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Background
Cutaneous leishmaniasis (CL) is a neglected tropical disease caused by protozoan parasites of the genus Leishmania. CL causes enormous suffering in many countries worldwide. There is no licensed vaccine against CL, and the chemotherapy options show limited efficacy and high toxicity. Localization of the parasites inside host cells is a barrier to most standard chemo- and immune-based interventions. Hence, novel drugs, which are safe, effective and readily accessible to third-world countries and/or drug delivery technologies for effective CL treatments are desperately needed.
Methodology/Principal
Findings Here we evaluated the antileishmanial properties and delivery potential of polyhexamethylene biguanide (PHMB; polyhexanide), a widely used antimicrobial and wound antiseptic, in the Leishmania model. PHMB showed an inherent antileishmanial activity at submicromolar concentrations. Our data revealed that PHMB kills Leishmania major (L. major) via a dual mechanism involving disruption of membrane integrity and selective chromosome condensation and damage. PHMB's DNA binding and host cell entry properties were further exploited to improve the delivery and immunomodulatory activities of unmethylated cytosine-phosphate-guanine oligodeoxynucleotides (CpG ODN). PHMB spontaneously bound CpG ODN, forming stable nanopolyplexes that enhanced uptake of CpG ODN, potentiated antimicrobial killing and reduced host cell toxicity of PHMB.
Conclusions
Given its low cost and long history of safe topical use, PHMB holds promise as a drug for CL therapy and delivery vehicle for nucleic acid immunomodulators.
The title compound, C\(_{12}\)H\(_{9}\)N\(_{3}\)O, is an intermediate in the synthesis of the muscarinic M2 receptor antagonist AFDX-384. The seven-membered ring adopts a boat conformation and the dihedral angle between the planes of the aromatic rings is 41.51 (9)°. In the crystal, molecules are linked into [001] chains of alternating inversion dimers formed by pairs of N-H・・・O hydrogen bonds and pairs of N-H・・・N hydrogen bonds. In both cases, R\(_{2}\)\(^{2}\)(8) loops are generated.
The International Symposium on Phytochemicals in Medicine and Food (ISPMF2015), organized by the Phytochemical Society of Europe (PSE) and the Phytochemical Society of Asia (PSA), was held June 26-29, 2015, in Shanghai of China. This was the first time that a PSE meeting has been held in Asia and a PSE-PSA joint symposium provided an opportunity for communication between scientists from Europe and Asia and other continents. ISPMF2015 has been jointly sponsored by Fujian Agriculture and Forestry University, Guizhou Medical University, Shanghai Normal University, Yancheng Institute of Technology, Beijing Normal University, and Fudan University. More than 270 scientists from 48 countries attended this meeting and presented their research and opinions on phytochemistry, phytomedicine and phytoneering. The international organizing committee and scientific advisory board of ISPMF 2015 comprised of outstanding scientists from around the globe. Dr. Jianbo Xiao was the chairman of the International Organizing Committee of ISPMF2015 and moderated the open address on June 26.
The organizing committee of ISPMF2015 assembled an exciting and diverse program, featuring 16 sessions including 12 plenary lectures, 20 invited talks, 55 short oral presentations, and more than 130 posters, which were dedicated to creating a podium for exchanging the latest research results in the phytochemicals for food and human health.
The Corona® charged aerosol detector (CAD) is an aerosol-based detector first de-scribed by Dixon and Peterson in 2002. It is capable of detecting compounds inde-pendent from their physico-chemical properties presumed the analyte is sufficiently non-volatile. Consequently, the CAD is often applied to the analysis of substances that do not possess a suitable UV chromophore. Major drawbacks are however, the detector signal is non-linear and depending on the content of organic solvent in the mobile phase.
This thesis tried to explore possible applications of the CAD for pharmaceutical analysis. Therefore, several substances from different compound classes were in-vestigated. Newly developed or existing methods were validated. Thus the perfor-mance of the CAD could be examined. Both assay and impurity determination were evaluated for their compliance with ICH Q2(R1) “Validation of Analytical Proce-dures” and the “Technical Guide for the Elaboration of Monographs”.
In the course of the establishment of reference substances at the EDQM, a generic screening method for the identification of organic and inorganic pharmaceutical counterions was needed. An HPLC-CAD method developed by Zhang et al. was therefore investigated for its suitability for pharmacopoeial purpose. Method valida-tion was performed. It was found that 23 ions could be separated and detected. Iden-tification was achieved via retention time of an authentic standard of the corre-sponding ions. Alternatively, peak assignment was performed by determination of the exact mass using TOF-MS. Ions could be quantified as impurities or for stoichi-ometric purpose.
For the impurity control in topiramate, the performance characterstics of the CAD were compared to that of an ELSD. CAD was superior to ELSD in terms of repeata-bility, sensitivity and linearity. However, impurities could be quantified with satisfac-tory accuracy with both detectors. The application of the ELSD was not feasible due to non-reproducible spike peaks eluting after the principle peak in the chromatogram of the test solution. One of the impurities, topiramate impurity A (diacetonide), gave no or a vastly diminished signal in the ELSD and the CAD, respectively. It is evapo-rated during the detection process due to its relatively high vapor pressure. The re-sponse could be enhanced by a factor of nine via post-column addition of acetoni-trile and a lower nebulizer temperature. As the response of topiramate impurity A was still about thousand-fold lower than the response of all other impurities, its quantification was not feasible. Additionally, the HPLC-CAD was successfully vali-dated as an assay procedure for topiramate.
There seems to be a great potential in the application of the CAD to the analysis of excipients as most compounds do not possess a suitable UV chromophore. Here, a simple and rapid HPLC-CAD method for the determination of polidocanol (PD) was developed. The method was successfully validated as a potential assay procedure for the Ph. Eur. as none is described in either of the two PD monographs. The same method was applied to the determination of the PD release from a pharmaceutical polymer matrix.
A method for the determination of the fatty acid (FA) composition of polysorbate 80 (PS80) was developed and validated. Using the CAD and mass spectrometry, we were able to identify two new FAs in 16 batches from four manufacturers. All batch-es complied with pharmacopoeial specification. Furthermore, the overall composi-tion of the different PS80 species (“fingerprinting”) and the peroxide content were determined. In addition to the chemical characterization, functionality related charac-teristics (FRCs) were determined. Correlations between chemical composition and FRCs were found.
