WO2025107039A1 - Composition comprising tetrahydrocannabinol and acetazolamide in a fixed dose combination capsule - Google Patents
Composition comprising tetrahydrocannabinol and acetazolamide in a fixed dose combination capsule Download PDFInfo
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- WO2025107039A1 WO2025107039A1 PCT/AU2024/051249 AU2024051249W WO2025107039A1 WO 2025107039 A1 WO2025107039 A1 WO 2025107039A1 AU 2024051249 W AU2024051249 W AU 2024051249W WO 2025107039 A1 WO2025107039 A1 WO 2025107039A1
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
- A61K9/50—Microcapsules having a gas, liquid or semi-solid filling; Solid microparticles or pellets surrounded by a distinct coating layer, e.g. coated microspheres, coated drug crystals
- A61K9/5084—Mixtures of one or more drugs in different galenical forms, at least one of which being granules, microcapsules or (coated) microparticles according to A61K9/16 or A61K9/50, e.g. for obtaining a specific release pattern or for combining different drugs
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/33—Heterocyclic compounds
- A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
- A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
- A61K31/433—Thidiazoles
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K31/00—Medicinal preparations containing organic active ingredients
- A61K31/658—Medicinal preparations containing organic active ingredients o-phenolic cannabinoids, e.g. cannabidiol, cannabigerolic acid, cannabichromene or tetrahydrocannabinol
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
- A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/0012—Galenical forms characterised by the site of application
- A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
- A61K9/4816—Wall or shell material
- A61K9/4825—Proteins, e.g. gelatin
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
- A61K9/4841—Filling excipients; Inactive ingredients
- A61K9/4858—Organic compounds
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
- A61K9/4841—Filling excipients; Inactive ingredients
- A61K9/4875—Compounds of unknown constitution, e.g. material from plants or animals
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K9/00—Medicinal preparations characterised by special physical form
- A61K9/48—Preparations in capsules, e.g. of gelatin, of chocolate
- A61K9/4891—Coated capsules; Multilayered drug free capsule shells
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
- A61P11/00—Drugs for disorders of the respiratory system
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
- A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00
Definitions
- compositions comprising a synergistic combination of ⁇ -9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof and acetazolamide or a pharmaceutically acceptable salt thereof, which beneficially enables simultaneous administration of the two active pharmaceutical ingredients (APIs) in a single dosage form.
- THC ⁇ -9-tetrahydrocannabinol
- APIs active pharmaceutical ingredients
- the present disclosure also relates to methods and uses of the composition for the treatment of obstructive sleep apnoea (OSA).
- OSA obstructive sleep apnoea
- FDC Fixed-dose combination
- APIs active pharmaceutical ingredients
- FDCs also require significant product formulation and manufacturing optimisation to address stability, dose differential and physical and chemical compatibility.
- THC ⁇ -9-tetrahydrocannabinol
- DAIs drug-drug interactions
- THC can synergize with other APIs for the treatment of a range of different conditions, including obstructive sleep apnoea (e.g., WO 2022/006636) and pain (e.g., Cichewicz et al., 2003, The Journal of Pharmacology and Experimental Therapeutics, 304(3): 1010-1015).
- compositions that enable the simultaneous delivery of THC and one or more additional APIs in a single dosage form (e.g., FDC) regardless of physical-chemical compatibility and/or stability liabilities.
- FDC ⁇ -9-tetrahydrocannabinol
- FIG. 1 is a schematic representation of the composition comprising a first capsule and a second capsule, in which the second capsule comprises a tablet solid dosage form of acetazolamide and is encapsulated by the first capsule.
- FIG. 2 is a schematic representation of the composition comprising a first capsule and a second capsule, in which the second capsule comprises a particulate solid dosage form of acetazolamide (e.g., a powder, a microgranule, a nanoparticle).
- Figure 3 shows that THC and acetazolamide are bioavailable following oral administration of soft gel capsule fixed dose combination product comprising 250 mg acetazolamide and 5 mg THC.
- A A graphical representation of acetazolamide concentration (ng/mL; y-axis) and time (hours; x-axis).
- B A graphical representation of THC concentration (ng/mL; y-axis) and time (hours; x-axis).
- the phrase “consisting of” indicates that the listed elements are required or mandatory, and that no other elements may be present.
- the phrase “consisting essentially of” means including any elements listed after the phrase, and limited to other elements that do not interfere with or contribute to the activity or action specified in the disclosure for the listed elements. Thus, the phrase “consisting essentially of” indicates that the listed elements are required or mandatory, but that other elements are optional and may or may not be present depending upon whether or not they affect the activity or action of the listed elements. [0015] As used herein the singular forms “a”, “an” and “the” include plural aspects unless the context clearly dictates otherwise.
- composition includes a single composition, as well as two or more compositions; reference to “an agent” includes one agent, as well as two or more agents; and so forth.
- agent includes one agent, as well as two or more agents; and so forth.
- THC ⁇ -9-tetrahydrocannabinol
- acetazolamide or a pharmaceutically acceptable salt thereof can be formulated by encapsulating the THC or a pharmaceutically acceptable salt or derivative thereof in a first capsule and encapsulating the acetazolamide or a pharmaceutically acceptable salt thereof in a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule, thereby enabling the simultaneous administration of the synergistic combination of THC and acetazolamide.
- compositions comprising: a. THC or a pharmaceutically acceptable salt or derivative thereof; and b. a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is encapsulated by a first capsule and the solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof is encapsulated by a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule.
- compositions allows for the delivery of two synergistic active pharmaceutical ingredients (APIs) that have not previously been combined in a single dosage form.
- the composition described herein advantageously avoids any problems associated with the incompatibility of APIs, which may limit the ability to formulate the combination into a single dosage form or fixed dose combination (FDC).
- FDC fixed dose combination
- the phrase "fixed dose combination” or “FDC” as used herein refers to a combination of two or more APIs contained in a single dosage form, such as a capsule or tablet. Accordingly, the composition described herein may also be referred to as an FDC.
- composition described herein that is, THC or a pharmaceutically acceptable salt or derivative thereof encapsulated in by a first capsule, and a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof encapsulated in a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule provides a physical barrier between the two APIs.
- the physical separation of the two APIs avoids any problems with incompatibility between the THC and acetazolamide, which may limit the ability to provide a synergistic FDC.
- Encapsulation may be achieved using any film-forming material known in the art, illustrative examples of which include gelatin, starch, carrageenans, gums or synthetic materials such as hydroxypropyl-methylcellulose (HPMC), other hydroxyalkylated celluloses and the like.
- the film-forming material typically has an aqueous base and is ingestible.
- ingestible refers to a film-forming material that dissolves under conditions simulating the human digestive tract or water.
- the first capsule may comprise, consist of or substantially consist of animal or non-animal based material.
- Suitable non-animal material for capsules would be known to persons skilled in the art, illustrative examples of which include starch, carrageenans, gums or synthetic materials such as hydroxalkylated celluloses (e.g., hydroxypropyl methylcellulose) and polymers (e.g., synthetic polymers).
- Suitable animal materials for capsules would be known to persons skilled in the art, illustrative examples of which include hard gelatin capsules and soft gelatin capsules.
- the first capsule is a soft gelatin capsule.
- Soft gelatin capsules or "softgels" generally comprise an outer shell primarily made of gelatin, a plasticizer, and water.
- Soft gelatin capsules are widely used in the pharmaceutical industry for oral administration or as suppositories for rectal or vaginal use. Other uses are topical and ophthalmic preparations and the like, e.g., the cosmetic industry use soft gelatin capsules as a specialized package for various types of perfumes, oils, shampoo, skin creams and the like. Soft gelatin capsules are available in a variety of sizes and shapes, e.g., tubes, ovals, oblongs, tubes and other special types of shapes such as stars. The finished soft gelatin capsules can be made in a variety of colors and opacifiers may be added to the soft gelatin capsules.
- the soft gelatin capsule comprises a gelatin selected from the group consisting of bovine gelatin, porcine gelatin, fish gelatin and blends thereof.
- the soft gelatin capsule may comprise one or more of starch, carrageenans, gums or synthetic materials such as hydroxalkylated celluloses.
- the THC or a pharmaceutically acceptable salt or derivative thereof is solubilized in a liquid solvent.
- suitable liquid solvents would be known to persons skilled in the art, illustrative examples of which include oils, alcohol (e.g., ethanol), propylene glycol and glycerol.
- the liquid solvent is an oil selected from the group consisting of hemp seed oil, olive oil, caprylic/capric triglyceride (MCT) oil, sunflower oil and sesame seed oil.
- MCT caprylic/capric triglyceride
- the oil is sesame seed oil.
- the liquid solvent further comprises one or more agents selected from the group of sweetening agents, flavoring agents, coloring agents and preserving agents.
- Suitable sweeteners include sucrose, lactose, glucose, aspartame or saccharin.
- Suitable flavoring agents include peppermint oil, oil of wintergreen, cherry, orange or raspberry flavoring.
- Suitable preservatives include sodium benzoate, vitamin E, alphatocopherol, ascorbic acid, methyl paraben, propyl paraben, sodium bisulphite or butylated hydroxytoluene (BHT).
- BHT butylated hydroxytoluene
- the separation of the first API and the second API is achieved based on the encapsulation of the second API using a material that is not solubilized by the liquid solvent in which the THC or a pharmaceutically acceptable salt or derivative thereof has been solubilized in.
- the THC or a pharmaceutically acceptable salt or derivative thereof may be formulated at a pH range that prevents the second capsule from being solubilized.
- the second capsule is a capsule that is not solubilized by the liquid solvent.
- the second capsule may comprise, consist of or substantially consist of animal or non-animal based material as described elsewhere herein.
- the second capsule is selected from the group consisting of a polymer capsule, a soft gelatin capsule, and a cellulose capsule. [0037] In an embodiment, the second capsule is a soft gelatin capsule. [0038] In another embodiment, the second capsule is a polymer capsule. [0039] Suitable polymer capsules would be known to persons skilled in the art, illustrative examples of which include capsules comprising polyvinyl alcohol, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose phthalate, hydroxypropyl methylcellulose acetate succinate, cellulose polymer, polyvinyl acetate, cellulose acetate phthalate, cellulose acetate trimellitate and polyvinyl acetate phthalate.
- the polymer capsule comprises polyvinyl alcohol (e.g., Opadry® 200).
- the first capsule and the second capsule are the same material, e.g., soft gelatin capsules.
- the first capsule and the second capsule are different materials, e.g., a soft gelatin first capsule and a polymer second capsule.
- the second capsule is an enteric capsule.
- enteric means a coating material to provide slow, modified or controlled release of the solid dosage form of hydroxychloroquine or a pharmaceutically acceptable salt thereof.
- the enteric capsule may also be used to prevent dissolution of the solid dosage form of hydroxychloroquine or a pharmaceutically acceptable salt thereof in the gastric environment.
- the second capsule further comprises a coating. Suitable coatings would be known to persons skilled in the art, illustrative examples of which include sealants, glazes, polishes and shellac. The coatings contemplated herein provide an additional functional barrier to moisture and far.
- the coating is a clear coating comprising sodium carboxymethylcellulose, maltodexrin, dextrose monohydrate and purified stearic acid (i.e., Opaglos® 2).
- solid dosage form refers to any solid form of acetazolamide or a pharmaceutically acceptable salt thereof, such as tablets, caplets, granules, nanoparticles, pellets and the like. Accordingly, in an embodiment, the solid dosage form is selected from the group consisting of a tablet, a powder, a microgranule, a nanoparticle and a pellet. [0045] In a preferred embodiment, the solid dosage form is a tablet. [0046] The phrase “at least partially encapsulated” refers to the complete or partial encapsulation of the solid dosage form of the acetazolamide or a pharmaceutically acceptable salt thereof by the first capsule.
- compositions for oral administration may contain one or more agents selected from the group of sweetening agents, flavoring agents, coloring agents and preserving agents in order to produce pharmaceutically elegant and palatable preparations.
- Suitable sweeteners include sucrose, lactose, glucose, aspartame or saccharin.
- Suitable disintegrating agents include corn starch, methylcellulose, polyvinylpyrrolidone, xanthan gum, bentonite, alginic acid or agar.
- Suitable flavoring agents include peppermint oil, oil of wintergreen, cherry, orange or raspberry flavoring.
- Suitable preservatives include sodium benzoate, vitamin E, alphatocopherol, ascorbic acid, methyl paraben, propyl paraben or sodium bisulphite.
- Suitable lubricants include magnesium stearate, stearic acid, sodium oleate, sodium chloride or talc.
- Suitable time delay agents include glyceryl monostearate or glyceryl distearate.
- the composition further comprises one or more pharmaceutically acceptable carriers, diluents or excipients.
- Suitable pharmaceutically acceptable carriers, diluents or excipients would be known to persons skilled in the art, illustrative examples of which include inert diluents (e.g., calcium carbonate, lactose, calcium phosphate or sodium phosphate), granulating and disintegrating agents (e.g., corn starch or alginic acid), binding agents (e.g., starch, gelatin or acacia), lubricating agents (e.g., magnesium stearate, stearic acid or talc) and material to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period (e.g., glyceryl monostearate or glyceryl distea
- compositions disclosed herein may be prepared according to conventional methods well known in the pharmaceutical and nutraceutical industries, such as those described in Remington’s Pharmaceutical Handbook (Mack Publishing Co., NY, USA).
- Oral administration of THC has been demonstrated to be an efficacious administration route (Goodwin et al., 2006, Therapeutic Drug Monitoring, 28(4): 545-551).
- oral administration of carbonic anhydrase inhibitors, such as acetazolamide have also been demonstrated to be effective for absorption and bioavailability (Wallace et al., 1977, Journal of Pharmaceutical Sciences, 66(4): 527-530).
- THC Tetrahydrocannabinol
- THC also exhibits partial agonist activity at the cannabinoid receptors CB1 and CB2.
- CB1 is mainly associated with the central nervous system, while CB2 is expressed predominantly in the cells of the immune system.
- THC is also associated with pain relief, relaxation, fatigue, appetite stimulation, and alteration of the visual, auditory and olfactory senses.
- THC mediates an anti-cholinesterase action, which may suggest its use for the treatment of Alzheimer's disease and myasthenia (Eubanks et al., 2006, Molecular Pharmaceuticals, 3(6): 773-7).
- THC may be extracted from any suitable plant parts including leaves, flowers or stems and may be produced by any suitable means known to those skilled in the art.
- THC extracts may be produced by extraction with supercritical or subcritical CO2, or by volatilization of plant material with a heated gas.
- Illustrative examples of methods used the extract THC and other cannabinoids from plant material include the methods described in US Patent No.10189762 and WO 2004/016277.
- the THC described herein is synthetic THC (i.e., man-made THC).
- the THC is dronabinol.
- Dronabinol is commercially available in capsule form under the trade name Marinol from Alkem and one or more manufacturers, distributors, and/or repackaged under a generic (i.e., non-proprietary) name. Dronabinol is also commercially available in liquid form under the trade name Syndros from Benuvia. [0058] Synthetic THC is particularly useful for pharmaceutical development as it can be prepared largely free from contaminants. A number of methods for the synthesis of THC are known in the art, illustrative examples of which include methods for the synthesis of dronabinol as described in US Patent Nos.7323576 and 5227537, and US Patent Application No.11/840,585.
- Suitable pharmaceutically acceptable salts of THC would be known to persons skilled in the art, illustrative examples of which include salts or esters prepared from pharmaceutically acceptable non-toxic bases or acids, including inorganic bases or acids and organic bases or acids, which would be known to persons skilled in the art.
