`
`
`
`appropriate nebulizers is a major precondition for a
`use of
`The
`treatment and prevention of Pneumocystis carinii pneumonia
`successful
`with pentamidine aerosol.
`The apparatus
`should supply a
`sufficient
`amount
`of
`pentamidine with
`adequate particle
`size. Using Fisons
`ultrasonic nebulizer FISO Neb, model FZ2V 40 BAMKI, De Vilbiss ultrasonic
`nebulizer, Porta-Sonic, model 8500 GB, and the Marquest Medical Products
`jet nebulizer Respirgard II,
`two pentamidine concentrations (300 mg/6 mi
`and 60 mg/6 ml) were compared by measuring nebulized pentamidine mass
`distribution and particle size distribution under in vitro conditions by
`means of a
`laser
`light-scattering particle sizer of
`the type Malvern
`Master sizer. It was found that there were significant differences among
`nebulizers. Mass distribution experiments with air flow 6 1/min showed
`that using FISO Neb the quantity of nebulized pentamidine was 201.4 mg
`and 36.7 mg, whereas using Porta-Sonic the values found decreased to
`85.2 mg and 23.6 mg. Using Respirgard II the values were 80.0 mg and
`10.64 mg. The measured total duration times of nebulization were 6 - 8.5
`min,
`12 min and 25 min for
`the nebulizers FISO Neb, Porta-Sonic and
`Respirgard II. A decomposition of pentamidine during nebulization in the
`case of ultrasonic nebulizers doesn*‘t
`take place. The measured mass
`median diameters (MMD) were 5.6 - 6.9 pm, 1.96 - 3.04 pm and 1.9 - 2.5
`wm for the nebulizers FISO Neb, Porta-Sonic and Respirgard II. Using 300
`mg pentamidine the nebulized amounts of pentamidine containing particles
`sizes < 2 um predominately available for alveolar deposition were with
`values of about 43 mg markedly higher for Respirgard II and Porta-Sonic
`than the measured 10.5 mg for FISO Neb.
`
`a
`
`|
`
`JOURNAL OF AEROSOL MEDICINE
`Volume 5, Number 2, 1992
`Mary AnnLiebert, Inc., Publishers
`
`Measurementof Particlé and Mass
`Distribution of Pentamidine Aerosol by
`Ultrasonic and Air Jet Nebulizers
`*
`ss
`o
`J. HAGER, K.-H. GOBER,J.-P. LOHR, and M. DURR
`
`’ Rhéne-Poulenc Rorer GmbH, Nattermannallee 1
`5000 Kéln 30
`
`.
`
`ABSTRACT
`
`:
`
`INTRODUCTION
`
`i
`
`te
`
`:
`
`1-
`i
`
`"
`
`n
`
`'s
`
`n s
`
`1
`2
`
`s
`a
`.
`5
`/
`>
`y
`
`Liquidia's Exhibit 1098
`Page 1
`
`'
`
`Pentamidine (Pentacarinat®) is used both in intravenous administra-
`tion and as aerosol
`for the treatment and prophylaxis of Pneumocystis
`carinii pneumonia associated with the acquired immunodeficiency syndrome
`(AIDS).
`In aerosol
`therapy aqueous pentamidine solutions with various
`
`Keywords:Pneumocystis carinii pneumonia, aerosol, nebulizer, pentamidine
`
`65
`
`aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaasaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaasaaaaaaaaaaaaaaaaaaaaasaaaaaaaasaaaaaaaaaaaasasaasaaassasaaaaasaal
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`Liquidia's Exhibit 1098
`Page 1
`
`

`

`including determination of drug content and decomposition products.
`
`Influence
`pentamidine
`for nebulizing liquids with
`The
`use of an ultrasonic method
`particle diameters < 5 ym showing alveolar deposition is associated with
`a high energy supply to the nebulization liquid. This explains
`the
`possibility of
`substance
`decomposition
`reported in the
`literature
`(Konietzko N., 1989). While temperatures of about 50°C were measured
`transitorily during ultrasonic nebulization of pentamidine
`solutions,
`the stability tests were performed at various temperatures. Nebulization
`liquids with various concentrations of pentamidine were nebulized at
`different
`temperatures by an ultrasonic method. The chemical stability
`of pentamidine was
`investigated according to a new analytical method
`
`4
`
`such as
`drug concentration are applied by means of air jet nebulizers,
`Respirgard II, or by ultrasonic nebulizers.
`Several publications (Dirnagel, 1971; Corkery et al., 1988; Matthys
`and Herceg, 1990; Doherty et al., 1990; Konietzko, 1989; Herer et. al.,
`1989; Kéhler et al., 1983; Baskin et al., 1990; Smith et al.,1989; Wong
`et al., 1990) contain investigations on the particle size of pentamidine
`aerosols. According
`to these
`reports,
`the use of
`a particle size
`exhibiting alveolar deposition is
`a precondition. for a successful
`therapy with pentamidine
`aerosol.
`‘There
`are
`only
`few reports
`on
`pentamidine mass
`distribution
`during
`nebulization
`by
`different
`nebulizers,
`duration of nebulization and
`influence
`of ultrasonic
`nebulization on the chemical stability of pentamidine.
`
`under
`the following investigations was to determine
`The aim of
`various
`conditions
`(nebulizers
`of
`various
`types,
`different
`concentrations of pentamidine, various flow rates)
`the above mentioned
`operating characteristics and to compare
`these results with published
`similar data.
`
`:
`
`METHODS
`
`Pentamidine mass distribution »
`
`"output" can be defined gravimetrically as the loss
`The nebulizer
`in weight of
`the nebulizer or
`the change in volume of
`the nebulizer
`solution over
`time
`(Smaldone
`et al.,
`1988).
`In our
`studies
`the
`pentamidine mass distribution was
`determined
`by gravimetry and
`a
`chemical-analytical method, of pentamidine after completing nebulization
`in conditions
`similar
`to those used
`in clinical practice,
`except
`breathing pattern.of the patient. The results were given with reference
`to the used liquid in ‘percentage, or pentamidine in mg, as
`follows:
`residue in nebulizer,
`residue in safe-vent, nebulized amount/
`amount
`provided for treatment.
`
`Duration of nebulization
`
`investigations was to determine the nebulization
`The aim of our
`time of pentamidine-containing solutions using the nebulizers Respirgard
`II, Porta-Sonic and FISO Neb. The influence of the following parameters
`was tested: concentration of pentamidine and air flow.
`
`of ultrasonic nebulization on the chemical stability of
`
`66
`
`
`
`
`
`Liquidia's Exhibit 1098
`Page 2
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`Liquidia's Exhibit 1098
`Page 2
`
`