The validation data of the above mentioned methods suggests that the CAD repre-sents a viable detection technique for pharmaceutical analysis. The CAD was suffi-ciently sensitive for non-volatile analytes. Impurity control down to concentrations of 0.05 or 0.03%, as demanded by ICH Q3A (R2), is achievable. However, the response of semi-volatile compounds may be drastically diminished. It could be confirmed that the response of the CAD is linear when the range does not exceed two orders of magnitude. Exceptions may be observed depending on the actual method setup. When the measuring range is sufficiently narrow, quantification can be done using single-point calibration which is common practice in pharmaceutical anlysis. Impuri-ties may also be quantified against a single calibration solution. However, correction factors may be needed and the accuracy is considerably lower compared to an as-say method. If a compound is to be quantified over a large concentration range, log-log transformation of the calibration curve is needed and a decreased accuracy has to be accepted.
Ionische Flüssigkeiten (engl. Ionic Liquids = IL) sind organische Salze mit einem Schmelzpunkt von unter 100 °C und bieten einen interessanten Ansatz um die orale Bioverfügbarkeit von schlecht wasserlöslichen Arzneistoffen zu verbessern.
Aufgrund seiner schlechten Wasserlöslichkeit wurde aus dem Wirkstoff BGG492 der Novartis AG eine Ionische Flüssigkeit (IL) mit dem sterisch anspruchsvollen Gegenion Tetrabutylphosphonium hergestellt. Die IL ist ein amorpher, glasartiger Feststoff mit einem Schmelzpunkt von 57 °C. Die freie Säure (FS), das Kaliumsalz (BGG-K+) und die IL (siehe Abb. 69) wurden in festem Zustand mittels polarisationsmikroskopischen Aufnahmen, Röntgen-Pulverdiffraktometrie, Röntgenkristallstrukturanalysen, Infrarot-Spektroskopie und Festkörper-NMR-Spektroskopie untersucht.
Der ionische Charakter der IL in festem Zustand konnte mittels Bandenverschiebung der deprotonierten Sulfonamidgruppe im IR-Spektrum bestätigt werden. In der Röntgenkristallstrukturanalyse konnte gezeigt werden, dass sich die Moleküle der FS in Schichten anordneten, in denen jedes Molekül mit vier Nachbarmolekülen über Wasserstoffbrücken verbunden war. Das BGG-K+ kristallisierte als Monohydrat. In dieser Kristallstruktur bildeten die Kaliumkationen in der bc-Ebene mit den BGG-Anionen ober- und unterhalb Schichten. Im Gegensatz zu der FS waren keine intermolekularen Wasserstoffbrücken zu beobachten. Die 15N-Festkörper-NMR-Spektren des BGG-K+ und der IL zeigten die gleiche chemische Verschiebung für den unsubstituierten Stickstoffes N-1‘ der Pyrazolgruppe und belegten somit ebenfalls die ionische Struktur der IL im festen Zustand. Die amorphe Struktur der IL wurde mittels Röntgen-Pulverdiffraktometrie und Polarisationsmikroskop bestätigt und eine flüssigkristalline Phase konnte ausgeschlossen werden.
Die IL zeigte im Vergleich zu der FS eine 700-fach schnellere Auflösungsrate J und eine signifikante Verlängerung der Dauer der Übersättigung in wässriger Lösung. Der sprunghafte Anstieg der Kon-zentration in Lösung („spring“) und die Dauer der Übersättigung („parachute“) wurden mittels photometrischen und potentiometrischen Titrationen untersucht. Mit Hilfe der NMR-Spektroskopie konnte der Mechanismus der Übersättigung aufgeklärt werden. Das sterisch anspruchsvolle Gegenion Tetrabutylphosphonium verhinderte die Protonierung der deprotonierten Sulfonamidgruppe von BGG. In Lösung kam es zur Bildung von Aggregaten („Cluster“), in die sich das Gegenion teilweise einlagerte. Nach der Protonierung und der Bildung von Kristallisationskeimen präzipitierte die ungeladenen FS und der metastabile Zustand der Übersättigung („parachute“) brach zusammen.
Um den Einfluss der Struktur des Gegenions auf die Auflösungsrate und die Dauer der Übersättigung zu untersuchen, wurden ca. 40 Phosphonium- und Ammonium-Kationen synthetisiert. Die Schmelzpunkte der Phosphonium- und Ammonium-Salze wurden mittels dynamischer Differenzkalorimetrie (DSC) ermittelt. Für das Phosphonium-Salz P3332OH-Bromid konnte eine enantiotrope Umwandlung der Modifikationen mittels temperaturabhängiger XRPD-Messungen bestätigt werden. Die Zelltoxizitäts-Untersuchungen der Phosphonium- und Ammonium-Salze an humanen Leberzellen (HepG2), Nierenzellen (HEK 293T) und murinen Makro-phagenzellen (J774.1) zeigten, dass mit höherer Lipophilie die Zelltoxizität zunahm. Polare Kationen zeigten keine Zytotoxizität (IC50 > 1000 µM). Die Zelltoxizität der Ammonium-Salze war im direkten Vergleich mit den Phosphonium-Salzen etwas geringer.
Die synthetisierten Phosphonium- und Ammonium-Salze, die als Chloride-, Bromide- und Iodide vorlagen, wurden durch Anionenaustausch in Hydroxide umgewandelt. Die Ionischen Flüssigkeiten wurden in einer Säure-Base-Reaktion mit der freien Säure des BGG-Moleküls und den Hydroxiden hergestellt. Der ionische Charakter konnte mittels Bandenverschiebung der deprotonierten Sulfonamidgruppe im IR-Spektrum bestätigt werden.
Die Substanzen waren amorph (XRPD) und die Glasübergangstemperaturen (DSC) bewegten sich für die Mono-Kationen im Bereich zwischen 40 °C – 97 °C, für Dikationen 81 °C - 124 °C und für Trikationen 124 °C - 148 °C. Damit erfüllten einige Substanzen die Definition einer Ionischen Flüssigkeit nicht (Smp. < 100 °C) und wurden daher als Niedrig-Gitter-Enthalpie-Salze (low lattice enthalpy salt = LLES) bezeichnet. Die ILs und LLES zeigten signifikante Unterschiede in der Auflösungsrate J, der Übersättigungszeit und der Wasserdampfsorption.