- the composition comprises at least about 0.25 mg THC or a pharmaceutically acceptable salt or derivative thereof (e.g., 0.25 mg, 0.50 mg, 0.75 mg, 1 mg, 1.25 mg, 1.50 mg, 1.75 mg, 2 mg, 2.25 mg, 2.50 mg, 2.75 mg, 3 mg, 3.25 mg, 3.50 mg, 3.75 mg, 4 mg, 4.25 mg, 4.50 mg, 4.75 mg, 5 mg, 5.25 mg, 5.50 mg, 5.75 mg, 6 mg, 6.25 mg, 6.50 mg, 6.75 mg, 7 mg, 7.25 mg, 7.50 mg, 7.75 mg, 8 mg, 8.25 mg, 8.50 mg, 8.75 mg, 9 mg, 9.25 mg, 9.50 mg, 9.75 mg, 10 mg, 10.25 mg, 10.50 mg, 10.75 mg, 11 mg, 11.25 mg, 11.50 mg, 11.75 mg, 12 mg, 12.25 mg, 12.50 mg, 12.75 mg, 13 mg, 13.25 mg, 13.50 mg, 13.75 mg, 14 mg, 14.25 mg, 14.50 mg, 14.75
- the composition comprises from about 0.25 mg to about 20 mg THC or a pharmaceutically acceptable salt or derivative thereof, preferably about 0.25 mg, preferably about 0.50 mg, preferably about 0.75 mg, preferably about 1 mg, preferably about 1.25 mg, preferably about 1.50 mg, preferably about 1.75 mg, preferably about 2 mg, preferably about 2.25 mg, preferably about 2.50 mg, preferably about 2.75 mg, preferably about 3 mg, preferably about 3.25 mg, preferably about 3.50 mg, preferably about 3.75 mg, preferably about 4 mg, preferably about 4.25 mg, preferably about 4.50 mg, preferably about 4.75 mg, preferably about 5 mg, preferably about 5.25 mg, preferably about 5.50 mg, preferably about 5.75 mg, preferably about 6 mg, preferably about 6.25 mg, preferably about 6.50 mg, preferably about 6.75 mg, preferably about 7 mg, preferably about 7.25 mg, preferably about 7.50 mg, preferably about 7.75 mg, preferably about 8 mg, preferably about 8.25 mg
- the composition comprises about 10 mg THC or a pharmaceutically acceptable salt or derivative thereof. [0063] In an embodiment, the composition comprises about 5 mg THC or a pharmaceutically acceptable salt or derivative thereof. [0064] In an embodiment, the composition comprises about 2.5 mg THC or a pharmaceutically acceptable salt or derivative thereof.
- Carbonic anhydrase inhibitors [0065] In an aspect, the present disclosure provides a composition comprising: a. ⁇ -9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof; and b.
- carbonic anhydrase inhibitor refers to a class of agents that inhibit the activity of carbonic anhydrase, an enzyme responsible for catalyzing the reaction between carbon dioxide and water into carbonic acid and subsequently to bicarbonate.
- Carbonic anhydrase inhibitors are used in the treatment or prevention of acute mountain sickness (i.e., altitude sickness), as described by Swenson (2014, Carbonic Anhydrase Inhibitors and High Altitude Illness, in: Frost and McKenna (eds), Carbonic Anhydrase: Mechanism, Regulation, Links to Disease, and Industrial Applications. Subcellular Biochemistry, vol. 75, Springer, Dordrecht).
- Suitable carbonic anhydrase inhibitors will be known to persons skilled in the art, illustrative examples of which include acetazolamide, methazolamide, dorolamide and brinzolamide.
- the present disclosure further contemplates the use of a pharmaceutically acceptable salt of the carbonic anhydrase inhibitor.
- Suitable pharmaceutically acceptable salts of the carbonic anhydrase inhibitor would be known to person skilled in the art, illustrative examples of which include salts or esters prepared from pharmaceutically acceptable non-toxic bases or acids, including inorganic bases or acids and organic bases or acids, which would be well known to person skilled in the art.
- the carbonic anhydrase inhibitor is selected from the group consisting of acetazolamide, methazolamide, dorolamide and brinzolamide.
- the carbonic anhydrase inhibitor is a sulfonamide, a member of thiadiazoles and a monocarboxylic acid amide, or pharmaceutically acceptable salts thereof.
- the carbonic anhydrase inhibitor is acetazolamide.
- the composition comprises at least about 1 mg acetazolamide or a pharmaceutically acceptable salt thereof (e.g., 1 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 21 mg, 22 mg, 23 mg, 24 mg, 25 mg, 26 mg, 27 mg, 28 mg, 29 mg, 30 mg, 31 mg, 32 mg, 33 mg, 34 mg, 35 mg, 36 mg, 37 mg, 38 mg, 39 mg, 40 mg, 41 mg, 42 mg, 43 mg, 44 mg, 45 mg, 46 mg, 47 mg, 48 mg, 49 mg, 50 mg, 51 mg, 52 mg, 53 mg, 54 mg, 55 mg, 56 mg, 57 mg, 58 mg, 59 mg, 60 mg, 61 mg, 62 mg, 63 mg, 64 mg, 65 mg, 66 mg, 67 mg, 68 mg, 69 mg, 70 mg, 1 mg, 2 mg,
- the composition comprises from about 1 mg to about 700 mg acetazolamide or a pharmaceutically acceptable salt thereof, preferably about 1 mg, preferably about 2 mg, preferably about 3 mg, preferably about 4 mg, preferably about 5 mg, preferably about 6 mg, preferably about 7 mg, preferably about 8 mg, preferably about 9 mg, preferably about 10 mg, preferably about 11 mg, preferably about 12 mg, preferably about 13 mg, preferably about 14 mg, preferably about 15 mg, preferably about 16 mg, preferably about 17 mg, preferably about 18 mg, preferably about 19 mg, preferably about 20 mg, preferably about 21 mg, preferably about 22 mg, preferably about 23 mg, preferably about 24 mg, preferably about 25 mg, preferably about 26 mg, preferably about 27 mg, preferably about 28 mg, preferably about 29 mg, preferably about 30 mg, preferably about 31 mg, preferably about 32 mg, preferably about 33 mg, preferably about 34 mg, preferably about 35 mg, preferably about 36 mg, preferably about 37 mg
- the composition comprises about 500 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition comprises about 250 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition comprises about 125 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition comprises about 10 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 500 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition comprises about 5 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 250 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition comprises about 2.5 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 125 mg acetazolamide or a pharmaceutically acceptable salt thereof.
- the composition defined herein is for use in the treatment of obstructive sleep apnoea (OSA).
- OSA obstructive sleep apnoea
- sleep apnoea refers to sleep disorders characterized by episodes of interrupted breathing during sleep, which results in decreased oxygen saturation or arousal from sleep. This disturbance results in fragmented, non-restorative sleep, typically accompanied by other symptoms including loud, disruptive snoring, witnessed apnoeas during sleep and excessive daytime sleepiness.
- apnoea refers to a complete or near complete cessation of airflow for at least 10 seconds.
- hypopnoea refers to 30% or greater decrease in airflow for at least 10 seconds followed by an arousal and/or > 3% oxygen desaturation.
- OSA structural sleep apnoea
- OSA may be classified using the apnoea-hypopnoea index (AHI) or respiratory disturbance index (RDI) as described by, e.g., Iber et al. (2007, The AASM Manual for the Scoring of Sleep and Associated Events, 1 st edition), which is based on the average number of obstructive events per hour. Methods for the measurement of obstructive events would be known to persons skilled in the art, illustrative embodiments of which include overnight polysomnography (PSG).
- AHI apnoea-hypopnoea index
- RDI respiratory disturbance index
- overnight polysomnography “overnight PSG”, “nocturnal polysomnography”, or “nocturnal PSG” may be used interchangeably herein to refer to a test used in the diagnosis of OSA.
- Overnight PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness.
- the physiological parameters recorded during PSG would be known to persons skilled in the art, illustrative examples of which include brain activity (e.g., electroencephalogram (EEG)), eye movements (e.g., electroculogram (EOG)), muscle activity of the jaw and legs (e.g., electromyogram (EMG)), heart rhythm (electrocardiogram (ECG)), respiratory airflow (e.g., via a nasal cannula and thermistor), respiratory effort (e.g., via abdominal and thoracic respiratory bands) and peripheral pulse oximetry (e.g., via an infrared finger probe).
- brain activity e.g., electroencephalogram (EEG)
- eye movements e.g., electroculogram (EOG)
- muscle activity of the jaw and legs e.g., electromyogram (EMG)
- EMG electromyogram
- ECG electrocardiogram
- respiratory airflow e.g., via a nasal cannula and thermistor
- OSA-related indices can be measured, including sleep onset latency, REM-sleep onset latency, the number of awakenings during the sleep period, the total sleep duration, percentages and durations of every sleep stage, number of arousals, the AHI and arterial oxygen saturation.
- the severity of OSA may be classified as none / minimal, mild, moderate or severe (Table 1).
- Classification of children with OSA may be performed using modified classification thresholds, with mild OSA defined as an AHI of > 1 and ⁇ 5 if one or more of the clinical symptoms of OSA have been reported; moderate OSA defined as an AHI of ⁇ 5 and ⁇ 10; and severe OSA defined as an AHI of ⁇ 10.
- the OSA is mild to severe OSA according to the AHI. In another embodiment, the OSA is moderate to severe OSA according to the AHI.
- the present inventors have surprisingly found that THC and acetazolamide act synergistically to reduce AHI and oxygen desaturation index (ODI) in subjects with sleep apnoea.
- OHI oxygen desaturation index
- Methods for the treatment of sleep apnoea [0089]
- the terms “treat”, “treating”, “treatment” and the like are used interchangeably herein to mean relieving, reducing, alleviating, ameliorating or otherwise inhibiting the severity of one or more symptoms of OSA in a subject.
- subject refers to any mammal, including livestock and other farm animals (such as cattle, goats, sheep, horses, pigs and chickens), performance animals (such as racehorses), companion animals (such as cats and dogs), laboratory test animals and humans. In an embodiment, the subject is a human.
- the composition comprises THC or a pharmaceutically acceptable salt thereof, and the acetazolamide or a pharmaceutically acceptable salt thereof in a dose sufficient to provide the subject in need thereof a therapeutically effective amount.
- therapeutically effective amount typically refers to an amount of THC and an amount of acetazolamide that is sufficient to affect one or more beneficial or desired therapeutic outcomes (e.g., reduction in apnoeic episodes, reduction in hypopnoeic episodes, reduction in AHI, reduction in excessive daytime sleepiness, reduction in oxygen desaturation index (ODI), improvement in mood and well-being).
- Said beneficial or desired therapeutic outcomes may be quantified by measuring clinical parameters, illustrative examples of which include the measurement of arterial oxygen saturation (SaO2) as described by Zamarron et al. (2003, Chest, 123(5): 1567-1576), movement of the chest and abdomen measured by inductance plethysmograph as described by Kogan et al. (2016, Respiratory Care, 61(8): 1033-1037), nasal airflow as described by de Souse Michels et al. (2014, International Journal of Otolaryngology, 2014: 717419) and heart rate spectral analysis as described by Roche et al. (2003, European Respiratory Journal, 22: 937-942).
- SaO2 arterial oxygen saturation
- Zamarron et al. 2003, Chest, 123(5): 1567-1576
- inductance plethysmograph as described by Kogan et al.
- nasal airflow as described by de Souse Michels et al. (2014, International Journal of O
- Subjective measures of sleep quality improvement can also be made using clinical instruments known in the art, illustrative examples of this include the Epworth Sleepiness Scale (ESS) (Johns, 1991, Sleep, 14: 540-545), the Leeds Sleep Evaluation Questionnaire (LSEQ) (Shahid et al., 2011, Leeds Sleep Evaluation Questionnaire (LSEQ), in Shahid et al.
- ESS Epworth Sleepiness Scale
- LSEQ Leeds Sleep Evaluation Questionnaire
- LSEQ Leeds Sleep Evaluation Questionnaire
- Changes in the symptoms or severity of OSA as measured by any of the quantitative methods or clinical instruments described elsewhere herein may be expressed using any appropriate statistical measure to demonstrate the magnitude of the reduction in the symptoms or severity of OSA.
- the methods disclosed herein reduce in the symptoms or severity of OSA by at least 10%, preferably at least 20%, preferably at least 30%, preferably at least 40%, preferably at least 50%, preferably at least 60%, preferably at least 70%, preferably at least 80%, preferably at least 90%, or more preferably at least 100% as compared to a subject with OSA who has not been administered the composition disclosed herein.
- the methods disclosed herein reduce the AHI in subjects with OSA.
- administration of the composition disclosed herein reduces the AHI of the subject by at least 30% (e.g., by 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78% 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or by 100%) relative to the baseline AHI of the subject prior to the administration of
- administration of the composition disclosed herein reduces the AHI of the subject by at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, at least 50%, at least 51%, at least 52%, at least 53%, at least 54%, at least 55%, at least 56%, at least 57%, at least 58%, at least 59%, at least 60%, at least 61%, at least 62%, at least 63%, at least 64%, at least 65%, at least 66%, at least 67%, at least 68%, at least 69%, at least 70%, at least 71%, at least 72%, at least 73%, at least 74%, at least 75%, at least 75%, at least 75%, at least 7
- the methods disclosed herein are useful in reducing ODI in subjects with OSA.
- administration of the composition disclosed herein reduces the ODI of the subject by at least 20% (e.g., by 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78% 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%,
- administration of the composition disclosed herein reduces the ODI of the subject by at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, at least 50%, at least 51%, at least 52%, at least 53%, at least 54%, at least 55%, at least 56%, at least 57%, at least 58%, at least 59%, at least 60%, at least 61%, at least 62%, at least 63%, at least 64%, at least 65%, at least 6
- periodic re-administration of the composition may be required to achieve a desirable therapeutic effect.
- the exact amounts and rates of administration of the composition will depend on a number of factors, examples of which are described elsewhere herein, such as the subject’s age, body weight, general health, sex and dietary requirements, as well as any drugs or agents used in combination or coincidental with the administration of the composition. Where multiple doses are required, these may be administered hourly, daily, weekly, monthly or at other suitable time intervals or the dose may be proportionally reduced as indicated by the exigencies of the situation.
- the composition is administered at least one, at least two, at least three, or at least four times per day.
- the composition is administered twice per day.
