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Comparative efficacy of cyclosporine eye drop formulations in a mouse model of dry eye

Authors:
  • Ospedale L. Sacco University of Milan

Abstract

Purpose:Dry eye disease (DED) is a complex multifactorial disease with both inflammation and tear film instability recognized as its core mechanism. Topical steroids are effective in treating inflammation but may have important secondary effects. The aim of the present study was to compare the efficacy of various CsA formulations in a mouse model of dry eye with severe corneal epithelium lesions. Methods:Eight to 12-week-old female C57BL6 mice with tail patches of scopolamine (replaced every other days) were housed in controlled environment room to induce dry eye. At day three, following dry eye confirmation by corneal fluorescein staining (CFS, score 0-15) and phenol red thread (PRT) lacrimation test, the mice (n=10/gp) were either treated 3 times a day in both eyes with: 0.05% CsA (Restasis, Allergan, USA), 0.1% CsA (Ikervis, Santen, France), 1% CsA oil solution, and 0.5% loteprednol etabonate (Lotemax, Baush+Lomb, USA), or left untreated. Aqueous tear production and CFS score were assessed during the treatment period, while CD4+ and CD11b+ counts on flat mounted cornea were evaluated at the end of the experiment (at day 10). Results:The PRT lacrimation test confirmed the scopolamine-induced decrease in tear secretion, even though the tear reduction was significant only for the Ikervis group. After 7 days of treatment, the CFS score was reduced (vs. dry eye baseline) by 21, 31, and 44% with Restasis, Ikervis, and the 1% CsA oil solution, respectively. CFS scores at day 3 decreased to 7.8±1.3, 7.3±1.4, and 5.9±1.3 at day 10 for Restasis, Ikervis and the 1% CsA oil solution, respectively. By contrast 0.5% Loteprednol etabonate was not able to decrease CFS. No statistically significant dose dependent CFS reduction was observed with the three CsA formulations. CD11b+ and CD4+ cell counts were slightly decreased both in central and peripheral cornea by Restasis and Ikervis when compared to the untreated control. Conclusions:This study indicates that the three CsA formulations are effective at reducing corneal epithelium lesions in a mouse model of severe DED, and represents good treatment options for the management of DED in patients. The study also suggests that no strict dose dependent relationship exists, since Ikervis (0.1% CsA) is not statistically different from the 1% CsA oil solution.
D0130
Abstract D0130 presented at the Annual Meeting of the Association of Research for Vision and Ophthalmology (ARVO); May 1–5, 2016; Seattle, WA, USA
Comparative efcacy of cyclosporine A eye drop formulations in a mouse model of dry eye
Jean-Sebastien Garrigue1, Philippe Daull1, Laurence Feraille2, Stefano Barabino3
1Novagali Innovation Center, Santen SAS, Evry, France; 2Iris Pharma, La Gaude, France; 3Clinica Oculistica, Di.N.O.G.M.I., Azienda Ospedaliera Universitaria San Martino-IST, Genoa, Italy
INTRODUCTION
Dry eye disease (DED) is a complex
multifactorial disease with both inammation
and tear lm instability recognized as its core
mechanisms.1 Topical steroids are effective
in treating inammation but may have
important secondary effects.2 Cyclosporine A
(CsA), a potent anti-inammatory molecule
with a good safety prole, is the most
commonly used prescription treatment for the
management of DED signs and symptoms.3,4
PURPOSE
The aim of this study was to compare the efcacy of a new cationic emulsion5
of CsA (CsA CE, Ikervis®)6 to that of other available CsA formulations (anionic
emulsion and oily solution) in a mouse model of dry eye with severe corneal
epithelial lesions.7
Table 1. Summary of the physicochemical characteristics of CsA
emulsions8
Parameters Anionic emulsion
Restasis®
Cationic emulsion
Ikervis®
Aspect White opaque to slightly translucent
pH 6.5–8.0 6.0
Osmolality (mOsmol/kg) 230–320 270
Mean droplet size, nm (%)a24 (6), 170 (85), 880 (9) 170 (100)
Zeta potential (mV)bNegative (–60 to –40) Positive (+20 to +40)
Sterility Sterile
CsA (%) 0.05 0.1
aMean droplet size was determined by dynamic light scattering (HPPS, Malvern Instruments).
bzeta potential was determined by electrophoretic mobility measurement (Zetasizer 2000,
Malvern Instruments).
