NZ711298B2 - Targeted gastrointestinal tract delivery of probiotic organisms and/or therapeutic agents - Google Patents

Abstract

Provided is an oral delivery system for the targeted delivery of therapeutic agents to the ileum and/or right colon of a subject. The oral delivery system is suitable for various indications including the treatment of Clostridium difficile infections. In a particular embodiment the system is a capsule-in-capsule system comprising a biodegradable first capsule contained within a biodegradable second capsule, wherein: the first capsule contains a first probiotic formulation and has a coating that solubilizes in a pH of less than 6.9; and the second capsule contains the first capsule and a second probiotic formulation and has a coating that solubilizes in a pH of about 7 to 8.

Description

TARGETED GASTROINTESTINAL TRACT DELIVERY OF PROBIOTIC ORGANISMS AND/OR THERAPEUTIC AGENTS CROSS REFERENCE TO RELATED APPLICATIONS The present ation and invention claims priority to US. Provisional Application No. 61/781,810 filed on March 14, 2013 and US. Provisional Application No. 61/897,378 filed on October 30, 2013, the contents of which are incorporated by reference herein for all purposes.

FIELD OF THE INVENTION The present invention relates to the development of platform technology for targeted, controlled delivery of oral enhanced probiotics for various indications, including for example the active and prophylaxis treatment of Clostridium dl'fi‘zcile Infection as well as Metabolic me and type 2 diabetes.

BACKGROUND OF THE ION The following includes information that may be useful in tanding the present inventions. It is not an admission that any of the information provided herein is prior art, or relevant, to the presently described or claimed inventions, or that any publication or nt that is specifically or implicitly referenced is prior art.

Recent studies have highlighted the importance of the human microbiome in health and disease. However, for the most part the mechanisms by which the microbiome mediates disease, or protection from it, remain poorly understood. Hajishengallis and gues have been developing the Keystone-pathogen hypothesis, which ghts the ant ctions between flora normally found in healthy humans, diseases associated with alterations in these flora, and the role of the host inflammatory system in the transition between health and a disease state (1). The keystone-pathogen hypothesis holds that certain low-abundance microbial ens can orchestrate inflammatory es, by remodeling a normally benign microbiota into a dysbiotic one. Hajishengallis and colleagues critically assess the available literature that supports the keystone hypothesis, which may provide a novel conceptual basis for the development of targeted diagnostics and treatments for complex dysbiotic diseases.

This work provides an elementary ound tanding for use of specific organisms red to specific sites in the Gastro-intestinal tract, which is the subject of the instant invention.

As currently understood, probiotics are live non-toxic microbial food supplements that can beneficially affect a host by improving the host’s intestinal microbial balance without causing disease. e probiotic organisms may be altered by antibiotic treatments or for other reasons, they do not permanently colonize in the body. It is therefore important that they be ingested regularly for their health-promoting effects to persist. After ingestion, probiotics typically adhere to a tissue of the host, such as the wall of the intestine or the vagina. Once attached, the desirable ia are capable of multiplying and colonizing, thereby enhancing optimal ora balance.

They are used to e healthy microflora (‘good ia “or commensals) e (good or eubiosis) in the lower GI tract and healthy pH balance (yeast fiJngus) in the oral cavity, large intestine and vaginal tract and minimize microbial imbalance or dysbiosis. Probiotics characteristics are the following: (1) from human origin; (2) stable and viable, gastric and bile acid resistant; (3) effectively adhere to and colonizing at the site of action; (4) compete with pathogens for adhesion sites; and (5) produce pathogen tory substances, e.g. bacteriocidins and organic acids.

Probiotics provide: (1) normalization of flora (e.g., suppress PPMs, provide for intestinal mucosal integrity, tion of bowel movement, IBS, etc.); (2) Immunomodulation (e.g., strengthen ty, alleviate food allergy symptoms, control of IBD, etc.); (3) Metabolic effects (e.g., Production of vitamins to improve digestion, minimize lactose intolerance, lower cholesterol, promote bile acid deconjugates, etc.) and many other benefits. Probiotics are sometimes combined with prebiotics (combination is called Symbiotic) which are range of range of non- digestible dietary supplements, which modify the balance of the intestinal micro flora, stimulating the growth and / or activity of beneficial rganisms and suppressing ially deleterious microorganisms. The supplements include oligosaccharides (fructo-oligosaccharides, galacto - oligosaccharides); Inulin, Lactulose, Lactitol and a few select bacterial strains that produce bifidogenic nutrients. In ular, prebiotics 2014/027228 promote the proliferation of Bifidobacteria in the colon and also promote the proliferation of Lactobacilli in the small intestine to a certain extent.

There are many nutritional tics products currently available and are marketed as dietary supplements with very soft DSHEA type “support health” benefit claims.

Probiotic products are marketed in all different types of dosage forms, by way of example liquids, es, enteric coated tablets and matrix sustained release formulations for oral administration. They use different mix of bacteria and sometimes are enteric coated and of the type which are conventionally released into duodenal target and would not survive transit to reach the potential target organs, e.g., colon. The normal pH profile of the GI tract changes (up and down) from the stomach to the colon, e. g. the pH of the h, duodenum, ileum and colon is in the range of 1-4, 5.5-6, 7.3-8.0 and 5.5-6.5, respectively. In some diseases conditions the pH of the GI tract may be modified, e. g. pH of the ileum in normal is 7.5 to 8.2, while pH of the ileum in Metabolic Syndrome, Type 2 es and Obese subjects is 7.3 to 7.5, as ered using the SmartPill to examine distal intestinal pH values in health and diseases.

To date it is assumed that there are no published reports of any kind that support any specific US FDA approved clinical efficacy or safety claims, nor delivery to any specific area or specific s of the probiotics. All of the current evidence is generated from different systems and has not been utilized for a practical treatment regimen that is directed toward flora replacement strategy prior to our foundation discoveries in Rouxmenm‘f gastric bypass {RYGB) patients (3). Likewise, no product currently exists that specifically delivers the tic sm(s) at the target specific pH of the colon at pH 5.5-6.2. Most of the enteric products release the probiotic to the um at pH 5.5-6.2 and e of degradation in the proximal intestine, organisms released may never actually reach the ileum or the right sided colon. Accordingly, it would be advantageous to develop a platform technology for controlled delivery ation of oral enhanced probiotics that specifically target to release in the pH environment of the ileum and the colon, for treatment / cure of various diseases (pill in a pill concept). These include the active and prophylaxis treatment for Clostrz'dz'um dz'fi‘zcz'le infection, and possible treatments of metabolic me in diabetes.

SUMMARY OF THE INVENTION In a first aspect, the invention provides one or more species of microencapsulated live probiotic organisms that have a biphasic release profile in a subject. The one or more species of microencapsulated live probiotic sms provided herein may be in the form of a ation (e.g. in the form of a tablet, capsule, or the like), wherein the formulation comprises one, or more than one species of bacteria that are normally present in the intestine of a t.

In n preferred embodiments, this biphasic release profile has a release profile in a subject such that living organisms are first released in a subject at pH values between about 7.0 and 8.0, and secondly to the first release, living organisms are uently released at pH values of between about 5.5 and 6.0.

In another aspect, the invention provides microencapsulated live tic organisms that have a release profile that targets replacement or revision of one or more species of live bacteria at a pre-determined location within the gastrointestinal tract of a . As will be described in greater detail herein below certain embodiments are provided wherein the pre-determined location within the gastrointestinal tract is the ileum or colon and other embodiments wherein the formulations provided have a pH dependent preferential release and site specific release of a probiotic organism in the intestinal tract of a mammal. Said organism replacements may be made cally to modify the course of metabolic syndrome associated diseases such as obesity, type 2 diabetes, or the like. Said organism replacements may also be made in other preferred embodiments of the invention to repair intestinal dysbiosis associated diseases, such as, Antibiotic associated diarrhea (AAD), z'dz'um dz'fi‘zcz'le associated diarrhea (CDAD), metabolic syndrome, etc. Each of these conditions will require specific iome replacements or restorations as will be disclosed herein.

In one preferred embodiment provided herein, the microencapsulated live probiotic organisms having a release profile in which one or more species of live probiotic organisms is released in the into the ileum of a subject in an area having a pH of from about 7 to 8. 2014/027228 In another aspect, the probiotic organism provided in certain embodiments is a mixture of bacterial genera in the amounts that are reflective of the mixture of strains derived from the ileum of a normal human, in amounts that replace these genera reflective of normal intestinal e. Typically, the number of said organisms released is more than 105 and less than 1012, where the probiotic organism is a mixture of ial genera that is reflective of the mixture of strains derived from the stool of a normal human, but it is appreciated that these s are not ng and that lower of higher amounts of any live organism that is administered may be lower or higher than these amounts.

In another aspect, compositions and methods are provided to ameliorate the nce of Clostridium dzfi’z‘cz’le in a subject ing from such an imbalance. Accordingly, in certain embodiments, one or more species of microencapsulated live probiotic organisms haVing a biphasic release profile results in a release of these live probiotic organisms into the distal segments of the gastrointestinal tract, including the ileum and colon of a subject, in order to rate the imbalance of Clostridium dz'fi‘zcz'le in a subject suffering from such an imbalance.

In another aspect, formulations are provided herein for the protection of the live probiotic sms from the digestive actions of the stomach, duodenum, and jejunum of the intestine. Accordingly, some embodiments provide one or more species of microencapsulated live probiotic organisms as a formulation that provides protection of the live probiotic organisms from the digestive actions of the stomach, duodenum, and jejunum of the intestine, such that the desired number of organisms is administered to the ileum of a subject.

In some embodiments, ations provided herein comprise an encapsulated live probiotic from which one or more tic bacteria are dispersed, the encapsulated probiotic comprising a coating comprising “polymers”. In certain embodiments, a live bacterial suspension including species from one or both of the s Lactobacillus and Bz'fidobacterium is provided. In ative embodiments, live bacterial suspensions including species from one or both of the genus’s Lactobacillus and Bifidobacterium and further comprising the organism Faecalz’bacterz’um prausm'tzz'z' are provided. In yet another ative embodiment, live bacterial suspensions including species from one or both of the genus’s Lactobacillus and Bzfidobacterz'um and r sing the sm Bacteroz'des thetaiotaomz’cron are provided.

In yet another aspect, one or more species of microencapsulated live tic organisms are provided in which the microencapsulated live probiotic organisms have a three phase release . Accordingly, in a fundamental embodiment of this aspect of the invention, one or more species of ncapsulated live probiotic organisms are provided wherein the microencapsulated live probiotic organisms have a three phase release profile in a subject in which living organisms are released in a subject i) at pH values between about 5.5 — 6.2 such that the live probiotic organisms are released in the duodenum, ii) at pH values between about 7.2 — 7.5 such that the live probiotic organisms are released in the ileum, and iii) at pH values between about 5.6 — 6.2 such that the live tic organisms are released in the colon.

In certain preferred variations of embodiments provided above, it is fiarther desirable that none of the bacterial organisms are released in the small ine at pH values below 6.9 or above 8.1. Thus, the area of release will be within the intestinal tract that includes a high level of Peyer’s Patches, that being the ileum.

In another variation of the filndamental embodiment provided above, there i) is an outer layer of microencapsulated probiotic organisms with release characteristics between pH values of 7.0 to 8.0, and ii) a protected inner core of microencapsulated probiotic organisms that are released at pH values below pH of 6.9. This will allow the probiotic to be ed in the ileum and colon of the subject.

In certain embodiments, one or more species of microencapsulated live probiotic organisms are provided where the organism cally stimulates L-cell sion of proteins, hormones or biomarkers of L-cell actions therefrom. In additional embodiments, one or more species of microencapsulated live probiotic organisms are provided wherein the probiotic sms specifically metabolize bile acids in the distal intestine of the mammal, and where the formulation has beneficial actions on cholesterol and triglyceride concentrations in a mammal.

In still another aspect of the ion, methods of treatment of a subject are ed (e.g. a mammal or human). ingly, in certain embodiments a method of treating a Clostrz'dz'um dz'fi‘zcz'le associated intestinal disorder in a subject is provided in which said method comprises administering a formulation claimed or otherwise provided herein in an amount ient to ate the disorder being treated in a subject. A z'dz'um cz'le associated disorder d by the formulation and methods provided herein may be associated with one or more of a Clostrz'dz'um dz'fi‘zcz'le infection, an imbalance of Clostridium dz'fiicz'le in the ileum or colon of said subject, diarrhea, inflammation, colitis fever, or the like. Administration of the formulations by methods provided herein alleviates one or more of the ing signs and symptoms of infection with Clostrz'dz'um dzfi’z‘cz’le. It is preferable that such treatment results in the prophylaxis or prevention of a Clostrz'dz'um dz'fi‘zcz'le infection.

In another aspect, kits comprising one or more species of encapsulated rganisms and formulations of the same are provided herein. Accordingly, some embodiments of the invention are directed to a kit comprising encapsulated rganisms and formulations claimed or otherwise provided herein in the form of a tablet, pill, capsule or sachet of microgranules in combination with instructions for administration of the formulation to a subject for the treatment of a disorder. Certain preferred embodiments of the kit are designed for the ent of a Clostrz'dz'um dz'fi‘zcz'le associated disorder in a subject suffering from such a disorder.

In yet another aspect, kits containing one or more species of encapsulated microorganisms and formulations of same are provided with instructions to patients in need of the procedure termed “fecal transplant” wherein the microgranules of the present invention and formulations are provided herein in the form of a tablet, pill, or capsule in combination with instructions for administration of the formulation to a subject in need of a fecal transplant. Certain preferred ments of said kit are designed for the treatment of a z'dz'um dz'fi‘zcz'le associated disorder in a subject suffering from such a disorder.

Microencapsulated live probiotic sms and formulations thereof are provided herein in various dosage forms, and they can be co-administered with drugs, foods, nutrients, vitamins, other beneficial substances, prebiotics, and other therapeutic agents such as pH ulated glucose, lipids or proteins that release in the distal small intestine at pH values between 7.0 and 8.0 in an amount sufficient to alleviate said disorder in a subject. Preferably, at least two coating are used to cover a tablet or capsule like form comprising the probiotic organism, wherein the outside coating is degraded in a pH environment of 5 to 6 and the inside coating is degraded in a pH nment of about 7 thereby dropping the probiotics in the ileum area and in close proximity to the Peyer’s Patches.

In certain embodiments, ncapsulated live probiotic organisms and formulations thereof are administered in conjunction with one or more antibiotic. The dosage formulation is designed in these ments to completely te the antibiotic from the bacteria, and testing is conducted to verify complete separation on a long term basis. le antibiotics include, but are not limited to, vancomycin, metronidazole, gentamicin, colistin, f1daxomicin, telavancin, oritavancin, dalbavancin, daptomycin. An exemplary embodiment is ed to one or more species of ncapsulated live probiotic organisms claimed or ise provided herein in a dosage of between 105 and 1012 CPU, wherein the dosage unit of the formulation contains vancomycin at a dose of between about 125 mg to about 4000 mg, wherein the antibiotics released from each dosage unit formulation at between about pH 1.0 to about pH 6.0. In certain embodiments, ncapsulated live probiotic organisms and ations thereof are co-administered with vancomycin in an effective amount for the beneficial treatment of Clostridium dz'fi‘zcz'le infection or complications thereof.

In still another aspect, the microencapsulated live probiotic organisms claimed or otherwise provided herein are used for the treatment of other disorders. In non- ng but preferred embodiments described herein, antibiotics are not included in the formulation.

One embodiment is directed to a method of ng an obesity-associated intestinal disorder in a subject, where the method comprises administering a probiotic formulation targeted to the ileum and right colon which is claimed or otherwise provided herein an amount sufficient to alleviate the disorder in said subject. Another embodiment is directed to a method of treating type 2 diabetes associated metabolic syndrome, where the method comprises administering a probiotic formulation targeted to the ileum and right colon which is claimed or otherwise provided herein an amount sufficient to alleviate the disorder in said subject. In a variation of this embodiment, the organism(s) being used are capable of signaling the release of GLP- l, PYY, GLP-2 or other beneficial peptides from the L-cell target site in the intestine, whereby the disease or condition or metabolic syndrome is modified beneficially. An e of this ation is the treatment of type 2 diabetes with said probiotic formulation in combination with an ileal brake hormone releasing substance active at the ileal brake, where both active moieties act to stimulate L-cell hormone release and to revise signaling of hormones. Replacement of numbers and specific species of probiotic organisms in targeted ileum and colon produces homeostatic and beneficial regulation of L-cell hormone release from the ileum and right sided colon. These novel approaches to treatment are disclosed herein in specific es.

Another preferred ment includes treatment with an anti-diabetic drug, an ileal brake hormone releasing substance and a probiotic organism, wherein said probiotic organism replacement or revision is directed to one or more species of microencapsulated live tic sms claimed or otherwise provided herein in a dosage of between 105 and 1012 CPU, wherein the dosage unit of the formulation contains metformin at a dose of between about 250 mg to about 1000 mg, wherein the metformin released is from each dosage unit formulation at between about pH 1.0 to about pH 6.0. In certain embodiments, microencapsulated live probiotic organisms and ations thereof are co-administered with metformin in an effective amount and are co-administered with about 5.0 gm to about 10.0 grams of microgranules of dextrose and nutritional substances, as disclosed in 0268795, said formulation encapsulated for release at intestinal pH between 7.0 and 7.5, said combination disclosed herein known to be beneficial in the treatment of Type 2 diabetes, metabolic syndromes or complications thereof Another embodiment is ed to one or more species of ncapsulated live probiotic sms claimed or otherwise provided herein in a dosage of between 105 and 1012 CPU, n the dosage unit of the formulation contains statin at a dose of between about 10 mg to about 80 mg, n the statin released is from each dosage unit formulation at between about pH 1.0 to about pH 6.0. In certain embodiments, microencapsulated live tic organisms and formulations f are co-administered with atorvastatin in an effective amount and are co- administered with about 5.0 grams to about 10.0 grams of microgranules of dextrose and ional substances, as disclosed in U820110268795, said formulation ulated for release at intestinal pH between 7.0 and 7.5, said combination disclosed herein known to be beneficial in the treatment of Type 2 diabetes, hyperlipidemia, metabolic syndrome or complications thereof.

In certain preferred ments, microencapsulated live probiotic organisms and ations thereof are inistered with Tumor Necrosis Factor (TNF) antagonist in an effective amount encapsulated for release at intestinal pH between 7.0 and 7.5, said combination disclosed herein known to be cial in the treatment of Crohn’s disease, Ulcerative colitis, inflammatory bowel disease or the like, or complications thereof.

Another embodiment is directed to a method of treating irritable bowel diseases associated with dysbiosis, where the method comprises administering a probiotic formulation targeted to the ileum and right colon which is claimed or otherwise provided herein an amount sufficient to alleviate the er in said subject. In certain embodiments the microencapsulated live tic organisms and formulations thereof are co-administered with drug treatments approved for treatment of irritable bowel diseases, such as linaclotide. Non-limiting examples of irritable bowel diseases and treatments thereof are contained within these embodiments.

Yet another aspect of the present invention is an oral delivery system that delivers a probiotic formulation targeted to the ileum and right colon of a subject; the system comprising: a core comprising a tic formulation; and a coating which encapsulates the probiotic formulation, which is substantially insoluble at a pH of less than a range of between about 7.0 to about 8.0 and soluble in the pH range of about 7.0 to about 8.0, and wherein the tic formulation is not released until the pH is about 7 and there is essentially no loss of the probiotic formulation through the digestive tract until the delivery systems reaches the ileum.

Preferably, the coating is comprised of one or more compositions selected from the group consisting of l-lactide-co-glycolide, an (Chi) stabilized with PVA (poly-vinylic l), a lipid, an te, carboxymethylethylcellulose (CMEC), cellulose acetate trimellitiate (CAT), ypropylmethyl cellulose phthalate (HPMCP), hydroxypropylmethyl cellulose, ethyl cellulose, color con, food glaze and mixtures of hydroxypropylmethyl cellulose and ethyl cellulose, polyvinyl acetate phthalate (PVAP), cellulose acetate phthalate (CAP), shellac, copolymers of methacrylic acid and ethyl acrylate, and copolymers of methacrylic acid and ethyl acrylate to which a monomer of methylacrylate has been added during polymerization, In yet another aspect, the present invention provides for an oral delivery system for delivering a probiotic ation targeted to the ileum and proximal colon of a t; the system sing: a core comprising a probiotic formulation wherein the probiotic formulation is included in a biodegradable first capsule that is coated with a first c coating that encapsulates the first capsule containing the tic formulation, and wherein the first enteric coating solubilizes in a pH of about 6.2 to about 6.5; and a second capsule sized to include the coated first capsule, wherein the second capsule is fabricated of a biodegradable material and n the second capsule is coated with a second enteric coating that solubilizes in a pH of about 7 to 8, wherein the second capsule releases the first capsule in the ileum and once released the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the release of the desirable Importantly, the second enteric coating is substantially insoluble at a pH of less than a range of between about 7.0 to about 8.0 and soluble in the pH range of about 7.0 to about 8.0. The first and second enteric coatings are comprised of one or more compositions selected from the group consisting of copolymers of methacrylic acid and ethyl acrylate, and copolymers of methacrylic acid and ethyl acrylate to which a monomer of methylacrylate has been added during polymerization. Notably, the second capsule releases the first capsule in the ileum and once ed the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the release of the tic formulation.

The tic formulation comprises at least one species of bacteria, preferably from 1 to 30, and more preferably from about 10 to 25 ent species or s, that are normally present in a pre-determined location within the gastrointestinal tract of a subject and preferably the pre-determined location is the ileum or colon. The s of bacteria may be different or just include different strains. The probiotic formulation comprises a mixture of bacterial genera that is reflective of the mixture of strains derived from the ileum of a normal human, and the number of said organisms released is more than 106 and less than 1012. Preferably, the release of the probiotic formulation is in the distal segments of the intestinal tract including the ileum and colon of a subject and to ameliorate the imbalance of Clostridium dz'fi‘zcz'le in a subject suffering from such an imbalance. An effective probiotic ation comprises a live bacterial suspension selected from the genus Lactobacillus and Bz'fidobacterz'um. Such a formulation may fiarther comprise the organism Faecalibacterium prausnz'tzz'z'.

The probiotic formulation can be combined with drugs, acetaminophen, foods, nutrients, Vitamins, beneficial substances, prebiotics, pH encapsulated glucose, lipids or proteins that release in combination with the probiotics or in a pH of from about 1 to 6 and before the release of the probiotics. Also the probiotic formulation may also be co-administered with an otic selected from the group ting of ycin, idazole, gentamicin, colistin, fidaxomicin, telavancin, oritavancin, dalbavancin and daptomycin. Still further the tic formulation may be combined with an ileal brake hormone releasing substance active at the ileal brake to stimulate L-cell hormone release and to revise signaling of hormones.

