RU2843523C1 - Use of heparin-based composition in treatment of viral lung diseases, acute and/or chronic lung diseases using "soft fog" inhaler or nebulizer with vibrating mesh technology by inhalation administration route - Google Patents

Abstract

FIELD: medicine; pharmaceutics.

SUBSTANCE: group of inventions relates to the use of a pharmaceutical composition for the treatment of viral lung diseases, including the disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), acute lung diseases and/or chronic lung diseases, wherein the pharmaceutical composition contains heparin or a pharmaceutically acceptable heparin derivative dissolved in a carrier solution for local administration to the lungs by means of a “soft fog” inhaler by the inhalation administration route; wherein heparin is low molecular weight heparin (LMWH); wherein carrier solution is water for inhalation, sterile physiological saline 0.9% NaCl or sterile half physiological saline 0.45% NaCl; wherein the pharmaceutical composition comprises another active substance selected from mannitol, acetylcysteine, sterile hypertonic normal saline 3–20% NaCl, wt./vol., or an anti-inflammatory corticosteroid selected from dexamethasone or mometasone; and wherein the dose of heparin used is 4000 IU, and also relates to the use of a pharmaceutical composition for the treatment of viral pulmonary diseases, including a disease of Covid-19 caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), acute lung diseases and/or chronic lung diseases, wherein the pharmaceutical composition contains unfractionated heparin (UFH) or a pharmaceutically acceptable derivative thereof, wherein it is administered locally to the lungs by means of a "soft fog" inhaler by means of the inhalation administration route; wherein the carrier solution is inhalation water, sterile 0.9% NaCl physiological saline or 0.45% NaCl sterile half physiological saline; wherein the pharmaceutical composition contains another active substance selected from mannitol, acetylcysteine, sterile hypertonic normal saline 3–20% NaCl, wt./vol., or an anti-inflammatory corticosteroid selected from dexamethasone or mometasone; and wherein the dose of heparin used is 4000 IU.

EFFECT: group of inventions provides safer, more effective delivery (with a high deposition rate) of heparin and improves oxygen flow in the airways and mucus decomposition.

29 cl, 7 dwg, 5 tbl

Description

Field of technology to which the invention relates

The present invention relates to the administration of heparin or its derivatives, which are anticoagulants, in particular low molecular weight heparin (LMWH), in the treatment of, in particular, COVID-19, viral lung diseases, acute and/or chronic lung diseases using a soft mist inhaler or a vibrating mesh technology (VMT) nebulizer via the inhalation route of administration. In the present invention, heparin and its derivatives can be administered using a passive vibrating mesh nebulizer or an active vibrating mesh nebulizer.

State of the art

Coronaviruses (CoV) are a large family of viruses that cause illnesses ranging from the common cold to more serious diseases such as Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV). Coronaviruses are enveloped, single-stranded, positive-sense RNA viruses. They have rod-like extensions (protrusions) on their surface. The Latin equivalent of the crown-like structure formed by such branches is called "corona", and based on this, these viruses were named Coronavirus (coronavirus, a virus with a crown-like structure). Coronaviruses are classified into four main genera alpha, beta, gamma, and delta coronaviruses. They can be found in humans, domestic animals, and wild animals (bat, camel, pig, cat, dog, rodent, poultry, etc.). Human coronaviruses were first identified in the 1960s. To date, seven coronaviruses are known to cause human infections. 229E (alphacoronavirus), NL63 (alphacoronavirus), OC43 (betacoronavirus), and HKU1 (betacoronavirus) are the coronaviruses that are the most common infectious agents in humans and affect the upper and lower respiratory tract. Three other human coronaviruses have recently been identified, namely SARS-CoV, MERS-CoV, and finally SARS-CoV-2. SARS-CoV was identified in 2002 in China. It causes severe acute respiratory syndrome (SARS). Its epidemic has resulted in the death of 774 people worldwide. The MERS-CoV virus emerged in Saudi Arabia in 2012 and was named Middle East respiratory syndrome (MERS) virus, and has spread to 24 countries, causing more than 1,000 cases and nearly 400 deaths. In turn, SARS-CoV-2 is an infectious and highly pathogenic coronavirus that emerged in Wuhan, Hubei Province, China, in late December 2019, causing pneumonia in humans, an epidemic of severe respiratory tract infection, and then spreading first across the country and then around the world. The epidemic was initially detected in people associated with a seafood and animal market in the region; however, it subsequently transmitted from person to person and spread to other cities in Hubei Province, especially Wuhan, to other provinces in the People's Republic of China, and to other countries around the world through human-to-human interactions and travel. Since December 2019, when the virus first emerged, the world's population has been under a virtual global lockdown, causing a slowdown in the global economy. With no cure available, how long this lockdown will last and its negative impact on people and the economy is unpredictable; it has killed over 3.8 million people by July 2021, and it is estimated that this number will exceed millions until herd immunity is achieved.

This new viral respiratory disease caused by the SARS-CoV-2 virus and its most common symptoms, which include fever, cough, and respiratory distress (shortness of breath, difficulty breathing), are defined as COVID-19 by the World Health Organization. The SARS-CoV-2 virus directly attacks the lungs, and lung destruction begins within 5 days. Patients usually die due to respiratory failure. There is currently no drug that can completely cure COVID-19 from a clinical point of view. Currently, drugs such as antivirals, cytokine inhibitors, and antibody administration methods used in palliative treatments for previous viruses are used.

COVID-19 is spread through coughing/sneezing of infected people and inhalation of droplets spread in the environment. People can become infected with the virus if they touch their face, eyes, nose or mouth unless they have washed/disinfected them after touching surfaces contaminated with respiratory droplets from infected people. For this reason, touching your eyes, nose or mouth with dirty hands is a high risk during this epidemic. The incubation period of SARS-CoV-2 coronavirus is from 2 days to 14 days, and milder complaints (such as fever, sore throat, weakness) are observed in the first few days of the disease, after which symptoms such as cough and difficulty breathing (shortness of breath) appear, and the condition of patients usually becomes severe enough to require hospitalization after 7 days. Based on the data obtained, the virus has an increased risk of causing severe disease in the elderly (65 years and older) and those with underlying medical conditions (asthma, diabetes, heart disease, etc.). Some people infected with the SARS-CoV-2 coronavirus have a mild form of the disease and do not show symptoms, however, as these people are carriers, they transmit the disease to people they are in contact with. Carrier patients are usually children and young adults. Although the mortality rate of this disease is currently around 2%, this information may change depending on the changes that may occur in the genetic structure of the virus. In severe cases, pneumonia, severe acute respiratory infection, severe respiratory failure, kidney failure, and even death may occur.

As is known, the viral infection affects the respiratory system and the cardiac system, and the pathogenesis of the SARS-CoV-2 virus begins in the body. Data obtained from a cohort and autopsies of deceased patients indicate that people infected with the SARS-CoV-2 virus develop a coagulopathic profile. A multicenter retrospective cohort study conducted in the People's Republic of China included 191 adult patients who were laboratory confirmed to have COVID-19. Coagulopathy was observed in 50% of patients who died. The degree of coagulopathy with complications representing sepsis was recorded at 70% in patients who died. In addition, coagulation disorders were observed in patients infected with COVID-19, but they were also stated to be different from the typical disseminated intravascular coagulation (DIC) observed in sepsis. Moreover, the formation of microthrombi in the lungs has also been confirmed in patients who underwent autopsy.

In addition to thrombus formation in patients infected with the SARS-CoV-2 virus, it is proposed that the procoagulant and anticoagulant state that occurs during infection causes an imbalance between immune and non-immune cells, and provokes thrombus formation. The endothelium plays a critical role in maintaining the body's homeostasis, and viral infections are known to disrupt the integrity of the endothelium, causing a possible risk of hematopathology. In addition, the elimination of von Willebrand factor, activation of the T-like receptor, and activation of the tissue factor pathway that occurs as a result of viral infection are proposed to play a role in the coagulation cascade, and this effect causes coagulation of cross-linked fibrin. Each physiological response to the excessive activation of the coagulation cascade required to destroy such thrombi is responsible for the procoagulant factor D-dimer. After antigen recognition, platelets are activated in addition to D-dimer, allowing white blood cells to coordinate to remove pathogens and form coagulation. As a result, immune cells, platelets, and endothelial cells play a role in the formation of a coagulopathic profile during viral infection. In addition to this clinical picture, it should be taken into account that the picture of venous thromboembolism will also be an additional reason in favor of coagulation, since patients with COVID-19 are on bed rest for a long time.

The COVID-19 disease, which is described in detail above, disrupts the coagulation pathway and causes severe disease. Therefore, heparin is generally considered as the preferred anticoagulant by the healthcare professional in the treatment of the disease. Heparin is a highly sulfated glycosaminoglycan present in the mast cells of many mammals. The compound binds to immune response proteins such as coagulation factors, growth factors, cytokines, and chemokines through this acidic property. A brief description of the mechanism of action of heparin as an anticoagulant is that heparin binds to antithrombin (AT) and enhances the action of AT to inactivate factor Xa and prevent the conversion of prothrombin to thrombin, as well as prevent the conversion of fibrinogen to fibrin (1). Heparin also non-specifically binds to various plasma proteins and endothelial cells, resulting in an unpredictable dose-response relationship and low bioavailability after subcutaneous (SC) administration. Low molecular weight heparins (LMWH) also bind AT and accelerate AT activity, but with a preferential and longer-lasting effect on factor Xa. Compared with heparin, LMWH have a lower ability to inhibit thrombin production and bind less to plasma proteins and endothelial cells due to their smaller size (2). This explains the bioavailability of 85-99% when administered by SC, a more predictable anticoagulant response, less interpatient variability, and a longer duration of action than heparin (3). To date, single doses of LMWH administered in the treatment of diseases are in the range of 4,000 IU–10,000 IU. On the other hand, the total daily dose currently used in the treatment of COVID-19 is no more than 20,000 IU.

Positive improvements in prothrombin time were observed in 99 of 449 patients with severe disease who were given parenteral anticoagulant heparin (especially low molecular weight heparin) for at least 7 days, while negative improvements in mortality and platelet counts were reported in a retrospective study conducted in the People's Republic of China, where SARS-CoV-2 was first identified.

Heparin, in addition to its anticoagulant action, has anti-inflammatory and immunomodulatory properties in the respiratory system. Studies in recent years have shown that unfractionated heparin (UFH) reduces endotoxin-induced pulmonary vascular resistance and has anti-inflammatory activity. In addition, heparin has been shown to have anti-asthma activity against specific and non-specific inflammatory stimuli in asthmatic patients with bronchial hyperreactivity. It alleviates histamine and leukotriene-induced bronchial hyperreactivity. Anionic heparin acts by binding to and neutralizing various proinflammatory cytotoxic proteins (4). Heparin has also been shown to affect neutrophil chemotaxis and lymphocyte influx (5). Taking all these studies into account, it has been proven that heparin or its derivatives with anticoagulant properties can be administered by inhalation. Enoxaparin sodium, which is a low molecular weight heparin, has been shown to reduce the amount of inflammatory mediators of mast cells and eosinophils when administered by inhalation. It has been noted that it causes the activation of interleukin-6 (IL6), interleukin-8 (IL8), and tumor necrosis factor-alpha (TNF-a) when blood encounters a foreign surface during bypass, and these inflammatory molecules are reduced in the case of heparin-coated materials. Moreover, this effect is directly proportional to the dose. The length of stay in the intensive care unit for these patients was also reduced.

