Stability of cyclosporine 1% in artificial tears

A comparative study between ciclosporine A eye drop (2%) and tacrolimus eye ointment (0.03%) in management of children with refractory vernal keratoconjunctivitis

PURPOSE

To compare the effects of ciclosporine A (2%) eye drop and tacrolimus (0.03%) eye ointment on children with vernal keratoconjunctivitis (VKC) who were not responding to corticosteroid eye drops.

METHODS

A prospective comparative study was carried out on children who were diagnosed with refractory VKC at the ophthalmology clinic in Benha University, Delta area, Egypt, during the period from October 2019 to February 2020.

RESULTS

Fifty-nine patients completed this study. Regarding the individual symptom score, redness, burning, photophobia, and foreign body sensation were significantly reduced in the tacrolimus group compared to those in the ciclosporine A group during the 1st week (p < 0.05). Moreover, the tacrolimus group showed a statistically significant reduction in burning and foreign body sensation at the 4th week (both p = 0.032), and in redness and burning sensation at the 12th week compared to those in the ciclosporine A group (p = 0.005 and 0.048, respectively). The tacrolimus group showed significantly lower mean scores for tarsal conjunctival papillary hypertrophy at the 1st week and 12th week (p = 0.037 and 0.046, respectively), and for punctate erosion and cobblestone papillae at the 1st week (p = 0.029 and 0.037, respectively) than the ciclosporine group. Failure of treatment was observed in 6 patients (19.35%) in the ciclosporine A group and in 5 patients (17.85%) in the tacrolimus group. No serious side effects were detected in any group.

CONCLUSION

A higher reduction in inflammatory symptoms and signs as well as compliance with tacrolimus 0.03% eye ointment than with ciclosporine A 2% eye drops was observed. Moreover, long-term medication for refractory cases is needed to control inflammation. Overall, our finding suggested that ciclosporine A eye drops and tacrolimus eye ointment could be considered as corticosteroid-sparing drugs in the management of children with refractory VKC.

Stability and Safety Traits of Novel Cyclosporine A and Tacrolimus Ophthalmic Galenic Formulations Involved in Vernal Keratoconjunctivitis Treatment by a High-Resolution Mass Spectrometry Approach

In this study, a sensitive quantitative method based on high performance liquid chromatography combined with high-resolution mass spectrometry, Q Exactive^TM-Orbitrap^® was set up and applied for the determination of the immunosuppressor agents cyclosporine A and tacrolimus in novel ethanol-free ophthalmic formulations for the treatment of Vernal keratoconjunctivitis. Different storage parameters in terms of storage temperatures and practical usage conditions were investigated to assess the stability of all formulations during shelf life simulating the real conditions as well to confirm the feasibility of use of ethanol-free products. The methodology was linear (r² = 0.995) over the concentration range 0–200 ng/mL, and its selectivity, precision, accuracy and recovery were all within the required limits. Under different conditions (storage period 0–90 days, 5–25 °C, unopened/usage simulated conditions), our results revealed that both active pharmaceutical ingredients (API) show satisfactory stability up to 30 days of storage/usage, with a significant and consistent concentration decline of cyclosporine A after this time point when its hydroalcoholic formulation was kept at 25 °C.

Intraocular minocycline for the treatment of ocular pythiosis

PURPOSE

A case of ocular pythiosis successfully treated with surgery and intraocular and oral minocycline is reported.

SUMMARY

A 30-year-old man who wore corrective contact lenses traveled to Brazil and Colombia where he swam in salt and fresh waters while wearing contact lenses. He sought treatment at an emergency department after 2 weeks of suffering with a painful corneal ulcer, redness, and loss of vision in his right eye that had been treated at other centers with ophthalmic moxifloxacin for 10 days and with fortified topical antibiotics (amikacin and vancomycin) for 2 days. Examination using a slit lamp revealed a deep central corneal ulcer with surrounding white infiltrate, endothelial plaque, and hypopyon. Due to infection severity, the patient was admitted and received empirical antibiotic therapy and i.v. and topical antifungals. During the first corneal transplantation, the patient's original infection relapsed and was treated with voriconazole and liposomal amphotericin B intraocular injections. A subsequent infection developed, and a second keratoplasty was performed. One month after hospital admission, the patient was diagnosed with ocular pythiosis and therapy with oral minocycline was initiated. After severe infection relapse in the anterior chamber, the patient underwent a third penetrating keratoplasty, where minocycline intraocular injection was administered. After this intervention, complete infection control was achieved, and the patient was discharged 45 days after admission with oral minocycline and 1% cyclosporine and 0.3% ofloxacin eye drops.

