[bilingual text:]
`The Tolerability of Nasal Drugs With Special Regard to Preservatives
`and Physico-chemical Parameters
`
`Th. Verse 1
`C. Sikora 2
`P. Rudolph 2
`N. Klöcker 3
`
`Rhinologie [Rhinology]
`
`782
`
`Institute information
`1 Ear, nose and throat hospital Mannheim University (director: Prof. Dr. med. K. Hörmann)
`2 Institute of Hygiene and Environmental Medicine, Ernst-Moritz-Arndt University (director: Prof. Dr. med.
`A. Kramer)
`3 AUDIT institute, Taunusstein
`
`Correspondence address
`Priv.-Doz. Dr. med. Thomas Verse – Ear, nose and throat hospital Mannheim University – 68135 Mannheim
`
`Email: thomas.verse@hno.ma.uni-heidelberg.de
`
`Received: June 20, 2003 – Accepted: August 27, 2003
`
`Bibliography
`Laryngo-Rhino-Otol 2003; 82: 782-789 © Georg Thieme Verlag Stuttgart – New York – ISSN 0935-8943
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 1
`
`

`

`Rhinologie
`
`783
`
`Introduction
`
`The European Pharmacopoeia (Ph. Eur.) stipulates the
`addition of suitable preservatives at an appropriate
`concentration for preparations for nasal application (nasal
`drugs) in multidose containers. The only exception are
`established and approved exemptions such as, e.g., oils,
`auto-microbicidal solutions or preparations for immediate
`and short-term application prepared by the pharmacist. Most
`of the nasal drugs on the market are preserved with
`benzalkonium chloride (BZC) at concentrations of 0.005%
`to 0.02%. The pharmacopoeia furthermore stipulates for
`preparations for nasal application that they are not irritating
`and do not have any adverse effects on the function of
`mucociliary clearance. This is a conflict in itself since the
`allergenic and cytotoxic potential of preservatives has been
`known
`for some
`time and
`the negative effect of
`preservatives on ciliary function has been described in many
`ways [1-6]. For this reason, the Federal Institute for Drugs
`and Medical Devices (FIDMD) has since then initiated a
`step-by-step plan combating BZC in nasal drugs [7].
`
`Knowledge of the harmful effect of preservatives [8] first
`led to the development of preservative-free (psf) alternatives
`in ophthalmology, initially in form of single-dose containers
`(SDC), then also multidose containers (COMOD system).
`Psf systems have also been available for nasal drugs for
`some time. A considerable amount of preparations have
`been changed or are currently being changed. The
`microbiological safety of the new psf systems has been
`proven without a doubt in extensive testing and they are thus
`the state of the art [9].
`
`To date, there were no extensive practical comparative
`studies that would allow for a justified statement on the
`comparison of the cytotoxic properties of market-based
`preparations and provide the physician or pharmacist with a
`rational selection. The data available to date on the toxicity
`of preservatives in nasal drugs is mostly based on animal
`experiments ex vivo, in vivo examinations on the cilia or
`rather in vitro examinations of the cell culture. In vivo
`studies were barely possible to date due to lack of
`comparative preparations free of preservatives.
`
`For this reason we conducted an extensive cytotoxic
`examination of almost all available preparations on the
`market. The selection was based on the respective market
`share so that the most important preparations were included.
`We also determined the pH and osmolality in all cases since
`a direct statement on the prefabricated compound is only
`possible if the main properties of the matrix are known.
`Most of the examinations were performed as part of a
`dissertation. The results presented here represent an excerpt
`that is relevant for the medical practice.
`
`
`
`
`
`
`Methodology
`
`Cytotoxicity testing was performed according to DIN EN
`30993-5. The growth values indicate the mean value from
`19 individual tests per preparation, compared to the
`respective control. These are thus relative values.
`
`The exact course of the testing was already described in an
`earlier work [10]. FL cells, a cell line of the human amnion,
`was used for cell cultivation. The inventory was kept in 250
`ml tissue culture bottles (Greiner GmbH, Solingen). The
`cells were passaged every 4 hours. The inventory was
`cultivated again from the cell culture after the 100th passage.