CsA, cyclosporine A.
METHODS
To induce dry eye, female C57BL/6 mice (8–12 weeks old) were housed in
a controlled environment room (CER) and tail patches of scopolamine were
replaced every 2 days.7 Dry eye was conrmed at Day 3 by corneal uorescein
staining (CFS; score 0–15) and the phenol red thread (PRT) lacrimation test. Mice
(10 per cohort) were treated three times a day in both eyes with 0.05% CsA
(Restasis®, Allergan, USA), 0.1% CsA (Ikervis®, Santen, France; Table 1), 1% CsA
oil solution, or 0.5% loteprednol etabonate (Lotemax®, Bausch+Lomb, USA)
or left untreated. Aqueous tear production and CFS score were assessed for 7
days and changes from baseline (Day 3) to Day 10 were calculated. CD4+ and
CD11b+ cell counts were evaluated at Day 10 on at-mounted cornea.
RESULTS
Figure 1. Tear secretion over time (A; n=20 eyes per group) and lacrimation improvement at Day 10 (B; n=20 eyes per group) in mice with induced dry eye treated
with different eye drops
Untreated Lotemax®Restasis®Ikervis®1% CsA oil
0
2
4
6
Untreated Lotemax®Restasis®Ikervis®1% CsA oil
0
20
60
80
40
100
B
A
PRT (mm)
Lacrimation improvement (%)
Baseline Day 3 – before treatment Day 6 Day 10
***
****
**p=0.001, ****p<0.0001.
Data are mean + standard deviation.
CsA, cyclosporine A; PRT, phenol red thread.
Figure 2. Mean CFS score over time (A) and mean reduction in CFS score at Day 10 (B) following induction of dry eye (vs Day 3)
Untreated Lotemax®Restasis®Ikervis®1% CsA oil
0
5
10
15
Untreated Lotemax®Restasis®Ikervis®1% CsA oil
–100
–50
0
50
B
A
Mean CFS score
Reduction in CFS score (%)
Baseline Day 3 – before treatment Day 6 Day 10
****
****
********
****
****
****
****
****
****
****
****
***
***
**
NS NS
n=202020 20 20 20 19 19 19 20 20 20 19 20 20 20 20 20 20 20 20 n=19 n=19 n=20 n=20
**p=0.001, ***p=0.0001, ****p<0.0001. Numbers within or below data columns indicate the number of eyes evaluated for each group. Data are mean + standard deviation.
CFS, corneal uorescein staining; CsA, cyclosporine A; NS, not signicant.
Figure 3. CD11b+ (A) and CD4+ (B) cell densities in at-mounted cornea from mice treated with Restasis® (n=10) or Ikervis® (n=8) or left untreated (n=10) at Day 10
0
10
20
30
40
50
60
70
80
90
100
110
Restasis®Ikervis®
Untreated control
Flat-mounted cornea CD11b+ density Flat-mounted cornea CD4+ density
Restasis®Ikervis®
Untreated control
Peripheral zone Central zone Peripheral zone Central zone
0
50
100
150
200
B
A
CD11b+
density (positive cells/mm
2)
CD4+
density (positive cells/mm
2)
SUMMARY
nThe PRT lacrimation test conrmed the scopolamine-induced decrease in
aqueous production by the lacrimal gland (Figure 1)
nAfter 7 days of treatment, mean CFS scores (Figure 2) reduced by 31% with
Ikervis®; CFS score at Day 3 before treatment was 10.8±1.7 vs 7.3±1.4 at
Day10
nThe anionic emulsion, Restasis®, and the 1% CsA oil solution reduced CFS by
21% and 45%, respectively (Figure 2)
nSurprisingly, Lotemax® did not perform well in this model and resulted in a
11% increase in mean CFS score (Figure 2)
nNo statistical difference in CFS reduction between 1% CsA oil and Ikervis®
was observed; however, a trend toward better efcacy for the 10-fold higher
CsA dose was observed
nA slight reduction, although not signicant, in CD11b+ and CD4+ cell density
was also observed in at-mounted cornea from the Ikervis® group when