In dieser Arbeit konnte gezeigt werden, dass allein durch die Auswahl des Gegenions wichtige Parameter für die orale Bioverfügbarkeit gesteuert werden können. Durch diesen Ansatz war es möglich, aus dem sehr schlecht wasserlöslichen Arzneistoff BGG492 Ionische Flüssigkeiten bzw. LLES herzustellen, die sich drastisch schneller auflösten und teilweise über mehrere Stunden übersättigte Lösungen bildeten. Insgesamt zeigte sich, dass durch eine Zunahme der Polarität des Gegenions eine größere Auflösungsrate J und eine geringere Zelltoxizität erzielt werden konnten. Jedoch verringerte sich dadurch die Dauer der Übersättigung in Lösung und erhöhte die Hygroskopizität der ILs und LLES.
SUMMARY
Insulin-like growth factor I (IGF-I) is a polypeptide with a molecular weight of 7.649 kDa and an anabolic potential. Thereby, IGF-I has a promising therapeutic value e.g. in muscle wasting diseases such as sarcopenia. IGF-I is mainly secreted by the liver in response to growth hormone (GH) stimulation and is rather ubiquitously found within all tissues. The effects of IGF-I are mediated by its respective IGF-I transmembrane tyrosine kinase receptor triggering the stimulation of protein synthesis, glucose uptake and the regulation of cell growth. The actions of IGF-I are modulated by six IGF binding proteins binding and transporting IGF-I in a binary or ternary complex to tissues and receptors and modulating the binding of IGF-I to its receptor. The nature of the formed complexes impacts IGF-I`s half-life, modulating the half-life between 10 minutes (free IGF-I) to 12 - 15 hours when presented in a ternary complex with IGF binding protein 3 and an acid labile subunit (ALS). Therefore, sustained drug delivery systems of free IGF-I are superficially seen as interesting for the development of controlled release profiles, as the rate of absorption is apparently and easily set slower by simple formulation as compared to the rapid rate of elimination. Thereby, one would conclude, the formulation scientist can rapidly develop systems for which the pharmacokinetics of IGF-I are dominated by the formulation release kinetics. However, the in vivo situation is more complex and as mentioned (vide supra), the half-life may easily be prolonged up to hours providing proper IGF-I complexation takes place upon systemic uptake. These and other aspects are reviewed in Chapter I, within which we introduce IGF-I as a promising therapeutic agent detailing its structure and involved receptors along with the resulting signaling pathways. We summarize the control of IGF-I pharmacokinetics in nature within the context of its complex system of 6 binding proteins to control half-life and tissue distribution. Furthermore, we describe IGF-I variants with modulated properties in vivo and originated from alternative splicing. These insights were translated into sophisticated IGF-I delivery systems for therapeutic use. Aside from safety aspects, the challenges and requirements of an effective IGF-I therapy are discussed. Localized and systemic IGF-I delivery strategies, different routes of administration as well as liquid and solid IGF-I formulations are reviewed. Effective targeting of IGF-I by protein decoration is outlined and consequently this chapter provides an interesting guidance for successful IGF-I-delivery. In Chapter II, we firstly outline the stability of IGF-I in liquid formulations with the intention to deliver the biologic through the lung and the impact of buffer type, sodium chloride concentration and pH value on IGF-I stability is presented. IGF-I integrity was preserved in histidine buffer over 4 months at room temperature, but methionine 59 oxidation (Met(o)) along with reducible dimer and trimer formation was observed in an acidic environment (pH 4.5) and using acetate buffer. Strong aggregation resulted in a complete loss of IGF-I bioactivity, whereas the potency was partly maintained in samples showing a slight aggregation and complete IGF-I oxidation. Atomization by air-jet or vibrating-mesh nebulizers yielded in limited Met(o) formation and no aggregation. The results of IGF-I nebulization experiments regarding aerosol output rate, mass median aerodynamic diameter and fine particle fraction were comparable with 0.9% sodium chloride reference, approving the applicability of liquid IGF-I formulations for pulmonary delivery. In Chapter III we escalated the development to solid delivery systems designed for alveolar landing upon inhalation and by deploying trehalose and the newly introduced for pulmonary application silk-fibroin as carriers. Microparticles were produced using nano spray drying following analyses including IGF-I integrity, IGF-I release profiles and aerodynamic properties. In vitro transport kinetics of IGF-I across pulmonary Calu-3 epithelia were suggesting similar permeability as compared to IGF-I’s cognate protein, insulin that has already been successfully administered pulmonary in clinical settings. These in vivo results were translated to an ex vivo human lung lobe model. This work showed the feasibility of pulmonary IGF-I delivery and the advantageous diversification of excipients for pulmonary formulations using silk-fibroin. Chapter IV focuses on an innovative strategy for safe and controllable IGF-I delivery. In that chapter we escalated the development to novel IGF-I analogues. The intention was to provide a versatile biologic into which galenical properties can be engineered through chemical synthesis, e.g. by site directed coupling of polymers to IGF-I. For this purpose we genetically engineered two IGF-I variants containing an unnatural amino acid at two positions, respectively, thereby integrating alkyne functions into the primary sequence of the protein. These allowed linking IGF-I with other molecules in a site specific manner, i.e. via a copper catalyzed azide-alkyne Huisgen cycloaddition (click reaction). In this chapter we mainly introduce the two IGF-I variants, detail the delivery concept and describe the optimization of the expression conditions of the IGF-I variants.
In conclusion, we span from simple liquid formulations for aerolization through solid systems for tailored for maximal alveolar landing to novel engineered IGF-I analogues. Thereby, three strategies for advanced IGF-I delivery were addressed and opportunities and limitations of each were outlined. Evidence was provided that sufficiently stable and easy to manufacture formulations can be developed as typically required for first in man studies. Interestingly, solid systems – typically introduced in later stages of pharmaceutical development – were quite promising. By use of silk-fibroin as a new IGF-I carrier for pulmonary administration, a new application was established for this excipient. The demonstrated success using the ex vivo human lung lobe model provided substantial confidence that pulmonary IGF-I delivery is possible in man. Finally, this work describes the expression of two IGF-I variants containing two unnatural amino acids to implement an innovative strategy for IGF-I delivery. This genetic engineering approach was providing the fundament for novel IGF-I analogues. Ideally, the biologic is structurally modified by covalently linked moieties for the control of pharmacokinetics or for targeted delivery, e.g. into sarcopenic muscles. One future scenario is dicussed in the ‘conclusion and outlook’ section for which IGF-I is tagged to a protease sensitive linker peptide and this linker peptide in return is coupled to a polyethylenglykole (PEG) polymer (required to prolong the half-life). Some proteases may serve as proxy for sarcopenia such that protease upregulation in compromised muscle tissues drives cleavage of IGF-I from the PEG. Thereby, IGF-I is released at the seat of the disease while systemic side effects are minimized.