`

`Particle size distribution
`
`So far
`
`it
`
`has not
`
`been possible
`
`to determine particle
`
`size
`
`in
`i.e.
`inhalation therapy,
`of
`conditions
`the
`distribution under
`a
`For
`patients with
`determination
`of
`pulmonary
`drug deposition.
`comparison of
`results described in the literature we need comparable
`conditions as to measuring methods used, and exact data on particle size
`designations. The aim of the particle size ‘measurements described below
`was to study the subjects hardly dealt with in the literature regarding
`the nebulization of pentamidine-containing solutions:
`influence of
`the
`concentration of pentamidine on particle size distribution; course of
`particle: size distribution during nebulization; comparison of particle
`size obtained -by the air jet.nebulizer and ultrasonic nebulizers. The
`present investigations were done by using Malvern Master sizer with mass
`median diameter for particle ‘size designation.
`
`Experimental protocol
`
`_
`
`The following conditions were fixed for each nebulizer: Respirgard
`II: airpressure 3.5 bar, airflow 6
`l/min, pentamidine
`(Pentacarinat
`300, Rhéne-Poulenc Rorer)
`300 mg or 60 mg/6 ml water
`f£.
`inj. DAB 9;
`total running time 25 min; Porta-Sonic with Safe-Vent: air flow 24 l/min
`and 6 l/min, pentamidine (Pentacarinat~
`300, Rhéne-Poulenc Rorer) 300 mg
`or 60 mg/6 ml water f.
`inj. DAB9
`;
`total
`running time 20 or 21 min.;
`FISO Neb:
`air
`flow 6
`l/min,
`power
`setting ‘“Minimum";
`pentamidine
`(Pentacarinat® 300, Rhéne-Poulenc Rorer) 300 mg/6 ml or 60 mg/6 ml water
`f.
`inj. DAB 9,
`total running time 6.5 min.. These conditions were used
`for measurements of mass distribution as well as for the particle size
`distribution with exception of the air flow value 24 l/min only used in
`determination .of mass distribution.
`In pilot studies with triplicate
`samples it was
`found that
`the measured mass distributions were in the
`range of
`3
`Z
`referring to the mean value of
`each device. For
`the
`particle size measurements
`a maximum deviation of
`4
`Z
`from the mean
`value was determined. Therefore, we considered that single measurements
`were
`sufficient
`to
`demonstrate
`the nebulizing properties
`of
`the
`investigated nebulizers for the conditions described in this paper.
`
`Pentamidine mass distribution and duration of nebulization.
`
`The nebulizers were operated according to Figures 1A, 1B and
`The
`nebulized
`amounts
`of
`pentamidine
`were
`collected
`in
`gaswasher/scrubber filled with 100 ml 1 Z ortho-phosphoric acid.
`
`1C.
`the
`
`'
`
`Influence
`pentamidine
`
`of ultrasonication on
`
`the
`
`chemical
`
`stability of
`
`and 60 mg/6 ml water
`Pentacarinat® 300 at concentrations of 300 mg
`inj. were investigated at 25 °C and 60 °C. The samples were sonicated
`f.
`by the nebulizers Porta-Sonic and FISO Neb and the Branson sonifier type
`250.
`For
`comparison
`samples
`autoclaved
`(121°C,
`20 min)
`were
`investigated. Drug contents and degradation products were analyzed by
`HPLC. The ultrasonication were done by the nebulizers Porta-Sonic and
`FISO Neb and the Branson sonifier type 250. The samples were analyzed by
`HPLC.
`
`-
`
`67
`
`Liquidia's Exhibit 1098
`Page 3
`
`|
`
`iJ
`
`|
`
`.
`-
`
`ch as
`
`thys
`
`al.,
`Wong
`idine
`size
`sful
`3
`on
`arent
`sonic
`
`nder
`erent
`ioned
`ished
`
`/
`+088
`-izer
`the
`doa
`‘tion
`tcept
`rence
`-Ows:
`rount
`
`‘gard
`‘ters
`
`“0
`
`£
`
`rith
`with
`the
`ture
`ured
`ons,
`tion
`1 at
`lity
`thod
`
`!
`
`!
`
`
`
`Liquidia's Exhibit 1098
`Page 3
`
`

