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NANO DRUG DELIVERY SYSTEMS IN TREATMENT OF RHEUMATOID ARTHRITIS FINAL REPORT Submitted In Fulfilment Of The Requirements Of STUDY IN ADVANCED TOPIC

NANO DRUG DELIVERY SYSTEMS IN TREATMENT OF RHEUMATOID ARTHRITIS
FINAL REPORT
Submitted In Fulfilment Of The
Requirements Of
STUDY IN ADVANCED TOPIC( BITS G513 )
Submitted by
Radhika R. Mahajan (2017H1460148H)
Under the supervision of
Dr. Swati BiswasAssistant Professor
Department of Pharmacy

18727625227

BIRLA INSTITUTE OF TECHNOLOGY & SCIENCE, PILANI
HYDERABAD CAMPUS
May 2018
INDEX:
CONTENTS PAGE NO.

INTRODUCTION
RHEUMATOID ARTHRITIS (RA)
TREATMENT OF RA DRAWBACKS OF AVAILABLE TREAMENTS INTRODUCTION OF NANODRUG DELIVERY SYSTEMS CHARACTERIZATION OF NANODRUG DELIVERY SYSTEMS NANODRUG DELIVERY SYSTEMS IN TREATMENT OF RA FDA APPROVED NANOFORMULATION FOR TREATMENT OF RA: CIMZIA FIGURES AND TABLES:
SR.NO. CONTENTS PAGE NO.

1 Figure1. Sequence of disease progression.

2 Figure 2. Illistrations demonstrating various types of nanosystems 3 Figure3. Humanised monoclonal antibody: CERTOLIZUMAB PEGOL structure
4 Figure 4: Lyophilized powder for reconstitution before use
5 Figure 5& 6: Prefilled syringe with Cimzia solution
INTRODUCTION:
Arthritis means inflammation in a joint. That inflammation causes redness, warmth, swelling, and pain within the joint. Rheumatoid arthritis affects joints on both sides of the body, such as both hands, wrists or knees. RA can also affect the skin, eyes, lungs, heart, blood, or nerves.

What Are the Symptoms?
Joint pain and swelling
Stiffness, especially in the morning or after you sit for a long time
FatigueRheumatoid arthritis affects everyone differently. For some, joint symptoms develop gradually over several years. In others, it may come on quickly. Rheumatoid arthritis is best characterized as an immune mediated inflammatory disease (IMID). Within a framework that recognizes both immunological activation and inflammatory pathways, we can begin to evaluate the multiple components of disease initiation and propagation
HISTOPATHOLOGY
Synovium:
In RA, this lining is greatly hypertrophied (8-10 cells thick). Primary cell populations in this layer are fibroblasts and macrophages.

The subintimal area is heavily infiltrated with inflammatory cells, including T and B lymphocytes, macrophages, mast cells, and mononuclear cells that differentiate into multinucleated osteoclasts.
The hypertrophied synovium (also called pannus) invades and erodes contiguous cartilage and bone.
Cartilage:
In RA, its integrity, resilience and water content are all impaired. This appears to be due to elaboration of proteolytic enzymes (collagenase, stromelysin) both by synovial lining cells and by chondrocytes themselves. Cytokines including IL1 and TNF drive the generation of reactive oxygen and nitrogen species and while increasing chondrocyte catabolic pathways and matrix destruction, also inhibit new cartilage formation.
Bone:
Composed primarily of type I collagen, bony destruction is a characteristic of RA. This process is driven by the activation of osteoclasts. Osteoclasts differentiate under the influence of cytokines especially the interaction of RANK with its ligand. The expression of these are driven by cytokines including TNF and IL1, as well as other cytokines including IL-17.

Synovial Cavity:
In RA, large collections of fluid (“effusions”) occur which are, in effect, filtrates of plasma (and, therefore, exudative – i.e., high protein content). The synovial fluid is highly inflammatory. However, unlike the rheumatoid synovial tissue in which the infiltrating cells are lymphocytes and macrophages but not neutrophils, in synovial fluid the predominant cell is the neutrophil.

