Class of 2010 Abstract / OBJECTIVES: To evaluate the product information and pivotal studies of injectable medications to determine if a specific size descriptor was included and if information was provided for dosing patients with extremes of body weight (body mass index < 18.5 or > 40 kg/m2). METHODS: This is a descriptive study of medications that received an approved new drug application (NDA) by the FDA between 1 January 2004 and 30 January 2009. Any information related to size descriptors, or dosing of patients with extremes of weight, was extracted and evaluated with a dosing usefulness score that ranged from a low of 0 to a high of 3. A score of 2 or greater was considered at least minimally adequate for dosing patients with extremes of weight. RESULTS: Of the 84 medications evaluated, some reference to weight descriptors was found for 23 (27%). None of the medications had information that generated a usefulness score of 2 or greater. CONCLUSIONS: The product information and pivotal studies involving newly approved medications is inadequate for dosing patients with extremes of weight and further research is needed. The FDA should mandate that product information contain the size descriptor and extremes of body weight relative to age and height that were used to develop dosing recommendations.

There has been a significant increase in the number of injectable pharmaceutical products over the last decade that have been incorporated into unique delivery systems such as pen injectors, auto-injectors, or pre-filled syringes. The advancement of these delivery systems and the paradigm shift towards administration of injectables in the out-of-hospital or home setting have introduced variables that can affect the bioavailability of injectable drugs and potential pharmacologic outcomes. An approach that allows for the qualitative and quantitative dispersion assessment of an injectable at the moment of tissue deposition coupled with an assessment of systemic exposure parameters could provide substantial information to researchers developing new injectable formulations and associated delivery systems. The overall goal of this research project was to develop an approach for investigating various injection dynamics, more specifically, dispersion dynamics associated with the administration of parenteral pharmaceutical products utilizing delivery technologies designed to deliver drug below the dermis. This was accomplished by first evaluating the safety and usability of computed tomography (CT) scanning as a novel radioimaging approach to assess qualitative and quantitative dispersion parameters in a cadaver study followed by a randomized, controlled, clinical study to assess CT tissue dispersion and the systemic exposure of iohexol, administered subcutaneously by two delivery systems in human volunteers. The primary finding of this work was the demonstration that CT scanning may be combined with a systemic exposure assessment to provide an effective paradigm for investigating dynamics of injectable delivery impacted by a variety of factors, including the choice of delivery system. In this study, iohexol delivered subcutaneously by an auto-injector resulted in notable qualitative and quantitative dispersion differences, including a higher rate of iohexol loss from the extravascular tissue, as well as differences in early plasma exposure as compared to a pre-filled syringe delivery system. The injections and CT scanning were well tolerated with adverse events limited to mild injection site reactions resolving without intervention. This research resulted in a novel local in-vivo(extravascular disappearance), systemic in-vivo(intravascular appearance) correlation approach that could be utilized to assess a wide variety of dynamics associated with injectable drug delivery below the dermis.

Functional biomaterials are being developed as scaffolds to support endogenous cells and to promote the regeneration of ischemic tissue. The aim for this study was to develop a new translational platform for injectable hydrogels using recombinant human collagen (rHC) of two types: type I (TI) and type III (TIII). The collagen solutions were characterized to ensure batch-to-batch consistency and protein integrity. The hydrogel preparation protocol was extensively monitored to ensure ease of use and high-quality production. Post-gelation, rHC TIII have a higher viscosity compared to rHC TI, yet water content was high for both hydrogels. The cross-linking degree is similar for both rHC hydrogels, which are stable well above physiological temperatures, but rHC TI is more susceptible to enzymatic degradation than rHC TIII. Furthermore, the micro-architecture differed with pore size dimensions of rHC TIII being significantly larger than that of rHC TI. Cardiac fibroblasts were cultured on the rHC hydrogels, and cells attached readily to the scaffold environment, which promoted proliferation. The rHC matrices mechanical and biological properties provide structural support, and demonstrate biodegradability and biocompatibility. The intrinsic physical differences between the rHC hydrogels will likely have implications in future studies. In conclusion, the rHC TI and TIII hydrogels are proven to be suitable matrices for continued investigation towards future translational applications.