- the composition is administered to the subject between about 10 minutes and about 120 minutes before sleep (e.g., 10 minutes, 11 minutes, 12 minutes, 13 minutes, 14 minutes, 15 minutes, 16 minutes, 17 minutes, 18 minutes, 19 minutes, 20 minutes, 21 minutes, 22 minutes, 23 minutes, 24 minutes, 25 minutes, 26 minutes, 27 minutes, 28 minutes, 29 minutes, 30 minutes, 31 minutes, 32 minutes, 33 minutes, 34 minutes, 35 minutes, 36 minutes, 37 minutes, 38 minutes, 39 minutes, 40 minutes, 41 minutes, 42 minutes, 43 minutes, 44 minutes, 45 minutes, 46 minutes, 47 minutes, 48 minutes, 49 minutes, 50 minutes, 51 minutes, 52 minutes, 53 minutes, 54 minutes, 55 minutes, 56 minutes, 57 minutes, 58 minutes, 59 minutes, 60 minutes, 61 minutes, 62 minutes, 63 minutes, 64 minutes, 65 minutes, 66 minutes, 67 minutes, 68 minutes, 69 minutes, 70 minutes, 71 minutes, 72 minutes, 73 minutes, 74 minutes, 75 minutes, 76 minutes, 77 minutes, 78 minutes,
- the composition is administered to the subject between about 10 minutes and about 120 minutes before sleep, preferably about 10 minutes, preferably about 11 minutes, preferably about 12 minutes, preferably about 13 minutes, preferably about 14 minutes, preferably about 15 minutes, preferably about 16 minutes, preferably about 17 minutes, preferably about 18 minutes, preferably about 19 minutes, preferably about 20 minutes, preferably about 21 minutes, preferably about 22 minutes, preferably about 23 minutes, preferably about 24 minutes, preferably about 25 minutes, preferably about 26 minutes, preferably about 27 minutes, preferably about 28 minutes, preferably about 29 minutes, preferably about 30 minutes, preferably about 31 minutes, preferably about 32 minutes, preferably about 33 minutes, preferably about 34 minutes, preferably about 35 minutes, preferably about 36 minutes, preferably about 37 minutes, preferably about 38 minutes, preferably about 39 minutes, preferably about 40 minutes, preferably about 41 minutes, preferably about 42 minutes, preferably about 43 minutes, preferably about 44 minutes, preferably about 45 minutes, preferably about 46 minutes, preferably about 47 minutes,
- the composition is administered to the subject between about 30 minutes and about 60 minutes before sleep.
- the invention described herein is susceptible to variations and modifications other than those specifically described. It is to be understood that the invention includes all such variations and modifications which fall within the spirit and scope.
- the invention also includes all of the steps, features, compositions and compounds referred to or indicated in this specification, individually or collectively, and any and all combinations of any two or more of said steps or features.
- all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art to which this invention belongs.
- All patents, patent applications and publications mentioned herein are hereby incorporated by reference in their entireties.
- each subject was screened at baseline to ensure that they met inclusion/exclusion criteria including an overnight PSG to ensure that AHI ⁇ 15 and medical history review and physical examination to confirm that they were physically well, with no severe psychiatric, cardiac, renal, endocrine, gastrointestinal, or bleeding disorders.
- the study consisted of four, seven-day treatment periods. During each treatment period the subject received a different dose of THC and acetazolamide, either low dose (2.5 mg dronabinol, 125 mg acetazolamide), medium dose (5 mg dronabinol, 250 mg acetazolamide), high dose (10 mg dronabinol, 500 mg acetazolamide), or placebo (appearance matched capsules containing no drug).
- AHI was determined using overnight polysomnography (PSG). Daytime somnolence was also assessed using the Epworth Sleepiness Scale (ESS) and alertness was assessed using the Stanford Sleepiness Scale (SSS). AHI was compared to baseline (screening) to determine the effect of the drug treatment on OSA. A blood sample was collected to assess blood cell count, electrolytes, urea, liver enzymes and levels of THC and the two main metabolites of THC, being OH- THC and COOH-THC. [0111] The primary endpoint of the study is reduction in AHI after each treatment period compared to baseline.
- Oxygen desaturation index (ODI) [0113] ODI data was collected during overnight PSG on night seven of the treatment periods. As shown in Table 6, all doses of THC and acetazolamide reduced ODI in patients with OSA compared to baseline. This reduction was greater than observed for placebo. The difference relative to baseline was statistically significant for the low dose and medium dose when compared to placebo (p ⁇ 0.05). Sleep metrics and reported sleep quality [0114] Each morning of the clinical trial, subjects recorded their sleep quality for the previous night as very poor, poor, fair, good, or very good.
- compositions comprising THC and acetazolamide
- Exemplary compositions according to the present disclosure comprise the ingredients in Table 9.
- the solid dosage form of acetazolamide according to this example is a solid tablet comprising a number of inactive ingredients (i.e., excipients) including those listed in Table 10.
- the compositions may be produced according to the methods disclosed in US Patent Nos.9,433,584, 10,383,826 and WO 2012/017325.
- composition described herein comprises a tablet solid dosage form (see, e.g., Figure 1) of acetazolamide
- exemplary compositions may be produced according to the methods described in US Patent Nos.9,433,584 and 10,383,826 as they relate to a "double" soft gel capsule (see, e.g., US Patent No.9,433,584, column 6, lines 25-50).
- Example 3 – Manufacture of fixed dose combination product [0119] Exemplary fixed dose combination products (i.e., composition) comprising a film coated acetazolamide tablet contained within a soft gel capsule comprising THC were manufactured by ProCaps (Barranquilla, Colombia).
- the manufacturing process consists of three steps: (i) manufacture of the solid dosage form of acetazolamide (e.g., tablet); (ii) manufacture of the THC oil solution; and (iii) combination of the solid dosage form of acetazolamide and THC oil solution within a soft gel capsule.
- Acetazolamide tablet [0120] Each acetazolamide tablet contains 125 or 250 mg of active pharmaceutical ingredient (API) and the inactive ingredients as listed in Table 10.
- API active pharmaceutical ingredient
- THC sesame oil solution contains 1% w/w dronabinol or 0.5% w/w dronabinol in the 5 mg and 2.5 mg THC dose forms, respectively.
- Dronabinol was supplied from the drug substance manufacturer as a 20% w/w solution in sesame oil. The drug substance was diluted in sesame oil, NF, to the required final concentration and mixed.
- the inactive ingredients of the fixed dose combination product are provided in Table 10. Samples of the fixed dose combination product were stored at 2°C to 8°C, 25 ⁇ 2°C at 60 ⁇ 5% relative humidity (RH), and 40 ⁇ 2°C at 75 ⁇ 5% RH and assessed for stability using methods from the US Pharmacopeia (USP) monograph for acetazolamide tablets and high performance liquid chromatography (HPLC) analysis for THC, acetazolamide and related substances at 1, 2, 3, 6, 9, 12, 18, 24, and 36 months. Dissolution of THC and acetazolamide from the fixed dose combination product was also assessed (Tables 11, 12 and 15-18).
- USP US Pharmacopeia
- HPLC high performance liquid chromatography
- the fixed dose combination product is manufactured according to the method described by Salazar Altamaer et al. (US Patent No. 9,433,584). Briefly, soft gel capsules containing a solid dose form drug encapsulated by a polymer capsule are manufactured in the liquid filled soft gel capsule.
- the acetazolamide tablet is contained within a soft gel capsule of THC in sesame oil.
- the resulting soft gel capsules are size 20 oblong soft gel capsules (i.e., 0.986-1.232 cc). Each soft gel capsule contains 125 mg acetazolamide and 2.5 mg THC or 250 mg acetazolamide and 5 mg THC.
- the soft gel capsules were manufactured and stored at ambient temperature prior to release analysis. Release of the acetazolamide tablet component was conducted using methods in the USP monograph for acetazolamide tablets with impurities assessed using HPLC. THC impurities were assessed using an HPLC method based on the method listed in the USP monograph for dronabinol, the synthetic form of THC.
- Example 4 – Stability of soft gel capsule fixed dose combination product [0124] The soft gel capsule fixed dose combination product described in Example 3 were packaged into blister packs and a formal stability study with conditions of 5 ⁇ 3 ⁇ C up to 12 months and 25 ⁇ 2 ⁇ C / 60 ⁇ 5 % RH with time points up to 6 months. At least six individual dose units were tested in each assay.
- Modified and slow-release dose forms of acetazolamide have previously been developed to offer sustained therapeutic effects, reduce dosing frequency and improve patient compliance in the context of treating glaucoma, epilepsy, altitude sickness, idiopathic intracranial hypertension and Meniere's disease. Accordingly, the modified release and uptake of acetazolamide following administration of the soft gel capsule fixed dose combination may assist in prolonging the beneficial effects of the combination of THC and acetazolamide throughout the treatment period. [0129] In many jurisdictions, it is possible to drive a vehicle with a blood level of 1-2 ng/mL THC.
- the soft gel capsule fixed dose combination also resulted in a peak THC blood concentration of 1.081 ng/mL at 1 hour post-administration (Table 23).
- the blood concentration of THC gradually reduced over time, with as little as 0.096 ng/mL THC measured at 6 hours post-administration, and 0.031 ng/mL THC measured at 8 hours post- administration. It follows, therefore, that administration of the soft gel capsule fixed dose combination just prior to sleep can achieve the therapeutic outcome of reduction in AHI, but beneficially achieve sufficient clearance of THC to allow patients to drive or operate other vehicles the morning after administration.
- THC and acetazolamide are bioavailable and therapeutically beneficial concentrations following oral administration as soft gel capsule fixed dose combination.
- the sustained release of acetazolamide beneficially provides maintained levels of acetazolamide, while avoiding adverse effects.
- the blood concentrations of THC observed following oral administration peak 1 hour post- administration, which clears to a level that is well below legal limits for operating vehicles, including motor vehicles, shortly after administration.
- Table 1 Classification of OSA according to Apnoea-Hypopnea Index (AHI)
- Table 2 Tetrahydrocannabinol and related cannabinoids Table 3. Average AHI at baseline and each treatment period Table 4. Percent reduction in AHI relative to baseline at the group level Table 5. Average change in AHI from baseline within subject (least square mean)
- Table 6 Reduction in ODI relative to baseline Table 7.
- Exemplary soft gel capsule fixed dose combination products comprising THC and acetazolamide Low - THC 2.5 mg + ACZ 125 mg; Medium - THC 5 mg + ACZ 250 mg
- Table 20 Stability of exemplary soft gel capsule fixed dose combination at six months storage in Zone II conditions (25 ⁇ C ⁇ 2 ⁇ C / 60% ⁇ 5% RH)
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Abstract
The present disclosure relates generally to compositions comprising a synergistic combination of Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof and acetazolamide or a pharmaceutically acceptable salt thereof, which beneficially enables simultaneous administration of the two active pharmaceutical ingredients (APIs) in a single dosage form. In an embodiment, the present disclosure also relates to methods and uses of the composition for the treatment of obstructive sleep apnoea (OSA).
Description
COMPOSITION COMPRISING TETRAHYDROCANNABINOL AND ACETAZOLAMIDE IN A FIXED DOSE COMBINATION CAPSULE Related application [0001] This application claims priority from Australian Provisional Patent Application No.2023903778 filed on 23 November 2023, the entire content of which is incorporated by reference. Field [0002] The present disclosure relates generally to compositions comprising a synergistic combination of Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof and acetazolamide or a pharmaceutically acceptable salt thereof, which beneficially enables simultaneous administration of the two active pharmaceutical ingredients (APIs) in a single dosage form. In an embodiment, the present disclosure also relates to methods and uses of the composition for the treatment of obstructive sleep apnoea (OSA). Background [0003] Fixed-dose combination (FDC) pharmaceutical products comprising multiple active pharmaceutical ingredients (APIs) are often difficult to formulate where active ingredients are incompatible, that is, the APIs deleteriously react with one another when combined in desired levels of concentrations. FDCs also require significant product formulation and manufacturing optimisation to address stability, dose differential and physical and chemical compatibility. [0004] In the context of FDCs comprising Δ-9-tetrahydrocannabinol (THC), these limitations can become more onerous due to issues with bioavailability, variable pharmacokinetic profiles, possible polymorphisms and a higher risk of drug-drug interactions (DDIs) associated with THC. However, recent studies have shown that THC can synergize with other APIs for the treatment of a range of different conditions, including obstructive sleep apnoea (e.g., WO 2022/006636) and pain (e.g., Cichewicz et al., 2003, The Journal of Pharmacology and Experimental Therapeutics, 304(3): 1010-1015).
[0005] In most cases, synergism between THC and one or more additional APIs occurs where the two or more APIs are delivered to a subject simultaneously. Using standard methods in the art, it would be expected that the formulation and development of any such single dosage forms or FDCs would require extensive consideration of the physical characteristics of the APIs, the mode of delivery, the flow properties of the composition, the excipient compatibility, the uniformity in production and the release profile to ensure that the pharmacokinetic properties of the APIs are maintained (or enhanced) and/or impart stability to the composition such that it can have an acceptable shelf life. [0006] Therefore, there remains an urgent need for the development of pharmaceutical compositions that enable the simultaneous delivery of THC and one or more additional APIs in a single dosage form (e.g., FDC) regardless of physical-chemical compatibility and/or stability liabilities. Summary [0007] In an aspect of the present disclosure, there is provided a composition comprising: a. Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof; and b. a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is encapsulated by a first capsule and the solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof is encapsulated by a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule. Brief Description of the Drawings [0008] Various examples and embodiments of the invention are described herein, by way of non-limiting example only, with reference to the following figures. [0009] Figure 1 is a schematic representation of the composition comprising a first capsule and a second capsule, in which the second capsule comprises a tablet solid dosage form of acetazolamide and is encapsulated by the first capsule.
[0010] Figure 2 is a schematic representation of the composition comprising a first capsule and a second capsule, in which the second capsule comprises a particulate solid dosage form of acetazolamide (e.g., a powder, a microgranule, a nanoparticle). [0011] Figure 3 shows that THC and acetazolamide are bioavailable following oral administration of soft gel capsule fixed dose combination product comprising 250 mg acetazolamide and 5 mg THC. (A) A graphical representation of acetazolamide concentration (ng/mL; y-axis) and time (hours; x-axis). (B) A graphical representation of THC concentration (ng/mL; y-axis) and time (hours; x-axis). Detailed Description [0012] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by those of ordinary skill in the art to which the disclosure belongs. Any materials and method similar or equivalent to those described herein can be used to practice the present invention. [0013] Throughout this specification, unless the context requires otherwise, the word “comprise”, or variations such as “comprises” or “comprising”, will be understood to imply the inclusion of the stated element or integer or group of elements or integers but not the exclusion of any other element or integer or group of elements or integers. [0014] The phrase "consisting of" means including, and limited to, whatever follows the phrase "consisting of". Thus, the phrase "consisting of" indicates that the listed elements are required or mandatory, and that no other elements may be present. The phrase "consisting essentially of" means including any elements listed after the phrase, and limited to other elements that do not interfere with or contribute to the activity or action specified in the disclosure for the listed elements. Thus, the phrase "consisting essentially of" indicates that the listed elements are required or mandatory, but that other elements are optional and may or may not be present depending upon whether or not they affect the activity or action of the listed elements. [0015] As used herein the singular forms "a", "an" and "the" include plural aspects unless the context clearly dictates otherwise. Thus, for example, reference to "a
composition" includes a single composition, as well as two or more compositions; reference to "an agent" includes one agent, as well as two or more agents; and so forth. [0016] The term “about” will be understood by persons skilled in the art and will vary to some extent depending on the context in which it is used. If there are uses of the term that are not clear to persons skilled in the art, given the context which it is used, “about” will mean up to plus or minus 10% of the particular term. [0017] The present disclosure is predicated, at least in part, on the inventor’s surprising finding that a single dose form of Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof and acetazolamide or a pharmaceutically acceptable salt thereof can be formulated by encapsulating the THC or a pharmaceutically acceptable salt or derivative thereof in a first capsule and encapsulating the acetazolamide or a pharmaceutically acceptable salt thereof in a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule, thereby enabling the simultaneous administration of the synergistic combination of THC and acetazolamide. [0018] Thus, in an aspect disclosed herein, there is provided a composition comprising: a. THC or a pharmaceutically acceptable salt or derivative thereof; and b. a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is encapsulated by a first capsule and the solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof is encapsulated by a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule. Compositions [0019] In accordance with the present disclosure, the composition allows for the delivery of two synergistic active pharmaceutical ingredients (APIs) that have not previously been combined in a single dosage form. The composition described herein advantageously avoids any problems associated with the incompatibility of APIs, which may limit the ability to formulate the combination into a single dosage form or fixed dose combination (FDC).