The probiotic formulation may be used to modify the course of lic syndrome associated diseases selected from the group consisting of obesity and type 2 diabetes; or to repair intestinal dysbiosis associated diseases selected from the group consisting of Antibiotic associated diarrhea (AAD), Clostrz'dz'um dz'fi‘zcz'le associated diarrhea (CDAD) and metabolic syndrome.

The probiotic formulation may also be combined with an anti-diabetic drug, such as metformin; a statin, such as statin; or an anti-inflammatory, such as a Tumor Necrosis Factor (TNF) antagonist.

Another aspect of the present invention es for a capsule-in-capsule oral delivery system that delivers ble tics or therapeutic agents to the ileum and/or proximal colon, the system comprising: a first capsule containing the desirable probiotics or therapeutic agents, wherein the first capsule is fabricated of a biodegradable material and wherein the first capsule is coated with a first c coating that solubilizes in a pH of about 6.2 to about 6.5; and a second capsule being of a size that can include within its dimensions the coated first capsule, wherein the second capsule is ated of a biodegradable material and wherein the second capsule is coated with a second enteric coating that solubilizes in a pH of about 7 to 8, wherein the second capsule releases the first capsule in the ileum and once ed the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the e of the desirable probiotics or therapeutic agents.

Notably, the second e may further comprise desirable probiotics for release in the ileum. Importantly, the desirable probiotics or therapeutic agents within the capsule system are delivered to the ileum and/or proximal colon without e of such probiotics or therapeutic agents in the proximal areas of the gastrointestinal tract positioned before the ileum and/or proximal colon. The present system provides for at least 90% of the ble probiotics or therapeutic agents to reach the ileum and/or right colon, more preferably at least 95%, and most preferably at least 97%.

The first and second enteric coatings of the capsule-in-capsule oral delivery system are preferably selected from the group consisting of copolymers of methacrylic acid and ethyl te, and copolymers of methacrylic acid, methyl acrylate and methyl methacrylate.

The capsule-in-capsule oral delivery system provide for a system wherein the n the outside and firstly exposed second capsule releases the first capsule in the ileum and once released the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the release of the desirable tics or therapeutic agents. If the content is desirable probiotics then such probiotics comprise at least one to 30 species of bacteria, more ably from about 10 to 25 different species or strains of such species that are normally present in a pre-determined location within the gastrointestinal tract of a subject and preferable the pre-determined location is the ileum or colon. The desirable probiotics may comprise a mixture of ial genera that is reflective of the mixture of strains derived from the ileum of a normal human, and the number of said organisms released is more than 105 and less than 1012 and preferably the release is in the distal segments of the gastrointestinal tract ing the ileum and colon of a subject and to ameliorate the imbalance of Clostridium dz'fi‘zcz'le in a subject suffering from such an imbalance. Such probiotics comprise a live bacterial suspension selected from the genus Lactobacillus and Bz'fidobacterium and may filrther the organism Faecalz’bacterz’um prausm'tzz'z'.

A very effective combination of coating for the capsule-in-capsule oral delivery system comprises a the first e is coated (first enteric coating) with about 10 mg/cm2 of Eudragit EPO and the second capsule is coated (second enteric g) with about 5 mg/cm2 of Eudragit LlOO/SlOO, 75/25 mix wherein the es are fabricated from hydroxypropylmethyl cellulose.

Still another aspect of the present invention provides for a method of treating the onset of a intestinal disorder, the method comprising administering to a subject in need of such treatment in a pharmaceutically effective amount of an oral formulation comprising: a first capsule containing desirable probiotics having beneficial effects on a gastrointestinal disorder, wherein the first capsule is fabricated of a biodegradable material and wherein the first e is coated with a first enteric g that solubilizes in a pH of about 6.2 to about 6.5; and a second e being of a size that can include within its dimensions the coated first capsule, n the second capsule is ated of a biodegradable material and wherein the second capsule is coated with a second enteric coating that solubilizes in a pH of about 7 to 8, wherein the second capsule releases the first capsule in the ileum and once ed the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the release of the desirable probiotics.

The gastrointestinal disorder includes a z'dz'um dz'fi‘zcz'le disorder that is associated with one or more of a Clostrz'dz'um dz'fi‘zcz'le infection, an imbalance of Clostridium dz'fi‘zcz'le in the ileum or colon of said subject, diarrhea, inflammation, colitis fever, and wherein the oral formulation is in an amount sufficient to alleviate the gastrointestinal disorder in the subject and comprises a live bacterial sion selected from the genus Lactobacillus and Bz'fidobacterium.

In a still further aspect, the present invention provides for the use of an oral formulation for preparing a ment for the treatment of gastrointestinal disorder wherein the oral formulation comprises: a first capsule containing a desirable bacteria effective against the gastrointestinal disorder, wherein the first capsule is fabricated of a biodegradable material and wherein the first e is coated with an enteric coating that solubilizes in a pH of about 6.2 to about 6.5; and a second capsule being of a size that can include within its dimensions the coated first capsule, wherein the second e is fabricated of a biodegradable material and wherein the second capsule is coated with an enteric coating that solubilizes in a pH of about 7 to 8, n the second capsule releases the first capsule in the ileum and once released the first capsule is solubilized in the proximal colon at a pH of about 6.2 to about 6.5 with the release of the desirable bacteria.

Another aspect of the present invention provides for an oral delivery system to r an oral formulation targeted directly to the ileum and/or colon of a subject with ially no loss of the oral formulation before reaching at least the ileum, the system comprising: a core comprising the oral formulation, wherein the oral formulation comprises probiotics or a therapeutic agent; a first enteric coating encapsulating the core, wherein the first coating dissolves in a dissolution pH of about 6.2 to about 6.5; a second enteric coating encapsulating the first coating, wherein the second coating dissolves in a ution pH of about 7 to 8.

Preferably, this oral delivery system further comprising a first biodegradable film layer positioned between the core and first g and also a second biodegradable film layer positioned between the first coating and the second coating, n the biodegradable film is hydroxypropylmethyl cellulose.

In a particular aspect, the t invention provides an oral delivery system for delivering a probiotic formulation targeted to both the ileum and proximal colon of a subject comprising: (a) a biodegradable first capsule comprising a probiotic ation targeted to the proximal colon, wherein the first capsule comprises a reverse enteric coating that lizes in a pH of less than 6.9; and (b) a biodegradable second capsule that includes the first capsule and a probiotic formulation targeted to the ileum, wherein the second capsule ses an enteric coating that solubilizes in a pH of about 7 to 8, wherein the second capsule releases the first capsule and the tic formulation ed to the ileum in the ileum upon administration to a subject, and once ed, the first capsule is solubilized in the proximal colon at a pH of less than 6.9 and releases the probiotic formulation targeted to the proximal colon.

In another particular aspect, the present invention provides a use of an oral formulation in the manufacture of a medicament for the treatment of a gastrointestinal disorder, wherein the oral formulation comprises: [FOLLOWED BY PAGE 16a] a radable first capsule comprising a probiotic formulation targeted to the proximal colon wherein the first capsule is coated with reverse enteric coating that solubilizes in a pH of less than 6.9; and a biodegradable second capsule that includes the first e and a probiotic formulation targeted to the ileum, wherein the second e is coated with an c coating that solubilizes in a pH of about 7 to 8, n the second capsule releases the first capsule and the probiotic formulation targeted to the ileum in the ileum and once released the first capsule is solubilized in the proximal colon at a pH of less than 6.9 and releases the probiotic formulation targeted to the proximal colon, n the gastrointestinal disorder is a Clostridium difficile er.

Other features and advantages of the invention will be apparent from the following detailed description, drawings and claims.

BRIEF PTION OF THE FIGURES Figure 1 shows the Distal Intestine Regulatory component of MetaSensor and associated host Metabolomics-Interactions between L-cells and Probiotic bacteria.

Figure 2 shows normal operations of the MetaSensor via stop signals GLP-1, PYY and other L-cell derived regulatory hormones.

Figure 3 shows the situation when a diabetogenic food, such as sugar ned beverage alters the microbiome and thus the hormonal operation of the MetaSensor.

Figure 4 shows the situation when there is a Microbiome dysbiosis that produces abnormal regulatory control of the MetaSensor via its action on the L-cells.

Figure 5 shows the impact of Roux-en-Y gastric bypass (RYGB) surgery on the MetaSensor.

Figure 6 shows the impact of an oral mimetic of RYGB, an ileal brake hormone releasing nce called Brake, on the MetaSensor.

[FOLLOWED BY PAGE 17] Figure 7 considers the impact of a common diabetes drug, metformin, in combined with Brake, on the operations of the MetaSensory s, illustrating synergistic interactions between a drug and a mimetic ofRYGB surgery.

Figure 8 shows the dissolution of Acetaminophen (APAP) 325 mg core tablets in pH 6.5 (USP dissolution apparatus: Basket at 50 rpm; n=3).

Figure 9 shows the dissolution profile of 325 mg APAP tablets sealed with 4 mg/cm2 seal (HPMC) and coated with Eudragit-EPO 18 cm2) in pH 6.0, pH 6.5, pH 6.8, pH 7.0 and pH 7.4. (USP dissolution apparatus: Basket at 50 rpm; n=3).

Figure 10 shows the dissolution of 325 mg APAP core tablet in pH 7.0 (USP dissolution apparatus: Basket at 50 rpm; n=3).

Figure 11 shows the ution profile of 325 mg coated APAP tablets coated with different ratios of FS30 D & L30D55 in pH 1.2, pH 5.5 & pH 7.0. (USP dissolution tus: Basket at 50 rpm; n=3).

Figure 12 shows the comparison of dissolution profiles of uncoated APAP (~91 mg) capsules (size # 3) in pH 6.5 (using two USP dissolution apparatus: basket @ 75 rpm and Paddle @ 50 rpm; n=3).

Figure 13 shows the comparison of dissolution profiles of coated APAP (~91 mg) capsules (size # 3) coated with 10 mg/cm2 Eudragit-EPO in pH 6.5 (using two USP dissolution apparatus: basket @ 75 rpm and Paddle @ 50 rpm; n=3).

Figure 14 shows the dissolution profile of coated APAP (~91 mg) capsules (size #3) coated with Eudragit-EPO (10 mg/cm2) in pH 6.8 (USP dissolution apparatus: Paddle at 100 rpm; n=3).

Figure 15 shows the dissolution profile of ed APAP (~335 mg) capsules (size # 0) sealed with 6 mg/cm2 HPMC in pH 6.5 (USP dissolution apparatus: Paddle at 100 rpm; n=3).

Figure 16 shows the dissolution profile of APAP (~335 mg) capsules (size # 0), sealed with HPMC-6 mg/cm2 and coated with Eudragit LlOO & Eudragit- LlOO/SlOO (50/50) - 7.5 mg/cm2 in multi- media (USP ution apparatus: Paddle at 100 rpm).

Figure 17 shows the ution profile APAP (~335 mg) capsules (size # 0), sealed with HPMC-6 mg/cm2) and coated with Eudragit- LlOO/SlOO (75/25) 5 mg/cm2 and 7.5 mg/cm2 in multi- media. (USP dissolution apparatus: paddle at 100 rpm).

Figure 18 shows the dissolution profile of APAP Capsule-in-capsule (CIC) [ Inner capsule (size # 3) band sealed and coated with 10 mg/cm2 Eudragit-EPO & Outer capsule (size # 0), band sealed and coated with 5mg/cm2 Eudragit-LlOO/S100 (75/25)] in edia. (USP dissolution apparatus — paddle at 100 rpm; n=6).

DETAILED DESCRIPTION OF THE INVENTION The practice of the present invention may employ various conventional techniques of molecular y (including recombinant techniques), microbiology, cell biology, biochemistry, nucleic acid chemistry, and immunology, which are within the skill of the art. Unless indicated otherwise, the following terms have the ing meanings when used herein and in the ed claims. Those terms that are not defined below or ere in the specification shall have their art-recognized meaning.

A "stable" formulation or composition is one in which the biologically active material therein essentially retains its physical stability, chemical stability, and/or biological activity upon storage. Stability can be measured at a ed temperature and humidity ions for a selected time . Trend analysis can be used to estimate an expected shelf life before a material has actually been in storage for that time period. For live bacteria, for example, stability may be defined as the time it takes to lose 1 log of CFU/g dry formulation under predefined conditions of temperature, humidity and time period.

"Viability" with regard to bacteria, refers to the ability to form a colony (CFU or Colony Forming Unit) on a nutrient media appropriate for the grth of the bacteria.

Viability, with regard to viruses, refers to the ability to infect and uce in a suitable host cell, resulting in the formation of a plaque on a lawn of host cells.

By e" or other forms of the word, such as "reducing" or "reduction," may in certain instances refer to ng of an event or characteristic (e.g., microorganism growth or survival). It is understood that this is lly in relation to some rd or expected value, in other words it is relative, but that it is not always necessary for the standard or relative value to be referred to. For example, "reduces the population of bacteria" in certain instances may refer to lowering the amount of bacteria relative to a standard or a control.

By "treat" or other forms of the word, such as "treated" or "treatment," may, in certain instances mean to administer a composition or to perform a method in order to reduce, prevent, inhibit, break-down, or eliminate a particular characteristic or event (e. g., microorganism growth or survival).

The term e cell" may in certain instances mean a microorganism that is alive and capable of regeneration and/or propagation, while in a vegetative, frozen, preserved, or reconstituted state.

The term "viable cell yield" or "viable cell concentration" may, in certain instances refer to the number of viable cells in a liquid culture, concentrated, or preserved state per a unit of measure, such as liter, milliliter, kilogram, gram or milligram.

The term "cell preservation" in n instances may refer to a process that takes a tive cell and preserves it in a metabolically inert state that retains viability over time. As used herein, the term "product" in certain instances may refer to a microbial composition that can be d with other components and contains specif1ed concentration of viable cells that can be sold and used.

The terms "microorganism" or "microbe" in n ces may refer to an organism of microscopic size, to a single-celled organism, and/or to any virus particle.

The definition of microorganism used herein includes Bacteria, Archaea, single-celled Eukaryotes (protozoa, fiangi, and ciliates), and viral agents.

The term "microbial" in certain ces may refer to processes or compositions of microorganisms, thus a "microbial-based product" is a composition that includes microorganisms, cellular components of the microorganisms, and/or metabolites produced by the microorganisms. rganisms can exist in various states and occur in vegetative, t, or spore states. Microorganisms can also occur as either motile or non-motile, and may be found as planktonic cells (unattached), substrate affixed cells, cells within colonies, or cells within a biofilm.

The term "prebiotic" in certain instances may refer to food ingredients or bacterial producing ingredients that are not readily digestible by endogenous host enzymes and confer beneficial effects on an sm that consumes them by selectively stimulating the grth and/or activity of a limited range of beneficial microorganisms that are ated with the intestinal tract. Also the term includes one or more live microorganisms that confer beneficial effects on a host organism. Benefits derived from the establishment of probiotic microorganisms within the digestive tract include reduction of pathogen load, improved microbial fermentation patterns, improved nutrient absorption, improved immune filnction, improved intestinal hormonal signaling and metabolic regulation, aided digestion and relief of symptoms of irritable bowel e and colitis.

The term "Symbiotic" in n instances may refer to a composition that contains both probiotics and prebiotics. Symbiotic compositions are those in which the prebiotic compound selectively favors the probiotic microorganism.

The term "gastrointestinal tract" in n instances may refer to the complete system of organs and regions that are involved with ingestion, digestion, and ion of food and liquids. This system generally consists of, but not limited to, the mouth, esophagus, h and or rumen, intestines (both small and large), cecum (plural ceca), fermentation sacs, and the anus.

The term "pathogen" in certain instances may refer to any rganism that produces a harmful effect and/or disease state in a human or animal host.

The pharmaceutical formulations ed herein may further include, as optional ingredients, pharmaceutically acceptable carriers, diluents, solubilizing or fying agents, and salts of the type that are available in the art. es of such substances include normal saline solutions such as physiologically ed saline solutions and water. Specific non-limiting examples of the carriers and/or diluents that are useful in the pharmaceutical formulations of the present invention include water and physiologically acceptable buffered saline solutions such as phosphate buffered saline solutions pH 7.0-8.0. le pharmaceutical carriers include, but are not limited to sterile water, salt solutions (such as Ringer's solution), ls, hylene glycols, gelatin, carbohydrates such as lactose, amylose or starch, magnesium stearate, talc, silicic acid, viscous paraffin, fatty acid esters, hydroxymethylcellulose, polyvinylpyrrolidone, etc. The pharmaceutical preparations can be mixed with ary agents, e.g., lubricants, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, coloring, and/or aromatic substances and the like which do not deleteriously react with the active nds. They can also be combined where desired with other active substances, e.g., ileal brake hormone regulatory substances to improve lism and ameliorate metabolic syndromes.

Compounds provided herein may be formulated in a pharmaceutical composition, which may include pharmaceutically acceptable carriers, thickeners, diluents, buffers, surface active , neutral or cationic lipids, lipid complexes, liposomes, penetration enhancers, carrier compounds and other pharmaceutically acceptable carriers or excipients and the like in addition to the compound.

Pharmaceutical compositions may also include one or more active ingredients such as, anti-inflammatory agents, anesthetics, and the like. Formulations for oral or intravaginal stration may include buffers, liposomes, diluents and other suitable additives. The compositions provided herein may additionally contain other adjunct components conventionally found in pharmaceutical compositions, at their art-established usage levels. Thus, for example, the compositions may contain additional ible pharmaceutically-active materials such as, e.g., statins, linaclotide, ileal brake hormone releasing nces, anti-inflammatory agents, or may contain additional als useful in physically formulating various dosage forms of the composition of t invention, such as dyes, flavoring agents, antioxidants, opacif1ers, thickening agents and stabilizers. Depending on the particular active ingredients, the formulations may be administered in the same pill or tablet or as a ct pill or tablet as part of a co-administration protocol. However, such materials, when added, should not unduly interfere with the biological activities of the ents of the compositions provided herein.

Regardless of the method by which nds are introduced into a patient, colloidal dispersion systems may be used as delivery vehicles to e the in vivo stability of the compounds and/or to target the compounds to a particular organ, tissue or cell type. Colloidal dispersion systems include, but are not limited to, macromolecule complexes, nanocapsules, microspheres, beads and lipid-based systems including oil- in-water emulsions, micelles, mixed micelles, liposomes and compound complexes of uncharacterized structure. A preferred dal dispersion system is a plurality of liposomes. Liposomes are microscopic spheres having an aqueous core surrounded by one or more outer layers made up of lipids arranged in a r configuration (see, generally, Chonn et al., Current Op. Biotech. 6, 698-708 (1995)).

Likewise, microparticulate or nanoparticulate polymeric bead dosage forms may be used in composition provided herein. nds ed herein may be used in ation with one or more additional active agent and ulated in a particulate dosage form. In this manner, certain compounds provided here, alone or in combination with other active agents, are released at that site over time to provide a sustained therapeutic benefit. Release of the active agent from the particulate dosage forms of the present invention can occur as a result of both diffilsion and particulate matrix erosion. Biodegradation rate directly impacts active agent release kinetics.

In preferred embodiments, the pharmaceutical ition of the invention is administered orally. Dosing can be ent on a number of factors, including severity and responsiveness of the disease state to be treated, and with the course of treatment lasting from several days to several months, or until a cure is effected or a diminution of the disease state is achieved. Toxicity and therapeutic cy of compounds provided herein can be determined by standard pharmaceutical procedures in cell cultures or experimental s. For example, for determining The LD50 (the dose lethal to 50% of the population) and the ED50 (the dose therapeutically effective in 50% of the population). The dose ratio between toxic and therapeutic effects is the therapeutic index and it can be sed as the ratio LD50 /ED50. Compounds which exhibit large therapeutic indices are preferred. While compounds that exhibit toxic side s may be used, care should be taken to design a delivery system that targets such compounds to the site of affected tissues in order to minimize potential damage to uninfected cells and, thereby, reduce side effects.

The data obtained from in vitro and in viva assays and animal studies can be used in formulating a range of dosage for use in . The dosage of such compounds lies preferably within a range of exposure concentrations that e the ED50 with little or no toxicity. The dosage may vary within this range depending upon the dosage form employed and the route of administration utilized. For any compound used in the method of the invention, the therapeutically effective dose can be ted initially from cell culture assays. A dose may be formulated in animal models to achieve a local exposure ranges that includes the cell derived IC50 (i.e., the concentration of the test nd which achieves a half-maximal inhibition of symptoms) as determined in cell culture. Such information can be used to more accurately determine useful doses in humans. Levels in plasma are ed to be unmeasurably low. Dosing schedules can be calculated from measurements of drug accumulation in the intestinal tract and feces of the patient. Not relevant, organisms are not absorbed.

Suitable dosage amounts for probiotic sms may, for example, vary from about 105 to 1012 organisms, typically about 106 based on the numbers of organisms found in the ileum of said patient. Similarly, delivery of compounds ed herein will be specific to particular cells, conditions, and locations, such as ileum. In general, dosage is from tablets, capsules, granules and microgranules, s, liquids and alike, and which may be given once or more daily, weekly, monthly or yearly, or even less frequently. In the treatment or prevention of certain ions, an appropriate dosage level will generally be as above per day which can be administered in single or multiple doses. Live microorganisms or therapeutic compounds according to the invention (e.g. live sms) may be formulated into pharmaceutical compositions for administration according to known methodologies, including for example using immediate-release, as well as pulsatile-release, and delayed-release technologies. ceutical compositions may, for example, comprise one or more constructs, in combination with a pharmaceutically acceptable carrier, excipient or diluent. Such carriers will be nontoxic to recipients at the dosages employed. A suitable dosage may be from about as above, per species at least 105 to 1012 oral and various ranges within these amounts being still more typical for administration. It will be evident to those skilled in the art that the number and ncy of administration will be dependent upon the response of the host. “Pharmaceutically acceptable carriers” for therapeutic use are well known in the pharmaceutical art, and are described, for example, in Remington ’s Pharmaceutical Sciences, Mack Publishing Co. (A.R.

Gennaro edit. 1985). For example, saline and phosphate-buffered saline at physiological pH may be used. Stabilizers, dyes and even flavoring agents may be provided in the pharmaceutical composition.

“Pharmaceutically acceptable salt” refers to salts of the compounds of the present invention d from the combination of such compounds and an organic or inorganic acid (acid addition salts) or an organic or inorganic base (base addition salts). The compounds of the present invention may be used in either the free base or salt forms, with both forms being considered as being within the scope of the present invention.

However, ceutical compositions ed herein may be in any form which allows for the composition to be stered to a patient by the oral route and less commonly by intravaginal or rectal routes. The pharmaceutical composition is formulated so as to allow the active ingredients contained therein to be bioavailable at the site targeted upon administration of the composition to a patient. Compositions that will be administered to a t take the form of one or more dosage units, where for example, a tablet may be a single dosage unit, and a container of one or more compounds of the invention in oral form may hold a ity of dosage units.

