Development of Novel Oral Lipid-Based Amphotericin B Formulations for theAmphotericin B Formulations for the

Treatment of Systemic Fungal Infections and Visceral Leishmaniasisand Visceral Leishmaniasis

Principal Investigator:Principal Investigator:Dr. Kishor M. Wasan, Ph.D.Professor & Distinguished University ScholarCIHR/iCo Therapeutics Research Chair in pDrug Delivery for Neglected Global DiseasesFaculty of Pharmaceutical SciencesUniversity of British Columbia

Team Members: Dr. Ellen K. Wasan Dr. Sheila J. ThorntonDr Karen Bartlett

2010 McGill Annual Global Health ConferenceApril 26th 2010Dr. Karen Bartlett

Mr. Ian BellDr. John Clement

April 26 2010

AcknowledgmentsResearch Faculty and Staff

• Dr. Kristina Sachs-Barrable

Research Funding

• Canadian Institutes of Health R h (CIHR) O G• Dr. Sheila Thornton

• Dr. Carlos Leon• Dr. Pavel Gershkovich• Ms. Olena Sivak• Dr Cheri Barta

Research (CIHR) Operating Grants• AAPS Lipid-Based Drug Delivery

Award/Grant• iCo Therapeutics Inc• Dr. Cheri Barta

• Dr. Robin Stoodley • Mr. Mike Rosland • Ms. Verica Risovic

• iCo Therapeutics Inc.• CPDD/Gates Foundation• Gattefosse Canada

Current Graduate Students• Jennifer Locke• Stephen Lee

Website• http://www.wasanlab.ubc.ca

• Stephen Lee• Jackie Fleischer• Alexis Twiddy

Numerous Undergraduate StudentsDr. Tom Kanyok (Gates Foundation) Dr. Richard Tidwell (CPDD)

Expert Opinion on Drug Delivery; Published March 2009

A h i i BAmphotericin B

M f f l h fPolyene antifungal drug discovered in 1955

Mainstay of antifungal therapy for systemic mycosesAvailable in 4 formulations

Demonstrated EfficacyDemonstrated Efficacy

Fungal infectionsCandidiasis

Fungal infectionsCryptococcosis

Aspergillosis

Candidiasis

Oral cavity of an AIDS patient covered by white curdlike exudate containing numerous fungal organisms.

Overcoming Barriers to Treatment

Oral route of administrationDecreased toxicityDecreased toxicity

EfficaciousThermal stability at tropical temperaturesThermal stability at tropical temperatures

Stability – pHAfford bilitAffordability

Rat Model of Aspergillus Fumigatus

• Aspergillus fumigatus collected from a pool of clinical isolates of patients with disseminated aspergillosis (BC Centre for Di C t l)Disease Control)

• Rats were inoculated 48 hours before the beginning of g gtreatment to allow for aspergillosis to develop.

• Treatment groupsg p– iCo-009 – 10 mg/kg PO, bid – Abelcet (ABLC) 5mg/kg IV, qd

• Organ colony forming units (CFU) as an indicator of antifungal activity

• Renal toxicity was indirectly assessed by determining creatinine concentration in plasma

Data Overview - Rat model of Aspergillus FumigatusAspergillus Fumigatus

- Reduction in CFU by iCo-009 comparable to ABLCTreatment

GroupInfected tissues (CFU*/ml of homogenized tissues)

Brain Lungs Heart Liver Spleen Kidney

Non-treated control 3538** 74 101 308 1163 364Non treated control(n=9)

3538+/- 1810

74 +/-30

101+/- 63

308+/- 114

1163+/- 772

364+/- 119

ABLC 550 10 15 18 88 10(5 mg/kg, IV, qd)(n=4)

+/- 445 +/- 4 +/- 3 +/- 5 +/- 44 +/- 0

iCo-009 (10 mg/kg, PO, bid)

736+/- 186

51+/- 18

20+/- 4

180+/- 48

107+/- 32

44+/- 10( g g, , )