[0020] The phrase "fixed dose combination" or "FDC" as used herein refers to a combination of two or more APIs contained in a single dosage form, such as a capsule or tablet. Accordingly, the composition described herein may also be referred to as an FDC. [0021] The configuration of the composition described herein, that is, THC or a pharmaceutically acceptable salt or derivative thereof encapsulated in by a first capsule, and a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof encapsulated in a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule provides a physical barrier between the two APIs. As described elsewhere herein, the physical separation of the two APIs avoids any problems with incompatibility between the THC and acetazolamide, which may limit the ability to provide a synergistic FDC. [0022] Encapsulation may be achieved using any film-forming material known in the art, illustrative examples of which include gelatin, starch, carrageenans, gums or synthetic materials such as hydroxypropyl-methylcellulose (HPMC), other hydroxyalkylated celluloses and the like. The film-forming material typically has an aqueous base and is ingestible. As used herein the term "ingestible" refers to a film-forming material that dissolves under conditions simulating the human digestive tract or water. [0023] In an embodiment, the first capsule may comprise, consist of or substantially consist of animal or non-animal based material. Suitable non-animal material for capsules would be known to persons skilled in the art, illustrative examples of which include starch, carrageenans, gums or synthetic materials such as hydroxalkylated celluloses (e.g., hydroxypropyl methylcellulose) and polymers (e.g., synthetic polymers). Suitable animal materials for capsules would be known to persons skilled in the art, illustrative examples of which include hard gelatin capsules and soft gelatin capsules. [0024] In an embodiment, the first capsule is a soft gelatin capsule. [0025] Soft gelatin capsules or "softgels" generally comprise an outer shell primarily made of gelatin, a plasticizer, and water. Soft gelatin capsules are widely used in the pharmaceutical industry for oral administration or as suppositories for rectal or vaginal use. Other uses are topical and ophthalmic preparations and the like, e.g., the cosmetic industry
use soft gelatin capsules as a specialized package for various types of perfumes, oils, shampoo, skin creams and the like. Soft gelatin capsules are available in a variety of sizes and shapes, e.g., tubes, ovals, oblongs, tubes and other special types of shapes such as stars. The finished soft gelatin capsules can be made in a variety of colors and opacifiers may be added to the soft gelatin capsules. [0026] Processes for the manufacture of soft gelatin capsules and encapsulation of APIs within soft gelatin capsules would be known to persons skilled in the art, illustrative examples of which include the methods described in US Patent Nos.9,433,584, 10,383,826 and WO 2012/017325. [0027] In an embodiment, the soft gelatin capsule comprises a gelatin selected from the group consisting of bovine gelatin, porcine gelatin, fish gelatin and blends thereof. [0028] It is also contemplated herein that the soft gelatin capsule may comprise one or more of starch, carrageenans, gums or synthetic materials such as hydroxalkylated celluloses. [0029] In an embodiment, the THC or a pharmaceutically acceptable salt or derivative thereof is solubilized in a liquid solvent. Suitable liquid solvents would be known to persons skilled in the art, illustrative examples of which include oils, alcohol (e.g., ethanol), propylene glycol and glycerol. [0030] In an embodiment, the liquid solvent is an oil selected from the group consisting of hemp seed oil, olive oil, caprylic/capric triglyceride (MCT) oil, sunflower oil and sesame seed oil. [0031] In a preferred embodiment, the oil is sesame seed oil. [0032] In an embodiment, the liquid solvent further comprises one or more agents selected from the group of sweetening agents, flavoring agents, coloring agents and preserving agents. Suitable sweeteners include sucrose, lactose, glucose, aspartame or saccharin. Suitable flavoring agents include peppermint oil, oil of wintergreen, cherry, orange or raspberry flavoring. Suitable preservatives include sodium benzoate, vitamin E,
alphatocopherol, ascorbic acid, methyl paraben, propyl paraben, sodium bisulphite or butylated hydroxytoluene (BHT). [0033] As described elsewhere herein, the composition beneficially separates one API (i.e., THC) from the second API (i.e., acetazolamide) by virtue of the second capsule that encapsulates the second API. In an embodiment, and without being bound by a particular theory, the separation of the first API and the second API is achieved based on the encapsulation of the second API using a material that is not solubilized by the liquid solvent in which the THC or a pharmaceutically acceptable salt or derivative thereof has been solubilized in. For example, the THC or a pharmaceutically acceptable salt or derivative thereof may be formulated at a pH range that prevents the second capsule from being solubilized. [0034] Accordingly, in an embodiment, the second capsule is a capsule that is not solubilized by the liquid solvent. [0035] The second capsule may comprise, consist of or substantially consist of animal or non-animal based material as described elsewhere herein. [0036] In an embodiment, the second capsule is selected from the group consisting of a polymer capsule, a soft gelatin capsule, and a cellulose capsule. [0037] In an embodiment, the second capsule is a soft gelatin capsule. [0038] In another embodiment, the second capsule is a polymer capsule. [0039] Suitable polymer capsules would be known to persons skilled in the art, illustrative examples of which include capsules comprising polyvinyl alcohol, hydroxypropyl methylcellulose, hydroxypropyl methylcellulose phthalate, hydroxypropyl methylcellulose acetate succinate, cellulose polymer, polyvinyl acetate, cellulose acetate phthalate, cellulose acetate trimellitate and polyvinyl acetate phthalate. In an embodiment, the polymer capsule comprises polyvinyl alcohol (e.g., Opadry® 200). [0040] In some embodiments, the first capsule and the second capsule are the same material, e.g., soft gelatin capsules. In another embodiment, the first capsule and the second capsule are different materials, e.g., a soft gelatin first capsule and a polymer second capsule.
[0041] In another embodiment, the second capsule is an enteric capsule. [0042] The term "enteric" as used herein means a coating material to provide slow, modified or controlled release of the solid dosage form of hydroxychloroquine or a pharmaceutically acceptable salt thereof. The enteric capsule may also be used to prevent dissolution of the solid dosage form of hydroxychloroquine or a pharmaceutically acceptable salt thereof in the gastric environment. [0043] In an embodiment, the second capsule further comprises a coating. Suitable coatings would be known to persons skilled in the art, illustrative examples of which include sealants, glazes, polishes and shellac. The coatings contemplated herein provide an additional functional barrier to moisture and far. In an embodiment, the coating is a clear coating comprising sodium carboxymethylcellulose, maltodexrin, dextrose monohydrate and purified stearic acid (i.e., Opaglos® 2). [0044] The phrase "solid dosage form" as used herein refers to any solid form of acetazolamide or a pharmaceutically acceptable salt thereof, such as tablets, caplets, granules, nanoparticles, pellets and the like. Accordingly, in an embodiment, the solid dosage form is selected from the group consisting of a tablet, a powder, a microgranule, a nanoparticle and a pellet. [0045] In a preferred embodiment, the solid dosage form is a tablet. [0046] The phrase "at least partially encapsulated" refers to the complete or partial encapsulation of the solid dosage form of the acetazolamide or a pharmaceutically acceptable salt thereof by the first capsule. Suitable configurations of the first capsule and the second capsule would be determined by persons skilled in the art by reference to, e.g., the manufacturing process, encapsulation materials and the formulation of the THC and solid dosage form of the acetazolamide. [0047] In an embodiment, the second capsule is completely incorporated within the first capsule. For example, the second capsule may be completely incorporated in accordance with the schematic representation of the composition shown in Figures 1 and 2.
[0048] In a preferred embodiment, the composition is formulated for oral administration. [0049] Compositions for oral administration may contain one or more agents selected from the group of sweetening agents, flavoring agents, coloring agents and preserving agents in order to produce pharmaceutically elegant and palatable preparations. Suitable sweeteners include sucrose, lactose, glucose, aspartame or saccharin. Suitable disintegrating agents include corn starch, methylcellulose, polyvinylpyrrolidone, xanthan gum, bentonite, alginic acid or agar. Suitable flavoring agents include peppermint oil, oil of wintergreen, cherry, orange or raspberry flavoring. Suitable preservatives include sodium benzoate, vitamin E, alphatocopherol, ascorbic acid, methyl paraben, propyl paraben or sodium bisulphite. Suitable lubricants include magnesium stearate, stearic acid, sodium oleate, sodium chloride or talc. Suitable time delay agents include glyceryl monostearate or glyceryl distearate. [0050] In an embodiment, the composition further comprises one or more pharmaceutically acceptable carriers, diluents or excipients. [0051] Suitable pharmaceutically acceptable carriers, diluents or excipients would be known to persons skilled in the art, illustrative examples of which include inert diluents (e.g., calcium carbonate, lactose, calcium phosphate or sodium phosphate), granulating and disintegrating agents (e.g., corn starch or alginic acid), binding agents (e.g., starch, gelatin or acacia), lubricating agents (e.g., magnesium stearate, stearic acid or talc) and material to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period (e.g., glyceryl monostearate or glyceryl distearate). [0052] Compositions disclosed herein may be prepared according to conventional methods well known in the pharmaceutical and nutraceutical industries, such as those described in Remington’s Pharmaceutical Handbook (Mack Publishing Co., NY, USA). [0053] Oral administration of THC has been demonstrated to be an efficacious administration route (Goodwin et al., 2006, Therapeutic Drug Monitoring, 28(4): 545-551). Similarly, oral administration of carbonic anhydrase inhibitors, such as acetazolamide, have also been demonstrated to be effective for absorption and bioavailability (Wallace et al., 1977, Journal of Pharmaceutical Sciences, 66(4): 527-530).
Tetrahydrocannabinol (THC) [0054] "Δ-9-tetrahydrocannabinolic acid" or "THCA" is synthesized in cannabis plants from the cannabigerolic acid (CBGA) precursor by THCA synthase (Table 2). THCA decarboxylates to the neutral form "Δ-9-tetrahydrocannabinol" or “THC”, which is associated with psychoactive effects of cannabis as primarily mediated by its activation of CB1G-protein coupled receptors, which result in a decrease in the concentration of cyclic AMP (cAMP) through the inhibition of adenylate cyclase. THC also exhibits partial agonist activity at the cannabinoid receptors CB1 and CB2. CB1 is mainly associated with the central nervous system, while CB2 is expressed predominantly in the cells of the immune system. As a result, THC is also associated with pain relief, relaxation, fatigue, appetite stimulation, and alteration of the visual, auditory and olfactory senses. Furthermore, more recent studies have indicated that THC mediates an anti-cholinesterase action, which may suggest its use for the treatment of Alzheimer's disease and myasthenia (Eubanks et al., 2006, Molecular Pharmaceuticals, 3(6): 773-7). [0055] THC may be extracted from any suitable plant parts including leaves, flowers or stems and may be produced by any suitable means known to those skilled in the art. For example, THC extracts may be produced by extraction with supercritical or subcritical CO2, or by volatilization of plant material with a heated gas. Illustrative examples of methods used the extract THC and other cannabinoids from plant material include the methods described in US Patent No.10189762 and WO 2004/016277. [0056] In an embodiment, the THC described herein is synthetic THC (i.e., man-made THC). In a preferred embodiment, the THC is dronabinol. [0057] Dronabinol is commercially available in capsule form under the trade name Marinol from Alkem and one or more manufacturers, distributors, and/or repackaged under a generic (i.e., non-proprietary) name. Dronabinol is also commercially available in liquid form under the trade name Syndros from Benuvia. [0058] Synthetic THC is particularly useful for pharmaceutical development as it can be prepared largely free from contaminants. A number of methods for the synthesis of THC are known in the art, illustrative examples of which include methods for the synthesis of
dronabinol as described in US Patent Nos.7323576 and 5227537, and US Patent Application No.11/840,585. [0059] The present disclosure further contemplates the use of a pharmaceutically acceptable salt of THC. Suitable pharmaceutically acceptable salts of THC would be known to persons skilled in the art, illustrative examples of which include salts or esters prepared from pharmaceutically acceptable non-toxic bases or acids, including inorganic bases or acids and organic bases or acids, which would be known to persons skilled in the art. [0060] In an embodiment, the composition comprises at least about 0.25 mg THC or a pharmaceutically acceptable salt or derivative thereof (e.g., 0.25 mg, 0.50 mg, 0.75 mg, 1 mg, 1.25 mg, 1.50 mg, 1.75 mg, 2 mg, 2.25 mg, 2.50 mg, 2.75 mg, 3 mg, 3.25 mg, 3.50 mg, 3.75 mg, 4 mg, 4.25 mg, 4.50 mg, 4.75 mg, 5 mg, 5.25 mg, 5.50 mg, 5.75 mg, 6 mg, 6.25 mg, 6.50 mg, 6.75 mg, 7 mg, 7.25 mg, 7.50 mg, 7.75 mg, 8 mg, 8.25 mg, 8.50 mg, 8.75 mg, 9 mg, 9.25 mg, 9.50 mg, 9.75 mg, 10 mg, 10.25 mg, 10.50 mg, 10.75 mg, 11 mg, 11.25 mg, 11.50 mg, 11.75 mg, 12 mg, 12.25 mg, 12.50 mg, 12.75 mg, 13 mg, 13.25 mg, 13.50 mg, 13.75 mg, 14 mg, 14.25 mg, 14.50 mg, 14.75 mg, 15 mg, 15.25 mg, 15.50 mg, 15.75 mg, 16 mg, 16.25 mg, 16.50 mg, 16.75 mg, 17 mg, 17.25 mg, 17.50 mg, 17.75 mg, 18 mg, 18.25 mg, 18.50 mg, 18.75 mg, 19 mg, 19.25 mg, 19.50 mg, 19.75 mg, or 20 mg). [0061] In an embodiment, the composition comprises from about 0.25 mg to about 20 mg THC or a pharmaceutically acceptable salt or derivative thereof, preferably about 0.25 mg, preferably about 0.50 mg, preferably about 0.75 mg, preferably about 1 mg, preferably about 1.25 mg, preferably about 1.50 mg, preferably about 1.75 mg, preferably about 2 mg, preferably about 2.25 mg, preferably about 2.50 mg, preferably about 2.75 mg, preferably about 3 mg, preferably about 3.25 mg, preferably about 3.50 mg, preferably about 3.75 mg, preferably about 4 mg, preferably about 4.25 mg, preferably about 4.50 mg, preferably about 4.75 mg, preferably about 5 mg, preferably about 5.25 mg, preferably about 5.50 mg, preferably about 5.75 mg, preferably about 6 mg, preferably about 6.25 mg, preferably about 6.50 mg, preferably about 6.75 mg, preferably about 7 mg, preferably about 7.25 mg, preferably about 7.50 mg, preferably about 7.75 mg, preferably about 8 mg, preferably about 8.25 mg, preferably about 8.50 mg, preferably about 8.75 mg, preferably about 9 mg, preferably about 9.25 mg, preferably about 9.50 mg, preferably about 9.75 mg, preferably about 10 mg, preferably about 10.25 mg, preferably about 10.50 mg, preferably about 10.75
mg, preferably about 11 mg, preferably about 11.25 mg, preferably about 11.50 mg, preferably about 11.75 mg, preferably about 12 mg, preferably about 12.25 mg, preferably about 12.50 mg, preferably about 12.75 mg, preferably about 13 mg, preferably about 13.25 mg, preferably about 13.50 mg, preferably about 13.75 mg, preferably about 14 mg, preferably about 14.25 mg, preferably about 14.50 mg, preferably about 14.75 mg, preferably about 15 mg, preferably about 15.25 mg, preferably about 15.50 mg, preferably about 15.75 mg, preferably about 16 mg, preferably about 16.25 mg, preferably about 16.50 mg, preferably about 16.75 mg, preferably about 17 mg, preferably about 17.25 mg, preferably about 17.50 mg, preferably about 17.75 mg, preferably about 18 mg, preferably about 18.25 mg, preferably about 18.50 mg, preferably about 18.75 mg, preferably about 19 mg, preferably about 19.25 mg, preferably about 19.50 mg, preferably about 19.75 mg, or more preferably about 20 mg. [0062] In an embodiment, the composition comprises about 10 mg THC or a pharmaceutically acceptable salt or derivative thereof. [0063] In an embodiment, the composition comprises about 5 mg THC or a pharmaceutically acceptable salt or derivative thereof. [0064] In an embodiment, the composition comprises about 2.5 mg THC or a pharmaceutically acceptable salt or derivative thereof. Carbonic anhydrase inhibitors [0065] In an aspect, the present disclosure provides a composition comprising: a. Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof; and b. a solid dosage form of a carbonic anhydrase inhibitor or a pharmaceutically acceptable salt thereof, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is encapsulated by a first capsule and the solid dosage form of the carbonic anhydrase inhibitor or a pharmaceutically acceptable salt thereof is encapsulated by a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule.