`For this, the medium was decanted, the cell layer rinsed with
`20 ml PBS (phosphate buffered saline), uniformly moistened
`with 20 ml of the enzyme solution (0.05% 1:250 trypsin +
`0.02% EDTA in Ca2+ and Mg2+ free PBS) and the solution
`decanted again. After incubation of the bottles at 37ºC for
`about 10 minutes, the separated cells were suspended in 40
`ml MEM (minimum essential medium) + 8% serum and the
`cell count determined by means of the universal counter. 4 x
`106 cells were sowed in 75 ml growth medium per
`subculture bottle.
`
`For testing the cells were sowed in culture tubes (ca.
`200,000 cells/1.5 ml growth medium per tube) after previous
`separation. The growth medium consists of 70% lactalbumin
`hydrolysate and 30% MEM with additives of 1% antibiotic
`solution (final concentration: 100 IU Penicillin G and 100
`µg Streptomycin sulfate/ml) and 8% bovine calf serum. The
`pH was adjusted to 7.2 with 1 M NaOH solution. Then, the
`medium was heated in a water bath at 37ºC.
`
`The cells were available as monolayer after 72 hours of
`cultivation. Afterwards, a medium change with incubation
`medium is performed. It consists of MEM + 1% antibiotic
`solution + 1% bovine calf serum (control). The incubation
`medium additionally contains the trial substance.
`
`The substances to be tested were initially dissolved in water.
`Medium was used for the two last dilution steps and the pH
`was adjusted to 7.2. The incubation medium was heated to
`37ºC in a water bath. The solutions are prepared anew for
`each test. The incubation medium is made about 30 minutes
`before the medium change and stored in a refrigerator after
`cooling. 1 ml of the antibiotic solution of Penicillin and
`Streptomycin is applied to 100 ml medium. The inventory
`solutions of antibiotics and serum are stored in a freezer at -
`18ºC. The cell were incubated in the medium with the trial
`substance for 24 hours.
`
`The medium is decanted, the cell layer uniformly moistened
`with 0.3 ml enzyme solution (0.05% 1:250 trypsin and
`0.02% EDTA in Ca2+ and Mg2+ free PBS) and the solution
`decanted. After the tubes are incubated at 37ºC for about 10
`minutes, the separated cells are suspended in 1 ml MEM and
`1% serum each and the cell count is determined by means of
`the universal counter.
`
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 2
`
`

`

` Dexpanthenol 5% Ø
`
` 5.58 422 84
`
` Hyaluronic acid Ø
`
` 5.90 286 41.8
`
` Dexpanthenol 5% BZC
` Ø
` Ø
` Ø
` Ø
` Ø
` BZC
` Ø
` BZC
` Ø
` Ø
` Ø
` BZC
` Ø
` BZC
` Ø
` BZC
` Dexpanthenol 5% BZC
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` BZC
`
` 6.01 419 38
` 5.79 274 20
` 5.86 295 17
` 5.91 297 13
` 6.51 292 8
` 5.75 274 6
` 6.35 289 4
` 6.24 279 2
` 5.92 289 1
` 5.95 407 46
` 5.72 270 21
` 5.86 295 15
` 6.00 300 11
` 6.35 282 7
`
`
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`0.1
`
`0.1
`
`
`0.1
`
`0.1
`
`0.1
`
`0.1
`0.1
`
`0.1
`
`0.1
`
`0.1
`
`0.1
`
`0.05
`0.05
`
`0.05
`
`0.05
`
`0.05
`
`
`
`
`
`
`1. Decongestants, Xylometazoline (tab. 1)
`This market-dominating group, like the two next groups,
`that also include decongestant α sympathomimetics are
`mostly purchased directly from the pharmacy over-the-
`counter. For this reason, controlled and limiting ingestion
`cannot be achieved and the medicinally induced side effects
`caused by “too often, too much, too long” such as mucosal
`atrophy, rhinitis medicamentosa and allergic reactions must
`thus be taken particularly seriously. Thus, any improvement
`in tolerance is welcome.
`
`Firstly, we generally noticed that the psf products are better
`tolerated than those preserved (fig. 1) at each concentration
`level and, secondly, that the tolerance was dose-dependent.