Heparin also antagonizes histones. Histones are released from damaged cells, leading to histone damage in COVID-19 infection. Enkhbaatar et al. noted that nebulized heparin increased oxygenation and reduced pulmonary edema as a result of its histone antagonist effect in smoke-induced lung injury (6).

In recent years, heparin has been used in the treatment of acute lung injury (ALI). ALI can occur due to various causes. It results in refractory hypoxemia and difficulty breathing. Increased vascular patency, exudation of proteinaceous substances and fibrin deposition are due to the release of inflammatory mediators in ALI. The mortality rate in ALI is 40-60%. In this context, an in vitro study by Camprubi-Rimblas et al. in 2017 showed that heparin used in a lung cell model mimicking AU significantly inhibited the NF-KB pathway. It was noted that this inhibition also reduced the levels of IL-6 and TNF-a in human pulmonary macrophages. Heparin was noted to significantly reduce the levels of IL-6, TNF-a and monocyte chemoinducible protein-1 (MCP-1) in human alveolar cell type II models. Nebulized heparin was observed to reduce the symptoms of ALI through procoagulant and proinflammatory pathways in an in vivo study on acute respiratory syndrome (ARDS) rat model by Chimenti et al. in 2017. In addition, the same rats also showed a significant decrease in IL-6, TNF-a, and even a decrease in NF-ĸB expression in alveolar macrophages was reported (7). A randomized controlled observational study involving 60 patients with severe ARDS and using nebulized heparin, streptokinase, and placebo was conducted by Abdelaal Ahmed Mahmoud et al. in 2020. Accordingly, patients who were administered 10,000 IU nebulized heparin every 4 hours showed significant improvement in ARDS at the end of day 8. APTT and INR levels, which are markers of systemic coagulation, did not change, and there was not even a large amount of bleeding or blood transfusion, indicating the benefit of heparin use (8). Most of the COVID-19 cases experienced mild to moderate respiratory symptoms, and about 20% of these cases experienced severe respiratory illness. These respiratory illnesses were mainly diagnosed as ALI and ARDS. Significantly increased levels of inflammatory cytokines such as interleukin-2 (IL-2), IL-6, TNF-a, and MCP-1 were found in studies conducted in patients with severe disease. This level of inflammatory cytokines, which is known as the “cytokine storm”, is an indicator of the body’s natural antiviral response to the replication of viral RNA. The aforementioned viral replication also causes a downstream induction of monocyte-macrophage infiltration and inflammatory signaling pathways such as NF-ĸB and IRF3, which cause an increase in neutrophils. When taken together, these processes cause progressive respiratory complications that develop in patients infected with SARS-CoV-2. Various therapeutic strategies, which also include anticoagulants, are being used by scientists to overcome the ALI and ARDS profiles in COVID-19 or in other cases.

Another beneficial effect of heparin observed in COVID-19 patients is that heparin binds to the SARS-CoV-2 spike protein and also down-regulates IL-6 expression, which plays an important role in the pathogenesis of COVID-19.

Systemic administration of commercially available unfractionated (UFH) and fractionated low molecular weight heparins (LMWH) and ultra low molecular weight heparins (ULMWH) may cause a risk of bleeding due to their anticoagulant properties. Therefore, studies have focused on the targeted use of heparin by nebulization in order to control and prevent the aforementioned risk of bleeding. It is noted that the local effect of heparin is reduced in case of systemic administration of heparin. As a result of tests conducted on rabbits, it was found that it increases the partial pressure of oxygen and reduces the total protein content in the alveoli. Heparin additionally reduces the level of malondialdehyde (MDA), which is an indicator of endothelial damage and, in turn, increases the amount of superoxide dismutase (SOD), which removes reactive oxygen products causing ischemic damage, and glutathione peroxidase (GSH-Px), which protects against oxidative stress. A prospective study showed that inhaled low molecular weight heparin requires a dose 10 times greater than subcutaneous administration to achieve therapeutic levels of anticoagulation.

Jaques et al. first reported the use of inhaled heparin in 1976 in a study published in the Lancet titled “Intrapulmonary Heparin, A New Procedure for Anticoagulant Therapy.” The studies involved administering 10–20 mg/min of heparin using a Devilbiss ultrasonic nebulizer. During the study, patients were asked to breathe slowly and deeply, and this practice was continued for 90 minutes, including rest periods. The study compared the inhaled route with the intravenous and subcutaneous routes. It was found that heparin administered by inhalation had significantly superior parameters in terms of the rate of side effects and the duration of anticoagulant activity.

Atz et al. in a 1998 study examined the use of inhaled heparin with nitric oxide in infants 4 months and younger with pulmonary hypertension. They found that nitric oxide, which has antioxidant, antiproliferative, and antihypertensive effects, plays an important role in maintaining the treatment of primary hypertension when used in combination with heparin, which stimulates smooth muscle and new vessel development (9).

Dixon et al. evaluated the therapeutic effect of nebulized heparin in 16 patients with early acute lung injury. The study noted that 4 doses of heparin did not cause significant changes in respiratory function or systemic anticoagulant effect (10).

In another study, a preclinical and clinical study was conducted by using a treatment regimen that included nebulized heparin, heparinoids, antithrombins, or fibrocytes. In preclinical and clinical studies, it was shown that this inhalation regimen reduced the severity of the disease without worsening coagulation and anticoagulation parameters (11). Chopra et al. in their study indicated that the use of aerosolized acetylcysteine/heparin produced clinically successful coagulopathy in a patient with 87% body burns and suffering from inhalation trauma (12).

It has been demonstrated that inhaled heparin is able to decrease expectoration and that it does not cause bleeding or any other side effects when administered at a dose of 50,000 IU twice daily for two weeks to patients with cystic fibrosis (13). Although the effect of heparin on bronchial hyperreactivity is known, its mechanisms of action are not fully elucidated. A large number of in vitro, in vivo, preclinical and clinical studies have shown that the main function of heparin is to reduce mast cell degranulation and the mechanisms that cause their inflammation, rather than its direct effects on smooth muscle (14-17). Heparin is a high sulfate glycosaminoglycan present in the mast cells of many mammals. It prevents coagulation due to its acidic property. Heparin, in addition to its anticoagulant action, also has anti-inflammatory and immunomodulatory properties. Fibrinolytic property of heparin and its derivatives; They also have the ability to act by binding to immune response proteins such as growth factor, cytokine, and chemokine. In addition, heparin, which is a polyanionic protein, is a highly effective inhibitor of viral binding. Herpes simplex competes with the virus for binding to host cell surface glycoproteins during Zika virus infection. Moreover, heparin has been reported to inactivate the virus and suppress interleukin 6 levels by binding to viral “spike proteins” in patients with severe COVID-19. It counteracts the histone released from damaged lung cells during COVID-19 disease. Numerous preclinical and clinical studies have been published on the use of “inhaled” heparin in lung diseases.

Tuinman et al. (2012) found that patient survival was increased with ALI depending on the inhalation of nebulized heparin smoke, and in preclinical studies, nebulized heparin administration produced the desired systemic coagulation effect without causing bleeding when compared with systemic administration (18).

Despite ongoing clinical studies involving the use of heparin and its derivatives in the treatment of COVID19 via nebulizer, there are still no published clinical trial data. One such ongoing study is the COVID-19 HOPE (Heparin-N-Acetylcysteine Pulmonary Function Evaluation in COVID-19 Patients) study protocol in the United States. The study protocol conducted by Steven Quay et al. suggests that the number of patients requiring mechanical ventilation will be reduced and in some cases eliminated by the use of heparin in combination with N-acetylcysteine via the inhalation route in patients with COVID-19.

Excluding the COVID-19 HOPE trial, there are 38 ongoing clinical trials analyzing anticoagulant activity in the treatment of COVID-19, and 30 of these use heparin and its derivatives as anticoagulants. These trials favored subcutaneous and intravenous routes of administration, which are the traditional routes of drug administration for the administration of heparin and its derivatives. Only one of these studies (a Johns Hopkins University-based clinical trial registered on May 21, 2020, and initiated on June 1, 2020) is designed to compare and analyze the effects of nebulized normal saline with heparin as the nebulized agent.

In the prior art, patent document number RU 2269346 C1 discloses a method for administering pathogenic heparin into an area defined as the tracheobronchial tree of a patient in a dose of 700 IU/kg 3-6 times over 3-5 days for the treatment of tuberculosis. In this case, the administration of heparin by inhalation or endobronchial use is claimed. Another patent application number US 4679555 A from the prior art discloses intrapulmonary administration of sodium heparin in the form of a powder or fine powder using a metered dose inhaler containing a propellant from the group of chlorofluorocarbons with a low boiling point. On the other hand, patent application number US 2002195101 A1 in the prior art discloses a stationary-type inhaler for administering therapeutic aerosols in an individually controlled manner. This patent application also discloses the use of said stationary-type inhaler for aerosol administration of low molecular weight heparin or a drug for the purpose of preventing thrombosis. Another patent application with the number CN 109260181 A in the prior art discloses pharmaceutical solutions in liquid form, which are obtained by mixing an auxiliary substance for adjusting pH, an isotonic auxiliary substance and a surfactant in purified water together with a pharmaceutically acceptable salt of heparin, and which are suitable for subsequent use in aerosol form. It was noted that said solutions can be used in the treatment of COPD, acute lung injury and acute respiratory distress syndrome.

The US patent document entitled "Aerosolization device" under the number US 2014020680 A1 discloses in the prior art a nebulizer device that allows for the production of an aerosol cloud containing a therapeutic agent and operates with a vibrating mesh system. The said patent document does not mention the therapeutic administration of a substance having anticoagulant properties and the use of the antibacterial substances amikacin and vancomycin as therapeutic agents specified in the claims for coronavirus indications.

In the US patent document entitled "Unit Dose Aerosols for Anticoagulation" under the number US 10668015 B2, the prior art mentions the inhalation administration of the active substance, which is an anticoagulant called argatroban, and which is a small molecule direct thrombin inhibitor for prophylactic purposes in acute coronary syndrome.

The said patent document does not mention any anticoagulant agent except argatroban, and only mentions prophylactic inhalation of the substance argatroban only in acute coronary syndrome, and no special emphasis is placed on the device, which is a nebulizer with a vibrating mesh, and no mention is made of the use of anticoagulants.