For oral stration, an excipient and/or binder may be present. Examples are sucrose, kaolin, glycerin, starch dextrins, sodium alginate, ymethylcellulose and ethyl ose. Coloring and/or flavoring agents may be present. A coating shell may be employed, applying common membranes used for microencapsulation and le for the microencapsulation of live probiotic organisms include biodegradable synthetic “polymers” such as polylactide, polyglycolic acid, and polyanhydride.

Established “polymers” for live encapsulation and enzyme encapsulation include alginate-polylysine-alginate (APA), alginate-polymethylene-co-guanidine-alginate (A-PMCG-A), hydroymethylacrylate-methyl methacrylate (HEMA-MMA), Multilayered HEMA-MMA-MAA, polyacrylonitrilevinylchloride (PAN-PVC), nitrile/sodium methallylsulfonate (AN-69), polyethylene glycol/poly ethylcyclopentasiloxane/polydimethylsiloxane (PEG/PDS/PDMS), poly N,N- yl acrylamide (PDMAAm), Siliceous encapsulates and cellulose sulphate/sodium te/polymethylene-co-guanidine (CS/A/PMCG). Other materials that are useful include, without limitation, cellulose e phthalate, m alginate and k-carrageenan-Locust bean gum gel beads, gellan-xanthan beads, poly(lactide-co-glycolides), carrageenan, starch poly-anhydrides, starch polymethacrylates, polyamino acids, enteric coating polymers.

A liquid pharmaceutical composition as used herein, r in the form of a solution, suspension or other like form, may include one or more of the following adjuvants: diluents such as water, fixed oils such as synthetic mono or , preferably diglycerides which may serve as the solvent or suspending medium, polyethylene glycols, glycerin, propylene glycol or other solvents; antioxidants such as ascorbic acid or sodium bisulfite; chelating agents such as nediaminetetraacetic acid; buffers such as acetates, citrates or phosphates and agents for the adjustment of tonicity such as sodium de or dextrose.

Compounds described herein can be used in stics, therapeutics, prophylaxis, and as research reagents and in kits. Provision of means for detecting compounds of the invention can routinely be accomplished. Such provision may include enzyme conjugation, radiolabelling or any other le detection systems. Kits for detecting the presence or absence of compounds of the invention may also be prepared.

The compounds of the invention may also be used for ch purposes. Thus, the specific activities or modalities exhibited by the compounds may be used for assays, purif1cations, cellular product preparations and in other ologies which may be appreciated by persons of ordinary skill in the art.

Using the Smart Pill to study pH of the intestinal tract and y define the pH of the target sites of ileum and colon for e of specific probiotic sms.

Recently, the SmartPill, a wireless pH/pressure recording capsule, has been utilized to measure the whole gut transit time. ss capsule motility, using the ill GI monitoring system, samples and transmits intraluminal pH, pressure, and temperature data from a capsule at regular intervals as it traverses through the gastrointestinal tract; from these, gastric emptying and whole gastrointestinal tract transit can be assessed. In addition, there are a few studies on the small bowel pH. The aim of this study was to igate the relationship between small bowel disease and the small bowel pH, using the SmartPill to non-invasively record sequential images and the pH.

Volunteers swallowed the SmartPill with 240mL of water. The SmartPill transmitted the acquired images and the pH to the recorder unit located outside the body for about ten hours while the subject was fasting. SmartPill capsule shows promise as a useful stic test to evaluate patients for GI transit disorders and to study the effects of diseases of the gastrointestinal tract on pH and GI transit (8). The intragastric pH was low and after gastric emptying the pH in the whole small intestine rose from 6.0 to as high as 8.1 in the ileum, then after passing the ileocecal valve, the pH of the right colon was once again 5.5 to 6.5. The pH value increased from the duodenum to the al ileum (p<0.0001) in all patients, but diabetic ts and obese patients did not rise as high as normal subjects. These findings were unexpected, and indicate that the release target is different for formulated probiotic organisms in the ileum and right colon of ics and obese patients, compared to normal ts. Clearly, effective ce of site specific delivery in the human intestinal tract requires adjustment for the differing conditions of the local ileum micro-environment, surprisingly a feature of disease associated changes in the microbiome as taught by experiments using SmartPill. Thus the concept of targeted probiotic replacements and making changes in signaling processes to treat disease is advanced to practice. Probiotic formulations and dosages and compositions must be completely changed to deal with these new discoveries.

Methods lic syndrome and obesity There were two organisms that were found in intestinal flora in minor numbers, but which represented major regulatory balance organisms in the development of y and ated metabolic abnormalities, Methanobrevibacter smithz'z' which promotes adiposity and Bacteroz'des theataiotaomz’cron, which down regulates metabolic me associated inflammation and thereby removes the associated risk to the cardiovascular integrity of the host (1). Another organism found by others to be important is Faecalobacterium prausm'tzz'z', the absence of which appears to correlate with worsening of obesity and Type 2 diabetes (2). In the practice of the t invention, this organism is a target for replacement via targeted delivery to the ileum as in the present invention.

Resident host microflora condition and prime the immune system in the preferred practice of the invention are disclosed herein. However, systemic and mucosal immune ses to bacteria may be divergent. Several workers have ed the relationships between the immune system and the microbiome components in the intestinal tract. For e, our work with ts having RYGB surgery showed elevated endotoxin and high levels of inflammation prior to surgery, followed after surgery by remediation and a lowering of inflammatory processes.(3). It is important to understand that current viewpoints show the ileum and the ileal brake hormone pathways to be the beneficial site of action of RYGB surgery, which is an effective treatment for obesity and in fact the only known means of curing metabolic syndrome associated type 2 es. It is shown herein that the actions are mediated at the level of the ileum and the ileal brake, and the novel discovery was a lowering of chronic inflammation, presumed a cause of revised microbiome and revised signaling at the level of the intestinal L-cells. Additional novel discovery was the level of close ction between the intestinal L-cells, the inal bacteria, and the systemic host inflammation, which is sible for the various diseases that are considered part of overall metabolic syndrome in humans(3). O’Mahony and colleagues examined the inflammatory signaling processes involved in this pathway. Their aim was to compare, in vitro, cytokine production by human mononuclear and dendritic cells (DCs) from mesenteric lymph nodes (MLNs) and peripheral blood mononuclear cells (PBMCs) to defined ial stimuli. Mononuclear cells and DCs isolated from the MLN (n = 10) and peripheral blood (11 = 12) of patients with active colitis were incubated in vitro with the probiotic bacteria Lactobacillus salivarz'us UCC118 or Bz'ficlobacterz'am infantis 35624 or the pathogenic organism Salmonella typhz'murz'am UKl. Interleukin (IL)-l2, tumor is factor (TNF)—alpha, transforming growth factor (TGF)-beta, and IL-10 cytokine levels were quantified by ELISA. PBMCs and PBMC-derived DCs secreted pha in response to the Lactobacz'llas, acterz'a, and Salmonella strains, whereas MLN cells and MLN-derived DCs secreted TNF-alpha only in response to Salmonella challenge. Cells from the systemic compartment secreted IL-12 after co-incubation with Salmonella or Lactobacz'llz', whereas MLN-derived cells produced IL-12 only in response to Salmonella. PBMCs secreted IL-10 in response to the Bz'ficlobacterz'am strain but not in response to the Lactobacz'llus or Salmonella . However, MLN cells secreted IL-10 in response to Bzfidobacterz'a and Lactobacz'llz' but not in response to Salmonella. In conclusion, commensal bacteria d regulatory cytokine production by MLN cells, whereas pathogenic bacteria induce T cell helper 1- polarizing cytokines. Commensal-pathogen ence in cytokine responses is more marked in cells ed from the l immune system compared with PBMCs(4).

This work indicates that the endogenous cellular signaling pathways at work in the distal gastrointestinal tract can discriminate their responses as the flora in the microbiome change between commensals and pathogens.

Immunoregulatory pathways Leukocyte recruitment is a central immune process. Multiple factors have been described to e leukocyte infiltration into inflamed s, but only recently has evidence for endogenous negative modulators of this inflammatory process emerged.

The discovery of several locally produced modulators has emerged into a new field of endogenous inhibitors of leukocyte extravasation. Recent findings from several inflammatory disease models show that tissues can self-regulate the tment of inflammatory cells, suggesting that local tissues may have a greater atory say' over the immune response than previously appreciated(5). Organisms targeted for replacement in obese or diabetic patients could be delivered as components of an oral site c ry formulation designed to assist in the management of metabolic syndrome and t or control associated inflammatory manifestations such as obesity and type 2 diabetes. This novel therapeutic approach, based on changing local signaling at the level of intestinal L-cells and dendritic cells, is proposed based on the observation that locally produced modulators of leukocyte recruitment may represent local homeostatic mechanisms that tissues and organs may have evolved for protection against the destructive potential of the immune system (5). The involvement of the local microbiome flora as a protective factor, beneficial to the host, is a novel aspect in the practice of the invention, since this would explain why use of certain antibiotics used for treatment of infection may cause more problems from dysbiosis than are solved by eradicating ens.

Larsen and colleagues have studied the link between metabolic diseases and bacterial populations in the gut. The aim of their studies was to assess the differences between the itions of the intestinal microbiota in humans with type 2 diabetes and e to controls who were non-diabetic persons. The study population included 36 male adults with a broad range of age and body-mass indices (BMIs), among which 18 subjects were diagnosed with diabetes type 2. The fecal ial composition was investigated by real-time quantitative PCR (qPCR) and in a subgroup of subjects (N = 20) by tag-encoded amplicon pyrosequencing of the V4 region of the 168 rRNA gene. The proportions of phylum Firmicutes and class idia were significantly reduced in the ic group compared to the control group (P = 0.03). Furthermore, the ratios of Bacteroidetes to Firmicutes as well as the ratios of Bacteroides-Prevotella group to C. coccoides-E. rectale group correlated positively and significantly with plasma e concentration (P = 0.04) but not with BMIs. Similarly, class Betaproteobacteria was highly enriched in ic compared to non-diabetic s (P = 0.02) and positively correlated with plasma glucose (P = 0.04). The results of this study indicated that type 2 diabetes in humans is associated with compositional changes in intestinal microbiota. The level of glucose tolerance should be considered when linking microbiota with metabolic diseases such as obesity and developing strategies to control metabolic diseases by modifying the gut microbiota(6).

Recent studies have focused additional attention on intestinal microbiota as environmental factors that increase energy yield from diet, regulate peripheral lism and thereby se body weight. Obesity is associated with substantial changes in ition and metabolic fianction of gut microbiota, but the pathophysiological processes driving this bidirectional relationship have not been fully elucidated. Clearly there are important relationships between the composition of gut microbiota, energy ted from diet, synthesis of gut hormones involved in energy homeostasis, production of butyrate and the regulation of fat storage (7). The most important discoveries of this work are from our own studies examining the release of hormones from the distal intestines in response to stimulating factors such as foods and probiotic organisms (3).

Regulation of the host metabolome and the invention of the Metabolomic MetaSensor The distal intestine’s responsiveness to molecules ted to it via diet is important in regulating the upstream sensory s of ion such as hunger, taste, smell, and appetite. Together the interaction between ingestion, selective tion and feedback tory control of appetite ensure that the organism is properly nourished and its energy needs are properly ed by intake of food as filel, and the current term used to describe the steps in these processes is Metabolomics. It is important to er the “organism” in this case to be the combination of all cells, including bacteria, viruses, fiangi and human cells, together a MetaOrganism, which in terms of cell numbers is more than 90% non-human cells. The biosensors effecting these complex processes are interactive n the non-human cells and the human cells, together a nsor, and it is expected that most Metabolomic processes will be controlled by MetaSensory signaling, i.e. interactiveness between non-human and human cells. Likewise, it is theorized that host immunity and thus conditions like food allergy are controlled by these same distal intestinal MetaSensors. Considering the central role of the master regulatory MetaSensor in host lomics at homeostasis, it is clear that food intake is regulated by the combined sensor signals g input (brain programmed appetite cting with taste and smell), rbalanced precisely by the distal intestinal sensor s such as the ileal brake and associated hormonal regulatory “stop input” signals that are received when ingestion exceeds the ability of the organism to absorb upstream in the duodenum and jejunum. In normal operations, host demand for energy dominates, and ingestion of nutrients proceeds unimpeded by stop signals. When energy intake exceeds demand, there is both short term and long term storage of excess. Short term storage includes abdominal adipose and liver, and long term storage is peripheral adipose, both of which interact with the MetaSensory signaling processes to balance supply and WO 52338 demand for energy. There is good understanding of the balance created n ingestion and storage, driven largely by appetite and the combined sensory input from taste and smell. However, it is novel to identify the ileal brake and its associated regulatory MetaSensor component as a stop signal on the ingestion process, and our work in this area with the pathways operative in RYGB patients is illustrative (see W02012-118712, hereby incorporated in its entirety), wherein we have shown that ileal delivery of food substances creates a stop signal e the MetaSensor s malabsorption and uses the hormones released from the L-cells of the ileum (GLP-l, PYY and many others) to shut down ingestion and te via brain stimulatory ck. In a breakthrough discovery, we are now ing a plausible means of operating the ileal brake component of the intestinal nsor, and its integral controllers. In an individual of normal weight and in nutritional balance the ileal brake component of the MetaSensor, (the controller of the stop signal) is comprised of host L-cells interacting with beneficial intestinal organisms. The inal bacteria are an essential component of MetaOrganism Metabolomics, and it is logical for them to have a major regulatory role in the operation of the stop signal from the ileum.

Intestinal microbes lack the ability to signal the host brain directly, so they use host ing pathways to make their needs known. The combined MetaSensor es in the distal intestine, via interaction with the L-cells to te the stop signal to mutual benefit. Described simply, certain intestinal bacteria can suppress the stop on the appetite signal from the brain. They do this when they are hungry for a nutrient, food or even a specific molecule. When microbes deep in the inal tract are hungry, the host is hungry because the stop signal of the MetaSensor is inactivated.

Figures 1 to 7 diagram the MetaSensor in detail, and show how it is comprised overall in Figure l, and in Figures 2-7 describe its operations in the ileum that control metabolomics and immunity. The MetaSensor in the ileum es regulatory hormonal output from the combined actions of the enteral L-cells, and the intestinal bacteria. Figure 2 shows normal operations of the MetaSensor via stop signals GLP- l, PYY and other L-cell derived regulatory hormones. Notably the system is in balance when diet is balanced and thus some excess reaches the distal intestine.

However, when the patient ingests only IR-CHOs, the bacteria in the ileum are not achieving nutrition. They react by Suppression of L-cell output and hunger ensues. If on the other hand the patient is having a balance diet with portions reaching the bacteria, they have no reason to ss the L-cell output and normal eating produces satiety. Figure 3 shows the situation when a diabetogenic food, such as sugar sweetened beverage alters the microbiome and thus the hormonal operation of the MetaSensor. Figure 4 shows the situation when there is a Microbiome sis that produces al regulatory control of the MetaSensor via its action on the L-cells.

With reference to our previous work with the ileal brake operations in health and disease, Figure 5 shows the impact of RYGB surgery on the MetaSensor. Notably, RYGB y mechanically diverts ingested contents past the absorptive (but non- signaling) area, and bombards the signaling areas further downstream in late jejunum and ileum. The arrival of massive nutrients at the ileum in such a large quantity creates a “malabsorptive emergency” and tes the satiety signal by shutting down the hormonal release from the s to regenerate signaling to a certain extent with the same or less amount of food needed, therefore ing maintenance and regeneration. And because it is not individualized, RYGB surgery will trigger more ration than signaling to the point that about 4 years down the line, the jejunum will evolve to restore absorption to a baseline levels. Figure 6 shows the impact of an oral mimetic of RYGB, an ileal brake hormone releasing substance called Brake, on the MetaSensor. Brake acts the distally in the same way as RYGB surgery. There is the same activation of L-cells, the output of which produce regeneration and make hunger disappear into satiety. The strength of the ileal signal is not as potent as RYGB, but it can be more prolonged because of the delayed e formulation.

Thus with Brake, the intensity of the stimulation will be more moderate and closer to physiological and therefore regeneration proceeds in Liver, pancreas, GI cytes in a much more l and physiological way compared to surgery. Of no great surprise, weight loss is more rapid with RYGB, since RYGB surgery also physically decreases the size of stomach, limiting ingestion in a second, profound manner over the ileal brake pathway alone. Finally, Figure 7 considers the impact of a common diabetes drug, metformin, in combined with Brake, on the ions of the MetaSensory process, illustrating synergistic interactions n a drug and a mimetic of RYGB surgery, this example is illustrative, and there are many more of these with other drugs used in the treatment of metabolic me stations such as type 2 diabetes.

Briefly, the MetaSensor gives the stop signal to the brain via ileal brake hormones in response to its detection of perceived malabsorption. In total, the novel aspect of the invention, shown by this sion and these figures, is the nature of this MetaSensors action on the host metabolome, that effect being the combined action of L-cell output from detection of food delivery and the actions of probiotic organisms on the L-cells to modify the signal in response to nutritional demands communicated by bacteria. It is remarkable how effectively the probiotic organisms l our appetite and selection of nutrients and foods to suit their own purposes. We are together with our probiotic symbionts, a balanced tem, a true MetaOrganism.

In homeostasis, all parties are successfully meeting their needs. Diseases, all loosely described as components of lic Syndrome, are the results of imbalances, which may be bacterial in origin, or arise from the cells of the host. Regardless, both components of the MetaSensor must e therapeutic attention if homeostasis is to be restored, and the current sion provides detailed means of re-balancing the MetaSensory output to restore homeostasis and remove diseases. All of the therapeutic advances described herein, and those to follow ongoing research, are transformational steps mediated by treatments changing the input-output properties of the MetaSensor described herein.

There are some other useful aspects to the nsor in the distal ileum.

Specifically, the MetaSensor provides a quick immune system mediated response when a foreign invader is detected in the GI tract lumen, and the rapid improvement of intestinal dysbiosis such as infection with C. difficile can be remediated by replacement of C. le with more beneficial organisms delivered by formulation to the ileum and colon via the oral formulations described herein. Furthermore, there are preferred enablements as distal ileum vaccines that are orally active. c examples are found in PCT/USl3/3 1483, the entirety of which is herein orated by reference.

In parallel with the stimulation of the MetaSensor with a foreign organism, it is now clearly nt that the MetaSensor is responsive to chemical substances that act on the probiotic bacteria, each of which has a specific molecule that excites a response which is then communicated to the human host via the s, lymphoid tissue in Peyer’s Patches, or in all possibility any enterocyte found in the lumen. When the host or the integrated intestinal organisms of the MetaOrganism encounters a deficiency of any nutritional ent or essential substance, the signal for this 2014/027228 deficiency comes to the brain from the MetaSensor in the intestine (if communicated by the host microbiome), and perhaps from the brain or tongue or nose if communicated by the host cells. The actions of the host to obtain that missing substance are perceived as “cravings” and after satisfied the MetaSensor stops the search. Thus, when the Microbiome organisms are hungry for something specific, we as the MetaOrganism are instructed to obtain that specific substance. This novel discovery immediately opens opportunities to regulate ingestion of potentially harmful substances like refined sugar, via therapeutic strategies focused on the MetaSensor , and explains the y of ileum delivered glucose to regulate diabetes and other diseases called metabolic syndrome (see WO 2010-027498 and WO 2013-063527 Al, herein incorporated by reference). While these ions focus on the needs of the host via regulatory MetaSensor action, it can readily be seen that regulating the Microbiome via ed replacement will also impact the diseases of the host in a beneficial way. Replacement of organisms missing in ation with metabolic diseases such as obesity, for example faecalz’bacterium prausm'tzz'z', is now possible with the ability disclosed herein to provide targeted oral delivery of live organisms to the site of the MetaSensor in the ileum.

The ing Examples are offered by way of illustration and not by way of limitation.

EXAMPLE 1 Example 1 is directed toward the making and testing of a ation according to the invention for the treatment of a z'dz'um dz'fi‘zcile infection.

Biological Assays Standard therapies for antibiotic-associated diarrhea (AAD) and Clostridium dz'fiicz'le- associated diarrhea (CDAD) have limited efficacy. Probiotic prophylaxis is a ing alternative for reduction of AAD and CDAD incidence. The preferred ment is microgranules administered to said patient with Clostrz'dz'um dz'fi‘zcz'le infection is about 105 to 1012 Cfil of one or more species of probiotic sms, targeted to ileum and ascending colon. Preferred embodiments would be a mixture of probiotic organisms reflective of the balance and components of the microbiome of a normal human subject, preferably a patient free of antibiotic exposure in the past and not infected with C. cile organisms. The clinical protocol for testing the efficacy of said formulation would administer said formulation of probiotic organisms to patients in the manner followed by others who have tested the effectiveness of probiotics or fecal transplantation for ions with Clostrz'dz'um dl'fi‘zcile in human ts. By way of example, a -center, ized, double-blind, placebo- controlled dose-ranging study, is ted for one of these probiotics in adult inpatients allocated to one of three groups: two probiotic capsules per day, one probiotic e and one placebo capsule per day, or two o capsules per day.

In the design using un-protected formulations of each probiotic organism, each probiotic capsule contained 50 billion c.f.u. of live organisms. Probiotic prophylaxis or treatment began within 36 h of initial antibiotic administration, continued for 5 days after the last antibiotic dose, and patients were followed for an additional 21 days. In this study, Pro-2 (15.5%) had a lower antibiotic associated diarrhea (AAD) incidence vs. Pro-1 (28.2%). Each probiotic group had a lower AAD incidence vs. placebo (44.1%). In patients who acquired AAD, Pro-2 (2.8 days) and Pro-1 (4.1 days) had shorter symptom duration vs. placebo (6.4 days). Similarly, Pro-2 (1.2%) had a lower Clostrz'dz'um dz'fi‘zcz'le associated diarrhea (CDAD) incidence vs. Pro-1 (9.4%). Each treatment group had a lower CDAD nce vs. placebo (23.8%). intestinal symptoms were less common in the ent groups vs. placebo and in Pro-2 vs. Pro-1. The proprietary probiotic blend used in this study was well tolerated and effective for reducing risk of AAD and, in particular, Clostrz'dz'um dz'fi‘zcile associated diarrheal ions in hospitalized patients on antibiotics. A dose- ranging effect was shown with 100 billion c.f.u., yielding superior outcomes and fewer gastrointestinal events compared to 50 billion c.fu. (9). Clearly, a protective formulation would allow the targeted delivery of smaller numbers of these organisms, lowering the costs of production of the organisms for the product.

