AQUESTIVE EXHIBIT 1128 Page 0001
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`D-05-00582.fm Page 1311 Tuesday, September 12, 2006 3:13 PM
`
`JPP 2006, 58: 1311–1318
`© 2006 The Authors
`Received December 21, 2005
`Accepted June 19, 2006
`DOI 10.1211/jpp.58.10.0003
`ISSN 0022-3573
`
`Pain and Palliation Research
`Group, Department of
`Circulation and Medical Imaging,
`Norwegian University of Science
`and Technology, 7489
`Trondheim, Norway
`
`Ola Dale, Turid Nilsen,
`Pål Klepstad, Stein Kaasa
`
`Department of Anaesthesia and
`Acute Medicine and Palliative
`Medicine Unit, Department of
`Oncology, St. Olavs University
`Hospital, Trondheim, Norway
`
`Ola Dale, Pål Klepstad, Stein Kaasa
`
`Department of Pharmacy,
`University of Oslo, Blindern, Norway
`
`Hanne Hjorth Tønnesen
`
`Department of Pharmacy,
`University of Iceland,
`Reykjavik, Iceland
`
`Thorstein Loftsson
`
`Gaustadalleen 21, 0349
`Norway
`
`Trond Holand, Per G, Djupesland
`
`Correspondence: O. Dale, Pain
`and Palliation Research Group,
`Department of Circulation and
`Medical Imaging, Norwegian
`University of Science and
`Technology, 7489 Trondheim,
`Norway. E-mail: ola.dale@ntnu.no
`
`Funding: This work was partially
`supported by a grant from
`Innovation, Norway.
`
`Conflicts of interest: PGD and
`TH are founders and
`shareholders of OptiNose AS, a
`commercial company holding
`the rights to the patent
`describing the bi-directional
`nasal delivery concept. TL has a
`patent related to the nasal
`midazolam formulation used,
`but this is now in the possession
`of DeCode Genetics, Iceland, to
`whom TL now has no relation.
`OD, responsible for the project,
`has received economic support,
`from a grant from Innovation,
`Norway through Optinose A/S, to
`cover research related net
`expenses. TN, PK HTT and SK
`have no conflicts of interest.
`
`Intranasal midazolam: a comparison of two delivery
`devices in human volunteers
`
`Ola Dale, Turid Nilsen, Thorsteinn Loftsson, Hanne Hjorth Tønnesen,
`Pål Klepstad, Stein Kaasa, Trond Holand and Per G. Djupesland
`
`Abstract
`
`Bidirectional nasal drug delivery is a new administration principle with improved deposition pattern
`that may increase nasal drug uptake. Twelve healthy subjects were included in this open, non-rand-
`omized 3-way crossover study: midazolam (3.4 mg) intravenously (1 mg mL−1), or nasally by bidirec-
`tional or traditional spray (2 × 100 mL of a 17 mg mL−1 nasal midazolam formulation). The primary
`outcome was bioavailability. Blood samples were drawn for 6 h for determination (gas-chromatog-
`raphy–mass-spectrometry) of midazolam and 1-OH-midazolam. Pharmacokinetic calculations were
`based on non-compartmental modelling, sedation assessed by a subjective 0–10 NRS-scale, and nasal
`dimensions by non-invasive acoustic rhinometry. Mean bioavailabilities were 0.68–0.71, and Tmax
`15 min for the sprays, which also were bioequivalent (ratio geometric means (90%) CI: 97.6% (90%
`CI 83.5; 113.9)). Sedation after bidirectional spray followed intravenous sedation closely, while seda-
`tion after the traditional spray was less pronounced. A negative correlation between Cmax and
`smallest cross-sectional area was seen. Adverse effects such as local irritation did not differ signifi-
`cantly between the sprays. Apparently bidirectional delivery did not increase systemic bioavailability
`of midazolam. We cannot disregard that only the traditional spray caused less sedation than intra-
`venous administration. This finding needs to be confirmed in trials designed for this purpose.
`
`Introduction
`
`In recent years a growing interest in alternative forms of drug administration has emerged.
`Nasal administration, with transmucosal absorption, may offer advantages such as ease of
`administration, rapid onset and patient control. It bypasses gastrointestinal and hepatic pre-
`systemic elimination, and is applicable in nauseated and vomiting patients who may have
`problems taking oral medication. Also, the rapid onset of action should make nasal adminis-
`tration of opioids an interesting tool for the management of breakthrough pain in cancer
`patients (Dale et al 2002).