CONCLUSION

A patient with ocular pythiosis was successfully treated with penetrating keratoplasty and 2 months of treatment with intracameral and oral minocycline.

Does the temperature of an artificial tear affect its comfort?

BACKGROUND

Refrigerated eye-drops have been advocated in cases of ocular allergies to provide a soothing effect upon instillation. This notion continues to be promoted by practitioners for artificial tears (AT) in the management of dry eye (DE) with little support in the literature. To further substantiate claims of a soothing effect of cold eye-drops, the aim of this study was to determine if refrigeration of an AT enhanced the subjective comfort upon instillation.

METHODS

Participants with mild to moderate DE participated in an open label contralateral study of two weeks duration. Each participant instilled Systane Ultra (Alcon Laboratories) in the morning (between 6.00-10.00 hours) and in the evening (between 18.00-22.00 hours). Participants were asked to report the subjective comfort immediately after both of these instillations, on a scale from 1 (poor) to 10 (excellent). This was done for ambient (aAT) and refrigerated (rAT) drops. An in vitro study evaluated if there were any changes in eye-drop pH and osmolarity with refrigeration.

RESULTS

Participants (n = 18, three male, 15 female, age 22-28 years, average 24.4 ± 1.6) reported mean comfort scores (± standard deviation) of 7.8 ± 0.9 and 7.6 ± 1.4, for the aAT and the rAT, respectively. Mean comfort scores (± standard deviation) for morning and evening, were 7.7 ± 1.2 and 7.8 ± 1.1, respectively. A non-parametric Friedman test of differences among repeated measures was conducted and rendered a chi-squared value of 3.74, which was not statistically significant (p = 0.29). The pH remained stable at 8.0 and the osmolality did not vary significantly with refrigeration.

CONCLUSION

There is no advantage, with respect to patient perceived comfort, in refrigerating the Systane Ultra (Alcon Laboratories) AT for mild to moderate DE.

A comparative review of Haute Autorité de Santé and National Institute for Health and Care Excellence health technology assessments of Ikervis® to treat severe keratitis in adult patients with dry eye disease which has not improved despite treatment with tear substitutes

Background: In 2015, Ikervis® became the only EMA-approved cyclosporine A (CsA) eye-drop for the treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes. Since the 1980s, CsA has been used empirically for ocular conditions in veterinary medicine then in humans. However, its extremely low aqueous solubility led to its administration in vegetable oils, which is characterized by low ocular availability, poor intraocular penetration, poor tolerability and short shelf-life. Concentrations from 0.05% to 2% are compounded on an industrial scale and reimbursed throughout Europe. In France, Ikervis® has been granted an ASMR score of 5 by HAS, whereas in UK NICE endorsed its use. Objective: To review the dry eye disease environment, its challenges and available treatment options, and compare the NICE and HAS assessments to question HAS' decision to maintain full reimbursement of compounded CsA formulations in the absence of evidence, while reimbursing the EMA-approved drug at 15%.

METHOD

extensive search on PubMED. Results: Comparator selection, composite score assessment and use of CE model are key differentiators. Conclusion: In topical formulations, improvements to the vehicle are key innovations that can bring significant benefits. After the USA, a Compounding Act is needed in Europe.

Systematic approach to managing vernal keratoconjunctivitis in clinical practice: Severity grading system and a treatment algorithm

Vernal keratoconjunctivitis is an ocular allergy that is common in the pediatric age group. It is often chronic, severe, and nonresponsive to the available treatment options. Management of these children is difficult and often a dilemma for the practitioner. There is a need to simplify and standardize its management. To achieve this goal, we require a grading system to judge the severity of inflammation and an algorithm to select the appropriate medications. This article provides a simple and practically useful grading system and a stepladder algorithm for systematic treatment of these patients. Use of appropriate treatment modalities can reduce treatment and disease-related complications.

Frequent Dosing of Topical Cyclosporine A for Severe Ocular Surface Disease

PURPOSE

To study the systemic safety and patient tolerability of frequent dosing of cyclosporine A (CsA) 0.05% eyedrops in the treatment of ocular surface disease. This is a retrospective case series. Patients with significant ocular surface diseases who were treated using topical CsA higher than the usual twice daily dosing (3-8 times daily and over a treatment period of 1-70 months). The main outcome measures are plasma levels of CsA and local tolerability.