Lattice forces are based on the attraction between the single moieties of molecules. The strength of lattice forces has an impact on the solid state and related physical properties such as melting point, boiling point, vapor pressure solvation and solubility. For solvation to occur, energy is required to break the lattice forces attracting ions and molecules among themselves. The energy for breaking up the attraction between the molecules is gained from the energy released when ions or molecules of the lattice associate with molecules of the solvent. Solubility is therefore, directly linked to the energy which is required to break the lattice forces and the energy which is liberated by solvation of the molecules or ions. Based on this relation, the lattice forces in two acidic compounds and a neutral compound were subsequently lowered by different approaches with the intention to increase the solubility, supersaturation, and dissolution rate.
The conversion to an ionic liquid and the embedding of the compound in a pH-sensitive matrix in an amorphous state were investigated with an acidic compound and its pro-drug. The tetrabutylphosphonium (TBPH) salt showed the most promising properties among the tested counter ions. It alters the properties of the compound from a highly crystalline physicochemical state to an amorphous readily soluble material showing supersaturation in a wider pH range and higher solubility than the sodium and potassium salts. A solid dispersion approach was developed in parallel. Solid dispersions with two different pH-sensitive polymers and different drug load were prepared by lyophilization to determine the miscibility of the compound and the polymer by differential scanning calorimetry (DSC). A miscibility of 50% of the amorphous acid with the pH-sensitive Eudragit L100-55 matrix and a miscibility of 40% with hydroxypropyl methylcellulose acetate succinate (HPMC-AS) was found. Both approaches, the TBPH salt and the solid dispersion based on the pH-sensitive Eudragit L100-55 were tested in vivo. The TBPH salt was dosed in a buffered solution to prevent precipitation in the acidic stomach pH. This resulted in BAV higher than the crystalline suspension but lower than the solid dispersion. There were no acute toxicology effects seen. Thus, TBPH was considered safe for further studies. The TBPH salts were very hygroscopic, sticky and prone to precipitation as free compound when exposed to low pH when simulating the passage through the stomach. Thus, the principle of the ionic liquid was combined with the principle of an amorphous solid dispersion. This mitigated the risk of precipitation of the TBPH salt during the passage of the stomach. Also delinquency upon open storage was improved by embedding the TBPH salt in a pH-sensitive polymer. Dissolution tests mimicking the pH gradient in the gastro intestinal tract confirmed the protective properties of the pH-sensitive polymer matrices against recrystallization at low stomach pH in vitro. Furthermore, supersaturation at pH ranges relevant in the intestines of preclinical species or humans was observed. The TBPH solid dispersion showed superior supersaturation behavior in vitro compared to the free acid in pH-sensitive matrix. However, equally increased bioavailability (BAV) was observed when the amorphous solid dispersion contained the free acid form or the TBPH salt. Absorption seemed to be so fast that the short in vitro supersaturation observed for the free from in pH-sensitive matrix was already sufficient for complete absorption within 15 - 30 minutes. This is in accordance with the short tmax of around 15 - 30 minutes after oral application of the low lattice force principles. The pharmacokinetic (PK) profile became the main focus of further optimization as the BAV was maximized already. Early maximal plasma concentration (tmax) went along with high maximal plasma concentration (Cmax) for the low lattice force principles. Central nervous system related side effects as consequence of the PK profile with such a high Cmax were likely to happen and therefore, the formulation principles were modified to maintain the doubled BAV and reduce the observed Cmax. Additionally, the compound showed a short half-life requiring a two times daily dose, which is suboptimal for a chronic treatment. The amorphous acid in pH-matrix showed a modified PK profile when dosed in a hydrogel but not in an oleo gel. Surprisingly, administration of the TBPH salt in pH-matrix suspended in oil showed a massive delay of the tmax to 8 hours and a reduction of Cmax by factor 2 - 3 with unchanged good BAV when administered as a suspension in oil without increased viscosity. TBPH salt solution with a high viscosity resulted in the same PK profile as when administered without increased viscosity.
The animal model was changed from rat to dog. The dose was limited to 15 mg/dog since they reacted much more sensitively to the drug. BAV at this dose level was 100% for the crystalline suspension already, thus the focus of this study was not increasing BAV but to achieve prolonged and/or delayed exposure using different formulation principles elaborated in rats before. An immediate release formulation of 3 mg was combined with a delayed/modified release principle containing 12 mg of the compound. An additional study arm was conducted with a remote controlled device programmed to deliver a first dose of 3 mg instantaneously after passing the stomach and a second dose of 12 mg when entering the caecum. The tmax remained short for all formulation principles and it seemed that delayed and modified release lead to BAV reduction. The modified PK profiles could not be translated to an oral dog model which endorsed the hypothesis of an absorption window; however, the in vitro results could be translated to a dog model for colonic absorption. A nanosuspension of the crystalline compound, the TBPH salt in pH-matrix and the TBPH salt of the pro-drug of the compound were administered rectally to determine colonic absorption. The nanosuspension showed exposure around the limit of quantification whereas the TBPH in pH-matrix showed 4% BAV and the pro-drug as TBPH salt in pH-matrix resulted in 12% BAV although the pro-drug is factor 3 less soluble. This was in line with the increased permeation of the pro-drug which was observed in the Caco2 experiments. The bioavailability was increased by using the low lattice force principles and validated the hypothesis for the acidic drug and its pro-drug in the colonic dog model. Chemical and physicochemical stability of the investigated solid dispersions was confirmed for at least 18 months at room temperature.