`Several techniques and devices for intranasal drug administration have been
`developed; however, the use of manually actuated spray pumps dominate. The Norwegian
`company OptiNose has patented a new concept for nasal delivery of drugs and vaccines
`based on bi-directional airflow between the two nasal passages connected in series
`(Djupesland etal 2004). The device has both a mouth and a nosepiece connected to the patient.
`When the patient exhales through the nosepiece, the soft palate closes to establish the bi-
`directional airflow entering one nostril and exiting through the other. The dose is released
`from a spray pump pre-charged by a spring and actuated by the airflow through the
`device. Gamma-scintigraphy deposition studies shown significantly improved deposition
`pattern of bi-directional administration compared with traditional nasal spray (Djupesland
`et al 2006), which possibly may improve drug bioavailability or clinical effects.
`Recent experiences in human subjects with a midazolam formulation designed for nasal
`use displayed maximum serum concentrations at 15 min, and a bioavailability of 64%. A
`sedative effect was recorded within 5–10 min and maximal effect about 10 min later. It fol-
`lows that this may serve as a model drug in volunteers, not least since a clinically relevant
`outcome, sedation, may be determined in volunteers (Gudmundsdottir et al 2001; Loftsson
`et al 2001).
`
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`Ola Dale et al
`
`In the above study the majority of the subjects reported
`mild to moderate irritation within the nasal cavity passages
`or the throat (Gudmundsdottiret al 2001; Loftsson et al
`2001)). Subjective symptoms, such as irritation and discom-
`fort, are frequently associated with congestion of the nasal
`mucosa, thus changes in the nasal airway dimensions may
`be an objective correlate to subjective reporting. Acoustic
`rhinometry (AR) is a reliable and sensitive method for fast,
`non-invasive assessment of changes in the nasal airway
`dimensions of clinical significance in small groups of indi-
`viduals (Djupesland 1999; Hilberg 2002; Djupesland et al
`2001). Previous studies suggest a correlation between
`nasal dimensions and nasal deposition/filtering efficiency
`(Kesavanathan & Swift 1998; Djupesland et al 2004). Nasal
`airway dimensions may also correlate with bioavailability
`and other outcome measures.
`The primary objective of this study was to compare phar-
`macokinetics and pharmacodynamics of a standard nasal
`spray pump (Traditional) with the new nasal delivery device
`(OptiMist) from OptiNose in human subjects, and with intra-
`venous (IV) administration. The anticipation was that the
`OptiMist may increase bioavailability and result in more pro-
`found sedation.
`
`Materials and Methods
`
`Ethical and regulatory aspects
`
`This study was conducted according to the principles of the
`Helsinki declaration and approved by the Regional Commit-
`tee for Medical Research Ethics, Central Norway. Written,
`informed consent was obtained from subjects before inclu-
`sion. The study was also approved by the Norwegian Medi-
`cines Agency, The Norwegian Data Directorate/Norwegian
`Social Science Data Service and the Ministry of Health.
`
`Inclusion and exclusion criteria
`
`Male and female, 18- to 45-year-old, healthy subjects were
`eligible. Subjects with a history of liver disease, taking any
`medications metabolized by or affecting CYP3A, having any
`local nasal disease, any history of drug allergies or a history
`of drug abuse or professional access to drugs of abuse were
`excluded from the study. Pregnant women were also
`excluded. Before inclusion the following pre-study clinical
`chemical tests were evaluated: haemoglobin, creatinine,
`ALAT, albumin.
`
`Design
`
`Subjects received 3.4 mg midazolam intravenously (IV) or
`nasally (one actuation delivered 100 mL (mean particle size of
`43 mm) in each nostril) by a standard (Traditional) multi-dose
`spray pump (Ing. Erich Pfeiffer, Radolfsee, GmHb) or the
`OptiNose device (OptiMist, containing an identical Pfeiffer
`spray pump), in an open, non-randomized three-way cross-
`over study (Djupesland et al 2006). The study was open as
`blinding with a double-dummy technique would have
`changed the absorption conditions by doubling spray volume.
`
`Each study session consisted of a 6-h stay in the research
`facilities. The sessions were separated by at least one week.
