EA047564B1 - CYCLOSPORINE FORMULATIONS FOR USE IN THE TREATMENT OF BRONCHIOLITHIA OBLITERATING SYNDROME (BOS) - Google Patents

Abstract

The invention relates to a composition containing cyclosporine A (CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for treating BOS, or for preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, where the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporine A.

Description

Field of technology

The invention relates to pharmaceutical compositions containing cyclosporine A (CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for treating BOS, or preventing or slowing the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS.

State of the art

Lung transplantation has become an effective treatment option for a number of chronic and end-stage lung diseases. Lung preservation techniques have been developed over a long period of time, which have allowed satisfactory results to be obtained in the short term (Hachem RR, Trulock EP. Bronchiolitis obliterans syndrome: pathogenesis and management. Semin Thorac Cardiovasc Surg 2004; 16:350-355). Immunosuppression is a key post-transplant intervention, usually consisting of a triple therapy regimen including cyclosporine A (CsA) or tacrolimus, azathioprine or mycophenolate mofetil for systemic use, and corticosteroids (Knoop C, et al. Immunosuppressive therapy after human lung transplantation. Eur Respir J 2004; 23:159-171).

Transplantation of one or both lobes of the lung is possible. Bilateral lung transplantation is indicated in cases of cystic fibrosis, primary pulmonary hypertension, alpha1-antitrypsin deficiency, emphysema with global insufficiency, frequent severe infections, and idiopathic pulmonary fibrosis complicated by recurrent infections.

Despite systemic immunosuppressive therapy with cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil, and corticosteroids, chronic rejection after transplantation is a severe pulmonary complication accounting for 30% of deaths in lung transplantation, making it desirable to evaluate new therapeutic options.

The development of bronchiolitis obliterans syndrome (BOS), a major contributor to chronic lung allograft dysfunction, is a major cause of morbidity and mortality in long-term lung transplant survivors and remains the major limitation to long-term survival after lung transplantation. It occurs in 60–70% of recipients surviving at five years. The median time to BOS is approximately 18 months. Although the pathogenesis of BOS is multifactorial and not fully understood, chronic rejection resulting from immune-mediated responses (episodes of acute rejection) is considered the dominant cause of BOS (Moffatt-Bruce S, Invited commentary, Ann Thorac Surg. 2009 Sep; 88(3):964-5. doi: 10.1016/j.athoracsur. 2009.06.014) after lung transplantation, despite the systemic use of calcineurin inhibitors for immunosuppression (lacono AT, et al. A randomized trial of inhaled cyclosporine in lung-transplant recipients. N Engl J Med 2006; 354:141-150). Once chronic rejection develops, airway damage increases and becomes irreversible, resulting in patients dying from transplant failure or pneumonia.

At present, there are no satisfactory therapeutic options for the effective treatment of BOS in the setting of bilateral lung transplantation. Increased immunosuppression using commonly used basal immunosuppressive drugs has proven ineffective and is currently associated with a higher incidence of long-term adverse events due to the increased drug burden. Immunosuppressive antibodies may be useful in preventing acute lung graft rejection, but attempts to treat chronic rejection have yielded disappointing results. This is pathomechanistically challenging because acute lung graft rejection is essentially the initial stage of a vasculitis with deleterious reactions against the epithelium of the blood vessels. In contrast, although not yet fully understood in all its details, there is agreement that the site of chronic pulmonary rejection is in the lumen of the lung, i.e., the bronchioles, and is therefore a bronchiolitis rather than a vasculitis. Thus, systemically administered drugs need to cross the alveolar-capillary barrier. Photopheresis is often chosen as a last resort in patients with advanced BOS and is performed for psychological rather than medical reasons. Therefore, new therapies to prevent and treat chronic lung graft rejection are highly desirable, especially after bilateral lung transplantation.

Currently, the median survival is 4.6 years in patients with unilateral lung transplantation, while in patients with bilateral lung transplantation it is 6.6 years. This difference in survival has been shown to be due to a significant delay in the onset of BOS after bilateral lung transplantation compared to unilateral lung transplantation (Hadjiliadis D, et al. Is transplant Operation important in determining posttransplant risk of bronchiolitis obliterans syndrome in lung transplant recipients? Chest 2002; 122:1168-1175).

Successful prevention of BOS or, in the case of already diagnosed BOS, slowing the progression of BOS is identified as a major requirement for improving the outcome of lung transplantation.

It is believed that the most important cause of BOS is the activation of T lymphocytes by

- 1 047564 major histocompatibility complex antigens - or immune-dependent mechanisms (Soubani AO, Uberti JP. Bronchiolitis obliterans following haematopoietic stem cell transplantation. Eur Respir J 2007; 29:1007-1019; Halloran PF, et al. The injury response: A concept linking nonspecific injury, acute rejection, and long-term outcomes. Transplant Proc 1997; 29:79-81). From systemic use, CsA is well known to block T-lymphocyte proliferation by inhibiting the activity of the phosphatase enzyme calcineurin and to reduce the expression of several cytokine genes (eg, interleukin [IL]-2) that are normally induced upon T-cell activation.

While most solid organ transplants are not accessible to localized immunotherapy, lung transplants are an exception due to their unique communication with the external environment, making inhalation a possible therapeutic option.

It has been suggested that topical application of CsA to the lungs may improve efficacy with the potential to reduce systemic exposure to toxic immunosuppressants (Iacono A, et al. Dose related reversal of acute lung rejection by aerosolized ciclosporin. Am J Respir Crit Care Med 1997; 155:1690-1698). Cyclosporin A is a cyclic polypeptide of 11 amino acids. It is produced as a metabolite by the fungus Beauveria nivea. Cyclosporine is an immunosuppressant belonging to the calcineurin inhibitor group, which has been used to prevent graft rejection following organ transplantation in most post-transplant settings since the early 1980s in Europe.

The use of cyclosporine in aerosol form for the prevention and treatment of lung diseases is described in WO 00/45834 A2. In particular, the delivery of cyclosporine to a transplanted lung by aerosol inhalation is disclosed. Cyclosporine can be administered either as a dry powder or in a wet form, such as cyclosporine powder aerosolized in propylene glycol. The document, however, does not mention anything regarding the use of cyclosporine in the form of liposomal cyclosporine A. In addition, no subject receiving the treatment was noted to suffer from obliterating bronchiolitis.

From the study by Corcoran et al. (Preservation of post-transplant lung function with aerosol cyclosporin. Eur Respir J 2004; 23:378-383) it was concluded that peripheral lung deposition of propylene glycol CsA (CsA-PG) at approximately 5 mg or greater may improve lung function in transplant patients, whereas lower doses resulted in deterioration. From the latter study, it was concluded that an effective threshold of > 15 mg/week or > 2 mg/day of CsA deposited in the peripheral lung(s) must be achieved to obtain a therapeutic effect.

A. T. Iacono et al. reported in Eur. Resspir. J. 2004; 23: 384-390 on treatment with aerosolized cyclosporine in lung transplant recipients with obliterating bronchiolitis. In the present study, cyclosporine was also used in the form of a powder dissolved in propylene glycol. In particular, it was noted that recipients with bilateral lung transplants had an increased risk of death from the onset of obliterating bronchiolitis compared with recipients with unilateral lung transplants.

A phase II clinical trial in 58 lung transplant patients showed, after two years of treatment with inhaled CsA-PG, a statistically significant difference in bronchiolitis-free and overall survival in favor of CsA-PG treatment compared with placebo (lacono AT, et al. A randomized trial of inhaled cyclosporine in lung-transplant recipients. N Engl J Med 2006; 354:141-150). In contrast, a phase III multicenter clinical trial showed no greater efficacy than standard care when CsA was used as an adjunctive targeted therapy to prevent chronic rejection in lung transplant patients. The results of the present study are contrary to numerous preclinical and clinical studies that suggest a therapeutic response is the expected outcome. Based on this result, it was concluded that the administration of aerosolized cyclosporine to this highly vulnerable patient population is not without its limitations and one or more of these limitations may have influenced the results of the study. Based on the analysis of these limitations, it was concluded that the use of a more convenient delivery system for the administered drug at more frequent intervals within the inhaled therapy regimen or systemic substitution may prove to be effective (Niven RW, et al. The challenges of developing an inhaled cyclosporine product for lung transplant patients. Respiratory Drug Delivery 2012; 51-60).

With regard to the CsA-PG formulation, patient intolerance and poor patient compliance have been reported due to prolonged inhalation periods of up to 30 minutes (Corcoran TE. Inhaled delivery of aerosolized cyclosporine. Adv Drug Deliv Rev 2006; 58:11191127). Propylene glycol is known to be hyperosmotic with possible patient intolerance and therefore requires pre-treatment with a bronchodilator and a local anesthetic.

Taking these factors into account, a new liposomal formulation of cyclosporine for inhalation use has been developed. The formulation is described in WO 2007/065588.

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Furthermore, new inhalation systems have been proposed for the inhalation of CsA, which are believed to provide more efficient deposition of CsA in the lungs. Examples of such systems are vibrating membrane nebulizers. Such inhalation systems achieve better targeted drug delivery by producing particles of appropriate size for maximum deposition in the peripheral region. Also, the high drug delivery rate from such devices allows for much shorter inhalation periods, which is expected to be an advantage in terms of patient compliance.

In a phase Ib clinical study, lung deposition and pharmacokinetics of 10 and 20 mg radiolabelled aerosolised liposomal CsA (L-CsA) were studied in five bilateral lung transplant patients and seven unilateral lung transplant patients. The aerosol was generated using an eFlow® nebuliser. Patients were administered a single dose of 10 or 20 mg liposomal CsA, which was well tolerated. It was shown that 40±6% (for the 10 mg dose) and 33±7% (for the 20 mg dose), respectively, were deposited in the lung. This resulted in a peripheral lung dose of 2.2±0.5 mg (for the 10 mg dose) and 3.5±0.9 mg (for the 20 mg dose), respectively. Based on once- or twice-daily dosing with 10 mg of the nominal amount of L-CsA, peripheral lung deposition of 14 and 28 mg/week, respectively, can be achieved. The total inhalation times for the nominal doses of 10 and 20 mg were approximately 9±1 min and 20±5 min, respectively. In patients with unilateral lung transplants, almost all deposition (88-90%) occurred in the transplanted portion of the lung. There were no statistically significant differences between patients with unilateral and bilateral lung transplants. Although several preclinical and clinical studies have been conducted with inhaled CsA, conclusions regarding the actual efficacy of inhaled cyclosporine in patients with bilateral lung transplants are inconsistent. Thus, the studies available to date do not allow any conclusions to be drawn regarding the actual efficacy of inhaled ciclosporin for the treatment of chronic lung transplant rejection and, in particular, post-lung transplant bronchiolitis obliterans syndrome (BOS).

Bronchiolitis obliterans syndrome (BOS) is physiologically defined as a sustained decline in FEV1 of 20% or more from maximal post-transplant values. Current immunosuppressive regimens remain largely ineffective. Increased amounts of cyclosporine may be deposited in the lungs when inhaled, resulting in higher concentrations in the airways, which may result in greater efficacy in the treatment of BOS.

WO 2016/146645 A1 discloses a liquid formulation of cyclosporine for use as an inhalation aerosol in a method for preventing or treating chronic lung transplant rejection in patients with unilateral lung transplantation. According to particular embodiments, chronic lung transplant rejection is characterized by bronchiolitis obliterans syndrome (BOS). However, while the document highlights the unexpectedly successful treatment of a subpopulation of patients with unilateral lung transplantation, no conclusion can be drawn for the treatment of patients with bilateral lung transplantation, in particular for those patients with bilateral lung transplantation who have already developed bronchiolitis obliterans syndrome (BOS). Taking into account the disclosed information, successful treatment of patients with bilateral lung transplantation who have already developed bronchiolitis obliterans syndrome does not seem possible.

A. Iacono et al. reported in The Journal of Heart and Lung Transplantation, Vol 37, No 4S, 211 on stabilization of lung function and improved survival with aerosolized liposomal cyclosporine A (L-CsA) in bronchiolitis obliterans syndrome. The paper, however, does not report the results of the study and, therefore, the effectiveness of the treatment in specific patient subpopulations, namely unilateral lung transplant recipients or bilateral lung transplant recipients.

Therefore, there is still a need for preventing or effectively treating bronchiolitis obliterans syndrome (BOS) when it develops and is diagnosed in patients who have undergone bilateral lung transplantation. Therefore, the object of the present invention is to provide means for successfully preventing or treating, in particular, patients with bilateral lung transplantation who have already developed or are diagnosed with BOS, in particular with more severe forms of BOS, such as BOS 1 or BOS 2. Other objects of the present invention will become apparent in view of the present description.

The essence of the invention

According to a first aspect, the present invention relates to a composition comprising liposomal cyclosporin A (L-CsA) for use in the prevention of bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient, or for the treatment of BOS or the prevention or delay in the development of BOS in a bilateral lung transplant patient diagnosed

- 3 047564 tested BOS, where the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporine A.