Amorphous solid dispersions were investigated to lower lattice forces of a neutral molecule. Solid dispersions are well known from literature; however, they are not frequently used as principles for dosage forms due to limitations in physical stability and complex manufacturing processes. A viable formulation principle was developed for a neutral compound assuming that the stability of a solid dispersion with a drug load below the maximal miscibility will be better than one which exceeds the maximal miscibility. The dispersed and amorphous state of the neutral compound resulted in a higher energy level and chemical potential compared to a crystalline form implying that they are thermodynamically instable and sensitive to recrystallization. This was confirmed by the fast recrystallization of an amorphous solid dispersion made from HPMC with 50% drug load which recrystallized within a few days. Solid dispersions with different drug loads in different polymers and in polymer mixtures were prepared by lyophilization. The miscibility of the compound and the polymer was determined by DSC as the miscibility is a surrogate for maximal stable drugload of the solid dispersion. HPMC was found to be miscible with 20% compound confirming the instability of the 50% HPMC solid dispersion observed earlier. Based on dosing needs, a miscibility/drug load of at least 30% was mandatory because of the dosing requirements to dose less than 1500 mg of final formulation. This was considered as maximal swallowable volume for later clinical development. Thus, all systems with a miscibility higher or equal to 30% drug in polymer were evaluated in an in vitro dissolution test and ranked in comparison with amorphous pure compound, crystalline compound and a 20% drug load solid dispersion made from HPMC. The HPMC based solid dispersion which gave good exposure in previous in vivo experiments did not support the high drugload that was needed. Therefore, similar in vitro behavior of this solid dispersion should result in similar in vivo performance. The polyvinylpyrrolidone (PVP) based solid dispersions scored with high drug load and medium initial kinetic solubility. The Soluplus based solid dispersion offer lower drug load and slightly lower initial kinetic solubility, but showed an extended supersaturation. The 4 best performing systems were evaluated in rats. They resulted in a short Tmax of 15 minutes and BAV higher than 85% indicating fast and complete absorption. The reference HPMC based solid dispersion with a drug load of 20% showed 65% BAV. This showed that higher drug loads were feasible and did not limit absorption in this animal model.
Since the estimated human dose required a higher formulation density than obtained from lyophilization or spray drying, melt extrusion of the solid dispersion was considered to be the most adequate technology. The process temperature needed to be below 200 °C as this value represents the degradation temperature of the polymers. It was investigated by differential scanning calorimetry whether the compound can be mixed with the molten polymer. None of the polymers could dissolve the crystalline compound below the degradation point of the polymer. The temperature had to be increased to 260 °C until the compound was molten together to a monophasic system with polymer. This resulted in degradation of the polymers. Therefore, different plasticizers and small organic molecules with similar functional groups as the compound were investigated on their ability to reduce the melting point of the mixture of polymer and compound. Positive results were obtained with several small molecules. Based on a literature review, nicotinamide had the least concerning pharmaceutical activities and was chosen for further development. Solid dispersions with the same composition as the ones tested in rat were prepared with 9% nicotinamide as softener. Extrusion without nicotinamide was not possible at 135 °C or at 170 °C whereas the addition of 9% nicotinamide led to a homogenous extrudate when processed at 135 °C. The solid state of the extrudates was not molecularly dispersed but the compound was in a crystalline state. They could not reach the in vitro performance observed for the lyophilized solid dispersions with Soluplus or PVP derivatives. Nevertheless, the performances in the supersaturation assay were comparable to the HPMC based lyophilized solid dispersion. The Soluplus and PVP based crystalline extrudates were evaluated in a dog PK showing that the crystalline solid dispersion does not enable BAV higher than 90% within 24 hours after application. In parallel, the hygroscopicity of the meltextrudates was investigated by DVS and the best performing system based on Kollidon VA64 was further optimized regarding the solid state after its extrusion. The minimal process temperature to obtain a fully amorphous solid dispersion was determined by hot stage X-ray powder diffraction analysis (XRPD) and confirmed by lab scale extrusion. Addition of 9% nicotinamide lowered the process temperature from 220 °C (without nicotinamide) to 200 °C with nicotinamide. The minimal temperature for obtaining crystal free material was independent of the nicotinamide amount as soon as it exceeded 9%. Lowering the process temperature with nicotinamide reduced the impurity levels from 3.5% at 220 °C to 1.1% at 200 °C. The fully amorphous extrudates performed now better in the in vitro supersaturation assay than the lyophilized amorphous HPMC solid dispersion and the crystalline extrudates which were extruded at 135 °C. The process was up-scaled to a pilot scale extruder with alternative screw designs increasing mechanical shear forces and mixing which enabled lower process temperatures. This resulted in a maximal process temperature of 195 °C when nicotinamide was present and 205 °C without nicotinamide. However, shorter process time and reduced process temperatures (compared to the lab scale equipment) resulted in impurity levels smaller than 0.5% for both compositions and temperatures and made the nicotinamide obsolete. The amorphous extrudates from the pilot scale extruder performed better in vitro than the crystalline extrudates from the lab scale extruder and the lyophilized HPMC solid dispersion. A comparable PK profile of the HPMC solid dispersion and the amorphous melt extruded formulation principle was anticipated from these in vitro results. This was confirmed by the pharmacokinetic profile in dogs after oral administration of the final extruded solid dispersion formulation which was equivalent with the pharmacokinetic profile of the HPMC based solid dispersion formulation. The assumption that using a drug load below the miscibility prevents the solid dispersion from recrystallization was verified at least for a limited time by a stability test at elevated temperatures for 3 months showing no change in solid state. This indicates the opportunities of the low lattice forces approach, but also showed the importance of developing principles first assuring stable solid state, performance in vitro and in vivo, tailor them in a second step based on performance and combine them with technology such as melt extrusion as third step. If these steps are done in the context of clinical needs and quality it can rationalize the development of a solid dispersion and minimalize the formulation related risks regarding biopharmacy and stability.
More and more newly registered drugs are proteins. Although many of them suffer from instabilities in aqueous media, the most common way of protein drug administration still is the injection of a solution. Numerous protein drugs require frequent administration, but suitable controlled release systems for proteins are rare. Chapter 1 presents current advances in the field of controlled delivery of particulate protein formulations. While the main focus lies on batch crystallized proteins, amorphous particulate proteins are also discussed in this work. The reason is that, on the one hand precipitated protein particles hold some of the advantages of crystalline proteins and on the other hand the physical state of the protein may simply be unknown for many drug delivery systems or semi-crystalline particles have been used. Crystallization and precipitations methods as well as controlled delivery methods with and without encapsulation in a polymeric delivery system are summarized and critically discussed.