In follow up to the study design above, Johnson and colleagues conducted a literature search for randomized, placebo-controlled efficacy studies of probiotic use among adults receiving antibiotics, in which z'dz'um cz'le infection (CDI) was one of the outcomes measured. In addition, they conducted meta-analyses of probiotics that were included in more than one randomized trial. Eleven studies were identified; most were sly underpowered to determine the efficacy of probiotics in the 2014/027228 prevention of CD1. Two showed significantly lower rates of CD1 among the probiotic recipients. A nalysis of three studies that used the probiotic combination Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R and a combined analysis of those studies with four studies that used Saccharomyces boulardz'z', showed lower CDI rates in recipients of probiotics compared with recipients of placebo (risk ratio=0.39; 95% confidence interval 0.19-0.79). Thus, while potential flaws in study design were identified, a review of the available literature suggested that the y prevention of CD1 with specific tic agents may be achievable. Additional studies of sufficient size and with rigorous design are needed to confirm these findings.(lO) By way of commentary, the studies reviewed did not target the probiotic organisms, and thus the t invention is far more effective than those unprotected formulations used thus far. als and Methods: Described below are formulations that are being made and tested for the target delivery for testing in biological assays, the formulation having an antibiotic (Vancomycin 250 mg) (millimeter range) for e at pH 1.0 — 6.0 in stomach, duodenum and ileum and symbiotic (prebiotic: L-Leucine; probiotic: species of: lactobacillus and bz'fidobacterz'um) for release at pH 5.5 - 6.2 in right colon every 6 hours.

Active Pharmaceutical Ingredient (API): Antibiotic — Vancomcyin hydrochloride (micronized) supplied by local generic US/non-US suppliers, e. g., LGM Pharma, USA, etc.

Prebiotics - proteins (casein, hydrolyzed n, etc.), peptides, amino acids (L-Leucine), carbohydrates glucose, lactose, es, inulin, etc. and n bacterial strains: provided by Denisco, CHR Hansen, Institu Risell — Lallemand and other high quality global suppliers of prebiotics.

Live probiotics Species of: lactobacillus and bacterium provided by Denisco, CHR Hansen, Institu Risell — Lallemand and other high quality global suppliers. ve Ingredients (Excipients): Microcrystalline, starch, HPMC “ or equivalent polymers”, hard gelatin capsules, and other fillers, etc. - purchased from local US supplier such as FMC, Capsugel, on, etc.

Intermediate Formulation/Manufacturing Process (at local CMO): ted Antibiotic Granules/Pellets” (millimeter : Ingredients Amount (%) Vancomcyin 50% Excipients (Microcrystalline cellulose — filler, 50% polyvinylpyrrolidone — binder, pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Water as required 0% Prepare a dry ation with antibiotic and excipients in a low or high shear mixer and/or perform wet granulations with water and further pelletize using extruder / spheronizer and then drying to remove excess water using optimized conditions “pH .0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets” (millimeter range): Ingredients Amount (%) Uncoated Antibiotic Granules/Pellets 95% HPMC or equivalent “polymers” (Barrier and Seal coats) 1% “Polymers” (pH 5.0 to 6.0 sensitive coating) 4% Water/Solvents as required 0% The ed Antibiotic Granules/Pellets are coated (the barrier coat) with aqueous or solvent coating on of HPMC or equivalent “polymers” to coat in a coating pan or fluid bed drier/coater using optimized conditions. The barrier coated micropellets or es are fiarther coated with aqueous or solvent coating solution of pH 5.0 to 6.0, ive coating “Polymers” in a g pan or fluid bed drier/coater using optimized conditions. The above pH 5.0 to 6.0, sensitive coated micropellets or granules are seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. “pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets” (100 micron).

Ingredients Amount (%) L. Leucine (prebiotic) 5% Freeze dried bacterial (species of acillus and l% bz'fidobacterium) probiotic) Excipients (Microcrystalline cellulose — filler, 82% polyvinylpyrrolidone — binder, pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium te - ant) HPMC or equivalent “polymers” (Barrier and Seal coats) 2% “Polymers” (pH 5.5 to 6.2 ive coating) 10% Water/Solvents as required 0% ed by dry granulating pre-/probiotic with excipients and/or wet granulations with water solvents in high or low shear mixer and further pelletizing using extruder/ spheronizer and then drying to remove water using optimized conditions. The above micropellets or granules are further coated (barrier coat) with s or solvent coating solution of HPMC or equivalent ers” in a coating pan or fluid bed drier/coater using optimized conditions. The above barrier coated micropellets or granules are further coated with aqueous or solvent coating solution of “Polymers” (pH 5.5 to 6.2 sensitive coating) in a g pan or fluid bed drier/coater using optimized conditions. The above pH 5.5 to 6.2 sensitive coated micropellets or granules are seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a g pan or fluid bed drier/coater using optimized conditions. “pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets” (100 micron). pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets 88% HPMC or equivalent “polymers” (Seal coats) “Polymers” (pH 7.2 to 7.5 sensitive g) Water/Solvents as required The above pH 5.5 to 6.2 Enteric Coated (EC) tic Granules/Pellets are coated with aqueous or solvent coating solution of “Polymers” (pH 7.2 to 7.5 sensitive coating) in a coating pan or fluid bed drier/coater using optimized conditions. The above micropellets or granules are fithher coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” (seal coat) in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Sachet — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Uncoated Antibiotic Granules/Pellets 50% pH 5.0 to 6.0 Enteric Coated (EC) otic Granules/Pellets 25% pH 7.2 to 7.5 c Coated (EC) Symblotic Granules/Pellets 15% Excipients tol — filler, Silicon dioxide — glidant/flow aid) 10% The above Uncoated Antibiotic Granules/Pellets, pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired ns in V-type or similar blender with excipients using zed conditions. The blended powders are filling into sachets using powder filling equipment.

Example: Final Product — Capsules (Hard gelatin/HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the s): Amm ed Antibiotic Granules/Pellets pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets Excipients (Microcrystalline cellulose — filler, Silicon dioxide — glidant/flow aid) Hard Gelatin/HPMC Capsules The above Uncoated Antibiotic Granules/Pellets, pH 5.0 to 6.0 c Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic es/Pellets intermediate formulations are d in desired portions in V-type or similar r with excipients. The blended powders are filled into capsules using encapsulating equipment. e: Final t — Capsules (Liquid Filled Hard or Soft Gelatin) — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Amoun Gelatin as powder and Hard Gelatin Capsules 5% The above Uncoated Antibiotic Granules/Pellets, pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions with immiscible liquid in a blender. Filled into capsules using soft or hard gelatin encapsulating equipment using optimized conditions.

Example: Final Product — Capsule-in-Capsule (Hard gelatin) (1) — Formulation/Manufacturing Process (at local CMO, controlled room and ty conditions throughout the process): Anew pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 12% Uncoated Antibiotic es/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 25% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 10% glidant/flow aid) Small and Large Hard Gelatin/HPMC Capsules 8% The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulation is blended in with portion of excipients in V-type or similar blender and the blend. The blend is filled into smaller capsules using encapsulating equipment and optimized conditions. The above Uncoated Antibiotic Granules/Pellets and pH .0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are blended together in desired portions in V-type or similar blender with excipients.

The blended ediate formulations along with the smaller filled capsules are further filled into larger capsules using specialized e filling equipment and optimized conditions. e: Final Product — Capsule-in-Capsule (Hard gelatin) (2) — ation/Manufacturing Process (at local CMO, controlled room and humidity ions throughout the process): Ingredients Amount (%) pH 5.5 to 6.2 c Coated (EC) Symbiotic Granules/Pellets 15% “Polymers” (pH 7.2 to 7.5 sensitive g) 10% Uncoated Antibiotic Granules/Pellets 45% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 10% glidant/flow aid) pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic es/Pellets 10% Small and Large Hard Gelatin/HPMC Capsules 10% Water/Solvents as required 0% The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulation is d in desired portions in V-type or similar blender with excipients. The blend is filled into smaller capsules using encapsulating equipment.

The smaller filled capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized ions. The above Uncoated Antibiotic Granules/Pellets and pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or r r with excipients. The smaller pH 7.2 to 7.5 coated capsules and the blends are fiarther filled into larger capsules using specialized e filling equipment and optimized conditions.

Example: Final Product — Tablets / Microtablets - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone 30% — binder, pregelatinized starch - egrant and silicon e — flow aid, magnesium stearate - lubricant) HPMC or equivalent “polymers” (Film coat) 1% Solvents as required 0% The ed Antibiotic Granules/Pellets, pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 c Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into Tablets / Microtablets using ing equipment. The tablets are further film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

WO 52338 Example: Final Product — Orally disintegrating Tablets (ODT) - Formulation/Manufacturing Process (at local CMO, controlled room and ty conditions throughout the s): Uncoated Antibiotic Granules/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) otic Granules/Pellets 12% pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 12% Excipients (Mannitol — filler, polyVinylpyrrolidone — binder, 3l% pregelatinized starch - disintegrant and silicon e — flow aid, magnesium stearate - lubricant) The ed Antibiotic Granules/Pellets, pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets ediate formulations are blended in desired portions in V-type or similar blender with excipients. The blended powders are compressed into soft tablets using tableting equipment.

Example: Final Product — Tablet-in-Tablet (l) - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Excipients (Microcrystalline cellulose — , polyVinylpyrrolidone 30% — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) HPMC or equivalent “polymers” (Film coat) 1% Solvents as required 0% The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulation is blended in desired portions in V-type or similar blender with excipients WO 52338 to aid in flow, disintegration and lubrication (for tableting machine). The blended s are compressed into small tablets / Microtablets using tableting equipment.

The above Uncoated Antibiotic Granules/Pellets, and pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are d in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powder is compress coated over the small s / Microtablets using compress coat tableting machine. The tablets are further film coated using aqueous or solvent coating on in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Final Product — Tablet-in-Tablet (2) - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone 25% — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive g) HPMC or equivalent “polymers” (Film coat) Water/Solvents as needed The pH 5.5 to 6.2 c Coated (EC) Symbiotic Granules/Pellets intermediate formulation is blended in d portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended s are compressed into small tablets / Microtablets using tableting equipment.

The compressed tablets are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating on of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC s”). The above Uncoated Antibiotic es/Pellets, and pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with additional ents to aid in flow, disintegration and lubrication (for tableting machine). The blended powder is compress coated over the small EC s / Microtablets using compress coat ing machine. The tablets are further film coated using aqueous or solvent coating on in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Example: Final Product — Tablet-in-Capsule (Hard gelatin) (1) - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Antibiotic Granules/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 13% pH 7.2 to 7.5 c Coated (EC) Symbiotic Granules/Pellets 13% Excipients (Microcrystalline cellulose — filler, polyVinylpyrrolidone — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, ium stearate - lubricant) Hard Gelatin/HPMC Capsules The Uncoated Antibiotic Granules/Pellets, pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets and pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into s / Microtablets using tableting equipment. The excipients and the tablets filled into hard gelatin capsules using specialized encapsulating equipment.

Example: Final t — Tablet-in-Capsule (Hard gelatin) (2) - Formulation/Manufacturing Process (at local CMO, lled room and humidity ions throughout the process): Uncoated Antibiotic Granules/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 13% pH 7.2 to 7.5 c Coated (EC) Symbiotic Granules/Pellets 13% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone — 24% binder, atinized starch - egrant and silicon e — flow aid, magnesium stearate - lubricant) Hard Gelatin / HPMC es 5% The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar r with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into small tablets / Microtablets using tableting equipment. The above Uncoated Antibiotic Granules/Pellets, and pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with additional excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powder and tablets are filled into large Hard Gelatin Capsules using encapsulating equipment.

Example: Final Product — -in-Capsule (Hard gelatin) (3) - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Antibiotic Granules/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 13% pH 5. 5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets l3% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone — binder, pregelatinized starch - disintegrant and silicon e — flow aid, magnesium stearate - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive coating) 4% Hard Gelatin/HPMC Capsules 5% Water/Solvents as required 0% The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The d powders are compressed into small s / Microtablets using tableting equipment. The compressed s are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating on of “Polymers” in a coating pan or fluid bed drier/coater with optimized ions (“EC tablets”). The above Uncoated Antibiotic Granules/Pellets, and pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine).

The blended powder and the EC tablets are filled into a larger capsule using encapsulating equipment.

Example: Final Product — Bi-Layer Tablets - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions hout the process): Ingredients Amount (%) Uncoated Antibiotic Granules/Pellets 45% pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 13% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - ant) pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 13% HPMC or lent “polymers” (Film coat) 1% Water/Solvents as required 0% The above Uncoated Antibiotic Granules/Pellets, and pH 5.0 to 6.0 c Coated (EC) Antibiotic es/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into tablets using bi-layer ing equipment (“EC Tablets”). The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powder is compressed over the EC tablets using bilayer tableting machine. The tablets are filrther film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Example: Final Product — Tri-Layer Tablets - Formulation/Manufacturing s (at local CMO, controlled room and humidity conditions throughout the process): ed Antibiotic Granules/Pellets 45% Excipients (Microcrystalline cellulose — flller, polyvinylpyrrolidone 28% — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets 13% pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 13% HPMC or equivalent “polymers” (Film coat) 1% Water/Solvents as required 0% The above Uncoated Antibiotic Granules/Pellets intermediate formulations is blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and ation (for tableting machine). The blended powders are compressed into tablets using tri-layer tableting equipment (“EC Tablets-l”). The above pH 5.0 to 6.0 Enteric Coated (EC) Antibiotic Granules/Pellets intermediate formulation is blended in desired portions in V-type or similar blender with additional ents to aid in flow, disintegration and lubrication (for tableting machine). The blend is compressed over the first layer of tablets (EC Tablets-l) using tri-layer tableting equipment (“EC Tablets-2”). The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets ediate formulations are blended in desired portions in V-type or similar blender with onal ents to aid in flow, disintegration and lubrication (for tableting machine). The d powder is compressed over the second layer of tablets (EC tablets-2) using yer tableting machine. The s are filrther film coated using s or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Final Product Packaging (at local CMO, dry low humidity and low oxygen (N2 purging) conditions hout the process): The above es are packaged in sachet, and the coated s, capsules are packaged into bottles with induction sealing or blistered at low humidity (at or below 40% RH) and lled room temperature conditions (at 20 to 25 degrees C).

Quality Control Release Testing (Active Pharmaceutical Ingredient (API) and Final Drug Product) Symbiotic — Test Methods and Assessment Description es, pellets, tablets, es in blisters or s or sachets Visual inspection for color, shape, etc.

Identification Genes, species, strains. Morphological appearance via Microscopic evaluation and /or multiplex PCR as well as other tests including biochemical methods such as fermentation profile or pic methods, e.g. ribotyping, restriction fragment length polymorphism (RFLP), or both.

In addition, develop a specific identity assay for critical biological activity. Others test may include: DNA-DNA hybridization to specify strains in species; DNA sequence coding per WHO; Strain typing e Pulsed Field Gel electrophoresis (PFGE), etc.

Potency — Microscopic testing, or Opacity to measure viable cells per organisms unit or dose, i.e. colony forming units (CFU) Potency Assay Assessment of CFU (on solid medium) and tests to correlating with activity. M-viability plating.

Purity Endotoxin content, residual antibiotics, and/or the fication of residual toxic components or contaminants introduced during manufacture by Elisa or amino acid profile Microbial bioburden or Extraneous als including pathogens by using Elisa or contaminants and limits amino acid profile or SDS page or ion exchange chromatography, etc. Microbial limits by US Pharmacopeia (USP 31 <61>).

Percent Viable cells Micro testing after regrown in appropriate media and test, e.g., Dead/live assay by ATP. Also determination of non- Viable units per g i.e., by electro-zone count of non- fluorescent cells (SDS PAGE) Particulate matter USP 31 <788> Pyrogens TBD pH Testing pH meter Residual moisture Water content, USP 31 <921> Content Uniformity TBD Package Integrity Leaker test by vacuum Stability y, Viable cell determination, microbial contamination, pH an residual moisture Antibiotic(s) Impurities and d sub HPLC and other Symbiotic and antibiotic Test Methods and Assessment ro release testing : pH 1 buffer (simulated gastric), pH 6 buffer, pH (Via dissolution testing 7.2 to 7.5 buffer (simulated intestinal fluid), followed by pH equipment) : USP 5.5 — 6.2 buffer (simulated colonic fluid). paddle or basket Sample Times: pH 1 buffer - 1 hour pH 6 buffer - 1 hour pH 7.2 to 7.5 - 1,2, 3 and 4 hours pH 5.5 to 6.2 — 1,2,4 and 8 hours Symbiotic Assay: Microbiology testing for count (cfu/gram) for Antibiotic Assay: HPLC Stability testing (0, 6, Symbiotic: 12, 18 and 24 months): Identification, y, viable cell determination, ial contamination, pH and residual moisture, etc.

Antibiotic: Identification, Assay, Impurities, Related Substances, microbial contamination, pH and residual moisture, etc.

Fecal Microbiota Transplantation (MET).

Materials and Methods: Described below are formulations that are being made and tested for the target delivery for testing in ical assays, the formulation having an y human bacterial fecal flora for release at pH 5.5 - 6.2 in right colon every 24 hours.

Active Pharmaceutical Ingredient (API): 1 0 Human ial fecal flora donated by health human volunteers, screened for safety.

Osmotic agents: proteins (casein, hydrolyzed protein, etc.), peptides, amino acids (L-Leucine), carbohydrates glucose, e, starches, inulin, sodium chloride, phosphate buffers, etc. Lallemand and other high quality global 1 5 suppliers.

Inactive Ingredients (Excipients): Fillers and carriers: Microcrystalline, , HPMC or equivalent “polymers”, hard HPMC capsules, soft gelatin and other materials, etc. - purchased from local US supplier such as FMC, Capsugel, Colorcon, as well as pregelatinized starch — disintegrant, n dioxide — flow aid, magnesium stearate - lubricant) from various reputable excipient suppliers.

Intermediate Formulation/Manufacturing Process (at local CMO): “Dried Healthy Human Bacterial Fecal Flora” : ients Amount (%) Healthy human donor’s bacterial fecal flora 40% Inactive ingredients - L. Leucine, sodium chloride, and/or dextrose, 40% etc.

Inactive ingredients - phosphate buffer, tylexopol, and/or sodium 20% ate, etc.

Water as required 0% Dissolve the phosphate buffer, sodium chloride, and/or dextrose, etc. in water. Add the healthy human donor’s ial fecal flora material to the mix and stir in a mixer.

Pass the suspension through a large mesh filter to remove insoluble material (flora mix). Dissolve the phosphate , tylexopol, and/or sodium glutamate, etc. in water and the dilute the flora mix. Fill into vials and freeze dry the mix or pass through sprayer drier or foam drier to remove moisture and produce fine powder.

“Dried Human ial Fecal Flora Granules” (75-100 micron range): Dried Human Bacterial Fecal Flora Excipients (Microcrystalline cellulose — filler, pregelatinized starch — disintegrant, silicon dioxide — flow aid, ium stearate - lubricant) Prepare a dry granulation with Dried Human Bacterial Fecal Flora and excipients in a low shear mixer.

Example: Final Product — Capsules (HPMC) — Formulation/Manufacturing Process (at local CMO, lled room temperature, humidity and oxygen ions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora 15% Polymers” (pH 5.5 to 6.2 sensitive coating) 25% Polymers” (pH 7.2 to 7.5 sensitive coating) 25% HPMC or equivalent “polymers” (Barrier and Seal coats) 5% HPMC Capsules 30% The above Dried Human Bacterial Fecal Flora is filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive g using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a g pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are r coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a g pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Capsules (HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount Dried Human Bacterial Fecal Flora es 68% Polymers” (pH 5.5 to 6.2 sensitive g) 10% rs” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% HPMC Capsules The above Dried Human ial Fecal Flora Granules are filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 ive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or t coating solution ofHPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are fiarther coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent g solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Liquid Filled Soft Gelatin/Veggie Gel Capsules — Formulation/Manufacturing Process (at local CMO, controlled room ature, humidity and oxygen conditions throughout the s): ients Amount (%) Dried Human Bacterial Fecal Flora 15% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) Polymers” (pH 5.5 to 6.2 sensitive coating) Polymers” (pH 7.2 to 7.5 sensitive coating) HPMC or equivalent ers” (Barrier and Seal coats) Vegetable gel mix or gelatin for producing veggie or soft n capsules The above Dried Human Bacterial Fecal Flora is mixed with Vegetable oil (immiscible liquid) and/or other no-aqueous ients (paste) in a blender using optimum conditions. The e is filled with vegetable gel mix or gelatin in an encapsulation equipment for producing veggie or soft gelatin capsules. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized WO 52338 conditions. The coated capsules are barrier coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated es are r coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final t — Liquid Filled Hard Capsules (e.g. HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions hout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora 15% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) Polymers” (pH 5.5 to 6.2 sensitive coating) Polymers” (pH 7.2 to 7.5 sensitive coating) HPMC or equivalent “polymers” (Barrier and Seal coats) Hard Gelatin/HPMC capsules The above Dried Human Bacterial Fecal Flora is mixed with ble oil (immiscible liquid) and/or other no-aqueous ingredients ) in a blender using optimum conditions. The e is filled into hard HPMC capsules using an encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using zed conditions. The coated capsules are barrier coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 sensitive g using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Capsule-in-Capsule (HPMC)(l) — Formulation/Manufacturing Process (at local CMO, lled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora Granules 35% Excipients (Microcrystalline cellulose — filler, pregelatinized starch — disintegrant, n e — flow aid, magnesium stearate - lubricant) rs” (pH 5.5 to 6.2 sensitive coating) Polymers” (pH 7.2 to 7.5 ive coating) HPMC or lent “polymers” (Barrier and Seal coats) HPMC Capsules The above Dried Human Bacterial Fecal Flora Granules are filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are r coated with aqueous or solvent coating solution ofHPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The above Excipients along with the smaller filled es are further filled into larger capsules using specialized capsule filling equipment and optimized conditions. The larger capsules are fiarther coated with pH 7.2 to 7.5 sensitive g using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using zed conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using zed conditions.

Example: Final Product — Softgel Capsule-in-Capsule (e.g. soft gelatin)(2) — Formulation/Manufacturing s (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora 15% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) Polymers” (pH 5.5 to 6.2 sensitive coating) Polymers” (pH 7.2 to 7.5 sensitive g) HPMC or equivalent “polymers” (Barrier and Seal coats) Vegetable gel mix or gelatin for producing veggie or soft gelatin es The above Dried Human Bacterial Fecal Flora is filled with vegetable gel mix or gelatin in encapsulation equipment for producing veggie or soft gelatin capsules using optimum ions. The veggie or soft gelatin capsules along with ble oil are together encapsulated using another encapsulation equipment for producing larger veggie or soft gelatin capsules. The larger capsules are coated with pH 5.5 to 6.2 sensitive g using s or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are r coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 sensitive g using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized ions.