`For practical reasons to reduce travelling (PGD, TH), the
`sequence of sessions was not randomized. Sedation level and
`local symptoms (nose and pharynx) were recorded systemati-
`cally, and subjects were requested to report all adverse
`events. Since PGD or TH were always present for acoustic
`rhinometry and delivery of the Optimist spray, observer
`blinding was not possible.
`Subjects also received a post-trial questionnaire to report
`aspects of sedation; was there a difference between treatments?
`If so, which gave the deepest sedation? Was there a difference
`between the nasal sessions? In that case, which gave the deep-
`est sedation? How significant was this difference?
`
`Drug doses and administration
`Commercial midazolam HCl (Alpharma, 1 mg mL−1 (free
`base) 3.4 mg was administered at the intravenous sessions,
`while a nasal midazolam formulation was employed for the
`two nasal session (Gudmundsdottir et al 2001; Loftsson et al
`2001). The 3.4-mg midazolam (free base; Sifa, Shannon,
`Ireland) doses given were within the range previously pub-
`lished for similar studies with midazolam (Gudmundsdottir
`et al 2001), and were censored by the volume one can admin-
`ister nasally, and by the midazolam concentration in this for-
`mulation. It was expected that this dose would induce
`sedation in a majority of subjects, with a minimal risk for
`over-sedation.
`The nasal formulation (midazolam free base 17 mg mL−1)
`was produced by our Hospital Pharmacy as described previ-
`ously (Loftsson et al 2001). Briefly, the nasal formulation was
`an aqueous solution containing midazolam base (1.7% w/v),
`sulfobutylether-b-cyclodextrin sodium salt with molar substi-
`tution of 6.2 (Captisol, 14% w/v), which was donated by
`CyDex Inc. (Kansas City, KS), hydroxypropyl methylcellu-
`lose (0.1% w/v), benzalkonium chloride (0.02% w/v), ethyl-
`enediaminetetraacetic acid (0.1% w/v) and phosphoric acid
`(0.73% w/v). The formulation was adjusted to pH 4.20–4.35
`with sodium hydroxide. The purity and content of midazolam
`was determined by the Department of Clinical Pharmacology
`at St Olavs University Hospital, Trondheim, Norway.
`
`Procedures
`
`Subjects were asked not to take alcohol, grapefruit, grapefruit
`juice, caffeine or medications for 12 h before, and during,
`each study period (6 days). Subjects were asked to abstain
`from food and liquids after midnight the day before study
`days. A washout period of at least one week was employed
`for each subject. Two subjects were studied on each study
`day over a period of 5 weeks. Before administration of mida-
`zolam, one or two (two for the intravenous sessions) periph-
`eral intravenous catheters were inserted in a hand or arm vein
`for drug administration and blood sampling. Subjects were
`monitored for 2 h (blood pressure, ECG, respiratory rate and
`oxygen saturation). Oxygen was administered if oxygen satu-
`ration decreased below 94. Venous blood samples (9 mL)
`were drawn just before and at 2, 5, 10, 15, 20, 25, 30, 35, 45,
`60, 90, 120, 240 and 360 min after drug administration.
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`Nasal midazolam: different device — different outcome
`
`1313
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`Subjects were fed a standard breakfast 2 h after midazolam
`administration, and had free access to food thereafter.
`
`Assessments
`
`Subjective sedation was scored by a numeric rating scale
`(NRS) 0–10 where 0 is awake and 10 is falling asleep (or as
`tired as you can imagine) at 0, 2, 5, 10, 15, 20, 25, 30, 35, 45,
`60, 90, 120 and 360 min. Sedation was also rated by the
`Observers Assessment Sedation/Scale (OAS/S)(Chernik et al
`1990) ranging from 9 (deep sedation) to 20 (no sedation).
`Subjective nasal discomfort, discharge, bad taste and
`throat discomfort were recorded by a verbal rating scale (0–3
`where: 0 = none, 1 = mild, 2 = moderate, 3 = severe) at 0, 2, 5,
`10, 15, 20, 25, 30, 120 and 360 min. Subjects were instructed
`about the procedures for the subjective ratings before the start
`of each study day. Subjects were asked by study personnel
`who recorded their ratings.