According to a second aspect, the present invention relates to a method for preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or treating BOS or preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, the method comprising the steps of (a) identifying a patient who has undergone bilateral lung transplantation and is at increased risk of developing or subsequently developing BOS, in particular BOS grade I or higher; and (b) administering to said patient a therapeutically effective dose of aerosolized liposomal cyclosporine A (L-CsA) by inhalation.

Brief description of the drawings

Fig. 1 shows a diagram summarizing the details of the inclusion of patients with unilateral and bilateral lung transplants in the clinical trial, as described further below.

Figure 2 shows the Kaplan-Meier plot of survival probabilities for patients with unilateral and bilateral lung transplantation and non-progressive BOS who were diagnosed with BOS during the 48-week study period.

Figure 3 shows the Kaplan-Meier plot of event-free survival probability for patients with bilateral lung transplantation who were diagnosed with BOS.

Figure 4 shows the Kaplan-Meier plot of event-free survival probability for patients with unilateral lung transplantation who were diagnosed with BOS.

Figure 5 shows the Kaplan-Meier plot of overall survival probabilities for patients with unilateral and bilateral lung transplantation who were diagnosed with BOS 5 years after randomization.

Figure 6 shows the trend analysis of graft destruction as absolute _FOV1 values change over the 48-week study period for unilateral and bilateral lung transplant patients in the L-CsA treatment group (upper graph; L-CsA) and the standard care (SC) group (lower graph; SC).

Figure 7 shows the trend analysis of graft destruction as absolute _FOV1 values changed over the 48-week study period for bilateral lung transplant patients in the L-CsA treatment group (upper graph; L-CsA) and the standard care (SC) group (lower graph; SC).

Figure 8 shows the trend analysis of graft destruction as absolute FEV1 values change over the 48-week study period for unilateral lung transplant patients in the L-CsA treatment group (upper graph; L-CsA) and the standard care (SC) group (lower graph; SC).

Detailed description of the invention

The following terms or expressions in the context of this document shall generally be construed as set forth in this section unless otherwise defined in the description of the invention or unless a different definition is indicated or required by the specific context:

The terms include, includes and including in the context of this document are so-called closed language, meaning that only the specified components are present. The terms contain, contains and containing in the context of this document are so-called open language, meaning that one or more other components may or may not also be present.

The term active pharmaceutical ingredient (also referred to as API throughout this document) means any type of pharmaceutically active compound or derivative that is useful in the prevention, diagnosis, stabilization, treatment, or - generally speaking - management of a condition, disorder or disease.

The term therapeutically effective amount in the context of this document means a dose, concentration or activity that is useful for obtaining the desired pharmacological effect. In the context of the present invention, the term therapeutically effective also includes a prophylactic effect. The therapeutic dose should be determined depending on the application in individual patients. Depending on the nature and severity of the disease, the route of administration, as well as the growth and condition of the patient, the therapeutic dose should be established in a manner known to a person skilled in the art.

In the context of the present invention, a pharmaceutical composition is a preparation of at least one API and at least one excipient, which, in the simplest case, can be, for example, an aqueous-based liquid carrier, such as water or a saline solution.

The singular forms do not exclude the plural; i.e., the singular forms are to be understood as including plural objects unless the context clearly indicates or requires otherwise. In other words, all references to characteristics or limitations

- 4 047564 singular forms of this disclosure shall include corresponding characteristics or limitations in the plural, and vice versa, unless they have been expressly defined otherwise or can be clearly understood to have the opposite meaning from the context in which the indication is made. The singular forms in this context have the same meaning as at least one or one or more, unless otherwise indicated. For example, an indication of one ingredient includes mixtures of ingredients, etc.

The expressions one embodiment, an embodiment, a particular embodiment, and the like mean that a particular feature, property, or characteristic, or a particular group or combination of features, properties, or characteristics, as indicated in conjunction with the corresponding expression, is present in at least one embodiment of the invention. The occurrence of these expressions in various parts throughout the present description does not necessarily refer to the same embodiment. Furthermore, individual features, properties, or characteristics may be combined in any suitable manner in one or more embodiments.

The term treatment, in the context of this document, includes therapeutic intervention capable of curing a disease, condition or symptom; but also positive dynamics, improvement, control, monitoring of development, etc.

The term prevention includes the prevention or slowing down of the development of a disease, condition, or symptom, or the prevention of further growth and spread and recurrence or development after the initial elimination of the cause of the disease, condition, or symptom.

The terms patient and subject are used synonymously in the context of this document. As a rule, these terms refer to humans. However, the invention is not limited to humans and can be applied to animals if necessary.

The terms essentially, approximately, roughly, essentially and the like, when combined with a feature or value, include the exact feature or exact value, as well as any feature or value that is within the range of normal values or variations acceptable in the relevant technical field. For example, essentially water-free means that water is intentionally not included in the composition, but the presence of residual moisture cannot be excluded.

In the context of this document, the use of the term approximately or roughly covers variations allowed in the pharmaceutical industry and inherent in pharmaceutical products, such as differences in content due to manufacturing variations and/or time-related degradation of the product. The term includes any variation that, in the practice of pharmaceutical products, allows the product to be assessed for bioequivalence of the stated activity of the claimed product in mammals.

A carrier, as used herein, may generally mean any compound, structure or material that is part of a formulation that facilitates, provides or enhances the delivery of a biologically active compound or material.

The term pharmaceutically acceptable means that the compound or mixture is suitable for the preparation of a pharmaceutical composition that is generally safe, non-toxic, and not biologically or otherwise undesirable and includes that which is acceptable for pharmaceutical use in humans.

In its broadest sense, the present invention relates to a composition comprising cyclosporine A (CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient, or for treating BOS or preventing or slowing the progression of BOS in a bilateral lung transplant patient diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporine A.

Further, the present invention relates to a composition comprising cyclosporine A (CsA) for use in the treatment of bronchiolitis obliterans syndrome (BOS) or the prevention or delay of the progression of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporine A.

According to a first aspect, in particular, the present invention relates to a composition comprising liposomal cyclosporin A (L-CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for treating BOS or preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporin A (CsA).

The compositions for use according to the present invention comprise cyclosporin A (CsA) or, in particular, liposomal CsA (L-CsA) in a therapeutically effective dose or amount, as described below and as described in detail, for example, in the above-mentioned WO 2007/065588. The pharmaceutical

- 5 047 564 compositions for use according to the present invention in particular embodiments may be liquid compositions. In these embodiments, the compositions for use according to the present invention comprise L-CsA and a liquid carrier or vehicle in which L-CsA can be dissolved, dispersed or suspended. In particular embodiments, these compositions comprise a therapeutically effective dose of CsA, an aqueous liquid carrier, a first solubility enhancer selected from the group of phospholipids and a second solubility enhancer selected from the group of nonionic surfactants to form liposomally solubilized CsA (L-CsA).

Phospholipids that can be included in the compositions for use according to the present invention are, in particular, mixtures of natural or enriched phospholipids, for example lecithins, such as the commercially available Phospholipon G90, 100, or Lipoid 90, S 100. Accordingly, in preferred embodiments, the phospholipids that can be contained in the compositions for use according to the present invention can be selected from the group of phospholipids that are mixtures of natural phospholipids.

Phospholipids are amphiphilic lipids that contain phosphorus. Also known as phosphatides, they play an important role in nature, in particular as bilayer components of biological membranes, and those phospholipids that are chemical derivatives of phosphatidic acid are often used for pharmaceutical purposes. The latter are (usually double) acylated glycerol-3-phosphate, in which the fatty acid residues can be of different lengths. Derivatives of phosphatidic acid are, for example, phosphocholines or phosphatidylcholines, in which the phosphate group is additionally esterified with choline, as well as phosphatidylethanolamine, phosphatidylinositols, etc. Lecithins are natural mixtures of various phospholipids that usually contain a high proportion of phosphatidylcholines. Preferred phospholipids according to the present invention are lecithins, as well as pure or enriched phosphatidylcholines, such as dimyristoylphosphatidinecholine, dipalmitoylphosphatidylcholine and distearoylphosphatidinecholine.

In particular embodiments, the first solubility enhancer selected from the group of phospholipids included in the compositions for use according to the present invention may be selected from the group of phospholipids and may be lecithin, in particular lecithin-containing residues of unsaturated fatty acids. In other preferred embodiments, the membrane-forming substance selected from the group of phospholipids is lecithin selected from the group consisting of soy lecithin, Lipoid S100, Phospholipon® G90,10, preferably Lipoid S100, or a comparable lecithin. In other preferred embodiments, the membrane-forming substance selected from the group of phospholipids is selected from Lipoid S100, Lipoid S75, in particular Lipoid S100.

In particular embodiments, the weight ratio of the membrane-forming substance selected from the group of phospholipids as described above relative to CsA is selected in the range of from about 8:1 to about 11:1, from about 8.5:1 to about 10:1, for example, about 13:1.

The pharmaceutical compositions for use according to the present invention may further comprise a second solubility enhancer or two or more different solubility enhancers selected from the group of non-ionic surfactants. Non-ionic surfactants have - like other surfactants - at least one sufficiently hydrophilic and at least one sufficiently lipophilic part of the molecule. They are monomeric, low-molecular non-ionic surfactants and non-ionic surfactants having an oligomeric or polymeric structure. Examples of suitable nonionic surfactants that may be included in the present invention include polyoxyethylene alkyl ethers, polyoxyethylene sorbitan fatty acid esters such as, for example, polyoxyethylene sorbitan oleate, sorbitan fatty acid esters, poloxamers, vitamin E-TPGS (N-a-to-copheryl-polyethyleneglycol-1000-succinate) and tyloxapol.

In particular embodiments, the second solubility enhancer selected from the group of non-ionic surfactants may be selected from the group of polysorbates and vitamin ETPGS is preferably selected from the group of polysorbates. In a particularly preferred embodiment, the solubility enhancer selected from the group of non-ionic surfactants is polysorbate 80.

In particular embodiments of the present pharmaceutical compositions, the amount of the first membrane-forming substance selected from the group of phospholipids, preferably lecithin, is greater than the amount of the second solubility enhancer selected from the group of nonionic surfactants. In examples of embodiments, the weight ratio of the first membrane-forming substance selected from the group of phospholipids, preferably lecithin, to

- 6 047564 the solubility enhancer selected from the group of nonionic surfactants, preferably polysorbate, is selected in the range from about 15:1 to about 9:1, preferably from about 14:1 to about 12:1, for example about 13:1.

In other particular embodiments, the weight ratio (total amount) of the first solubility enhancer selected from the group of phospholipids to the second solubility enhancer selected from the group of nonionic surfactants, on the one hand, and CsA, on the other hand, is selected in the range of about 5:1 to about 20:1, preferably about 8:1 to about 12:1, and more preferably about 10:1.

In still other particular embodiments, the weight ratio of the first solubility enhancer selected from the group of phospholipids, preferably lecithin, to the second solubility enhancer selected from the group of nonionic surfactants, preferably polysorbate and CsA is selected in the range of from about 15:1:1.5 to about 5:0.3:0.5, and preferably about 9:0.7:1.

In particular embodiments, the compositions, or in particular the liquid compositions for use according to the present invention comprise cyclosporin A (CsA) in the form of liposomal cyclosporin A (L-CsA) or, in other words, in liposomally solubilized form. Therefore, in particular embodiments, the liquid composition for use according to the present invention is a liposomal formulation. The liposomes containing CsA, or, in other words, liposomal CsA (L-CsA), are formed predominantly by the phospholipids included in the composition and are preferably unilamellar liposomes. The liposomes preferably have an average diameter of no more than about 100 nm, as measured as a z-mean by photon correlation spectroscopy using, for example, a Malvern ZetaSizer device, and a polydispersity index of no more than about 0.5, preferably no more than about 0.4, also as measured by photon correlation spectroscopy.

In particular embodiments, the liquid composition for use according to the present invention comprises an aqueous liquid carrier. The liquid carrier may comprise water and, optionally, one or more physiologically acceptable organic solvents, such as ethanol or propylene glycol. In preferred embodiments, however, the present pharmaceutical compositions, in particular in the form of liquid pharmaceutical compositions, do not contain or substantially do not contain organic solvents, in particular do not contain propylene glycol, or contain only ethanol as an organic solvent.

The liquid composition for use according to the present invention may optionally be obtained by providing an aqueous solution or suspension of CsA in a suitable liquid carrier, preferably a suitable aqueous liquid carrier, and dissolving the CsA after adding at least one phospholipid and at least one nonionic surfactant as described above in the form of liposomes.

In particular embodiments, the liquid composition for use according to the present invention may optionally be prepared from a corresponding solid composition for dilution containing miscible or reacting L-CsA with an aqueous solvent or carrier immediately prior to inhalation. Therefore, in particular embodiments, the liquid composition containing liposomal CsA (L-CsA) for use according to the present invention is prepared by diluting liposomal cyclosporin A (L-CsA), preferably L-CsA in lyophilized form.

The solid dilution composition containing L-CsA can be prepared by any method suitable for removing the solvent from the liquid composition. Examples of preferred methods for preparing such solid compositions or formulations, however, include lyophilization and spray drying. Preferably, lyophilization is used.