Example: Final Product — Tablet-in-Capsule (HPMC) — Formulation/ Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Dried Human Bacterial Fecal Flora Granules Polymers” p(H 5. 5 to 6.2 sensitive coating) 10% Polymers” (pH 7.2 to 7.5 sensitive coating) 2014/027228 HPMC or equivalent “polymers” (Barrier and Seal coats) HPMC Capsules The above Dried Human Bacterial Fecal Flora Granules are compressed into soft microtablets using compression machine and optimum conditions. The microtablets are then filled into small es using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using zed conditions.

The coated es are barrier coated with aqueous or solvent coating solution of HPMC or lent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The ated capsules are r coated with pH 7.2 to 7.5 ive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or t coating solution of HPMC or equivalent “polymers” in a g pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Tablet-in-Capsule (Liquid Filled Soft Gelatin/Veggie Gel) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions hout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora Granules 35% Vegetable oil (immiscible liquid) and/or other no-aqueous ients (paste) Polymers” (pH 5.5 to 6.2 sensitive coating) Polymers” (pH 7.2 to 7.5 sensitive coating) HPMC or equivalent “polymers” (Barrier and Seal coats) Vegetable gel mix or gelatin for producing veggie or soft gelatin capsules The above Dried Human Bacterial Fecal Flora Granules are compressed into soft microtablets using compression machine and optimum conditions. The microtablets and the vegetable oil mix are filled with vegetable gel mix or gelatin in an encapsulation equipment for producing veggie or soft gelatin capsules. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or solvent coating on of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are filrther coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent g solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent g solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Final Product Packaging (at local CMO, dry low humidity and low oxygen (N2 purging) conditions throughout the process). The above es are packaged in sachet, and the coated tablets, capsules are packaged into bottles with induction sealing or blistered at low humidity (at or below 40% RH) and controlled room temperature conditions (at 20 to 25 s C). y Control Release Testing (Active Pharmaceutical Ingredient (API) and Final Drug Product) Human Bacterial Fecal Flora Test Methods and Assessment Description Powder, Granules, capsules in rs or bottles or sachets Appearance Visual inspection for color, shape, etc.

Identification Genes, species, strains. Morphological appearance via Microscopic evaluation and /or multiplex PCR as well as other tests including biochemical methods such as fermentation profile or genotypic methods, e.g. ribotyping, restriction fragment length rphism (RFLP), or both.

In addition, develop a specific identity assay for critical ical activity. Others test may include: DNA-DNA hybridization to specify strains in species; DNA sequence coding per WHO; Strain typing include Pulsed Field Gel electrophoresis (PFGE), etc.

Potency — Viable Microscopic testing, or Opacity to measure viable cells per organisms unit or dose, i.e. colony forming units (CFU) Potency Assay Assessment of CFU (on solid ) and tests to correlating with activity. M-viability plating. Elisa or amino acid profile.

Purity / Related Endotoxin content, antibiotic residue and/or the substances quantification of residual toxic components or contaminants uced during manufacture by Elisa or amino acid profile; SDS page and or amino acid profile.

Microbial bioburden or Extraneous materials including pathogens by using Elisa or contaminants and amino acid profile or SDS page or ion exchange limits (related chromatography, etc. Microbial limits by US Pharmacopeia substances) (USP 31 <6l>).

Percent viable cells Micro testing after regrown in appropriate media and test, e.g., Dead/live assay by ATP. Also ination of non- viable units per g i.e., by electro-zone count of non- fiuorescent cells (SDS PAGE) ulate matter USP 31 <788> Pyrogens TBD pH Testing pH meter Residual moisture Water content, USP 31 <92l> Content Uniformity ATP Live/Dead Assay ATP Heavy metals Inductively Coupled Plasma-Atomic Emission Spectrophotometry (ICP-AES); Inductively Coupled -Mass Spectroscopy (ICP-MS); Atomic Emission Spectrophotometry (AES); or Atomic Absorption Spectrophotometry (AAS).

Water content Karl Fischer Package Integrity Leaker test by vacuum ity Potency, viable cell determination, ial contamination, pH an residual moisture In-vitro release testing USP paddle or basket (via dissolution testing Medium: pH 1 buffer (simulated gastric), pH 6 buffer, pH equipment) : 7.2 to 7.5 buffer (simulated intestinal fluid), followed by pH .5 — 6.2 buffer (simulated colonic fluid).

Sample Times: pH 1 buffer - 1 hour pH 5.5 — 6.2 buffer — 1,2, 3 and 4 hours pH 7.2 to 7.5 - 1,2,3 and 4 hours pH 5.5 to 6.2 — l, 2, 4 and 8 hours Human Bacterial Fecal Flora — Assay: Microbiology testing for count (cfu/gram) Stability testing (0, 6, Identification, Appearance, y, viable cell 12, 18 and 24 ): determination, microbial contamination, pH and residual moisture, d substance, water t, Live/dead Assay, etc.

Fecal Microbiota Transplantation (MET) with C. dz'fiz‘cile anti-toxin (CDAT) als and Methods: Described below are formulations that are being made and tested for the target delivery for testing in biological assays, the ation having an Healthy human bacterial fecal flora for release at pH 5.5 - 6.2 in right colon every 24 hours.

Active Pharmaceutical Ingredient (API): Human bacterial fecal flora donated by health human volunteers, screened for safety.

C. dz'fi‘zcile anti-toxin (CDAT) provided from specialty supplier Osmotic agents: proteins (casein, hydrolyzed protein, etc.), peptides, amino acids (L-Leucine), ydrates glucose, lactose, starches, inulin, sodium chloride, phosphate buffers, etc. Lallemand and other high quality global suppliers.

Inactive Ingredients (Excipients): Fillers and carriers: rystalline, , HPMC or equivalent p“o”lymers, hard HPMC capsules, soft gelatin and other materials, etc - purchased from local US supplier such as FMC, Capsugel, Colorcon, as well as pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) from various reputable excipient ers.

Intermediate Formulation/Manufacturing Process (at local CMO): “Dried Healthy Human Bacterial Fecal Flora” : Ingredients Amount (%) Healthy human donor’s bacterial fecal flora 40% Inactive ingredients - L. Leucine, sodium chloride, and/or dextrose, 40% etc.

Inactive ingredients - phosphate , tylexopol, and/or sodium 20% glutamate, etc.

Water as required 0% Dissolve the ate buffer, sodium de, and/or dextrose, etc. in water. Add the healthy human donor’s bacterial fecal flora material to the mix and stir in a mixer.

Pass the suspension h a large mesh filter to remove insoluble material (flora mix). Dissolve the phosphate buffer, tylexopol, and/or sodium glutamate, etc. in water and the dilute the flora mix. Fill into vials and freeze dry the mix or pass through sprayer drier or foam drier to remove moisture and produce fine powder.

“Dried Human Bacterial Fecal Flora Granules” (75-100 micron : Dried Human Bacterial Fecal Flora Excipients (Microcrystalline cellulose — filler, pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Prepare a dry granulation with Dried Human Bacterial Fecal Flora and excipients in a low shear mixer. “CDAT Granules” (75-100 micron range): Excipients (Microcrystalline cellulose — filler, pregelatinized starch — disintegrant, silicon dioxide — flow aid, ium stearate - lubricant) Prepare a dry granulation with CDAT and excipients in a low shear mixer.

Example: Final Product — Capsules (HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen ions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora 10% CDAT 5% rs” (pH 5.5 to 6.2 sensitive coating) 25% Polymers” (pH 7.2 to 7.5 sensitive coating) 25% HPMC or equivalent “polymers” (Barrier and Seal coats) 5% HPMC Capsules 30% The above Dried Human Bacterial Fecal Flora and the CDAT is filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive g using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or t coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 ive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with s or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed coater using optimized conditions. e: Final Product — Capsules (HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Dried Human ial Fecal Flora Granules 34% CDAT Granules 34% rs” (pH 5.5 to 6.2 sensitive coating) 10% Polymers” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% HPMC Capsules 10% The above Dried Human Bacterial Fecal Flora and CDAT Granules are filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated With aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent g solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized ions.

Example: Final Product — Liquid Filled Soft Gelatin/Veggie Gel Capsules — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen ions throughout the process): Dried Human Bacterial Fecal Flora CDAT 5% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients 53% (paste) Polymers” (pH 5.5 to 6.2 sensitive g) 10% Polymers” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent ers” (Barrier and Seal coats) 2% Vegetable gel mix or gelatin for producing veggie or soft gelatin capsules 10% The above Dried Human Bacterial Fecal Flora and CDAT are mixed with Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) in a r using m conditions. The mixture is filled with vegetable gel mix or gelatin in encapsulation equipment for producing veggie or soft gelatin capsules. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed coater using optimized conditions. The coated capsules are r coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using zed conditions. The film-coated capsules are filrther coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Liquid Filled Hard es (e.g. HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): ients Amount (%) Dried Human Bacterial Fecal Flora 10% CDAT 5% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) rs” (pH 5.5 to 6.2 sensitive coating) WO 52338 rs” (pH 7.2 to 7.5 sensitive coating) HPMC or lent ers” (Barrier and Seal coats) Hard Gelatin/HPMC capsules The above Dried Human Bacterial Fecal Flora and CDAT are mixed with Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients (paste) in a blender using optimum conditions. The mixture is filled into hard HPMC capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a g pan or fluid bed drier/coater using optimized ions. The coated capsules are barrier coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a g pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating on of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Capsule-in-Capsule (HPMC)(l) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount Dried Human Bacterial Fecal Flora Granules 23% CDAT Granules l2% Excipients crystalline cellulose — filler, pregelatinized starch — 33% disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Polymers” (pH 5.5 to 6.2 sensitive coating) 10% Polymers” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% HPMC Capsules 10% The above Dried Human Bacterial Fecal Flora and CDAT Granules are filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated With aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The above Excipients along with the smaller filled capsules are further filled into larger es using specialized capsule filling equipment and optimized ions. The larger capsules are fiarther coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating on of HPMC or equivalent “polymers” in a coating pan or fluid bed coater using optimized conditions.

Example: Final Product — Capsule-in-Capsule (HPMC)(2) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the s): Ingredients Amount (%) Dried Human Bacterial Fecal Flora Granules 23% CDAT Granules 12% Excipients (Microcrystalline cellulose — filler, pregelatinized starch — 33% disintegrant, silicon dioxide — flow aid, ium stearate - lubricant) Polymers” (pH 5.5 to 6.2 ive coating) 10% Polymers” (pH 7.2 to 7.5 sensitive g) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% HPMC es 10% The above Dried Human ial Fecal Flora are filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or solvent g on of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The above Excipients along with the, CDAT and smaller filled capsules are filrther filled into larger capsules using specialized capsule filling equipment and optimized conditions. The larger es are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating on of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using zed conditions.

Example: Final Product — Softgel Capsule-in-Capsule (e.g. soft n)(3) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora 10% CDAT 5% Vegetable oil (immiscible liquid) and/or other no-aqueous ingredients 53% (paste) Polymers” (pH 5.5 to 6.2 sensitive g) 10% Polymers” (pH 7.2 to 7.5 sensitive g) 10% HPMC or equivalent “polymers” er and Seal coats) 2% Vegetable gel mix or gelatin for producing veggie or soft n capsules 10% The above Dried Human Bacterial Fecal Flora is filled with vegetable gel mix or gelatin in encapsulation equipment for producing veggie or soft gelatin capsules using optimum conditions. The veggie or soft gelatin capsules along with vegetable oil are together encapsulated using another encapsulation equipment for producing larger veggie or soft gelatin capsules. The larger capsules are coated with pH 5.5 to 6.2 ive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed coater using optimized conditions. The film-coated capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent ers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final t — Tablet-in-Capsule (HPMC) — Formulation/ Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora Granules 45.3% CDAT Granules 22.7% Polymers” (pH 5.5 to 6.2 sensitive coating) 10% rs” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% HPMC Capsules 10% The above Dried Human Bacterial Fecal Flora Granules are compressed into soft microtablets using compression machine and optimum conditions. The microtablets and the CDAT Granules are then filled into small capsules using encapsulation equipment. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating on of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with s or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated capsules are r coated with pH 7.2 to 7.5 ive coating using aqueous or t coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are finally seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using zed conditions.

Example: Final Product — -in-Capsule (Liquid Filled Soft Gelatin/Veggie Gel) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions hout the process): Ingredients Amount (%) Dried Human Bacterial Fecal Flora Granules 23% CDAT 12% Vegetable oil (immiscible liquid) and/or other no-aqueous ients 33% (paste) Polymers” (pH 5.5 to 6.2 sensitive coating) 10% Polymers” (pH 7.2 to 7.5 sensitive coating) 10% HPMC or equivalent “polymers” (Barrier and Seal coats) 2% Vegetable gel mix or gelatin for producing veggie or soft gelatin capsules 10% The above Dried Human Bacterial Fecal Flora Granules are compressed into soft microtablets using compression machine and optimum ions. The microtablets, CDAT and the vegetable oil mix are filled with ble gel mix or gelatin in encapsulation equipment for ing veggie or soft gelatin capsules. The capsules are coated with pH 5.5 to 6.2 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are barrier coated with aqueous or solvent coating on of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The film-coated es are filrther coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater using optimized conditions. The coated capsules are y seal coated with s or solvent coating solution of HPMC or lent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Final Product Packaging (at local CMO, dry low humidity and low oxygen (N2 purging) conditions throughout the process). The above granules are packaged in sachet, and the coated tablets, capsules are ed into bottles with induction sealing or blistered at low humidity (at or below 40% RH) and controlled room temperature conditions (at 20 to 25 degrees C).

Quality Control Release Testing (Active ceutical ient (API) and Final Drug Product). Human Bacterial Fecal Flora — Test Methods and Assessment Description Bacterial flora and CDAT: Powder, Granules, capsules in blisters or s or sachets Appearance Bacterial flora and CDAT: Visual inspection for color, shape, etc.

Identification Bacterial flora: Genes, s, strains. Morphological appearance via Microscopic evaluation and /or lex PCR as well as other tests including biochemical methods such as fermentation profile or genotypic methods, e.g. ribotyping, restriction fragment length polymorphism (RFLP), or both. In addition, develop a specific identity assay for critical biological activity. Others test may include: DNA-DNA hybridization to specify strains in species; DNA sequence coding per WHO; Strain typing include Pulsed Field Gel electrophoresis (PFGE), etc.

CDAT: Amino acid profile Potency Bacterial flora (Viable organisms): Microscopic testing, or Opacity to e viable cells per unit or dose, i.e. colony forming units (CFU) CDAT: Elisa and amino acid profile Potency Assay Bacterial flora: Assessment of CFU (on solid medium) and tests to correlating with activity. M-viability plating. Elisa or amino acid .

CDAT: Elisa and amino acid profile Purity / Related Bacterial flora: Endotoxin content, antibiotic residue substances and/or the quantification of residual toxic components or contaminants introduced during manufacture by Elisa or amino acid ; SDS page and or amino acid profile.

CDAT: Elisa or amino acid profile; SDS page and or amino acid profile.

Microbial bioburden or Bacterial flora and CDAT: Extraneous materials including contaminants and pathogens by using Elisa or amino acid profile or SDS page limits (related or ion exchange chromatography, etc. Microbial limits by substances) US Pharmacopeia (USP 31 <6l>).

Percent viable cells ial flora: Micro testing after regrown in appropriate media and test, e.g., Dead/live assay by ATP. Also determination of non-viable units per g i.e., by electro-zone count of non-fluorescent cells (SDS PAGE) Particulate matter Bacterial flora and CDAT: USP 31 <788> Pyrogens Bacterial flora and CDAT: TBD pH Testing Bacterial flora and CDAT: pH meter Residual moisture Bacterial flora and CDAT: Water content, USP 31 <921> Content Uniformity Bacterial flora: ATP CDAT: Elisa or amino acid profile ead Assay Bacterial flora: ATP Heavy metals ial flora and CDAT: Inductively Coupled - Atomic Emission Spectrophotometry ES); Inductively Coupled Plasma-Mass Spectroscopy (ICP-MS); Atomic Emission Spectrophotometry (AES); or Atomic tion Spectrophotometry (AAS).

Water content Bacterial flora and CDAT: Karl Fischer e Integrity Bacterial flora and CDAT: Leaker test by vacuum ity Bacterial flora: Potency, viable cell determination, microbial contamination, pH an residual moisture CDAT: Potency, pH an residual moisture In-vitro release testing Bacterial flora: USP paddle or basket (via dissolution testing Medium: pH 1 buffer (simulated gastric), pH 6 buffer, pH equipment) : 7.2 to 7.5 buffer ated intestinal fluid), followed by pH .5 — 6.2 buffer (simulated colonic fluid).

Sample Times: pH 1 buffer - 1 hour pH 5.5 — 6.2 buffer — 1,2, 3 and 4 hours pH 7.2 to 7.5 - 1,2, 3 and 4 hours pH 5.5 to 6.2 — 1,2,4 and 8 hours Human Bacterial Fecal Flora — Assay: Microbiology testing for count (cfu/gram) ; CDAT: Assay Stability testing (0, 6, Bacterial flora: Identification, Appearance, Potency, viable 12, 18 and 24 months): cell determination, microbial contamination, pH and residual moisture, related substance, water content, Live/dead Assay, etc.

CDAT: Identification, Appearance, Potency, pH and residual moisture, related substance, water content, etc. e 2: Obesity, Metabolic Syndrome and Type 2 Diabetes Obesity results from alterations in the body's regulation of energy , expenditure, and storage. Animal and human data demonstrate that phylogenic changes occur in the microbiota composition in obese individuals. rmore, evidence from animal models suggest that the alterations of the gut microbiota with obesity results in increased energy tion and lipid tion, altered e of entero-hormones, increased inal permeability and metabolic endotoxemia. Treatment with pre- and probiotics may reverse many of metabolic s linked with the altered microbiota in obese patients. The gut microbiota is, therefore, a potential nutritional and cological target for the management of obesity and obesity-related disorders (12).

Materials and Methods: Described below are methods and materials toward the making and testing of a formulation according to the invention for the treatment of Metabolic Syndrome, Obesity and type 2 diabetes.

Target Delivery: Target Delivery: Symbiotic (prebiotic: L-Leucine probiotic: live s of lactobacz'llus, bifidobacterz'um and Faecalz'bacterl'um prausm'tzz'l') for release at 7.2 — 7.5 in ileum every 24 hours.

WO 52338 Active Pharmaceutical Ingredient (API): Prebiotics - proteins (casein, hydrolyzed protein, etc.), peptides, amino acids (L-Leucine), carbohydrates glucose, lactose, starches, dextrose monohydrate, inulin, etc.: provided by Roquette, etc. and certain ial strains: provided by Denisco, CHR Hansen, Institu Risell — Lallemand and other high quality global suppliers of prebiotics. Live probiotics Species of: lactobacz'llus, bifidobacterz'um and Faecalz'bacterl'um prausm'tzz'z' are provided by Denisco, CHR Hansen, Institu Risell — Lallemand and other high quality global suppliers.

Inactive ients (Excipients): Microcrystalline, pregelatinized starch, polyvinylpyrrolidone, silicon dioxide, HPMC or equivalent “polymers”, hard gelatin es, and other fillers, etc. - purchased from local US supplier such as FMC, Capsugel, Colorcon, Evonik, etc. Intermediate Formulation/Manufacturing Process (at local CMO, controlled room and ty conditions hout the process): “Uncoated Symbiotic Granules/Pellets” (100 micron) Ingredients Amount (%) Freeze dried bacteria (species of lactobacillus, bz'fidobacterium 0.90% andfaecalibacterz'um prausnz'tzz'z') (probiotic) L-Leucine 0. l% Excipients crystalline cellulose — filler, 99% polyvinylpyrrolidone — binder, atinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Water as required 0% Prepared by mixing l-leucine, suspension or freeze dried ia (species of lactobacz'llus, acterz'um and faecalibacterium prausnl'tzz'z') With water and further spray/ freeze dried to remove water using optimized conditions. The probiotic powder is mixed with excipients in V-blender or similar blender. “pH 7.2 to 7.5 Enteric Coated Symbiotic Granules/Pellets” (100 micron) Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 95% HPMC or equivalent “polymers” (Barrier and Seal coats) 1% “Polymers” (pH 7.2 to 7.5 ive coating) 4% Water/Solvents as required 0% The Uncoated Symbiotic es/Pellets are coated (the barrier coat) with aqueous or solvent coating on of HPMC or equivalent “polymers” to coat in a coating pan or fluid bed drier/coater using optimized conditions. The barrier coated micropellets or es are r coated with aqueous or t coating solution of pH 7.2 to 7.5, sensitive coating “Polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The above pH 7.2 to 7.5 sensitive coated micropellets or granules are seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

“Uncoated dextrose monohydrate Pellets/Granules” Ingredients Amount (%) Dextrose monohydrate 80% Excipients (Microcrystalline cellulose — filler, 20% polyvinylpyrrolidone — , pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Water as required 0% Prepared by dry and/0r wet granulating dextrose monohydrate, with excipients in high or low shear mixer and filrther pelletizing using extruder / spheronizer and then drying to remove water using optimized conditions. “pH 7.2 to 7.5 Enteric Coated Dextrose Monohydrate Granules/Pellets” (100 micron) Ingredients Amount (%) ed se Monohydrate Granules/Pellets 95% WO 52338 HPMC or equivalent “polymers” (Barrier and Seal coats) “Polymers” (pH 7.2 to 7.5 ive coating) Water/Solvents as required The Uncoated Dextrose Monohydrate Granules/Pellets are r coated (barrier coat) with s or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. The above micropellets or granules are fidrther coated with aqueous or solvent coating solution of “Polymers” (pH 7.2 to 7.5 sensitive coating) in a coating pan or fluid bed drier/coater using optimized conditions. The above micropellets or es are seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

Example: Final Product — Sachet — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Intermediate Formulation Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets pH 7.2 to 7.5 Enteric Coated (EC) Dextrose Monohydrate 90% Granules/Pellets Excipients (Mannitol — filler, n dioxide — glidant/flow aid) The above pH 7.2 to 7.5 Enteric Coated (EC) tic and Dextrose Monohydrate Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow. The blended powders are filled into sachets using powder filling equipment. e: Final Product — Capsules (Hard gelatin/HPMC) — ation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the s): Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 1% Uncoated Dextrose drate Granules/Pellets 83% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 7% glidant/flow aid) Hard Gelatin/HPMC es 7% “Polymers” (pH 7.2 to 7.5 sensitive coating) 2% Water/Solvents as required 0% The above Uncoated Symbiotic and Dextrose Monohydrate Granules/Pellets intermediate formulations are d in desired portions in V-type or similar blender with ents to aid in flow. The blended powders are filled into capsules using ulating equipment. The filled capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed coater with optimized ions.