Currently, heparin is used parenterally in patients with COVID-19. However, its parenteral use causes the following limiting effects on heparin activity.

1) Parenteral administration of heparin reduces its local effect on the lungs in patients with COVID-19.

2) Parenteral heparin causes systemic effects throughout the body. This causes unwanted hemorrhage throughout the body and some unwanted side effects. A prospective study showed that inhaled low molecular weight heparin requires a dose 10 times greater than that given subcutaneously to achieve therapeutic anticoagulation. These data suggest that local pulmonary heparin administration will not cause systemic effects throughout the body.

The choice of a drug used in the treatment of lung diseases (as well as any organ or tissue) is carried out primarily for local treatment of the said organ or tissue. Local treatment provides the applied drugs only in a certain organ or tissue, and other parts of the body are not exposed to the systemic effect of the drug. The administration is more effective and its side effects are reduced with local administration of the drug, although the active substances are used in smaller quantities. The effect of neutralizing the viral load of COVID-19 and preventing the penetration of the virus into the cell by binding to spike proteins was revealed along with the anticoagulant and anti-inflammatory effect of heparin. This pharmacological feature of heparin indicates that its antiviral effect on COVID-19 will create a more effective and successful application compared to parenteral administration in case of its local administration to the lungs. Similarly, local treatment is known to be more effective and successful in the treatment of other viral lung diseases compared to oral or parenteral applications.

The COVID-19 pandemic creates a need for formulations and technologies that can be formulated very quickly. Inhalation devices used in clinical practice are metered dose inhalers (MDIs), dry powder inhalers (DPIs), nebulizers (jet, ultrasonic, new type nebulizers (e.g. VMT and electronic) and soft mist inhalers). The use of MDIs and DPIs is not very beneficial, especially for patients with severe respiratory distress, and has many disadvantages (difficulty in use, inability to control their activity, risk of contamination). At this stage, the choice of device becomes especially important. Standard nebulizers are not safe for COVID-19 patients due to common problems with inhalation and exhalation, wide spread of droplets, spreading of patient saliva by the nebulizer and creating a risk of infection for healthcare workers. In practice, jet, ultrasonic or electronic nebulizers cause the spread of the virus and pose a risk of infection, and should not be preferred in terms of the health of medical personnel due to the fact that they cause the death of doctors and nurses, as observed in Italy and the United States. Droplets dispersed by breathing carry viruses, and it is very important to minimize this risk during treatment. Therefore, choosing the right route of administration and the right nebulizer is extremely important in the treatment of viral lung diseases, including COVID-19.

A soft mist inhaler (so named to describe the mechanisms of aerosol generation and the properties of the aerosol cloud) is a non-pressurized metered dose inhaler that uses microfluidic technology and has a metering function that allows for variable dose delivery (19-20). With a DPI, the delivered fine particle dose is highly dependent on the inspiratory airflow and absolute vital capacity, which varies greatly between patients (19). On the other hand, soft mist inhalers offer many advantages in terms of lung deposition and ease of administration. Soft mist inhalers are active systems that do not require a propellant, in other words, the energy required to generate the aerosol comes from the inhaler and is thus independent of the patient's tidal volume (20). Soft mist inhalers offer many more advantages in terms of lung deposition and ease of administration. The soft mist inhaler works with an active mechanism that does not require a propellant; the energy required to create the aerosol comes from the inhaler itself. Thus, the soft mist inhaler is independent of the patient's tidal volume. The size range of the aerosol droplets emitted from the device is in the range of 2-6 micrometers, and these aerosol droplets act on the lungs. Another advantage of the soft mist inhaler is that dosing is done with a syringe. The true parenteral form of the drug/active substances can be administered by incorporating it into the soft mist inhaler without the need for an additional stage of preparation using the said syringe system.

The dose-to-dose reproducibility of soft mist inhalers, which deliver a volume of drug in solution from a depot or single-dose delivery system, is more consistent than that of dry powder inhalers, which deliver small amounts of suspension carried in the powder. In soft mist inhalers, the drug is dissolved in the solution; thus, it is less susceptible to moisture than dry powders, making soft mist inhalers suitable for use in humid environments. The relatively low velocity and long nebulization time of a soft mist inhaler facilitate reproducible inhalation of the aerosol. However, there is often a requirement for the drug to be soluble and stable in the solution for a soft mist inhaler unless certain formulation technologies are used.

Historically, jet nebulizers have been the standard delivery system for aerosolized medications. They are relatively inefficient and require an external air source to operate. On the other hand, vibrating mesh technology has been developed as an alternative to jet nebulizers. Vibrating mesh technology nebulizers are known to be more efficient than jet nebulizers and do not require additional gas in the breathing circuit. On the other hand, vibrating mesh nebulizers may be more sensitive to contamination risk and device directionality and have precise electronic controls compared to jet nebulizers. Vibrating mesh technology (VMT) nebulizers offer many advantages due to their consistent and improved aerosol generation efficiency, fine particle fraction that can reach the peripheral lungs, and the ability to deliver low residual volumes and low drug volumes. VMT nebulizers are active systems that do not require a propellant and use micropump technology, with the energy required to create the aerosol supplied from the inhaler by a physical mechanism. Thus, the delivery of the drug to the target area in the lungs is independent of the patient's tidal volume. VMT nebulizers feature short processing times and silent operation. The pore size of VMT nebulizers can be optimized by adjusting the aerosol chamber and the output speed for different drugs. The principle of operation of the VMT nebulizer is based on the fact that thousands of holes in the membrane vibrate simultaneously hundreds of thousands of times per second, and the liquid passing through these holes forms aerosol droplets of the appropriate size for the targeted effect of the drug on the lungs. The system control sensors detect any contact of the liquid with the nebulizing membrane and allow the liquid to pass through thousands of holes created by a high-precision laser through vibrations in the resonant mode of bending, thus creating fine droplets with a narrower size distribution than in existing systems. The membrane can be designed to produce droplets of a specific size, suitable for the physical properties of the solution, by changing the pore size of the said membrane. The VMT nebulizer provides better dosing quality since there is no aerosol emission, unlike conventional nebulizers (jet or ultrasonic), due to the fact that its system is placed in the mouth and is designed for maskless use. In addition, the problem of room contamination observed with the use of a classic type nebulizer in the treatment of COVID-19 is no longer an issue since the VMT nebulizer works in a closed system due to its mouthpiece. In the VMT nebulizer, the drug is in dissolved form in the solution, so it is less susceptible to moisture than dry powders, so VMT nebulizers are suitable for use in humid environments. Another advantage of VMT nebulizers is that they facilitate the inhalation of the aerosol in a reproducible manner due to a long nebulization time at a low speed. The drug used in the vibrating mesh nebulizer is located on the concave side of the mesh, and the mesh vibrates at a high frequency using a piezoelectric drive. This allows the drug to turn into a cloud of small droplets that can be delivered from the lower (convex) side of the mesh. In addition, the droplet size can be adjusted using the above-mentioned technology. In particular, geometric changes can be made in the mesh structure to ensure the desired specific droplet size. The droplets can move away from the device under the action of gravity at a low speed due to the absence of nebulizing gas. In addition, the number of holes in the mesh and their location on the mesh can also be changed to meet individual requirements.

The limitations and shortcomings of the available solutions in the prior art have led to the need for improvements for the effective treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases.

Brief description and objectives of the present invention

The present invention discloses the administration of heparin and its derivatives, which are anticoagulants, in particular low molecular weight heparin (LMWH), for use in the treatment of symptoms caused in particular by COVID-19, viral lung diseases, acute and / or chronic lung diseases, by using a soft mist inhaler or a vibrating mesh technology (VMT) nebulizer via an inhalation route of administration, and compositions comprising heparin and its derivatives, effective dosage forms and doses. In the present invention, said anticoagulant substance is administered locally and directly to the lung via the pulmonary route of administration. The pulmonary route of administration is a suitable route for the administration of active substances with a weaker absorption than the oral route, for peptide-protein structures that are broken down in the stomach, or active substances that are rapidly metabolized. The pharmaceutical composition according to the present invention may contain an additional active substance and/or excipients, as well as heparin or heparin derivatives.

The most important objective of the present invention is to provide effective treatment, in particular for COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases. The present invention provides the possibility of administering the active substance locally (directly) to the lungs in the treatment of viral lung diseases, which provides many advantages over other routes of administration (oral, parenteral, etc.), thereby providing more effective treatment.

Another objective of the present invention is to provide higher efficacy of drugs/active substances used in the treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases, and to minimize their side effects. In the present invention, the efficacy of the drug is increased and the side effects of the drug, which may occur systemically, are reduced when administered locally compared to oral and parenteral routes.

Another objective of the present invention is to provide effective treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases using a highly bioavailable administration form. In the present invention, the administration of heparin and its derivatives via the pulmonary route increases bioavailability because the first-pass effect through the liver is eliminated. In addition, since the passage of macromolecular structures through the lungs occurs in a sufficiently proper manner, the effectiveness of the treatment is higher than with existing administration methods.

Another object of the present invention is to treat lung injury caused by COVID-19 disease. In the present invention, cases such as acute lung injury caused by SARS-CoV-2 virus in the lungs, bronchial hyperresponsiveness due to inflammation, thromboembolism, histone release from damaged lung cells and histone damage in the lungs, ARDS and associated hypoxemia are treated by administering heparin or its derivatives, especially low molecular weight heparin, through the pulmonary route.

Another objective of the present invention is to minimize the risk of infection of medical personnel and uninfected people in the environment during treatment, in particular COVID-19 and viral lung diseases. The risk of environmental contamination is reduced by the inhalation form of application according to the present invention. The present invention provides such a form of application to prevent contamination of the air in the room due to the operation of a closed system.

In the present invention, accumulation (condensation of solutions containing the drug/active substance) in the environment and in the upper respiratory tract is minimized, and thus a low-velocity aerosol that optimizes drug accumulation is created by administering heparin or heparin derivatives using vibrating mesh nebulizers. Nebulizers with vibrating mesh technology do not affect the stability of the drug/active substance, since they do not generate heat.

In the present invention, the localization of the drug in the lungs is significantly higher (20% and higher) compared to other devices as a result of the administration of heparin or heparin derivatives using a "soft mist" inhaler. This is due to the fact that the range of droplet sizes in the "soft mist" inhaler is so localized in the lungs that it is incomparable with a metered dose inhaler (MDI), a dry powder inhaler (DPI), a jet or ultrasonic nebulizer. In the "soft mist" inhaler, the user places the device in his mouth using a mouthpiece and inhales through the mouth and then exhales through the nose, thereby minimizing the risk of exhalation through the mouth. Contamination of saliva with the environment is prevented by creating a closed system. The soft mist inhaler used in the present invention is provided with an application device attached to an endotracheal tube designed for intubated patients, and this attachment makes the inhaler superior to existing inhalers.