In chapter 2 a novel way of protein crystal encapsulation by electrospinning is introduced. Electrospinning of proteins has been shown to be challenging via the use of organic solvents, frequently resulting in protein unfolding or aggregation. Encapsulation of protein crystals represents an attractive but largely unexplored alternative to established protein encapsulation techniques because of increased thermodynamic stability and improved solvent resistance of the crystalline state. We herein explore the electrospinning of protein crystal suspensions and establish basic design principles for this novel type of protein delivery system. Poly-ε-caprolactone (PCL) is an excellent polymer for electrospinning and matrix-controlled drug delivery combining optimal processability and good biocompatibility. PCL was deployed as a matrix, and lysozyme was used as a crystallizing model protein. By rational combination of lysozyme crystals with a diameter of 0.7 or 2.1 μm and a PCL fiber diameter between 1.6 and 10 μm, release within the first 24 h could be varied between approximately 10 and 100%. Lysozyme loading of PCL microfibers between 0.5 and 5% was achieved without affecting processability. While relative release was unaffected by loading percentage, the amount of lysozyme released could be tailored. PCL was blended with poly(ethylene glycol) and poly(lactic-co-glycolic acid) to further modify the release rate. Under optimized conditions, an almost constant lysozyme release over 11 weeks was achieved.
Chapter 3 takes on the findings made in chapter 2 and further modifies the properties of the nonwovens as protein crystal delivery system. Nonwoven scaffolds consisting of poly-ε-caprolactone (PCL), poly(lactic-co-glycolic acid) (PLGA) and polidocanol (PD), and loaded with lysozyme crystals were prepared by electrospinning. The composition of the matrix was varied and the effect of PD content in binary mixtures, and of PD and PLGA content in ternary mixtures regarding processability, fiber morphology, water sorption, swelling and drug release was studied. Binary PCL/PD blend nonwovens showed a PD-dependent increase in swelling of up to 30% and of lysozyme burst release of up to 45% associated with changes of the fiber morphology. Furthermore, addition of free PD to the release medium resulted in a significant increase of lysozyme burst release from pure PCL nonwovens from approximately 2% to 35%. Using ternary PCL/PD/PLGA blends, matrix degradation could be significantly improved over PCL/PD blends, resulting in a biphasic release of lysozyme with constant release over 9 weeks, followed by constant release with a reduced rate over additional 4 weeks. Based on these results, protein release from PCL scaffolds is improved by blending with PD due to improved lysozyme desorption from the polymer surface and PD-dependent matrix swelling.
Chapter 4 gives deeper insight on lysozyme batch crystallization and shows the influences of the temperature on the precipitation excipients. Yet up to now protein crystallization in a pharmaceutical useful scale displays a challenge with crystal size and purity being important but difficult to control parameters. Some of these influences are being discussed here and a detailed description of crystallization methods and the achieved crystals are demonstrated.
Therapeutic use of such protein crystals may require further modification of the protein release rate through encapsulation. Silk fibroin (SF) harvested from the cocoons of Bombyx mori is a well-established protein suitable for encapsulation of small molecules as well as proteins for controlled drug delivery. This novel polymer was deployed for as carrier for the model drug crystals. Lysozyme again was used as a crystallizable protein and the effect of process- as well as formulation parameters of batch crystallization on crystal size were investigated using statistical design of experiments. Lysozyme crystal size depended on temperature and sodium chloride and poly(ethylenglycol) concentration of precipitant solution. Under optimized conditions, lysozyme crystals in a size range of approximately 0.3 to 10 µm were obtained. Furthermore, a solid-in-oil-in-water process for encapsulation of lysozyme crystals into SF was developed. Using this process, coating of protein crystals with another protein was achieved for the first time. Encapsulation resulted in a significant reduction of dissolution rate of lysozyme crystals, leading to prolonged release over up to 24 hours.
Starting in the late 1990s ionic liquids (ILs) gained momentum both in academia as well as industry. ILs are defined as organic salts with a melting point below 100 °C. Active pharmaceutical ingredients (APIs) may be transferred into ILs by creating salts with a bulky counterion with a soft electron density. ILs have demonstrated the potential to tune important pharmaceutical features such as the solubility and the dissolution rate, particularly addressing the challenge of poor water soluble drugs (PWSD). Due to the tunability of ILs, modification of physico-chemical properties of APIs may be envisioned without any modifications of the chemical structure.
In the first chapter the potential as well as the limitation of ILs are discussed. The chapter commences with an overview of preparation and characterization of API-ILs. Moreover, examples for pharmaceutical parameters are presented which may be affected by IL formation, including the dissolution rate, kinetic solubility or hygroscopicity as well as biopharmaceutical performance and toxicology. The impact of IL formation on those pharmaceutically relevant features is highlighted, resulting in a blueprint for a novel formulation concept to overcome PWSD challenges without the need for structural changes of the API.
Within the second chapter the IL concept is detailed for one specific API - counterion combination. A poorly water soluble acidic API against migraine attacks was transformed into an IL in an effort to minimize the time to maximum plasma concentration (tmax) and optimize the overall bioavailability. These studies were conducted in parallel to a prodrug of the API for comparison of the IL strategy versus a strategy involving modification of the API’s structure. A significantly longer duration of API supersaturation and a 700 fold faster dissolution rate of the IL in comparison to the free acid were obtained and the underlying mechanism was elucidated. The transepithelial absorption was determined using Caco-2 cell layers. For the IL about 3 times more substance was transported in comparison to the prodrug when substances were applied as suspensions, despite the higher permeability of the prodrug, as increased solubility of the IL exceeded this effect. Cytotoxicity of the counterion was assessed in hepatic, renal and macrophage cell lines, respectively, and IC50 values were in the upper µM / lower mM range. The outcome of the study suggested the IL approach instrumental for tuning biopharmaceutical properties, without structural changes of the API as required for preparation of prodrugs. Thus the toolbox for formulation strategies of poorly water soluble drugs could be extended by an efficient concept.
The third chapter focuses on the effect of different counterions on the physico-chemical properties of an API-IL, in particular to overcome the challenge of poor water solubility. Therefore, the same poorly water soluble acidic API against migraine attacks mentioned above was combined with 36 counterions resulting in ILs and low lattice enthalpy salts (LLES). Depending on the counterions, different dissolution rates, durations of supersaturation and hygroscopicities were obtained and release profiles could be tailored from immediate to sustained release. Besides, in vitro the cytotoxicity of the counterions was assessed in three cell lines. Using molecular descriptors such as the number of hydrophobic atoms, the graph theoretical diameter and the number of positive charges of the counterion, the dissolution rate, supersaturation and hygroscopicity as well as the cytotoxicity of counterions could be adequately modeled, rendering it possible to predict properties of new LLESs.