(n=7)/ 186 / 18 / 4 / 48 / 32 / 10

*CFU = colony forming units ** mean +/-SEM

-plasma galactomannan levels (an indicator of fungal load) were significantly reduced 80% by 48 hr

Data Overview - Plasma creatinine levels

- iCo-009 vs ABLC - no kidney toxicity at doses h i ti f l ti it

Treatment Group Creatinine (mg/dl)

showing anti-fungal activity

Blank** 0 hr 48 hr

Control (infected – non treated)(n=9)

0.4*+/- 0.1

0.5+/- 0.1

0.9+/- 0.2( )

ABLC (5 mg/kg, IV)(n=4)

0.3+/- 0.2

0.4+/- 0.1

0.5+/- 0.1

iCo-009 (10 mg/kg, PO) (n=7)

0.6+/- 0.2

0.6+/- 0.2

0.5+/- 0.1

*mean +/- SEM **Blank: plasma sample before fungal infection and before treatment"0" : plasma sample after 48 hrs of fungal infection and before treatment"48" : plasma sample after 96 hrs of fungal infection and after 48 hrs of treatment

Data Overview - Rat Model of Candida AlbicansAlbicans

• Candida Albicans (1-1.35 x 106 colony forming units (CFU)) was injected via the jugular vein & 48h later male rats (350-400 g) were treated

• Treatment groups– iCo-009, 5 or 10 mg/kg, PO bid

Abelcet (ABLC) 5 mg/kg IV qd– Abelcet (ABLC) 5 mg/kg IV qd– Physiological saline, IV qd

• Organs were harvested at sacrifice (day 3)

• Blood was drawn before inoculation (Blank), pre-dose (0 hour) and 48 hours after treatment for plasma creatinine analysis

• Efficacy determined by decrease in CFU

• Renal toxicity was assessed using plasma creatinineRenal toxicity was assessed using plasma creatinine

Data Overview - Rat model of C. albicans

Kidney [CFU/ml]Mean +/- SEM

60000 0

40000 0

50000.0

60000.0

CFU = colony forming unit

30608.030000.0

40000.0

CFU/

ml * p<0.05

7830

1811.4 174

10000.0

20000.0 ***

0.0Control (n=11) iCo-009 [5mg/kg,

PO] (n=5)iCo-009 [10mg/kg,

PO] (n=7)ABLC [5mg/kg, IV]

(n=5)

Treatment

Plasma creatinine levels in animals infected with C. albicanswith C. albicans

Treatment Group Creatinine (mg/dl)

Blank** 0 hr 48 hr

Control (infected – non treated)(n=9)

0.5*+/- 0.3

0.5+/- 0.3

1.0+/- 0.5

iCo-009 (10 mg/kg, PO)(n=6)

0.6+/- 0.5

0.5+/- 0.5

0.5+/- 0.2

ABLC (5 mg/kg, IV)(n=4)

0.3+/- 0.3

0.4+/- 0.2

0.5+/- 0.2

*mean +/_ SEM **Blank: plasma sample before fungal infection and before treatment"0" : plasma sample after 48 hrs of fungal infection and before treatment"48" : plasma sample after 96 hrs of fungal infection and after 48 hrs of treatment

Candidiasis Infection of Kidney - Gross Morphology of a Treated & Untreated Kidney o a eated & U t eated d ey

How can the poorest of the poor h i U i i Di i ?share in University Discoveries?

Need mechanisms for encouraging and fundingNeed mechanisms for encouraging and fundingexpensive research for Neglected Diseases.Must creatively protect early discoveriesMust creatively protect early discoveries.Delivery!!!!

