hg) human subject. The subject first underwent baseline IOP testing using standard applanation tonometry via slit lamp, which revealed a baseline IOP of 15. After fluorescein instillation, the drug was instilled as a morning dose at between about 7:00 and 9:00 AM. Preliminary measurements at 2, 3, 3.5, 4 and 4.5 hours demonstrated a substantial peak effect between about 3.45 and 4.15 hours for a preferred formulation of the invention. Follow up IOP checks were designed to be about 4 hours after initial instillation, where instillation consisted of 1-2 drops.

Experimental Results

[000150] In particular, testing of prior art formulations of dexmedetomidine (in phosphate buffer 6.4) and brimonidine (Alphagan^® P) were consistent with published data showing 30-35% IOP reduction in normotensive rabbits (equivalent to about 20% reduction in normotensive human eyes which have thicker corneas and less intraocular penetration). In contrast, the present invention demonstrates a surprising increase in IOP reduction to 8.66 (42% of baseline vs. less than 15%-20% for Alphagan^® in normotensiveeyes), peaking at about 3.5 hours (versus 2 hours for brimonidine) in a human subject, nearly two and one half-fold greater IOP reduction versus brimonidine, greater topical comfort, greater redness reduction, reduced topical side effects, and reduced systemic side effects.

EXAMPLE 3 Effects on Intraocular Pressure (IOP) and Side Effects

Experimental Design

[000151] First, baseline IOP measurements were performed on a subject using applanation slit lamp tonometry following instillation of fluorescein. Then, two drops of the topical agent to be tested were applied seconds apart to the left eye, and the punctum occluded for 30 seconds. Approximately four hours later, IOP testing was again performed. Three initial readings were taken and discarded to ensure minimal patient blepharospasm, following which the next three readings were recorded and averaged. There was a washout period of several days - 1 week between tests. All baseline IOP measurements were between 15.0 - 15.5 mm Hg at 8:00 AM - 9:00 AM at the time of instillation.

[000152] Side effects were qualitatively graded from 0-4 (0 - no side effects; 4- high degree of side effects (stinging on instillation, eye dryness, pharyngeal dryness, fatigue, sedation)) for the two tested dexmedetomidine formulations.

Experimental Results

[000153] The comparative human studies of: a) a preferred embodiment of the present invention versus; b) a dexmedetomidine formulation at 0.10% in a buffered phosphate at pH 6.4- 6.5 without poloxamer; and c) brimonidine, demonstrated significant therapeutic advantages of the inventive composition over prior art formulations of brimonidine or dexmedetomidine.

[000154] The present invention demonstrates a surprising increase in IOP reduction, nearly two-fold greater IOP reduction versus brimonidine, greater topical comfort, greater redness reduction, reduced topical side effects, and reduced systemic side effects. Table 9 demonstrates the results of this experiment.

TABLE 9

*Published data

**Dexmedetomidine 0.10%, Poloxamer gel 5-6%. CMC high blend 0.75%. BAK 0.02%, pH 6.0 [000155] This experiment demonstrated that the provided inventive compositions result in a substantially greater therapeutic benefit than prior art formulations of brimonidine or dexmedetomidme with improved systemic and topical side effect profile.

EXAMPLE 4 Effect of Carbopol^® 954 and Poloxamer 407 on dexmedetomidme, with and

without Viscosity Agent Enhancement, with and without NaCl

Experimental Design

[000156] The goal of this experiment was to investigate the effects of adding Carbopol^®

954 (C) and Poloxamer 407 (P) (both separately and in combination) on the effectiveness of topical dexmedetomidme at 0.025% weight by volume in normal saline. The concentrations of Carbopol^® 954P and Poloxamer 407 ranged from 1% to 8%.

Experimental Results

[000157] Table 10 demonstrates the results of this experiment.

TABLE 10

Formulation pH Stinging 0-4 Color IOP Effect Observation blend CMC uncomfortable. 0.25% Mod - hi pharyngeal dryness

P 1-10% + high 4.5 - 7.0 0 - 0.25 Clear >30% with Great comfort, blend CMC 0.50- (slight,transient high of 40% at barely noticeable 0.75% + Nacl <=15 seconds) 5-6% no pH pharyngeal dryness 0.025% effect

P 1-10% + high 6.5 0-0.25 Clear Not tested Tear break up time blend CMC 0.50- (slight,transient improvement 30 - 0.75% + Nacl 55 minutes; initial

<=15 seconds)

0.025% w/o blurring 30-60 dexmedetomidine seconds.

