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`
` EXHIBIT 1021
`
`

`
`millions worldwide and substantially altering productivity and quality of life (1,2), therapies for KCS
`&&%,l+l&+#%+,,'#%'&#$#'&%/.+('&3&'$#%+i#&'$-&-j k'2#.&,-5 
`have been palliative at best. Recent advances in understanding the pathophysiology of disease allow
`2#3%.#&#'&3#',') (%'#+3#%(,&%%+,'#%+&%/'2.#'2.2$,&/$-+&,#,#l
`the development of effective therapies for the first time.
`'2+3.%'---('&3'2#.&,-'2-&,''&)
`The ocular surface, lacrimal glands, and interconnecting nerves form a homeostatic functional
`2(#,-#(#(&#/#%+,#%+&%'(%%('&%/%3,-#2,'#'&(-%('&%#
`unit that maintains normal tear production. Chronic dry eye disease results from a T cell-mediated in­
`%&''2#'#&%'#&%,%#'#.+('&%) 2%&(+$$+&,#,,',-#(0+&#'+&%0
`flammatory process leading to a disruption of this nerve traffic. Multiple factors, including an age-
`-##'$.(,,#+&%/'#+&,.'&%-'2&,%3'#--&()

'&.-#(',&%(+&%/#%#/0
`related drop in systemic androgen levels and chronic ocular surface irritation, create an environment
`#'++.&%,$,'&(#%+/%3,#%+(2%&((#,-#(&&'#'&%(#'#%%3&%%'
`in which activated T cells are recruited to the ocular surface and lacrimal glands in a vicious cycle
`&%l2&(2#('&3#'+(,#(&'+''2(#,-#(#%+#(&#/#%+,&%#3&(&,($(
`of inflammation that ultimately results in destruction of the lacrimal glands (3). Cyclosporin A (CsA)
`-&%-##'&%'2#''&#'$,',&%+,'('&%-'2#(&#/#%+,j4k) $(,.&%j ,k
`topical ophthalmic emulsion targets the inflammatory basis of disease by acting as a local im-
`'.&(#.2'2#&(,&%'#/','2&%-##'$#,&,-+&,#,$#('&%/#,#(#&0
`munomodulator and anti-inflammatory agent. By inhibiting activation of infiltrating T cells on the
`%+#'#%+#%'&0&%-##'$#/%')*$&%2&&'&%/#('&3#'&%-&%-&'#'&%/(,%'2
`ocular surface and lacrimal glands, production of inflammatory cytokines is prevented (4). CsA treat­
`(#,-#(#%+#(&#/#%+,.+('&%-&%-##'$($'m&%,&,.3%'+j6k) ,'#'0
`ment has been shown to decrease several molecular markers of immune-based inflammation in con­
`%'2#,%,2l%'+(#,,3#(##m,-&%0#,+&%-##'&%&%(%0
`junctival biopsies of dry eye patients (5-7).
`u%('&3#&.,&,-+$$.#'&%',jx8k)
`Phase 2 and Phase 3 clinical trials have established both the safety and efficacy of topical CsA
`
`2#, #%+
`2#,4(&%&(#'&#,2#3,'#&,2+'2'2,#-'$#%+--&(#($-'.&(# ,
`at concentrations ranging from 0.05% to 0.4% (8, 9). CsA is currently approved for systemic treat­
`#'(%(%'#'&%,#%/&%/-!)!o'!)6ojsk) ,&,(%'$#..3+-,$,'&('#'0
`ment of immune-related disorders at much higher doses than those given for KCS. Oral administra­
`%'-&%0#'++&,+,#'(22&/2+,,'2#%'2,/&3%-5 ) ##+&%&,'#0
`tion for treatment of psoriasis or rheumatoid arthritis produces blood CsA concentrations in the range
`'&%-'#'%'-.,&#,&,2#'&+#'2&'&,.+(,+ ,(%(%'#'&%,&%'2#%/
`of 75 ng/mL (Cmin) to 655 ng/mL (Cmax) (10). Because it is a potent immunosuppressant when used
`-8%/qj &%k'7%/qj #tkj!k)*(#,&'&,#.'%'&%,..,,#%'l2%,+
`at these high doses, it is important to assess systemic exposure to CsA upon administration of the
`#''2,2&/2+,,&'&,&.'#%''#,,,,,$,'&(t.,' ,.%#+&%&,'#'&%-'2
`very low doses needed for treatment of KCS.
`3$l+,,%++-'#'%'-5 )
`Topical ophthalmic treatment with CsA requires 2600-fold lower dosage than does systemic us­
`.&(#.2'2#&('#'%'l&'2 ,i&, 7!!0-+l+,#/'2#%+,,$,'&(,0
`age (10). A preliminary study of topical ophthalmic CsA conducted during Phase 2 development found
`#/j!k).&&%#$,'+$-'.&(#.2'2#&( ,(%+('++&%/
`2#, +3.%'-%+
`that topical instillation produced negligible blood CsA concentrations, although sampling was sparse
`'2#''.&(#&%,'&#'&%.+(+%/&/&+ ,(%(%'#'&%,#'2/2,#.&%/l#,,.#,
`(8). The present study examines blood CsA concentrations of KCS patients participating in a much
`jk)2.,%','+$t#&%,+ ,(%(%'#'&%,-5 .#'&%',.#'&(&.#'&%/&%#(2
`larger Phase 3 study of CsA topical ophthalmic emulsions. We show conclusively that CsA is prac­
`#/
`2#,4,'+$- ,'.&(#.2'2#&(,&%,)1,2l(%(,&3$'2#' ,&,.#(0
`tically undetectable in the blood of patients treated with these ophthalmic preparations.
`'&(#$%+'('#&%'2+-.#'&%','#'+l&'2'2,.2'2#&(..##'&%,)
`
`PATIENTS AND METHODS
`
`