In the present invention, the pharmaceutical composition containing heparin or heparin derivatives can be formulated for single or multiple use. The single-dose dosage form is advantageous in the treatment of acute lung diseases because it does not carry the risk of contamination and does not require the addition of additional excipients (antioxidant, antimicrobial agent, etc.) to the composition to ensure stability. However, in the treatment of chronic diseases (COPD, asthma, etc.), the multi-dose form is more advantageous for long-term treatment, taking into account patient compliance and cost, since the patient uses the drug at home on his own.

In the present invention, the administration of heparin or heparin derivatives using a soft mist inhaler equipped with a syringe for dose adjustment makes it possible that the dose adjustment for the administration aimed at the lungs can be performed by the physician in the most sensitive manner in response to the patient's needs. The said syringe system makes it possible to significantly improve the practicality of the application of a patient-specific dosage by physicians in hospitals. In addition, the presented heparin-containing syringes can be directly attached to the soft mist inhaler, so that the treatment can be quickly offered to patients when needed, which eliminates the supply problem. In addition, heparin and heparin derivatives can be pre-filled into the soft mist inhaler during the manufacturing process at the pharmaceutical factory according to single-dose or multi-dose use and made ready for use by means of the packaging.

Description of graphic materials

Fig. 1 shows an exploded view of a soft mist inhaler used to administer the agent of the present invention.

Fig. 2 shows a schematic representation of a nebulizer with a passive vibrating mesh, which is used to administer the agent of the present invention.

Fig. 3 shows a schematic representation of a nebulizer with an active vibrating mesh, which is used to administer the agent of the present invention.

Fig. 4 shows a histogram of LMWH deposition in the lungs.

Fig. 5 shows the study procedure schedule (*3 patients had low device compliance and therefore did not receive inhaled LMWH).

Fig. 6 shows a view of the use of a soft mist inhaler, which is used to administer the agent of the present invention, with a holder for delivering a respiratory agent.

Fig. 7 shows a view of the use of a soft mist inhaler, which is used to administer the agent of the present invention, with a holder for delivering a respiratory agent.

Description of elements/parts/components of the present invention

The parts and components in the drawings are listed to better explain the present invention, and the correspondence of each number is given below.

1 - Nebulizer device with passive vibrating mesh

1.1 - Piezo crystal

1.2 - Tank 1

1.3 - Batteries

1.4 - Working button

1.5 - Split-end adapter

1.6 - Mouthpiece

1.7 - Grid 1

2 - Nebulizer device with active vibrating mesh

2.1 - Lid

2.2 - Tank 2

2.3 - Grid 2

2.4 - T-shaped mouthpiece

3 - Syringe/injector

4 - Connecting tube

5 - Housing for the soft mist inhaler

6 - Respiratory device delivery holder

Detailed description of the invention

The present invention relates to the use of heparin or heparin derivatives, in particular low molecular weight heparin (LMWH), for use in the treatment of, in particular, COVID-19, viral lung diseases, acute and/or chronic lung diseases using a soft mist inhaler or a vibrating mesh technology (VMT) nebulizer via the inhalation route of administration, and a pharmaceutical composition and dosage form related to said use. The localization of the drug in the lungs (the heparin-based composition therein) is 20% or more when the pharmaceutical composition according to the present invention is administered using a soft mist inhaler or a vibrating mesh technology (VMT) nebulizer by inhalation. In an embodiment of the present invention, the localization of the drug in the lungs (the heparin-based composition therein) is 40%, 50% or 60% when using a soft mist inhaler by inhalation. One of the reasons for choosing heparin in these treatments is that heparin is suitable for local administration to the lungs. Heparin, in addition to its anticoagulant properties, has antiviral, anti-inflammatory and mucolytic properties.

Heparin or heparin derivatives are an anticoagulant indicated in the treatment of acute lung injury caused by the SARS-CoV-2 virus in the lungs, bronchial hyperresponsiveness due to inflammation, thromboembolism, histone release from damaged lung cells and histone damage in the lungs, and further in the treatment of hypoxemia associated with acute respiratory distress syndrome (ARDS) and breathing difficulties. In the present invention, low molecular weight heparin (LMWH) or unfractionated heparin (UFH) having anticoagulant, anti-inflammatory, antiviral and mucolytic effects can be used as heparin in the treatment of viral, acute and/or chronic lung diseases. The heparin derivatives indicated in the pharmaceutical composition according to the present invention can be all pharmaceutically acceptable heparin derivatives. Heparin sodium salts, heparin esters, heparin ethers, heparin bases, heparin solvates, heparin hydrates or forms thereof used as prodrugs of heparin may be examples of heparin derivatives. All LMWH and UFH derivatives that are administered by inhalation for pulmonary effects are suitable for topical administration to the lungs via the inhalation route using a soft mist inhaler or a nebulizer with passive VMT in the treatment of viral lung diseases, acute lung diseases and/or chronic lung diseases, in particular COVID-19.

In the present invention, heparin or heparin derivatives can be added to a device that is a soft mist inhaler or a device that is a nebulizer with vibrating mesh technology (VMT) at the manufacturing stage, or a solution containing the active substance is packaged and stored in a dropper, a pre-filled syringe (PFS), an ampoule or a vial, and said solution can be added to the device later by a patient or medical staff before use in a hospital or any environment.

In an embodiment of the present invention, a nebulizer with active or passive vibrating mesh technology (VMT) is used as a nebulizer with vibrating mesh technology (VMT). The device, which is a nebulizer with a passive vibrating mesh (1), comprises; a piezoelectric crystal (1.1), a reservoir 1 (1.2), batteries (1.3), an operating button (1.4), a horn adapter (1.5), a mouthpiece (1.6) and a mesh 1 (1.7). The device, which is a nebulizer with an active vibrating mesh (2), in turn, comprises; a cover (2.1), a reservoir 2 (2.2), a mesh 2 (2.3) and a T-shaped mouthpiece (2.4). The key component is the mesh plate (1.7), which contains a membrane perforated with precisely made holes. The piezoelectric crystal (1.1) vibrates the diaphragm mesh, which acts as a micropump, drawing liquid through the holes to create uniformly sized dispersed particles of 1-6 μm in diameter. The above particle size is advantageous because particles of 6-10 μm in diameter do not pass beyond the large airways in the lungs. VMT nebulizers create a low-velocity aerosol, which minimizes its accumulation (condensation of drug-containing solutions) in the environment and in the upper airways, thereby optimizing drug accumulation. They do not generate heat and therefore do not affect the stability of the drug.

In an embodiment of the present invention, heparin or heparin derivatives are administered using a soft mist inhaler via the inhalation route of administration in the treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases. In the present invention, the PulmoSpray® device available in the prior art can be used as a soft mist inhaler. The soft mist inhaler comprises a soft mist inhaler body (5) comprising a special membrane, a connecting tube, a syringe and, optionally, in the case where the holder for delivering the respiratory agent is in a pre-filled form, a holder (6) for delivering the respiratory agent or a similar holding system in which the syringe is placed (Figs. 6-7); and the soft mist inhaler body (5) ensures maximum efficiency of use. In this case, maximum efficiency means maintaining a balance between the greatest transfer of the active substance and the lowest risk of infection. Aerosol droplets suitable for targeted drug delivery to the lungs are formed by passing liquid through a membrane in the body (5) of the soft mist inhaler by pushing the liquid under pressure. The said soft mist inhaler is extremely suitable for ensuring safety in the treatment of COVID-19 because, due to its mechanism, it is inserted into the patient's mouth as a closed system, and the patient inhales the drug from the device and exhales through the nose. The droplet size range of the soft mist inhaler, which is effective in the treatment of both COVID-19 and other viral lung diseases, is quite narrow due to the accumulation of the drug/active substance and the ease of use provided by the soft mist inhaler in the lungs. The soft mist inhaler is placed in the mouth with a mouthpiece, inhalation is carried out through it, and exhalation is carried out through the nose; thus, closed-loop breathing minimizes contamination of the environment with saliva. In addition, the soft mist inhaler has two more advantages that nebulizers do not have: dose accuracy and practicality of use. In the soft mist inhaler, the dose adjustment depending on weight and age can be easily carried out by a doctor in a hospital taking into account the individual characteristics of the patient using a syringe system attached to the device. Parenteral forms of heparin, which are commercially available in the form of a pre-filled syringe, can also be immediately used in patients using the method of use according to the present invention without the need for an additional preparation step due to the fact that the device works with a syringe system.

The present invention provides a syringe (injector) with a metering function in a "soft mist" inhaler used for administering heparin or its derivatives in the treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases. The dosage adjustment for the application aimed at the lungs can be carried out by the physician in the most sensitive manner according to the patient's needs using the said special syringe. The said syringe system makes it possible to significantly improve the practicality of the application of a dosage targeted at a specific patient by physicians in hospitals. In addition, a parenteral dosage form of heparin and heparin derivatives, which is commercially available in the form of a ready-to-use syringe, can be directly connected to the "soft mist" inhaler used in the present invention. The fact that the parenteral form of heparin and heparin derivatives is directly compatible with the device allows the three-component "formulation-device-administration" system to work most effectively and to be applied most quickly to patients, especially to the elderly at risk (>65 years) in these time-limited pandemic conditions. Heparin or heparin derivatives pass through the connecting tube (4) between the devices after the syringe (3), and the heparin or its derivatives become aerosol droplets in a range of particle sizes that can be localized in the lungs and thus can be administered to the lungs by the soft mist inhaler using the nozzle mechanism in the body (5) of the soft mist inhaler. The soft mist inhaler works with an active mechanism that does not require a propellant; the energy required to create the aerosol comes from the inhaler itself and is thus independent of the patient's tidal volume. The size range of the aerosol droplets emitted from the device is in the range of 2-6 micrometers, and these aerosol droplets affect the lungs. Thus, the present invention provides effective treatment. Another advantage of the "soft mist" inhaler is that dosing is carried out using a syringe.

In a preferred embodiment of the present invention, low molecular weight heparin (LMWH) is used for administration via a soft mist inhaler or a vibrating mesh technology (VMT) nebulizer for the treatment of, in particular, COVID-19, viral lung diseases, acute lung diseases and/or chronic lung diseases. Low molecular weight heparin (LMWH), which is a member of the group of anticoagulant drugs, exhibits high efficacy by providing a local effect on the lungs when inhaled through the mouth. LMWH, due to its antiviral, anti-inflammatory and mucolytic properties, is also effectively used in the treatment of COVID-19 and other viral lung diseases.