C: Carbomer 934P

P: Poloxamer 407

[000158] As Table 10 demonstrates, neither Poloxamer 407 alone nor Carbomer 934P alone provided satisfactory topical comfort for human use. However, a combination of specific concentrations of Poloxamer 407 and a viscosity agent (such as CMC) provided improved comfort and IOP reduction. There was an additional comfort and even stronger IOP reduction effect at more hypotonic solutions.

[000159] In particular, a combination of Poloxamer 1-10%, a viscosity agent and reduced salinity provided excellent comfort. The best formulation contained Poloxamer 5-6% + high blend CMC 0.62-0.75% + NaCl 0.025%. It provided best comfort, IOP effect treated eye and least local-systemic effect (pharyngeal dryness). EXAMPLE 5 Comparison of Treated and Non-Treated Eye Intraocular Pressure with

Brimonidine 0.20% , Dexmedetomidine 0.010% in phosphate buffered saline vs. Dexmedetomidine Preferred Embodiment

Experimental Design

[000160] The following formulations were compared: a) brimonidine (Alphagan^® P) (Composition B)

b) dexmedetomidine at 0.01%, phosphate buffered to pH 6.4 (Composition C); and c) dexmedetomidine at 0.1% with 5% Poloxamer 407 (F127), 0.25% NaCl, CMC high blend 0.75%>, and BAK 0.02%> at pH 6.1 (Composition A) (preferred embodiment).

[000161] Two drops of each of the tested formulations were placed in the left eye of a subject without punctual occlusion on separate days with a washout (break) (between several days to a week) between the administrations. Intraocular pressure measurements were taken 2.5 and 3.75 hours later in both the treated and non-treated eye.

Experimental Results

Table 11 demonstrates the results of this experiment.

12 12.5 14 14

15

Composition B (20% (16.6% 15 (6.6% (6.6% 33% reduction) reduction) reduction) reduction)

12 12 12.5 13

15 15

Composition C (20% (20% (16.6% (13.4% 83% reduction) reduction) reduction) reduction)

[000162] As Table 11 demonstrates, this experiment showed the following:

1) two-fold greater IOP peak % reduction in the treated eye with the inventive formulation (Composition A) vs. brimonidine (Composition B);

2) two-fold less IOP % reduction in the non-treated eye with the inventive formulation (Composition A) vs. brimonidine (Composition B);

3) two-fold greater IOP reduction in the treated eye after 4 hours with the inventive formulation (Composition A) vs. alternative dexmedetomidine formulation (Composition C); and

4) Longer duration of action to peak IOP reduction for the inventive formulation (Composition A) increasing from 2.5 hours to 4 hours vs. brimonidine (Composition B).

[000163] These results demonstrate improved efficacy and systemic absorption reduction of the inventive compositions as compared with similar dexmedetomidine compositions and conventional brimonidine compositions.

[000164] A greater differential of IOP reduction between treated and non-treated eye using the inventive compositions represents a lower systemic side effect profile as it is interpreted to correlate with reduced systemic absorption of drug reaching the non-treated eye.

EXAMPLE 6 Effect of Composition A on IOP vs. baseline over a 24 hour period

Experimental Design [000165] Three subjects with normo-tensive baseline IOP (< 21 mm Hg) were treated with a single instillation of two drops of the composition A (as described in Example 5) per eye at 8:30 AM, followed by 30 seconds of punctual occlusion with application on days 1, 3, and 5.

[000166] IOP was measured at one or more of 4 hrs, 8 hrs, 12 hrs, 24 hrs, 32 hrs and comfort and side effect profile were qualitatively assessed.

Experimental Results

Table 12 demonstrates the results of this experiment.

TABLE 12

TABLE 12 (continued)

TABLE 12 (continued)

[000167] As Table 12 demonstrates, the tested inventive formulation achieved a peak IOP reduction effect at about 4 to 8 hours after instillation. Furthermore, in two out of three patients the IOP remained below the baseline 24 hours after instillation. Typically, conventional brimonidine formulations achieve a peak IOP reduction effect of only about 15-18% in normotensive eyes about 2-3 hours after instillation. The IOP reduction effect of the inventive formulation was much stronger: from 41.7% to 58.8% at 8 hours after instillation.

[000168] Therefore, the formulations of the invention demonstrate improved performance over brimonidine as well as other known glaucoma drugs under similar conditions of testing (1-2 days of use, normotensive eyes).

[000169] No significant local or systemic side effects were observed.