Interpenetrating polymer networks (IPN’s) consist of two overlapping cross-linked networks that are not bonded to each other. Hydrogel IPN’s are of application interest due to properties such as mechanical reinforcement, modulated drug release and biodegradation kinetics, dual polymer activities in vivo, and novel nanostructured morphologies. Prior IPN hydrogels reported in the literature either required surgical implantation (disadvantageous for several reasons) or were polymerized in situ (limited to a small subset of biologically safe chemistries). Alternatively, we formed IPN’s using a mixing injector to deliver orthogonally reactive functionalized prepolymer solutions that gel upon contact. Specifically, we use hydrazone chemistry to gel a thermosensitive poly(N-isopropylacrylamide) (PNIPAM) network and kinetically orthogonal thiosuccinimide or disulfide chemistry to cross-link a second network of hydrophilic poly(vinylpyrrolidone) (PVP). The resulting IPN’s preserve the thermoresponsive properties of the PNIPAM constituent but exhibit slower, smaller, and more reversible transitions due to entanglement with the highly hydrophilic PVP network (potentially useful to reduce the problem of burst release in thermoresponsive drug delivery systems). Mechanical reinforcement was evidenced by the increased shear storage modulus of IPN composites relative to the sum of the individual component moduli, particularly so in IPN’s employing the thiosuccinimide-cross-linked PVP. The nanostructure of the IPN hydrogels was further studied using small angle neutron scattering with contrast matching, and was found to combine features characteristic to each single network component (PNIPAM-rich static domains embedded in PVP-rich fractal clusters). However, our results suggest some slight changes to their scattering profiles, indicative of partial mixing or influence of each network structure upon the other. Corroborating investigations with single-molecule super-resolution fluorescence microscopy, operating at a slightly larger length scale, show the formation of separate populations of mixed and individual domains or clusters of each polymer type. These properties suggest such injectable IPN’s for further investigation as prospective biomaterials. / Thesis / Doctor of Philosophy (PhD) / This thesis describes the development of overlapping but unconnected polymer networks formed by mixing of completely injectable polymer precursors. The interlocking pair of networks is based on one component that shrinks upon heating and the other component that offers the potential for biological adhesion. Entanglement between the two components renders them mutually reinforcing and changes the shrinking and reswelling behaviour of the temperature-responsive component. The structure of the composite network is also distinctive from either individual component, forming alternating, unevenly mixed regions richer in one or the other component. The composite’s properties are attractive for a potential bioadhesive drug delivery carrier and, in the future, a possible wound closure biomaterial.