`

`
`
`
`
`_==,
`,
`
`2
`
`
`
`=
`
`3
`
`
`
`
`
`spentair
`
`_=,
`
`4
`
`5
`
`1: air compressor
`2: nebulizer
`* 3: gas washer
`4: flow meter
`5: vacuum pump
`
`— air supply
`— spentair
`
`= aerosol
`
`FIGURE 1A: The Respirgard II arrangement
`
`ambientair
`
`—
`
`'
`
`<=
`=
`=
`
`
`
`
`
`
`
`1
`
`2
`
`3
`
`4
`
`spentair
`
`]
`
`1: nebulizer
`2: gas washer
`3: flow meter
`4: vacuum pump
`
`-
`
`—— air supply
`== spentair
`a
`= aerosol
`
`FIGURE 1B: The Porta-Sonic arrangement
`
`ambientair
`sucked by nebulizer
`
`
`
`
`
`
`=—
`=
`=
`
`1
`
`2
`
`3
`
`4
`
`—
`
`spent air
`
`|
`
`1: nebulizer
`2: gas washer
`3: flow meter
`4: vacuum pump
`
`— air supply
`=== Spent air
`= aerosol
`
`FIGURE 1C: The FISO Neb arrangement
`
`Particle size distribution
`
`the Malvern Master Sizer was used. From the
`the measurements
`For
`size distribution curves
`and
`the
`total
`pentamidine mass
`particle
`6
`available for
`inhalation with an air flow of
`l/min the fractions of
`particles < 2 pm were calculated. The liquids used in the measurements
`
`68
`
`Liquidia's Exhibit 1098
`Page 4
`
`
`Liquidia's Exhibit 1098
`Page 4
`
`

`

`
`
`i
`
`COMPOSITION:
`PENTAMIDINE
`WATER f.
`INJ. |
`
`mg
`ml
`
`appearance
`
`colour
`
`pH
`
`density (m/V)
`
`refraction index
`
`viscosity (mPa.s)
`
`6.70.
`
`0.998
`
`1.3329
`
`1.000
`
`superficial tension
`(mN/m)
`
`72.8
`
`.
`
`osm. pressure (Z NaCl
`
`)
`
`0
`
`TABLE 1
`
`Physical data of nebulized liquids
`
`-
`6.0
`
`clear
`‘liquid
`
`300.0
`6.0
`
`ad
`
`clear
`liquid
`
`60.0
`6.0
`
`ad
`
`clear
`liquid
`
`colourless
`
`colourless
`
`colourless
`
`6.19
`
`0.0124
`
`1.3419
`
`1.1830
`
`71.2
`
`0.3806
`
`6.31
`
`1.0014
`
`1.3348
`
`1.0560
`
`68.0
`
`.
`
`not
`measured
`
`
`
`of particle size distribution showed the characteristics represented in
`Table 1, pentamidine (Pentacarinat
`300, Rhéne-Poulenc Rorer).
`
`Points of sizing measurements were:
`Respirgard II: 1, 5, 10 ,15 and 20 min
`Porta-Sonic
`;: 0.5 (10 mg/ml), 1, 5 and 9 min
`FISO Neb
`: 1,
`3 and 5 min
`
`the aerosol
`In case of Porta-Sonic the air supply was used to direct
`into the laser beam. The vacuum pump connected with the filter was only
`used to collect the pentamidine waste.
`
`The nebulizers used were operated according to FIGURES 2A, 2B, 2C
`
`air supply1
`*
`
`1: air compressor
`2: flow meter
`3: nebulizer
`4: laser particlesizer
`5: filter
`6: vacuum pump
`
`aan
`
`— air supply
`.
`== Spentair
`== aerosol
`
`FIGURE 2A: The Respirgard II arrangement
`
`69
`
`the
`mass
`is of
`
`nents
`
`Liquidia's Exhibit 1098
`Page 5
`
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`Liquidia's Exhibit 1098
`Page 5
`
`