compared with the untreated group (Figure 3)
nNo differences between Restasis® and Ikervis® were observed in CD11b+ or
CD4+ cell counts
CONCLUSIONS
nThe three tested CsA formulations
effectively reduced corneal epithelial lesions
in a mouse model of DED, and this study
provides preclinical data in support of these
treatment options for the management of
severe keratitis in DED patients
nNo clear evidence of a CsA-dose-dependent
relationship was observed among the
different CsA formulations in this study
nThese data support the mechanism of
action of the cationic emulsion of CsA
(Ikervis®) recently approved for the
treatment of severe keratitis in patients
with DED6,8,9
REFERENCES 1. DEWS. Ocul Surf 2007;5:75–92. 2. Jung HH et al. Chonnam Med J 2015;51:26–32. 3. Kashani S,
Mearza AA. Expert Opin Drug Saf 2008;7:79–89. 4. Lallemand F, Daull P, Benita S, Buggage R, Garrigue JS. J Drug Deliv
2012;2012:604204. 5. Bague S et al. US Patent 2007-0248645. Santen, 2007. 6. European Medicines Agency. Ikervis
Authorisation. January 2015. 7. Barabino S et al. Invest Ophthalmol Vis Sci 2005;46:2766–2771. 8. Daull P et al. Cornea
2013;32:345–534. 9. Daull P, Lallemand F, Garrigue JS. J Pharm Pharmacol 2014;66:531–541.
Note: In March 2015, IKERVIS® (IKERVIS® 1 mg/mL eye drops, emulsion) was granted Marketing Authorization
by the European Commission.
IKERVIS®, once a day at bed time, is indicated for “treatment of severe keratitis in adult patients with dry eye
disease, which has not improved despite treatment with tear substitutes.”6
ACKNOWLEDGEMENTS/DISCLOSURES
J.-S. Garrigue and P. Daull are employees of Santen SAS (E). L. Feraille is an employee of Iris Pharma (E). S. Barabino
(placeholder for disclosures)
... Effects of CE-CsA and CE alone on signs of DED have also been tested using in vivo mice models. [59][60][61][62][63][64] DED was induced in mice using a controlled environment room with low humidity, as previously described in the literature. 67 Clinically, two Ref. ...
... Decreased secretion of IL-17, TNFα, IFN-γ, IL-2, IL-6 and IL-8 in presence of CE. 55 Human corneal epithelial cell line with scrapping area Wound healing analysis (fluorescence microscopy) Similar behavior of wound healing for CE-CsA, AE-CsA, and PBS. 56,57 In vivo 64 Rats with corneal scraping Quantification of corneal wound healing and inflammatory cell infiltration by IVCM 5 days after scrapping, IVCM scores and cell infiltration were found lower for CE-CsA group compared to CE, 0.2% BAK solution or NaCl. common signs of DED are a loss of tear fluid volume and keratitis. ...
... Results showed that the CFS scores of mice with induced DED were reduced by 36% for the group treated with CE alone (CE-CsA vehicle) and by 59% for the group treated with CE-CsA when compared to the untreated group 62 (Figure 2b), however, only CE-CsA was found to significantly increase tear fluid volume of mice. 64 CE-CsA also exhibited a greater reduction of CFS scores compared to other corticosteroids including 1% methylprednisolone 62 and 0.5% loteprednol etabonate (LE, Lotemax®, Baush+Lomb) 60 as well as 5% lifitegrast solution (Xiidra®, Shire), a lymphocyte functionassociated antigen-1 (LFA-1) antagonist. 61 Interestingly, CE alone was found to be more efficient at reducing CFS scores compared to 5% lifitegrast solution. ...