`These differences are particularly visible in the example of
`the market-leading products Otriven® and Olynth®, both of
`which are available preserved and unpreserved at two
`different concentrations each. The excellent tolerance of
`
`1. Xylometazoline + Dexpanthenol*
`3. Xylometazoline + hyaluronic acid*
`
`14. Xylometazoline
`
`Bundeswehr
`
`Growth rate (%)
`
`
`Fig. 1 Cell growth using the example of Xylometazoline
`(0.1 %, *new developments).
`
`Manufacturer
`
`Form
`
`Active agent
`
`New development NS
`
`Xylometazoline
`
`New development NS
`
`Xylometazoline
`
`
`
`Tab. 1 Decongestants, Xylometazoline
`
`
`
`Trade name
`
`
`
`Xylometazoline +
`
`Dexpanthenol
`Xylometazoline +
`
`Hyaluronic acid
`
`Casella med
`Nasic
`
`
`Novartis
`
`Otriven OK
`
`Pfizer
`
`Olynth OK
`
`Hexal
`
`Nasan
`
`Schnupfen Endrine Asche
`
`
`Nasenspray E
`ratiopharm
`
`Otriven
`
`Novartis
`
`
`Olynth
`
`Pfizer
`
`
`Xylometazoline
`Bundeswehr
`
`Nasic for children
`Cassella med
`Otriven 0.05% OK Novartis
`
`
`Olynth 0.05% OK
`Pfizer
`
`
`Nasenspray K
`ratiopharm
`
`Otriven 0.05%
`Novartis
`
`
`
`
`
`
`
`
`
`
`
`
`
`Tonicity and pH were always determined by the same
`person using the same device and conventional standard
`procedures.
`
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`Xylometazoline
`
` A
`
` statistical analysis was not sensible due to the large
`number of tests performed. However, differences in growth
`of >10% are always of statistical significance (p < 0.05,
`α=10, Wilcoxon-Mann-Whitney U
`test)
`and
`the
`significances are of descriptive nature.
`
`
`Results
`
`The results are shown in seven groups with respective tables
`and short comments on each. The highest concentration of a
`substance class is always listed first in the presentation. The
`substance tolerated best is shown first, measured by relative
`cell growth, and the comparable preparations follow based
`on their tolerance in descending order. Providing the
`absolute values with standard deviation is not helpful since
`the values are based on many different test series with
`different values for the respective controls. For this reason,
`the growth percentage in relation to the control is indicated.
`Anomalous matrix properties are highlighted; these mostly
`relate to osmolality since the pH range of almost all
`examined preparations was comparable.
`
`We following common abbreviations were used: WP =
`without preservatives, A = adult preparation, C = child
`preparation, NS = nasal spray, ND = nasal drops, ED = eye
`drops, MD = medical device.
`
`
`
`Rhinologie
`
`784
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 3
`
`

`

`Tab. 2 Decongestants, Oxymetazoline
`
`
`
`Trade name
`
`
`
`Merck
`Nasivin-Sanft
`Merck
`Nasivin
`
`
`Sinex Schnupfen- Wick
`
`Spray
`
`
`
`Nasivin-Sanft
`Merck
`
`Nasivin
`
`Merck
`
`Nasivin-Sanft for Merck
`babies
`
`
`
`
`
`
`
`
`
`
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`0.05
`0.05
`
`0.05
`
`
`
`0.025
`
`0.025
`
`0.01
`
`
`
`
`
`2. Decongestants, Oxymetazoline (tab. 2)
`The statements in the previous chapter regarding better
`tolerance when no preservative is used and the worse
`tolerance the higher the dose were also confirmed in the
`Oxymetazoline preparation (fig. 2). The assertion sometimes
`made that tolerance is better due to half of the dose burden is
`no
`longer comprehensible
`in comparison
`to modern
`preservation-free Xylometazoline preparations.
`
`The preparation Sinex® with the combination of camphor,
`cineol and levomenthol is not very adequate in comparison.
`
`tolerance on active agent
` Dependence of
`Fig. 2
`Interestingly, it is the only one of the agents shown here that
`concentration using
`the example of Oxymetazoline
`is not preserved with BZC. Chlorhexidine gluconate used
`(unpreserved).
`instead is questionable from today’s point of view [8]. The
`
`significantly hypo-osmolar galenic must also be considered
`
`an additional source of damage.