Within the forth chapter different poorly water soluble APIs were combined with the counterion tetrabutylphosphonium (TBP) studying the impact on the pharmaceutical and physical properties of the APIs. TBP-ILs and low lattice enthalpy salts were prepared of the acidic APIs Diclofenac, Ibuprofen, Ketoprofen, Naproxen, Sulfadiazine, Sulfamethoxazole and Tolbutamide. NMR and IR spectroscopy, DSC, XRPD, DVS and dissolution rate measurements, release profiles and saturation concentration measurements were used to characterize the free acids and TBP salts as compared to the corresponding sodium salts. The TBP salts as compared to the free acids displayed lower melting points and glass transition temperatures and up to 1000 times higher dissolution rates. The increase in the dissolution rate directly correlated with the salts’ hygroscopicity, an aspect which is critically discussed in terms of pharmaceutical translation challenges. In summary TBP ILs of solid salts were proved instrumental to approach the challenge of poor water solubility. The outcome profiled tailor-made counterions as a powerful formulation strategy to address poor water solubility, hence bioavailability and ultimately therapeutic potential of challenging APIs.
In summary, a plethora of ILs and LLESs were prepared by combination of different acidic APIs and counterions. The IL and LLESs concept was compared to conventional salt and prodrug strategies. By choice of the counterion, biopharmaceutical relevant parameters were deliberately modified and release profiles were tuned ranging from immediate to prolonged release. The impact of distinct structural counterion features controlling the dissolution, supersaturation, hygroscopicity and counterion cytotoxicity were identified, correlations were presented and predictive models were built. ILs and LLESs could be proven to be a powerful concept for the formulation of poorly water soluble acidic APIs.
Glucocorticoide werden in der Herzschrittmachertherapie eingesetzt, um einen Anstieg der Reizschwelle nach der Implantation des Schrittmachers zu verringern und dauerhaft auf niedrigerem Niveau zu halten, als dies ohne Glucocorticoid-Behandlung der Fall wäre. Die Applikation der zu diesem Zweck eingesetzten Glucocorticoide Dexamethasonacetat (DXA) und Dexamethasonphosphat, in seltenen Fällen auch Beclomethasondipropionat (BDP), erfolgt dabei in der Regel mittels einem an der Elektrodenspitze angebrachten Matrixsystem, das für eine langsame lokale Freisetzung der Arzneistoffe an der Grenzfläche zwischen kathodischem Elektrodenkontakt und Herzgewebe sorgen soll. Diese Anwendungsform ist speziell, da trotz einer systemischen Freisetzung der Substanzen eine lokale Wirkung erzielt werden soll, welche die Funktion des Schrittmachers als Medizinprodukt unterstützen soll – aus pharmakokinetischer Sicht ein wichtiger Unterschied zu den üblichen topischen Glucocorticoid Anwendungen. Unter physiologischen Bedingungen wurde diese Applikationsform hinsichtlich der Arzneistofffreisetzung und anschließender Umverteilung mit Bindung der Glucocorticoide an das kardiale Gewebe bislang ebenso wenig untersucht, wie verschiedene Glucocorticoide in dieser Anwendung hinsichtlich ihrer Pharmakokinetik verglichen wurden. In der vorliegenden Arbeit wurden deshalb die pharmakokinetischen Vorgänge der drei Glucocorticoide DXA, BDP und des potentiell einsetzbaren Glucocorticoids GCX (dessen Identität aus patentgründen derzeit nicht offengelegt werden kann) untersucht. Die Freisetzungssysteme enthielten, je nach Glucocorticoid, Arzneistoffdosen im Bereich von etwa 150 bis 260 µg. In einem in-vitro Freisetzungsmodell in Methanol wurde zunächst bestätigt, dass sich die Freisetzungskinetik der untersuchten Matrizes gemäß den Modellvorstellung zu einem dünnwandigen monolithischen Freisetzungssystem nach dem Quadratwurzelgesetz beschreiben ließ. DXA wurde mit einer Freisetzungsrate von 55,6 ± 1,9 µg/h1/2 in 24 Stunden annähernd vollständig freigesetzt, während die Rate für BDP bei 21,8 ± 0,7 µg/h1/2 lag und nur für eine Freisetzung von etwa zwei Dritteln des Gesamtgehalts der Freisetzungsmatrix sorgte. GCX wurde gar mit nur 4,2 ± <0,1 µg/h1/2 freigesetzt. Die ermittelten Freisetzungsraten (DXA > BDP >>> GCX) waren überraschenderweise nicht konsistent mit den logP-Werten der Substanzen. Dies wies darauf hin, dass nicht alleine die unterschiedlichen physikochemischen Eigenschaften der Substanzen zu den differierenden Freisetzungsprofile führten, sondern wohl auch die Formulierung der Silikonmatrix einen starken Einfluss ausübte – eine wichtige Erkenntnis für die Weiterentwicklung derartiger Glucocorticoid haltiger Matrixfreisetzungssysteme. Vor allem während der bis zu 4 wöchigen Phase unmittelbar nach der Elektrodenimplantation ist die Matrix dem Blutstrom ausgesetzt, bevor sich als Reaktion des Organismus auf den implantierten Fremdkörper eine fibröse Hülle um die Elektrodenspitze bildet. Zur Annäherung an die physiologischen Freisetzungsverhältnisse in dieser initialen Phase, in nach dem Quadratwurzelgesetz die mengenmäßig stärkste Glucocorticoid-Freisetzung erfolgen sollte, wurden deshalb erstmals Freisetzungsversuche in Humanplasma über 28 Tage durchgeführt. Mit einer Freisetzungsrate von 2,26 ± 0,08 µg/h1/2 wurde hier eine unerwartet starke Freisetzung von BDP beobachtet, wohingegen diese für DXA und GCX mit Raten von 0,39 ± 0,03 µg/h1/2 und 0,42 ± 0,01 µg/h1/2 deutlich langsamer ausfiel und sich kaum voneinander unterschied. Die Reihenfolge der Freisetzungsgeschwindigkeiten (BDP >>> GCX = DXA) unterschied sich somit unter physiologischen Bedingungen gänzlich von den in-vitro Bedingungen. Womöglich kamen im wässrigen Freisetzungsmedium Humanplasma dabei die Formulierungseinflüsse verstärkt zum Tragen, die sich bereits unter den in-vitro