To protect the active ingredient during the drying process, it may be useful to include lyoprotective and/or bulking agents such as a sugar or sugar alcohol, in particular sucrose, fructose, glucose, trehalose, mannitol, sorbitol, isomalt or xylitol. Of these agents, sucrose is particularly preferred.

A portion of the solid composition containing an effective amount of the active compound, in particular CsA, presented in the form of L-CsA (i.e. a single dose) is preferably dissolved or dispersed in the above-mentioned aqueous liquid carrier. In particular embodiments, the aqueous liquid carrier has a volume not exceeding about 10 ml. Preferably, the effective amount or single dose of CsA or L-CsA is dissolved or dispersed in a volume not exceeding about 5 ml, not exceeding about 4 ml, or even not exceeding about 3 ml of aqueous liquid carrier. The volume of aqueous liquid carrier required to dilute the solid L-CsA composition will depend on the dose of the active ingredient, as well as the desired concentration. If a lower dose is required for the therapeutic effect, a lower volume of aqueous liquid carrier may be sufficient to dissolve or disperse the solid composition containing L-CsA.

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In particular embodiments, an aqueous solution is preferably used as an aqueous liquid carrier for dilution. Therefore, in preferred embodiments of the liquid compositions of the present invention, the aqueous liquid carrier is a saline solution.

In particular embodiments, a saline solution is used as the aqueous liquid carrier, in which the sodium chloride concentration is adjusted to yield a liquid formulation with physiologically acceptable osmolality and tolerability upon dilution. The osmolality of liquid compositions for use according to the present inventions is in the range of from about 450 to about 550 mOsmol/kg in preferred embodiments. Hypo- and hyperosmolality to a certain extent, however, can still be tolerated in most cases. The presence of permeate anions (such as chloride) at a concentration of 31 to 300 mM can improve tolerability (Weber et al. Effect of nebulizer type and antibiotic concentration on device performance, Paediatric Pulmonology 23 (1997) 249-260). A hyperosmotic formulation may in fact be preferred for certain applications. For example, the osmolality of the diluted liquid composition for use according to the present invention can vary from 150 to 800 mOsmol/kg. Preferably, the aqueous liquid composition has an osmolality of about 250 to about 700 mOsmol/kg, or about 250 to 600 mOsmol/kg. Most preferably, the aqueous liquid composition for use according to the present invention has an osmolality of about 400 to about 550 mOsmol/kg.

In particular embodiments, the liquid composition for use according to the present invention is an aqueous solution that essentially consists of a saline solution. In these particular embodiments, as well as in other embodiments in which the aqueous liquid carrier further comprises components or solvents, the concentration of sodium chloride can vary from about 0.1 to about 0.9% (w/v). Preferably, a saline solution with a sodium chloride concentration of about 0.25% (w/v) is used, where the term w/v means the mass of dissolved sodium chloride per volume of liquid carrier contained in one liquid composition.

In cases where the liquid composition is prepared by diluting a dry composition, depending on the osmolality of the composition before drying, the concentration of sodium chloride may also vary from about 0.1 to about 0.9% (w/v). Preferably, a 0.25% (w/v) saline solution is used, as described above.

When used to prepare liquid compositions for use according to the present invention, the solid composition containing CsA, preferably in the form of L-CsA, for dilution may be part of a pharmaceutical kit. Such a kit is preferably a solid composition in combination with a liquid aqueous carrier for dilution. Such a kit for preparing a liquid composition for administration as an aerosol is described in WO 03/035030.

After dilution, the CsA or, in particular, L-CsA formulation should have the same composition as before drying. In case the formulation is a liposomal formulation, it should also contain liposomes after dilution. Preferably, the size of the liposomes is equal to the size of the liposomes before drying and after dilution. With regard to the size of the liposomes, it is particularly preferred that the size of the liposomes, when measured as a z-average by photon correlation spectroscopy, is from 40 to 100 nm, showing the same size distribution (polydispersity coefficient < 0.4) after substitution with 0.25% (w/v) saline.

It has been unexpectedly found that a liquid composition comprising, in particular, liposomal cyclosporin A(L-CsA), as described above, is useful for a method for preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation or for treating BOS or preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in an aerosol form containing a therapeutically effective dose of cyclosporin A(Cs-A).

According to the present invention, bronchiolitis obliterans syndrome (also referred to herein as BOS) can be effectively prevented or treated, preferably treated, in patients with bilateral lung transplantation or the development of BOS can be effectively prevented or slowed down in patients who have undergone bilateral lung transplantation (also referred to herein as patients with bilateral lung transplantation) and in patients diagnosed with BOS, in particular BOS1 or BOS2.

Surprisingly, it was found that when comparing patients who have undergone unilateral lung transplantation (also referred to herein as unilateral lung transplant patients), in particular with patients diagnosed with BOS, treatment or, in particular, prevention or slowing down of the development of manifest BOS can be achieved with greater efficiency in patients with bilateral lung transplantation. In particular, a significant slowing down or even prevention of the development of manifest BOS is achieved in those patients with bilateral lung transplantation who make inhalation of a liquid formulation of liposomal cyclosporine A for

- 8,047,564 uses according to the present invention in addition to standard immunosuppressive therapy (also referred to herein as standard treatment or SOT). Comparable slowing or prevention of BOS was not found in the same time frame in a population with bilateral lung transplants receiving standard immunosuppressive therapy alone, or when compared to patients with unilateral lung transplants, or when treated with L-CsA-containing compositions for use according to the present invention, or when receiving SOT alone.

It should be noted that the different effect of the inhaled cyclosporine composition for use according to the present invention in terms of the type of transplantation (bilateral versus unilateral lung transplantation) was completely unexpected and unforeseen, taking into account the earlier results of the clinical studies disclosed in WO 2016/146645.

According to the present invention, liquid compositions containing L-CsA are useful for a method for preventing bronchiolitis obliterans syndrome (BOS) in patients with bilateral lung transplantation or for treating BOS or preventing or slowing down the development of BOS in patients with bilateral lung transplantation diagnosed with BOS. In preferred embodiments, however, liquid compositions containing L-CsA for use according to the present invention are useful for a method for treating bronchiolitis obliterans syndrome (BOS) or for preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS. The presence of BOS can be determined based on spirometric measurements of forced expiratory volume (FEV). Preferably, a decrease in forced expiratory volume in one second (FEV1) is used as an indicator of the presence of BOS and, therefore, the risk of chronic rejection of the lung graft. FEV1 measurements can be performed according to the current American Thoracic Society (ATS)/European Respiratory Society (ERS) spirometry guidelines. Forced expiratory volume in one second (FEV1) is expressed in liters (L).

The presence of BOS is considered if there is a sustained decline in _FEV1 of at least 20% from the patient's peak values in the absence of other causes. BOS can be confirmed by at least two _FEV1 measurements taken at least three weeks apart. Peak post-transplant values are the two best _FEV1 values taken at least three weeks apart. _FEV1 measurements should be confirmed and taken at least three weeks apart. Bronchodilators should be discontinued before FEV1 is assessed. It can be assumed that a decline in FEV1 due to causes other than chronic rejection, such as acute rejection or lymphocytic bronchitis or infection, will respond to appropriate medical management and that a sustained, irreversible decline in function is associated with the development of chronic rejection and BOS.

Based on the percentage of FEV1 decline, it is possible to create a BOS classification scale (Estenne M, et al. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 2002; 21(3): 297-310). The following definitions and criteria can be used:

BOS 0: FEV! > 90% of baseline,

BOS 0-p: FEV1 from 81% to 90% of the initial value,

BOS 1: _FEV1 from 66% to 80% of baseline,

BOS 2: FEV1 from 51% to 65% of baseline,

BOS 3: FEV1 50% or less of baseline.

The compositions for use according to the present invention may be useful for a method for treating BOS or preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS in general, namely, or a degree of BOS, such as BOS 0, BOS 0-p, BOS 1, BOS 2 or BOS 3, and preferably for BOS 1, BOS 2 or BOS 3. In particular embodiments, however, the liquid composition for use according to the present invention is particularly useful for treating patients with bilateral lung transplantation diagnosed with BOS 0-p or higher, preferably BOS 1 or BOS 2. In other particular embodiments, the liquid composition for use according to the present invention is particularly useful for treating patients with bilateral lung transplantation diagnosed with BOS 0-p or BOS 1.

In fact, in order to treat both unilateral and bilateral lung transplant patients as a single population in a single study, the dose administered to unilateral lung transplant patients is preferably approximately half of the dose administered to bilateral lung transplant patients. Since the active compound CsA has a local effect, it is expected that the same effect will be obtained with a dose reduced by half when the target surface is also reduced by half. In other words, it was expected that the same effect will be obtained in unilateral and bilateral lung transplant patients when the dose is adjusted depending on the type of transplant. However, even when a comparable dose is administered, the inventors of the present invention unexpectedly found that the effect of the cycle

- 9 047564 losporin for inhalation in preventing or slowing the progression of manifest BOS, in particular BOS 1 or BOS 2, was much more pronounced in the population with bilateral lung transplantation.

It has been unexpectedly found that the compositions for use according to the present invention can prevent or significantly slow down or reduce the development of BOS, in particular BOS 1 or BOS 2 from the time of manifestation and diagnosis after bilateral lung transplantation when compared with conventional treatment using standard immunosuppressive therapy (SI) alone or when compared with patients with unilateral lung transplantation.

Therefore, the compositions containing CsA or L-CsA for use according to the present invention, used for the treatment of patients with bilateral lung transplantation, can make a significant contribution to increasing and maximizing the probability of survival and survival time for patients with an increased risk of developing or developing BOS, in particular BOS 1 or BOS 2 after bilateral lung transplantation and, thus, reduce or minimize the development and progression of chronic lung transplant rejection. The composition for use according to the present invention can be administered according to a predetermined dosing regimen. In particular, the composition can be administered to a patient with bilateral lung transplantation a specific number of times during each week of treatment. For example, the composition can be administered three times a week. In preferred embodiments, the composition for use according to the present invention is administered daily. In a particular embodiment, the composition for use according to the present invention is administered to said patient with bilateral lung transplantation with an increased risk of developing BOS or with a diagnosed BOS two or even several times a day.

The composition, preferably the liquid composition for use according to the present invention, preferably has a concentration of CsA in the range of about 0.5 to about 10 mg/ml, or in other words, the liquid composition contains CsA in the form of L-CsA in a concentration of about 0.5 to about 10 mg/ml, preferably about 1 to about 6 mg/ml, and more preferably about 1 to about 5 mg/ml. Most preferably, the composition for use according to the present invention contains CsA (in the form of L-CsA) in a concentration of about 4 mg/ml.

The volume of a single dose of the composition for use according to the present invention is preferably low in order to allow a short period of nebulization. The volume, also referred to as dose volume or unit dose volume or single dose volume should be understood as the volume that is intended to be used for a single administration. A single dose is defined as a dose of CsA (in the form of L-CsA) in a composition, in particular a liquid composition, filled into a nebulizer for a single administration. In particular, the volume of a single dose can be less than 10 ml. Preferably, the volume is in the range of about 0.3 to about 3.5 ml, more preferably about 1 to about 3 ml. For example, the volume is 1.25 ml or about 2.5 ml. In case the composition is obtained after dilution, the volume of the liquid carrier, preferably an aqueous liquid carrier or even more preferably a saline solution for dilution should be adjusted to the desired volume of the diluted composition.

The therapeutically effective single dose of CsA contained in the composition for use according to the present invention preferably ranges from about 1 mg to about 15 mg per day for patients with unilateral lung transplantation. Most preferably, an effective single dose of about 10 mg of CsA per day can be used in patients with unilateral lung transplantation. Such doses have been found to be well tolerated by patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS.

A therapeutically effective daily dose of CsA for administration to bilateral lung transplant patients diagnosed with BOS may range from 2 mg to 30 mg. Therefore, in preferred embodiments, CsA is administered at an effective daily dose in the range of 2 to 30 mg or at an effective daily dose in the range of 5 to 30 mg. In a preferred embodiment, an effective daily dose of about 20 mg of CsA may be administered to bilateral lung transplant patients at increased risk of developing or diagnosed with BOS. It should be understood that when CsA is administered in the form of L-CsA, all amounts as stated above refer to the amount of CsA contained in the liposomes.

The compositions or, more preferably, the liquid compositions for use according to the present invention can be effectively converted into an aerosol state and administered using a nebulizer, which can convert a solution, colloidal composition or suspension, such as the compositions according to the present invention containing CsA in the form of L-CsA, into a highly respirable fraction that is capable of reaching the periphery of the lungs. In practice, a jet nebulizer, an ultrasonic nebulizer, a piezoelectric nebulizer, an electrohydrodynamic nebulizer, a membrane nebulizer, an electronic membrane nebulizer, or an electronic nebulizer with

- 10 047564 vibrating membrane. Examples of suitable nebulizers include the SideStream® (Philips), AeroEclipse® (Trudell), LC Plus® (PARI), LC Star® (PARI), LC Sprint® (PARI), I-Neb® (Philips/Respironics), IH50 (Beurer), MicroMesh® (Health & Life, Schill), Micro Air® U22 (Omron), Multisonic® (Schill), Respimat® (Boehringer), eFlow® (PARI), AeroNe-bGo® (Aerogen), AeroNeb Pro® (Aerogen), and AeroDose® (Aerogen) families of devices.