`
`
`Nasic® at both concentrations must be highlighted, even
`Tetryzoline,
`Decongestants,
`3.
`though the product is still preserved. This is achieved by the
`Naphazoline, Dimetin (tab. 3)
`combination with Dexpanthenol. Our own examinations, in
`The remarks made for Xylometazoline and Oxymetazoline
`the meantime confirmed by clinical data, showed that
`regarding the effect of preservation and concentration on
`Dexpanthenol is able to significantly lower the toxic
`tolerance also apply to this group. The combination with
`potentials of Xylometazoline and BZC [10-12]. The
`in Rhinospray plus® and Dexa-
`other substances, as
`preparation by the Bundeswehr is at the bottom of the
`Rhinospray® also seems questionable. Furthermore, the
`rankings regarding tolerance. This should be emphasized
`latter preparation has very hypertonic galenic with a very
`since it is based on the standard approval by the FIDMD.
`low pH.
`
`
`
`
`Tab. 3 Decongestants, Tetryzoline, Tramazoline, Naphazoline, Dimetindene
`
`
`
`
`
`Trade name
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`
`
`
`
`MIP
`Tetrilin E
`0.1
`
`
`
`MIP
`Tetrilin K
`0.05
`
`
`Pfizer
`Yxin
`0.05
`
`
`Rhinospray-sensitive Boehringer Ing.
`0.1
`
`
`Dexa-Rhinospray Mann
`0.1
`
`
`
`
`
`
`
`
`
`
`Rhinospray plus
`0.1
`Boehringer Ing.
`
`
`
`
`
`
`
`
`Privin
`0.1
`
`Novartis
`
`
`Rhinex “S” for
`0.02
`Wernigerode
`
`
`infants
`
`
`Fenistil nasal
`0.1
`
`
`Vibrocil
`0.025
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Manufacturer
`
`Form
`
`Active agent
`
`
`
`
`
`
`
`
`
`NS
`NS
`NS
`
`NS
`ND
`NS
`
`Oxymetazoline
`Oxymetazoline
`Oxymetazoline
`
`
`Oxymetazoline
`Oxymetazoline
`Oxymetazoline
`
` 6.85 297 23
` Ø
` Ø
` 6.85 294 20
` BZC
` Ø
` Camphor, cineol, Chlorhexidine 5.53 213 3
` levomenthol digluconate
` Ø
` Ø
` 6.86 292 30
` Ø
` BZC
` 6.86 297 27
` Ø
` Ø
` 6.85 301 28
`
`Concentration (%)
`
`
`
`Cell growth (%)
`
`Rhinologie
`
`785
`
`Tramazoline,
`
`Manufacturer
`
`Form
`
`Active agent
`
`NS
`NS
`ED
`NS
`ND
`
`NS
`
`NS
`ND
`
`ND
`NS
`
`
`Tetryzoline
`Tetryzoline
`Tetryzoline
`Tramazoline
`Tramazoline
`
`
`Tramazoline
`
`
`Naphazoline
`Naphazoline
`
`Dimetindene mal.
`Dimetindene mal.
`
`
`
` Ø
` Ø
` Ø
` Ø
` BZC
` Ø
` Ø
` Ø
` Dexamethasone BZC
` 0.02%
` Cineol menthol BZC
` Camphor
` Ø
` Ø
`
` BZC
` BZC
`
` Phenylephrine BZC
` Phenylephrine BZC
` 2.50 mg/g
`
` 6.03 310 60
` 6.06 314 73
` 6.36 292 2
` 6.1 303 16
` 4.62 760 2
`
` 6.17 297 3
`
` 5.1 310 18
` 5.17 307 10
`
` 5.09 345 72
` 6.43 306 9
`
`Novartis
`Novartis
`
`
`
`
`
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 4
`
`

`

` 6.01 313 53
` Ø
` Ø
` 6.81 286 17
` Ø
` Ø
` 6.72 287 4
` BZC
` Ø
` 6.73 293 4
` BZC
` Ø
` 5.45 290 3
` BZC
` Ø
` 5.40 291 3
` BZC
` Ø
` 6.77 287 2
` BZC
` Ø
` 5.48 72 2
` Xylo 0.025% BZC
` 5.52 70 2
` Ø
` BZC
` Ø
` Ø 5.54 70 1
` Ø
` BZC
` 5.02 326 3
` Ø
` BZC
` 7.01 976 3
` Ø
` BZC
` 4.95 288 2
` Ø
` BZC
` 4.60 316 1
` Ø
` BZC
` 4.34 317 4
` Ø
` BZC
` 6.34 301 4
` Ø
` BZC
` 6.41 334 2
` Ø
` BZC
` 6.30 304 2
`
`
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`2
`2
`
`2
`
`2
`
`2
`
`2
`
`2
`2
`
`2
`
`2
`
`0.9
`
`0.5
`
`1
`0.5
`
`0.1
`
`0.05
`
`0.05
`
`0.05
`
`
`
`
`Particularly the comparison between the two unpreserved
`preparations Cromohexal-sanft® and Cromo-ratiopharm®
`which are interchangeable due to the same indication,
`application, the same active ingredient, potency and the
`same dose according to the aut-idem rule shows the dangers
`of the aut-idem rule.