`

`
`
`
`
`
`
`
`spentair
`
`
`
`LJ
`
`— air supply
`
`== spentair
`2 aerosol
`
`
`
`| air supply
`
`1: air compressor
`. 2: flow meter
`3: nebulizer
`4: laser particlesizer
`5:filter
`6: vacuum pump
`
`FIGURE 2B: The Porta-Sonic arrangement
`
`spent air
`
`4
`
`
`
`
`
`
`
`e
`
`ambientair
`sucked by nebulizer
`
`.
`
`-
`
`1: nebulizer
`2: laser particlesizer
`3: filter
`4: vacuum pump
`
`
`
`
`
`|
`
`
`
`
`
`
`
`3
`
`——~ air supply
`=== spentair
`<= aerosol
`
`
`
`
`
`FIGURE 2C: The FISO Neb arrangement
`
`= Particle size measurement principle: laser-light scattering,
`apparatus: Malvern Master Sizer
`
`HPLC analysis
`
`in different solutions
`of pentamidine
`the content
`fo determine
`during this study a new HPLC-assay method was established. The different
`samples
`to be analyzed by HPLC were obtained from starting solutions,
`retaining solutions from nebulizer chambers, outwashing solutions from
`the pipes
`and collected aerosols
`in water. The new HPLC-method was
`statistically validated and the linearity of
`the determinations was
`checked.
`Two analytical HPLC-runs of each sample with two injections
`were made
`to calculate the mean value of
`the different components of
`interest.
`Chromato-
`2500
`D
`LC-System with
`HPLC Merck-Hitachi:
`Apparatus:
`Integrator. Reagents: water,
`HPLC grade; acetonitrile,
`HPLC grade;
`trifluoroacetic-acid,
`puriss;
`methanol,
`p.a..
`The
`quantitative
`determination follows the method ‘external standard". For
`this purpose,
`exactly identical portions
`(10 pl) of each sample
`and standard are
`injected into the
`separating column. Column: Kromasil
`5C8,
`250 mm
`length,
`4 mm internal diameter; mobile phase: A: 0.12 trifluoroacetic-
`
`70
`
`
`
`Liquidia's Exhibit 1098
`Page 6
`
`
`Liquidia's Exhibit 1098
`Page 6
`
`

`

`7B 23 - 100,
`acid, B: acetonitrile; gradient:
`Flow rate: 1 ml/min;
`temperature: 40°C.
`
`7 min; detection: 263 nm,
`
`4
`
`Pentamidine mass distribution
`
`RESULTS
`
`The relationships between pentamidine concentrations in the liquids
`the
`air
`flows,
`the
`types
`of nebulizer
`and
`the
`"static"
`used,
`nebulization without’ motion or
`tapping nebulization with motion or
`tapping and
`the
`repartition of
`the pentamidine mass
`introduced to
`nebulization are shown in TABLE 2, 3, 4, 5, 6, 7 and 8.
`
`TABLE 2
`
`Pentamidine ‘mass distribution with Respirgard II nebulizer
`
`PENTAMIDINE CONCENTR.
`AIR FLOW
`NEBULIZING TIME, TOTAL
`
`300 mg /6 ml
`6 1/min
`25 min
`
`.
`
`nebulizing liquid
`
`Pentamidine
`mg
`desired
`
`Pentamidine
`mg
`actual
`
`retained in Respirgard. II
`
`18.93 Z (m/m)
`
`56.79
`
`109.10
`
`retained in filter and
`tubes
`
`nebulized
`
`40.78 Z (m/m)
`
`40.29 Z (m/m)
`
`122.34
`
`120.87
`
`110.90
`
`80.00
`
`TABLE 3
`
`Pentamidine mass distribution with Respirgard II
`
`PENTAMIDINE CONCENTR.
`AIR FLOW
`NEBULIZING TIME, TOTAL
`
`60 mg/6 ml
`6 1/min
`25 min
`
`nebulizing liquid
`
`Pentamidine
`mg
`desired
`
`Pentamidine
`mg
`actual
`
`retained in Respirgard II
`
`10.17 Z (m/m)
`
`6.10
`
`retained in filter and
`tubes
`
`47.50 2 (m/m)
`
`28.50
`
`10.86
`
`38.50
`
`10.64
`25.40
`42.33 Z (m/m)
`nebulized
`eee
`
`71
`
`
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`Liquidia's Exhibit 1098
`Page 7
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`Liquidia's Exhibit 1098
`Page 7
`
`

`

`TABLE 4
`;
`
`Pentamidine mass distribution with Porta-Sonic with Safe-Vent
`
`s
`
`PENTAMIDINE CONCENTR.
`AIR FLOW
`NEBULIZING TIME WITHOUT
`MOTION
`.
`NEBULIZING TIME, TOTAL
`
`300 mg/6 mi
`24 L/min
`
`12 min
`21 min .
`nebulizing liquid
`,
`:
`
`retained in Porta-Sonic
`
`retained in Safe-Vent
`
`nebulized
`
`16.45 Z
`
`39.35 Z
`
`44.20 2
`
`Table 5
`
`. Pentamidine Pentamidine
`mg
`mg
`desired
`actual
`
`49.35
`
`118.05
`
`132.60
`
`63.00
`
`119.00
`
`118.00
`
`Pentamidine mass distribution with Porta-Sonic with Safe-Vent
`
`PENTAMIDINE-CONCENTR.
`AIR FLOW
`NEBUL. TIME WITHOUT
`MOTION
`NEBUL. TIME TOTAL
`
`60 mg/6 m2
`24 L/min
`
`®
`
`6 min
`20 win
`
`60 mg/6 mi
`6 l/min
`
`9 min
`21 min
`
`~
`
`Penta
`nebulizing midine
`liquid
`mg
`desired
`
`Penta
`nidine
`ng
`actual
`
`Penta
`nebulizing midine
`liquid
`mg
`desired
`
`Penta
`midine
`ng
`actual
`
`-
`
`retained in Porta-Sonic
`
`retained in Safe-Vent
`
`12.09 %
`(a/n)
`
`28.21 %
`(m/m)
`
`7.25
`
`15.60
`
`16.99
`
`35.80
`
`9.97 %
`(n/m)
`
`40.86 %
`(m/m)
`
`5.98
`
`10.30
`
`24.52
`
`26.10
`
`nebulized
`59.60 %
`35.76
`8.60
`49.17 2%
`29.50
`23.60
`(nfm)
`(m/m)
`
`
`Pentamidine mass distribution with Porta-Sonic with Safe-Vent
`
`TABLE 6
`
`PENTAMIDINE-CONCENTR.
`AIR FLOW
`NEBULIZING TIME WITHOUT
`MOTION
`NEBULIZING TIME, TOTAL
`
`300 mg/6 ml
`6 1/min
`
`12 min
`20 min
`nebulizing liquid
`
`retained in Porta-Sonic
`
`retained in Safe-Vent
`
`nebulized
`
`16.91 2%
`(m/m)
`
`33.01 Z
`(m/m)
`
`50.08 Z
`(m/m)
`
`Pentamidine Pentamidine
`mg
`mg
`desired
`actual
`
`50.73
`
`80.90
`
`99.03
`
`133.90
`
`150.24
`
`85.2
`
`Liquidia's Exhibit 1098
`Page 8
`
`
`Liquidia's Exhibit 1098
`Page 8
`
`