Preferably, however, in particular in cases where liquid compositions containing L-CsA are to be nebulized, a piezoelectric nebulizer, an electrohydrodynamic nebulizer, a membrane nebulizer, an electronic membrane nebulizer, or an electronic vibrating membrane nebulizer is used. In these cases, suitable nebulizers include the I-Neb® (Philips/Respironics), IH50 (Beurer), MicroMesh® (Health & Life, Schill), Micro Air® U22 (Omron), Multisonic® (Schill), Respimat® (Boehringer), eFlow® (PARI), AeroNebGo® (Aerogen), AeroNeb Pro® (Aerogen) and AeroDose® (Aerogen) families of devices. In preferred embodiments, for targeting the CsA medicament, either as such or in the form of liposomal CsA (L-CsA), to the lower respiratory tract, the composition for use according to the present invention is nebulized using an electronic nebulizer with a vibrating membrane. In a particularly preferred embodiment, the liquid composition for use according to the present invention is nebulized using an eFlow® nebulizer (PARI Pharma GmbH).

The eFlow® Nebulizer atomizes a liquid drug formulation, such as the compositions of the present invention, using a perforated vibrating membrane, resulting in an aerosol with a low ballistic momentum and a high percentage of particles with sizes in the respirable range, typically less than 5 μm. The eFlow® Nebulizer is designed to atomize the drug more quickly and efficiently, due to a higher nebulization rate, lower drug loss and a higher percentage of drug availability as a delivered dose (DD) and an inhaled dose (ID) compared to traditional nebulizers, such as jet nebulizers.

Preferably, a suitable nebulizer, in particular a vibrating membrane nebulizer, can deliver such a single dose at a rate of at least about 0.1 ml/min or, provided that the relative density of the composition is normally about 1, at a rate of at least about 100 mg/min. More preferably, the nebulizer can create a performance of at least 0.15 ml/min or 150 mg/min, respectively. In other embodiments, the performance of the nebulizer is at least about 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9 or 1 ml/min.

Therefore, the performance of the nebulizer should be selected to achieve a short period of atomization of the liquid composition. Obviously, the period of atomization will depend on the volume of the composition to be converted into an aerosol and the performance. Preferably, the nebulizer should be selected or adapted so that it can convert into an aerosol a volume of the liquid composition containing an effective dose of the active compound, for no more than about 20 minutes. More preferably, the period of atomization for a single dose does not exceed about 10 minutes. Even more preferably, the period of atomization for a single dose does not exceed about 5 minutes.

In addition to providing a high delivered dose and a short nebulization period, a nebulizer for administering CsA in the form of L-CsA is preferably designed to prevent contamination of the environment with CsA. For this purpose, a filter device can be installed on the exhalation valve of the nebulizer.

In a preferred embodiment, the nebulizer comprises devices for monitoring, for example, the time, date and duration of inhalation by the patient. An example of such devices is a chip card on which the time and duration of nebulization are recorded.

Alternatively, wireless transmission of such data to the cloud and/or a server can be used. This allows health care professionals to check the patient's compliance with the prescribed therapy regimen. The monitoring system may include a nebulizer, such as one of those described above, a controller, a server, a data bank, a cloud, a provider, a physician, a health insurance company, and a telephone service.

Compliance with the prescribed treatment regimen of at least 65% or at least 75% has been found to be effective in achieving adequate prevention or delay of the development of BOS in patients with bilateral lung transplantation. To achieve compliance with the prescribed treatment regimen of at least 65%, a bilateral lung transplant patient at increased risk of developing or diagnosed with BOS, particularly BOS 1 or BOS 2, should inhale the formulation as prescribed for at least 65% of the prescribed inhalation courses. Based on the inhalation frequency of, for example, twice daily, this means that the patient cannot miss more than 39 inhalations over 8 weeks, which is equivalent to approximately 5 inhalations per week. Any inhalation that is missed that is not administered prior to receiving

- 11 047564 full single dose, or which was incomplete for any other reason, is considered a missed inhalation, or in other words, an inhalation that was not performed as prescribed. More preferably, the inhalation of the composition for use according to the present invention is carried out with compliance with the prescribed therapy regimen by at least 75%, i.e. the patient should receive inhalations of the composition as prescribed in a volume of at least 75% of the prescribed inhalation courses, based on the inhalation frequency of 2 times a day. This is achieved when no more than 28 inhalations are missed over 8 weeks, or approximately 3.5 inhalations per week.

In another embodiment, the devices for recording the time, date and duration of the nebulization are connected to a system that immediately emits a signal when the inhalation is not carried out on time and correctly for a predetermined number of courses. By using such monitoring systems, with or without using systems that emit a signal, it is possible to ensure that patients will use the nebulizer correctly. The system that emits a signal can include, for example, detection by a sensor, for example, the presence of liquid in a liquid reservoir, measurement of the inspiratory flow, inhalation time, inhalation duration and / or inhalation volume. Visual, audio or sensory feedback can be given, for example, on the appropriate patient mode and the use of factors affecting the treatment or on the diagnosis of application. This feedback can include information for improving patient compliance with the prescribed therapy regimen to the specified therapeutic treatment protocol and / or deposition and distribution of CsA in the lungs.

In embodiments where, for example, the time, date and duration of each inhalation are recorded on monitoring devices, it is possible to monitor the patient over a long period of time. In an embodiment where the monitoring systems are linked to a system that emits a signal, the patient's inhalation regimen can be adjusted immediately as soon as the patient's compliance with the prescribed therapy regimen drops below a predetermined compliance limit. The signal can be a signal emitted by the nebulizer itself, but can also be a signal emitted by a remote device that, for example, notifies the patient's attending physician. Upon receiving a notification of non-compliance with the prescribed therapy regimen, the attending physician can contact the patient in order to remind him/her that correct inhalation is a prerequisite for the successful prevention of chronic rejection of the lung transplant.

The present inventors have found that monitoring is useful in lung transplant patients, and in particular in bilateral lung transplant patients, since the effect of the inhaled liquid formulation of L-CsA is more pronounced in patients who comply with the treatment regimen.

Furthermore, the effectiveness of administering the composition for use according to the present invention to a patient with bilateral lung transplantation at increased risk of developing or diagnosed with BOS for a long period of time, such as a period of at least 2 weeks, or at least 4 weeks, or at least 8 weeks, or at least 12 weeks, or at least 16 weeks, or at least 20 weeks or even longer, has been found. In particularly preferred embodiments, the liquid composition for use according to the present invention is administered for at least 24 weeks, or even 36 or even 48 weeks, or an even longer period, such as 12 months, 24 months, 36 months or even years, such as 4 years or 5 years or even 6 years, if this can be indicated for preventing BOS or slowing down or reducing the progression of BOS, in particular BOS 1 or BOS 2 in a patient with bilateral lung transplantation.

In other preferred embodiments, the administration of the compositions for use according to the present invention is carried out on a continuous daily basis, preferably once or even more times a day, preferably twice a day for at least 24 weeks, preferably at least 48 weeks.

In another embodiment, the inhalation composition of CsA of the present invention is used in combination with one or more active ingredients used in standard immunosuppressive therapy after lung transplantation. Therefore, in preferred embodiments, the liquid composition for use according to the present invention is characterized in that the patient with bilateral lung transplantation is co-administered with standard immunosuppressive therapy (also referred to herein as SI).

In standard immunosuppressive therapy after lung transplantation, one or more active ingredients from the immunosuppressant and corticosteroid groups may be administered. Examples of immunosuppressants are compounds belonging to the immunoglobulin (antibody) groups, cell cycle inhibitors (antimetabolites/antiproliferative agents) such as azathioprine and mycophenolic acid and its salts, and calcineurin inhibitors such as cyclosporine, tacrolimus, or mTOR inhibitors such as sirolimus and everolimus. Examples of corticosteroids are compounds belonging to the hydrocortisone group, methylprednisolone, prednisone and any of their salts, esters and derivatives.

- 12 047564

In particular embodiments, the composition for use according to the invention is used in combination with one or more active ingredients selected from the group consisting of tacrolimus, mycophenolate mofetil and/or corticosteroids, preferably in an oral standard immunosuppressive therapy. Therefore, in particular embodiments, the composition for use according to the present invention is administered in combination with a standard immunosuppressive therapy comprising the administration of one or more active ingredients selected from the group consisting of tacrolimus and cyclosporine; mycophenolate mofetil or sirolimus; and corticosteroids.

In other particular embodiments, the composition for use according to the present invention is used in combination with a triple combination therapy in which a combination of calcineurin inhibitors, cell cycle inhibitors and a corticosteroid are administered. Preferably, the calcineurin inhibitor is tacrolimus, the cell cycle inhibitor is mycophenolate mofetil and the corticosteroid is prednisone. The active ingredients that are used in combination with the composition according to the invention are preferably administered orally. In these cases of standard immunosuppressive therapy, tacrolimus is typically administered in an amount that provides a whole blood level (WBTL) of 8 to 12 ng/ml, preferably an amount of about 0.06 mg/kg (taking into account the body weight of the patient undergoing treatment). In addition, mycophenolate mofetil in standard immunosuppressive therapy is typically administered in an amount of about 1 g, sometimes up to and including 3 g, preferably about 1 g. Prednisone, when used as part of standard immunosuppressive therapy, is typically administered in an amount of about 20 to about 25 mg/day, preferably about 20 mg/day.

In this regard, the standard dose of active ingredients used in standard immunosuppressive therapy can be reduced when the liquid cyclosporine inhalation composition of the present invention is used in combination with these ingredients. In other words, the dose that is usually required for successful immunosuppression when CsA for inhalation, or in particular L-CsA - which is defined herein as the standard dose - is not used - can often be reduced. This is advantageous since immunosuppressants for systemic administration can cause significant undesirable effects, which are usually dose-dependent.

The compositions for use according to the present invention allow for the effective treatment or prevention of BOS in patients with bilateral lung transplantation or the effective slowing of the development of BOS in patients with bilateral lung transplantation diagnosed with BOS. As mentioned earlier, a decrease in forced expiratory volume in one second (FEV1) can be used as an indicator of the presence of BOS and, therefore, an increased risk of chronic lung transplant rejection. Therefore, in particular embodiments, the compositions for use according to the present invention are suitable for the treatment of BOS, in particular BOS 1 or BOS 2, in patients with bilateral lung transplantation, wherein the development of BOS in a patient with bilateral lung transplantation is substantially prevented or reduced by up to and including 50%, or up to and including 40%, or up to and including 30%, or up to and including 20%, or even up to and including 15% or 10%, or even up to and including 5% reduction in forced expiratory volume in one second (FEV1) in said patient compared to the _FEV1 value of said patient at the start of treatment, or at the start of randomization, or at the start of the study, respectively. In preferred embodiments, the development of BOS, in particular BOS 1 or BOS 2, in a bilateral lung transplant patient is substantially prevented or reduced to a level of up to and including a 20% decrease in forced expiratory volume in one second (FEV1) in said patient compared to said patient's FEV1 value at the start of treatment, or at the start of randomization, or at the start of the study, respectively.

This effect can be achieved by treating bilateral lung transplant patients at increased risk of developing or diagnosed with BOS with the compositions of the present invention or according to the methods of the present invention for a prolonged period of time, such as at least 2 weeks, or at least 4 weeks, or at least 8 weeks, or at least 12 weeks, or at least 16 weeks, or at least 20 weeks or even longer, such as at least 24 weeks, or even 36, or even 48 weeks, or even longer, such as 12 months, 24 months, 36 months or even years, such as 4 years or 5 years or even 6 years, in case it can be indicated for preventing, slowing down or reducing the development of BOS, in particular BOS 1 or BOS 2 in a bilateral lung transplant patient.

In other preferred embodiments, the development of BOS in a bilateral lung transplant patient is substantially prevented or reduced by up to and including 20%, preferably up to and including 10%, in the reduction in forced expiratory volume in one second (FEV1) in said patient compared to said patient's FEV1 value at the start of treatment, or at the start of randomization, or at the start of the study, respectively, after treating said bilateral lung transplant patient for at least 24 weeks with the compositions for use

- 13 047564 treatments according to the present invention, followed by at least 24 weeks without treatment.

Furthermore, it has been found that the compositions for use according to the present invention allow for a significant increase in event-free survival in patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, preferably diagnosed with BOS, wherein event-free survival is characterized as the survival time during which a patient with bilateral lung transplantation does not experience a decrease in FEV1 of at least 20% and/or the need for retransplantation or death.