Thesis (MScMedSc)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Background Individuals who are latently infected with Mycobacterium tuberculosis (M.tb) are able to quell the infection by balancing the innate and adaptive immune responses. Glucocorticoids (GCs) can affect this balance and can increase the risk of reactivation of TB. The three month injectable contraceptive medroxyprogesterone acetate (MPA) is widely used by women in developing countries, where TB is rife. MPA, unlike the two monthly contraceptive norethisterone enanthate (NET), possesses selective glucocorticoid activity, and could therefore alter immune responses to TB. Aims The aim of my investigation was to elucidate the immune modulatory effects of the synthetic progestins, MPA and NET, compared to the endogenous hormones, cortisol and progesterone, in Mycobacterium bovis Bacillus Calmette–Guérin (BCG) or anti-CD3 stimulated peripheral blood mononuclear cells (PBMC). I aim to determine the effects of MPA, NET, cortisol and progesterone on the receptor expression of glucocorticoid and various progesterone receptors. I investigate the effect of the above mentioned hormones on the downstream signalling cascades in the presence or absence of either BCG or anti-CD3. The overall immune modulation will be determined with regard to the cytokine production in PBMCs. Methods The presence of receptors for these steroid hormones in PBMCs was verified and BCG, anti-CD3 and hormone induced changes in receptor expression determined through RT-PCR. The impact of cortisol, MPA, NET and progesterone on BCG or anti-CD3 mediated activation of downstream signalling molecules were determined by Western blot as well as Luminex analysis. Results and Conclusion My results show that BCG and anti-CD3 mediated activation of the T cell receptor associated signalling molecules, Lck, ZAP-70, LAT was inhibited by the steroid hormones. Similarly several kinases including JNK, ERK and p38 and transcription factors including STAT3, STAT5 and CREB were differentially affected by the hormones. The inhibition of phosphorylation seen in the different signalling molecules indicated an inhibition of activation of downstream signalling cascades. To investigate the impact of the hormone induced changes in the signalling cascades on the expression of inflammatory and anti-inflammatory cytokines Luminex analysis was performed on the supernatant of the BCG and anti-CD3 stimulated PBMC cultures. Cortisol and MPA, but not NET and progesterone, significantly inhibited the secretion of IL-1α, IL-1β, IL-6, IL-10, TNF-α, IL-12 and IL-13. These results suggest that the immune suppressive effects of MPA are likely mediated through a combination of direct genomic GR action as well as through direct or indirect inhibition of several signalling molecules. The inhibition of the IFN-γ, IL-12, IL-1and IL-6 secretion by MPA could potentially increase the risk of susceptibility to TB in women using this contraceptive. Therefore the absence of glucocorticoid activity seen with NET could make this contraceptive a better choice for women in TB endemic areas. / AFRIKAANSE OPSOMMING: Agtergrond Individue wat latent met Mikobakterium tuberkulose (M.tb) geïnfekteer is, is in staat om die infeksie te onderdruk deur die ingebore en aanpasbare immuunrespons te balanseer. Glukokortikoïede (GCs) kan hierdie balans beïnvloed en kan die risiko van heraktivering van tuberkulose (TB) verhoog. Die drie maande inspuitbare voorbehoedmiddel medroksiprogestroon-asetaat (MPA) word algemeen gebruik deur vroue in ontwikkelende lande, waar TB volop is. MPA, in teenstelling met die twee maandelikse voorbehoedmiddel noretisteroon enantaat (NET), beskik selektiewe glukokortikoïed aktiwiteit, en kan dus die immuunrespons teenoor TB verander. Doelwitte Die doel van my studie was om die immuunregulerende effekte van die sintetiese progestiene, MPA en NET, toe te lig , in vergelyking met die endogene hormone, kortisol en progesteroon, in Mycobacterium bovis Bacillus Calmette - Guerin (BCG) of anti- CD3 gestimuleerde perifere bloed mononukleêre selle (PBMSe). Ek het beoog om die gevolge van MPA, NET, kortisol en