[0066] As used herein, the term “carbonic anhydrase inhibitor” refers to a class of agents that inhibit the activity of carbonic anhydrase, an enzyme responsible for catalyzing the reaction between carbon dioxide and water into carbonic acid and subsequently to bicarbonate. The suppression of carbonic anhydrase activity leads to metabolic acidosis, and as a result, increases ventilation and oxygenation. Carbonic anhydrase inhibitors are used in the treatment or prevention of acute mountain sickness (i.e., altitude sickness), as described by Swenson (2014, Carbonic Anhydrase Inhibitors and High Altitude Illness, in: Frost and McKenna (eds), Carbonic Anhydrase: Mechanism, Regulation, Links to Disease, and Industrial Applications. Subcellular Biochemistry, vol. 75, Springer, Dordrecht). Suitable carbonic anhydrase inhibitors will be known to persons skilled in the art, illustrative examples of which include acetazolamide, methazolamide, dorolamide and brinzolamide. [0067] The present disclosure further contemplates the use of a pharmaceutically acceptable salt of the carbonic anhydrase inhibitor. Suitable pharmaceutically acceptable salts of the carbonic anhydrase inhibitor would be known to person skilled in the art, illustrative examples of which include salts or esters prepared from pharmaceutically acceptable non-toxic bases or acids, including inorganic bases or acids and organic bases or acids, which would be well known to person skilled in the art. [0068] In an embodiment, the carbonic anhydrase inhibitor is selected from the group consisting of acetazolamide, methazolamide, dorolamide and brinzolamide. In another embodiment, the carbonic anhydrase inhibitor is a sulfonamide, a member of thiadiazoles and a monocarboxylic acid amide, or pharmaceutically acceptable salts thereof. [0069] In an embodiment, the carbonic anhydrase inhibitor is acetazolamide. [0070] In an embodiment, the composition comprises at least about 1 mg acetazolamide or a pharmaceutically acceptable salt thereof (e.g., 1 mg, 2 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9 mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg, 15 mg, 16 mg, 17 mg, 18 mg, 19 mg, 20 mg, 21 mg, 22 mg, 23 mg, 24 mg, 25 mg, 26 mg, 27 mg, 28 mg, 29 mg, 30 mg, 31 mg, 32 mg, 33 mg, 34 mg, 35 mg, 36 mg, 37 mg, 38 mg, 39 mg, 40 mg, 41 mg, 42 mg, 43 mg, 44 mg, 45 mg, 46 mg, 47 mg, 48 mg, 49 mg, 50 mg, 51 mg, 52 mg, 53 mg, 54 mg, 55 mg, 56 mg, 57 mg, 58 mg, 59 mg, 60 mg, 61 mg, 62 mg, 63 mg, 64 mg, 65 mg, 66 mg, 67 mg, 68 mg, 69 mg, 70 mg, 71 mg, 72 mg, 73 mg, 74 mg, 75 mg, 76 mg, 77 mg, 78 mg, 79 mg,
80 mg, 81 mg, 82 mg, 83 mg, 84 mg, 85 mg, 86 mg, 87 mg, 88 mg, 89 mg, 90 mg, 91 mg, 92 mg, 93 mg, 94 mg, 95 mg, 96 mg, 97 mg, 98 mg, 99 mg, 100 mg, 101 mg, 102 mg, 103 mg, 104 mg, 105 mg, 106 mg, 107 mg, 108 mg, 109 mg, 110 mg, 111 mg, 112 mg, 113 mg, 114 mg, 115 mg, 116 mg, 117 mg, 118 mg, 119 mg, 120 mg, 121 mg, 122 mg, 123 mg, 124 mg, 125 mg, 126 mg, 127 mg, 128 mg, 129 mg, 130 mg, 131 mg, 132 mg, 131 mg, 134 mg, 135 mg, 136 mg, 137 mg, 138 mg, 139 mg, 140 mg, 141 mg, 142 mg, 143 mg, 144 mg, 145 mg, 146 mg, 147 mg, 148 mg, 149 mg, 150 mg, 151 mg, 152 mg, 153 mg, 154 mg, 155 mg, 156 mg, 157 mg, 158 mg, 159 mg, 160 mg, 161 mg, 162 mg, 163 mg, 164 mg, 165 mg, 166 mg, 167 mg, 168 mg, 169 mg, 170 mg, 171 mg, 172 mg, 173 mg, 174 mg, 175 mg, 176 mg, 177 mg, 178 mg, 179 mg, 180 mg, 181 mg, 182 mg, 183 mg, 184 mg, 185 mg, 186 mg, 187 mg, 188 mg, 189 mg, 190 mg, 191 mg, 192 mg, 193 mg, 194 mg, 195 mg, 196 mg, 197 mg, 198 mg, 199 mg, 200 mg, 201 mg, 202 mg, 203 mg, 204 mg, 205 mg, 206 mg, 207 mg, 208 mg, 209 mg, 210 mg, 211 mg, 212 mg, 213 mg, 214 mg, 215 mg, 216 mg, 217 mg, 218 mg, 219 mg, 220 mg, 221 mg, 222 mg, 223 mg, 224 mg, 225 mg, 226 mg, 227 mg, 228 mg, 229 mg, 230 mg, 231 mg, 232 mg, 233 mg, 234 mg, 235 mg, 236 mg, 237 mg, 238 mg, 239 mg, 240 mg, 241 mg, 242 mg, 243 mg, 244 mg, 245 mg, 246 mg, 247 mg, 248 mg, 249 mg, 250 mg, 251 mg, 252 mg, 253 mg, 254 mg, 255 mg, 256 mg, 257 mg, 258 mg, 259 mg, 260 mg, 261 mg, 262 mg, 263 mg, 264 mg, 265 mg, 266 mg, 267 mg, 268 mg, 269 mg, 270 mg, 271 mg, 272 mg, 273 mg, 274 mg, 275 mg, 276 mg, 277 mg, 278 mg, 279 mg, 280 mg, 281 mg, 282 mg, 283 mg, 284 mg, 285 mg, 286 mg, 287 mg, 288 mg, 289 mg, 290 mg, 291 mg, 292 mg, 293 mg, 294 mg, 295 mg, 296 mg, 297 mg, 298 mg, 299 mg, 300 mg, 301 mg, 302 mg, 303 mg, 304 mg, 305 mg, 306 mg, 307 mg, 308 mg, 309 mg, 310 mg, 311 mg, 312 mg, 313 mg, 314 mg, 315 mg, 316 mg, 317 mg, 318 mg, 319 mg, 320 mg, 321 mg, 322 mg, 323 mg, 324 mg, 325 mg, 326 mg, 327 mg, 328 mg, 329 mg, 330 mg, 331 mg, 332 mg, 333 mg, 334 mg, 335 mg, 336 mg, 337 mg, 338 mg, 339 mg, 340 mg, 341 mg, 342 mg, 343 mg, 344 mg, 345 mg, 346 mg, 347 mg, 348 mg, 349 mg, 350 mg, 351 mg, 352 mg, 353 mg, 354 mg, 355 mg, 356 mg, 357 mg, 358 mg, 359 mg, 360 mg, 361 mg, 362 mg, 363 mg, 364 mg, 365 mg, 366 mg, 367 mg, 368 mg, 369 mg, 370 mg, 371 mg, 372 mg, 373 mg, 374 mg, 375 mg, 376 mg, 377 mg, 378 mg, 379 mg, 380 mg, 381 mg, 382 mg, 383 mg, 384 mg, 385 mg, 386 mg, 387 mg, 388 mg, 389 mg, 390 mg, 391 mg, 392 mg, 393 mg, 394 mg, 395 mg, 396 mg, 397 mg, 398 mg, 399 mg, 400 mg, 401 mg, 402 mg, 403 mg, 404 mg, 405 mg, 406 mg, 407 mg, 408 mg, 409 mg, 410 mg, 411 mg, 412 mg, 413 mg, 414 mg, 415 mg, 416 mg, 417 mg, 418
mg, 419 mg, 420 mg, 421 mg, 422 mg, 423 mg, 424 mg, 425 mg, 426 mg, 427 mg, 428 mg, 429 mg, 430 mg, 431 mg, 432 mg, 433 mg, 434 mg, 435 mg, 436 mg, 437 mg, 438 mg, 439 mg, 440 mg, 441 mg, 442 mg, 443 mg, 444 mg, 445 mg, 446 mg, 447 mg, 448 mg, 449 mg, 450 mg, 451 mg, 452 mg, 453 mg, 454 mg, 455 mg, 456 mg, 457 mg, 458 mg, 459 mg, 460 mg, 461 mg, 462 mg, 463 mg, 464 mg, 465 mg, 466 mg, 467 mg, 468 mg, 469 mg, 470 mg, 471 mg, 472 mg, 473 mg, 474 mg, 475 mg, 476 mg, 477 mg, 478 mg, 479 mg, 480 mg, 481 mg, 482 mg, 483 mg, 484 mg, 485 mg, 486 mg, 487 mg, 488 mg, 489 mg, 490 mg, 491 mg, 492 mg, 493 mg, 494 mg, 495 mg, 496 mg, 497 mg, 498 mg, 499 mg, 500 mg, 501 mg, 502 mg, 503 mg, 504 mg, 505 mg, 506 mg, 507 mg, 508 mg, 509 mg, 510 mg, 511 mg, 512 mg, 513 mg, 514 mg, 515 mg, 516 mg, 517 mg, 518 mg, 519 mg, 520 mg, 521 mg, 522 mg, 523 mg, 524 mg, 525 mg, 526 mg, 527 mg, 528 mg, 529 mg, 530 mg, 531 mg, 532 mg, 533 mg, 534 mg, 535 mg, 536 mg, 537 mg, 538 mg, 539 mg, 540 mg, 541 mg, 542 mg, 543 mg, 544 mg, 545 mg, 546 mg, 547 mg, 548 mg, 549 mg, 550 mg, 551 mg, 552 mg, 553 mg, 554 mg, 555 mg, 556 mg, 557 mg, 558 mg, 559 mg, 560 mg, 561 mg, 562 mg, 563 mg, 564 mg, 565 mg, 566 mg, 567 mg, 568 mg, 569 mg, 570 mg, 571 mg, 572 mg, 573 mg, 574 mg, 575 mg, 576 mg, 577 mg, 578 mg, 579 mg, 580 mg, 581 mg, 582 mg, 583 mg, 584 mg, 585 mg, 586 mg, 587 mg, 588 mg, 589 mg, 590 mg, 591 mg, 592 mg, 593 mg, 594 mg, 595 mg, 596 mg, 597 mg, 598 mg, 599 mg, 600 mg, 601 mg, 602 mg, 603 mg, 604 mg, 605 mg, 606 mg, 607 mg, 608 mg, 609 mg, 610 mg, 611 mg, 612 mg, 613 mg, 614 mg, 615 mg, 616 mg, 617 mg, 618 mg, 619 mg, 620 mg, 621 mg, 622 mg, 623 mg, 624 mg, 625 mg, 626 mg, 627 mg, 628 mg, 629 mg, 630 mg, 631 mg, 632 mg, 633 mg, 634 mg, 635 mg, 636 mg, 637 mg, 638 mg, 639 mg, 640 mg, 641 mg, 642 mg, 643 mg, 644 mg, 645 mg, 646 mg, 647 mg, 648 mg, 649 mg, 650 mg, 651 mg, 652 mg, 653 mg, 654 mg, 655 mg, 656 mg, 657 mg, 658 mg, 659 mg, 660 mg, 661 mg, 662 mg, 663 mg, 664 mg, 665 mg, 666 mg, 667 mg, 668 mg, 669 mg, 670 mg, 671 mg, 672 mg, 673 mg, 674 mg, 675 mg, 676 mg, 677 mg, 678 mg, 679 mg, 680 mg, 681 mg, 682 mg, 683 mg, 684 mg, 685 mg, 686 mg, 687 mg, 688 mg, 689 mg, 690 mg, 691 mg, 692 mg, 693 mg, 694 mg, 695 mg, 696 mg, 697 mg, 698 mg, 699 mg or 700 mg). [0071] In an embodiment, the composition comprises from about 1 mg to about 700 mg acetazolamide or a pharmaceutically acceptable salt thereof, preferably about 1 mg, preferably about 2 mg, preferably about 3 mg, preferably about 4 mg, preferably about 5 mg, preferably about 6 mg, preferably about 7 mg, preferably about 8 mg, preferably about 9 mg, preferably about 10 mg, preferably about 11 mg, preferably about 12 mg, preferably about
13 mg, preferably about 14 mg, preferably about 15 mg, preferably about 16 mg, preferably about 17 mg, preferably about 18 mg, preferably about 19 mg, preferably about 20 mg, preferably about 21 mg, preferably about 22 mg, preferably about 23 mg, preferably about 24 mg, preferably about 25 mg, preferably about 26 mg, preferably about 27 mg, preferably about 28 mg, preferably about 29 mg, preferably about 30 mg, preferably about 31 mg, preferably about 32 mg, preferably about 33 mg, preferably about 34 mg, preferably about 35 mg, preferably about 36 mg, preferably about 37 mg, preferably about 38 mg, preferably about 39 mg, preferably about 40 mg, preferably about 41 mg, preferably about 42 mg, preferably about 43 mg, preferably about 44 mg, preferably about 45 mg, preferably about 46 mg, preferably about 47 mg, preferably about 48 mg, preferably about 49 mg, preferably about 50 mg, preferably about 51 mg, preferably about 52 mg, preferably about 53 mg, preferably about 54 mg, preferably about 55 mg, preferably about 56 mg, preferably about 57 mg, preferably about 58 mg, preferably about 59 mg, preferably about 60 mg, preferably about 61 mg, preferably about 62 mg, preferably about 63 mg, preferably about 64 mg, preferably about 65 mg, preferably about 66 mg, preferably about 67 mg, preferably about 68 mg, preferably about 69 mg, preferably about 70 mg, preferably about 71 mg, preferably about 72 mg, preferably about 73 mg, preferably about 74 mg, preferably about 75 mg, preferably about 76 mg, preferably about 77 mg, preferably about 78 mg, preferably about 79 mg, preferably about 80 mg, preferably about 81 mg, preferably about 82 mg, preferably about 83 mg, preferably about 84 mg, preferably about 85 mg, preferably about 86 mg, preferably about 87 mg, preferably about 88 mg, preferably about 89 mg, preferably about 90 mg, preferably about 91 mg, preferably about 92 mg, preferably about 93 mg, preferably about 94 mg, preferably about 95 mg, preferably about 96 mg, preferably about 97 mg, preferably about 98 mg, preferably about 99 mg, preferably about 100 mg, preferably about 101 mg, preferably about 102 mg, preferably about 103 mg, preferably about 104 mg, preferably about 105 mg, preferably about 106 mg, preferably about 107 mg, preferably about 108 mg, preferably about 109 mg, preferably about 110 mg, preferably about 111 mg, preferably about 112 mg, preferably about 113 mg, preferably about 114 mg, preferably about 115 mg, preferably about 116 mg, preferably about 117 mg, preferably about 118 mg, preferably about 119 mg, preferably about 120 mg, preferably about 121 mg, preferably about 122 mg, preferably about 123 mg, preferably about 124 mg, preferably about 125 mg, preferably about 126 mg, preferably about 127 mg, preferably about 128 mg, preferably
about 129 mg, preferably about 130 mg, preferably about 131 mg, preferably about 132 mg, preferably about 131 mg, preferably about 134 mg, preferably about 135 mg, preferably about 136 mg, preferably about 137 mg, preferably about 138 mg, preferably about 139 mg, preferably about 140 mg, preferably about 141 mg, preferably about 142 mg, preferably about 143 mg, preferably about 144 mg, preferably about 145 mg, preferably about 146 mg, preferably about 147 mg, preferably about 148 mg, preferably about 149 mg, preferably about 150 mg, preferably about 151 mg, preferably about 152 mg, preferably about 153 mg, preferably about 154 mg, preferably about 155 mg, preferably about 156 mg, preferably about 157 mg, preferably about 158 mg, preferably about 159 mg, preferably about 160 mg, preferably about 161 mg, preferably about 162 mg, preferably about 163 mg, preferably about 164 mg, preferably about 165 mg, preferably about 166 mg, preferably about 167 mg, preferably about 168 mg, preferably about 169 mg, preferably about 170 mg, preferably about 171 mg, preferably about 172 mg, preferably about 173 mg, preferably about 174 mg, preferably about 175 mg, preferably about 176 mg, preferably about 177 mg, preferably about 178 mg, preferably about 179 mg, preferably about 180 mg, preferably about 181 mg, preferably about 182 mg, preferably about 183 mg, preferably about 184 mg, preferably about 185 mg, preferably about 186 mg, preferably about 187 mg, preferably about 188 mg, preferably about 189 mg, preferably about 190 mg, preferably about 191 mg, preferably about 192 mg, preferably about 193 mg, preferably about 194 mg, preferably about 195 mg, preferably about 196 mg, preferably about 197 mg, preferably about 198 mg, preferably about 199 mg, preferably about 200 mg, preferably about 201 mg, preferably about 202 mg, preferably about 203 mg, preferably about 204 mg, preferably about 205 mg, preferably about 206 mg, preferably about 207 mg, preferably about 208 mg, preferably about 209 mg, preferably about 210 mg, preferably about 211 mg, preferably about 212 mg, preferably about 213 mg, preferably about 214 mg, preferably about 215 mg, preferably about 216 mg, preferably about 217 mg, preferably about 218 mg, preferably about 219 mg, preferably about 220 mg, preferably about 221 mg, preferably about 222 mg, preferably about 223 mg, preferably about 224 mg, preferably about 225 mg, preferably about 226 mg, preferably about 227 mg, preferably about 228 mg, preferably about 229 mg, preferably about 230 mg, preferably about 231 mg, preferably about 232 mg, preferably about 233 mg, preferably about 234 mg, preferably about 235 mg, preferably about 236 mg, preferably about 237 mg, preferably about 238 mg, preferably about 239 mg, preferably about 240 mg, preferably