EXAMPLE 7 Effect of Replacing the Poloxamer or Polyoxyl Alkyl Surfactant with Captisol^® Table 13. Effect of Replacing the Poloxamer or Polyoxyl Alkyl Surfactant with Captisol^®

CAPB - - - - 0.1%

0.90%- 0.90%- 0.90%-

CMC 0.80% 0.80%

1.1% 1.1% 1.1%

EDTA 0.015% 0.015% 0.015% 0.015% 0.015%

NaCl 0.037% 0.037% 0.037% 0.037% 0.037%

BAK 0.02% 0.02% 0.02% 0.02% 0.02% pH 6.5 6.5 6.5 6.5 6.5

Effects

30% 33.5% 43.5% 47.0% 47.0%

IOP Reduction

Sting (0-none, 4-most) 0 0 0 1.5 0

Rate ("-" bad, "+++++"

1 11 1 -1— 11—-V- 1 11 11 1 1 11 11 11 1 r best)

[000170] Formulas of Table 13 were unilaterally administered to a normotensive (< 21 mm

Hg) human subject. The subject first underwent baseline IOP testing using standard applanation tonometry via slit lamp, which revealed a baseline IOP of about 15.0 - 16.5 (diurnal curve, depending on time of day). After fluorescein instillation, the drug was instilled as a morning dose at between about 7:00 and 9:00 AM. Preliminary measurements at 2, 3, 3.5, 4 and 4.5 hours demonstrated a substantial peak effect between about 3.45 and 4.15 hours for a preferred formulation of the invention. Follow up IOP checks were designed to be about 4 hours after initial instillation, where instillation consisted of 1-2 drops.

Experimental Results

[000171] In particular, testing of prior art formulations of dexmedetomidine (in phosphate buffer 6.4) and brimonidine (Alphagan^® P) were consistent with published data showing 30-35% IOP reduction in normotensive rabbits (equivalent to about 20% reduction in normotensive human eyes which have thicker corneas and less intraocular penetration). In contrast, (as seen in Example 2 above) formula #33 demonstrated a surprising increase in IOP reduction of about 5.0 in a normotensive eye (30%> reduction from baseline), peaking at about 3.5 hours (versus 2 hours for brimonidine) in a human subject, nearly two and one half-fold greater IOP reduction versus brimonidine. The addition of sodium lauryl sulfate ("SLS") in formula #34 resulted in a further increase in IOP reduction to about 33.5% reduction from baseline (3.5% improvement over formula #33). Switching from polyoxyl 40 stearate to Captisol^® resulted in a further increase in IOP reduction to about a 43.5% reduction from baseline (10% improvement over formula #33). Switching to Captisol^® along with the addition of SLS resulted in an additive effect further increasing IOP reduction to about a 47% reduction from baseline (13.5% improvement over formula #33). However, SLS in Captisol^® as opposed to polyoxyl 40 stearate, resulted in significant stinging. The addition of CAPB relieved the stinging found with SLS in Captisol® resulting in the highest rated formulation (formula #37). Additionally, due to the relative increase in fluidity of Captisol^® over polyoxyl 40 stearate, the concentration of CMC was increased from 0.80%> w/v (formulas #33 and #34) to a range of 0.90%> to 1.1% w/v (formulas #35-37), 1.05% preferred.

Claims

WHAT IS CLAIMED IS:

1. A pharmaceutical composition comprising

i. an a-2 adrenergic receptor agonist at a concentration from between about

0.0125% to about 0.125% weight by volume, wherein said a-2 adrenergic receptor has a Log P value of 2.0 or greater and has a binding affinity of 950 fold or greater for a-2 over a-1 adrenergic receptors;

ii. a hypotonic salt or sterile water;

iii. a cyclodextrin, a poloxamer or a polyoxyl alkyl at a concentration from about 2% to about 12%) weight by volume; and

iv. a viscosity enhancer,

wherein said pharmaceutical composition has a viscosity of between 25 and 500 cps, and wherein said pharmaceutical composition is effective for the treatment of glaucoma in a patient in need thereof.

2. The pharmaceutical composition of claim 1, wherein said a-2 adrenergic receptor agonist is dexmedetomidine at a concentration from between about 0.035% to about 0.10% weight by volume.

3. The pharmaceutical composition of claim 1, wherein said salt is selected from the group consisting of sodium chloride, citrate, mesylate, hydrobromide/bromide, acetate, fumarate, sulfate/bisulfate, succinate, phosphate, maleate, nitrate, tartrate, benzoate, carbonate, and pamoate.

4. The pharmaceutical composition of claim 1, wherein said salt is sodium chloride.

5. The pharmaceutical composition of claim 1, wherein said viscosity enhancer is selected from carboxymethyl cellulose, methylcellulose, hydroxymethyl cellulose, hydroxypropylmethyl cellulose, hydroxyethyl cellulose, polyethylene glycol, dextran, povidone, alginic acid, guar gum, acacia, Veegum^®, gelatin, chitosan, Carbopol^®, locust bean gum, acidic polycarbophil, dextran, pectin, povidone, polyvinylpyrridone, polyvinyl alcohol, and hyaluronic acid.