`

`TABLE 7
`
`Pentamidine mass distribution with FISO Neb,
`power setting "Minimum"
`
`PENTAMIDINE CONCENTR.
`AIR FLOW
`NEBULIZING TIME, TOTAL
`
`300 mg/6 mi”
`6 l/min
`6.5 min
`
`-
`
`nebulizing liquid
`
`‘
`
`Pentamidine
`mg
`desired
`
`Pentamidine
`mg
`actual
`
`retained in FISO Neb
`
`16.45 Z (m/m)
`
`49.35
`
`70.80
`
`retained in filter and
`tubes
`.
`10.38 Z (m/m)
`31.14
`27.80
`, 73.17 Z (m/m) 219.51nebulized 201.40
`
`
`
`
`
`
`
`
`
`‘ine
`
`cal
`
`00
`
`00
`
`00
`
`ine
`
`al
`
`90
`
`90
`
`TABLE 8
`
`Pentamidine mass distribution with FISO Neb,
`power setting "Minimum"
`
`PENTAMIDINE CONCENTR.
`AIR FLOW
`NEBULIZING. TIME, TOTAL
`
`60 mg/6 ml
`6 l/min
`6.5 min
`
`nebulizing liquid
`
`Pentamidine
`mg
`desired
`
`Pentamidine
`mg
`actual
`
`retained .in FISO Neb
`
`12.12 Z (m/m)
`
`7.27
`
`retained in filter and
`tubes
`
`19.06 Z (m/m)
`
`11.44
`
`11.60
`
`11.70
`
`
`
`68.82 Z (m/m) 41.29nebulized 36.70
`
`
`
`
`
`comparison of nebulized pentamidine mass in Z%, available for
`The
`PCP inhalation therapy is shown in FIGURE 3.
`
`reveals that with an
`the tested three nebulizers
`A comparison of
`initial amount of 60 or 300 mg pentamidine for nebulization,
`the FISO
`Neb is superior in respect of the quantity of nebulized pentamidine. The
`pentamidine
`concentrations,
`i.e.
`60 mg/6 ml
`and
`300 mg/6
`ml
`respectively, used in aerosol
`therapy hardly influence the proportion of
`nebulized pentamidine. During nebulization concentration of pentamidine
`occurs in the nebulizing chambers.
`
`Duration of nebulization
`
`The results are given in FIGURE 4
`
`73
`
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` Page 9
`
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`Page 9
`
`

`

`ReeeeAotot
`
`m
`
`+
`
`thbeEO
`
`a
`
`[%] of Pentamidine
`nebulized
`
` Péntamidine
`
`
`60 mg/6 mi
`
`Pentamidine
`300 mg/6 ml
`
`FIGURE 3: 2 of nebulized pentamidine mass available for inhalation.
`Air flow:
`6 1/min
`
`Duration of nebulization
`
`The results are given in FIGURE 4
`
`time
`[min]
`30-7
`
`Pentamidine 300 mg/6 mi
`
`
`Respirgard I!
`
`6 Yimin.
`
`air flow
`
`Porta-Sonic
`6 Umin.
`
`FISO Neb
`position min.
`
`FIGURE 4: Duration of nebulization
`
`The results given in FIGURE 4 suggest that the nebulization time is
`shortest with the FISO Neb.
`In the case of Porta-Sonic and Respirgard IT
`the nebulization time was prolonged by moving (shaking,
`tapping)
`the
`nebulizers. Our experiments confirmed the variation in nebulization time
`reported in the literature (Vinciguera, Smaldone, 1990). With regards to
`the Respirgard II and Porta-Sonic it
`is recommended not
`to perform
`nebulization by static procedure, but
`to strive for a prolongation of
`nebulization time by slightly shaking and tapping the nebulizer.
`
`
`
`
`- P
`
`entamidine 60 mg/6 mi
`
`
`
`Liquidia's Exhibit 1098
`Page 10
`
`Liquidia's Exhibit 1098
`Page 10
`
`