Bedingungen andeutenden. Ein zusätzlicher Einfluss mochte von der Bildung des 9,11 Epoxy Belcomethasons als Abbauprodukt des BDP ausgegangen sein, welches unter den physiologisch angenäherten Bedingungen in hohem Ausmaß entstand. Dies führte zu einer Stabilitätsuntersuchung von Beclomethason in Humanplasma und verschiedenen Puffersystemen, bei welcher sich ein stabilitätsmindernder Einfluss von Carbonat-Puffersystemen herausstellte. Im Zuge der Freisetzungsversuche in Humanplasma wurde zudem erstmals die Entstehung von 17 Oxo Dexamethason als Abbauprodukt von DXA beobachtet und durch Nachsynthese bestätigt. Für die Phase der Herzschrittmachertherapie, in der an der Grenzfläche zwischen Elektrode und Herzgewebe eine lokale und akute Entzündung infolge der Implantation der Schrittmacherelektrode auftritt und üblicherweise ein starker Anstieg der Reizschwelle zu beobachten ist, lieferten die Versuche in Humanplasma somit erstmals Daten zur Freisetzung verschiedener Glucocorticoide unter Einbezug angenäherter physiologischer Verhältnisse. Für die korrekte Durchführung der Freisetzungsversuche ist das Vorliegen von Sink Bedingungen essentiell. Da die praktische Löslichkeit von Glucocorticoiden in Humanplasma bislang nicht bekannt war, wurde die Aufnahmekapazität des Humanplasmas (Kombination aus Löslichkeit und Plasmaproteinbindung) für DXA, GCX und BDP untersucht. Sink Bedingungen konnten für alle Substanzen sichergestellt werden, wobei gegenüber der reinen Wasserlöslichkeit eine deutlich höhere Aufnahmekapazität gezeigt werden konnte und den hohen Einfluss der Proteinbindung hervorhob. Um die insgesamt herrschenden physiologischen Verhältnisse noch besser zu beschreiben und dabei die Umverteilung der Arzneistoffe nach Freisetzung aus dem Implantat an das Zielgewebe zu untersuchen, wurde ein neuartiges ex-vivo Modell entwickelt. Dies erlaubte eine Simulation der Arzneistofffreisetzung aus dem Implantat in Gegenwart eines Gewebekompartiments und berücksichtigte eine flussartige Konvektion des Mediums. Mit diesem Modell wurden Verhältnisse der AUCs der Glucocorticoide zwischen Gewebe und Humanplasma ermittelt, die mit Werten von 3,4 für DXA, 3,8 für BDP und 2,5 für GCX auf eine ausgeprägte Umverteilung aus dem Humanplasma in das Gewebe hinwiesen. Insgesamt schien damit aufgrund der raschen Freisetzung und Diffusion in das Gewebe eine Verwendung von BDP zur Bekämpfung einer lokalen akuten Entzündung unmittelbar nach der Implantation aus pharmakokinetischer Sicht vorteilhaft. Mit Blick auf einen jahrelangen Effekt konnte jedoch auch die langsame Freisetzung von DXA und GCX mit deren sehr stabilen Wirkformen als vorteilhaft diskutiert werden. Die Versuche können letztlich bei der Auswahl eines möglichst idealen Glucocorticoids für die Herzschrittmachertherapie behilflich sein und bieten erstmals ein weitestgehend physiologisches Untersuchungsmodell für diese Applikationsform. Inwiefern sich die unterschiedliche Pharmakokinetik der drei Glucocorticoide auch in pharmakodynamischer Sicht auswirken könnte, sollte schließlich im Zellkulturmodell untersucht werden. Zuvor wurde jedoch in-vitro getestet, ob sich der elektrische Schrittmacherimpuls selbst als Entzündungsreiz bemerkbar machen und damit einen Hinweis auf eine dadurch hervorgerufene dauerhafte Entzündung des Herzgewebes geben würde. Dazu wurde eigens ein Modell entworfen, das die Applikation des elektrischen Stimulus in einem Zellkulturansatz zuließ. Die Messung der Entzündungsmarker IL-6, IL-8, MMP-9 und MCP-1 ließ keine entzündliche Reizung der Zellen durch einen Schrittmacherimpuls in Höhe von 1 V und 0,5 ms Dauer erkennen. Anschließend wurde untersucht, ob sich die selbst ermittelten pharmakokinetischen Unterschiede der drei Glucocorticoide in der akuten Entzündungsphase nach Elektrodenimplantation in-vitro in unterscheidbaren biologischen Aktivitäten auswirken würden. Signifikante Unterschiede in der Inhibition der Sekretion der Entzündungsmarker IL-6 und MMP 9 konnten allerdings trotz der unterschiedlichen freigesetzten Dosen an DXA, GCX und BDP nicht beobachtet werden. Somit erwies sich keine der drei Substanzen, trotz unterschiedlicher pharmakokinetischer Voraussetzungen und Affinitäten zum Glucocorticoid-Rezeptor, als überlegen. In einem ersten Ausblick ließ dies für die klinische Anwendung von GCX und BDP – zumindest in der initialen Phase nach Elektrodenimplantation – einen zu DXA vergleichbaren Einfluss auf die Reizschwelle vermuten. Neben einer antiinflammatorischen Wirkung wird auch eine Minderung des Reizschwellenanstieges durch eine bei Glucocorticoid Exposition nur dünn ausgeprägte fibröse Kapsel an der Elektrodenspitze diskutiert. Als Beitrag zur Untersuchung der in der klinischen Praxis beobachteten Wirkung des DXA wurde daher abschließend geprüft, ob die freigesetzten Glucocorticoid Dosen zu einer Proliferationshemmung von Endothelzellen und Fibroblasten führen konnten. Ein vermindertes Wachstum der Zelllinien EA.hy926 und IMR-90 unter den freigesetzten Glucocorticoid Dosen konnte jedoch nicht beobachtet werden. Künftige Untersuchungen des Einflusses der Glucocorticoide auf die Synthese einzelner Bindegewebsbestandteile wie Kollagen könnten hierzu womöglich weitere Erkenntnisse liefern. In der vorliegenden Arbeit wurde erstmals erfolgreich die Pharmakokinetik dreier Glucocorticoide im Kontext der Herzschrittmachertherapie unter physiologischen Verhältnissen beschrieben und ein neuartiges ex-vivo Modell entwickelt, das zukünftig ein hilfreiches Werkzeug zur Untersuchung der Pharmakokinetik von kardiovaskulären Implantaten sein kann. Darauf aufbauend wurde zudem erstmalig die Pharmakodynamik dieser Glucocorticoide in der Herzschrittmachertherapie verglichen und begonnen, den Glucocorticoid Effekt in der Herzschrittmachertherapie näher zu beleuchten.