Journal of Pharmaceutical Sciences, Published On-line August 7th 2008

Neglected Global Diseases Initiative (NGDI) – UBC: Providing Practical Solutions to Practical Problems

Mission Statement Mission Statement To develop drugs for Neglected Global Diseases and to ensure delivery to

those in need

Working Group MembersWorking Group MembersDr. Charles LarsonDr. Charles Larson www.ngdiwww.ngdi--ubc.caubc.caJennifer Choi Jennifer Choi Dr. Brett Finlay Dr. Brett Finlay Dr. Jennifer LoveDr. Jennifer LoveDr. Rebecca Goulding Dr. Rebecca Goulding Dr Mike GretesDr Mike Gretes

Social SciencesTechnology & MedicinesHealth & DiseaseCross-cutting

Themes

PillarsSocial SciencesTechnology &

MedicinesHealth & DiseaseCross-cutting Themes

Pillars

Dr. Mike Gretes Dr. Mike Gretes Dr. Robert Hancock Dr. Robert Hancock VP Dr. John Hepburn VP Dr. John Hepburn Kevin Hooi Kevin Hooi Dr. Jerry Spiegel Dr. Jerry Spiegel UILO

University IndustryIntellectual

Liu Institute for Global IssuesSocial Policy

Centre for Sustainability and Social Innovation (CSSI), Liu Institute for

Global Issues

Centre for Microbial Diseases and Immunity

Research (CMDR)

Pharmaceutical Sciences; Medicine; Science

Drug Discovery/Development

UILO University IndustryIntellectual

Liu Institute for Global IssuesSocial Policy

Centre for Sustainability and Social Innovation (CSSI), Liu Institute for

Global Issues

Centre for Microbial Diseases and Immunity

Research (CMDR)

Pharmaceutical Sciences; Medicine; Science

Drug Discovery/Development

Mr. Terry Kellam Mr. Terry Kellam Mr. Angus Livingstone Mr. Angus Livingstone Dr. James Tansey Dr. James Tansey Dr. Kishor WasanDr. Kishor Wasan

UBC-UAEM, UBC FacultyUBC-UAEM, UILOUBC-UAEM, UBC FacultyEducation

CSSI, W. Maurice Young Centre for Applied Ethics,

UILO University Industry Liaison Office (UILO),

Intellectual Property/Law

UBC-UAEM, UBC FacultyUBC-UAEM, UILOUBC-UAEM, UBC FacultyEducation

CSSI, W. Maurice Young Centre for Applied Ethics,

UILO University Industry Liaison Office (UILO),

Intellectual Property/Law

Leishmaniasis – Current Disease Status

• Spectrum of disease which affectsSpectrum of disease which affects approximately 12 million people in 88 countries– About 2 million new cases annually– 75% involve cutaneous leishmaniasis,

with the remainder being visceral leishmaniasis (VL)

• Mortality rate for VL is close to 100%

Source: WHO/TDR/Marsden

• Mortality rate for VL is close to 100% in the absence of treatment

“Real World” EfficacyReal World Efficacy

illi d (WHO)2 million new cases reported every year (WHO)Visceral leishmaniasis causes ~59 000 deaths annually

C T f VLCurrent Treatments of VL

Wasan & Thornton 2009

Implications for Developing CountriesImplications for Developing Countries

Parenteral administration results in:

Loss of incomeIncreased cost of

administrationIncreased risk of side

effectseffectsDecreased availability of

treatment

Published NEJM Feb 2010

Published Journal of Infectious Diseases Aug 2009

Data Overview - Visceral Leishmania (VL)

• Mice were infected i.v. with 1×107 Leishmania donovani

T t t b i D 7 t i f ti• Treatment begins on Day 7 post infection

• Oral Amp B administered bid for 5 consecutive days p y

• Mice were sacrificed Day 14 post infection

• Livers were then weighed and impression smears prepared • The number of Leishmania amastigotes per liver cell nuclei wasThe number of Leishmania amastigotes per liver cell nuclei was

determined microscopically• studies performed in independent laboratory

t f th C ti f P iti D D l t G t– part of the Consortium for Parasitic Drug Development, a Gates Foundation funded organization

Data Overview - Antiparasitic Activity

3097.4

3500

Miltefosine - 3mg/kg PO, qd x 5 dAmbisome - 2 mg/kg iv, onceiCo-009 - 10 & 20 mg/kg PO, bid x 5 d