`

`
`
`
`
`Influence of ultrasonic nebulization on the chemical stability of
`Pentamidine
`
`concentrations of pentamidine
`Nebulization liquids with various
`were nebulized for 30 minutes at different temperatures by an ultrasonic
`method. Additionally; pentamidine
`solutions were
`autoclaved. Under
`laboratory
`nebulization
`conditions
`‘no
`evidence was
`obtained
`of
`decomposition of pentamidine neither. with the ‘Porta-Sonic nor with the
`FISO Neb nebulizer.
`No
`decomposition was
`detectable
`even
`under
`ultrasonic treatment
`involving a higher energy supply using the Branson
`Sonifier 250 at
`room temperature for
`30 minutes. It was
`shown that
`decomposition reactions
`occur
`only at high
`temperatures
`of
`121°C
`(autoclaving) over a period of 20 minutes, affecting 10 - 15 2 of
`the
`pentamidine. Based
`on
`the
`results,
`the
`stability of
`pentamidine-
`containing liquids used for ultrasonic nebulization can be considered
`guaranteed.
`
`Particle size distribution
`
`each
`aerosols obtained by
`the
`Particle size distribution of
`nebulizer under conditions described in the experimental protocol are
`shown in FIGURE 5.
`.
`
`
`
`WRespirgard 11
`
`GRBFiso Neb
`
`Porta-Sonic
`
`
`
`water
`f. injection
`
`Pentamidine
`60 mg/6 ml
`
`Pentamidine
`300 mg/6 ml
`
`FIGURE 5: Mass median diameter
`
`lowest mass median diameter
`For the tested nebulized liquids the
`values 1.91 - 2.51 pum, were obtained by Respirgard II.
`In the case of
`the Porta-Sonic nebulizer the corresponding values were 1.96 - 3.04 um.
`The values for the FISO Neb nebulizer were 5.8 - 6.93 pm. A comparison
`of the data from FIGURE 5
`shows
`that pentamidine concentrations in the
`nebulization liquid of
`0
`-
`300 mg pentamidine/6 ml hardly influence
`particle diameter. A slight decrease of
`the mass median diameters were
`found for all 3 nebulizers at concentration of 300 mg pentamidine/6 ml.
`All measurements of particle size distribution during nebulization are
`shown in FIGURES 6 and 7.
`
`There was no increase in particle size diameter during nebulization
`for any of the liquids nebulized by the 3 nebulizers under study.
`
`75
`
`Liquidia's Exhibit 1098
`Page 11
`
`Liquidia's Exhibit 1098
`Page 11
`
`

`

`
`
`FIG
`
`int)
`conc
`mas<
`FIS(
`ear]
`dec]
`aerc
`162
`pent
`prin
`and
`obta
`nebu
`(eff
`labo
`nebu
`dete
`trea
`pent:
`in t
`dist:
`
`deper
`Sonic
`nebul
`have
`treat
`relat
`
`case
`corre
`confi
`
`tion
`diffr:
`
`Liquidia's Exhibit 1098
`Page 12
`
` IT rr time
`
`
`
` .
`
`v FiSO Neb
`
`.
`
`e
`
`5
`
`*Porta-Sonic
`°
`
`. Respirgard ile
`
`10
`
`15
`
`20.
`
`[min]
`
`FIGURE 6: Change of MMD during nebulization
`Pentamidine 60 mg/6 ml
`
`MMD
`[om]
`
`77
`of.
`
`+ *
`
`+ FISO Neb
`
`-
`
`|
`
`.
`°
`
`* Porta—-Sonic
`°
`
`* Respirgard Ile
`
`= a
`
`fon
`of
`e
`2
`.
`.
`1
`
`DI tere A tim
`0
`5
`10
`15
`20
`{min}
`
`FIGURE 7: Change of MMD during nebulization
`Pentamidine 300 mg/6 ml
`
`Considering the percentage of pentamidine mass nebulized from 300
`mg pentamidine available for inhalation
`and the part of particle sizes
`S$ 2 pm see FIGURE 8 it’s evident that comparing the nebulizers used,
`the
`Porta-Sonic and the Respirgard II nebulizers deliver the highest amounts
`of pentamidine, with the value of about 43 mg available for alveolar
`deposition. For
`the FISO Neb nebulizer only 10.5 mg of particle sizes <
`2 um were found in spite of the highest total mass output of 201.4 mg.
`Similar relations between total mass output and available particle sizes
`< 2 um were observed for 60 mg pentamidine.
`
`DISCUSSION
`
`the
`already mentioned
`As
`alveolar deposition is
`only
`
`output
`a part
`
`of
`of
`
`pentamidine available for
`the
`amount
`of pentamidine
`
`76
`
`Liquidia's Exhibit 1098
`Page 12
`
`