 
`
`Clinical Trial Overview
`
` &%&(#&# 33&l
`Therapeutic blood monitoring was done at selected sites on a subset of patients enrolled in a
`2#.'&(+%&'&%/l#,+%#',('+,&',%#,,'-.#'&%',%+&%#
`Phase 3, multicenter, double-masked, randomized, parallel group study of cyclosporin A topical oph­
`
`2#,4'&(%'+0#,m+#%+&n+.##/.,'+$-($(,.&%'.&(#.20
`thalmic emulsions for the treatment of dry eye disease (9). Eligible study participants had moderate
`'2#&(,&%,-'2'#'%'-+$$+&,#,jsk)&/&,'+$.#'&(&.#%',2#++#'
`to severe dry eye disease as defined by 1) Schirmer test of > 5 mm/5 min (without anesthesia) in at
`',3+$$+&,#,#,+-&%+$k(2&','-yq&%jl&'2'#%,'2,&#k&%#'
`least one eye; 2) sum of corneal and interpalpebral conjunctival staining of > +5 in the same eye in
`#,'%$p k,-(%##%+&%'.#.#(%u%('&3#,'#&%&%/-yz&%'2,#$&%
`which corneal staining was ^ +2; 3) indication of moderate to severe dry eye disease by the Ocular
`l2&(2(%#,'#&%&%/l#,yz p4k&%+&(#'&%-+#'',3+$$+&,#,$'2 (#
`Surface Disease Index (11) and Subjective Facial Expression Scale. Patients were excluded if they
`-#(&,#,%+tjk#%+u('&3#(&#t.,,&%(#)
`#'&%',lt(++&-'2$
`had end-stage lacrimal disease, punctal plugs, were using medications that could interfere with the
`2#+%+0,'#/#(&#+&,#,.%('#./,l,&%/+&(#'&%,'2#'(+&%'-l&'2'2
`study results, wore contact lenses during the study, or were pregnant or lactating. The study was con­
`,'+$,',l(%'#('%,,+&%/'2,'+$l./%#%'#('#'&%/)2,'+$l#,(%0
`ducted from July 1997 to January 1999 and was in compliance with Good Clinical Practices, inves­
`+('+-$ss8'#%#$sss#%+l#,&%(.&#%(l&'2 + &%&(#
`#('&(,&%3,0
`tigational site Institutional Review Board Regulations, Sponsor and Investigator Obligations, Informed
`'&/#'&%#,&'%,'&''&%# 3&l*#+ /#'&%,.%,#%+%3,'&/#' &/#'&%,%-+
`Consent Regulations, and the Declaration of Helsinki.
` %,%' /#'&%,#%+'2(##'&%-,&%m&)
`After a 2-week run-in period with Refresh® artificial tears (Allergan, Inc., Irvine, CA), patients
`-'# 0lm%0&%.&+l&'2 -,2{ #'&-&(&#'#,j/#%%()3&% k.#'&%',
`were randomly assigned 0.05% CsA topical ophthalmic emulsion eyedrop b.i.d., 0.1% CsA b.i.d., or
`l#%+$#,,&/%+!)!o ,'.&(#.2'2#&(,&%$+.)&)+)!)o ,)&)+)
`vehicle for 6 months. The vehicle consisted of a sterile, non-preserved castor oil-in-water emulsion
`32&(-7%'2,)232&((%,&,'+-#,'&%%0.,3+(#,'&0&%0l#',&%
`that was identical to the 0.1% CsA preparation except for the presence of medication. Patients in­
`'2#'l#,&+%'&(#''2!)o ,..##'&%t(.'-'2.,%(-+&(#'&%)
`#'&%',&%0
`stilled one drop in each eye every morning and evening, no later than 8:00 p.m. the night before clin­
`,'&+%+.&%#(2$3$%&%/#%+3%&%/%#''2#%|!!.))'2%&/2'-(&%0
`ical visits. They could use Refresh® as needed through month 4, but no more than 8 times daily af-
`&(#3&,&',)2$(+, -,2{ #,%++'2/2%'26'%'2#%'&,+#&$#-0
`412
`vw}
`
`