`
`5. Medicines and care products with pharmaceutical
`additives, oils (tab. 5)
`Dexpanthenol is in the foreground in this group; we already
`alluded to its positive characteristics. In total, this group is
`well tolerated. Even the preserved Nasicur® shows good cell
`growth. It
`is remarkable
`that
`the attempt
`to sneak
`Dexpanthenol past the Medicinal Products Act as a medical
`device
`containing
`a
`pharmacologically
`ineffective
`concentration (for example Mar plus®) achieved neither the
`tolerance
`of
`saline
`solutions
`nor
`that
`of
`the
`pharmacologically effective Dexpanthenol preparations.
`
`The example Kamillan supra® has tolerance that is low for
`medicines and care products. The application of alcohol
`extracts on the nose does not seem to make much sense due
`to a high danger of allergies, particularly for chamomile.
`
`Emser Nasenspray® was the only saline solution added to
`this group since it is approved as a pharmaceutical and has
`shown a pharmacological effect.
`
`We would like to expressly point out the three oils with their
`excellent tolerance which make them appear perfectly
`suitable for nasal tamponades and preparing prescriptions at
`the pharmacy.
`
`
`
`
`Manufacturer
`
`Form
`
`Active agent
`
`
`
`Tab. 4 Antiallergics
`
`
`
`Trade name
`
`
`
`Ursapharm
`Allergo-COMOD
`Hexal
`
`Cromohexal sanft
`
`Hexal
`
`Cromohexal
`
`STADA
`
`DNCG nasal spray
`
`Ursapharm
`Allergocrom
`
`Dr. Winzer
`Crom-Ophtal
`
`Cromoglicin Heumann Heumann
`Lomupren comp.
`FISONS
`
`
`LOMUPREN
`FISONS
`
`
`Cromo-ratiopharm
`ratiopharm
`
`Nasacort
`
`Aventis
`
`
`Livocab
`
`Janssen
`
`
`Irtan
`
`Aventis
`
`Nasonex
`
`Essex
`
`
`Pulmicort Topinasal Astra-Zeneca
`
`Beconase
`Glaxo
`
`
`Flutide Nasal
`Glaxo
`
`
`Beclomet
`Orion
`
`
`
`
`
`
`
`
`
`
`4. Antiallergics (tab. 4)
`
`Most of the preparations have Cromoglycin as the active
`
`ingredient. The tolerance of the substance as well as of the
`
`
`steroids can generally be described as unsatisfactory. It is
`
`worth mentioning that there were significant improvements
`
`in cell growth in the psf formulations in the comparisons
`
`between Allergocrom® and Allergo-COMOD® and between
`
`Cromohexal® and Cromohexal-sanft®. This is even more
`
`remarkable considering that Cromo-ratiopharm® (the market
`
`
`leader, by the way), which is also unpreserved, had the
`
`worst tolerance of all nasal sprays containing Cromoglycin.