Example: Final Product — Capsules (Hard gelatin/HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room and ty conditions throughout the process): pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 1% pH 7.2 to 7.5 Enteric Coated (EC) Dextrose Monohydrate 85% Granules/Pellets Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 7% glidant/flow aid) Hard Gelatin/HPMC Capsules 7% The above pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic and Dextrose Monohydrate Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with excipients to aid in flow. The blended powders are filled into capsules using ulating equipment Example: Final Product — es (Hard gelatin/HPMC)(2) — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 1% Uncoated Dextrose Monohydrate Granules/Pellets 81% Excipients (Microcrystalline ose — filler, Silicon dioxide — 7% glidant/flow aid) Hard n/HPMC Capsules 7% “Polymers” (pH 7.2 to 7.5 sensitive coating) 4% Solvents as required 0% The above Uncoated Symbiotic and Dextrose Monohydrate Granules/Pellets intermediate ations are d in desired portions in V-type or similar blender with excipients to aid in flow. The blended powders are filled into capsules using encapsulating equipment. The filled capsules are enteric coated using s or solvent coating solution of Polymers” (pH 7.2 to 7.5 sensitive coating) in coating pan or fluid bed coating equipment using optimized conditions.

Example: Final Product — es Co-pack(2)(Hard Gelatin/HPMC capsules) — ation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 1% ed Dextrose Monohydrate Granules/Pellets 81% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 7% glidant/flow aid) Hard Gelatin/HPMC Capsules 7% “Polymers” (pH 7.2 to 7.5 sensitive coating) 4% Water/Solvents as required 0% The above Uncoated Symbiotic Granules/Pellets ediate formulation is blended in desired portions in V-type or similar blender with excipients. The blended powders are filled into smaller capsules using encapsulating equipment. The filled capsules are enteric coated using aqueous or solvent coating on of Polymers” (pH 7.2 to 7.5 sensitive coating) in coating pan or fluid bed coating equipment using optimized conditions. The above Uncoated Dextrose Monohydrate Granules/Pellets intermediate formulation is blended in desired portions in V-type or similar r with excipients to aid in flow. The d powders are filled into capsules using encapsulating ent. The filled capsules are enteric coated using aqueous or t coating solution of Polymers” (pH 7.2 to 7.5 sensitive coating) in coating pan or fluid bed coating equipment using optimized conditions. The Two capsules ts are co- packed Example: Final Product — es-Capsules Co-pack(2)(Liquid Filled Hard or Soft Gelatin/Hard Gelatin/HPMC capsules) — Formulation/ Manufacturing Process (at local CMO, lled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Coated (EC) Symbiotic Granules/Pellets 1% Vegetable oil (immiscible ) 8.5% Gelatin as powder and Hard Gelatin Capsules 0.5% Uncoated Dextrose Monohydrate Granules/Pellets 76% ents (Microcrystalline cellulose — filler, Silicon dioxide — 6% glidant/flow aid) Hard Gelatin/HPMC Capsules 6% “Polymers” (pH 7.2 to 7.5 ive coating) 2% Water/Solvents as required 0% The above Uncoated Symbiotic Granules/Pellets intermediate formulation is blended in desired portions with Vegetable oil (immiscible liquid) in a blender. Filled into capsules using soft or hard gelatin encapsulating equipment. The filled capsules are enteric coated using aqueous or solvent coating solution of Polymers” (pH 7.2 to 7.5 ive coating) in coating pan or fluid bed coating equipment using optimized conditions.

The above Uncoated Dextrose drate Granules/Pellets is blended in desired portion with excipients in V-type or similar. The blender is filled into capsules using encapsulating equipment. The filled capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a g pan or fluid bed drier/coater with zed ions.

Example: Final Product — Tablets / Microtablets - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions hout the process): Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 1% Uncoated se Monohydrate Granules/Pellets 81% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) HPMC or equivalent “polymers” er coat) ers” (pH 7.2 to 7.5 sensitive coating) Water/Solvents as required The above Uncoated Symbiotic and Dextrose Monohydrate Granules/Pellets intermediate formulations are blended in desired portions in V-type or similar blender with to aid in flow, disintegration and lubrication (for tableting machine). The d powders are compressed into Tablets / Microtablets using tableting equipment. The tablets are fiarther barrier coated in a coating pan or fluid bed dryer using aqueous or solvent coating solution of HPMC or equivalent “polymers” (Barrier coat). The barrier coated tablets are further enteric coated using aqueous or solvent coating solution of Polymers” (pH 7.2 to 7.5 sensitive coating) in coating pan or fluid bed coating equipment using optimized conditions. 2014/027228 Example: Final Product — Orally disintegrating Tablets (ODT) - Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets pH 7.2 to 7.5 Enteric Coated (EC) Dextrose Monohydrate Granules/Pellets Excipients (Microcrystalline cellulose — filler, pregelatinized starch - 14% disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) The pH 7.2 to 7.5 Enteric Coated (EC) Symbiotic and se Monohydrate Granules/Pellets intermediate formulation are blended in desired portions in V-type or similar blender with additional excipients to aid in flow. The blended powders are compressed into soft s using tableting equipment.

Example: Final Product — Tablets Co-pack(2)(Hard n/HPMC capsules) — Formulation/Manufacturing Process (at local CMO, controlled room and humidity conditions throughout the process): Ingredients Amount (%) Uncoated Symbiotic Granules/Pellets 1% Uncoated Dextrose Monohydrate es/Pellets 81% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 14% glidant/flow aid) HPMC or lent “polymers” (Barrier coat) 1% “Polymers” (pH 7.2 to 7.5 sensitive coating) 4% Water/Solvents as required 0% The above Uncoated Symbiotic Granules/Pellets ediate formulation is d in desired portions in V-type or similar r with excipients. The blended powders are compressed into Tablets / Microtablets using tableting equipment. The tablets are r barrier coated in a coating pan or fluid bed dryer using aqueous or solvent 2014/027228 g solution of HPMC or lent “polymers” (Barrier coat). The barrier coated tablets are fiarther enteric coated using aqueous or solvent coating solution of Polymers” (pH 7.2 to 7.5 sensitive coating) in coating pan or fluid bed coating equipment using optimized conditions. The above Uncoated Dextrose Monohydrate Granules/Pellets intermediate formulation is blended in desired portions in V-type or similar blender with ents. The blended powders are compressed into Tablets / Microtablets using tableting equipment. The tablets are fiarther r coated in a g pan or fluid bed dryer using aqueous or t coating on of HPMC or equivalent “polymers” (Barrier coat). The barrier coated tablets are further enteric coated using s or solvent coating solution of Polymers” (pH 7.2 to 7.5 sensitive g) in coating pan or fluid bed coating equipment using optimized conditions.

The two tablet products are ked.

Final Product Packaging (at local CMO, dry low humidity and low oxygen (N2 purging) conditions throughout the process). The above granules are packaged in sachet, and the coated tablets, as well as capsules are packaged into bottles with induction sealing or blistered (co-packs) at low humidity (at or below 40% RH) and controlled room temperature conditions (at 20 to 25 degrees C).

Quality Control Release Testing (Active Pharmaceutical Ingredient (API) and Final Drug Product) Symbiotic — Methods and Assessment Description Granules, pellets, tablets, capsules in blisters or bottles or sachets Appearance Visual inspection for color, shape, etc.

Identification Genes, species, strains. Morphological appearance Via copic evaluation and /or multiplex PCR as well as other tests including mical methods such as fermentation profile or genotypic methods, e.g. ribotyping, restriction fragment length polymorphism (RFLP), or both.

WO 52338 In addition, develop a specific identity assay for critical biological actiVity. Others test may include: DNA-DNA hybridization to specify strains in s; DNA sequence coding per WHO; Strain typing include Pulsed Field Gel electrophoresis (PFGE), etc.

Potency — Microscopic testing, or Opacity to measure Viable cells per organisms unit or dose, i.e. colony forming units (CFU) Potency Assay Assessment of CFU (on solid medium) and tests to correlating with ty. M-Viability plating.

Endotoxin content, residual antibiotics, and/or the quantification of residual toxic components or contaminants introduced during manufacture by Elisa or amino acid profile Microbial bioburden or eous materials including pathogens by using Elisa or contaminants and limits amino acid profile or SDS page or ion exchange chromatography, etc. Microbial limits by US Pharmacopeia (USP 31<61>).

Percent Viable cells Micro testing after regrown in appropriate media and tests, e.g., Dead/live assay by ATP. Also determination of non- Viable units per g i.e., by electro-zone count of non- fiuorescent cells (SDS PAGE) ulate matter USP 31 <788> Pyrogens Rabbit pyrogencity test (USP 31 <151>) pH g pH meter Residual moisture Water content, USP 31 <921> Content Uniformity ATP e ity Leaker test by vacuum Stability Potency, Viable cell determination, microbial contamination, pH an residual moisture In-Vitro release testing Medium: pH 1 buffer (simulated gastric), pH 6 , pH (Via dissolution testing 7.2 to 7.5 buffer (simulated intestinal fluid), followed by equipment) : USP pH 5.5 — 6.2 buffer (simulated colonic fluid). paddle or basket Sample Times: pH 1 buffer - 1 hour pH 6 buffer - 1 hour pH 7.2 to 7.5 - 1,2,3 and 4 hours pH 7.2 to 7.5 — l, 2, 4 and 8 hours Symbiotic Assay: Microbiology testing for count ram) for Stability testing (0, 6, Symbiotic: 12, 18 and 24 months): Identification, Potency, viable cell determination, microbial contamination, pH and residual moisture, etc.

EXAMPLE 3 Example 3 is directed toward the making and testing of a formulation according to the invention for the treatment of a Gastro intestinal reflux disease .

GERD is a chronic symptom of mucosal damage caused by h acid coming up from the stomach into the gus. GERD is usually caused by s in the barrier between the stomach and the gus, including al relaxation of the lower esophageal sphincter, which ly holds the top of the stomach closed, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. These changes may be permanent or temporary.

Treatment is typically via lifestyle changes and medications such as proton pump inhibitors, H2 receptor blockers or antacids with or without alginic acid. Surgery may be an option in those who do not improve. In the Western world between 10 and 20% of the population is affected. Probiotics or Fecal Microbiota For Transplation (FMT) (subject on another patent application) may also help in balancing microbiota before and after usage of proton pump inhibitors.

Materials and Methods: Described below are formulations that are being made and tested for the target delivery for testing in chemical and biological , the formulation having an proton pump inhibitor (e.g. Omeprazole magnesium, 22.4 mg equivalent to 20 mg 2014/027228 base (range: 10-40 mg)) (millimeter range) for release at pH 7.2 — 7.5 in ileum and symbiotic otic: L-Leucine; probiotic: species of: acillus and bz'fidobacterium) to FMT for release at pH 5.5 - 6.2 in right colon every 24 hours.

Active Pharmaceutical Ingredient (API): Proton pump inhibitor — For example, omeprazole ed by local generic US/non-US suppliers, e.g., Manus Aktteva, etc.

Prebiotics - proteins (casein, hydrolyzed protein, etc.), peptides, amino acids (LLeucine ), carbohydrates glucose, lactose, starches, inulin, etc. and certain bacterial strains: provided by Denisco, CHR Hansen, Institu Risell — and and other high quality global suppliers of prebiotics. Live probiotics Species of: lactobacillus and bifidobacterz'um provided by Denisco, CHR Hansen, Institu Risell — Lallemand and other high quality global suppliers or FMT from volunteers.

Inactive ients ients): Microcrystalline, starch, HPMC or equivalent “polymers”, hard gelatin es, and other fillers, etc. - purchased from local US supplier such as FMC, el, Colorcon, as well as polyvinylpyrrolidone — binder, pregelatinized starch — disintegrant, silicon e — flow aid, magnesium stearate - lubricant) from various reputable excipient ers.

Intermediate Formulation/Manufacturing Process (at local CMO): “Uncoated Proton pump inhibitor Granules/Pellets” (100 micron range): Ingredients Amount (%) Proton pump inhibitor 13% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone — 87% binder, pregelatinized starch — egrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Water as required 0% Prepare a dry granulation with proton pump inhibitor and excipients in a low or high shear mixer and/or perform wet granulations with water/solvent and further pelletize using extruder / spheronizer and then drying to remove excess water/solvent using optimized conditions. “pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets” (100 micron range): Uncoated Proton pump inhibitor Granules/Pellets HPMC or equivalent “polymers” (Barrier and Seal coats) “Polymers” (pH 7.2 to 7.5 sensitive coating) Water/Solvents as required The Uncoated Proton pump inhibitor Granules/Pellets are coated (the barrier coat) with aqueous or solvent coating solution of HPMC or equivalent “polymers” to coat in a coating pan or fluid bed coater using zed conditions. The barrier coated micropellets or granules are fiarther coated with aqueous or solvent coating solution of pH 7.2 to 7.5, sensitive coating “Polymers” in a coating pan or fluid bed coater using optimized conditions. The above pH 7.2 to 7.5, sensitive coated micropellets or es are seal coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions.

“Uncoated Symbiotic Granules/Pellets” (100 micron range): Ingredients Amount (%) L. Leucine (prebiotic) 5% Freeze dried bacteria priate species and strains of acillus 3% and bz'fidobacterz'um) tic) Excipients crystalline cellulose — filler, polyvinylpyrrolidone — 92% binder, pregelatinized starch — disintegrant, silicon dioxide — flow aid, magnesium stearate - lubricant) Prepare a dry blend with prebiotic, freeze dried bacteria and excipients in a low or high shear mixer. “pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets” (100 micron).

Uncoated Symbiotic Granules/Pellets HPMC or equivalent “polymers” (Barrier and Seal coats) ers” (pH 5.5 to 6.2 sensitive coating) Solvents as required The Uncoated Symbiotic Granules/Pellets are coated (barrier coat) with aqueous or t coating solution of HPMC or equivalent “polymers” in a g pan or fluid bed drier/coater using optimized conditions. The above barrier coated micropellets or granules are further coated with aqueous or solvent coating solution of “Polymers” (pH 5.5 to 6.2 sensitive coating) in a coating pan or fluid bed drier/coater using optimized conditions. The above pH 5.5 to 6.2 coated micropellets or granules are seal coated with s or solvent coating solution of HPMC or equivalent “polymers” in a coating pan or fluid bed drier/coater using optimized conditions. “pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic es/Pellets” (100 micron) . pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets HPMC or equivalent “polymers” (Barrier and seal coats) “Polymers” (pH 7.2 to 7.5 sensitive coating) Water/Solvents as required The above pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets are coated with aqueous or solvent coating solution of “Polymers” (pH 7.2 to 7.5 sensitive coating) in a coating pan or fluid bed drier/coater using optimized conditions. The above micropellets or granules are r coated with aqueous or solvent coating solution of HPMC or equivalent “polymers” (seal coat) in a g pan or fluid bed coater using optimized conditions.

Example: Final t — Sachet — Formulation/Manufacturing s (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic 15% Granules/Pellets Excipients (Mannitol — filler, Silicon dioxide — glidant/flow aid) 55% The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or r blender with excipients using optimized conditions. The blended powders are filled into sachets using powder filling ent.

Example: Final Product — Powder for Reconstitution — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% es/Pellets pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic 15% Granules/Pellets Excipients (Mannitol — filler, Silicon dioxide — glidant/flow aid) 55% Diluent 100 mL The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic es/Pellets are blended in desired portions in V-type or similar blender with excipients using optimized conditions. The blended powders are filled into s (induction sealed) or pouches (sealed) using powder filling equipment.

Example: Final Product — Fast sible s — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions hout the s): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic 15% Granules/Pellets Excipients (Mannitol — filler, Silicon dioxide — glidant/flow aid) 55% Diluent 100 mL The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 62/72 to 7.5 c Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients using optimized conditions. The blended powders are ssed to produce small tablets with scoring for ease of dosing for pediatric applications.

Example: Final Product — Capsules (Hard gelatin/HPMC) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets 30% pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, Silicon e — glidant/flow aid) Hard Gelatin/HPMC Capsules 10% The above pH 7.2 to 7.5 c Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients. The blended powders are filled into capsules using encapsulating equipment.

Example: Final Product — Capsules (Liquid Filled Hard or Soft Gelatin) — Formulation/Manufacturing s (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the s): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic 15% Granules/Pellets Vegetable oil (immiscible liquid) and other ingredients (paste) 50% Gelatin as powder and Hard n Capsules 5% The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions with immiscible liquid in a blender. Filled into capsules using soft or hard gelatin encapsulating equipment using optimized conditions.

Example: Final Product — e-in-Capsule (Hard gelatin) (1) — Formulation/Manufacturing Process (at local CMO, controlled room ature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 5. 5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% pH 7.2 to 7. 5 Enteric Coated (EC) Proton pump inhibitor 30% es/Pellets Excipients (Microcrystalline cellulose — filler, Silicon e — glidant/flow aid) Small and Large Hard Gelatin/HPMC Capsules The pH 5.5 to 6.2/7.2 to 7.5 c Coated (EC) Symbiotic Granules/Pellets is blended in with n of excipients in V-type or similar blender and the blend. The blend is filled into smaller capsules using encapsulating equipment and optimized conditions. The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets are blended together in desired portions in V-type or similar r with excipients. The blended intermediate formulations along with the smaller filled es are further filled into larger capsules using specialized capsule filling ent and optimized conditions.

Example: Final Product — Capsule-in-Capsule (Hard gelatin) (2) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions hout the process): Ingredients Amount (%) pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets 15% “Polymers” (pH 7.2 to 7.5 sensitive g) 10% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — glidant/flow aid) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets Small and Large Hard Gelatin/HPMC Capsules 8% Water/Solvents as required 0% The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets is blended in desired portions in V-type or similar blender with excipients. The blend is filled into smaller capsules using encapsulating equipment. The smaller filled capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized ions. The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump tor Granules/Pellets are blended in desired portions in V-type or similar r with ents. The smaller pH 7.2 to 7.5 coated capsules and the blends are further filled into larger capsules using specialized e filling equipment and optimized conditions.

Example: Final Product — Capsule-in-Capsule (Hard gelatin) (3) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Uncoated Proton pump inhibitor Granules/Pellets 25% Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 40% glidant/flow aid) “Polymers” (pH 7.2 to 7.5 sensitive coating) 10% Small and Large Hard Gelatin/HPMC Capsules 10% The above uncoated Proton pump inhibitor es/Pellets and a portion of excipients are d together in V-type or similar blender. The blend is filled into smaller capsules using encapsulating equipment and zed conditions. The smaller filled capsules are further coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating on of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions. The pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets is blended in with n of ents in V-type or similar blender. The blended intermediate ations along with the smaller pH 7.2 to 7.5 EC capsules are further filled into larger capsules using specialized capsule filling equipment and optimized conditions.

Example: Final Product — Capsule-in-Capsule (Hard n) (4) — Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Uncoated Symbiotic Granules/Pellets Uncoated Proton pump inhibitor Granules/Pellets Excipients (Microcrystalline cellulose — filler, Silicon dioxide — 30% glidant/flow aid) “Polymers” (pH 5.6 to 6.2 sensitive coating) “Polymers” (pH 7.2 to 7.5 sensitive coating) Small and Large Hard Gelatin/HPMC Capsules The Uncoated Symbiotic Granules/Pellets is blended in with portion of excipients in V-type or similar blender. The blend is filled into smaller capsules using encapsulating equipment and optimized ions. The r filled capsules are further coated with pH 5.6 to 6.2 sensitive coating using aqueous or solvent coating solution of ers” in a coating pan or fluid bed drier/coater with optimized conditions. The above uncoated Proton pump inhibitor Granules/Pellets are blended together in desired portions in V-type or similar blender with excipients. The d intermediate formulations along with the smaller pH 5.6 to 6.2 EC capsules are further filled into larger capsules using specialized e filling equipment and optimized conditions. The larger capsules are fiarther coated with pH 7.2 to 7.5 sensitive coating using aqueous or t coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions.

Example: Final Product — Orally disintegrating s (ODT) - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen ions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets 30% pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Mannitol — filler, pob/vinylpyrrolidone — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) The ed Proton pump inhibitor Granules/Pellets, pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets s are d in d portions in V-type or similar blender with excipients. The blended powders are compressed into soft tablets using tableting equipment.

Example: Final Product — Tablets / Microtablets - Formulation/Manufacturing Process (at local CMO, controlled room ature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, pob/vinyZpyrrolz'done — 53% binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - ant) HPMC or equivalent “polymers” (Film coat) 2% Water/Solvents as required 0% The pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor es/Pellets and pH .5 to 6.2/7.2 to 7.5 c Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for ing e). The blended powders are compressed into s / Microtablets using tableting equipment. The tablets are further film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Final Product — Tablet (2) - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Uncoated Proton pump tor Granules/Pellets pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets Excipients (Microcrystalline ose — filler, pob/vinyZpyrrolz'done — 2014/027228 binder, pregelatinized starch - egrant and silicon dioxide — flow aid, magnesium te - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive g) HPMC or equivalent “polymers” (Film coat) Water/Solvents as needed The above Uncoated Proton pump inhibitor Granules/Pellets and pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic es/Pellets is blended in desired portions in V- type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into tablets using tableting equipment. The compressed tablets are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent g solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC tablets”). The tablets are further film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Example: Final t — Tablet-in-Tablet (l) - Formulation/Manufacturing s (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 c Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, pob/vinyZpyrrolz'done — 53% binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) HPMC or equivalent “polymers” (Film coat) 2% Water/Solvents as ed 0% The pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets is blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The d powders are compressed into small tablets / Microtablets using tableting equipment. The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets are blended in d portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting e). The blended powder is compress coated over the small tablets / Microtablets using compress coat tableting e. The tablets are fiarther film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Final Product — Tablet-in-Tablet (2) - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) Uncoated Proton pump inhibitor Granules/Pellets 25% pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, polyvinylpyrrolidone — 48% binder, pregelatinized starch - egrant and n dioxide — flow aid, magnesium stearate - lubricant) ers” (pH 7.2 to 7.5 ive coating) 10% HPMC or equivalent “polymers” (Film coat) 2% Water/Solvents as needed 0% The above Uncoated Proton pump inhibitor Granules/Pellets is blended in desired portions in V-type or similar blender with additional excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended s are compressed into small tablets / Microtablets using tableting equipment. The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic es/Pellets is blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended EC Symbiotic Granules/Pellets are compress coated over the small EC tablets / Microtablets using ss coat tableting e. The ssed tablets are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent g solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC tablets”). The tablets are further film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Example: Final Product — Tablet-in-Capsule (Hard gelatin) (1) - Formulation/Manufacturing Process (at local CMO, controlled room ature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, nyZpyrrolz'done — 45% binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium te - lubricant) Hard Gelatin/HPMC Capsules 10% The pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets and pH .5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are d in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into Tablets / Microtablets using tableting equipment. The excipients and the compressed tablets filled into hard gelatin capsules using specialized encapsulating equipment.