In the present invention, a pharmaceutical composition administered via an inhalation route comprises heparin or a heparin derivative and a carrier solution having the properties of a heparin solvent. The pharmaceutical composition disclosed in the present invention and containing heparin or a heparin derivative may also be referred to hereinafter as a heparin-based composition or a heparin solution. The heparin-containing composition intended for inhalation comprises 4,000-25,000 IU of heparin or a heparin derivative dissolved in a carrier solution (preferably water for injection), preferably low molecular weight heparin (LMWH). The solvent may be aqueous or non-aqueous in the heparin-based composition. The dosage form can be formulated with one pharmaceutically acceptable solvent, which can be, without limitation, glycerin, propylene glycol, polyethylene glycol, polypropylene glycol, ethyl alcohol, isopropyl alcohol, water, mineral oil, peanut oil and corn oil, or a mixture of more than one of them. Pharmaceutical solvents can be used to obtain a concentrate of the composition, as well as to reconstitute the dosage form. Pharmaceutically acceptable solvents, such as water, ethyl alcohol, isopropyl alcohol, easily evaporate and are usually used to dissolve or disperse the drug and excipients in the concentrate of the composition. Glycerin, propylene glycol and polyethylene glycol are co-solvents and are used to promote the solubilization of water-insoluble or poorly water-soluble drugs in the concentrate of the composition. Pharmaceutically acceptable reconstituting solvents such as sterile water for injection, water for inhalation, sterile normal saline (0.9% NaCl), sterile half-strength saline (0.45% NaCl), sterile phosphate buffered saline (pH 4.5-7.4) and/or sterile 5% dextrose solution are used to reconstitute the dosage form to obtain a solution or suspension of finely dispersed particles of the pharmaceutically active substance prior to oral or nasal inhalation using a VMT nebulizer or a soft mist inhaler.

The composition according to the present invention comprises 4000 IU, 6000 IU, 8000 IU or 10000 IU of heparin or a heparin derivative. More specifically, the composition according to the present invention may be a sterile inhalation solution comprising 4000 IU/ml, 6000 IU/ml, 8000 IU/ml or 10000 IU/ml of heparin, in particular LMWH or UFH, which is contained in water for injection or water for inhalation, or physiological saline, or half physiological saline, or phosphate buffer.

In a preferred embodiment of the present invention, the composition is a sterile inhalation solution with a concentration of 4000 IU/mL, which is obtained by dissolving 4000 IU of LMWH in 1 mL of a carrier solution. The carrier solution in the composition is used to the required volume of a milliliter (mL) to obtain a heparin solution with a concentration of 4000 IU/mL; wherein the carrier solution acts as a carrier and a solvent, and it is selected from water for injection, water for inhalation, physiological saline (0.9% NaCl), or half physiological saline (0.45% NaCl), or phosphate buffer (pH 7.4). The heparin solution with a concentration of 4000 IU/mL is packaged and used as a single dose. However, if the drug is to be used in pediatric patient groups, the user dose adjustment is made with respect to the specified single dose. The only route of administration of the finished composition is inhalation, however, the direction of local or systemic action may vary depending on the disease to be treated.

The heparin-based composition, in addition to heparin or a heparin derivative, may contain at least another active substance or at least one auxiliary substance. The heparin mentioned herein is preferably LMWH or UFH or any derivative thereof. In an embodiment of the present invention, the active substances that can be used in addition to heparin or heparin derivatives are presented in three pharmacological groups, and any combination thereof can be used together;

1 - those with a mucolytic effect: mannitol, acetylcysteine or hypertonic (3-20% NaCl, w/v) physiological saline solution;

2 - those aimed at eliminating oxidative stress in the lungs: ascorbic acid and its derivatives;

3 - corticosteroids with anti-inflammatory properties: budesonide, beclomethasone dipropionate, fluticasone, mometasone or dexamethasone.

In an embodiment of the present invention, mannitol or acetylcysteine can be added to a low molecular weight heparin (LMWH) or unfractionated heparin (UFH) solution in a pharmaceutical composition containing heparin or a heparin derivative. In this way, the effect of opening the mucus plug in the lungs is also achieved. In another embodiment of the present invention, a heparin solution in which mannitol is added to a LMWH or UFH heparin solution is made hypertonic (3-20% NaCl, w/v), and thereby provides the effect of opening the mucus plug.

In a heparin-based composition, the auxiliary substance(s) can be used in the case of using another active substance in addition to heparin or heparin derivatives, or directly in addition to the heparin-based composition. The pharmaceutical composition can contain at least one auxiliary substance selected from tonicity-regulating auxiliary substances, pH-regulating or buffering agents, tonicity-regulating agents, antioxidants, antimicrobial preservatives, surfactants, solubility enhancers (co-solvents), stabilizing agents, auxiliary substances for providing prolonged release or prolonged local retention, wetting agents, dispersing agents, taste-masking agents, sweeteners and/or flavor additives. Such auxiliary substances are used to obtain optimal pH, viscosity, surface tension and taste, which maintain the stability of the composition, aerosolization, tolerability and/or effectiveness of the composition upon inhalation.

One or more cosolvents (solubility enhancer) can be included in the heparin-based pharmaceutical composition to improve the solubility of the active substance and/or other excipients. Examples of pharmaceutically acceptable cosolvents include, but are not limited to, propylene glycol, dipropylene glycol, ethylene glycol, glycerol, ethanol, polyethylene glycols (e.g., PEG300 or PEG400), methanol, polyethylene glycol castor oil, polyoxyethylene castor oil, and/or lecithin.

Stabilizing agents that can be used for the heparin-based composition are antioxidant and chelating agents that are capable of inhibiting the oxidation reaction and chelating metals, respectively, to improve the stability of the pharmaceutically active substance and excipients. The dosage forms can be formulated with one or more pharmaceutically acceptable stabilizing agents at a concentration suitable for the intended pharmaceutical uses and can include, but are not limited to, chelating agents such as disodium edetate (ethylenediaminetetraacetic acid, EDTA) or its sodium salt, citric acid, sodium citrate, vitamin E, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate, sodium bisulfite, sodium metabisulfite, sodium formaldehyde sulfoxylate, thiourea, lysine, tryptophan, phenylpropylglycine, glycine, glutamic acid, leucine, isoleucine, serine, tea polyphenols, ascorbyl palmitate, hydroxymethyl ester, hydroxyethyl tetramethylpiperidinol, bis(2,2,6,6-tetramethyl-4-piperidyl)sebacate, polysuccinate ester-(4-hydroxy-2,2,6,6-tetramethyl-1-piperidinylethanol), 2-[2-hydroxy-4-[3-(2-ethylhexyloxy)-2-hydroxypropoxy]phenyl]-4,6-bis(2,4-dimethylphenyl) and/or 1,3,5-triazine.

Antioxidants, which are natural or synthetic substances that prevent or interrupt the oxidation of active agents and/or oxidative damage in tissues and cells subjected to stress, can be used in the heparin-based composition. Antioxidants that can be used in the heparin-based composition can be auxiliary agents that are themselves oxidizable (i.e. primary antioxidants) or auxiliary agents that act as reducing agents (i.e. reducing antioxidants), such as tocopherol acetate, lycopene, reduced glutathione, catalase and/or peroxide dismutase. Other auxiliary agents used to prevent oxidative reactions are synergistic antioxidants that act not directly in oxidation processes, but indirectly through complexation of metal ions that are known to catalyze oxidation reactions. Frequently used synergistic antioxidants are ethylenediaminetetraacetic acid (EDTA) and its derivatives. Further suitable antioxidants (basic, reductive and/or synergistic antioxidant mechanism of action) are ascorbic acid and/or its salts, ascorbic acid esters, fumaric acid and/or its salts, malic acid and/or its salts, citric acid and/or its salts, butylated hydroxyanisole, butylated hydroxytoluene, propyl gallate and/or maltol. As an alternative to the commonly used antioxidants, substances such as acetylcysteine, R-cysteine, vitamin E TPGS, pyruvic acid and/or its magnesium and/or sodium salts, gluconic acid and/or its magnesium and/or sodium salts may also be suitable in inhalation formulations. Gluconic acid salts have the additional benefit of being described as having an antioxidant effect on stressed tissues and cells, which may be particularly useful in the treatment of inflammation, since oxygen radicals initiate and maintain inflammatory processes. Pyruvate salts are also thought to have such antioxidant effects in vivo. An additional measure to prevent oxidation and help prevent unwanted discoloration is to replace the oxygen above the solution with an inert gas, not limited to nitrogen or argon.

Antimicrobial preservatives may be used in the heparin-based composition to inhibit the growth of microorganisms. Dosage forms may be formulated with one or more pharmaceutically acceptable antimicrobial preservatives at suitable concentrations to prevent the growth of microorganisms. Compositions for administration to the lungs or nose may contain one or more excipients, may be protected from microbial or fungal contamination or growth by including one or more preservatives. Examples of pharmaceutically acceptable antimicrobials or preservatives include, but are not limited to, quaternary ammonium compounds (e.g., benzalkonium chloride, benzethonium chloride, cetrimide, cetylpyridinium chloride, lauralkonium chloride, and/or myristylpicolinium chloride), thiomersal-based alcohols (e.g., chlorobutanol, phenylethyl alcohol, and/or benzyl alcohol), antibacterial esters (e.g., para-hydroxybenzoic acid esters), chelating agents such as disodium edetate (EDTA), other antimicrobials such as chlorhexidine, chlorocresol, sorbic acid and/or its salts (such as potassium sorbate), and polymyxin. Examples of pharmaceutically acceptable antifungal agents or preservatives include, but are not limited to, sodium benzoate, sorbic acid, sodium propionate, methylparaben, ethylparaben, propylparaben, butylparaben, ethyl p-hydroxybenzoate and/or n-propyl p-hydroxybenzoate.

pH adjusting or buffering agents can be used in a heparin-based composition to adjust or maintain the pH of a pharmaceutical dosage form in a desired range for the following reasons: to provide an environment for better product stability, so that a pharmaceutically active substance can exhibit better chemical stability in a certain pH range, or to provide greater patient comfort during administration. An extreme pH level can cause irritation and/or discomfort at the injection site and provide a pH range for better activity of the antimicrobial preservative. The heparin-based composition can contain one or more auxiliary substances for adjusting and/or buffering the pH of the solution. Physiologically acceptable acids, bases, salts and/or combinations thereof can be used to adjust and, optionally, buffer the pH. Excipients often used to lower the pH or to serve as an acidic component in a buffer system are strong mineral acids, in particular sulfuric acid and hydrochloric acid. Medium-strength inorganic and organic acids and acid salts such as phosphoric acid, citric acid, tartaric acid, succinic acid, fumaric acid, methionine, acid hydrogen phosphates with sodium or potassium, lactic acid and/or glucuronic acid can also be used. Auxiliary substances suitable for increasing the pH or as the main component in a buffer system are, in particular, mineral bases such as sodium hydroxide or other alkaline earth metal hydroxides and oxides such as magnesium hydroxide and calcium hydroxide, ammonium hydroxide and basic ammonium salts such as ammonium acetate, as well as basic amino acids such as lysine, carbonates such as sodium or magnesium carbonate, sodium hydrogen carbonate, and citrates such as sodium citrate. The heparin-based composition can contain a buffer system consisting of two components. One of the most preferred buffer systems comprises citric acid-sodium citrate, citric acid-disodium phosphate, potassium dihydrogen phosphate-disodium hydrogen phosphate or citric acid-sodium hydroxide, trometamol, disodium phosphate (e.g. dodecahydrate, heptahydrate, dihydrate and their anhydrous forms) and/or sodium mixtures. However, other buffer systems can also be used.