`Nasal cavity dimensions were measured by acoustic rhi-
`nometry (Rhin2100; RhinoMetrics AS, Lynge, Denmark) in
`the seated position, using a handheld sound wave tube and an
`anatomic nasal adapter. The mean of three independent meas-
`urements with a CV% < 5% were used for calculations
`(Hilberg 2002). Nasal volumes (VOL) and cross-sectional
`areas (CSA) were calculated as the sum of both nasal cavities,
`to minimize bias due to the nasal cycle. The smallest total
`CSA and total volumes of 0–5cm, 0–7 cm and 2–5 cm from
`the nostril were determined. Measurements were performed
`before administration of the nasal midazolam, after the last
`blood sample and 15 min after nasal administration of a stand-
`ard dose of a topical decongestant (xymetazoline, Otrivin).
`The degree of mucosal swelling was estimated from the
`decongestive effect (Taverner et al 1999).
`
`Drug analysis and pharmacokinetics
`
`The plasma concentration of midazolam and 1-hydroxymida-
`zolam were determined according to Martens & Banditt
`(1997). Plasma spiked with diazepam and temazepam as
`internal standard (IS) was alkalinized and extracted by toluene
`containing 0.1% amyl alcohol. The organic phase was evapo-
`rated and the residue was derivatised with TBDMSTFA (tert-
`butyldimethylsilyl)-N-methyltrifluoroacetamide with 1%
`tert-butyldimethylsilyllchloride) at 60°C. After the excess of
`TBDMSTFA was evaporated, the residue was dissolved in
`ethyl acetate and analysed on a gas chromatograph (Hewlett
`Packard HP 5890) with a mass-spectrometry detector
`(Hewlett Packard HP 5972). Midazolam and diazepam (IS)
`were quantified by the mass ions 310 and 256, respectively,
`and 1-hydroxymidazolam and temazepam (IS) were quantified
`by the mass ions 398 and 357, respectively. The same proce-
`dure was applied to samples of unknown concentration, calibra-
`tors (CALs) and quality controls (QCs). The standard curves
`were linear in the range 0.25–250ngmL−1 for both midazolam
`(r2 = 0.9994, CV = 0.07% and
`and 1-hydroxymidazolam
`r2 = 0.9987, CV = 0.11%, respectively (n=13)). The limit of
`quantification (LOQ) for both midazolam and 1-hydroxymida-
`zolam was 0.25 ng mL−1. The precision (CV) for LOQ was
`11.0% and 9.8% and the inaccuracy was 7.3% and −7.2% for
`midazolam and 1-hydroxymidazolam, respectively (n = 12).
`
`Quality controls for both midazolam and 1-hydroxymida-
`zolam were prepared at 0.75, 25.0, 50.0 and 200 ng mL−1. As
`assessed by QC samples, the overall inter-assay precision
`(CV) was 8.4% for midazolam and 9.7% for 1-hydroxymida-
`zolam, and the overall inaccuracy was −1.3% for both mida-
`zolam and 1-hydroxymidazolam.
`Plasma concentration data was analysed by noncompart-
`mental techniques. Midazolam clearance, volume of distribu-
`tion, elimination rate, Cmax (maximum serum concentration),
`Tmax (time maximum serum concentration) and area under
`the curve AUC (linear trapezoidal rule) were calculated by
`computerized curve fitting using the Win-Nonlin Standard
`4.1 (Pharsight Corporation, USA). Systemic clearance
`(Cl) = dose/AUCiv, apparent nasal clearances (Cln) = dose/
`AUCn, and the respective bioavailabilities (Fx) = (AUCx/
`dosey)/(AUCy/dosex) were determined. Bioequivalence was
`described as the ratios (%) of the geometric means of the
`AUC last test administration (OptiMist)/reference administra-
`tion (Traditional) with its 90% confidence interval. The
`power was also calculated.
`
`Outcome measures
`
`The primary objective of this study was to compare bio-
`availability of a Traditional nasal spray pump with Opti-
`Mist in human subjects. The anticipation was that
`OptiMist increased bioavailability. Secondary aims were
`comparison of time to maximum concentrations and the
`maximum concentration levels and finally comparison of
`onset times by means of sedation. Additional objectives
`were to compare the subjective evaluation of irritation and
`discomfort and potential corresponding objective changes
`in nasal airway dimensions as determined by acoustic
`rhinometry.