`
`One can plainly see the reason for this when looking at the
`matrix properties (fig. 3). The effect of pH and tonicity has
`been known since 1965 and
`this
`is outstandingly
`documented [13-14]. A tonicity of only 70 (!) mOsm/kg as
`in Cromo-ratiopharm® is simply not consistent with the
`physiology of an intact nasal mucosa. It is therefore
`surprising that this preparation was approved. The similar
`applies to the preparations Lomupren® and Lomupren
`comp®. The extremely high tonicity of Livocab® should give
`cause for caution during longer-term use.
`
`
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Cromoglycin
`Triamcinolone
`Levocabastine
`Nedocromil
`Mometasone
`Budesonide
`Beclomethasone
`Fluticasone
`Beclomethasone
`
`Rhinologie
`
`786
`
`
`
`Cell growth (%)
`
`Osmolality (mOsm/kg)
`
`
`Fig. 3 Influence of osmolality on tolerance using the
`example of nasal sprays containing Cromoglycin.
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 5
`
`

`

`5
`
`5
`1
`5
`
`Tab. 5 Medicines and care products with pharmaceutical additives; oils
`
`
`
`Trade name
`
`
`Otriven Pflege with Novartis
`
`Dexp.
`
`
`Nasicur
`
`Mar plus (MP)
`
`Rhinoclir
`
`
`Emser Nasenspray
`
`Ph. Wernigerode
`Kamillan supra
`
`
`
`
`
`
`Coldastop nasal oil Desitin
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Paraffin oil
`Pharmacy
`Peanut oil
`Pharmacy
`
`
`
`
`
`
`
`
`Tab. 6 Hormones
`
`
`
`
`
`Trade name
`
`
`
`
`
`Calcitonin-ratiopharm
`
`
`Karil
`
`Kryptocur
`
`
`Synarela
`
`
`Profact nasal
`Suprecur
`
`
`
`
`
`
`
`
`
`Tab. 7 Saline solutions
`
`
`
`
`Trade name
`
`
`
`
`
`Olynth salin dose spray Pfizer
`
`
`Rhinomer Soft
`Novartis
`Wero-mar
`Wero-medical
`
`St. Christoph
`ALDI
`
`
`Rhinospray Atlantik Thomae
`
`Tetesept-Meerwasser Tetesept
`
`
`Rhinodoron
`Weleda
`
`
`
`
`
`
`
`
`
`
`6. Hormones (tab. 6)
`
`
`Medical need is ahead of tolerance for this group. The latter
`
`is characterized by significant differences regarding cell
`growth. We noticed that tolerance was identical in both
`products containing calcitonin, even
`though one was
`preserved and
`the other unpreserved. Similarly
`to
`gonadorelin, the influence of the hormone seems to
`neutralize that of the preservative here.
`
`
`
`
`
`
`Manufacturer
`
`Form
`
`Active agent
`
`NS
`
`NS
`NS
`NS
`
`NS
`
`NS
`
`ND
`
`
`
`
`ND
`ND
`
`Dexpanthenol
`
`Dexpanthenol
`Dexpanthenol
`Dexpanthenol
`
`Emser salt
`
`Chamomile liquid
`extract (1:1)
`Retinol palmitate
`α-tocopherol
`Citric oil
`
`Orange oil
`Terpineol
`Paraffin oil
`Peanut oil
`
`
`
`Cassella med
`Stada
`
`Febena
`
`
`Siemens & Co
`
` E
`
`Manufacturer
`
`Form
`
`Active agent
`
`ratiopharm
`Novartis
`
`Aventis
`
`Heumann
`HMR
`
`Aventis
`
`
`NS
`NS
`NS
`NS
`NS
`NS
`
`Calcitonin
`Calcitonin
`Gonadorelin
`Nafarelin
`Buserelin
`Buserelin
`
`Manufacturer
`
`Form
`
`Active agent
`
`NS
`NS
`NS
`NS
`NS
`NS
`NS
`
`
`NaCl
`
`NaCl
`
`Sea salt
`Sea water
`NaCl
`
`Sea water
`NaCl
`
`
`10
`
`0.9
`0.9
`0.9
`0.9
`0.9
`0.9
`0.5
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`
`
`
`
`1.175
`
`
`
`
`15000 IU Ø
`
`20 mg
`4 mg
`
`2 mg
`
`2 mg
`
`
`
`
`
`
`
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`100 IU/0.1 ml Ø
`
`100 IU/puff Ø
`
`0.2
` Ø
`
`0.2
` Ø
`
`0.15
` Ø
`
`0.15
` Ø
`
`
`
`
`
`Conc. (%) Additives Preservation pH Osmolality Growth (%)
`
`
`
`
`
`
`
`
`
`
`
`7. Saline solutions, medical devices (tab. 7)
`All market-based saline solutions are preservative-free in the
`meantime and of excellent tolerance, as expected. The
`significantly lower cell growth in Rhinodoron® shows that a
`combination with aloe vera that is usually used in cosmetics
`is not sensible (with simultaneous reduction of the salt ratio
`to 0.5%).