The compositions for use according to the present invention furthermore make it possible to significantly increase the probability of event-free survival in patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, in particular BOS 1 or BOS 2. Therefore, in preferred embodiments, the composition for use according to the present invention makes it possible to treat a patient with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the probability of event-free survival is at least 50%, or at least 60%, or at least 70%, or at least 80%, or even at least 90% for a period of at least 12 or at least 24 or at least 36 or even for at least 48 weeks or an even longer period, such as 12 months, 24 months, 36 months or even years, such as 4 years or 5 years or even 6 years from the start of treatment, wherein the event is selected from a decrease in _FEV1 of at least 10% or at least 20% and/or the need for retransplantation or death. In preferred embodiments, the probability of event-free survival for a bilateral lung transplant patient at increased risk of developing or diagnosed, preferably diagnosed with BOS, is at least 60%, preferably at least 80% after at least 24 weeks of treatment with the compositions for use according to the present invention, followed by at least 24 weeks without treatment.

In other embodiments, the risk of occurrence of an event selected from a decrease in FEV1 of at least 10% or at least 20%, the need for retransplantation and/or death over an extended period of time, such as at least 2 weeks, or at least 4 weeks, or at least 8 weeks, or at least 12 weeks, or at least 16 weeks, or at least 20 weeks or even longer, such as at least 24 weeks, or even 36, or even 48 weeks, or even longer, such as 12 months, 24 months, 36 months or even years, such as 4 years or 5 years or even 6 years, preferably, however, within 48 weeks from the start of treatment for a patient with a bilateral lung transplant at increased risk of developing or diagnosed with BOS, can be significantly reduced.

Therefore, the composition for use according to the present invention provides for the treatment of patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the risk of occurrence of an event selected from a decrease in _FEVb of at least 10% or at least 20%, the need for retransplantation and/or death (event-free survival probability) over a prolonged period of time, such as at least 2 weeks, or at least 4 weeks, or at least 8 weeks, or at least 12 weeks, or at least 16 weeks, or at least 20 weeks or even longer, such as at least 24 weeks, or even 36, or even 48 weeks, or even longer, such as 12 months, 24 months, 36 months or even years, such as 4 years or 5 years or even 6 years, preferably at at least 48 weeks from the start of treatment for a patient with bilateral lung transplantation receiving a composition according to the present invention in an aerosol form containing CsA or, preferably, L-CsA, is reduced by at least 30% (abs.), preferably by at least 35% (abs.) compared to the risk of occurrence of the corresponding event using standard immunosuppressive therapy (SIT) alone.

In preferred embodiments, the risk of occurrence of an event selected from a decrease in FEV1 of at least 20%, the need for retransplantation and/or death as described above is reduced by at least 30%, preferably by at least 35% (abs), in particular after at least 24 weeks of treatment with the compositions for use according to the present invention, followed by at least 24 weeks without treatment.

Another indicator for identifying the probable prevention or slowing down of the development of BOS in a patient with bilateral lung transplantation is the determination of the average monthly change or, in particular, the monthly loss or decline in FEV1 (AQFEV1/month, also referred to hereinafter as the FEV1 decline) as determined for each patient based on FEV1 measurements carried out on the basis of regular and repeated measurements over a prolonged period of time, as indicated above, such as a period of at least 12 or at least 24 or at least 36 or even after at least 48 weeks or 12 months or even 24 or 36 months or even a longer period such as 4 years or 5 years or even 6 years, preferably over 48 weeks. Therefore, in preferred embodiments, the composition for use according to the present invention provides for the treatment of patients with bilateral trans

- 14 047564 at-risk lung transplantation or diagnosed with BOS, where the monthly change in _FEV1 (AOFEV1/month) remains substantially constant and has a value in the range of about 0 to about 0.055 L/month (corresponding to a loss or decrease in _FEV1 up to and including 0.055 L/month) or about 0 to about 0.05 L/month, or about 0 to about 0.045 L/month, or about 0 to about 0.04 L/month. In preferred embodiments, the composition for use according to the present invention provides treatment for patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the monthly change in _FEV1 (AOFEV^month) remains substantially constant and has a value in the range of about 0 to about 0.04 L/month, meaning that the monthly loss of _FEV1 is in the range of about 0 to about 0.04 L.

Another indicator for identifying a potential slowing down or development of BOS in a patient with bilateral lung transplantation at increased risk of developing or diagnosed with BOS is the determination of the absolute change, or in particular the absolute loss of _FEV1 (AOFEV^abs.) as determined for each patient on the basis of _FEV1 measurements taken at the beginning of treatment and at the end of treatment, in particular after an extended period of time, such as a period of at least 12 weeks or at least 24 weeks or at least 36 weeks or even after at least 48 weeks or 12 months or even 24 or 36 months or even more than 4 years or 5 years or even 6 years, preferably over 48 weeks. Therefore, in particular embodiments, the composition for use according to the present invention provides for the treatment of patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the absolute change in _FEV1 (AOFEVus) from baseline (at the start of treatment) to the end of the treatment period, such as the 48th week after the start of treatment of the patient with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, is no more than 350 ml, which means that the total loss of _FEV1 in said patient is no more than 350 ml, preferably no more than 300, or 250, or 200 or even 150 ml. In other embodiments, the absolute change in _FEV1 (AOFEV^abs) from baseline (at the start of treatment) to the end of the treatment period, such as week 48 after the start of treatment in a bilateral lung transplant patient at increased risk for developing or diagnosed, preferably diagnosed with BOS, is in the range of 150 to 350 mL.

Another indicator for detecting a potential slowing down or development of BOS in a patient with a bilateral lung transplant at increased risk of developing or diagnosed with BOS and receiving treatment with the compositions for use according to the present invention is to determine the relative change, or in particular the relative loss of FEV ₁ (ΔΟΦΒ ₁ /οτη.) relative to the loss of FEV ₁ in a patient receiving only standard immunosuppressive therapy (SI), in particular after a prolonged period of treatment, such as a period of at least 12 or at least 24 or at least 36 or even after at least 48 weeks or 12 months or even 24 or 36 months or even more than 4 years or 5 years or even 6 years, preferably within 48 weeks. Therefore, in particular embodiments, the composition for use according to the present invention provides for the treatment of bilateral lung transplant patients diagnosed with BOS, wherein the relative change or difference in FEV ₁ (ΔΟΦΒ ₁ /οτη.) in a bilateral lung transplant patient receiving a composition comprising L-CsA for use according to the present invention, compared to the loss of FEV ₁ in a patient receiving standard immunosuppressive therapy (SIT) alone, is at least 200 ml, or at least 250 ml, or at least 300 ml, or even more, such as at least 350 ml or at least 400 ml, after a period of at least 12 or at least 24 or at least 36 or even after a period of at least 48 weeks or 12 months or even 24 or 36 months or even more than 4 years, or 5 years or even 6 years, preferably within 48 weeks after the start of treatment.

In preferred embodiments, a composition comprising L-CsA for use according to the present invention provides treatment of patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the relative loss or difference in FEV ₁ (ΔΟΦΒ ₁ /οτη.) relative to the loss in a patient receiving standard immunosuppressive therapy (SI) alone is in the range of about 200 to about 400 ml after 48 weeks from the start of treatment. This means that, for example, according to these preferred embodiments, after a period of 48 weeks, a patient receiving the compositions according to the present invention has an FEV ₁ value that is about 200 to 400 ml greater than the FEV ₁ value of a bilateral lung transplant patient receiving standard immunosuppressive therapy alone.

The composition for use according to the present invention may be particularly useful for the successful treatment of those patients with bilateral lung transplantation with an increased risk

- 15 047564 patients with pulmonary embolism or diagnosed BOS who were not diagnosed with airway stenosis before starting treatment, and in particular those who were not further diagnosed with airway stenosis at 24 weeks after starting treatment, as determined by bronchoscopy with bronchoalveolar lavage (BAL).

Furthermore, the composition for use according to the present invention may be particularly useful for the successful treatment of those patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS who have not been diagnosed with an untreated infection before the start of treatment, and in particular those who have not been diagnosed with an untreated infection at 24 weeks after the start of treatment.

The composition containing CsA, in particular L-CsA for use according to the present invention, should be administered by inhalation in aerosol form. However, this can significantly contribute to reducing the systemic exposure to the patient. Therefore, the composition for use according to the present invention further provides treatment for patients with bilateral lung transplantation at increased risk of developing or diagnosed with BOS, wherein the average concentration of CsA in the blood of a patient with bilateral lung transplantation receiving a liquid composition containing CsA by inhalation is up to 100 ng/ml, preferably up to 60 ng/ml.

According to another aspect, the present invention provides the use of a composition comprising cyclosporine A (CsA) for the preparation of a medicament for the prevention or treatment of bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation or for the prevention or delay of the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of CsA. As indicated above in connection with the compositions according to the first aspect of the invention, the compositions containing CsA can be used in solid or liquid form for the preparation of a medicament according to the present aspect of the invention. In case of using solid compositions, they can be diluted with a suitable liquid carrier or solvent, as described in detail above. In addition, all features disclosed and described above for compositions for use according to the first aspect of the invention can also be applied to such compositions according to the present aspect of the invention.

According to another aspect, the present invention provides a method for preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or treating BOS or preventing or slowing the progression of BOS in a patient with bilateral lung transplantation diagnosed with BOS, the method comprising the steps of (a) identifying a patient who has undergone bilateral lung transplantation and is at increased risk of developing or will subsequently develop BOS; and (b) administering to said patient a therapeutically effective dose of aerosolized cyclosporine A (CsA) by inhalation.

It should be noted that also for the method according to the present aspect of the invention, all the features disclosed and described above for the compositions for use according to the first aspect of the invention can also be used for the method of preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation or treating BOS or preventing or slowing down the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, according to the present aspect of the invention.

For the avoidance of doubt, however, there is provided below a list of numbered embodiments of a composition comprising cyclosporine A (CsA), in particular liposomal CsA (L-CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient, for preventing or slowing the progression of BOS in a bilateral lung transplant patient diagnosed with BOS, according to the present invention, which is also included in a method for preventing bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient or treating BOS or preventing or slowing the progression of BOS in a bilateral lung transplant patient diagnosed with BOS, according to the present aspect of the invention:

1. A composition comprising cyclosporine A (CsA) for use in preventing bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for treating BOS, or for preventing or slowing the progression of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient by inhalation of said composition in aerosol form containing a therapeutically effective dose of cyclosporine A.

2. A composition containing cyclosporine A (CsA) for use according to paragraph 1, for the treatment of bronchiolitis obliterans syndrome (BOS) or for the prevention or slowing of the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, characterized in that the composition is administered to said patient by inhalation of said composition in aerosol form,

- 16 047564 containing a therapeutically effective dose of cyclosporine A.

3. A composition for use according to paragraph 1 or 2, characterized in that the patient with bilateral lung transplantation has been diagnosed with BOS 1 or BOS 2.

4. A composition for use according to any preceding paragraph, characterized in that the composition contains cyclosporin A in the form of liposomal cyclosporin A (L-CsA).

5. A composition for use according to any preceding paragraph, characterized in that the composition is a liquid composition.

6. A composition for use according to paragraph 5, characterized in that the composition contains an aqueous liquid carrier.

7. A composition for use according to paragraph 6, characterized in that the aqueous liquid carrier contains a saline solution.

8. A composition for use according to claim 6 or 7, characterized in that the aqueous liquid carrier essentially consists of a saline solution, preferably a saline solution with a concentration of 0.25%.

9. A composition for use according to any preceding paragraph, characterized in that the liquid composition has a CsA concentration in the range of 0.5 to 10 mg/ml.

10. A composition for use according to any preceding paragraph, characterized in that the liquid composition is prepared by diluting liposomal cyclosporin A in lyophilized form.

11. A composition for use according to any preceding paragraph, characterized in that cyclosporin A is administered in an effective daily dose in the range of 5 to 30 mg.

12. A composition for use according to any preceding paragraph, characterized in that cyclosporin A is administered in an effective daily dose of 20 mg.

13. A composition for use according to any preceding paragraph, characterized in that the composition is administered to said patient twice daily.

14. A composition for use according to any preceding paragraph, characterized in that the composition is administered for at least 24 weeks.

15. A composition for use according to any preceding paragraph, wherein the patient with bilateral lung transplantation is concomitantly receiving standard immunosuppressive therapy.

16. A composition for use according to claim 15, wherein the standard immunosuppressive therapy comprises the administration of one or more active ingredients selected from the group consisting of tacrolimus or cyclosporine; mycophenolate mofetil or sirolimus; and corticosteroids.

17. A composition for use according to paragraph 15 or 16, characterized in that the standard immunosuppressive therapy includes oral administration of tacrolimus, mycophenolate mofetil and prednisone.

18. A composition for use according to any of paragraphs 15-17, characterized in that tacrolimus is administered in an amount of 0.06 mg/kg.

19. A composition for use according to any one of paragraphs 15-18, characterized in that mycophenolate mofetil is administered in an amount of 1 g.

20. A composition for use according to any one of claims 15 to 19, characterized in that prednisone is administered in an amount of approximately 20 to approximately 25 mg/day.

21. A composition for use according to any preceding paragraph, characterized in that the composition is sprayed using an electronic nebulizer with a vibrating membrane.

22. A composition for use according to any preceding paragraph, characterized in that the composition is sprayed using an eFlow® nebulizer.