2951.2

2500

3000

ts)*

1550

2000

man

-Donovan

Un

i

1000

1500

LD

U (

Leis

hm

0 14.7 5.10

500

Untreated control Vehicle controlPO BID

Miltefosine PO QD Ambisome singledose IV

iCo-009 (10mg/kg, PO BID)

iCo-009 (20mg/kg, PO BID)

Efficacy of iCo-009 in Murine VL ModelModel

LDU

Vehicle iCo 009 2 5 iCo 009 5 iCo 009 10 AmBisome 2Vehicle, PO BID

iCo-009, 2.5mg/kg BID

iCo-009, 5 mg/kg BID

iCo-009, 10 mg/kg BID

AmBisome, 2 mg/kg IV bolus

J. Infect. Dis. (2009) 200:357-360.

VL-infected Hamster Study (Acute Results)

Li [LDU]

3000 03500.04000.0

Liver [LDU]Mean +/- SD

1500.02000.02500.03000.0

*0.0

500.01000.0

Untreated AmBisome 2 Miltefosine 30 iCo-009 10

** *Untreated

Controls (n=3)AmBisome 2

mg/kg iv (n=4)Miltefosine 30 mg/kg PO QD

(n=4)

iCo 009 10 mg/kg PO bid

(n=4)Treatment

* P<0.05 vs. Untreated Controls

Kayser et al., IJP 2003

Mechanisms of Enhanced Drug AbsorptionAbsorption

• Solubility Issues• Solubility Issues• Dissolution Rate Limited Issues• Passive Diffusion/Active Transport• Passive Diffusion/Active Transport • Drug Efflux Transporters

H t bilit• pH stability• Lymphatic Transport

I i l W ll M h• Intestinal Wall Macrophages • Peyer’s Patches

Oral Amphotericin BOral Amphotericin BFormulation Technology

• Proprietary blend of mono- and di-glycerides (FDA GRAS approved)(FDA GRAS approved)

• Solubilized AmpB Formulations

N i /di i• Nanosuspensions/dispersions

• Affordable lipid excipients

E f f l l• Ease of formulation scale-up

• Formulation Stability over 7 days

• Drug Stability at 37˚C over 21days

Advantages of OralAdvantages of Oral Amphotericin B Formulation

• Affordable A• Easy to store• Easy to administerEasy to administer• Lack of kidney toxicity• Lack of Infusion related side effects• Lack of Infusion-related side effects

(i.e. fever, chills etc.)• Lack of liver and GI toxicityLack of liver and GI toxicity

Advantages of OralAdvantages of Oral Amphotericin B Formulation

• Treating patients with drug-resistant strains (decrease T g p g (hospitalization and eliminate IV AmpB Therapy)

F l bl O l F d l A ( l F• First available Oral Fungicidal Agent (only Fungistatic Agents, Diflucan® from Pfizer)

AcknowledgmentsResearch Faculty and Staff

• Dr. Kristina Sachs-Barrable

Research Funding

• Canadian Institutes of Health R h (CIHR) O G• Dr. Sheila Thornton

• Dr. Carlos Leon• Dr. Pavel Gershkovich• Ms. Olena Sivak• Dr Cheri Barta

Research (CIHR) Operating Grants• AAPS Lipid-Based Drug Delivery

Award/Grant• iCo Therapeutics Inc• Dr. Cheri Barta

• Dr. Robin Stoodley • Mr. Mike Rosland • Ms. Verica Risovic

• iCo Therapeutics Inc.• CPDD/Gates Foundation• Gattefosse Canada

Current Graduate Students• Jennifer Locke• Stephen Lee

Website• http://www.wasanlab.ubc.ca

• Stephen Lee• Jackie Fleischer• Alexis Twiddy

Numerous Undergraduate StudentsDr. Tom Kanyok (Gates Foundation) Dr. Richard Tidwell (CPDD)