Example: Final Product — -in-Capsule (Hard gelatin) (2) - ation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor 30% Granules/Pellets pH 5.5 to 62/72 to 7.5 Enteric Coated (EC) tic Granules/Pellets ents (Microcrystalline cellulose — filler, pob/vinyZpyrrolz'done — binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - ant) Hard Gelatin / HPMC Capsules The pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into small tablets / Microtablets using ing equipment. The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets are blended in desired portions in V-type or similar blender with additional excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powder and compressed tablets are filled into large Hard Gelatin Capsules using encapsulating equipment.

Example: Final Product — -in-Capsule (Hard gelatin) (3) - Formulation/Manufacturing Process (at local CMO, controlled room ature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets 30% pH 5. 5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets l5% ents (Microcrystalline ose — filler, pob/vinyZpyrrolz'done — binder, atinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive coating) 10% Hard Gelatin/HPMC es 10% Water/Solvents as ed 0% The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into small tablets / Microtablets using tableting equipment. The compressed tablets are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC tablets”). The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and ation (for tableting machine). The blended powder and the EC tablets are filled into a larger capsule using encapsulating equipment.

Example: Final Product — Tablet-in-Capsule (Hard gelatin) (4) - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount Uncoated Proton pump inhibitor Granules/Pellets 25% pH 5.5 to 2 To 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% ents (Microcrystalline cellulose — filler, pob/vinyZpyrrolz'done — 40% binder, atinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive g) 10% Hard Gelatin/HPMC Capsules 10% Water/Solvents as required 0% The above Uncoated Proton pump inhibitor Granules/Pellets formulation is blended in d ns in V-type or similar r with excipients to aid in flow, disintegration and ation (for tableting machine). The blended powders are compressed into small tablets / Microtablets using tableting equipment. The compressed tablets are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC tablets”). The pH 5.5 to 6.2 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, disintegration and ation (for tableting machine). The blended powder and the small EC s are filled into a larger capsule using encapsulating equipment.

Final Product — Tablet-in-Capsule Hard Gelatin (5) - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen ions throughout the process): Uncoated Proton pump tor Granules/Pellets 25% pH 5.5 to 6.2 c Coated (EC) Symbiotic Granules/Pellets 15% Excipients (Microcrystalline cellulose — filler, nylpyrrolz'done — 38% binder, atinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) “Polymers” (pH 7.2 to 7.5 sensitive coating) 10% Hard Gelatin/HPMC Capsules 10% HPMC or equivalent “polymers” (Film coat) 2% Water/Solvents as needed 0% The above Uncoated Proton pump tor Granules/Pellets is blended in d portions in V-type or similar blender with additional excipients to aid in flow, disintegration and ation (for tableting machine). The blended powders are compressed into small tablets / Microtablets using tableting equipment. The pH 5.5 to 6.2 Enteric Coated (EC) tic Granules/Pellets is blended in desired ns in V-type or similar blender with excipients to aid in flow, disintegration and lubrication (for tableting machine). The blended EC Symbiotic Granules/Pellets along with the proton pump inhibitor small compressed s are filled into larger capsules using encapsulating machine. The large capsules are coated with pH 7.2 to 7.5 sensitive coating using aqueous or solvent coating solution of “Polymers” in a coating pan or fluid bed drier/coater with optimized conditions (“EC tablets”). The capsules are further film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Example: Final Product — Bi-Layer Tablets - Formulation/Manufacturing Process (at local CMO, controlled room temperature, humidity and oxygen conditions throughout the process): Ingredients Amount (%) pH 7.2 to 7.5 Enteric Coated (EC) Proton pump tor Granules/Pellets 30% Excipients (Microcrystalline cellulose — filler, pob/vinyZpyrrolz'done — 53% binder, pregelatinized starch - disintegrant and silicon dioxide — flow aid, magnesium stearate - lubricant) pH 5.5 to 6.2/7.2 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets 15% HPMC or equivalent “polymers” (Film coat) 2% Water/Solvents as required 0% The above pH 7.2 to 7.5 Enteric Coated (EC) Proton pump inhibitor Granules/Pellets are blended in d portions in V-type or similar r with ents to aid in flow, disintegration and lubrication (for tableting machine). The blended powders are compressed into tablets using bi-layer ing equipment (“EC Tablets”). The pH .5 to 62/72 to 7.5 Enteric Coated (EC) Symbiotic Granules/Pellets are blended in desired portions in V-type or similar blender with excipients to aid in flow, egration and lubrication (for tableting machine). The blended powder is compressed over the EC tablets using bilayer tableting machine. The tablets are r film coated using aqueous or solvent coating solution in a coating pan or fluid bed dryer using HPMC or equivalent “polymers” (Film coat).

Final t Packaging (at local CMO, dry low humidity and low oxygen (N2 purging) conditions throughout the process): The above es are packaged in sachet, and the coated tablets, capsules are packaged into bottles with ion sealing or blistered at low humidity (at or below 40% RH) and controlled room temperature conditions (at 20 to 25 degrees C).

Quality Control Release g (Active Pharmaceutical Ingredient (API) and Final Drug Product) Symbiotic.

Methods and Assessment Granules, pellets, tablets, capsules in blisters or bottles or sachets Appearance Visual inspection for color, shape, etc.

Identification Genes, species, strains. Morphological appearance Via Microscopic evaluation and /or multiplex PCR as well as other tests including biochemical methods such as fermentation profile or pic methods, e.g. ribotyping, restriction fragment length polymorphism (RFLP), or both.

In addition, develop a specific identity assay for critical biological actiVity. Others test may include: DNA-DNA hybridization to specify strains in species; DNA sequence coding per WHO; Strain typing include Pulsed Field Gel electrophoresis (PFGE), etc.

Potency — Viable Microscopic testing, or Opacity to measure Viable cells per organisms unit or dose, i.e. colony forming units (CFU) Potency Assay Assessment of CFU (on solid ) and tests to correlating with actiVity. ility plating.

Purity xin content, antibiotic residue and/or the quantification of residual toxic components or contaminants introduced during manufacture by Elisa or amino acid profile Microbial bioburden or Extraneous materials including pathogens by using Elisa or inants and amino acid profile or SDS page or ion exchange limits (related chromatography, etc. Microbial limits by US copeia substances) (USP 31 <6l>).

Percent Viable cells Micro testing after regrown in appropriate media and test, e.g., Dead/live assay by ATP. Also ination of non- Viable units per g i.e., by electro-zone count of non- fluorescent cells (SDS PAGE) Particulate matter USP 31 <788> Pyrogens TBD pH Testing pH meter Residual moisture Water content, USP 31 <92l> t Uniformity ATP Live/Dead Assay D>TP Heavy metals Inductively Coupled Plasma-Atomic Emission Spectrophotometry (ICP-AES); Inductively Coupled Plasma-Mass Spectroscopy (ICP-MS); Atomic Emission Spectrophotometry (AES); or Atomic Absorption Spectrophotometry (AAS).

Water content Karl Fischer Package Integrity Leaker test by vacuum Stability Potency, viable cell determination, ial contamination, pH an al moisture Proton pump inhibitor(s) Test Methods and Assessment Identification HPLC and other Assay HPLC and other Impurities and Related HPLC and other Content uniformity HPLC and other Microbial limits US Pharmacopeia (USP 31 <6l>).

Symbiotic and proton pump inhibitor Test s and Assessment In-vitro release testing USP paddle or basket (via dissolution g : pH 1 buffer (simulated gastric), pH 6 buffer, equipment) : pH 7.2 to 7.5 buffer (simulated intestinal fluid), followed by pH 5.5 — 6.2 buffer (simulated colonic fluid).

Sample Times: pH 1 buffer - 1 hour pH 6 buffer - 1 hour pH 7.2 to 7.5 - 1,2, 3 and 4 hours pH 5.5 to 6.2 — 1,2,4 and 8 hours Symbiotic Assay: Microbiology testing for count (cfu/gram) for Proton pump inhibitor Assay: HPLC Stability testing (0, 6, 12, tic: 18 and 24 months): Identification, ance, Potency, viable cell determination, microbial contamination, pH and residual moisture, related substance, water content, Live/dead Assay, etc.

Proton pump inhibitor: Identification, Assay, Impurities, Related Substances, microbial contamination, pH and residual re, IVRT, etc.

EXAMPLE 4 Oral delivery of biologic and ologic drugs to distal ileum and/or colon.

The pill-in-pill dosage form (e.g., tablet-in- tablet or capsule-in-capsule, etc.) would pass through the GI tract from stomach (pH 1 to 4), to duodenum (pH 5.5 to 6.2) and deliver to distal ileum (pH 7.3 to 8.0) and/or proximal colon (pH 5.5 to 6.2), ing on the design. The release from this pill-in-pill dosage form would not require any other aid (e.g. sugars, starches etc.) or external conditions or energy source such as presence or absence of enzymes or bacterial flora in the distal ileum or proximal colon. Another advantage of the pill-in-pill dosage form would be that the drug release is le in various disease conditions (e.g. IBD, etc.) when the pH of the distal ileum and proximal colon may have significantly different from the normal values of above pH 7.4 and below pH 6.5, tively. In order to demonstrate the concept, the tablet was initially developed and ed by the capsule-in-capsule dosage form (See Table 1 below) to deliver a small molecule or biologic directly to the proximal colon, within a 2 hour delivery target window, bypassing the stomach (2 hours) and duodenum (1 hour) and the ileum (2 hours).

Table l: Capsule-in-Capsules Design Inner Capsule Outer Capsule Material and Gelatin or HPMC or other, Gelatin or HPMC or other, Size of smaller size, e.g. smaller than larger size, e.g. larger than #1, Capsule #3, etc. Band sealed for coating etc. Band sealed for coating (with or t seal coat) (with or without seal coat) API (biologic Small molecules, prokaryotes Small molecules, prokaryotes and non- cells (e.g. archaea, bacteria), cells (e.g. archaea, bacteria), biologic drugs) eukaryote cells (e.g. fiJngus, eukaryote cells (e.g. , plants), virus particles, proteins, plants) virus particles, proteins, , peptides, parasites, e cells, peptides, parasites, vaccine antigens, etc. or nothing antigens, etc., or nothing Excipients Prebiotics, solids, liquids, semi- Prebiotics, solids, liquids, semi- solids, growth promoters , growth promoters Dosage forms Formulated tablets, soft and hard Formulated tablets, soft and hard capsules, pellets, powders, etc. capsules, s, powders, etc.

Coatings Reverse c with or without r enteric with or without fillers fillers Target release At pH 6.5 (or below) within 2 At pH 7.0 (or above) within 2 hours delivery target window hours delivery target window (goal: proximal colon ry) (goal: distal ileum delivery) Testing Standard USP dissolution testing in various multiple media The target release for drugs in dissolution media was pH 6.5 in 2 hours, representing the proximal colon and with no release at pH 1.2 (gastric) for 2 hours, pH 5.5 (duodenal) for 1 hour, pH 7.0 (ileum) for 1 hour and pH 7.4 (distal ileum) for 1 hour.

Probiotic and inophen were used as representative biologic agent ilized bacteria) and small molecule, respectively. Acetaminophen was also used as a marker for probiotic during release testing. The small molecule and the tic mixes were prepared separately with and without additional ents. Hydroxypropylmethyl cellulose (HPMC) capsules were used as the reservoir for carrying these drugs.

HPMC capsules have several advantages as they are made from non-animal materials, chemically stable, have low moisture t (protect lyophilized bacteria), less brittle even at low humidity (survive the GI transit), fast dissolution, biodegradable, no crosslinking and suitable to automatic es filling es. These capsules can be band sealed, which has the following advantages: avoid the need for additional steps of seal coating with polymers; avoid the need for excess moisture and heat required for processing, especially important for maintenance of the viability of the biologicals; and minimize the impact on release of drug from the capsules.

The polymers evaluated were aqueous based methacrylic acid copolymers and were designated as either reverse enteric (e.g. Eudragit® E P0) or regular enteric (e.g.

Eudragit® FS 30D, Eudragit® S100, Eudragit® L100, Eudragit® L30D-55) alone or in combinations. Eudragit® E PO is designed to solubilize at pH 6.5 or below and also possess good moisture barrier properties which protected lyophilized bacteria and further improved stability. Eudragit® FS 30D, Eudragit® S100, Eudragit® L100, Eudragit® L30D-55 are designed to solubilize above pH 7.0, 6.5, 6.0, 5.5, respectively. These polymers can be d on the s and capsules with heat and moisture below, 30°C and 40% RH, respectively, which is important for the maintenance of the viability of biological drugs. The tablet dosage form was ted and then followed by the capsule-in-capsule dosage form. These capsules were subject to standard USP dissolution testing. Notably, these similar principles apply for ry to distal ileum alone and in combination with proximal colon.

Applications of this technology would broadly include the delivery of Microbiome Ecology Therapy (MET); Small molecule drugs and Vaccines, etc.

Initial development focused on coating of the inophen (APAP) core tablets using APAP as the marker for monitoring the release of biologic and ologic small molecule drugs from the dosage form. The 325 mg uncoated tablet cores dissolved fairly rapidly, r than 85% in 45 minutes in USP dissolution apparatus with basket at 50 rpm in pH 6.5 phosphate buffer (Formulation 1, Figure 8). When these APAP tablets were coated with reverse enteric material (Evonik® EPO) at up to 18 mg/cm2 level and performed the ution testing under the same conditions, 100% of the APAP was ed at target pH 6.5 within 2 hours, simulating the release of the drug in the proximal colon (Formulation 2, Figure 9). Since this coating normally was designed to dissolve below pH 6.5, the rate of release from the tablet WO 52338 formulation was more rapid at pH 6.0, as expected. Also as expected, no release of APAP was observed from the s at pH 6.8, pH 7.0 and pH 7.4.

The 325 mg uncoated tablet cores dissolved fairly rapidly, greater than 85% in 45 minutes in USP ution apparatus with basket at 50 rpm in pH 7.0 phosphate buffer (Formulation 1, Figure 10). These APAP tablets were coated with regular enteric material k® FS30D/L30 Mixtures) at up to 15 mg/cm2 level, and subject to dissolution in pH 1.2 for 2 hours, pH 5.5 for 1 hour and pH 7.0 for 2 hours using the same tus and speed. The formulation passed the performance test in pH 1.2 for 2 hours and 1 hour at pH 5.5. The release rate at pH 7 was slower and did not pass the 2 hour test. r, the release rate increased as expected with lower ratio of Evonik® FS30D/L30, e.g. 50/50 (Formulations 3 (a-c), Figure ll). Based on these results, it was concluded that more permeable coatings would be required to obtain the desired release profiles in pH 7.0. Additional optimization would also be required for the tablet dosage form including consideration of other formulation factors, such as g thickness, total polymer applied, physico-chemical properties of the drug, g dose, size and shape of the tablets, etc.

As indicated earlier, the aim was to develop a capsule-in-capsule dosage form which would deliver a small molecule or a ic to the proximal colon, within a 2 hour delivery target window, without the need for additional compression and also for ease of demonstrating the applications of colonic drug delivery technology. The principles developed here can be easily adapted to other dosage forms, such as compressed tablets, pellets, oral disintegrating tablets, liquid fllled capsules, etc.

The uncoated inner smaller capsule containing APAP was subjected to USP dissolution tests with basket at 75 rpm and paddle at 50 rpm in pH 6.5 dissolution media. The release from the capsules was much slower (Formulation 4, Figure 12) as compared to the tablets and higher speeds would be required to disintegrate the es in the basket. However, there was almost no difference n the release profiles for the capsules either in the basket or paddle. Based on physical appearance of the capsules in the paddle method, the capsules appear to break down more easily as compared to the basket method, but were still not completely egrated. The smaller inner APAP capsules were coated with reverse enteric coat, Eudragit® EPO at mg/cmz. The coated capsules were subjected to USP dissolution tests with basket at 75 rpm and paddle at 100 rpm in pH 6.5 dissolution media. The es met the release requirement at pH 6.5 in 2 hours when using the paddle method at 100 rpm (Formulation 5, Figure 13). Physically all the capsules had broken down and completely disintegrated. Note there was no release from the capsules in the basket at 75 rpm and also the capsules were physically intact (not broken down or disintegrated) in the basket even after 2 hours. The coated capsules were also subject to pH 6.8 dissolution media for 2 hours at 10 mg/cm2 coating level using the paddle at 100 rpm. As expected there was no release from the capsules lation 5, Figure 14). Also, physically, the capsules had not disintegrated. The paddle speed of 100 rpm for dissolution g was justified since the release in vivo is generally associated with a significant gut agitation and compression, something that may not been seen with the in vitro dissolution test. Also, typically for enteric coated capsules, disintegration tus (similar to USP dissolution apparatus 111) with high turbulence are lly used for evaluation of release.

The larger outer seal coated (no enteric) capsule containing APAP was subjected to USP dissolution tests with paddle at 100 rpm in pH 6.5 dissolution media. The release from these capsules was rapid and all capsules released the drug within 1 hour (Formulation 6, Figure 15). Also physically all capsules had disintegrated. The larger outer APAP ning es were coated with regular enteric coat, Eudragit® L100 and L100/S100, 50/50 mix at 7.5 mg/cm2. These coated capsules were subjected to USP ution tests with paddle at 100 rpm in pH 1.2 (2 hours), pH 5.5 (1 hour), pH 7.0 (1 hour) and pH 7.4 (1 hour) dissolution medias. The coated capsules containing L100 alone had slight release due to drug permeation at pH 5.5 in 1 hour, but otherwise acceptable. The coated capsules containing L100/S100 50/50 mix did not pass the release test at pH 7.0/7.4 in 2 hours (Formulation 7 (a-b) Figure 16). Hence the lager outer APAP containing capsules were coated with regular enteric coat, Eudragit® 100, 75/25 mix at 5 and 7.5 mg/cm2. These coated capsules were subjected to USP ution tests with paddle at 100 rpm in pH 1.2 (2 hours), pH 5.5 (1 hour), pH 7.0 (1 hour) and pH 7.4 (1 hour) dissolution medias. All the capsules passed the dissolution at pH 1.2 for 2 hours. However, the coated capsules containing 7.5 mg/cm2 did not pass the e test at pH 7.0/pH 7.4 over 2 hours. The coated capsules containing 5 mg/cm2 L100/S100 75/25 mix did pass the release test at all the pH conditions (Formulation 8 (a-b), Figure 17), except for slight permeation of drug at pH 5.5. Hence, applying a slightly higher coating thickness would eliminate this problem for drug release targeted to the distal ileum.

Based on the above results, with the goal of release in the proximal colon, the smaller capsules containing APAP, band sealed and c coated with Eudragit® EPO 10 mg/cm2 were filled into larger capsules, band sealed and r coated with Eudragit® L100/S100, 75/25 mix, 5 mg/cm2 on the outside. These e-incapsules were subject to in-vitro USP dissolution testing, paddle at 100 rpm, for APAP release in pH 1.2 media for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour, pH 7.4 for 1 hour, pH 6.5 (phosphate) for 2 hours. The results confirm filll APAP release cally at pH 6.5 within 2 hours from the inner capsule, and with no release at pH 1.2 for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour and pH 7.4 for 1 hour.

(Formulation 9, Figure 18) Physically the outer capsules ed intact with no egration at pH 1.2 for 2 hours and pH 5.5 for 1 hour. Then the outer capsules completely disintegrated after exposure to pH 7.0 for 1 hour and pH 7.4 for 1 hour, and the inner capsule was observed and it had physically remained intact. The inner capsules then completely disintegrated when exposed to the pH 6.5 media within 2 hours. The physical observations are very consistent with the drug e data reported in Figure 18.

Similar to the APAP capsule-in-capsules, the smaller probiotic containing capsules, were band sealed and enteric coated with Eudragit® EPO 10 mg/cm2 and were filled into larger capsules, band sealed and further coated with Eudragit® LlOO/S100, 75/25 mix at 5 mg/cm2 on the outside. These e-in-capsules were subject to USP dissolution testing, paddle at 100 rpm, for probiotic bacteria release in pH 1.2 media for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour, pH 7.4 for 1 hour, pH 6.5 for 2 hours (saline phosphate buffer). Saline buffer was used to maintain isotonicity of the dissolution medium and ensure viability of the lyophilized bacteria once they are exposed to the aqueous solution. Physically, these probiotic capsules behaved exactly in the same manner as the APAP es. It could be surmised ed the bacteria would be released from probiotic capsules exactly in the same manner as the APAP from the APAP capsules, i.e. filll release at pH 6.5 within 2 hours from the inner capsule, and no release at pH 1.2 for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour and pH 7.4 for 1 hour.

Based on SEM evaluations of reverse and regular coatings, the a preferable coating level thickness is: First capsule (inner pill) — Eudragit® EPO, 5 mg/cm2 - 10 mg/cm2: 60 — 180 microns (um) for size #3 capsule Second capsule (outer pill) - Eudragit® 100 (75/25) - 5 mg/cm2 - 10 mg/cm2 60 — 180 microns (um) for size #0 capsule The uncoated and coated CIC capsules were analyzed to determine the level of degradation due to processing. The data suggested, and shown in Table 2, that the total strain count as measured by total CFU per es did not change significantly.

Hence the process of handling, banding and coating applications, storage and shipment did not have any significant effect on viability of the 3 bacteria strains tested in the formulations, ing the aerobic strains of S. thermophilus and L. acidophilus and anaerobic s of B. longum als and Methods Acetaminophen!APAP 1: (Receiving # RCA31252; Guardian Drugs) Malinckrondt Inc.-lot # 784513B054- 3% PVP granulated powder for tableting.

Aacetaminophen (Paracetamol, USP-APC-150)- ALP Co.(China)-Lot # 0908302.