Article
Full-text available
Background Cyclosporine A (CsA) has been used as a topical treatment for various ocular surface diseases including dry eye disease (DED). Several CsA formulations are available as solutions or emulsions. Purpose This review describes the development and the preclinical testing of a cationic oil-in-water emulsion of CsA (CE-CsA) in terms of pharmacodynamics, pharmacokinetics, and ocular tolerance. Due to the cationic charge, CE electrostatically interacts with the negatively-charged ocular surface, improving its residence time. Compared to other CsA formulations, CE-CsA and CE itself were found to reduce the signs and symptoms of DED, by restoring tear film stability and properties, and inhibiting the expression and secretion of pro-inflammatory factors. No delay in wound healing nor ocular toxicity were observed using CE formulations. Conclusion these findings indicate that the type of vehicle can significantly affect the performance of eye drops and play an ancillary role in DED treatment. CE appears as a promising strategy to deliver drugs to the ocular surface while maintaining its homeostasis.
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Ciclosporin ophthalmic emulsion 0.1% (hereafter referred to as ciclosporin 0.1%) [Ikervis®] is an unpreserved cationic emulsion formulation containing an 0.1% concentration of ciclosporin. It has been approved in various countries worldwide, including those of the EU, for the treatment of severe keratitis in adults with dry eye disease, which has not improved despite treatment with tear substitutes. In a multinational, phase III study in this patient population, once-daily ciclosporin 0.1% was associated with statistically significant and clinically relevant improvements in the signs (corneal surface damage and ocular surface inflammation) of dry eye disease relative to vehicle during the first 6-month treatment period. These beneficial effects were maintained or improved in a subsequent 6-month period, with data suggesting sustainability following treatment discontinuation in a 24-month, phase III extension study. Ciclosporin 0.1% was well tolerated in these studies, with instillation-site pain (which was mostly mild in severity) being the most frequently reported ocular treatment-related adverse event. There were no findings to suggest the systemic absorption of ciclosporin. Thus, once-daily ciclosporin 0.1% is an effective and well tolerated option for the treatment of severe keratitis in adults with dry eye disease.
Article
Full-text available
Dry eye disease (DED) is a multifactorial disease that results in symptoms of discomfort, visual disturbance, and damage to the ocular surface. Because chronic inflammation plays an important role in DED, treatment with topical corticosteroids has been demonstrated to ameliorate the signs and symptoms of the disease. Although these agents have proven short-term efficacy, their long-term use may cause intraocular pressure elevation and cataract progression. A carefully review of the different studies shows that differences between corticosteroids may exist regarding the incidence of side effects and evidence of efficacy in DED patients.
  • Hh Jung
1. DEWS. Ocul Surf 2007;5:75–92. 2. Jung HH et al. Chonnam Med J 2015;51:26–32. 3. Kashani S,
2012:604204. 5. Bague S et al. US Patent European Medicines Agency. Ikervis Authorisation
  • Aa Mearza
  • F Lallemand
  • P Daull
  • S Benita
  • R Buggage
  • Js Garrigue
Mearza AA. Expert Opin Drug Saf 2008;7:79–89. 4. Lallemand F, Daull P, Benita S, Buggage R, Garrigue JS. J Drug Deliv 2012;2012:604204. 5. Bague S et al. US Patent 2007-0248645. Santen, 2007. 6. European Medicines Agency. Ikervis Authorisation. January 2015. 7. Barabino S et al. Invest Ophthalmol Vis Sci 2005;46:2766–2771. 8. Daull P et al. Cornea 2013;32:345–534. 9. Daull P, Lallemand F, Garrigue JS. J Pharm Pharmacol 2014;66:531–541.
  • H H Jung
REFERENCES 1. DEWS. Ocul Surf 2007;5:75-92. 2. Jung HH et al. Chonnam Med J 2015;51:26-32. 3. Kashani S,
European Medicines Agency. Ikervis Authorisation
  • A A Mearza
  • F Lallemand
  • P Daull
  • S Benita
  • R Buggage
  • J S Garrigue
  • S Barabino
Mearza AA. Expert Opin Drug Saf 2008;7:79-89. 4. Lallemand F, Daull P, Benita S, Buggage R, Garrigue JS. J Drug Deliv 2012;2012:604204. 5. Bague S et al. US Patent 2007-0248645. Santen, 2007. 6. European Medicines Agency. Ikervis Authorisation. January 2015. 7. Barabino S et al. Invest Ophthalmol Vis Sci 2005;46:2766-2771. 8. Daull P et al. Cornea 2013;32:345-534. 9. Daull P, Lallemand F, Garrigue JS. J Pharm Pharmacol 2014;66:531-541.