progesteroon op die reseptor uitdrukking van glukokortikoïede en verskeie progesteroon reseptore te bepaal. Ek het ondersoek ingestel op die effek van die bogenoemde hormone op die sein transduksie in die teenwoordigheid of afwesigheid van óf BCG of anti-CD3. Die algehele immuun -modulasie sal bepaal word met betrekking tot die produksie van sitokiene in PBMSe . Metodes Die teenwoordigheid van reseptore vir die steroïedhormone in PBMSe is geverifieer en BCG en anti-CD3 en die veranderinge deurdie hormone in verband met die reseptor uitdrukking bepaal deur RT -PCR. Die impak van kortisol, MPA, NET en progesteroon op BCG of anti- CD3 aktivering van sein transduksie molekules is bepaal deur ‘Western blot’ asook Luminex analise. Resultate en gevolgtrekking My resultate toon dat BCG en anti-CD3 die aktivering van die T-sel reseptor wat verband hou met sein molekules , LCK , ZAP -70 , en LAT word geïnhibeer deur die steroïedhormone . Van die kinases insluitend JNK , ERK en p38 en transkripsie faktore, insluitend STAT3 , STAT5 en CREB is beïnvloed deur die hormone. Die inhibisie van fosforilering gesien in die verskillende sein molekules dui daarop aan dat 'n inhibisie van aktivering van sein transduksie. Die impak van die hormoon veroorsaak veranderinge in die sein transduksie met betrekking tot die uitdrukking van inflammatoriese en anti -inflammatoriese sitokiene Luminex analise is uitgevoer op die supernatant van die BCG en anti-CD3 gestimuleerde PBMS kulture. Kortisol en MPA, maar nie NET en progesteroon , het aansienlik die produksie van IL-1α , IL-1β , IL-6 , IL-10 , TNF-α , IL-12 en IL-13 geïnhibeer. Hierdie resultate dui daarop dat die immuunstelsel se onderdrukkende effekte van MPA is waarskynlik bemiddel deur 'n kombinasie van direkte genomiese GR interaksie sowel as deur direkte of indirekte inhibisie van verskeie sein molekules . Die inhibisie van die IFN-γ, IL-12, IL-1 en IL-6 sekresie deur MPA kan potensieel die risiko verhoog van vatbaarheid vir TB in vroue wat hierdie voorbehoedmiddel gebruik. Daarom oor die afwesigheid van glukokortikoïede aktiwiteit wat gesien is met NET, kan maak laat hierdie voorbehoedmiddel 'n beter keuse vir vroue in TB endemiese gebiede.

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Injectable hydrogels are important for use in tissue engineering due to their permeability and biocompatibility. Those that have shear thinning properties allow for minimally-invasive surgical procedures and a way to administer bioactive agents, and therapeutic cells by injection. Currently available injectable hydrogels have a single or dual input/stimulus for crosslinking which limits the range of mechanical properties and often utilize potentially toxic ultraviolet radiation that reduces viability of injected cells. To overcome these shortcomings, a tri-stimuli-responsive alginate-based injectable hydrogel was developed based on: 1) supramolecular complex formation between β-cyclodextrin (β-CD) conjugated alginate and thermo-responsive tri-block Pluronic® copolymers, 2) visible light crosslinking via acrylate conjugation, and 3) ionic crosslinking of the alginate backbone via exposure to calcium chloride. The capabilities of the novel multi-stimuli injectable hydrogel were demonstrated with a custom microfluidic devices (MFDs) to create microspheres encapsulating human mesenchymal stem cell (MSCs). These experiments proved that the new hydrogel was capable of serving as a stimuli responsive material for MSC cell delivery in the therapeutic range of 10-1000 µm in diameter. In order to enhance the drug delivery capabilities of the hydrogel, heparin sodium was conjugated onto the alginate backbone. The affinity of the growth factor, vascular endothelial growth factor (VEGF), to the heparin helped to prevent denaturing of the protein and improved vascularization. This new tri-crosslinking hydrogel with conjugated heparin allows the end-user to control the final physicomechanical and biochemical properties of the hydrogel using different external stimuli. The tri-crosslinking hydrogel is a versatile material that has great promise for a variety of soft tissue repair applications.