A tonicity adjusting agent is one or more pharmaceutical excipients that are osmotically active and that are used in routine practice to adjust the osmolality or tonicity of liquid pharmaceutical formulations. In general, tonicity adjusting agents are used to increase the overall comfort of the patient during administration. A tonicity adjusting agent can be used in a heparin-based composition, selected from sodium chloride, mannitol or dextrose. Other salts that can be used in a heparin-based composition to adjust tonicity are sodium gluconate, sodium pyruvate and/or potassium chloride. Carbohydrates can also be used for this purpose. Examples are sugars such as glucose, lactose, sucrose or trehalose, sugar alcohols such as xylitol, sorbitol and/or isomaltol. Alternatively, the dosage form can be formulated without adding a basic tonicity adjusting agent. The required tonicity of the dosage form is achieved by reconstitution with sterile isotonic saline.

The surface tension of a liquid composition is important for optimal inhalation. Compositions with the required surface tension are expected to distribute properly on the mucous membranes of the respiratory tract. Optimum surface tension is necessary to ensure smooth atomization of the composition and the formation of uniform and stable aerosol particles that will be absorbed by the patient. Moreover, surface tension may need to be adjusted to ensure proper extraction of the composition from the primary packaging. Surfactants are materials with at least one relatively hydrophilic and at least one relatively lipophilic molecular region that accumulates at the boundaries of the hydrophilic and lipophilic phases and reduces the surface tension. Surfactant materials can be ionic or non-ionic. Particularly preferred surfactants are those that are characterized by high physiological compatibility and are considered safe for oral or nasal inhalation. A preferred surfactant in the heparin-based composition may be tyloxapol, polysorbates, polysorbate 20, polysorbate 60, polysorbate 80, lecithin, vitamin E TPGS, macrogol hydroxystearates and/or macrogol-15-hydroxystearate. The surfactant used in the heparin-based composition may also include a mixture of two or more surfactants, for example, polysorbate 80 in combination with vitamin E TPGS.

In some embodiments of the present invention, taste masking agents or sweeteners or flavor additives can also be used as an auxiliary substance. The unpleasant taste of inhalation formulations is extremely unpleasant and irritating. The sensation of unpleasant taste upon inhalation occurs as a result of direct deposition of aerosol droplets in the oral cavity and pharynx during oral inhalation, transfer of the drug from the nose to the mouth during nasal inhalation, and transfer of the drug from the respiratory tract to the mouth associated with mucociliary clearance in the respiratory system. A taste masking agent is any pharmaceutically acceptable compound or mixture of compounds capable of improving the taste of an aqueous system, regardless of the mechanism by which this improvement is achieved. For example, a taste masking agent can cover up an unpleasant taste, i.e. reduce the intensity of its perception, or it can adjust the taste by adding another, usually more pleasant flavor additive to the composition, thereby improving the overall organoleptic impression. Other taste masking mechanisms include complexation, encapsulation, embedding or any other interaction between the drugs and other compounds of the composition. A taste masking agent that can be used in a heparin-based composition is selected from the group of pharmaceutically acceptable sweeteners such as saccharin, aspartame, cyclamate, sucralose, acesulfame, neotame, thaumatin and/or neohesperidin, including their salts and solvates such as sodium saccharin and potassium acesulfame. Furthermore, sugars such as sucrose, trehalose, fructose and lactose, or sugar alcohols such as xylitol, mannitol or isomalt can be used. Further suitable taste masking agents include pharmaceutically acceptable surfactants, alkaline earth metal salts, organic acids such as citric acid and lactic acid, and/or amino acids such as arginine. It is also possible to use flavor additives such as essential oil ingredients (menthol, thymol or cineole) in the heparin-based composition to improve the taste and tolerability of the composition according to the present invention.

Wetting or dispersing agents may be used in a heparin-based composition to enhance wettability and aid in dispersion of water-insoluble or poorly water-soluble particles. For water-insoluble and poorly water-soluble drugs, the addition of one or more wetting or dispersing agents to the drug formulation may facilitate the release of particles of the pharmaceutically active substance from the auxiliary material impregnated therewith into the reconstituted solution and may facilitate dispersion of the particles to form a finely dispersed suspension. Examples of pharmaceutically acceptable wetting and dispersing agents suitable for oral or nasal inhalation for a heparin-based composition are poloxamers, butyric acid or its salts, lecithin, hydrogenated lecithin, sorbitan fatty acid esters, oleyl alcohol, phospholipids including but not limited to phosphatidylglycerol, phosphatidylcholine, polyoxyethylene fatty alcohol ethers, polyoxypropylene fatty alcohol ether, polyoxyethylene fatty acid ester, glycerol fatty acid esters, glycolipid such as sphingolipid and sphingomyelin, polyoxyethylene glycol fatty acid ester, polyhydric alcohol fatty acid esters, polyethylene glycol glycerol fatty acid esters, polypropylene glycol fatty acid esters, ethoxylated lanolin derivatives, polyoxyethylene fatty alcohol, polyoxyethylene sorbitan fatty acid esters, polyoxyethylene stearate, propylene glycol alginate, dilauryl dimethyl ammonium chloride, D-a-tocopheryl PEG-1000 succinate, polyoxy-40 stearate, polyoxyethylene-polyoxypropylene block copolymers, polyoxyethylene vegetable oils, fatty acid derivatives of amino acids, glyceride derivatives of amino acids, benzalkonium chloride and/or bile acids.

In the present invention, the primary packaging to be used for LMWH should be transparent, or amber-colored, or opaque, and it is made of a pharmaceutical grade material that is biocompatible with the contents of the heparin-based composition. The material of the chamber that will contain the heparin-based composition may be glass or a synthetic material. The composition may be packaged in a single-dose or multi-dose form. The composition may be pre-filled into the inhaler or may be presented in a form that allows the composition to be supplied to the inhaler during its use. Respiratory drugs in single-dose form are packaged in soft plastic containers that are typically made of low-density polyethylene (LDPE) or LPDE in order to control costs and facilitate opening of the containers. In the present invention, the primary packaging used for LMWH may be made of a glass-based material.

The said composition may be intended for single or multiple use. If the said composition is intended for multiple use, it may also contain an antioxidant, an antimicrobial preservative, a vitamin, a pH-regulating agent, a buffering agent, a surfactant, a tonicity-regulating agent, a stabilizer, and a complexing agent. If it is intended for single use, only a carrier solution (water for injection, water for inhalation, phosphate buffer, etc.) is sufficient as an auxiliary substance. However, an additional auxiliary substance is also used if another active substance is added to the single-use composition. In the case of multiple use or in combination with other active substances, substances from the groups of auxiliary substances specified in detail above may be added to the contents of the composition.

The composition according to the present invention is prepared in the form of a solution and is administered to a patient via the inhalation route of administration using devices such as a soft mist inhaler or a VMT nebulizer. The heparin-based composition may be a solution, suspension or emulsion containing heparin or a heparin derivative. The composition according to the present invention or in addition to the heparin-based composition, the compositions in combination with antiviral, mucolytic agents, vitamins or corticosteroids are used in the treatment of viral or acute or chronic lung diseases; in particular, COVID-19, influenza, tuberculosis, cystic fibrosis, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, acute respiratory distress syndrome (ARDS), hypoxemia, pulmonary embolism, pulmonary hypertension, acute lung injury (AU) and / or burning associated with AU. Patient groups to which the composition according to the present invention can be applied may include inpatients, outpatients or patients receiving home treatment.

The indications for which heparin in the dosage form of a sterile solution for administration by means of a soft mist inhaler into the lungs can be used are grouped under three main headings within the scope of the present invention:

1 - viral lung diseases: COVID-19, influenza;

2 - acute lung diseases: acute pulmonary infection, bronchitis, acute lung injury (AU), burning associated with AU, acute pulmonary embolism, bronchial hyperreactivity, acute respiratory distress syndrome (ARDS), hypoxemia;

3 - Chronic lung diseases: pulmonary embolism, pulmonary hypertension, cystic fibrosis, idiopathic pulmonary fibrosis, asthma (exercise-induced asthma, mild asthma, cold-induced asthma, etc.), sarcoidosis, chronic pulmonary embolism, COPD.

To simulate the distribution of sterile inhalable formulations obtained within the scope of the present invention in the lungs, impactors were used according to the method described in the European Pharmacopoeia 2.9.18 (EP Monograph 2.9.18, 2010). The device was connected to a soft mist inhaler. The aerodynamic particle size data were interpreted as mass median aerodynamic diameter (MMAD), geometric standard deviation (GSD) and fine particle fraction values (percentage of particles with an aerodynamic size of less than 5 μm). The dispersed phase of the aerosol obtained from the compositions of the present invention is characterized by a mass median aerodynamic diameter (MMAD) of preferably from about 1 to about 6 μm, more preferably from about 2 to about 4.5 μm or from about 1.5 to about 4 μm. Aerodynamic particle size is very important for drug delivery to the lungs. For local delivery to the lungs, particles in the range of 1 to 6 μm are directed to the bronchi and bronchioles. Aerosol localization studies of LMWH solution showed that the mean MMAD was 1 to 6 μm, and the mean FPF was 10% to 60%, more preferably 5.3 μm and 44%, respectively.

Inhaled LMWH by nebulizer (UFH) has shown high efficacy against acute lung injury and acute respiratory injury in previous studies. Therefore, patients with the worst clinical course were given priority (by ethical choice) for treatment with inhaled LMWH. LMWH was used in the study group at a dose of 4000 IU twice daily, in addition to subcutaneous low molecular weight heparin. The control group received standard therapy only.

Patients were eligible to receive inhaled LMWH if they were male or non-pregnant female aged 18 years or older, had a positive nasopharyngeal swab reverse transcriptase polymerase chain reaction (RT-PCR) test for COVID-19 and pneumonia confirmed by computed tomography (CT), or had a negative nasopharyngeal swab RT-PCR test for COVID-19 but were clinically, radiologically, and biochemically suggestive of COVID-19. Any other possible diagnoses were excluded. Exclusion criteria included unwillingness to provide informed consent, pregnancy, and heparin allergy. The full list of inclusion and exclusion criteria is provided in Table 1.