`
`
`
`
`
`
`
`
`Rhinologie
`
`787
`
`
`
` Ø
` Ø
`
`
` Ø
`
` Ø
`
` Ø
`
` 7.20 369 101
`
` BZC
` Ø
` Ø
`
` 5.78 732 81
` 6.15 317 73
` 7.18 401 63
`
` Ø
`
` 8.76 288 64
`
` BZC
`
` 6.02 not meas. 21
`
` Ø
`
` Ø Ø 99
`
` Ø
` Ø
`
` Ø
` Ø
`
` Ø Ø 100
` Ø Ø 99
`
` 4.10 273 94
` Ø
` BZC 4.04 274 92
` BZC 6.39 416 74
` BZC 5.28 328 4
` BZC 5.64 281 3
` BZC 5.70 285 2
`
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Ø
` Aloe vera 0.5% Ø
`
` 6.25 291 98
` 7.87 326 96
` 7.40 306 93
` 7.70 308 93
` 9.12 307 92
` 7.14 295 84
` 5.82 287 56
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 6
`
`

`

`Discussion
`
`The data presented here leave little doubt that preservatives
`in pharmaceuticals for nasal application have a significant
`cytotoxic effect. The results of this examination are thus
`consistent with data from literature. The highly sensitive
`mucociliary apparatus represents one of the human body’s
`most important defense mechanisms. More and more
`research groups detected a harmful effect of BZC on the
`ciliary function as well [15, 16]. This damage can cause
`irreversible loss of ciliary activity [7]. Preservatives in nasal
`drugs should be viewed critically because of this cyto- and
`ciliary toxic potential, the side effects and the allergenic
`risk. Pharmaceuticals
`can
`now
`be
`produced
`in
`microbiologically harmless, unpreserved form due to new
`technical developments in the field of pump systems for
`nasal sprays.
`
`It was shown that unpreserved nasal drugs are tolerated
`much better than preserved ones. However, other factors
`such as the concentration of the active ingredient, its dosage
`and toxic characteristics as well as the matrix of the solution
`also play an important role regarding tolerance in addition to
`preservation. With that said, preservatives in any case
`represent an additional stress that has become unnecessary
`in the meantime.
`
`Toxic effects on the isolated cell, as tested in our model, are
`generally more severe than on the intact mucosa which is
`physiologically protected by its secretion coating. It is
`therefore certainly possible that the cytotoxic effects of the
`active
`ingredient, preservative and physical-chemical
`parameters described here have been overestimated. On the
`other hand, the nasal mucosa is frequently previously
`damaged, at least in industrial nations, due to chronic or
`acute
`infections, multiple
`and
`long-term use of
`pharmaceuticals, allergies, severe exposure to environmental
`burdens, smoking habits, etc. This previous damage to the
`nasal mucosa is generally associated with a reduction of the
`protective secretory coating and previous damage to the
`highly sensitive cilia. Furthermore, the consistent results of
`cytotoxicity and ciliary toxicity testing confirm the validity
`of the ex vivo in vitro cytotoxicity tests to determine the
`harmful effect of topical noxa on the mucociliary apparatus.
`Also, the validity of our data for in vivo conditions is
`supported by the recently published work by Kehrl et al.
`[12] in which a randomized, double-blind study of 152
`patients detected the same results and interpretations.
`
`In Germany alone about 60 million bottles of nasal spray are
`sold annually on the controlled pharmacy market, generally
`over the counter. Additionally, an amount that cannot be
`estimated is sold in drugstores and discount stores. For this
`reason, the type and duration of application cannot be
`reliably controlled. The risk potential is not insignificant
`here since it is difficult for the user to detect adverse drug
`reactions as such, but are rather associated with the
`underlying illness.