about 241 mg, preferably about 242 mg, preferably about 243 mg, preferably about 244 mg, preferably about 245 mg, preferably about 246 mg, preferably about 247 mg, preferably about 248 mg, preferably about 249 mg, preferably about 250 mg, preferably about 251 mg, preferably about 252 mg, preferably about 253 mg, preferably about 254 mg, preferably about 255 mg, preferably about 256 mg, preferably about 257 mg, preferably about 258 mg, preferably about 259 mg, preferably about 260 mg, preferably about 261 mg, preferably about 262 mg, preferably about 263 mg, preferably about 264 mg, preferably about 265 mg, preferably about 266 mg, preferably about 267 mg, preferably about 268 mg, preferably about 269 mg, preferably about 270 mg, preferably about 271 mg, preferably about 272 mg, preferably about 273 mg, preferably about 274 mg, preferably about 275 mg, preferably about 276 mg, preferably about 277 mg, preferably about 278 mg, preferably about 279 mg, preferably about 280 mg, preferably about 281 mg, preferably about 282 mg, preferably about 283 mg, preferably about 284 mg, preferably about 285 mg, preferably about 286 mg, preferably about 287 mg, preferably about 288 mg, preferably about 289 mg, preferably about 290 mg, preferably about 291 mg, preferably about 292 mg, preferably about 293 mg, preferably about 294 mg, preferably about 295 mg, preferably about 296 mg, preferably about 297 mg, preferably about 298 mg, preferably about 299 mg, preferably about 300 mg, preferably about 301 mg, preferably about 302 mg, preferably about 303 mg, preferably about 304 mg, preferably about 305 mg, preferably about 306 mg, preferably about 307 mg, preferably about 308 mg, preferably about 309 mg, preferably about 310 mg, preferably about 311 mg, preferably about 312 mg, preferably about 313 mg, preferably about 314 mg, preferably about 315 mg, preferably about 316 mg, preferably about 317 mg, preferably about 318 mg, preferably about 319 mg, preferably about 320 mg, preferably about 321 mg, preferably about 322 mg, preferably about 323 mg, preferably about 324 mg, preferably about 325 mg, preferably about 326 mg, preferably about 327 mg, preferably about 328 mg, preferably about 329 mg, preferably about 330 mg, preferably about 331 mg, preferably about 332 mg, preferably about 333 mg, preferably about 334 mg, preferably about 335 mg, preferably about 336 mg, preferably about 337 mg, preferably about 338 mg, preferably about 339 mg, preferably about 340 mg, preferably about 341 mg, preferably about 342 mg, preferably about 343 mg, preferably about 344 mg, preferably about 345 mg, preferably about 346 mg, preferably about 347 mg, preferably about 348 mg, preferably about 349 mg, preferably about 350 mg, preferably about 351 mg, preferably about 352 mg, preferably
about 353 mg, preferably about 354 mg, preferably about 355 mg, preferably about 356 mg, preferably about 357 mg, preferably about 358 mg, preferably about 359 mg, preferably about 360 mg, preferably about 361 mg, preferably about 362 mg, preferably about 363 mg, preferably about 364 mg, preferably about 365 mg, preferably about 366 mg, preferably about 367 mg, preferably about 368 mg, preferably about 369 mg, preferably about 370 mg, preferably about 371 mg, preferably about 372 mg, preferably about 373 mg, preferably about 374 mg, preferably about 375 mg, preferably about 376 mg, preferably about 377 mg, preferably about 378 mg, preferably about 379 mg, preferably about 380 mg, preferably about 381 mg, preferably about 382 mg, preferably about 383 mg, preferably about 384 mg, preferably about 385 mg, preferably about 386 mg, preferably about 387 mg, preferably about 388 mg, preferably about 389 mg, preferably about 390 mg, preferably about 391 mg, preferably about 392 mg, preferably about 393 mg, preferably about 394 mg, preferably about 395 mg, preferably about 396 mg, preferably about 397 mg, preferably about 398 mg, preferably about 399 mg, preferably about 400 mg, preferably about 401 mg, preferably about 402 mg, preferably about 403 mg, preferably about 404 mg, preferably about 405 mg, preferably about 406 mg, preferably about 407 mg, preferably about 408 mg, preferably about 409 mg, preferably about 410 mg, preferably about 411 mg, preferably about 412 mg, preferably about 413 mg, preferably about 414 mg, preferably about 415 mg, preferably about 416 mg, preferably about 417 mg, preferably about 418 mg, preferably about 419 mg, preferably about 420 mg, preferably about 421 mg, preferably about 422 mg, preferably about 423 mg, preferably about 424 mg, preferably about 425 mg, preferably about 426 mg, preferably about 427 mg, preferably about 428 mg, preferably about 429 mg, preferably about 430 mg, preferably about 431 mg, preferably about 432 mg, preferably about 433 mg, preferably about 434 mg, preferably about 435 mg, preferably about 436 mg, preferably about 437 mg, preferably about 438 mg, preferably about 439 mg, preferably about 440 mg, preferably about 441 mg, preferably about 442 mg, preferably about 443 mg, preferably about 444 mg, preferably about 445 mg, preferably about 446 mg, preferably about 447 mg, preferably about 448 mg, preferably about 449 mg, preferably about 450 mg, preferably about 451 mg, preferably about 452 mg, preferably about 453 mg, preferably about 454 mg, preferably about 455 mg, preferably about 456 mg, preferably about 457 mg, preferably about 458 mg, preferably about 459 mg, preferably about 460 mg, preferably about 461 mg, preferably about 462 mg, preferably about 463 mg, preferably about 464 mg, preferably
about 465 mg, preferably about 466 mg, preferably about 467 mg, preferably about 468 mg, preferably about 469 mg, preferably about 470 mg, preferably about 471 mg, preferably about 472 mg, preferably about 473 mg, preferably about 474 mg, preferably about 475 mg, preferably about 476 mg, preferably about 477 mg, preferably about 478 mg, preferably about 479 mg, preferably about 480 mg, preferably about 481 mg, preferably about 482 mg, preferably about 483 mg, preferably about 484 mg, preferably about 485 mg, preferably about 486 mg, preferably about 487 mg, preferably about 488 mg, preferably about 489 mg, preferably about 490 mg, preferably about 491 mg, preferably about 492 mg, preferably about 493 mg, preferably about 494 mg, preferably about 495 mg, preferably about 496 mg, preferably about 497 mg, preferably about 498 mg, preferably about 499 mg, preferably about 500 mg, preferably about 501 mg, preferably about 502 mg, preferably about 503 mg, preferably about 504 mg, preferably about 505 mg, preferably about 506 mg, preferably about 507 mg, preferably about 508 mg, preferably about 509 mg, preferably about 510 mg, preferably about 511 mg, preferably about 512 mg, preferably about 513 mg, preferably about 514 mg, preferably about 515 mg, preferably about 516 mg, preferably about 517 mg, preferably about 518 mg, preferably about 519 mg, preferably about 520 mg, preferably about 521 mg, preferably about 522 mg, preferably about 523 mg, preferably about 524 mg, preferably about 525 mg, preferably about 526 mg, preferably about 527 mg, preferably about 528 mg, preferably about 529 mg, preferably about 530 mg, preferably about 531 mg, preferably about 532 mg, preferably about 533 mg, preferably about 534 mg, preferably about 535 mg, preferably about 536 mg, preferably about 537 mg, preferably about 538 mg, preferably about 539 mg, preferably about 540 mg, preferably about 541 mg, preferably about 542 mg, preferably about 543 mg, preferably about 544 mg, preferably about 545 mg, preferably about 546 mg, preferably about 547 mg, preferably about 548 mg, preferably about 549 mg, preferably about 550 mg, preferably about 551 mg, preferably about 552 mg, preferably about 553 mg, preferably about 554 mg, preferably about 555 mg, preferably about 556 mg, preferably about 557 mg, preferably about 558 mg, preferably about 559 mg, preferably about 560 mg, preferably about 561 mg, preferably about 562 mg, preferably about 563 mg, preferably about 564 mg, preferably about 565 mg, preferably about 566 mg, preferably about 567 mg, preferably about 568 mg, preferably about 569 mg, preferably about 570 mg, preferably about 571 mg, preferably about 572 mg, preferably about 573 mg, preferably about 574 mg, preferably about 575 mg, preferably about 576 mg, preferably
about 577 mg, preferably about 578 mg, preferably about 579 mg, preferably about 580 mg, preferably about 581 mg, preferably about 582 mg, preferably about 583 mg, preferably about 584 mg, preferably about 585 mg, preferably about 586 mg, preferably about 587 mg, preferably about 588 mg, preferably about 589 mg, preferably about 590 mg, preferably about 591 mg, preferably about 592 mg, preferably about 593 mg, preferably about 594 mg, preferably about 595 mg, preferably about 596 mg, preferably about 597 mg, preferably about 598 mg, preferably about 599 mg, preferably about 600 mg, preferably about 601 mg, preferably about 602 mg, preferably about 603 mg, preferably about 604 mg, preferably about 605 mg, preferably about 606 mg, preferably about 607 mg, preferably about 608 mg, preferably about 609 mg, preferably about 610 mg, preferably about 611 mg, preferably about 612 mg, preferably about 613 mg, preferably about 614 mg, preferably about 615 mg, preferably about 616 mg, preferably about 617 mg, preferably about 618 mg, preferably about 619 mg, preferably about 620 mg, preferably about 621 mg, preferably about 622 mg, preferably about 623 mg, preferably about 624 mg, preferably about 625 mg, preferably about 626 mg, preferably about 627 mg, preferably about 628 mg, preferably about 629 mg, preferably about 630 mg, preferably about 631 mg, preferably about 632 mg, preferably about 633 mg, preferably about 634 mg, preferably about 635 mg, preferably about 636 mg, preferably about 637 mg, preferably about 638 mg, preferably about 639 mg, preferably about 640 mg, preferably about 641 mg, preferably about 642 mg, preferably about 643 mg, preferably about 644 mg, preferably about 645 mg, preferably about 646 mg, preferably about 647 mg, preferably about 648 mg, preferably about 649 mg, preferably about 650 mg, preferably about 651 mg, preferably about 652 mg, preferably about 653 mg, preferably about 654 mg, preferably about 655 mg, preferably about 656 mg, preferably about 657 mg, preferably about 658 mg, preferably about 659 mg, preferably about 660 mg, preferably about 661 mg, preferably about 662 mg, preferably about 663 mg, preferably about 664 mg, preferably about 665 mg, preferably about 666 mg, preferably about 667 mg, preferably about 668 mg, preferably about 669 mg, preferably about 670 mg, preferably about 671 mg, preferably about 672 mg, preferably about 673 mg, preferably about 674 mg, preferably about 675 mg, preferably about 676 mg, preferably about 677 mg, preferably about 678 mg, preferably about 679 mg, preferably about 680 mg, preferably about 681 mg, preferably about 682 mg, preferably about 683 mg, preferably about 684 mg, preferably about 685 mg, preferably about 686 mg, preferably about 687 mg, preferably about 688 mg, preferably
about 689 mg, preferably about 690 mg, preferably about 691 mg, preferably about 692 mg, preferably about 693 mg, preferably about 694 mg, preferably about 695 mg, preferably about 696 mg, preferably about 697 mg, preferably about 698 mg, preferably about 699 mg or more preferably about 700 mg. [0072] In an embodiment, the composition comprises about 500 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0073] In an embodiment, the composition comprises about 250 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0074] In an embodiment, the composition comprises about 125 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0075] In an embodiment, the composition comprises about 10 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 500 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0076] In an embodiment, the composition comprises about 5 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 250 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0077] In an embodiment, the composition comprises about 2.5 mg THC or a pharmaceutically acceptable salt or derivative thereof, and 125 mg acetazolamide or a pharmaceutically acceptable salt thereof. [0078] In an embodiment, the composition defined herein is for use in the treatment of obstructive sleep apnoea (OSA). Sleep apnoea [0079] The term “sleep apnoea” as used herein refers to sleep disorders characterized by episodes of interrupted breathing during sleep, which results in decreased oxygen saturation or arousal from sleep. This disturbance results in fragmented, non-restorative sleep, typically accompanied by other symptoms including loud, disruptive snoring, witnessed apnoeas during sleep and excessive daytime sleepiness.