Immunotherapy has been widely investigated in cancer, infectious diseases and allergies for prevention or amelioration of disease progression. In the case of vaccines, the key cellular target in stimulating an effective and appropriate immune response is the professional antigen presenting cell or dendritic cell (DC). Cancer vaccines are primarily aimed at the activation of a tumor-specific cytotoxic T lymphocyte (CTL) response whilst vaccines to allergies are aimed at reducing IgE responses. Such vaccines normally involve the administration tumor-associated antigens (TAAs) for cancer, or antigens (Ags) derived from infectious microbes and allergens in the case of allergies. Ags, whether derived from tumor or allergen, can be combined with adjuvants, that include immunostimulatory molecules recognized by the pathogen associated receptors expressed by DCs and can trigger the activation/maturation of DCs. Co-delivery of an appropriate adjuvant with an Ag can stimulate DCs to subsequently promote a robust Ag-specific CTL response which may favor anti-tumor immunity. Cancer vaccines have been widely investigated in the clinics as a complementary therapy to surgery, radiation and chemotherapy. Activation of CTLs against tumor cells that express TAAs could lead to the complete eradication of a cancer and prevent its reoccurrence. In this study I developed microparticles using a polyanhydride polymer prepared from 1,8-bis(p-carboxyphenoxy)-3,6-dioxaoctane (CPTEG) and 1,6-bis(p-carboxyphenoxy) hexane (CPH) that has shown inherent adjuvant properties. I prepared 50:50 CPTEG:CPH microparticles encapsulating a model tumor Ag, ovalbumin (OVA), and synthetic oligonucleotide containing an unmethylated CpG motif, CpG, as an adjuvant. CpG has shown significant potential as an adjuvant for TAA-based vaccines leading to significant anti-tumor immune activity. I have shown that mice vaccinated with OVA-encapsulated 50:50 CPTEG:CPH microparticles developed OVA-specific CTL responses. These mice showed enhanced survival compared to the control treatment groups when challenged with OVA expressing tumor cells . In a more novel in-situ cancer vaccine, TAAs from dying tumor cells (caused by certain chemotherapeutic drugs) can be used as the source of Ags delivered to DCs. The presence of an adjuvant with dying cancer cells can assist in appropriate maturation of DCs so as to promote the generation of an effective tumor/TAA-specific CTL response against released TAAs. In this work I developed a therapeutic in situ tumor vaccine encapsulating a chemotherapeutic drug and CpG. Doxorubicin (Dox) is a widely used chemotherapeutic drug that induces tumor cells to undergo an immunogenic form of apoptosis. Sustained release of Dox in solid tumors of mice can cause the release of a variety of TAAs which can be presented by DCs and, in the presence of CpG, stimulate a strong anti-tumor CTL response. I prepared formulations of poly(lactic-co-glycolic acid) (PLGA) particles loaded with Dox and CpG which demonstrated sustained release of their cargo. I show that among various formulations of Dox and CpG, co-delivery of Dox and CpG in the same PLGA particles in-vivo showed the highest reduction in tumor growth and longest survival when compared to treatment groups of PLGA particles delivering Dox and CpG either alone or in combination. PLGA particles have also been investigated as a prophylactic vaccine delivery system that generates a robust Ag-specific CTL response. This system has been employed for the development of vaccines against various infectious diseases and allergies. However, there has been conflicting opinions regarding the optimum size of PLGA particles required to stimulate an active CTL response. Thus, I developed different sizes of PLGA particles encapsulating OVA and CpG to study the relationship of particle size with the magnitude of OVA-specific CTL responses. I showed that the degree of particle uptake and activation of DCs increased with decreasing size of PLGA particles. I also showed that immunization of mice with 300 nm sized particles demonstrated a higher proportion of OVA-specific CTLs and increased the secretion of IgG2a antibody responses. I also evaluated the efficacy of these particles with a clinically relevant Ag, Dermatophagoides pteronyssinus-2 (Der p2). Mice vaccinated with different sizes of PLGA particles loaded with CpG and coated with Der p2 displayed different magnitudes and types of immune activation against Der p2. The small sized particles decreased the airway hyperresponsiveness associated with allergy-induced asthma. The presence of CpG in the PLGA particle vaccines also reduced the airway hyperresponsiveness. This thesis research has contributed to the identification and development of a delivery system for Dox in combination with CpG which gives sustained release of these molecules within tumors and show the longest survival in tumor bearing mice. This study also optimized the size of PLGA particles for the delivery of vaccine to produce a robust Ag specific immune response for development of vaccination against intracellular diseases, cancer and allergy.