`
`
`
`
`Unfortunately, there are a number of inhibition levels that
`oppose
`the reasonable restructuring
`to preserved psf
`products:
`1. The higher technical complexity in manufacturing
`(aseptic filling, highly complex pump systems) results
`in higher production costs. However, there is no
`economic incentive for investment as long as identical
`sales prices can be achieved for technically inferior
`preparations with worse
`tolerance due
`to fixed
`reference prices.
`2. Many companies do not have the technical know-how
`to make this switch and for in-house production so that
`external service providers must be consulted, resulting
`in another cost factor.
`3. The FIDMD has to date tended to interfere with the
`switch to psf formulations rather than support it and has
`made this process very costly for the industry.
`4. As a result of globalization many pharmaceutical
`companies are dependent on foreign, mostly Anglo-
`American headquarters regarding decisions; they are
`mostly indifferent to German quality standards and
`concerns.
`5. The medical profession and pharmacists are mostly not
`yet sufficiently familiar with and aware of the problem.
`However, comparative data has also been absent to date
`and this needs to be presented first.
`6. As is well known, patients who are self-medicating tend
`to
`select
`the cheapest
`alternative and brand
`management by large corporations has shaped our
`buying habits. Recommendations from the medical
`profession or pharmacists can have positive effects
`here.
`
`
`The nasal route of application for systemically effective
`substances will become more and more important in the
`coming years while topically effective nasal substances were
`in the foreground of medical-pharmaceutical interest in the
`past, as evidenced by the number of preparations and
`indications listed here. Not just the group of hormones
`examined here will continue to grow. For example, the
`introduction of nasal triptans recently decisively enriched
`the field of migraine therapy. Nasal vaccines and the
`addition of hyaluronic acid are currently being researched
`intensively [17, 18]. There is currently also interest in a
`nasal route of application for opioids [19], central acting
`substances, e.g. for epilepsy and dyskinesia [20] and drugs
`for treatment of erectile dysfunction. For this reason, a
`comparative presentation of tolerance, as presented here,
`seems necessary.
`
`In summary, we would like to again point out the partially
`significant differences between the cytotoxicity of individual
`nasal drugs. The greatest differences are in dependence on
`preservation, the active ingredient’s dosage and galenic. The
`aut-idem rule must be reviewed critically because of this.
`
`
`Rhinologie
`
`788
`
`Opiant Exhibit 2199
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00694
`Page 7
`
`

`

`Rhinologie
`
`6 Klöcker N, Rudolph P. Preserved nasal sprays are obsolete. Pharm
`Journal 2000: 21: 1710-1712
`7 FIDMD, Federal Gazette 2002, no. 120 (07/03/2002)
`
`
`9 Bagel S, Wiedemann B. Nasal sprays without preservatives. Dt.
`Pharm. Journal 1999: 139: 4438-4441
`10 Klöcker N, Verse T, Rudolph P. The mucosal protective effect of
`Dexpanthenol in nasal sprays. First results of cytotoxic and ciliary
`toxic in vitro attempts. Laryngo-Rhin-Otol 2003; 82: 177-182
`
`
`12 Kerl W, Sonnemann U. Dethlefsen U. Advances in the therapy of
`acute rhinitis. Comparison of efficacy and harmlessness of
`Xylometazoline with
`the
`combination of Xylometazoline-
`Dexpanthenol in patients with acute rhinitis. Laryngo-Rhino-Otol
`2003; 82: 266-271
`
`
`14 Stepper M, Wayer M, Kedvessy G, Szabon J. The role of tonicity
`and viscosity of solutions in the activity of the ciliated epithelium of
`the nasal mucosa. Pharmaceutical research 1965; 11: 1347-1349
`15 Neugebauer P, Seine R, Meister H, Mickenhagen A, Bonnekoh B.
`The effect of benzalkonium chloride on the ciliary frequency of nasal
`ciliated epithelial cells in vitro. Abstract ENT 1998: 46: 433
`
`789
`
`Based on the present data, it no longer seems justifiable for
`new pharmaceutical developments
`to use preserved
`formulations. Preparations that are still preserved should be