`
`ter that. At month 6, patients receiving vehicle were reassigned to 0.1% CsA b.i.d. for a further 6
`''2#')'%'27.#'&%',(&3&%/32&(l#,,&/%+'!)o ,)&)+)-#-'27
`months. Those initially placed in the 0.05% and 0.1% CsA treatment groups continued their assigned
`%'2,)2,&%&'&#$.#(+&%'2!)!o#%+!)o ,'#'%'/.,(%'&%+'2&#,,&/%+
`treatments. Table 1 lists sample numbers collected at each clinical visit.
`'#'%',)#&,',,#.%,(('+#'#(2(&%&(#3&,&')
`Total daily doses of CsA were 0.057 mg/day (0.05% CsA treatment group) and 0.114 mg/day
`'#+#&$+,,- ,l!)!8/q+#$j!)!o ,'#'%'/.k#%+!)6/q+#$
`(0.1% CsA group).
`j!)o ,/.k)
`
`Blood Sampling
`*+#.&%/
`Trough blood samples were collected immediately before the morning dose at day 0 and months
`/2+,#.,l(('+&+&#'$-'2%&%/+,#'+#$!#%+%'2,
`1 and 6. A final sample was collected at a single visit that occurred between months 9 and 12 (called
`#%+7)-&%#,#.l#,(('+#'#,&%/3&,&''2#'((+'l%%'2,s#%+ j(#+
`the "month 9-12 visit"). In order to quantify peak CsA concentrations, 26 patients also provided se­
`'2~%'2sx 3&,&'k)%+'i#%'&-$.#m ,(%(%'#'&%, 7.#'&%',#,.3&++,0
`rial blood samples at 1, 2, 3, 4, 6, 8, 10, and 12 hours after the morning dose during the month 9 -
`&#+,#.,#' 467!#%+ 2,#-''2%&%/+,+&%/'2%'2s0
`12 visit. All blood samples were frozen until shipment to Allergan, Inc. (Irvine, CA) for analysis.
` 3&,&')+,#.,l-n%%'&,2&.%''/#%%()j3&% k-#%#$,&,)
`
`Blood Bioanalysis
`*+*&#%#$,&,
`A validated HPLC/tandem mass spectroscopy assay was used to quantify blood concentrations
`3#&+#'+
` q'#%+#,,,.(',(.$#,,#$l#,,+'i#%'&-$+(%(%'#'&%,
`of cyclosporin A. Briefly, 1 mL of blood was acidified with 0.2 mL of 0.1 N HC1, then extracted with
`-($(,.&%)*&-$-+l#,#(&+&-&+l&'2!) -!) '2%t'#('+l&'2
`5 mL methyl-i-butyl ether. The organic phase was neutralized by addition of 2 mL 0.1 N NaOH, evap­
`
`'2$0L0'$'2)2/#%&(.2#,l#,%'#&n+$#++&'&%- !)# 3#.0
`orated, reconstituted in a water/acetonitrile-based mobile phase, and injected onto a 2.1 X 50 mm, 3
`#'+(%,'&''+&%#l#'q#('%&'&0#,+&.2#,#%+&%u('+%'# )€!4
`/um pore size C-8 reverse phase HPLC column (Keystone Scientific, Bellefonte, PA). Compounds
`.,&n 03,.2#,
` (%j5$,'%(&%'&-&(*-%'
`k) .%+,
`were gradient-eluted at 0.2 mL/min and detected using an API III triple quadrupole mass spectrom­
`l/#+&%'0'+#'!) q&%#%++'('+,&%/#%
`'&.i#+.#,,,.('0
`eter with a turbo-ionspray source (PE-Sciex, Concord, Ontario, Canada). Molecular reaction moni­
`'l&'2#'0&%,.#$,(j
`0(&t %(+ %'#& #%#+#k)