23. A composition for use according to any preceding paragraph, wherein the development of BOS in a bilateral lung transplant patient diagnosed with BOS is prevented or reduced to a level of 20% reduction in the fixed expiratory volume per second (FEV1) of said patient compared to the _FEV1 value at the start of treatment.

24. A composition for use according to any preceding paragraph, wherein the probability of event-free survival of a patient with bilateral lung transplantation diagnosed with BOS is at least 60% after at least 48 weeks from the start of treatment, wherein the event is selected from a decrease in FEV ₁ of at least 20%, the need for retransplantation and/or death.

25. A composition for use according to any preceding claim, wherein the risk of an event selected from a decrease in _FEV1 of at least 20%, the need for retransplantation and/or death within at least 48 weeks from the start of treatment for a patient with bilateral lung transplantation receiving the aerosol composition of the present invention containing CsA is reduced by at least 30% (abs.), preferably by at least 35% (abs.) compared to the risk of the corresponding event when receiving

- 17 047564 with standard immunosuppressive therapy (SI) alone.

26. A composition for use according to any preceding claim, wherein the mean monthly change in _FEV1 (aMFEV^month) in a bilateral lung transplant patient diagnosed with BOS remains substantially constant or has a value in the range of about 0 to about 0.04 L/month.

27. A composition for use according to any preceding paragraph, characterized in that the absolute change in _FEV1 (AOFEV^abs.) from baseline (at the start of treatment) to the end of treatment in a patient with bilateral lung transplantation diagnosed with BOS does not exceed 350 ml.

28. A composition for use according to any preceding paragraph, characterized in that the relative loss of FEV ₁ (ΔΟΦΒ ₁ /οτη.) in a patient with bilateral lung transplantation diagnosed with BOS relative to the loss of FEV ₁ in a patient receiving only standard immunosuppressive therapy (SI) is at least 200 ml.

29. A composition for use according to any preceding claim, wherein the patient with bilateral lung transplantation has not been diagnosed with airway stenosis prior to the start of treatment, and preferably within 24 weeks after the start of treatment, as determined by bronchoscopy with bronchoalveolar lavage (BAL).

30. A composition for use according to any preceding claim, wherein the bilateral lung transplant patient diagnosed with BOS has not been diagnosed with an untreated infection prior to randomization, and preferably within 24 weeks of starting treatment.

31. A composition for use according to any preceding paragraph, wherein the maximum concentration of CsA in the blood of a patient with bilateral lung transplantation diagnosed with BOS and receiving a liquid composition containing CsA is up to 100 ng/ml, preferably up to 60 ng/ml.

32. A composition for use according to claim 21 or 22, wherein the nebulizer is capable of delivering a single dose at a rate of at least approximately 0.1 ml/min.

33. A method for preventing bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient, or treating BOS or preventing or slowing the progression of BOS in a bilateral lung transplant patient diagnosed with BOS, the method comprising the steps of (a) identifying a patient who has undergone a bilateral lung transplant and is at increased risk for or will subsequently develop BOS; and (b) administering to said patient a therapeutically effective dose of aerosolized cyclosporine A (CsA) by inhalation.

34. A method for treating bronchiolitis obliterans syndrome (BOS) in a patient with a bilateral lung transplant or for preventing or slowing the development of BOS in a patient with a bilateral lung transplant diagnosed with BOS according to claim 33, comprising the steps of (a) identifying a patient who has undergone a bilateral lung transplant and subsequently develops BOS; and (b) administering to said patient a therapeutically effective dose of aerosolized cyclosporine A (CsA) by inhalation.

35. The method according to paragraph 33 or 34, characterized in that the patient with bilateral lung transplantation is diagnosed with BOS 1 or BOS 2 (BOS I or II degree).

36. The method according to paragraph 33 or 34, characterized in that CsA is administered in the form of an aerosol composition containing liposomal cyclosporin A (L-CsA).

37. The method according to paragraph 33, characterized in that CsA is administered in the form of an aerosol liquid composition containing cyclosporine A (CsA).

38. The method according to paragraph 33, characterized in that CsA is administered in the form of liposomal cyclosporine A (L-CsA).

39. The method according to paragraph 34, characterized in that the composition additionally contains an aqueous liquid carrier.

40. The method according to paragraph 39, characterized in that the aqueous liquid carrier contains a saline solution.

41. The method according to paragraph 39 or 40, characterized in that the aqueous liquid carrier essentially consists of a saline solution, preferably a saline solution with a concentration of 0.25% (w/v).

42. The method according to paragraph 37, characterized in that the liquid composition contains CsA in a concentration in the range from 0.5 to 10 mg/ml.

43. The method according to paragraph 38, characterized in that the liquid composition is prepared by diluting liposomal cyclosporin A (L-CsA) in lyophilized form.

44. The method according to paragraph 33, characterized in that cyclosporine A is administered in an effective daily dose in the range from 5 to 30 mg.

- 18 047564

45. The method according to paragraph 33, characterized in that cyclosporine A is administered in an effective daily dose of 20 mg.

46. The method according to paragraph 33, characterized in that the composition is administered to the said patient twice a day.

47. The method according to paragraph 33, characterized in that CsA is administered for at least 24 weeks.

48. The method according to paragraph 33, characterized in that the patient with a bilateral lung transplant simultaneously receives standard immunosuppressive therapy.

49. The method according to claim 48, characterized in that the standard immunosuppressive therapy comprises the administration of one or more active ingredients selected from the group consisting of tacrolimus or cyclosporine; mycophenolate mofetil or sirolimus; and corticosteroids.

50. The method according to paragraph 48, characterized in that the standard immunosuppressive therapy includes oral administration of tacrolimus, mycophenolate mofetil and prednisone.

51. The method according to paragraph 49 or 50, characterized in that tacrolimus is administered in an amount of 0.06 mg/kg.

52. The method according to any of paragraphs 49 or 51, characterized in that mycophenolate mofetil is administered in an amount of 1 g.

53. The method according to any of paragraphs 49 or 52, characterized in that prednisone is administered in an amount of 20 mg/day.

54. The method according to paragraph 33, characterized in that the composition is converted into an aerosol using an electronic nebulizer with a vibrating membrane.

55. The method according to paragraph 33, characterized in that the composition is converted into an aerosol using an eFlow® nebulizer.

54. The method according to any preceding paragraph, characterized in that the composition is administered by inhalation, observing a regimen of at least 75%.

57. The method according to paragraph 33, characterized in that the development of BOS in a patient with a bilateral lung transplant with an increased risk of developing or diagnosed with BOS is prevented or slowed down to a level of 20% decrease in forced expiratory volume in one second (FEV ₁ ) in said patient compared to the FEV ₁ value at the beginning of treatment.

58. The method according to paragraph 33, characterized in that the probability of event-free survival of a patient with a bilateral lung transplant at increased risk or with a diagnosis of BOS is at least 60% after at least 48 weeks from the start of treatment, where the event is selected from a decrease in FEV ₁ of at least 20%, the need for retransplantation, or death.

59. The method according to claim 33, characterized in that the risk of occurrence of an event selected from a decrease in _FEV1 of at least 20%, the need for retransplantation or death within at least 48 weeks from the start of treatment for a patient with bilateral lung transplantation receiving the composition of the present invention in an aerosol form containing CsA, is reduced by at least 30% (abs.), preferably by at least 35% (abs.) compared to the risk of occurrence of the corresponding event when receiving only standard immunosuppressive therapy (SI).

60. The method according to paragraph 33, characterized in that the average monthly change in _FEV1 (AOFEV|/month) of a patient with bilateral lung transplantation diagnosed with BOS remains substantially constant or has a value in the range from about 0 to about 0.04 L/month.

61. The method according to paragraph 33, characterized in that the absolute change in _FEV1 (AOFVCabs.) from the initial level (from the start of treatment) to the end of the treatment period of a patient with bilateral lung transplantation with diagnosed BOS is no more than 350 ml.

62. The method according to paragraph 33, characterized in that the relative loss in _FEV1 (ΔΟΦΒ ₁ /οτη.) in a patient with bilateral lung transplantation diagnosed with BOS relative to the loss of FEV1 in a patient receiving only standard immunosuppressive therapy (SI) is at least 200 ml.

63. The method according to claim 33, characterized in that the patient with bilateral lung transplantation at increased risk of developing or diagnosed with BOS has not been diagnosed with airway stenosis before the start of treatment, and preferably within 24 weeks after the start of treatment, as determined by bronchoscopy with bronchoalveolar lavage (BAL).

64. The method according to paragraph 33, characterized in that the patient with a bilateral lung transplant at increased risk or with a diagnosis of BOS was not diagnosed with an untreated infection before the start of treatment, and preferably within 24 weeks after the start of treatment.

65. The method according to paragraph 33, characterized in that the maximum concentration of CsA in the blood of a patient with bilateral lung transplantation with an increased risk of developing or diagnosed

- 19 047564

BOS and receiving a liquid composition containing CsA is up to 100 ng/ml, preferably up to 60 ng/ml.

66. The method according to paragraph 54 or 55, characterized in that the nebulizer is capable of delivering a single dose at a rate of at least approximately 0.1 ml/min.

65. Use of a composition comprising liposomal cyclosporin A (CsA) for the preparation of a medicament for the prevention of bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for the treatment of BOS, or for the prevention or slowing of the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is administered to said patient in an aerosol form containing a therapeutically effective dose of CsA.

Detailed description of the drawings

Figure 1 shows a flow chart summarizing the details of enrollment of unilateral and bilateral lung transplant patients in the clinical trial described in the example below. A total of 43 patients were assessed for eligibility, of which 23 met the inclusion criteria. One patient died and one patient was withdrawn before randomization. A total of 21 patients were randomized; 11 to the L-CsA treatment group and 10 to the SL (standard care, i.e., standard immunosuppressive therapy) group. One patient in the L-CsA group was withdrawn early from the study due to progressive skin cancer during the 24-week follow-up. Conventional systemic immunosuppression was discontinued due to progressive cancer in this patient, and this patient was managed in the randomized population.

Figure 2 shows the Kaplan-Meier survival probability plot for unilateral and bilateral lung transplant patients with non-progressive BOS who developed BOS during the 48-week study period (i.e., without differentiating between unilateral and bilateral lung transplant patients). Patients in the SL group had a trend toward increased risk of therapeutic failure during the study period (defined as BOS development, retransplantation, retransplant, or death) compared with L-CsA (relative risk (RR): 3.19; 95% confidence interval (95% CI): 0.62 to 16.50; p=0.14).

Figure 3 shows the Kaplan-Meier plot of the event-free survival probability for bilateral lung transplant patients only who were diagnosed with BOS (i.e., excluding results for unilateral lung transplant patients). The event-free survival probability for a bilateral lung transplant patient diagnosed with BOS was 83% for the L-CsA-treated group compared with 50% for the SL-only group. Furthermore, for bilateral lung transplant patients, the relative risk (RR) was 3.43 with a 95% CI of 0.31 to 37.95; p = 0.29, meaning a 3.43-fold higher risk of developing BOS, needing retransplantation, or dying for bilateral lung transplant patients receiving SL only compared with bilateral lung transplant patients receiving L-CsA.

Figure 4 shows the Kaplan-Meier plot of the event-free survival probability for unilateral lung transplant patients diagnosed with BOS only (i.e., no outcome for bilateral lung transplant patients): the event-free survival probability for a unilateral lung transplant patient diagnosed with BOS was 80% for the L-CsA-treated group compared with 50% for the SL-treated group. Furthermore, for unilateral lung transplant patients, the relative risk (RR) was 2.78 with a 95% CI of 0.29 to 26.98; p = 0.36, meaning a 2.78-fold higher risk of developing BOS, needing retransplantation, or dying for unilateral lung transplant patients receiving SL only compared with unilateral lung transplant patients receiving L-CsA.

Figure 5 shows the Kaplan-Meier plot of the overall survival probabilities for patients with unilateral and bilateral lung transplants who were diagnosed with BOS at 5 years after randomization. The data show a marked improvement for patients with unilateral or bilateral lung transplants who received L-CsA: 5 patients of 11 participants treated with LCsA (45%) were alive at 5-year follow-up compared with 0 patients of the original 10 patients who received LCsA alone. The median survival in the L-CsA-treated group was 4.1 years compared with 2.9 years for the LCsA-treated group (p = 0.03). The cause of death was chronic allograft rejection with the exception of two deaths, one from disseminated skin cancer (L-CsA) and one from renal failure (LCs).

Figure 6 shows the analysis of change in total FEV1 for patients with unilateral and bilateral lung transplantation (i.e., without differentiating between patients with unilateral and bilateral lung transplantation) after adjusting for pre-randomization and post-randomization measurement data in a mixed model with varying regression slopes: in the group of patients receiving L

- 20 047564

In the CsA group (11 patients), a small decrease in mean absolute FEV1 values was observed from approximately 1.75 L at randomization to 1.70 L at the end of the 48-week period, whereas in the SL group (10 patients; one patient had missing post-randomization FEL measurements due to the need for mechanical ventilation; this patient was included in the calculations of the _FEV1 regression slope: an _FEV1 value of 0 was assumed at the time the patient was on mechanical ventilation; this patient had missing post-randomization FEL measurements) a consistent and significant decrease in _FEV1 values was observed from approximately 1.75 L to approximately 1.15 L. In this pooled analysis of patients with unilateral and bilateral lung transplantation, the monthly change in _FEV1 (FEV1/month) was -0.007, with 95% CI -0.033 to 0.018 for the L-CsA group versus -0.054 with 95% CI -0.100 to -0.006 (p = 0.10).