`

`
`
`
`
`§ nebulized Pentamidine particles < 2 um
`
`total nebulized Pentamidine
`
`
`
`
`
`om 300
`2 sizes
`ad,
`the
`amounts
`lveolar
`sizes <
`1.4 mg.
`2 sizes
`
`le for
`amidine
`
`Pentamidine
`Pentamidine
`60 mg/6 mi
`300 mg/6 mi
`FIGURE 8: Output of total nebulized pentamidine and nebulized
`pentamidine with particle size < 2 pm
`
`laboratory standard
`the
`on
`independent
`introduced in the nebilizer
`conditions or clinical use. Comparisons between the present pentamidine
`masses nebulized found to be 80.0 mg and 201.4 mg for Respirgard II and
`FISO Neb by introducing 300 mg pentamidine into the nebulizers,
`and
`earlier published data for Respirgard II by Smaldone et al.
`(1988)
`declared as efficiency: 4.6 Z,
`by Smith et al.
`(1990) declared as
`aerosol output: 127.3 mg, and for FISO Neb by Smaldone et al.
`(1988):
`16Z and Smith et al.
`(1990): 82.7 mg,
`indicate that output of nebulized
`pentamidine is a sensitive function of various parameters: nebulizing
`principle, characteristics and attachment of nebulizer used, air flow
`and air pressure, duration of nebulization, breathing pattern etc.. For
`obtaining of comparable
`data under
`in vitro conditions concerning the
`nebulizing
`capacity,
`the
`terminology
`of
`nebulized
`pentamidine
`(efficiency, aerosol output, pentamidine mass distribution etc.) and the
`laboratory conditions
`should be
`standardized.
`For determination of
`nebulized
`pentamidine
`output
`in
`conditions
`of
`clinical
`use
`the
`determination
`of
`alveolar
`pentamidine
`deposition
`or
`inhalation
`treatment,
`should
`be correlated with investigations
`concerning the
`pentamidine retained in the nebulizer container,
`tubes and valves. Only
`in this way it will be possible to do a real balance of pentamidine mass
`distribution.
`
`The duration of nebulization determined under laboratory conditions
`depends specially on the nebulizer used: Respirgard II: 25 min, Porta-
`Sonic: 9-12 min, FISO Neb:
`5
`-
`6 min. Considering the duration of
`nebulization as treatment time in clinical uses, patient related factors
`have to be considered.
`In the case of Respirgard II for 24 patients a
`treatment
`time of
`15
`to 60 min with a mean
`(SD) of 29.1 (9.6)
`is
`related.
`(Vinciguera, Smaldone, 1990).
`
`evidence of decomposition of pentamidine was obtained in the
`No
`ultrasonic
`nebulizers
`Porta-Sonic
`and
`FISO Neb.
`Thus,
`of
`case
`corresponding
`data
`in the
`literature
`(Konietzko,
`1989) were
`not
`confirmed.
`
`aerosol particle size distribu-
`The published data of pentamidine
`determined
`by
`laser
`light-scattering
`(LL-S),
`laser
`light-
`tion
`diffraction (LL-D) and cascade-impactor
`(CI) methods are different not
`
`77
`
`Liquidia's Exhibit 1098
`Page 13
`
`
`Liquidia's Exhibit 1098
`Page 13
`
`

`

`
`
`é
`
`only by using different nebulizers, but also using the same nebulizer
`and
`similar
`pentamidine
`concentration. Additional, with regard
`to
`particle size, different designations are used: mass median aerodynamic
`diameter
`(MMAD),
`in wm,
`a fictive size,
`referring to a model particle
`with specific weight of water,
`(Corkery et al.,
`1988; Herer et al.,
`1989; Dirnagel, 1971; Matthys.and Herceg, 1990 a, 1990 b); count median
`diameter
`(CMD),
`in’pm (Huchon, 1990); mass median diameter
`(MMD),
`in pm
`(Simonds et al., 1990); diameter,
`in pm (Dirnagel, 1971): volume median
`diameter D(V) 50 Z-value,
`in‘pm, equal
`to the mass median diameter when
`homogeneous. material of
`the same density is used.
`In literature the
`following data are described for the nebulizers Respirgard II and FISO
`Neb: Respirgard IT,
`(CI), MMAD = 0.76 pm, FISO Neb,
`(CI), MMAD = 2.5 pm
`(Smaldone et al., 1988); Respirgard II,
`(LL-D), MMD = 1.2 pm, FISO Neb,
`(LL-D), MMD = 4:7 pm (Smith et al., 1990); Respirgard II,
`(CI), MMAD =
`0.93 pm (Corkery et al., 1988), Respirgard II with baffle,
`(LL-D), MMD
`1 pm, without baffle,
`(LL-D), MMD = 1.7 pm (Simonds et al., 1989). These
`data indicate that smaller particle sizes are measured according to the
`cascade-impactor, method used specially for particle size measurements of
`powder-aerosols..” Laser
`light methods should be preferred, because they
`are able to measure the real droplet size distribution of nebulized
`pentamidine-containing solutions.
`In our investigations we measured mass
`median diameters between 1.9 - 2.5 pm for the Respirgard II nebulizer.
`This values were slightly,higher than the above mentioned data. Mass
`median
`diameters
`obtained
`from Porta-Sonic were
`comparable with
`Respirgard II, whereas the values measured for FISO Neb (5.8 - 6.9 wm)
`were much higher than expected. Due to this fact,
`the FISO Neb nebulizer
`delivers
`only
`small amounts
`of pentamidine
`available
`for alveolar
`deposition in spite of its high total pentamidine mass output. According
`to Simonds et al., 1990, we
`suggest
`from our results to use in the
`future for characterisation of pentamidine containing liquid-aerosols
`only measurement systems based on laser light-diffraction,
`laser light-
`scattering etc., systems, able’ to measure the droplet size distribution.
`
`ACKNOWLEDGMENTS
`
`The authors would
`technical assistance.
`
`like to thank Ernst Vélkel
`
`for his excellent
`
`REFERENCES
`
`(1988). Characteristics of
`CORKERY, K., LUCE, J.M., MONTGOMERY, A.B.
`Nebulizers used in Aerosolized Pentamidine Studies. Respiratory
`care. Vol. 33, No 10, 916.
`JOHNSON, M.A., TALAEE, N. LEE, C.A.,
`SIMONDS, A.K., NEWMAN, S.P.,
`CLARKE, S.W.
`(1990). Alveolar Targeting of Aerosol Pentamidine.
`Am. Rev. Respir. Dis. 141, 827-829.
`HERER, B., GIRAUD, V., MORDELET-DAMBRINE, M.,COLLIGNON, M.A.,
`CHRETIEN, J., HUCHON, G.J.
`(1989). Pentamidine particle size
`increases during aerosolization. Am. Rev. Respir. Dis.139, A248.
`KOHLER, D., SIMONIDES, R., ROTHFUSS, J., VATSAG, E., DAIKELER, G.,
`MATTHYS, H.
`(1983). Aerosolverteilungsmuster von 16 handelstiblichen
`Inhalationspraparaten. Prax: Klin. Pneumol. 37, 922-924.
`DIRNAGEL, K.
`(1971). Technisch-physikalische Grundlagen der
`Inhalationstheorie mit Aerosolen in ihrer Bedeutung fiir die
`Auswahl von Aerosolgeraten. Dtsch. Med. J. 22, 245-247.
`MATTHYS, H., HERCEG, R.
`(1990). Lungendeposition von 300 und 600 mg
`
`Pentamidin,
`inhaliert mit verschiedenen Verneblern. Med. Klin.
`85, 251-254.
`MATTHYS, H., HERCEG, R.
`(1990). Corporal Deposition of Aerosolized
`
`78
`
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`
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`Page 14
`
`