(##('&%%&0
`toring enhanced the sensitivity and selectivity of this assay. Protonated molecules for the analyte and
`'&%/%2#%(+'2,%,&'&3&'$#%+,('&3&'$-'2&,#,,#$)
`'%#'+(,-'2#%#$'#%+
`internal standard were collisionally dissociated and product ions at m/z 425 were monitored for the
`&%'%#,'#%+#+l(&,&%#$+&,,(&#'+#%+.+('&%,#'qn6 l%&'+-'2
`analyte and internal standard. Under these conditions, cyclosporin A and the internal standard cy­
`#%#$'#%+&%'%#,'#%+#+)%+'2,(%+&'&%,($(,.&%#%+'2&%'%#,'#%+#+($0
`closporin G eluted with retention times of —3.8 minutes. The lower limit of quantitation was 0.1
`(,.&% '+l&'2'%'&%'&,-‚4)&%',)2l&&'-i#%'&'#'&%l#,!)
`ng/mL, at which concentration the coefficient of variation and deviation from nominal concentration
`%/q#'l2&(2(%(%'#'&%'2(--&(&%'-3#&#'&%#%++3&#'&%-%&%#(%(%'#'&%
`was <15%.
`l#,ƒo)
`For serial post-dose blood samples, the area under the blood concentration-time curve (AUCQ.^)
`,&#.,'0+,+,#.,'2##%+'2+(%(%'#'&%0'&(3j !0 k
`was calculated using the linear trapezoidal rule (12). Since most concentrations were below the limit
`l#,(#(#'+,&%/'2&%#'#.n&+#j k)&%(,'(%(%'#'&%,ll'2&&'
`
`Table 1. Numbers of Trough Blood Samples Collected for CsA Quantitation
`…†‡ˆ‰Šw‹ ,-/2*+#., ('+- ,Œ#%'&'#'&%
`Treatment
`Samples Per Treatment Group Per Visit
`=<?LT<@L
`_?TU;<KBJ<=B=<?LT<@LBŽ=N[UBJ<=B\GKGL
`Group
`Ž=N[U
`
`All Visits
`:;;B\GKGLK
`112
`
`139
`4s
`171
`8
`422
`6
`
`Month 9—12
`aN@LYB‘’9I
`0b
`!
`26
` 7
`58c
`
`84
`6
`
`(
`
`Vehicle
`2&(
`0.05% CsA
`!)!o ,
`0.1% CsA
`!)o ,
`All treatment
`'#'%'
`groups:
`/.,|
`aSamples were collected from 128 patients. Two patients from the vehicle group and 2 from the 0.1% CsA
`##.,l(('+- .#'&%',)l.#'&%',-'232&(/.#%+ -'2!)o ,
`group each gave 2 samples. Baseline was not collected for 1 patient.
`/.#(2/#3 ,#.,)*#,&%l#,%'(('+-.#'&%')
`bPatients assigned to vehicle were reassigned to 0.1% CsA at month 6.
`
`
`#'&%',#,,&/%+'32&(l#,,&/%+'!)o ,#'%'27)
`Clncludes patients who had crossed over from the vehicle group at month 6.
`(%(+,.#'&%',l22#+(,,+3-'232&(/.#'%'27)
`413
`vw„
`
`Day 0
`?RB
`(Prestudy)
`“J=<KL[SR”
`45
`6
`43
`64
`43
`64
`131a
`4#
`
`Month 1
`aN@LYB9
`37
`48
`40
`6!
`36
`47
`113
`4
`
`Month 6
`aN@LYBc
`30
`4!
`30
`4!
`34
`46
`94
`s6
`
`