Figure 7 shows the change in mean absolute FEV1 values over the 48-week study period for patients with bilateral lung transplants (i.e., no results for patients with unilateral lung transplants) in the L-CsA treatment group (upper graph; L-CsA) and for the SL treatment group (lower graph; SL): in patients in the L-CsA treatment group (6 patients), the mean absolute FEV1 values remained essentially constant at 1.8 L over the 48-week period. In contrast, for the group of patients with bilateral lung transplants in the SL treatment group (4 patients), the mean absolute FEV1 values decreased markedly from approximately 1.8 L to approximately 1.1 L over the same period. Therefore, the monthly change in FEV1 (\FEV _y month) for patients with bilateral lung transplantation was 0.000 with 95% CI -0.049 to 0.049 for patients in the L-CsA treatment group and -0.061 with 95% CI 0.096 to -0.026 (p = 0.07) for the SL treatment group.

Figure 8 shows the change in mean absolute FEV1 values over the 48-week study period for patients with unilateral lung transplantation (i.e., no results for patients with bilateral lung transplantation) in the L-CsA treatment group (upper graph; L-CsA) and in the SL treatment group (lower graph; SL): in patients in the L-CsA treatment group (5 patients), there was a decrease in mean absolute FEV1 values from approximately 1.75 L immediately after randomization to approximately 1.4 L at week 48 after randomization. For the group of patients with unilateral lung transplantation in the LS treatment group (6 patients; one patient had missing post-randomization LFP measurements due to the need for mechanical ventilation; this patient was included in the calculations of the FEV1 regression slope: an FEV1 value of 0 was assumed at the time the patient was on mechanical ventilation; this patient had missing post-randomization LFP measurements), the mean FEV1 values decreased markedly from approximately 1.75 L to approximately 1.05 L during the same period (due to the way of calculation, the graph for the LS treatment group ends at month 1). Therefore, the monthly change in FEV1 (\FEV _y month) for patients with bilateral lung transplantation was -0.029, 95% CI -0.019 to 0.001, for the L-CsA treatment group and -0.600, 95% CI -2.074 to 0.872 (p = 0.37) for the SL treatment group.

The following examples serve as illustrations of the invention; however, this should not be understood as limiting the objective of the invention:

Examples

Example 1. In vitro characterization of aerosol of liquid CsA formulation

A liquid formulation of cyclosporine for inhalation was obtained, consisting of the active substance CsA (Eur. Pharm.) and excipients: lipoid S100, polysorbate 80, disodium edetate, sodium hydrogen phosphate dodecahydrate and sodium dihydrogen phosphate monohydrate. The composition was brought to physiologically tolerated pH values (6.5 ± 0.2) and osmolality (350-450 mOsmol/kg).

The aerosol was nebulized using an eFlow® nebulizer with a mixing chamber volume of approximately 95 ml. The aerosol nebulized using this nebulizer was characterized using breath simulation, laser diffraction, and impactor measurements. The results of these measurements are summarized in Table 1.

Table 1

Aerosol Characterization of Liposomal Cyclosporine (L-CsA) Formulation Delivered by the eFlow® Nebulizer

Nominal amount of drug [mg] 15.0 ± 0.4 MMD [µm] 2.8 ±0.1 DD [%] 75.9 ±2.6 BD [% < 5 µm] 67.7 ±2.8 BD [%, <3.3 µm] 46.7 ±2.9

- 21 047564

Values are expressed as mean ± standard deviation; MMD = mass median diameter; DD = delivered dose (via mouthpiece); ID = inspired dose.

A delivered dose (DD) (amount through the mouthpiece) of 76% and a respirable dose (RD) of particles smaller than 3.3 μm of approximately 47% were achieved. Particles smaller than 3.3 pm have a high probability of deposition in the distal lung, which is considered the optimal site for drug deposition for effective lung graft protection. In general, aerosol particles smaller than 5 μm have a high probability of deposition in the whole lung and should also be considered to some extent for lung graft protection. The respirable dose of particles smaller than 5 μm was approximately 68%.

Based on these results, it can be concluded that for a nominal drug amount of 10 mg, the corresponding delivered dose (in mg) will be approximately 7.6 mg CsA. The inhaled dose (in mg) for particles smaller than 5 and 3.3 pm will be approximately 6.8 and 4.7 mg CsA, respectively.

Example 2. In vitro characterization of aerosol of diluted CsA composition

Sucrose was added as a lyoprotectant to the formulation described in Example 1. The formulation was then lyophilized. Immediately prior to spraying, the formulation was diluted with 2.3 ml of 0.25% saline. The liposome size was in the range of 40-100 nm (0.040-0.10 μm) with a polydispersity coefficient of less than 0.40 after dilution.

The reconstituted formulation was nebulized using an eFlow® nebulizer, which had the same inhalation chamber as the nebulizer in Example 1, i.e., a mixing chamber of approximately 95 ml. Aerosol characterization results obtained using the diluted formulation are presented in Table 2.

The results showed no significant differences when compared with the results obtained in Example 1.

Table 2

Characteristics of the aerosol of the reconstituted formulation of liposomal cyclosporine sprayed at

Values are expressed as mean ± standard deviation; MMAD = mass median aerodynamic diameter; GSD = geometric standard deviation; DD = delivered dose (via mouthpiece); ID = inspired dose.

Example 3. Clinical trial of inhaled cyclosporine for the treatment of BOS

Inclusion in the study:

Forty-three patients were assessed for study eligibility, of whom 23 met the inclusion criteria. One patient died and one patient was withdrawn before randomization. Twenty-one patients were randomized; 11 to the L-CsA treatment group and 10 to the SL group (Fig. 1). One patient in the L-CsA group was withdrawn from the study due to progressive skin cancer during the 24-week follow-up. In this case, conventional systemic immunosuppression was discontinued.

Patients with BOS 1 or BOS 2 were eligible if they had no untreated infection and no airway stenosis as determined by bronchoscopy with bronchoalveolar lavage (BAL) performed before randomisation at week 24 and if clinically indicated.

The classification scale for bronchiolitis obliterans syndrome (BOS) was applied as follows: BOS was assessed based on _FEV1 measurements twice monthly on a continuous basis. The definition of VO was based on the modifications of the BOS criteria from Estenne et al.

- 22 047564 al. (Estenne M, et al. Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Haert Lung Transplant. 2002; 21(3): 297-310).

The following definitions and criteria were used:

BOS 0: FEV1 > 90% of baseline,

BOS 0-p: FEV1 from 81% to 90% of the initial value,

BOS 1: FEV1 from 66% to 80% of baseline,

BOS 2: FEV1 from 51% to 65% of baseline,

BOS 3: FEV1 50% or less of baseline.

Research plan:

Patients with unilateral or bilateral lung transplantation diagnosed with BOS grade 1 or 2 were included in the present single-center, randomized, open-label clinical trial to evaluate the addition of aerosolized L-CsA to standard immunosuppression in BOS 1 and BOS 2 (grades 1-2) compared with standard immunosuppression alone (SIS).

Patients were scheduled for a further 48 weeks (24 weeks with L-CsA administration as described below and 24 weeks of follow-up without administration in the study arm). Patients in the SL arm could cross over to the L-CsA treatment arm upon reaching the primary endpoint or to the L-CsA arm if the primary endpoint was reached within 24 weeks of follow-up.

Patients were assigned to receive twice daily either 5 mg/1.25 mL or 10 mg/2.5 mL L-CsA, for patients with unilateral lung transplant (ULT) or bilateral lung transplant (BLT) (L-CsA group), respectively, in addition to standard systemic immunosuppression or standard systemic immunosuppression alone (SL group) for 24 weeks, followed by 24 weeks without study drug administration (L-CsA).

The L-CsA formulation was administered as a reconstituted lyophilisate in 0.25% saline and nebulized using an eFlow® nebulizer (PARI, Germany). A filter was installed on the exhalation valve of the inhalation chamber. In addition, the nebulizer was designed in such a way that it could only be activated if a key card (eFlow® chip card), which tracks the time and duration of inhalation, was inserted into the nebulizer.

Treatment protocol:

Patients were randomly assigned to either the L-CsA group (treatment) or the SL group (no CsA treatment). L-CsA was administered at a dose of 5 mg or 10 mg twice daily (for patients with unilateral or bilateral lung transplants, respectively), in addition to standard immunosuppression consisting of tacrolimus (0.06 mg/kg; trough concentration 812 ng/mL), mycophenolate mofetil (1 g orally twice daily) or sirolimus (2 mg orally daily; concentration 7-12 ng/mL), and prednisone (20 mg/day), while the SL group received standard immunosuppression alone. When sirolimus was given in combination with tacrolimus, blood levels were maintained at 4-5 ng/mL. Adjustments were made by the treating clinicians based on clinical parameters and study center protocols. Infection prophylaxis included valcyte, voriconazole, and sulfamethoxazole/trimethoprim. Enhanced immune suppression consisted of intermittent corticosteroid regimens (IV methylprednisolone 1 g daily for 3 days or oral prednisone (100 mg tapered to 10 mg over 14 days) or antithymocyte globulin (1.5 mg per kilogram daily for 3 to 5 days). Development of BOS was assessed by pre- and posttreatment FEV ₁ with assessment of comorbidities, at least three weeks apart, and monitored by two co-investigators.

End points:

The primary endpoints for BOS development were:

1) >20% decrease in FEV1 since randomization;

2) death or

3) retransplantation.

Secondary endpoints included changes in lung function, aerosol tolerance, pharmacokinetics, cytokine changes, and drug toxicity. Routine laboratory data were collected at 30-day intervals. Cytokines (IL-1e, IL-2, IL-6, IL-8, IL-10, IL-17, IFN-γ, and TNF-α) were measured before randomization and at the end of the treatment period from BAL fluid using a multiplex assay (Biorad®) using a Luminex 100 reader and analyzed using Biorad software.

Statistical analysis:

The combined primary endpoint of BOS and overall patient survival were compared using the Kaplan-Meier method and the long-range test. Transplant type as a factor influencing survival was assessed using the Cox proportional hazards model. Data are presented using relative risks (RRs) and 95% confidence intervals (95% CIs). Multivariate linear

- 23,047,564 mixed-effects statistical models (PROC MIXED, SAS version 9.1.3; SAS Institute, Cary, NC) (Laird NM, Ware JH. Random-effects models for longitudinal data; Biometric 1982; 38:963–974). Prerandomization and postrandomization within- and between-group mixed-model values were analyzed, adjusting for changes that could potentially affect function after randomization. Cytokine values were compared using two-way ANOVA. Mixed-model statistics were used to analyze laboratory values and drug levels. All outcomes, including cross-over cases, were analyzed according to randomization results. A total of 242 lung function tests, 42 bronchoalveolar lavage (BAL) samples for cytokine assays, and 603 blood samples were analyzed.

Results Patient characteristics:

patients were randomized to the L-CsA group and 10 to the SL group (see Fig. 1). Baseline characteristics and clinical management were comparable between the two groups. The distribution of key demographic variables did not differ significantly between the groups. The mean duration of L-CsA treatment was 167.5 ± 12.5 days. There were no L-CsA-related adverse events requiring early withdrawal from the study, and no patients were lost to follow-up.

In the two cases where the primary endpoint was met in the LC group, patients received crossover treatment with L-CsA and one patient randomized to L-CsA restarted LCsA ( _FEV1 decline >20%) after the initial 24-week drug interval. One patient was withdrawn early from the study after the initial 24-week L-CsA interval due to withdrawal of systemic immunosuppression required by recurrent skin cancer.

Stabilization of obliterating bronchiolitis:

Event-free survival probabilities were analyzed using the Kaplan-Meier overall survival analysis, i.e., without stratification into patients with unilateral and bilateral lung transplantation, and stratification into unilateral or bilateral lung transplantation (also referred to herein as ALT or DLT, respectively). Patients discontinuing their participation in the study at any time and for any reason before reaching the endpoint event were censored.

To conduct the analyses, the full analysis set (FAS) and the per-protocol population (PPS) were defined. The FAS included all patients who received at least one dose of study treatment. The PPS included all patients in the FAS without significant protocol violations that are likely to compromise the scientific aspects and interpretation of the study results (e.g., inclusion errors, <75% compliance, prohibited concomitant medications).