[0080] The term “apnoea” as used herein refers to a complete or near complete cessation of airflow for at least 10 seconds. [0081] The term “hypopnoea” as used herein refers to 30% or greater decrease in airflow for at least 10 seconds followed by an arousal and/or > 3% oxygen desaturation. [0082] “Obstructive sleep apnoea” or “OSA” is characterised by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep. [0083] OSA may be classified using the apnoea-hypopnoea index (AHI) or respiratory disturbance index (RDI) as described by, e.g., Iber et al. (2007, The AASM Manual for the Scoring of Sleep and Associated Events, 1st edition), which is based on the average number of obstructive events per hour. Methods for the measurement of obstructive events would be known to persons skilled in the art, illustrative embodiments of which include overnight polysomnography (PSG). [0084] The terms “overnight polysomnography”, “overnight PSG”, “nocturnal polysomnography”, or “nocturnal PSG” may be used interchangeably herein to refer to a test used in the diagnosis of OSA. Overnight PSG consists of a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness. The physiological parameters recorded during PSG would be known to persons skilled in the art, illustrative examples of which include brain activity (e.g., electroencephalogram (EEG)), eye movements (e.g., electroculogram (EOG)), muscle activity of the jaw and legs (e.g., electromyogram (EMG)), heart rhythm (electrocardiogram (ECG)), respiratory airflow (e.g., via a nasal cannula and thermistor), respiratory effort (e.g., via abdominal and thoracic respiratory bands) and peripheral pulse oximetry (e.g., via an infrared finger probe). From these parameters, OSA-related indices can be measured, including sleep onset latency, REM-sleep onset latency, the number of awakenings during the sleep period, the total sleep duration, percentages and durations of every sleep stage, number of arousals, the AHI and arterial oxygen saturation. [0085] According to the AHI, the severity of OSA may be classified as none / minimal, mild, moderate or severe (Table 1).
[0086] Classification of children with OSA may be performed using modified classification thresholds, with mild OSA defined as an AHI of > 1 and < 5 if one or more of the clinical symptoms of OSA have been reported; moderate OSA defined as an AHI of ≥ 5 and < 10; and severe OSA defined as an AHI of ≥ 10. [0087] In an embodiment, the OSA is mild to severe OSA according to the AHI. In another embodiment, the OSA is moderate to severe OSA according to the AHI. [0088] The present inventors have surprisingly found that THC and acetazolamide act synergistically to reduce AHI and oxygen desaturation index (ODI) in subjects with sleep apnoea. Methods for the treatment of sleep apnoea [0089] The terms “treat”, "treating", “treatment” and the like are used interchangeably herein to mean relieving, reducing, alleviating, ameliorating or otherwise inhibiting the severity of one or more symptoms of OSA in a subject. It is to be understood that the terms “treat”, "treating", “treatment” and the like, as used herein, do not imply that a subject is treated until the OSA has been eliminated or are no longer evident. Said treatment may also reduce the severity of the one or more symptoms of OSA. [0090] The term “subject” as used herein refers to any mammal, including livestock and other farm animals (such as cattle, goats, sheep, horses, pigs and chickens), performance animals (such as racehorses), companion animals (such as cats and dogs), laboratory test animals and humans. In an embodiment, the subject is a human. [0091] It is to be understood that the composition comprises THC or a pharmaceutically acceptable salt thereof, and the acetazolamide or a pharmaceutically acceptable salt thereof in a dose sufficient to provide the subject in need thereof a therapeutically effective amount. As used herein, the term “therapeutically effective amount” typically refers to an amount of THC and an amount of acetazolamide that is sufficient to affect one or more beneficial or desired therapeutic outcomes (e.g., reduction in apnoeic episodes, reduction in hypopnoeic episodes, reduction in AHI, reduction in excessive daytime sleepiness, reduction in oxygen desaturation index (ODI), improvement in mood and well-being). Said beneficial or desired therapeutic outcomes may be quantified by measuring clinical parameters, illustrative
examples of which include the measurement of arterial oxygen saturation (SaO2) as described by Zamarron et al. (2003, Chest, 123(5): 1567-1576), movement of the chest and abdomen measured by inductance plethysmograph as described by Kogan et al. (2016, Respiratory Care, 61(8): 1033-1037), nasal airflow as described by de Souse Michels et al. (2014, International Journal of Otolaryngology, 2014: 717419) and heart rate spectral analysis as described by Roche et al. (2003, European Respiratory Journal, 22: 937-942). Subjective measures of sleep quality improvement can also be made using clinical instruments known in the art, illustrative examples of this include the Epworth Sleepiness Scale (ESS) (Johns, 1991, Sleep, 14: 540-545), the Leeds Sleep Evaluation Questionnaire (LSEQ) (Shahid et al., 2011, Leeds Sleep Evaluation Questionnaire (LSEQ), in Shahid et al. (eds), STOP, THAT and One Hundred Other Sleep Scales, Springer, New York), the Profile of Mood States (POMS) (McNair et al., 1971, POMS Manual for the Profile of Mood States, San Diego, CA: Educational and Industrial Testing Service), Short Form-36 (SF-36) (Saris- Baglama et al., 2010, QualityMetric Health Outcomes Scoring Software 4.0, Lincoln, RI) and the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989, Psychiatry Research, 28(2): 193-213). [0092] Changes in the symptoms or severity of OSA as measured by any of the quantitative methods or clinical instruments described elsewhere herein may be expressed using any appropriate statistical measure to demonstrate the magnitude of the reduction in the symptoms or severity of OSA. In an embodiment, the methods disclosed herein reduce in the symptoms or severity of OSA by at least 10%, preferably at least 20%, preferably at least 30%, preferably at least 40%, preferably at least 50%, preferably at least 60%, preferably at least 70%, preferably at least 80%, preferably at least 90%, or more preferably at least 100% as compared to a subject with OSA who has not been administered the composition disclosed herein. [0093] In an embodiment, the methods disclosed herein reduce the AHI in subjects with OSA. [0094] In an embodiment, administration of the composition disclosed herein reduces the AHI of the subject by at least 30% (e.g., by 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%,
69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78% 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or by 100%) relative to the baseline AHI of the subject prior to the administration of the composition disclosed herein. [0095] Accordingly, in an embodiment, administration of the composition disclosed herein reduces the AHI of the subject by at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, at least 50%, at least 51%, at least 52%, at least 53%, at least 54%, at least 55%, at least 56%, at least 57%, at least 58%, at least 59%, at least 60%, at least 61%, at least 62%, at least 63%, at least 64%, at least 65%, at least 66%, at least 67%, at least 68%, at least 69%, at least 70%, at least 71%, at least 72%, at least 73%, at least 74%, at least 75%, at least 76%, at least 77%, at least 78% at least 79%, at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or by at least 100% relative to the baseline AHI of the subject prior to the administration of the composition disclosed herein. [0096] In an embodiment, the methods disclosed herein are useful in reducing ODI in subjects with OSA. [0097] In an embodiment, administration of the composition disclosed herein reduces the ODI of the subject by at least 20% (e.g., by 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78% 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or by 100%) relative to the baseline ODI of the subject prior to the administration of the composition disclosed herein. [0098] Accordingly, in an embodiment, administration of the composition disclosed herein reduces the ODI of the subject by at least 20%, at least 21%, at least 22%, at least
23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34%, at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, at least 50%, at least 51%, at least 52%, at least 53%, at least 54%, at least 55%, at least 56%, at least 57%, at least 58%, at least 59%, at least 60%, at least 61%, at least 62%, at least 63%, at least 64%, at least 65%, at least 66%, at least 67%, at least 68%, at least 69%, at least 70%, at least 71%, at least 72%, at least 73%, at least 74%, at least 75%, at least 76%, at least 77%, at least 78% at least 79%, at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, or by at least 100% relative to the baseline ODI of the subject prior to the administration the composition disclosed herein. [0099] In some embodiments, periodic re-administration of the composition may be required to achieve a desirable therapeutic effect. The exact amounts and rates of administration of the composition will depend on a number of factors, examples of which are described elsewhere herein, such as the subject’s age, body weight, general health, sex and dietary requirements, as well as any drugs or agents used in combination or coincidental with the administration of the composition. Where multiple doses are required, these may be administered hourly, daily, weekly, monthly or at other suitable time intervals or the dose may be proportionally reduced as indicated by the exigencies of the situation. [0100] In an embodiment, the composition is administered at least one, at least two, at least three, or at least four times per day. [0101] In an embodiment, the composition is administered twice per day. [0102] In an embodiment, the composition is administered to the subject between about 10 minutes and about 120 minutes before sleep (e.g., 10 minutes, 11 minutes, 12 minutes, 13 minutes, 14 minutes, 15 minutes, 16 minutes, 17 minutes, 18 minutes, 19 minutes, 20 minutes, 21 minutes, 22 minutes, 23 minutes, 24 minutes, 25 minutes, 26 minutes, 27 minutes, 28 minutes, 29 minutes, 30 minutes, 31 minutes, 32 minutes, 33 minutes, 34 minutes, 35 minutes, 36 minutes, 37 minutes, 38 minutes, 39 minutes, 40 minutes, 41
minutes, 42 minutes, 43 minutes, 44 minutes, 45 minutes, 46 minutes, 47 minutes, 48 minutes, 49 minutes, 50 minutes, 51 minutes, 52 minutes, 53 minutes, 54 minutes, 55 minutes, 56 minutes, 57 minutes, 58 minutes, 59 minutes, 60 minutes, 61 minutes, 62 minutes, 63 minutes, 64 minutes, 65 minutes, 66 minutes, 67 minutes, 68 minutes, 69 minutes, 70 minutes, 71 minutes, 72 minutes, 73 minutes, 74 minutes, 75 minutes, 76 minutes, 77 minutes, 78 minutes, 79 minutes, 80 minutes, 81 minutes, 82 minutes, 83 minutes, 84 minutes, 85 minutes, 86 minutes, 87 minutes, 88 minutes, 89 minutes, 90 minutes, 91 minutes, 92 minutes, 93 minutes, 94 minutes, 95 minutes, 96 minutes, 97 minutes, 98 minutes, 99 minutes, 100 minutes, 101 minutes, 102 minutes, 103 minutes, 104 minutes, 105 minutes, 106 minutes, 107 minutes, 108 minutes, 109 minutes, 110 minutes, 111 minutes, 112 minutes, 113 minutes, 114 minutes, 115 minutes, 116 minutes, 117 minutes, 118 minutes, 119 minutes, or 120 minutes before sleep). [0103] Thus, in an embodiment the composition is administered to the subject between about 10 minutes and about 120 minutes before sleep, preferably about 10 minutes, preferably about 11 minutes, preferably about 12 minutes, preferably about 13 minutes, preferably about 14 minutes, preferably about 15 minutes, preferably about 16 minutes, preferably about 17 minutes, preferably about 18 minutes, preferably about 19 minutes, preferably about 20 minutes, preferably about 21 minutes, preferably about 22 minutes, preferably about 23 minutes, preferably about 24 minutes, preferably about 25 minutes, preferably about 26 minutes, preferably about 27 minutes, preferably about 28 minutes, preferably about 29 minutes, preferably about 30 minutes, preferably about 31 minutes, preferably about 32 minutes, preferably about 33 minutes, preferably about 34 minutes, preferably about 35 minutes, preferably about 36 minutes, preferably about 37 minutes, preferably about 38 minutes, preferably about 39 minutes, preferably about 40 minutes, preferably about 41 minutes, preferably about 42 minutes, preferably about 43 minutes, preferably about 44 minutes, preferably about 45 minutes, preferably about 46 minutes, preferably about 47 minutes, preferably about 48 minutes, preferably about 49 minutes, preferably about 50 minutes, preferably about 51 minutes, preferably about 52 minutes, preferably about 53 minutes, preferably about 54 minutes, preferably about 55 minutes, preferably about 56 minutes, preferably about 57 minutes, preferably about 58 minutes, preferably about 59 minutes, preferably about 60 minutes, preferably about 61 minutes, preferably about 62 minutes, preferably about 63 minutes, preferably about 64 minutes,
preferably about 65 minutes, preferably about 66 minutes, preferably about 67 minutes, preferably about 68 minutes, preferably about 69 minutes, preferably about 70 minutes, preferably about 71 minutes, preferably about 72 minutes, preferably about 73 minutes, preferably about 74 minutes, preferably about 75 minutes, preferably about 76 minutes, preferably about 77 minutes, preferably about 78 minutes, preferably about 79 minutes, preferably about 80 minutes, preferably about 81 minutes, preferably about 82 minutes, preferably about 83 minutes, preferably about 84 minutes, preferably about 85 minutes, preferably about 86 minutes, preferably about 87 minutes, preferably about 88 minutes, preferably about 89 minutes, preferably about 90 minutes, preferably about 91 minutes, preferably about 92 minutes, preferably about 93 minutes, preferably about 94 minutes, preferably about 95 minutes, preferably about 96 minutes, preferably about 97 minutes, preferably about 98 minutes, preferably about 99 minutes, preferably about 100 minutes, preferably about 101 minutes, preferably about 102 minutes, preferably about 103 minutes, preferably about 104 minutes, preferably about 105 minutes, preferably about 106 minutes, preferably about 107 minutes, preferably about 108 minutes, preferably about 109 minutes, preferably about 110 minutes, preferably about 111 minutes, preferably about 112 minutes, preferably about 113 minutes, preferably about 114 minutes, preferably about 115 minutes, preferably about 116 minutes, preferably about 117 minutes, preferably about 118 minutes, preferably about 119 minutes, or more preferably about 120 minutes before sleep. [0104] In another embodiment, the composition is administered to the subject between about 30 minutes and about 60 minutes before sleep. [0105] Those skilled in the art will appreciate that the invention described herein is susceptible to variations and modifications other than those specifically described. It is to be understood that the invention includes all such variations and modifications which fall within the spirit and scope. The invention also includes all of the steps, features, compositions and compounds referred to or indicated in this specification, individually or collectively, and any and all combinations of any two or more of said steps or features. [0106] Unless otherwise defined, all technical and scientific terms used herein have the same meanings as commonly understood by one of ordinary skill in the art to which this invention belongs.
[0107] All patents, patent applications and publications mentioned herein are hereby incorporated by reference in their entireties. [0108] The various embodiments enabled herein are further described by the following non-limiting examples. Examples Example 1 – Clinical trial [0109] Nine subjects with known or suspected OSA (i.e., Apnoea-Hypopnoea Index (AHI) ≥ 15) were randomized to investigate the effects of Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt thereof (i.e., dronabinol) and acetazolamide at three different dose levels on AHI, oxygen desaturation index (ODI), daytime somnolence, and subject well-being. Each subject was screened at baseline to ensure that they met inclusion/exclusion criteria including an overnight PSG to ensure that AHI ≥ 15 and medical history review and physical examination to confirm that they were physically well, with no severe psychiatric, cardiac, renal, endocrine, gastrointestinal, or bleeding disorders. [0110] The study consisted of four, seven-day treatment periods. During each treatment period the subject received a different dose of THC and acetazolamide, either low dose (2.5 mg dronabinol, 125 mg acetazolamide), medium dose (5 mg dronabinol, 250 mg acetazolamide), high dose (10 mg dronabinol, 500 mg acetazolamide), or placebo (appearance matched capsules containing no drug). All subjects received placebo for the first treatment period and the order of the low, medium and high dose treatment periods were randomised between subjects. On night seven of each treatment period, AHI was determined using overnight polysomnography (PSG). Daytime somnolence was also assessed using the Epworth Sleepiness Scale (ESS) and alertness was assessed using the Stanford Sleepiness Scale (SSS). AHI was compared to baseline (screening) to determine the effect of the drug treatment on OSA. A blood sample was collected to assess blood cell count, electrolytes, urea, liver enzymes and levels of THC and the two main metabolites of THC, being OH- THC and COOH-THC.