6. The pharmaceutical composition of claim 4, wherein said viscosity enhancer is

carboxymethyl cellulose.

7. The composition of claim 6, wherein said carboxymethyl cellulose is of a high blend at a concentration of between 0.1% and 1.25% weight by volume.

8. The pharmaceutical composition of claim 1, wherein said cyclodextrin, poloxamer or polyoxyl alkyl is present at concentration range of 5% to 6% weight by weight.

9. The pharmaceutical composition of claim 1, further comprising a buffer.

10. The pharmaceutical composition of claim 9, wherein said buffer is selected from the group consisting of citrate buffer, borate buffer, maleate buffer, succinate buffer, phosphate buffer, acetate buffer, sorbate buffer and carbonate buffer.

11. The pharmaceutical composition of claim 9, wherein said buffer is at a concentration between 4 millimolar and 10 millimolar.

12. The pharmaceutical composition of claim 1, further comprising a mucoadhesive selected from the group consisting of a Carbopol^®, xanthan gums, and cellulose derivatives.

13. A pharmaceutical composition comprising :

i. dexmedetomidine at a concentration from about 0.0125% to about 0.125% w/v; ii. a surfactant selected from polyoxyl 40 stearate, cyclodextrin, gamma cyclodextrin and Captisol^® at a concentration from about 1% to about 15% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) at a concentration from

about 0.10% to about 1.25% w/v;

iv. sodium chloride at a concentration from about 0.025% to about 0.90% w/v; v. benzalkonium chloride at a concentration from about 0.007% to about 0.02% w/v;

vi. optionally an antioxidant at a concentration from about 0.005% to about

0.05% w/v;

vii. optionally a buffer at a concentration from about 1 millimolar to about 100 millimolar; and

wherein w/v denotes weight by volume, wherein pH of the composition is from about 4.0 to about 8.0 and wherein said pharmaceutical composition is effective for the treatment of glaucoma in a patient in need thereof.

The pharmaceutical composition of claim 13 wherein,

i. dexmedetomidine is at a concentration from about 0.060% to about 0.087% w/v;

ii. the surfactant is polyoxyl 40 stearate at a concentration of about 5.5% w/v; iii. carboxymethyl cellulose (1% = 2,500 centipoise) is at a concentration of about 0.80% w/v;

iv. sodium chloride is at a concentration of about 0.037%) w/v;

v. benzalkonium chloride is at a concentration of about 0.02% w/v; and vi. the optional antioxidant is at a concentration of about 0.015% w/v;

vii. the optional buffer is a phosphate buffer at a concentration from about 1 to about 5 millimolar,

wherein the pH of the composition is from about 6.0 to about 7.0.

15. The composition of claim 14 further comprising sodium lauryl sulfate at a concentration from about 0.01% to about 5.0% w/v.

16. The composition of claim 13 wherein;

i. dexmedetomidine is at a concentration from about 0.06% to 0.087% w/v; ii. the surfactant is Captisol^® at a concentration of about 5.5% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) is at a concentration from about 0.90% to about 1.2% w/v;

iv. sodium chloride is at a concentration of about 0.037%) w/v;

v. benzalkonium chloride is at a concentration of about 0.02% w/v;

vi. the optional antioxidant is at a concentration of about 0.015% w/v; and vii. the optional buffer is a phosphate buffer at a concentration from about 1 to about 5 millimolar;

wherein the pH of the composition is from about 6.0 to about 7.0.

17. The composition of claim 16 further comprising sodium lauryl sulfate at a concentration from about 0.1% to about 1.0 % w/v.

18. A pharmaceutical composition comprising:

i. dexmedetomidine at a concentration of about 0.080% w/v;

ii. Captisol^® at a concentration of about 5.5% w/v;

iii. carboxymethyl cellulose (1% = 2,500 centipoise) at a concentration from about 0.90% to about 1.2% w/v;

iv. sodium chloride at a concentration of about 0.037%) w/v;

vi. benzalkonium chloride at a concentration of about 0.02% w/v; and vii. optionally a phosphate buffer or a borate buffer at a concentration from about 1 millimolar to about 5 millimolar,

wherein w/v denotes weight by volume, wherein pH of the composition is from about 6.0 to 7.0 and wherein said pharmaceutical composition is effective for the treatment of glaucoma in a patient in need thereof.

19. A method of treating glaucoma in a patient in need thereof comprising administering to said patient the pharmaceutical composition of claim 1.

20. A method of treating posterior pole ocular neurodegenerative conditions in a patient in need thereof comprising administering to said patient the pharmaceutical composition of claim 1.