`
`of quantitation, an upper limit to AUCQ.^ was calculated by assuming a concentration equal to the
`-i#%'&'#'&%#%..&&'' !0 l#,(#(#'+$#,,&%/#(%(%'#'&%i#''2
`limit of quantitation at each sampling time, then expressing the mean AUCQ.^ as below this theo­
`&&'-i#%'&'#'&%#'#(2,#.&%/'&'2%t.,,&%/'2#% !0 #,l'2&,'20
`retical upper limit of 1.2 ng*hr/mL. No statistical calculations were performed on serial postdose or
`'&(#..&&'-) %/•2q),'#'&,'&(#(#(#'&%,l.-+%,&#.,'+,
`trough blood concentrations because most data were below the limit of quantitation.
`'/2+(%(%'#'&%,(#,,'+#'#ll'2&&'-i#%'&'#'&%)
`
`RESULTS
` 
`
`Study Participants
`'+$
`#'&(&.#%',
`Blood was collected from a subpopulation of 128 patients out of 405 enrolled in a Phase 3 trial
`*+l#,(('+-#,..#'&%- .#'&%','-6!%+&%#
`2#,4'&#
`of cyclosporin A for the treatment of dry eye disease, yielding a total of 422 trough blood samples
`-($(,.&%-'2'#'%'-+$$+&,#,$&+&%/#''#-6 '/2+,#.,
`over the study period (Table 1). Patients ranged from 24 to 88 years of age (n = 128), and 78%
`3'2,'+$.&+j#k)
`#'&%',#%/+- 6'$#,-#/j%r k#%+8o
`(100/128) were women (9). Baseline characteristics of the subpopulation were similar to those of the
`j!!q kll%jsk)*#,&%(2##('&,'&(,-'2,..#'&%l,&&#''2,-'2
`larger study population. The rate of completion of the subpopulation (68%, 87/128) was slightly lower
`#/,'+$..#'&%)2#'-(.'&%-'2,..#'&%j7o8q kl#,,&/2'$l
`than the study population (77%, 671/877), but the reasons for discontinuation were similar in both
`'2#%'2,'+$..#'&%j88o78q88k''2#,%,-+&,(%'&%#'&%l,&&#&%'2
`populations and were primarily non-treatment-related.
`..#'&%,#%+l.&#&$%%0'#'%'0#'+)
`
`Trough Blood CsA Concentrations
`/2*+ , %(%'#'&%,
`Of 96 samples from the 0.05% CsA treatment group, none contained any quantifiable CsA. Mean
` -s7,#.,-'2!)!o ,'#'%'/.%%(%'#&%+#%$i#%'&-&# ,)

#%
`trough blood CsA concentrations were below the limit of quantitation in both treatment groups at all
`'/2+ ,(%(%'#'&%,ll'2&&'-i#%'&'#'&%&%'2'#'%'/.,#'#
`time points, including month 9-12 (Table 2). The only study samples above the limit of quantitation
`'&.&%',&%(+&%/%'2s0 j# k)2%$,'+$,#.,#3'2&&'-i#%'&'#'&%
`were 7 samples from the 0.1% CsA treatment group, representing only 5.5% (7/128) of the samples
`l8,#.,-'2!)o ,'#'%'/..,%'&%/%$)oj8q k-'2,#.,
`collected from this group. Quantifiable blood CsA concentrations ranged from 0.104 ng/mL to 0.299
`(('+-'2&,/.)Œ#%'&-&#+ ,(%(%'#'&%,#%/+-!)!6%/q'!) ss
`ng/mL and came from 7 different patients who had no obvious commonalities with respect to age,
`%/q#%+(#-8+&--%'.#'&%',l22#+%3&,(%#&'&,l&'2,.(''#/
`sex, or time point at which CsA was detected (Table 3). No individual patient had quantifiable CsA
`,t'&.&%'#'l2&(2 ,l#,+'('+j#4k)&%+&3&+#.#'&%'2#+i#%'&-&# ,
`at more than one time point.
`#''2#%%'&.&%')
`
`Serial Blood CsA Concentrations During One Dosing Interval
`&#*+ , %(%'#'&%,&%/ %,&%/%'3#
`Serial post-dose blood samples (n = 208 samples) were collected from 26 patients during the 12
`&#.,'0+,+,#.,j%r !,#.,kl(('+- 7.#'&%',+&%/'2
`hours following the morning dose. As was the case with trough blood measurements, no patient in
`2,-l&%/'2%&%/+,),l#,'2(#,l&'2'/2+#,%',%.#'&%'&%
`the 0.05% CsA treatment group had any quantifiable CsA. Overall, 99% of samples (205/208) did
`'2!)!o ,'#'%'/.2#+#%$i#%'&-&# ,) 3#sso-,#.,j !q !k+&+
`not contain quantifiable CsA. The 3 samples that were above the limit of quantitation came from 3
`%'(%'#&%i#%'&-&# ,)24,#.,'2#'l#3'2&&'-i#%'&'#'&%(#-4
`
`Table 2. Mean Trough Blood CsA Levels
`…†‡ˆ‰Š}‹

#%/2*+ ,3,
`Treatment Group
`=<?LT<@LBŽ=N[U
`
`Blood CsA Concentration (ng/ml)
`–;NNSBHK:BHN@D<@L=?LGN@B“@>—T;”
`Month 1
`Month 6
`Day 0
`aN@LYB9
`aN@LYBc
`?RB
`(Prestudy)
`“J=<KL[SR”
`Vehicle
`<0.1
`<0.1
`<0.1
`ƒ!)
`ƒ!)
`ƒ!)
`2&(
`0.05% CsA
`<0.1
`<0.1
`<0.1
`ƒ!)
`ƒ!)
`ƒ!)
`!)!o ,
`0.1% CsA
`<0.1
`<0.1
`<0.1
`ƒ!)
`ƒ!)
`ƒ!)
`!)o ,
`'Includes samples from patients in the vehicle group who crossed over to the 0.1% CsA group.
`#%(+,,#.,-.#'&%',&%'232&(/.l2(,,+3''2!)o ,/.)
`NA = Not applicable.
`r '#..&(#)
`
`Month 9—12
`aN@LYB‘’9I
`NA
`
`<0.1
`ƒ!)#
`<0.1a
`ƒ!)#
`
`414
`vwv
`
`