Table 1. Inclusion and exclusion criteria for the study

Eligibility criteria for the study Written informed consent without pressure Inclusion Criteria Positive reverse transcriptase polymerase chain reaction (RT-PCR) test of nasopharyngeal swab for COVID-19 and pneumonia confirmed by computed tomography (CT) scan A negative reverse transcriptase polymerase chain reaction (RT-PCR) test of a nasopharyngeal swab for COVID-19, but radiographic and biochemical testing strongly suggest COVID-19 if other possible diagnoses have been excluded. Patients aged ≥18 years Exclusion criteria Patients with pregnancy History of allergy to heparin and concomitant medications Patients unwilling to give informed consent

Informed written consent was obtained from patients before enrollment. For those patients who were unable to provide informed written consent, it was obtained from the patient’s first-degree relatives after review of the study. Patients who were not prepared to provide written informed consent were not included in the enrollment. Additional information on the study design is available in the study procedures flow chart (Fig. 5).

The primary outcome of the study was to assess oxygen saturation, fever, and other vital signs during routine patient follow-up. In addition, changes in biochemical parameters such as C-reactive protein, ferritin, D-dimer, neutrophil count, lymphocyte count, and neutrophil-to-lymphocyte ratio were assessed. Secondary outcome measures included assessing the appropriateness of oxygen therapy, intubation, and intensive care unit treatment for these patients.

The study of the present invention consisted of two groups: a device group and a control group. The device-treated group included 35 patients (20 M/15 F) with COVID-19, while the control group included 40 patients (25 M/15 F) (see Table 1). The device-treated group was treated with the new device and the concomitant new formula, while the control group received standard treatment for COVID-19. The average age of the device-treated group was 60.01 ± 10.04, while that of the control group was 59.62 ± 14.60 (see Table 2).

Table 2. Baseline characteristics of patients

Group with heparin in a "soft mist" inhaler Control group Demographic indicators Age (years) 60.02 ± 10.04, n = 35 59.62 ± 14.60, n= 40 Women n=15 (43%) n=15 (37.5%) Men n=20 (57%) n=25 (62.5%) Body mass index (kg/m2) 1.92 ± 0.21, n = 35 1.97 ±, n =40 Associated diseases Smoking tobacco n=3 (8.5%) n=6 (15%) COPD n=2 (5.7%) n=2 (5%) Heart disease n=7 (20%) n=9 (22.5%) Diabetes mellitus n=8 (22.8%) n=10 (25%) Duration of COVID-19
Time from onset of symptoms
(d.) 3.54 ± SD, n = 35 4.4 ± 4.18, n= 40

According to the standard COVID-19 treatment algorithm used in the experiments of the present invention, patients received favipiravir 200 mg, 16 tablets on the first day and 200 mg, 6 tablets per day for the next 4 days, and patients were also administered subcutaneous LMWH and methylprednisolone according to the clinical condition. Both the control group and the device group received subcutaneous LMWH and intravenous methylprednisolone 40 mg/day. After hospitalization, patients underwent low-dose CT of the lungs.

Parenchymal findings were classified by severity according to the following criteria: lobe involvement, lobe area involved, lesion, or extension, as shown in Table 3. The mean radiographic severity score in patients in the device group was 5.6 ± 1.5, while in the control group, the mean score was 6.4 ± 1.8. There was no significant difference in radiographic severity between the device group and the control group.

Table 3. Radiographic severity index

Severity Explanation 1 One share, less than 25% of the share area 2 One share, more than 25% of the share area 3 Unilateral and more than one lobe, less than 25% of the area of each lobe 4 Unilateral and more than one lobe, less than 25% of the area of each lobe 5 Bilateral focal lesions of all lobes 6 Bilateral, but completely in one, and not in all parts 7 Bilateral, in all lobes, widespread but less than 25% of the area of each lobe 8 Bilateral, in all lobes, widespread and 25-50% of the area of each lobe 9 Bilateral, in all lobes, widespread and 50-75% of the area of each lobe 10 Bilateral, in all lobes, widespread and more than 75% of the area of each lobe

Patients in both groups mainly presented with respiratory distress characteristic of COVID-19, including persistent cough, sputum production and shortness of breath, as well as other symptoms such as high fever and severe fatigue, as shown in Table 4. The patients' fever data at the beginning of treatment, clinical parameters of peripheral blood oxygen saturation together with CRP, ferritin, white blood cell count, neutrophil/lymphocyte ratio and other laboratory parameters are presented in Table 4.

From a clinical perspective, dyspnea and sputum production were significantly higher in the device group (<0.01). Cough was not significantly different between the two groups or when compared between them. In terms of clinical symptom scores, the device group had significantly higher symptom scores, meaning that (statistically on average) participants in this group experienced COVID-19 with significantly more severe symptoms. Inhaled LMWH has been shown to be effective in reducing lung injury in previous studies (link?). For this reason, patients with more severe symptoms were given priority (for medically justified ethical reasons) to receive inhaled LMWH (Table 4).

Table 4. Patient parameters in the device and control groups

Device Control Prevalence of symptoms (number of cases) Cough 25 (71.4%) 27 (67.5%) Mucus 10 (28.5%) 1 (2.5%) Dyspnea 32 (91.4%) 23 (57.5%) Hypoxemia state Room air Hypoxemic 33 (94.3%) 11 (27.5%) Normal oxygen conditions 2 (5.7%) 29 (72.5%) Clinical parameters Fever 36.6±0.4 37.4±0.8 SpO2 (with O2 administration) 95±2.5 93.8±2.89 Laboratory parameters CRP average 41 72 CRP min. 1 2 CRP max. 232 372 Ferritin average 698 487 Ferritin min. 102 23 Ferritin max. 3713 5785 Leukocytes average 8400 5675 Leukocytes min. 3000 2250 Leukocytes max. 45200 13610 Neutrophils/lymphocytes average 11.28 5.22 Neutrophils/lymphocytes min. 1.45 0.97 Neutrophils/lymphocytes max. 27.66 20.86

The mean fever (body temperature measured in degrees Celsius) on admission was higher in the control group than in the device-treated group (<0.001), while there was no significant difference in oxygen saturation values on day 1. The significant difference in fever suggests that the control group patients experienced a more intense form of COVID-19 (Table 4). This is an important feature in the study associated with the present invention, namely the recognition that some specific parameters were worse in the control group, and these parameters did not improve with standard therapy, which likely implies that the therapy of the present invention could be much more effective.

A peripheral saturation value of 95% or more at the start of treatment was pre-defined as “normal” for both the device and control groups, and any value below was defined as hypoxemia. Accordingly, in the device group, only 2/35 (5.7%) cases had normal oxygen conditions: and 33/35 (94.3%) cases were hypoxemic. In contrast, in the control group, 29/40 (72.5%) cases had normal oxygen conditions and 11/40 (27.5%) cases were hypoxemic, indicating that hypoxemia was more pronounced and patients were in a more critical condition in the device group on day 1 of treatment (Table 4).

Of the laboratory parameters, CRP was significantly higher (<0.01) in the control group, while ferritin, white blood cells, and neutrophil-lymphocyte ratio were significantly higher (<0.01) in the device group. The upper limits of D-dimer were found not to be significantly different between the two groups (Mann-Whitney U). The device-treated group included more severely ill patients compared to the control group based on laboratory parameters.

The severity of hypoxemia and peripheral oxygen saturation in patients were measured on days 1 and 10 (the last day of the study) of treatment based on the patients' response to the oxygen therapy device. Each therapy implies a different level of disease severity. The cutoff value was defined as 95% and above.

The severity levels were categorized as follows: Level 1: if peripheral oxygen saturation improved with oxygen therapy up to 6 L/min using a nasal cannula; Level 2: if it could be improved with an oxygen mask with a 500 mL reservoir and oxygen therapy at 15 L/min; Level 3: if it could be improved with high-flow oxygen therapy; Level 4: if intubation was the only choice (Table 5). A significant difference exists between the device group and the control group in terms of the number of patients in the room air category at the end of 10-day treatment. The device group mainly consists of severe patients, while 40 percent of the control group are non-severe patients. This difference gives a clear indication of how patients may perceive existing oxygen delivery methods as opposed to the delivery device proposed in this study.

Table 5. Oxygen therapy method for the device and control groups on days 1 and 10 of treatment

Day 1 of treatment Day 10 of treatment Method of oxygen supply Device
n(%) Control n(%) Device n(%) Control n(%) 0: Room air 0 (5.7%) 16 (40%) 27 (77.1%) 29 (72.5%) 1: Nasal cannula 13 (39.5%) 15 (37.5%) 5 (14.3%) 6 (15%) 2: Oxygen mask with reservoir 12 (31.6%) 7 (17.5%) 2 (5.7%) 1 (2.5%) 3: High flow oxygen supply 8 (23.7%) 2 (5%) 1 (2.9%) 1 (2.5%) 4: Intubation 0 (0%) 2 (0%) 0 (0%) 3 (7.5%)

Patients in the device group required significantly (p<0.01) intensive oxygen therapy to overcome hypoxemia. At the end of the 10-day treatment period, the improvement in hypoxemia of patients according to the oxygen delivery method is shown in Table 5 (device group and control group).

In the device group, 13/13 hypoxemic patients who were oxygenated via nasal cannula were in normal oxygen conditions at the end of treatment. In the device group, 16/35 cases (45.7%) showed a 1-step improvement, 12/35 cases (34.3%) showed a 2-step improvement, and 3/35 cases (8.6%) showed a 3-step improvement for better clinical outcome. There were no cases of intubation at the end of treatment, as most cases achieved “room air supply” condition.

However, in the control group, the 10-day period showed more heterogeneous results. For example, in the nasal cannula group, on day 1, 4/15 cases (26.6%) had no change in status. However, at some point during the 10-day period, 3 patients had to be intubated. In terms of the overall improvement rate, 14/40 cases (35%) improved by one severity level, 2/40 cases (5%) improved by 2 severity levels, and only 1/40 cases (2.5%) improved by 3 severity levels. This was 3 patients in the device group. The greatest contrast was seen in the 2-level improvement, with only 5 percent of the control group being able to improve by 2 severity levels with standard therapy. In particular, however, the fact that 3 (7.5%) of the nasal cannula cases progressed to a severity level requiring intubation suggests that the results of modern treatments can be quite variable in terms of patient response. Even if many can be treated with standard treatments, some patients do progress to “more severe” levels that include intubation. Furthermore, in the device group, improvements were more “broadly distributed” across levels, i.e., improvements of more than one level, meaning that more patients benefited from the device because case weights shifted more uniformly toward lower severity levels.

The reduction in the amount of oxygen supplied to patients in the device group is significant compared with the control group. This difference was clearly evident in the subgroup receiving oxygen mask with reservoir or high-flow oxygen therapy. Moreover, there was no intubation in the device group, while 3 patients had to be intubated in the control group, indicating that the risk of intubation was markedly reduced in the device group. Regarding clinical respiratory symptoms at day 1, the improvement in the device group was higher than that in the control group (Table 5).

The statistical power analysis was determined by the type I error of 0.05 and type II error of 0.20. In terms of the statistical power analysis of oxygen supply, there is no difference between the data before and after treatment. The sample size was 19 for each group compared with 50% in the four control groups. With a sample size of 50% in the four subgroups, the sample size was 19 patients for each group. In the statistical power analysis for oxygen supply (type I error of 0.05, type II error of 0.20 were taken as power), no change was noted between the two groups at the beginning and at the end of treatment.