`
`Statistics
`
`Sample size was not calculated for this explorative pilot
`study. Data are given as median (range). Friedmans test was
`used for multiple, related comparisons. Wilcoxon signed
`ranks test was used for group comparisons. No corrections
`were made for multiple comparisons. Bivariate correlation
`(Pearson) was used to determine associations between varia-
`bles. A linear mixed model, allowing correlation between
`repeated observations, was employed with the median seda-
`tion as the outcome variable. This model assumes that each
`individual patient possesses a random intercept (i.e. an indi-
`vidual offset), in addition to being affected by the different
`treatments. Model parameters were estimated by the method
`of restricted maximum likelihood (REML) using the linear
`mixed models. The SPSS 12 for Windows was used for the
`statistical calculations.
`
`Results
`
`Fourteen subjects met for screening, one was excluded (sub-
`ject 11) due to allergy, one was a potential substitute. Twelve
`healthy male (n = 4; age 21–24 years, height 179–192 cm,
`weight 71–80 kg) and female subjects (n = 8; age 20–25 years,
`
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`D-05-00582.fm Page 1314 Tuesday, September 12, 2006 3:13 PM
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`0.68 (0.55) and 0.71 (0.59) for OptiMist and Traditional spray
`(median (range)), respectively. The ratio (Optimist/Tradi-
`tional) between the geometric means of AUClast was 97.6%
`(90% CI 83.5; 113.9) with a power of 0.77.
`Figure 2 shows the time course of the formation of mida-
`zolam metabolite 1-OH midazolam. Somewhat lower serum
`concentrations were seen for the nasal administrations than
`for the intravenous over the first 90 min. The nasal sessions
`displayed similar pharmacokinetic characteristics (Table 2).
`However, Tmax was shorter after IV. The AUC ratios for the
`nasal administrations differed significantly (P = 0.017: IV vs
`Optimist (P = 0.023); IV versus Traditional (P = 0.012)).
`Subjective reporting of median sedation scores is dis-
`played in Figure 3. IV showed the most rapid onset and offset
`of sedation, OptiMist did not differ significantly from the IV
`curve, while sedation for the Traditional spray was slower
`and less pronounced than after IV (P = 0.033, linear mixed
`model comparing medians). The objective sedation score
`(OAS/S) did not show any differences between the groups, as
`very few observations with sedation scores below 17 were
`observed. The subjects evaluated (n = 12) the treatments with
`respect to sedation after the study was completed as follows:
`eleven of the subjects reported differences in sedation; one
`person rated them to be equal. Eight subjects reported the
`strongest sedation with the IV, two with OptiMist, while none
`rated Traditional spray to cause the strongest sedation. One
`person rated IV and OptiMist to be equal. Nine subjects
`reported difference between OptiMist and Traditional, eight
`of these expressed that OptiMist gave the strongest sedation.
`Four reported that the difference was minor, while five
`reported a moderate difference between the nasal sessions.
`No subject reported that the difference was significant.
`Two subjects reported short periods with nausea that
`recovered spontaneously without any intervention. One
`person (subject 4) apparently showed signs of experienc-
`ing hallucinations at 2 h for a brief period when she was
`waking up. During this episode she displayed tachycardia
`(heart rate about 120 beats/min). Midazolam was adminis-
`tered by the OptiMist device at this session. The subject
`was kept in-house for an extra 2-h period. The subject
`explained that she had slept little the night before the study
`as she had been travelling by bus from her home during the
`preceding night.
`Table 3 displays the reporting of nasal and pharyngeal
`discomfort. Individual subjects (n = 12) reported moderate
`or strong nasal discomfort (n = 3), discharge (n = 0), conges-
`tion (n = 0) or throat discomfort (n = 9) at any time after
`
`1314
`
`Ola Dale et al
`
`height 165–182 cm, weight 52–68 kg) completed the study.
`There were no clinically relevant changes apparent in clinical
`laboratory parameters or vital signs. One case report form
`(subject 13) disappeared and data on sedation, adverse effect
`and safety were lost, although demographic data, acoustic
`rhinometry, post-study postal survey and blood samples for
`pharmacokinetics were available. Traditional spray was given
`at the first session for two subjects and at the third session for
`10 subjects. Intravenous treatment was given to 4 subjects at
`the first session, six subjects at the second session and to two
`subjects at the third session. The corresponding numbers for
`bidirectional spray (Optimist) were 6, 6 and 0, respectively.
`Figure 1 shows the time course (360 min) of serum con-
`centrations of midazolam after the three administrations of
`3.4 mg. The curves of the two nasal administrations did not
`differ; however, intravenous midazolam always displayed
`higher, although parallel, time–concentrations curves. The
`curves did not seem to be log-linear, indicating that a true
`elimination phase was not reached within 6 h.