`
`Table 3. Quantifiable Trough CsA Concentrations in Individual Patients
`…†‡ˆ‰Š„‹ Œ#%'&-&#/2 , %(%'#'&%,&%%+&3&+#
`#'&%',
`Age, Sex
`Treatment
`Blood CsA Concentration (ng/mL)
`:><AB_<™
`=<?LT<@L
`–;NNSBHK:BHN@D<@L=?LGN@B“@>—TQ”
`Group
`Ž=N[U
`
`Day 0
`?RB
`(Prestudy )
`“J=<KL[SR”
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`
`Month 1
`aN@LYB9
`0.134
`!)46
`0.110
`!)!
`0.143
`!)64
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`
`56, M
`7

`56, F
`7
`64, F
`76
`86, F
`7
`81, F
`
`52, F
`
` 
`76, M
`87

`
`0.1% CsA
`!)o ,
`0.1% CsA
`!)o ,
`0.1% CsA
`!)o ,
`0.1% CsA
`!)o ,
`0.1% CsA
`!)o ,
`0.1% CsA
`!)o ,
`vehicle—> 0.1%
`32&(š !)o
`CsA
`
` ,
`BLQ = Below limit of quantitation.
`*Œr *l&&'-i#%'&'#'&%)
`NS = No sample collected.
`r ,#.(('+)
`
`Month 6
`aN@LYBc
`BLQ
`*Œ
`NS
`
`BLQ
`*Œ
`0.299
`!) ss
`0.144
`!)66
`0.125
`!) 
`BLQ
`*Œ
`
`Month 9—12
`aN@LYB‘’9I
`BLQ
`*Œ
`NS
`
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`BLQ
`*Œ
`0.104
`!)!6
`
`different patients in the 0.1% treatment group. One of these patients had received 0.1% CsA for 9-
`+&--%'.#'&%',&%'2!)o'#'%'/.) %-'2,.#'&%',2#+(&3+!)o ,-s0
`12 months, while the other 2 had received vehicle for 6 months before being reassigned to the 0.1%
` %'2,l2&'2'2 2#+(&3+32&(-7%'2,-&%/#,,&/%+''2!)o
`CsA treatment group 3 to 6 months prior to the sampling period. CsA was barely detectable in these
`
` ,'#'%'/.4'7%'2,.&''2,#.&%/.&+) ,l#,#$+'('#&%'2,
`3 samples, with Cmax ranging from 0.102 ng/mL to 0.105 ng/mL. These values occurred early in the
`4,#.,l&'2 #t#%/&%/-!)! %/q'!)!%/q)2,3#,((+#$&%'2
`12-hour time course, with tmax ranging from 1 to 3 hours (Table 4). Mean Cmax was not calculable
` 02'&(,l&'2'#t#%/&%/-'42,j#6k)