[0111] The primary endpoint of the study is reduction in AHI after each treatment period compared to baseline. Secondary endpoints including reduction in ESS and SSS score are also calculated relative to baseline. Apnoea-Hypopnoea Index (AHI) [0112] The Applicant has previously shown that THC and a carbonic anhydrase inhibitor synergize in the treatment of OSA (WO 2022/006636). Consistent with these findings, THC and acetazolamide was shown to reduce AHI in patients with OSA compared to baseline at three different doses (Table 3). This reduction was greater than observed for placebo. At the group level, the difference relative to baseline was statistically significant for the low dose and medium dose (p < 0.05; Table 4). When comparing baseline directly to each individual subject, the reduction in AHI from baseline was statistically significant (p < 0.001) across all three doses and placebo (Table 5). Oxygen desaturation index (ODI) [0113] ODI data was collected during overnight PSG on night seven of the treatment periods. As shown in Table 6, all doses of THC and acetazolamide reduced ODI in patients with OSA compared to baseline. This reduction was greater than observed for placebo. The difference relative to baseline was statistically significant for the low dose and medium dose when compared to placebo (p < 0.05). Sleep metrics and reported sleep quality [0114] Each morning of the clinical trial, subjects recorded their sleep quality for the previous night as very poor, poor, fair, good, or very good. To compare patient reported sleep quality, the proportion of subjects who reported good or very good sleep each night was averaged across each treatment period (Table 7). During the treatment periods, subjects more frequently reported that their sleep quality was good or very good than placebo. [0115] Sleep metrics were measured using an Actiwatch, a non-invasive, watch-like device to monitor rest/activity cycles, sleep parameters and motor activity. As shown in Table 8, all doses of THC and acetazolamide improved sleep efficiency (i.e., percentage of
time in bed that a subject is asleep), the number of awakenings per night and the total minutes the subject was awake during the night (WASO) compared to placebo. Example 2 – Exemplary compositions comprising THC and acetazolamide [0116] Exemplary compositions according to the present disclosure comprise the ingredients in Table 9. [0117] The solid dosage form of acetazolamide according to this example is a solid tablet comprising a number of inactive ingredients (i.e., excipients) including those listed in Table 10. [0118] As described elsewhere herein, the compositions may be produced according to the methods disclosed in US Patent Nos.9,433,584, 10,383,826 and WO 2012/017325. As an exemplary composition described herein comprises a tablet solid dosage form (see, e.g., Figure 1) of acetazolamide, such exemplary compositions may be produced according to the methods described in US Patent Nos.9,433,584 and 10,383,826 as they relate to a "double" soft gel capsule (see, e.g., US Patent No.9,433,584, column 6, lines 25-50). Example 3 – Manufacture of fixed dose combination product [0119] Exemplary fixed dose combination products (i.e., composition) comprising a film coated acetazolamide tablet contained within a soft gel capsule comprising THC were manufactured by ProCaps (Barranquilla, Colombia). The manufacturing process consists of three steps: (i) manufacture of the solid dosage form of acetazolamide (e.g., tablet); (ii) manufacture of the THC oil solution; and (iii) combination of the solid dosage form of acetazolamide and THC oil solution within a soft gel capsule. Acetazolamide tablet [0120] Each acetazolamide tablet contains 125 or 250 mg of active pharmaceutical ingredient (API) and the inactive ingredients as listed in Table 10. The acetazolamide, talc, glycerin, sodium starch glycolate, pregelatinized starch, lactose monohydrate, gelatin type LB115 Bloom-RXL R2, were first blended as dry powders. Water was then added to 21.5% to act as a binding agent and mixing continued. The mixture was then heated at 40°C to dry,
followed by addition of magnesium stearate and a final mixing step. The blended powder was then pressed into tablets. Δ-9-tetrahydrocannabinol (THC) sesame oil solution [0121] The THC sesame oil solution contains 1% w/w dronabinol or 0.5% w/w dronabinol in the 5 mg and 2.5 mg THC dose forms, respectively. Dronabinol was supplied from the drug substance manufacturer as a 20% w/w solution in sesame oil. The drug substance was diluted in sesame oil, NF, to the required final concentration and mixed. [0122] The inactive ingredients of the fixed dose combination product are provided in Table 10. Samples of the fixed dose combination product were stored at 2°C to 8°C, 25 ± 2°C at 60 ± 5% relative humidity (RH), and 40 ± 2°C at 75 ± 5% RH and assessed for stability using methods from the US Pharmacopeia (USP) monograph for acetazolamide tablets and high performance liquid chromatography (HPLC) analysis for THC, acetazolamide and related substances at 1, 2, 3, 6, 9, 12, 18, 24, and 36 months. Dissolution of THC and acetazolamide from the fixed dose combination product was also assessed (Tables 11, 12 and 15-18). Fixed dose combination product [0123] The fixed dose combination product is manufactured according to the method described by Salazar Altamaer et al. (US Patent No. 9,433,584). Briefly, soft gel capsules containing a solid dose form drug encapsulated by a polymer capsule are manufactured in the liquid filled soft gel capsule. For the fixed dose combination product described herein, the acetazolamide tablet is contained within a soft gel capsule of THC in sesame oil. The resulting soft gel capsules are size 20 oblong soft gel capsules (i.e., 0.986-1.232 cc). Each soft gel capsule contains 125 mg acetazolamide and 2.5 mg THC or 250 mg acetazolamide and 5 mg THC. The soft gel capsules were manufactured and stored at ambient temperature prior to release analysis. Release of the acetazolamide tablet component was conducted using methods in the USP monograph for acetazolamide tablets with impurities assessed using HPLC. THC impurities were assessed using an HPLC method based on the method listed in the USP monograph for dronabinol, the synthetic form of THC.
Example 4 – Stability of soft gel capsule fixed dose combination product [0124] The soft gel capsule fixed dose combination product described in Example 3 were packaged into blister packs and a formal stability study with conditions of 5 ± 3^C up to 12 months and 25 ± 2 ^C / 60 ± 5 % RH with time points up to 6 months. At least six individual dose units were tested in each assay. Data from the stability study is presented below in Tables 13, 14, 19 and 20. Results from all tests met the acceptance criteria across all conditions. Example 5 – Pharmacokinetics analysis following oral administration of soft gel capsule fixed dose combination product [0125] 125 human subjects were recruited to participate in clinical studies to assess inter alia the bioavailability and pharmacokinetics of acetazolamide and THC following oral administration of the soft gel capsule fixed dose combination product comprising 250 mg acetazolamide and 5 mg THC. [0126] Each subject received one dose of the soft gel capsule fixed dose combination product and were monitored for 48 hours. Blood samples were collected pre-administration, and 0.08, 0.25, 0.5, 1, 1.5, 2, 2.5, 3, 3.5, 4, 6, 8, 12, 16, 24, 36, and 48 hours post- administration. Blood samples were assessed for acetazolamide, THC and THC metabolite concentration. [0127] Both THC and acetazolamide were found to be bioavailable within 30 minutes of administrations, with peak blood concentrations of THC and acetazolamide observed at 1 hour and 3.5 hours post-administration, respectively (Figure 3). [0128] Surprisingly, the soft gel capsule fixed dose combination resulted in the gradual release of acetazolamide compared to acetazolamide as a single agent, as evidenced by a higher Tmax and lower Cmax values (Table 22). Modified and slow-release dose forms of acetazolamide have previously been developed to offer sustained therapeutic effects, reduce dosing frequency and improve patient compliance in the context of treating glaucoma, epilepsy, altitude sickness, idiopathic intracranial hypertension and Meniere's disease. Accordingly, the modified release and uptake of acetazolamide following administration of
the soft gel capsule fixed dose combination may assist in prolonging the beneficial effects of the combination of THC and acetazolamide throughout the treatment period. [0129] In many jurisdictions, it is possible to drive a vehicle with a blood level of 1-2 ng/mL THC. Pleasingly, the soft gel capsule fixed dose combination also resulted in a peak THC blood concentration of 1.081 ng/mL at 1 hour post-administration (Table 23). The blood concentration of THC gradually reduced over time, with as little as 0.096 ng/mL THC measured at 6 hours post-administration, and 0.031 ng/mL THC measured at 8 hours post- administration. It follows, therefore, that administration of the soft gel capsule fixed dose combination just prior to sleep can achieve the therapeutic outcome of reduction in AHI, but beneficially achieve sufficient clearance of THC to allow patients to drive or operate other vehicles the morning after administration. [0130] The pharmacokinetic parameters for THC and other major metabolites COOH- THC and OH-THC were otherwise comparable to single agent THC (i.e., dronabinol) (Tables 24-28). Summary [0131] The combination of THC and acetazolamide synergize to treat OSA. The simultaneous administration of these two APIs has been enabled by the encapsulation of THC in a first capsule and a solid dosage form of acetazolamide in a second capsule, which is incorporated into the first capsule. The present disclosure thus provides a composition that allows for the simultaneous delivery of the synergistic combination of THC and acetazolamide, regardless of physical-chemical compatibility and/or stabilities liabilities of the two APIs. [0132] Moreover, it has been demonstrated that THC and acetazolamide are bioavailable and therapeutically beneficial concentrations following oral administration as soft gel capsule fixed dose combination. The sustained release of acetazolamide beneficially provides maintained levels of acetazolamide, while avoiding adverse effects. In addition, the blood concentrations of THC observed following oral administration peak 1 hour post- administration, which clears to a level that is well below legal limits for operating vehicles, including motor vehicles, shortly after administration.
Table 1. Classification of OSA according to Apnoea-Hypopnea Index (AHI)
Table 2. Tetrahydrocannabinol and related cannabinoids
Table 3. Average AHI at baseline and each treatment period
Table 4. Percent reduction in AHI relative to baseline at the group level
Table 5. Average change in AHI from baseline within subject (least square mean)
Table 6. Reduction in ODI relative to baseline
Table 7. Patient reported sleep quality
Table 8. Sleep metrics measured by actigraphy
Table 9. Exemplary soft gel capsule fixed dose combination products comprising THC and acetazolamide
Low - THC 2.5 mg + ACZ 125 mg; Medium - THC 5 mg + ACZ 250 mg
Table 10. List of inactive ingredients in exemplary soft gel capsule fixed dose combination products
Table 11. Dissolution of THC from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Q= Percentage amount of API dissolved; T= Time required
Table 12. Dissolution of acetazolamide (ACZ) from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Q= Percentage amount of API dissolved; T= Time required
Table 13. Stability of exemplary soft gel capsule fixed dose combination at one, two and three months storage in refrigerated conditions (5^C ± 3^C)
ND = None detected; NLT = Not less than; NMT = No more than
Table 14. Stability of exemplary soft gel capsule fixed dose combination at one, two and three months storage in Zone II conditions (25^C ± 2^C / 60% ± 5% RH)
ND = None detected; NLT = Not less than; NMT = No more than
Table 15. Dissolution of THC from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Table 16. Dissolution of acetazolamide (ACZ) from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Table 17. Dissolution of THC from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Table 18. Dissolution of acetazolamide (ACZ) from exemplary soft gel capsule fixed dose combination products using the USP monograph UV-spectrophotometric method
Table 19. Stability of exemplary soft gel capsule fixed dose combination at 6, 9 and 12 months storage in refrigerated conditions (5^C ± 3^C)
Table 20. Stability of exemplary soft gel capsule fixed dose combination at six months storage in Zone II conditions (25^C ± 2^C / 60% ± 5% RH)
Table 21. Blood concentrations of acetazolamide following oral administration of exemplary soft gel capsule fixed dose combination or single agent acetazolamide
Table 22. Acetazolamide pharmacokinetic (PK) values
Table 23. Blood concentrations of THC following oral administration of exemplary soft gel capsule fixed dose combination or single agent acetazolamide
Table 24. THC PK values
Table 25. Blood concentrations of COOH-THC following oral administration of exemplary soft gel capsule fixed dose combination or single agent acetazolamide
Table 26. COOH-THC PK values
Claims
THE CLAIMS DEFINING THE INVENTION ARE AS FOLLOWS: 1. A composition comprising: a. Δ-9-tetrahydrocannabinol (THC) or a pharmaceutically acceptable salt or derivative thereof; and b. a solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is encapsulated by a first capsule and the solid dosage form of acetazolamide or a pharmaceutically acceptable salt thereof is encapsulated by a second capsule, wherein the second capsule is at least partially encapsulated by the first capsule. 2. The composition of claim 1, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is solubilized in a liquid solvent selected from the group consisting of an oil, an alcohol, propylene glycol and glycerol. 3. The composition of claim 2, wherein the liquid solvent is an oil selected from the group consisting of hemp seed oil, olive oil, caprylic/capric triglyceride (MCT) oil, sunflower oil and sesame seed oil. 4. The composition of any one of claims 1 to 3, wherein the first capsule is a soft gelatin capsule. 5. The composition of any one of claims 2 to 4, wherein the second capsule is a capsule that is not solubilized by the liquid solvent. 6. The composition of claim 5, wherein the second capsule is selected from the group consisting of a polymer capsule, a soft gelatin capsule and a cellulose capsule. 7. The composition of claim 6, wherein the second capsule is a polymer capsule. 8. The composition of any one of claims 1 to 7, wherein solid dosage form is selected from the group consisting of a tablet, a powder, a microgranule, a nanoparticle and a pellet.
9. The composition of claim 8, wherein the solid dosage form is a tablet. 10. The composition of any one of claims 1 to 9, wherein the second capsule is incorporated within the first capsule. 11. The composition of any one of claims 1 to 10, wherein the THC or a pharmaceutically acceptable salt or derivative thereof is dronabinol. 12. The composition of any one of claims 1 to 11, which comprises at least about 0.25 mg THC or a pharmaceutically acceptable salt or derivative thereof. 13. The composition of claim 12, which comprises from about 0.25 mg to about 20 mg THC or a pharmaceutically acceptable salt or derivative thereof. 14. The composition of claim 13, which comprises about 10 mg THC or a pharmaceutically acceptable salt or derivative thereof. 15. The composition of claim 13, which comprises about 5 mg THC or a pharmaceutically acceptable salt or derivative thereof. 16. The composition of claim 13, which comprises about 2.5 mg THC or a pharmaceutically acceptable salt or derivative thereof. 17. The composition of any one of claims 1 to 16, which comprises at least about 1 mg acetazolamide or a pharmaceutically acceptable salt thereof. 18. The composition of claim 17, which comprises from about 1 mg to about 700 mg acetazolamide or a pharmaceutically acceptable salt thereof. 19. The composition of claim 18, which comprises about 500 mg acetazolamide or a pharmaceutically acceptable salt thereof. 20. The composition of claim 18, which comprises about 250 mg acetazolamide or a pharmaceutically acceptable salt thereof. 21. The composition of claim 18, which comprises about 125 mg acetazolamide or a pharmaceutically acceptable salt thereof.
22. The composition of any one of claims 1 to 21 for use in the treatment of obstructive sleep apnoea (OSA). 23. Use of the composition of any one of claims 1 to 21 in the manufacture of a medicament for the treatment of OSA. 24. A method for the treatment of OSA comprising administering the composition of any one of claims 1 to 21 to a subject in need thereof.
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