BOS stabilization was observed according to the primary endpoint of the study for the L-CsA treatment group compared with the SL group and in double- and single-lung recipients analyzed separately: in 9 of 11 patients receiving L-CsA and SL, the probability of event-free survival was 82% compared with 50% for 5 of 10 patients receiving SL alone. (HR (relative risk): 3.19; 95% CI (confidence interval): 0.62 -16.50; p = 0.14; see Fig. 2)

For patients with bilateral lung transplants, the probability of event-free survival was 83% for the L-CsA treatment group compared with the SL alone group. Additionally, for patients with bilateral lung transplants, the relative risk (RR) was 3.43, 95% CI 0.31–37.95; p = 0.29, indicating a 3.43-fold higher risk of developing BOS, needing retransplantation, or death for the SL alone group of bilateral lung transplant patients compared with the L-CsA-treated bilateral lung transplant patients. (See Fig. 3)

For patients with unilateral lung transplantation, the probability of event-free survival was 80% for the L-CsA-treated group compared with 50% for the SL-only group. Additionally, for patients with unilateral lung transplantation, the relative risk (RR) was 2.78, 95% CI 0.29–26.98; p=0.36, indicating a 2.78-fold higher risk of developing BOS, needing retransplantation, or death for unilateral lung transplantation patients receiving SL-only compared with unilateral lung transplantation patients receiving L-CsA. (See Fig. 4)

In the two cases where the primary endpoint was met in the L-CsA group, one patient responded to resumption of L-CsA (based on the primary endpoint criteria) and the other underwent retransplantation; of the 5 primary events in the SL group, 2 patients underwent retransplantation, 2 required mechanical ventilation, and 1 of the two cases who switched from SL responded to L-CsA.

As can be seen from the Kaplan-Meier plot in Fig. 2-4, the effect of L-CsA administered to patients with bilateral lung transplantation is significantly higher than that in patients with unilateral

- 24,047,564 lung transplants when analyzed over a full 48-week treatment and follow-up period. The relative risk (RR) as an indicator of the likelihood of survival of 1:2.78 (L-Cs-A: SL) for patients with unilateral lung transplantation is significantly less favorable than for patients with bilateral lung transplantation with a ratio of 1:3.43 (L-CsA: SL).

The probability of overall survival at 5 years after randomization showed a clear improvement for patients with unilateral or bilateral lung transplantation who received L-CsA: 5 of 11 patients receiving L-CsA (45%) were alive at 5 years of follow-up compared with 0 of the original 10 patients receiving SL alone. The median survival of the L-CsA group was 4.1 years compared with 2.9 years for the SL group (p = 0.03; see Fig. 5). The cause of death was chronic allograft rejection, with two exceptions, one death due to disseminated skin cancer (L-CsA) and renal failure (SL).

Changes in lung function

As an indicator of stabilization or development of BOS in patients with unilateral and bilateral lung transplantation diagnosed with BOS, changes in _FEV1 (forced expiratory volume after the first second of forced expiration) values were observed in the L-CsA group and the SL group during the 48-week study period.

As shown in Fig. 6 Analysis of the change in total _FEV1 for patients with unilateral and bilateral lung transplantation after adjustment for pre- and post-randomization measurement data in a mixed model with varying regression slope was consistent: in the L-CsA group (11 patients), a small decrease in mean absolute FEV1 values was observed, from approximately 1.75 L at randomization to 1.70 L at the end of the 48-week period, while in the SL group (10 patients; one patient had missing post-randomization FLP measurements due to the need for mechanical ventilation; this patient was included in the calculations of the FEV1 regression slope: an FEV1 value of 0 was assumed at the time when the patient was on mechanical ventilation; this patient had missing post-randomization FLP (lung function test) measurements) there was a consistent and significant decrease in FEV1 values from approximately 1.75 L to approximately 1.15 L. Of note, in this pooled analysis of patients with unilateral and bilateral lung transplantation, the monthly change in FEV1 (AOFEV1month) was -0.007, 95% CI -0.033 to 0.018, for the L-CsA-treated group compared with -0.054, 95% CI -0.100 to -0.006 (p = 0.10).

As shown in Fig. 7, the change in absolute FEV1 values over the 48-week study period for bilateral lung transplant patients in the L-CsA treatment group (upper graph; L-CsA) and for the SL treatment group (lower graph; SL) reveals an even more significant result: in patients in the L-CsA treatment group (6 patients), the mean absolute FEV1 values remained essentially constant at 1.8 L over the 48-week period. In contrast, for the group of bilateral lung transplant patients in the SL treatment group (4 patients), the mean absolute FEV1 values decreased markedly from approximately 1.8 L to approximately 1.1 L over the same period. Therefore, it is noteworthy that the monthly change in FEV1 (AOFVCmonth) for patients with bilateral lung transplantation was 0.000 with 95% CI -0.049 to 0.049 for patients in the L-CsA treatment group and -0.061 with 95% CI -0.096 to -0.026 (p = 0.07) for the SL treatment group.

As shown in Fig. 8, the change in absolute FEV1 values over the 48-week study period for patients with unilateral lung transplantation in the L-CsA treatment group (upper graph; L-CsA) and for the SL-treated group (lower graph; SL) shows a similar trend: in patients in the L-CsA treatment group (5 patients), there was a decrease in mean absolute FEV1 values from approximately 1.75 L immediately after randomization to approximately 1.4 L at week 48 after randomization. For the group of patients with unilateral lung transplantation in the LS treatment group (6 patients; one patient had missing post-randomization LFP measurements due to the need for mechanical ventilation; this patient was included in the calculations of the FEV1 regression slope: an FEV1 value of 0 was assumed at the time the patient was on mechanical ventilation; this patient had missing post-randomization LFP (lung function test) measurements), the mean FEV1 values decreased markedly from approximately 1.75 L to approximately 1.05 L during the same period (due to the way of calculation, the graph for the LS treatment group ends at month 1). Therefore, the monthly change in FEV1 (AOFVCmonth) for patients with bilateral lung transplantation was -0.029, 95% CI 0.019 to 0.001, for the L-CsA treatment group and -0.600, 95% CI 0.050 to 0.001. -2.074 to 0.872 (p = 0.37) for the SL treatment group.

Claims (36)

1. The use of a composition containing a therapeutically effective dose of liposomal cyclosporine A (L-CsA) for the prevention of bronchiolitis obliterans syndrome (BOS) in a patient with bilateral lung transplantation, or for the treatment of BOS in a patient with bilateral lung transplantation, or for the prevention or slowing of the development of BOS in a patient with bilateral lung transplantation diagnosed with BOS, wherein the composition is intended for administration by inhalation in aerosol form, and the composition is intended for the administration of cyclosporine A in an effective daily dose in the range of 5 to 30 mg. 2. Use according to paragraph 1, characterized in that the patient with bilateral lung transplantation has been diagnosed with BOS 1 or BOS 2. 3. Use according to paragraph 1 or 2, characterized in that the composition is a liquid composition. 4. The use according to claim 3, characterized in that the composition is a liquid composition containing an aqueous liquid carrier. 5. The use according to claim 4, characterized in that the aqueous liquid carrier essentially consists of a saline solution, preferably a saline solution with a concentration of 0.25%. 6. Use according to any of paragraphs 3-5, characterized in that the liquid composition has a CsA concentration in the range from 0.5 to 10 mg/ml. 7. Use according to any of paragraphs 3-6, characterized in that the liquid composition is obtained by diluting liposomal cyclosporin A in lyophilized form. 8. Use according to any of paragraphs 1-7, characterized in that the effective daily dose of cyclosporine A is 20 mg. 9. Use according to any one of paragraphs 1-8, characterized in that the composition is intended for the administration of cyclosporine A to said patient twice a day. 10. A method for preventing bronchiolitis obliterans syndrome (BOS) in a bilateral lung transplant patient, or treating BOS in a bilateral lung transplant patient, or preventing or slowing the progression of BOS in a bilateral lung transplant patient diagnosed with BOS, comprising the steps of (a) identifying a patient who has undergone a bilateral lung transplant and is at increased risk of developing or who subsequently develops BOS; and (b) administering to said patient a therapeutically effective dose of aerosolized liposomal cyclosporine A (L-CsA) by inhalation, wherein cyclosporine A is administered at an effective daily dose in the range of 5 to 30 mg. 11. The method of claim 10, comprising the steps of (a) identifying a patient who has undergone a bilateral lung transplant and who subsequently develops BOS; and (b) administering to said patient a therapeutically effective dose of aerosolized liposomal cyclosporine A (L-CsA) by inhalation. 12. The method according to any of paragraphs 10, 11, characterized in that the patient with bilateral lung transplantation is diagnosed with BOS 1 or BOS 2. 13. The method according to any one of claims 10-12, characterized in that liposomal cyclosporin A (L-CsA) is administered in the form of an aerosol liquid composition. 14. The method according to claim 13, characterized in that the composition is a liquid composition containing an aqueous liquid carrier. 15. The method according to claim 14, characterized in that the aqueous liquid carrier essentially consists of a saline solution, preferably a saline solution with a concentration of 0.25%. 16. The method according to any one of claims 13-15, characterized in that the liquid composition has a CsA concentration in the range from 0.5 to 10 mg/ml. 17. The method according to any one of paragraphs 13-16, characterized in that the liquid composition is obtained by diluting liposomal cyclosporin A in lyophilized form. 18. The method according to any one of paragraphs 10-17, characterized in that cyclosporine A is administered in an effective daily dose of 20 mg. 19. The method according to any one of paragraphs 10-18, characterized in that cyclosporine A is administered to said patient twice a day. 20. The method according to any one of claims 10 to 19, characterized in that cyclosporin A is administered over a period of at least 24 weeks. 21. The method according to any one of claims 10-20, characterized in that the patient with bilateral lung transplantation receives combined standard immunosuppressive therapy. 22. The method according to claim 21, characterized in that the patient with bilateral lung transplantation receives combined treatment with a combination of a calcineurin inhibitor, a cell cycle inhibitor and a cortex - 26 047564 ticosteroids. 23. The method according to claim 21 or 22, characterized in that the standard immunosuppressive therapy comprises the administration of one or more active ingredients selected from the group consisting of tacrolimus or cyclosporine; mycophenolate mofetil or sirolimus; and corticosteroids. 24. The method according to any one of claims 21-23, characterized in that the standard immunosuppressive therapy includes oral administration of tacrolimus, mycophenolate mofetil and prednisone. 25. The method according to any of paragraphs 10-24, characterized in that the composition is converted into an aerosol using an electronic nebulizer with a vibrating membrane. 26. The method according to claim 25, characterized in that the nebulizer is capable of delivering a standard dose at a rate of at least 0.1 ml/min. 27. The method according to any one of paragraphs 10-26, characterized in that the composition is administered in the form of inhalations in compliance with the prescribed therapy regimen, at least in an amount of 75%. 28. The method according to any one of claims 10-27, characterized in that the development of BOS in a patient with a bilateral lung transplant diagnosed with BOS is prevented or reduced to a level of 20% decrease in the forced expiratory volume in one second ( _FEV1 ) of said patient compared to the FEV1 value at the beginning of treatment. 29. The method according to any of claims 10-28, characterized in that the probability of event-free survival of a patient with a bilateral lung transplant diagnosed with BOS is at least 60% after at least 48 weeks from the start of treatment, where the event is selected from a decrease in FEV by at least 20%, the need for retransplantation and/or death. 30. The method according to any one of claims 10 to 29, characterized in that the average monthly change in FEV (AOFEV|/month) in a patient with bilateral lung transplantation diagnosed with BOS remains approximately constant or has a value in the range from 0 to 0.04 L/month. 31. The method according to any one of claims 10 to 30, characterized in that the risk of occurrence of an event selected from a decrease in _FEVb by at least 20%, the need for retransplantation and/or death within at least a 48-week period from the start of treatment for a patient with bilateral lung transplantation receiving an aerosol composition according to the present invention containing CsA, is reduced by at least 30% (abs.), preferably by at least 35% (abs.) compared to the risk of occurrence of the corresponding event when receiving only standard immunosuppressive therapy (SI). 32. The method according to any one of paragraphs 10-31, characterized in that the absolute change in FEV1 (ΔΟΦΒι/abs.) from the initial (at the beginning of treatment) to the end of the treatment period of a patient with bilateral lung transplantation with diagnosed BOS is no more than 350 ml. 33. The method according to any one of claims 10 to 32, characterized in that the relative loss in FEV1 (AOFEV|/rel.) in a patient with bilateral lung transplantation diagnosed with BOS relative to the loss of FEV1 in a patient receiving only standard immunosuppressive therapy (SI) is at least 200 ml. 34. The method according to any one of claims 10 to 33, characterized in that the patient with bilateral lung transplantation has not been diagnosed with airway stenosis before the start of treatment and preferably within 24 weeks after the start of treatment, as determined by bronchoscopy with bronchoalveolar lavage (BAL). 35. The method according to any one of claims 10 to 34, characterized in that the patient with bilateral lung transplantation diagnosed with BOS was not diagnosed with untreated infection before randomization and preferably within 24 weeks after the start of treatment. 36. The method according to any one of claims 10 to 35, characterized in that the maximum concentration of CsA in the blood of a patient with bilateral lung transplantation diagnosed with BOS and receiving a liquid composition containing CsA is up to 100 ng/ml, preferably up to 60 ng/ml.