`Table 1 shows the pharmacokinetic characteristics of
`midazolam for the three administrations. As can be seen, the
`two nasal administrations displayed similar pharmacokinet-
`ics, including rapid mean Tmax of 15 min. IV had a shorter
`Tmax, and a significantly larger area under the curve. The
`absolute bioavailabilities for the nasal administrations were
`
`Intravenous
`OptiMist
`Traditional
`
`0
`
`100
`
`200
`Time (min)
`
`300
`
`400
`
`1000
`
`100
`
`10
`
`1
`
`Midazolam concn (ng mL–1)
`
`Figure 1 The time course (0–6 h) of serum concentrations of mida-
`zolam (mean ± s.d.) in 12 healthy subjects after intravenous and two nasal
`administrations (OptiMist and Traditional spray) of 3.4 mg midazolam
`(three-way crossover design). Pharmacokinetic calculations are shown in
`Table 1.
`
`Table 1 Pharmacokinetic variables after intravenous (IV), OptiMist and Traditional nasal administration of midazolam (3.4 mg) in 12 human
`subjects studied in a crossover fashion
`Cmax (ng mL−1)
`
`Vza (obs) (mL)
`
`Cla (obs)
`(mL min−1)
`
`Route
`
`Tmax (min)
`
`t½ (min)
`
`AUClast
`(min ng mL−1)
`
`AUCinf
`(min ng mL−1)
`
`IV
`OptiMist
`Traditional
`
`2 (3)*
`15 (15)
`15 (15)
`
`125 (484)
`41 (52)
`51 (78)
`
`109 (88)
`108 (114)
`103 (92)
`
`7022 (7589)
`4632 (3736)
`4660 (2012)
`
`7559 (9225)
`5507 (4615)
`5489 (2273)
`
`64206 (58066)
`111551 (160243)
`92758 (162824)
`
`450 (426)
`590 (1166)
`605 (883)
`
`Data are expressed as median (range). aCalculations for OptiMist and Traditional are not corrected for F (bioavailability). *P = 0.000, Friedman test,
`Wilcoxon signed rank test 0.02.
`
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`Intrvenous
`OptiMist
`Traditional
`
`100
`
`10
`
`1
`
`0,1
`
`0,01
`
`0,001
`
`1-OH-Midazolam concn (ng mL–1)
`
`0
`
`100
`
`200
`Time (min)
`
`300
`
`400
`
`Figure 2 The time course (0–6 h) of serum concentrations of 1-OH-
`midazolam (mean ± s.d.) in 12 healthy subjects after intravenous and two
`nasal administrations (OptiMist and Traditional spray) of 3.4 mg mida-
`zolam (three-way crossover design). Pharmacokinetic calculations are
`shown in Table 1.
`
`OptiMist. Subjects reported moderate or strong nasal dis-
`comfort (n = 5), discharge (n = 2), congestion (n = 0) or
`throat discomfort (n = 5) at any time after Traditional spray.
`With few exceptions, moderate and strong symptoms
`appeared within 2 min and resolved after 5 min.
`Acoustic rhinometry data are displayed in Table 4. There
`was no significant difference between the rhinometric meas-
`urements at the start of the two nasal sessions. The sums of
`the volumes (S 0–7) were reduced by approximately 25%
`(P < 0.005) of recumbence (Cole & Haight 1984) as described
`previously (Taverner et al 1999). Nasal mucosa decongestion
`with Otrivin significantly increased all volumes. Volumes
`returned to pre-study levels after 8 h.
`Correlation analysis, adjusting for difference in volume 0–7
`and minimum cross-sectional area (MCA) between OptiMist
`and Traditional spray showed no significant difference between
`the treatments with respect to AUC and Cmax. Except for the
`correlation between the sum of the cross-sectional areas
`(SMCA) and maximum serum concentrations (Cmax), no
`other correlations between acoustic rhinometry data measured
`before start and pharmacokinetic variables were found. For
`Traditional spray there was a significant correlation between
`Cmax and SMCA (−0.61, P = 0.036), while the corresponding
`calculations for OptiMist showed a trend (−0.6, P = 0.068).
`
`Nasal midazolam: different device — different outcome
`
`1315
`
`By pooling the data for both sessions the correlation was the
`same (−0.61), but statistically much stronger (P = 0.003) than
`for the separate observations.