If there is a two-level difference between the two groups before and after treatment (type I error of 0.05, type II error of 0.80, taken as power), then it is 34.3 percent in the device group and 5 percent in the control group, where the sample size is 25. If type I error is defined as 0.05 and type II error as 0.80, then the two-level difference between the groups before and after treatment is 34.3 percent in the device group and 5 percent in the control group, where the sample size is 25.

The reduction in oxygen delivery to correct hypoxemia in the device group was statistically significant compared with the control group (p<0.01). In subgroup analyses based on oxygen delivery mode, the significance of treatment was inconsistent with nasal cannula, while the so-called “surge in improvement” (difference in improvement) was even more pronounced in sicker patients receiving oxygen via reservoir mask or high-flow oxygen therapy (p<0.01).

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Claims (36)

1. Use of a pharmaceutical composition for the treatment of viral lung diseases, including COVID-19 disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), acute lung diseases and/or chronic lung diseases, wherein the pharmaceutical composition contains heparin or a pharmaceutically acceptable heparin derivative dissolved in a carrier solution for local administration to the lungs using a soft mist inhaler via the inhalation route of administration; in this case, the heparin is low molecular weight heparin (LMWH); the carrier solution is water for inhalation, sterile physiological saline solution 0.9% NaCl or sterile half-physiological saline solution 0.45% NaCl; wherein the pharmaceutical composition comprises another active substance selected from mannitol, acetylcysteine, sterile hypertonic physiological saline solution 3-20% NaCl, w/v, or an anti-inflammatory corticosteroid selected from dexamethasone or mometasone; and The dose of heparin used is 4000 IU. 2. The use according to claim 1, wherein the pharmaceutically acceptable heparin derivative is selected from heparin sodium salts, heparin esters, heparin ethers, heparin bases, heparin solvates, heparin hydrates or forms used as prodrugs of heparin. 3. Use according to claim 1 or 2, wherein the composition additionally contains at least one other active substance or at least one auxiliary substance. 4. The use according to claim 3, wherein the composition contains at least one auxiliary substance selected from tonicity-regulating auxiliary substances, pH-regulating agents, buffering agents, tonicity-regulating agents, antioxidants, antimicrobial preservatives, surfactants, solubility enhancers - co-solvents, stabilizing agents, auxiliary substances for providing prolonged release or prolonged local retention, wetting agents, dispersing agents, taste-masking agents, sweeteners and/or a flavor additive. 5. The use according to claim 4, wherein the co-solvent is selected from propylene glycol, dipropylene glycol, ethylene glycol, glycerol, ethanol, polyethylene glycols, PEG300, PEG400, methanol, polyethylene glycol-castor oil, polyoxyethylene castor oil and/or lecithin. 6. The use according to claim 4, wherein the stabilizing agent is selected from EDTA or its sodium salt, citric acid, sodium citrate, vitamin E, ascorbic acid, ascorbyl palmitate, butylated hydroxyanisole, butylated hydroxytoluene, hypophosphorous acid, monothioglycerol, propyl gallate, sodium bisulfite, sodium metabisulfite, sodium formaldehyde sulfoxylate, thiourea, lysine, tryptophan, phenylpropylglycine, glycine, glutamic acid, leucine, isoleucine, serine, tea polyphenols, ascorbyl palmitate, hydroxymethyl ester, hydroxyethyl tetramethylpiperidinol, bis(2,2,6,6-tetramethyl-4-piperidyl)sebacate, ester polysuccinate-(4-hydroxy-2,2,6,6-tetramethyl-1-piperidinylethanol), 2-[2-hydroxy-4-[3-(2-ethylhexyloxy)-2-hydroxypropoxy]phenyl]-4,6-bis(2,4-dimethylphenyl) and/or 1,3,5-triazine. 7. The use according to claim 4, wherein the antioxidant is selected from primary antioxidants, regenerative antioxidants and/or synergistic antioxidants. 8. The use according to claim 7, wherein the antioxidant is selected from tocopherol acetate, lycopene, reduced glutathione, catalase, peroxide dismutase, acetylcysteine, R-cysteine, vitamin E TPGS, pyruvic acid and/or its magnesium or sodium salts, gluconic acid and/or its magnesium and/or sodium salts, ethylenediaminetetraacetic acid (EDTA) and/or its derivatives, ascorbic acid, ascorbic acid esters, fumaric acid, malic acid, citric acid, butylhydroxyanisole, butylhydroxytoluene, propyl gallate, maltol and/or its salts. 9. The use according to claim 4, wherein the antimicrobial preservative is selected from quaternary ammonium compounds, thiomersal-based alcohols, antibacterial esters, chelating agents and/or antifungal agents. 10. The use according to claim 4, wherein the antimicrobial preservative is selected from benzalkonium chloride, benzethonium chloride, cetrimide, cetylpyridinium chloride, lauralkonium chloride, myristylpicolinium chloride of divalent mercury, chlorobutanol, phenylethyl alcohol, benzyl alcohol, esters of para-hydroxybenzoic acid, disodium edetate (ethylenediaminetetraacetic acid, EDTA), chlorhexidine, chlorocresol, sorbic acid and/or its salts, potassium sorbate, polymyxin, sodium benzoate, sorbic acid, sodium propionate, methylparaben, ethylparaben, propylparaben, butylparaben, ethyl p-hydroxybenzoate and/or n-propyl p-hydroxybenzoate. 11. Use according to claim 4, wherein the pH-regulating agent is selected from physiologically acceptable acids, bases, salts or combinations thereof. 12. Use according to item 4, where the pH-regulating agent is selected from strong mineral acids, mineral bases, medium-strength inorganic acids, medium-strength organic acids, hydroxides and oxides of alkaline earth metals, basic ammonium salts, carbonates, citrates. 13. The use according to claim 4, wherein the pH-regulating agent is selected from sulfuric acid, hydrochloric acid, phosphoric acid, citric acid, tartaric acid, succinic acid, fumaric acid, methionine, acidic hydrogen phosphates with sodium or potassium, lactic acid, glucuronic acid, sodium hydroxide, magnesium hydroxide, calcium hydroxide, ammonium acetate, lysine, sodium carbonate, magnesium carbonate, sodium hydrogen carbonate, sodium citrate. 14. The use according to claim 4, wherein the buffering agent is selected from citric acid-sodium citrate, citric acid-sodium dibasic phosphate, potassium dihydrogen phosphate-disodium hydrogen phosphate, citric acid-sodium hydroxide, trometamol, disodium phosphate, dodecahydrate, heptahydrate, dihydrate and their anhydrous forms and/or sodium mixtures. 15. The use according to claim 4, wherein the tonicity regulating agent is selected from sodium chloride, mannitol, dextrose, sodium gluconate, sodium pyruvate and/or potassium chloride, glucose, lactose, sucrose, trehalose, xylitol, sorbitol and/or isomaltol. 16. The use according to claim 4, wherein the surfactants are ionic or non-ionic surfactants that are safe for oral or nasal inhalation. 17. The use according to claim 16, wherein the surfactant is selected from tyloxapol, polysorbates, polysorbate 20, polysorbate 60, polysorbate 80, lecithin, vitamin E TPGS, macrogol hydroxystearates and/or macrogol-15-hydroxystearate. 18. The use according to claim 4, wherein the taste-masking agent is selected from the group of pharmaceutically acceptable sweeteners containing saccharin, aspartame, cyclamate, sucralose, acesulfame, neotame, thaumatin, neohesperidin and/or their salts or solvates. 19. The use according to claim 4, wherein the taste-masking agent is sodium saccharin or potassium acesulfame. 20. The use according to claim 4, wherein the taste-masking agent is sucrose, trehalose, fructose, lactose, xylitol, mannitol and/or isomalt. 21. The use according to claim 4, wherein the taste-masking agent is selected from pharmaceutically acceptable surfactants, alkaline earth metal salts, organic acids and/or amino acids. 22. The use according to claim 21, wherein the taste-masking agent is citric acid, lactic acid and/or arginine. 23. Use according to item 4, wherein the flavor additive is selected from essential oils. 24. The use according to claim 23, wherein the flavor additive is menthol, thymol or cineole. 25. The use according to claim 23, wherein the wetting or dispersing agents are selected from poloxamers, butyric acid or its salts, lecithin, hydrogenated lecithin, sorbitan fatty acid esters, oleyl alcohol, phospholipids including but not limited to phosphatidylglycerol, phosphatidylcholine, polyoxyethylene fatty alcohol ethers, polyoxypropylene fatty alcohol ether, polyoxyethylene fatty acid ester, glycerol fatty acid esters, a glycolipid such as a sphingolipid and sphingomyelin, polyoxyethylene glycol fatty acid ester, polyhydric alcohol fatty acid esters, polyethylene glycol, glycerol fatty acid esters, polypropylene glycol fatty acid esters, ethoxylated lanolin derivatives, polyoxyethylene fatty alcohol, polyoxyethylene sorbitan fatty acid esters, polyoxyethylene stearate, propylene glycol alginate, dilauryl dimethyl ammonium chloride, D-a-tocopheryl PEG-1000 succinate, polyoxy-40 stearate, polyoxyethylene-polyoxypropylene block copolymers, polyoxyethylene vegetable oils, fatty acid derivatives of amino acids, glyceride derivatives of amino acids, benzalkonium chloride and/or bile acids. 26. The use according to any of the preceding claims, wherein the disease is selected from COVID-19, influenza, tuberculosis, cystic fibrosis, chronic obstructive pulmonary disease (COPD), asthma, acute lung infection, bronchitis, acute respiratory distress syndrome (ARDS), hypoxemia, pulmonary embolism, pulmonary hypertension, idiopathic pulmonary fibrosis, acute lung injury (ALI), sarcoidosis and/or chronic pulmonary embolism. 27. The use according to any of the preceding paragraphs, which provides for single or multiple dosing of the composition. 28. Use according to any one of claims 1-4, wherein said pharmaceutical composition is in the form of an emulsion or suspension. 29. Use of a pharmaceutical composition for the treatment of viral lung diseases, including COVID-19 disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), acute lung diseases and/or chronic lung diseases, wherein the pharmaceutical composition contains unfractionated heparin (UFH) or a pharmaceutically acceptable derivative thereof, wherein it is locally administered to the lungs using a soft mist inhaler via the inhalation route of administration; the carrier solution is water for inhalation, sterile physiological saline solution 0.9% NaCl or sterile half-physiological saline solution 0.45% NaCl; wherein the pharmaceutical composition comprises another active substance selected from mannitol, acetylcysteine, sterile hypertonic physiological saline solution 3-20% NaCl, w/v, or an anti-inflammatory corticosteroid selected from dexamethasone or mometasone; and The dose of heparin used is 4000 IU.