#% #tl#,%'(#(#
`because most samples were below the limit of quantitation. Based on these results, the AUC0-12 was
`
`(#,,',#.,ll'2&&'-i#%'&'#'&%)*#,+%'2,,','2 !0 l#,
`less than 1.2 ng*hr/mL in both treatment groups.
`,,'2#%) %/•2q&%'2'#'%'/.,)
`
`DISCUSSION
`  
`Systemic exposure to CsA during treatment with CsA ophthalmic emulsions is barely detectable,
`$,'&(t.,' ,+&%/'#'%'l&'2 ,.2'2#&(,&%,&,#$+'('#
`even with an extremely sensitive assay capable of measuring blood CsA concentrations as low as 0.1
`3%l&'2#%t'$,%,&'&3#,,#$(#.#-#,&%/+ ,(%(%'#'&%,#,l#,!)
`ng/mL. A striking result of this study is that no patient receiving 0.05% CsA had quantifiable CsA
`%/q),'&m&%/,'-'2&,,'+$&,'2#'%.#'&%'(&3&%/!)!o ,2#+i#%'&-&# ,
`in the blood at any time during the yearlong study. Phase 2 and Phase 3 clinical trials have demon­
`&%'2+#'#%$'&+&%/'2$#%/,'+$)
`2#, #%+
`2#,4(&%&(#'&#,2#3+%0
`strated this formulation of CsA to be clinically effective for the treatment of dry eye disease.
`,'#'+'2&,-#'&%- ,'(&%&(#$--('&3-'2'#'%'-+$$+&,#,)
`For those very few patients who did have quantifiable blood CsA in the present study, concen­
`'2,3$-l.#'&%',l2+&+2#3i#%'&-&#+ ,&%'2.,%','+$(%(%0
`trations were no more than 2-fold higher than the limit of quantitation. No patient had quantifiable
`'#'&%,l%'2#% 0-+2&/2'2#%'2&&'-i#%'&'#'&%).#'&%'2#+i#%'&-&#
`blood CsA at more than one time point, for either trough or serial postdose sampling, even for pa­
`
`+ ,#''2#%%'&.&%'-&'2'/2,&#.,'+,,#.&%/3%-.#0
`tients treated up to 1 year, demonstrating that long-term use of topical ophthalmic CsA emulsions
`'&%','#'+.'$#+%,'#'&%/'2#'%/0',-'.&(#.2'2#&( ,,&%,
`produces insignificant systemic exposure. This is consistent with animal pharmacokinetic studies that
`.+(,&%,&/%&-&(#%',$,'&(t.,)2&,&,(%,&,'%'l&'2#%&#.2##(m&%'&(,'+&,'2#'
`have demonstrated ready penetration of topical CsA into ocular surface tissues but minimal absorp­
`2#3+%,'#'+#+$.%'#'&%-'.&(# ,&%'(#,-#('&,,,'&%&##,.0
`tion into the blood (13).
`'&%&%''2+j4k)
`
`Table 4. Quantifiable Serial Postdose Blood CsA Concentrations in Individual Patients
`…†‡ˆ‰Šv‹ Œ#%'&-&#&#
`,'+,*+ , %(%'#'&%,&%%+&3&+#
`#'&%',
`Age, Sex
`Treatment Group
`Blood Cmax (ng/mL)
`:><AB_<™
`=<?LT<@LBŽ=N[U
`–;NNSBHT?™“@>—TQ”
`0.1% CsA
`0.104
`59, F
`s
`!)o ,
`!)!6
`64, F
`Vehicle
`0.1% CsA
`0.102
`2&(š !)o ,
`76
`!)!
`Vehicle
`0.1% CsA
`50, M
`0.105
`2&(š !)o ,
`!

`!)!
`
`tmax (hr)
`LT?™“Y=”
`2
`
`1
`
`3
`4
`
`415
`vw˜
`
`

`
`Trough blood CsA concentrations measured in this study should be assessed within the context
`/2+ ,(%(%'#'&%,#,+&%'2&,,'+$,2+#,,,,+l&'2&%'2(%'t'
`of concentrations produced by approved treatments whose safety has been demonstrated. The ap­
`-(%(%'#'&%,.+(+$#..3+'#'%',l2,,#-'$2#,%+%,'#'+)2#.0
`proved oral treatment producing the lowest systemic exposure is the use of oral NEORAL® Soft
`.3+#'#'%'.+(&%/'2l,',$,'&(t.,&,'2,-# { -'
`Gelatin Capsules for treatment of rheumatoid arthritis and psoriasis (10). Table 5 compares blood
`
` #'&% #.,,-'#'%'-2#'&+#'2&'&,#%+.,&#,&,j!k)#(.#,+
`concentrations produced by topical treatment with CsA emulsions to those produced by systemic treat­
`(%(%'#'&%,.+(+$'.&(#'#'%'l&'2 ,,&%,''2,.+(+$,$,'&('#'0
`ment with NEORAL® Soft Gelatin Capsules (10). On a weight-normalized basis assuming a typical
`%'l&'2 { -' #'&% #.,,j!k) %#l&/2'0%#&n+#,&,#,,&%/#'$.&(#
`60 kg patient, the recommended starting dose of NEORAL® is 150 mg/60 kg/day taken as a divided
`7!m/.#'&%''2(%++,'#'&%/+,- { &,!/q7!m/q+#$'#m%#,#+&3&++
`dose of 75 mg/60 kg/day. This produces trough blood CsA concentrations (mean ± S.D.) of 74.9 ±
`+,-8/q7!m/q+#$)2&,.+(,'/2+ ,(%(%'#'&%,j#%› ))k-86)s›
`46.7 ng/mL and 96.4 ± 37.7 ng/mL, as reported in 2 studies summarized in the approved label for
`67)8%/q#%+s7)6›48)8%/q#,.'+&% ,'+&,,#&n+&%'2#..3+#-
`NEORAL® treatment of rheumatoid arthritis and psoriasis (10).
` { '#'%'-2#'&+#'2&'&,#%+.,&#,&,j!k)
`In contrast to oral therapy, the cyclosporine dose instilled during topical treatment with 0.05%
`%(%'#,''#'2#.$'2($(,.&%+,&%,'&++&%/'.&(#'#'%'l&'2!)!o
`and 0.1% cyclosporine ophthalmic emulsions is 0.057 mg/day and 0.114 mg/day, respectively (Table
`#%+!)o($(,.&%.2'2#&(,&%,&,!)!8/q+#$#%+!)6/q+#$,.('&3$j#
`5). Assuming again a typical 60 kg patient, these doses are 0.00095 mg/kg/day and 0.0190 mg/kg/day.
`
`k),,&%/#/#&%#'$.&(#7!m/.#'&%''2,+,,#!)!!!s/qm/q+#$#%+!)!s!/qm/q+#$)
`These are 2,630 and 1,320 times lower, respectively, than the recommended starting dose of
`2,# 74!#%+4 !'&,l,.('&3$'2#%'2(%++,'#'&%/+,-
`NEORAL®. Mean trough blood concentrations produced by topical ophthalmic use of CsA emulsions
` {)