`

`Pentamidine 300 mg Versus 600 mg Inhaled With Three Different
`Nebulizers. Suppl.
`to JAMA SEA, Vol 6, No 2, 29-32.
`HUCHON, G.
`(1990). Effect of Different Nebulizers on the Particle
`Size of Aerosolized Pentamidine. Suppl.
`to JAMA SEA, Vol. 6,
`No 2, 33-35.
`(1990).
`O'DOHERTY, M.,; ‘THOMAS, S., PAGE, Ch., NUNAN, T., BATEMAN, N.
`Lung Deposition Following Aerosolization of Pentamidine with
`Different Nebulizers -.clinical Perspectives. Suppl.
`to JAMA SEA,
`Vol. 6, No 2, 36-38.
`KONIETZKO, N.
`(1989). Verteilung von Aerosolen in der Lunge.
`Die Pneumocystis carinii Pneumonie (Springer Verlag), 85-93.
`VINCIGUERRA, C., SMALDONE, G.
`(1990). Treatment Time and Patient
`Tolerance for Pentamidine Delivery by Respirgard II and
`AeroTech II. Respiratory care, Vol 35, No 11, 1037-1041.
`SMALDONE, G., PERRY, R., DEUTSCH, D.
`(1988). Characteristics of
`Nebulizers Used in the Treatment of AIDS-Related PCP. Journal of
`aerosol medicine, Vol.1, No 2, 113-126.
`WONG, R., HARDY, D.
`(1990). Focus on aerosolized pentamidine: An agent
`for prophylaxis of Pneumocystis carinii pneumonia. Hosp. Formul.,
`Vol. 25, 1061-1075.
`(1989). Comparison of
`SMITH, D., ERSKINE, D., STEELE, I. et al.
`nebulizer efficiency for aerosolizing pentamidine. Fifth Intern.
`Conference of AIDS, Montreal, Canada.
`(abstract TBP 64).
`BASKIN, M., ANTOINE, G. et al.
`(1990). Regional Deposition of
`Aerosolized pentamidine. Annals of Internal Medicine, Vol. No 113,
`677-683.
`
`Article received on August 12, 1991
`in final form February 26, 1992
`
`Reviewed by:
`Myrna Dolovich
`
`Address reprint requests to:
`Jérg Hager, Dipl. Ing.
`Pharmaceutical Development
`Rhone-Poulenc Rorer GmbH
`Nattermannallee 1
`D-5000 Kdln 30
`
`|
`
`ulizer
`rd
`to
`ynamic
`rticle
`= al.,
`median
`in pm
`median
`r when
`ze
`the
`d FISO
`2.5 pm
`O Neb,
`MMAD =
`MMD =
`These
`to the
`nts of
`e
`they
`ulized
`d mass
`lizer.
`Mass
`with
`-9 pm)
`ulizer
`reolar
`ording
`in the
`‘rosols
`
`light-
`ition.
`
`rllent
`
`then
`
`79
`
`Liquidia's Exhibit 1098
`Page 15
`
`
`Liquidia's Exhibit 1098
`Page 15
`
`

`

`
`
`Liquidia's Exhibit 1098
`Page 16
`
`Liquidia's Exhibit 1098
`Page 16
`
`