`
`Discussion
`
`Some other studies have recently examined the pharmacology
`of nasal formulations of midazolam. Knoester et al (2002)
`found a bioavailability of 0.83 after 5 mg midazolam, which
`was higher than the 0.64 reported by Gudmundsdottir et al
`(2001) and Loftsson et al (2001) and that of about 0.7 found
`in our study. This is probably due to the fact that Knoester
`et al studied a different formulation. However, all studies
`report Tmax of about 15 min. By and large, our study con-
`firmed the pharmacokinetic observations made previously
`with the same nasal formulation (Gudmundsdottir et al 2001;
`Loftsson et al 2001).
`The formation of the major midazolam metabolite 1-OH
`midazolam also displayed a striking similarity between Opti-
`Mist and Traditional spray. Knoester et al (2002) reported a
`relationship between AUCs for the metabolite and midazolam
`of about 0.12–0.13, but no difference in metabolite formation
`for intravenous and nasal administration. The ratios AUClast
`(1-OH midazolam)/AUClast (midazolam) in our study were
`statistically lower for the intravenous administration (0.11)
`than for the two nasal administrations (0.13–0.14), indicating
`some signs of presystemic elimination of midazolam. Since
`the tmax for the metabolite after the nasal administrations was
`significantly longer than that of intravenous administration,
`one may assume that oral absorption has taken place. This
`may explain the lower bioavailability than reported by
`Knoester et al (2002).
`The hypothesis that OptiMist, compared with a traditional
`spray pump device, would increase bioavailability and Cmax
`together with a decreased Tmax was not confirmed. On the
`contrary, the administrations met the criteria for bioequiva-
`lence. The basis for this assumption was previous observa-
`tions that OptiMist gave more extensive nasal distribution
`than Traditional spray, as measured by scintigraphy after
`nasal administration of 99mTc aerosols (Djupesland et al
`2006). Although venous sampling is commonly used in
`pharmacokinetic studies, venous samples may display much
`lower concentrations than those of arterial blood in the early
`distribution phase (Chiou 1989a, b). For diazepam, a fat solu-
`ble drug, the initial arterio-venous difference in man after
`
`Table 2 Pharmacokinetic variables for 1-OH-midazolam after IV, OptiMist and Traditional nasal administration of midazolam (3.4 mg) in
`12 human subjects studied in a crossover design
`Cmax (ng mL−1)
`
`Route
`
`Tmax (min)
`
`t½ (h)
`
`AUClast
`(min ng/ml)
`
`Ratio AUClast
`(1-OH Midaz/Midazolam)
`
`IV
`OptiMist
`Traditional
`
`28 (45)#
`90 (110)
`60 (66)
`
`5 (11)
`3 (5)
`4 (3)
`
`120 (129)
`115 (113)
`112 (49)
`
`822 (1159)
`627 (719)
`628 (644)
`
`0.11 (0.7)*
`0.13 (0.17)
`0.14 (0.13)
`
`Data are expressed as median (range). *P = 0.017 (Friedman test). IV vs OptiMist 0.023, IV vs Traditional 0.012 (Wilcoxon signed rank test);
`#P = 0.006 (Friedman test), IV versus OptiMist: 0.01, IV versus Traditional 0.006, (Wilcoxon signed rank test).
`
`

`

`AQUESTIVE EXHIBIT 1128 Page 0006
`
`D-05-00582.fm Page 1316 Tuesday, September 12, 2006 3:13 PM
`
`1316
`
`Ola Dale et al
`
`Although preliminary, an interesting observation in this
`study was that the depth of subjectively reported sedation
`after OptiMist did not differ from that of the intravenous
`formulation, while Traditional produced less sedation than
`IV. We acknowledge that the limitations of this study, such
`as lack of randomization of treatment sequence done for
`practical reasons, and lack of opportunity to blind subjects
`and observers, may reduce the validity of these observa-
`tions. Nevertheless, we believe that this finding deserves
`some attention as we can speculate that it may indicate dif-
`ferences in nasal distribution and absorption patterns
`between the two devices. After bi-directional delivery with
`OptiMist more drug is likely to be delivered beyond the
`nasal valve to the upper nasal segments, including the olfac-
`tory region (Djupesland et al 2006). It has been shown that
`administration of midazolam with nasal atomizer in dogs
`produced significantly higher CSF (cerebral spinal fluid)
`concentrations compared with a drop approach, despite sim-
`ilar cephalic vein pharmacokinetics (Henry et al 1998). If
`midazolam is deposited in this area after OptiMist, it may
`diffuse along olfactory nerves penetrating the cribriform
`plate and thus gain direct access to the CSF. Although the
`clinical relevance of this mechanism in man is still contro-
`versial, such direct transport has been shown for a number
`of substances in man (Born et al 2002; Illum 2004), particu-
`larly those that are water-soluble.