#%'/2+(%(%'#'&%,.+(+$'.&(#.2'2#&(,- ,,&%,
`are less than 0.1 ng/mL, which is at least 750 times lower than mean trough levels seen with systemic
`#,,'2#%!)%/ql2&(2&,#'#,'8!'&,l'2#%#%'/23,,%l&'2,$,'&(
`therapeutic use. In addition, peak CsA concentrations are over 6500 times lower, and the area under
`'2#.'&(,)%#++&'&%.#m ,(%(%'#'&%,#37!!'&,l#%+'2##%+
`the blood concentration-time curve is over 1900-fold lower with topical CsA treatment than with sys­
`'2+(%(%'#'&%0'&(3&,3s!!0-+ll&'2'.&(# ,'#'%''2#%l&'2,$,0
`temic treatment (Table 5). Thus, systemic exposure produced by topical ophthalmic CsA is several
`'&('#'%'j#k)2,,$,'&(t.,.+(+$'.&(#.2'2#&( ,&,,3#
`orders of magnitude lower than that produced by currently approved therapies that are themselves
`+,-#/%&'+l'2#%'2#'.+(+$(%'$#..3+'2#.&,'2#'#'2,3,
`considered safe for non-life-threatening conditions.
`(%,&++,#--%%0&-0'2#'%&%/(%+&'&%,)
`Our finding that topically-administered CsA is not quantifiable in the blood of patients using
` -&%+&%/'2#''.&(#$0#+&%&,'+ ,&,%'i#%'&-&#&%'2+-.#'&%',,&%/
`0.05% ophthalmic CsA, and is barely detectable in patients using 0.1% CsA, is consistent with the
`!)!o.2'2#&( ,#%+&,#$+'('#&%.#'&%',,&%/!)o ,&,(%,&,'%'l&'2'2
`excellent systemic safety profile of these formulations. In a 12-week Phase 2 study of 0.05% to 0.4%
`t(%',$,'&(,#-'$.-&-'2,-#'&%,)%# 0lm
`2#, ,'+$-!)!o'!)6o
`CsA ophthalmic emulsions, there were no occurrences of ocular infections or overgrowths of micro­
`
` ,.2'2#&(,&%,'2l%((%(,-(#&%-('&%,3/l'2,-&(0
`bial organisms, nor were there any clinically significant changes in visual acuity or measures of liver
`
`&#/#%&,,%l'2#%$(&%&(#$,&/%&-&(#%'(2#%/,&%3&,##(&'$#,,-&3
`and renal function (8). In 2 much larger vehicle-controlled Phase 3 studies of 0.05% and 0.1% CsA
`#%+%#-%('&%jk)% (2#/32&(0(%'+
`2#,4,'+&,-!)!o#%+!)o ,
`ophthalmic emulsions, only 2 of 877 patients developed ocular infections and those were in the ve­
`.2'2#&(,&%,%$ -88.#'&%',+3.+(#&%-('&%,#%+'2,l&%'230
`hicle group (9).
`2&(/.jsk)
`The results of the current study, considered in concert with blood concentrations measured in
`2,',-'2(%','+$(%,&++&%(%('l&'2+(%(%'#'&%,#,+&%
`the Phase 2 study (8) and during NEORAL® treatment (10), indicate that systemic exposure to cy­
`'2
`2#, ,'+$jk#%++&%/ { '#'%'j!k&%+&(#''2#',$,'