Despite its widespread use, little research has been undertaken on the use of progestogen-only injectable contraceptives by South African women. This thesis is comprised of two sections. Section 1 provides the first comprehensive description of injectable contraceptive use among rural South African women. It includes an analysis of the contraceptive method mix, prevalence of injectable contraceptive use, discontinuation patterns and reported side effects. A comparison of depot medroxyprogesterone acetate (DMPA) versus norethisterone oenanthate (NET-EN) focuses on utilization patterns and costs. The second section gives an account of the pharmacokinetics of DMPA including the first ever population analysis. A cross-sectional, community-based household survey was undertaken in the Hlabisa sub-district of KwaZulu-Natal, South Africa. Interviews were held during 1998 and 1999, with 848 randomly selected women (aged 15-49 years) and with 14 focus groups. There was a heavy reliance on injectable contraceptives which were used by 74% of women practising contraception. By contrast, the condom was the current method of only 4%. The injectable method was the most commonly used method among teenagers. However, in most cases, contraceptive use appeared to commence only after the first pregnancy. Slightly more NET-EN (54%) than DMPA (46%) was used, with younger women more likely to use NET-EN than DMPA (p=0.001). No significant differences in self-reported side effects were found between current users of the two injectables. Health workers played an important role in women's decisions to use the injectable, and in product selection, with NET-EN being recommended for younger women on the basis of concerns about method reversibility. While some women used injectables for long periods of time, discontinuation rates at two years were high, most commonly due to menstrual disturbances. Many side effects were reported by users of both DMPA and NET-EN, with amenorrhoea the most common, experienced by 63% of current injectable users. Heavy bleeding was most commonly reported by previous users (38%). Vaginal wetness was also common, mentioned by 18% and 29% of current and previous users respectively. Utilisation patterns of the two injectable products (DMPA and NET-EN) were analysed by means of a Pareto analysis of injectables issued from four South African provincial pharmaceutical depots over three financial years (1997/8, 1998/9 and 1999/2000). Injectables accounted for a substantial share of total state expenditure on drugs. While more DMPA than NET-EN was issued, NET-EN distribution from two depots increased over the period of analysis, even though DMPA was the cheaper option. The pharmacokinetic analysis was undertaken amongst DMPA users routinely attending family planning services in three Durban clinics in 1996. Medroxyprogesterone acetate levels at the end of the dosing interval were analysed for 94 women. In addition a population pharmacokinetic analysis of 291 serum levels from 111 DMPA users was undertaken. This involved the use of Non Linear Mixed Effect Modelling (NONMEM) to fit the data and determine the pharmacokinetic parameters, apparent clearance (CLIP) and apparent volume of distribution (VIP), and to estimate the influence of covariates on CLIP and VIP (where P is the bioavailability). The final model estimates for CLIP and VIP were 1080 (95% confidence interval: 994, 1166) litres/day and 86200 litres (95% confidence interval: 68246, 104154) respectively. No significant relationships were found between the covariates tested and CLIP and VIP. Concerns raised in the literature about the influence of weight or ethnicity on the pharmacokinetics of DMPA were shown to be unfounded. In the context of South Africa's HIV epidemic, the heavy reliance on injectable contraceptives, which offer no protection against HIV, should be addressed by expanding the contraceptive method mix to include barrier methods such as the female condom. Health providers are influential in contraceptive decision-making and should be encouraged and supported to redress the dependence on the injectable method alone, taking into account the need of many for dual protection against HIV and unwanted pregnancy. Provider counseling should also focus on adherence to dosing regimens, improving continuation rates, and should provide appropriate advice for women complaining about vaginal wetness with injectable use. Promotion of one injectable product over another to younger women is not appropriate. Since DMPA is the cheaper product, provider training about the rational use of injectable contraceptives should include cost considerations. / Thesis (Ph.D.)-University of Natal, 2003.

Thesis (M.A.)--Northern Kentucky University, 2006. / Made available through ProQuest. Publication number: AAT 1435883. ProQuest document ID: 1140194581. Includes bibliographical references (p. 22-24)