`If midazolam is deposited higher and deeper in the nasal
`cavity after OptiMist, we may also speculate over other pos-
`sible mechanisms for a more rapid uptake to the brain.
`Veins in these parts of the nasal cavity drain mainly via the
`ophthalmic, ethmoidal and sphenopalatine veins to the sinus
`cavernous. The sinus cavernous communicates with a
`number of other intracerebral venous sinuses and plexi of
`veins including a plexus on the internal carotid artery tra-
`versing the sinus cavernous. All of these communications
`are valveless and therefore the direction of flow is reversi-
`ble. A substance absorbed from the nasal cavity to these
`
`Intravenous
`OptiMist
`Traditional
`
`02468
`
`NRS
`
`0
`
`100
`
`200
`Time (min)
`
`300
`
`400
`
`Figure 3 The time course (0–6 h) of subjectively rated sedation (NRS
`0–10, where 0 = awake and 10 is falling asleep/as tired as you can imag-
`ine) in 11 healthy subjects after intravenous (IV) and two nasal adminis-
`trations (OptiMist and Traditional spray) of 3.4 mg midazolam (IV
`different from Traditional, P = 0.033, linear mixed model).
`
`intravenous administration was of 2 orders of magnitude and
`maximum arterial concentrations was seen after 30 s in arte-
`rial blood, while that of venous blood was 5 min (Chiou
`1989a). Midazolam, also a highly fat soluble drug after ring
`opening, may display similar arterio-venous differences in
`drug concentrations. Since Optimist probably distributes
`midazolam over a larger nasal surface, as well as deeper into
`the nose (Djupesland et al 2006), we cannot disregard the pos-
`sibility that arterial sampling might have reflected differences
`in nasal distribution between the devices in the early phase.
`However, for ethical reasons it would probably not have been
`accepted to perform three sessions of arterial sampling from
`healthy subjects in this non-therapeutic drug trial.
`
`Table 3 Number of incidences and severity of nose discomfort
`
` Symptom
`
`Severity
`
`Time point(min)
`
`0
`
`Opt
`
`
`
`Trad
`
`2
`
`Opt
`
`
`
`Trad
`
`5
`
`Opt
`
`
`
`Trad
`
`Discomfort
`
`
`Discharge
`
`
`Congestion
`
`
`Throat
`
`
`
`mild
`moderate
`strong
`mild
`moderate
`strong
`mild
`moderate
`strong
`mild
`moderate
`strong
`
`7
`2
`
`3
`0
`
`1
`
`
`2
`1
`
`
`5
`5
`
`5
`1
`
`0
`
`
`1
`0
`
`
`9
`1
`0
`2
`
`
`2
`
`
`4
`4
`1
`
`6
`1
`1
`4
`
`
`3
`
`
`0
`3
`1
`
`5
`0
`
`2
`0
`
`2
`
`
`3
`6
`1
`
`1
`1
`
`2
`1
`
`1
`
`
`4
`5
`1
`
`10
`
`Opt
`
`
`
`
`
`
`
`
`0
`
`0
`
`
`
`10
`1
`
`
`
`
`
`Trad
`
`15
`
`Opt
`
`
`
`Trad
`
`
`
`
`2
`
`
`1
`
`
`7
`1
`
`
`
`
`
`0
`
`
`
`
`
`7
`
`
`
`
`
`
`1
`
`
`
`
`
`2*
`
`
`
`*Five, two, and two subjects reported discomfort at 20, 25 and 30 min in OptiMist group (Opt), while two and one subject(s) complained at 20 and
`25 min in the Traditional group (Trad).
`
`

`

`AQUESTIVE EXHIBIT 1128 Page 0007
`
`S 0–7
`
`L 0–7
`
`R 0–7
`
`S 0–5
`
`L 0–5
`
`R 0–5
`
`S 2–5
`
`L 2–5
`
`R 2–5
`
`SMCA
`
`LMCA
`
`RMCA
`
`TP