METHODS

Symptom assessment, corneal staining using fluorescein, conjunctival staining using lissamine green, tear film breakup time, and other signs according to the disease process were monitored. Discontinuation of treatment due to intolerability was recorded. CsA levels were measured in the plasma at a clinical laboratory.

RESULTS

Plasma levels of CsA were below the level of detection (7 ng/mL) in all the 41 patients included. All patients tolerated the treatment well with none discontinuing due to any treatment-related local adverse effects.

CONCLUSIONS

This study demonstrates that CsA 0.05% ophthalmic emulsion applied more frequently than the usual twice daily dosing was safe and well tolerated in patients with significant ocular surface diseases.

A water-soluble prodrug of cyclosporine A for ocular application: a stability study

UNIL088 is a water-soluble prodrug of cyclosporine A (CsA) developed for topical eye delivery. Such a prodrug has to fulfil two paradoxical requirements as it must be rapidly hydrolysed under physiological conditions but also retain a long shelf-life in aqueous media. This study has been conducted to explore the stability of UNIL088 formulated as an eyedrop solution. The stability study of the prodrug was performed over a pH range of 5-7 at 20 degrees C and at various ionic strengths. The molecule was more stable at pH 5 than at pH 7 with conversion rate constant of 3.2 x 10(-3) and 26.0 x 10(-3)days(-1), respectively. The effect of temperature was studied at four different temperatures and activation energy was determined. Conversion of UNIL088 followed a pseudo-first-order kinetic with an activation energy of 79.4 kJ mol(-1). Due to its low solubility, CsA generated precipitated in the solution. The average size of CsA precipitates, determined by photon spectroscopy, was 0.22 and 1.08 microm at 7 and 14 days, respectively. The hydrolysis mechanism was partially elucidated by identification of the intermediate pSer-Sar-CsA.

A novel water-soluble cyclosporine A prodrug: ocular tolerance and in vivo kinetics

The purpose of this study is to demonstrate that a novel water-soluble prodrug of cyclosporine A (CsA) intended for topical ocular administration, does not induce eye irritation in a rabbit model and is able to generate therapeutic concentrations of CsA in the precorneal area immediately after administration. The eye irritancy of the prodrug and CsA control solution was assessed by the Draize test and by confocal laser ophthalmoscopy (CLSO). Residence time and tear concentrations of prodrug and CsA in the rabbit eye were assessed by HPLC. The Draize test showed an excellent tolerance for the prodrug solution while the reference CsA oil solution induced lachrymation and irritation. The CLSO-measured corneal lesions, subsequent to treatment with the prodrug and reference solutions, were 3% and 9%, respectively. The prodrug transformed rapidly, leading to relatively stable CsA concentrations in tears with a maximal concentration of 94 microg ml(-1) over the observation period. This study demonstrated that the prodrug solution was well tolerated and that clinically significant CsA tear concentrations were achieved. UNIL088 is a promising molecule in the treatment of immune-related disorders of the eye.

Préparation d’un collyre de ciclosporine à 2 %

PURPOSE

Cyclosporine administration is very effective in the case of immunological diseases of the cornea, conjunctive or uvea. Moreover, it is widely used in the case of high-risk rejection corneal transplantation. We present a preparation of cyclosporine 2% eye drops.

METHODS

Cyclosporine 2% eye drops are prepared following a particular formulation including one part commercially available cyclosporine oral solution (Sandimmun) diluted in four parts of sterile castor oil. Manufacturing procedures maintain the sterile state of the preparation with a laminar airflow hood placed in a particulate controlled room, with pharmacists, technicians and clerical personnel wearing sterile clothes. Physical and chemical monitoring during and after manufacture for each batch guarantees the process and minimizes the risk of batch rejection. Chemical analysis of cyclosporine is conducted using a validated stability-indicating high-performance liquid chromatographic assay (reverse-phase). Blood dosages taken after the first administration at the 24th hour (after administration of the 6th drop) check for systemic integration.

RESULTS

Cyclosporine 2% eye drops are fairly stable: 12 months after manufacturing, concentrations result in levels not statistically different from concentrations measured the day of preparation. After a daily regimen of six drops in the eye, cyclosporine 2% eye drops have a very low systemic bioavailability, because the blood concentrations only reach the detection limit of the fluorescence polarization immunoassay used for cyclosporine drug monitoring. This explains the absence of systemic toxicity.

CONCLUSION

Cyclosporine 2% eye drops can be available in the hospital pharmacy. The eye drops are stable at room temperature and can be delivered up to 12 months after manufacture. No local adverse effects have been noted, probably in relation with the very low concentration of ethanol in the ocular preparation.