Acetaminophen (APAP) 325 mg core tablets (Lot # L0577Guardian Drugs, NJ) Probiotic Capsule: Azodyl (size # 3) (Batch # 023042-20; Lot # 5241113; Kibow Biotech; Newtown Square, PA 19073) HPMC Capsules: Qualicaps Size # 3 /S-LOK-Lot # 82-Clear VAA(cap & body) aps Size # 3 /S-LOK-Lot # E1205667-Op. White XAK (cap & body) aps Size # 3/S-LOK-Lot # E1106719-Op.Brown 15 XJX (cap & body) Qualicaps Size # 0 /S-LOK-Lot # E1101410-Op. White XAK (cap & body) Qualicaps Size # 0 /S-LOK-Lot # E1106476-Op. Brown 15 XJX (cap & body) Methacrylic Acid Co-polm ers for coating: EPO-Ready Mix- Evonik-lot# H131 181012 Eudragit-L30D 55-Evonik —Lot# B130514207 Eudragit-FS 30D Evonik —Lot# B130365004 Eudragit-S100-Evonik —Lot# B100405 198 Eudragit-L100-Evonik —Lot# B 120603009 Plasacryl T20-Evonik-Lot # PT 1 30705 Coating Polmers: HPMC E5-Dow-Lot # YG040124L1 Plasticizers: Triethyl Citrate (TEC)—Vertellus-Lot 3 132530 Surfactants: Polyethylene Glycol 4000-AlfaAesar-Lot # 10167045 Polysorbate 80(Tween 80)—BASF-Lot# 3158092 Other Excip_ients: Talc- Brenntag-Lot # -43 Microcrystalling cellulose (MCC)-MCBlanver-Lot3 135002006 Lactose Monohydrate (Supertab 11SD)-DFE Pharma--Lot# 10677724 Pre-gelatinized Starch-DFE Pharma-Lot 1223 Crospovidone-QJNI tch # 20130115 DiCalcium Phosphate-Innophos- Lot# 0701047 Coloidal n dioxide il-200)-Evonik- Btch # 1012082200 Silicon dioxide il R972)-Degussa-Lot# 3158092923 Magnesium Stearate-FACI Asia-Batch # MGSP0216 Magnesium Stearate-Mallinkrodt-Lot# -071226. y-propyl Methyl ose-Shinogi-Lot # 90936C Chemicals : um Hydroxide-AlfaAesar—Lot # E302012 Ethyl Alcohol-Fischer—Lot # M02539 Potassium Dihydroigen Phosphate- Alfa Aesar—Lot # 1013774 Sodium Hydroxide- Macron Chemicals- Batch 98# 0000039706 Method for Prepare core tablets and Compression The required amount as shown in the formula A of APAP, MCC, Pre-Gelatinized Starch, Crospovidone & Colloidal Silicon di-oxide was passed thru # 20 sieve and was loaded in a suitable belnder and mixed for 25 minutes. At the end of the process the Magnesium stearate was added and blend was mixed for additional 5 minutes. At the end of the process the material was unloaded into clean poly-lined containers.

The blend (100 kg) was compressed on a Korsch XL-lOO lO n press. A modified-oval shaped, standard concave tooling (16.5 mm x 7.5 mm) having plain es (no logo) on both sides was used. This was design was chosen based on providing suitable substrate for onal coating. Tablets were compressed to a target weight of 600 mg (containing 325 mg APAP) with Friability of NMT 1% and Hardness of > 24kP. The tablet , thickness, hardness and friability was monitored as in-process test throughout the batch manufacturing. Tablet samples were taken to ensure disintegration time was < 5 min.

Encapsulation and Banding Encapsulation of Formulation B: All the ingredients were passed thru a MMC l to ensure no agglomerates were present in the blend. A 8Qt V-Blender was used to mix all the ingredients except Magnesium stearate. After mixing all the ingredients Magnesium stearate was added.

The blend was mixed for 2 additional minutes before discharge into a double-poly lined container. The index K120i (S/N 0963-27) was set-up to run the capsules (size # 3) from Qualicaps. The capsule polisher (Model TG-20) and weight scales (Mettler Toledo Scale) were set-up appropriately for the run. The processing room temperature and ty log was documented for the run. In-process weight samples were ted during the run to ensure the target weight is achieved. The capsules were ed and collected in a -lined poly-bags in container.

Encapsulation of Formulation D: A FastLock K200F with vibration table was used for filling the size # 0 capsules from formulation D. Size # 0 Quali V capsules were used to fill the 3% granulated APAP powder. Approximate 100 capsules were filled each time. The weights for capsules were recorded.

Banding of capsules: Banding of capsules was performed on the IMA Bander (BD 1723) Typically banding of capsules s in a weight gain of 1-1 .5 mg which is within the weight variation of the capsules so it is typically considered a part of the capsule weights and the associated variations.

Preparation of spraying dispersions Preparation of Eudragit-EPO ready mix: The Ready mix is a standard coating system from Evonik which has 51% EPO r. About 150 g of this dry mix is added to about 850 g of water to give approximately 1 kg of spray suspension. The al is mixed using a high shear mixer for approx. 30 minutes. The entire suspension is then passed through a 0.5 mm sieve. The sion is next ready for spraying to the substrate using typical standard processing ters.

Preparation of L-30D 55: For 1 kg of spray sion approx. 570 g of Eudragit L30D 55 dispersion is added in a larger mixer vessel. Approx. 145.5 g of ryl HTP20 (anti-tacking/ plasticizer system) is added to the mix. The suspension is diluted with required amount of water to get 1 kg of spray dispersion. The PlasAcryl need to be shaken before transfer to any vessel. The entire suspension is stirred for 10 minutes using a propeller stirrer. The entire suspension is passed through a 0.5 mm sieve. The suspension is next ready for spraying to the substrate using typical standard sing parameters. ation of FS 30 D: For 1 kg of spray suspension approx. 606.1 g of Eudragit FS30D dispersion is added in a larger mixer vessel. Approx. 90.9 g of Plasacryl HTP20 (anti-tacking/ plasticizer system) is added to the mix. The suspension is diluted with required amount of water to get 1 kg of spray dispersion. The PlasAcryl need to be shaken before transfer to any vessel. The entire suspension is stirred for 10 minutes using a propeller stirrer.

The entire suspension is passed through a 0.5 mm sieve. The suspension is next ready for spraying to the substrate using typical standard processing parameters.

Preparation of L100 Dispersion: For 1 kg of spray suspension approx. 99.5 g of it L100 was added into 2/3 rd of the water and stir for approximately 5 minutes and making sure the powder is all wetted. Add 1N NH3 (56 g) slowly into the Eudragit sion and stir for approximatly 60 minutes. Add 49.8 g of Triethyl citrate (TEC) and stir for additional 60 minutes. Separately, homogenize 49.8 g of Talc with the remaining amount (1/3 rd) of water for 10 minutes using a high shear mixer. Pour the talc suspension into the Eudragit dispersion while stirring with a conventional r. The entire suspension is passed through a 0.5 mm sieve. The suspension is next ready for spraying to the substrate using typical standard processing parameters.

Preparation of $100 dispersion: For 1 kg of spray suspension approximately 99.4 g of Eudragit 8100 is added into 2/3 rd of the water and stirred for approximately 5 minutes and making sure the powder is all wetted. Add 1N NH3 (67.5 g) slowly into the Eudragit suspension and stir for approximately 60 minutes. Add 49.7 g of Triethyl e (TEC) and stir for onal 60 minutes. Separately, homogenize 49.7 g of Talc with the remaining amount (1/3 rd) of water for 10 minutes using a high shear mixer. Pour the talc suspension into the Eudragit dispersion while stirring with a conventional stirrer. The entire sion is passed through a 0.5 mm sieve. The suspension is next ready for spraying to the substrate using typical standard processing parameters.

For es of two components prepare them separately and then add as per the desired ratios.

Coating of the tablets and es All coatings of tablets and capsules were med on the Thomas ering Accela Cota Compu-Lab190. The formulations were coated in a 12” pan with two baffles. A minimum batch size of 400 g was used for the gs. For some formulations a larger batch size of 700-1500 g was processed. A single Schlick gun (970/7-l 75 S) with a nozzle size from 0.8-1.2 mm depending on the batch size and the flow rate of the suspension was used. The processing conditions were varied depending on the batch size and the coating material used. For each type of coating specific processing conditions were followed. For the safety of the product, the product temperature was always ined below 30°C.

The general sing parameters used broadly is as follows: Inlet air temp: 30-40 °C Exhaust ature- 25-30 °C t Temperature: 24-29°C Inlet air flow: 100-300 CFM Pump speeds: 2.5- 20 rpm Atomization air pressure: 10-30 psi ID of the tubing used: 3.2 mm, Pan speed: 4-l5 rpm.

Dissolutions testing: egration apparatus, dissolution apparatus, baskets, paddles and speeds, temperature and dissolution media, Assay, HPLC, CPU for probiotics, sampling scheme. The inner capsules were subject to ution testing at pH 6.5 or pH 6.8 phosphate buffers for up to 2 hours. The outer capsules were subject to dissolution media at pH 1.2 for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour and pH 7.4 for 1 hour. The combined capsules were subject to dissolution media at pH 1.2 for 2 hours, pH 5.5 for 1 hour, pH 7.0 for 1 hour, pH 7.4 for 1 hour, pH 6.5 for 2 hours (with saline as isotonic agent for probiotic.

Analysis of probiotic capsules before and after coating The contents of capsules were aseptically transferred into a sterile bottle. The two capsule contents were dissolved in saline. A sample was drawn for ation and incubated at 37°C. After 3 days of incubation at 37°C (aerobically for S.

WO 52338 thermophilas and L. acidophz'las, anaerobically for B. longam) the colonies were counted in triplicate.

Table 2: Strain count (CFUs in billions), pre and post coating of capsules ted capsules Coated capsules Average (range) Strain Count (CFU in billions), n=3 . thermophi/es* 13.5 (12.5 — 15.5) 14.2 ( 13.5 — 14.5) L. hilus* 2.6 (2.2 - 3.3) 1.8 (1.25 — 2.1) 2.6 (2.0 — 3.1) 1.9 (1.65 — 2.15) *Aerobic **Anaerbic Formulations: Formulation l: 325 mg APAP tablets Core Ingredients Acetaminophen (APAP)—3% PVP granulated form for 335 tableting Microcrystalline Cellulose, USP —ri_ Formulation 2: APAP tablets 325 mg — sealed with 4 mg/cm2 seal (HPMC) coated with Eudragit® EPO 18 cm2 Ingredients Amount Core Tablet: Acetaminophen 325 mg tablet lation 1) above 606 4% w/w Seal Coating: HPMC E5 20 PEG 6000 USP 3 Water, qs (removed from formulation) Functional coatlng (18 mg/cm ): Eudragit® EPO Readymix 147 Water, qs (removed from formulation) Formulation 3a: APAP tablets 325 mg, seal coated with 4% HPMC & enteric coated with FS30:L30D55 (90:10), 7.5 mg/ cm2 Ingredients Amount mg % Core Tablet: inophen 325 mg tablet (Formulatlon 1) above 606 89 2014/027228 Formulation 3b: APAP tablets 325 mg, seal coated with 4% HPMC & enteric coated with FS30:L30D55 (75:25), 7.5 mg/ cm2 Ingredients Amount mg 3 Core Tablet: Acetaminophen 325 mg tablet (Formulation 1) above 606 00 Q Seal Coating (4%) HPMC E5 NO DJ |PEG 6000, USP /\ )—A Water, qs (removed from formulation) Functional coating ) 7.5 mg/cm Eudragit® FS30D Eudragit® L30D55 H0.) N\] |Plasacryl /\ )—A TEC l Water, qs (removed from formulation) Total 685 100 ation 3c: APAP tablets 325 mg, seal coated with 4% HPMC & enteric coated with FS30:L30D55 (50:50), 7.5 mg/ cm2 Amount Ingredients mg % Core Tablet: Acetaminophen 325 mg tablet (Formulation 1) above 606 87 Seal Coating (4%): HPMC E5 19 |PEG 6000, USP /\ )—A Water, qs (removed from formulation) |Functional g (50:50) 7.5 mg/cm Eudragit® FS30D 25 Eudragit® L30D55 25 |Plasacryl )—A 2014/027228 Water, qs (removed from formulation) -_ Formulation 4: Composition of Uncoated APAP capsules (size # 3) Ingredients Amount mg % Formulation 5: Composition APAP capsules coated with Eudragit® EPO, lO mg/cm2 Ingredients Amount mg % Formulation 6: APAP capsules (size # 0) seal coated with HPMC, 6 mg/cm2 Ingredients Water q.s. (removed from the formulation) -_ Formulation 7 (a): APAP capsules (size # 0) seal coated with HPMC, 6 mg/cm2 and enteric coated with Eudragit® L100, 7.5mg/cm2 Ingredients mg Amount (%) APAP capsule (size #0), seal coated (Formulation 6 ) 480 Functional coating (7.5 mg/cm ): Eudragit® L100 39 TEC l9 Formulation 7 (b): APAP capsules (size # 0) seal coated with HPMC, 6 mg/cm2 and enteric coated with Eudragit® L100/Eudragit® S100 ) 7.5mg/cm2 Ingredients Amount (%) APAP e (size #0), seal coated (Formulation 6 ) 87 Functional coating (7.5 mg/cm ): Eudragit® S 100 Eudragit® Ll 00 Talc Total Formulation 8 (a). APAP capsules (size # 0) seal coated with HPMC, 6 mg/cm2 and enteric coated with Eudragit® L100/Eudragit® S100 (75/25) 5 mg/cm2 Ingredients mg Amount (%) APAP capsule (size #0), seal coated (Formulation 6 ) 480 87 Functional g (5 mg/cm ) (75:25) Eudragit® L100 l8 Eudragit® S 100 TEC 13 Formulation 8 (b). APAP capsules (size # 0) seal coated with HPMC, 6 mg/cm2 and enteric coated with Eudragit® L100/Eudragit® S100 (75/25) 7.5 mg/cm2 Ingredients mg Amount (%) APAP capsule (size #0), seal coated (Formulation 6 ) 480 87 Functional coating (7.5 mg/cm ) (75:25) it® L100 27 5 it® S 100 9 2 TEC l7 3 Talc l8 3 Total 551 100 Formulation 9: APAP capsule-in-capsule (CIC) [inner capsule (size#3) enteric coated with Eudragit® EPO, lOmg/cmz; and outer e (size #0) enteric coated Eudragit® L100/S100 75/25, 5 mg/cmz —gmm Acetaminophen (3% PVP granulation) APAP powder 155 38 Wt. of banded uncoated CIC (size # 0) filled with 358 TEC l2 3 2014/027228 From the foregoing, it will be appreciated that, although specific embodiments of the invention have been described herein for the purpose of illustration, s modifications may be made without deviating from the spirit and scope of the invention. Accordingly, the present invention is not limited except as by the appended claims.

All patents, patent applications, publications, scientific articles, web sites, and other documents and materials referenced or mentioned herein are indicative of the levels of skill of those d in the art to which the invention pertains, and each such nced document and material is hereby incorporated by reference to the same extent as if it had been incorporated by reference in its entirety individually or set forth herein in its entirety. Additionally, all claims in this application, and all priority applications, including but not limited to al claims, are hereby incorporated in their entirety into, and form a part of, the written description of the invention.

Applicants reserve the right to physically incorporate into this specification any and all materials and ation from any such patents, applications, publications, scientific articles, web sites, electronically available information, and other referenced materials or documents. Applicants reserve the right to physically incorporate into any part of this document, including any part of the written description, the claims referred to above ing but not limited to any original claims.

The specific methods and compositions described herein are representative of preferred embodiments and are exemplary and not intended as limitations on the scope of the invention. Other s, aspects, and embodiments will occur to those skilled in the art upon consideration of this specification, and are encompassed within the spirit of the invention as defined by the scope of the claims. It will be readily apparent to one skilled in the art that varying substitutions and modifications may be made to the ion disclosed herein without departing from the scope and spirit of the invention. The invention ratively described herein suitably may be practiced in the absence of any element or elements, or limitation or limitations, which is not specifically disclosed herein as essential. Thus, for example, in each ce herein, in ments or es of the present invention, any of the terms “comprising”, WO 52338 “consisting essentially of”, and “consisting of” may be replaced with either of the other two terms in the specification. Also, the terms “comprising”, “including”, containing”, etc. are to be read expansively and without limitation. The methods and processes illustratively described herein suitably may be practiced in differing orders of steps, and that they are not necessarily cted to the orders of steps indicated herein or in the claims. It is also that as used herein and in the appended claims, the singular forms CC 3, (C a an,” and “the” include plural reference unless the context clearly dictates otherwise. Thus, for example, a reference to “a host cell” includes a plurality (for example, a culture or population) of such host cells, and so forth. Under no circumstances may the patent be interpreted to be limited to the specific examples or ments or s specifically disclosed herein. Under no circumstances may the patent be interpreted to be limited by any statement made by any Examiner or any other official or employee of the Patent and Trademark Office unless such ent is specifically and without qualification or reservation expressly adopted in a sive writing by Applicants.

The terms and expressions that have been employed are used as terms of description and not of limitation, and there is no intent in the use of such terms and expressions to exclude any equivalent of the features reported and described or portions thereof, but it is recognized that various ations are possible within the scope of the invention as claimed. Thus, it will be understood that although the present invention has been specifically disclosed by preferred embodiments and optional features, modification and variation of the concepts herein disclosed may be resorted to by those skilled in the art, and that such modifications and variations are considered to be within the scope of this invention as defined by the appended claims.

The invention has been described broadly and generically herein. Each of the narrower species and subgeneric groupings falling within the c disclosure also form part of the ion. This includes the generic description of the invention with a proviso or ve tion removing any subject matter from the genus, regardless of whether or not the excised material is specifically recited herein.

Other embodiments are within the following claims. In on, where features or aspects of the invention are described in terms of Markush , those skilled in the art will recognize that the invention is also thereby described in terms of any individual member or subgroup of s of the Markush group.

References The contents of all references cited herein are incorporated by reference herein for all purposes. l. Hajishengallis G, u RP, Curtis MA. The keystone-pathogen hypothesis. Nat Rev Microbiol. 2012;10(lO):7l7-25. 2. Furet JP, Kong LC, Tap J, Poitou C, Basdevant A, Bouillot JL, et al.

Differential tion of human gut microbiota to bariatric surgery-induced weight loss: links with metabolic and low-grade inflammation s.

Diabetes. 2010;59(l2):3049-57. 3. Monte SV, Caruana JA, Ghanim H, Sia CL, Korzeniewski K, Schentag JJ, et al. Reduction in endotoxemia, oxidative and inflammatory stress, and insulin resistance after Roux-en-Y gastric bypass surgery in patients with morbid obesity and type 2 es mellitus. Surgery. 2011. 4. O'Mahony L, McCarthy J, Kelly P, Hurley G, Luo F, Chen K, et al.

Lactobacillus and bz'fidobacterium in irritable bowel syndrome: symptom responses and relationship to cytokine profiles. Gastroenterology. 2005;128(3):54l-51. 5. Hajishengallis G, Chavakis T. Endogenous modulators of inflammatory cell recruitment. Trends Immunol. 2012. 6. Larsen N, Vogensen FK, van den Berg FW, Nielsen DS, Andreasen AS, Pedersen BK, et al. Gut iota in human adults with type 2 diabetes differs from non-diabetic adults. PLoS One. (2):e9085. 7. Vrieze A, Holleman F, Zoetendal EG, de Vos WM, Hoekstra JB, Nieuwdorp M. The environment within: how gut iota may influence metabolism and body ition. Diabetologia. 2010;53(4):606-l3. 8. Maqbool S, Parkman HP, Friedenberg FK. Wireless capsule motility: comparison of the SmartPill GI monitoring system with graphy for measuring whole gut transit. Dig Dis Sci. 4(lO):2l67-74. 9. Gao XW, Mubasher M, Fang CY, Reifer C, Miller LE. Dose-response efficacy of a proprietary probiotic formula of Lactobacillus hilus CLl285 and Lactobacillus casei LBC80R for antibiotic-associated diarrhea and idium dz'yj’zcile-associated diarrhea prophylaxis in adult patients. Am J Gastroenterol. 05(7):l636-4l.

. Johnson S, Maziade PJ, McFarland LV, Trick W, Donskey C, Currie B, et al. Is primary prevention of Clostridium dz'fi‘zcz'le infection possible with specific probiotics? Int J Infect Dis. 2012. ll. Brenner DM, Moeller MJ, Chey WD, feld PS. The y of probiotics in the treatment of irritable bowel syndrome: a systematic review.

Am J Gastroenterol. 2009;104(4):lO33-49; quiz 50. 12. Marik PE. Colonic flora, Probiotics, Obesity and Diabetes. Front Endocrinol (Lausanne). 2012;3:87.

Claims (11)

What is claimed is:

1. An oral delivery system for delivering a probiotic formulation targeted to both the ileum and proximal colon of a subject sing: (a) a biodegradable first capsule comprising a probiotic formulation targeted to the proximal colon, wherein the first capsule ses a reverse enteric coating that solubilizes in a pH of less than 6.9; and (b) a biodegradable second capsule that includes the first capsule and a probiotic ation ed to the ileum, wherein the second capsule comprises an c coating that solubilizes in a pH of about 7 to 8, wherein the second capsule releases the first capsule and the probiotic formulation targeted to the ileum in the ileum upon administration to a subject, and once released, the first capsule is solubilized in the proximal colon at a pH of less than 6.9 and releases the probiotic formulation targeted to the proximal colon.

2. The oral delivery system of claim 1, wherein the enteric coating comprises one or more polymers each selected from the group consisting of hydroymethylacrylatemethyl methacrylate MMA), Multilayered HEMA-MMA-MAA (methylacrylic acid).

3. The oral delivery system of claim 1 or 2, wherein the probiotic formulation targeted to the proximal colon is a mixture of bacterial genera that is reflective of the mixture of strains derived from the stool of a normal human and the probiotic formulation targeted to the ileum se a mixture of bacterial genera that is reflective of the mixture of s derived from the ileum of a normal human.

4. The oral ry system of any one of claims 1 to 3, wherein the probiotic formulation targeted to the proximal colon and the probiotic formulation targeted to the ileum each comprise a live bacterial sion comprising a bacteria selected from the genus Lactobacillus and Bifidobacterium.

5. The oral delivery system of claim 4, wherein the probiotic formulation ed to the proximal colon and the probiotic formulation targeted to the ileum each r comprise Faecalibacterium itzii and/or Bacteroides otaomicron.

6. The oral delivery system of any one of claims 1 to 5, wherein the biodegradable first and second es each comprise hydroxypropylmethyl cellulose.

7. The capsule-in-capsule oral delivery system of any one of claims 1 to 6, wherein the first and second probiotic formulation each comprise the sm Faecalibacterium prausnitzii.

8. Use of an oral formulation in the manufacture of a medicament for the treatment of a gastrointestinal disorder, wherein the oral formulation comprises: a biodegradable first capsule comprising a probiotic formulation targeted to the proximal colon wherein the first capsule is coated with reverse enteric coating that solubilizes in a pH of less than 6.9; and a radable second capsule that es the first capsule and a probiotic formulation targeted to the ileum, wherein the second capsule is coated with an enteric coating that solubilizes in a pH of about 7 to 8, wherein the second capsule es the first capsule and the tic formulation targeted to the ileum in the ileum and once released the first capsule is lized in the proximal colon at a pH of less than 6.9 and releases the probiotic formulation targeted to the proximal colon, wherein the gastrointestinal disorder is a Clostridium difficile disorder.

9. The use claim 8, wherein the enteric coating comprises a polymer selected from the group consisting of hydroymethylacrylate-methyl methacrylate (HEMAMMA ), Multilayered HEMA-MMA-MAA (methylacrylic acid).

10. The oral delivery system of any one of claims 1-6 or the use of claim 8 or 9, wherein the first capsule is a size no. 3 hydroxypropylmethyl cellulose capsule.

11. The oral delivery system of any one of claims 1-6 or the use of claim 8 or 9, wherein the second capsule is a size no. 0 hydroxypropylmethyl cellulose capsule.