Figure1. Sequence of disease progression.Current therapy for the treatment of active rheumatoid arthritis (RA) favours aggressive treatment with disease modifying anti-rheumatic drugs (DMARDs) with the goal of preventing or slowing permanent structural damage to the joints and limiting long-term disability. Inherent in this strategy is accurate monitoring of disease activity in order to follow disease progression and assess the effect of therapy. NSAIDS act as an adjuvant therapy because of their analgesic and anti-inflammatory effects. In general, more than 50% of patients with arthritis use NSAIDs. Corticosteroids are commonly used in the treatment of RA because of their ability to reduce symptoms of inflammation reliably and rapidly. In patients treated with corticosteroids, there was an overall improvement in general well-being and functional capacity along with a reduction in radiographic progression, as compared to the analgesic-treated group.

In addition, attempts to induce tolerance to putative arthritogenic antigens by monoclonal antibodies, other biologic agents, vaccination, or oral administration of antigen have also been investigated. Other approaches are also being evaluated and include tenidap, a combination inhibitor of COX and cytokine production; immunomodulators, such as levamisole; immunosuppressive agents, such as mycophenolate, mofetil, bucillamine, and leflunomide; and inhibitors of cartilage catabolism, such as metalloprotease inhibitors.

DRAWBACKS OF AVAILABLE TREAMENTS:
Each drug of Disease modifying drugs (DMARDs) class which is considered to be single line therapy for treatment of RA has some side effects.
HYDROXYCHLOROQUINE:
Adverse effects are generally mild and include gastrointestinal disturbance, rash, headaches, irritability, and tinnitus. A rare but potentially serious side effect is ocular toxicity.

CHLOROQUINE:
It is associated with a higher incidence of retinopathy than hydroxychloroquine and is therefore less commonly used.
GOLD THERAPY:
Potential side effects include rash, stomatitis, thrombocytopenia, leukopenia, proteinuria, and nephrotic syndrome. Interstitial pneumonitis is a rare side effect of gold therapy.

SULFASALAZINE:
Gastrointestinal toxicity is the most common side effect seen with sulfasalazine therapy and can include nausea, vomiting, anorexia, dyspepsia, and abdominal pain. Other adverse effects include oligospermia, discoloration of urine and sweat, hepatitis, fibrosing alveolitis, and eosinophilic pneumonia.

D-PENICILLAMINE:
These effects include rashes, alopecia, dysgeusia, stomatitis, and gastrointestinal upset. Bone marrow suppression, including thrombocytopenia, leukopenia, and aplastic anemia, can occur. Proteinuria is a potential problem.

NSAIDs:
Gastrointestinal complications remain a pre-valent and serious problem. Other side include reversible impairment of renal blood flow, which can cause fluid retention In addition, acute interstitial nephritis, renal papillary necrosis, and nephrotic syndrome can be seen. Headaches, confusion, and aseptic meningitis are among some of the central nervous system side effects that may occur. NSAIDs also interfere with platelet adhesiveness.
CORTICOSTEROIDS:
The adverse effects associated distinctly limit their use. Cutaneous atrophy, cataracts, glaucoma, and mild glucose intolerance have been reported to occur with low-dose corticosteroid therapy. Some other probable effects include myopathy, withdrawal symptoms, hypothalamic-pituitary- adrenal axis dysfunction, and osteoporosis.

All these side effects limit the use of effective drugs. An increased understanding in the pathophysiology of chronic inflammatory diseases, such as rheumatoid arthritis, reveals that the diseased tissue and the increased presence of macrophages and other overexpressed molecules within the tissue can be exploited to enhance the delivery of nanomedicine. Nanomedicine can passively accumulate into chronic inflammatory tissues via the enhanced permeability and retention phenomenon, or be surface conjugated with a ligand to actively bind to receptors overexpressed by cells within chronic inflammatory tissues, leading to increased efficacy and reduced systemic side-effects. Hence nano drug delivery can be used as a promising drug delivery for treatment of RA.

INTRODUCTION OF NANODRUG DELIVERY SYSTEMS:
Nanomedicine is defined as the application of nanotechnology in the diagnosis, treatment or prevention of disease. Nanomedicines may include drug-loaded liposomes, nanoparticles, polymeric micelles, nanogels and nanocapsules. In addition, polymer–drug conjugates, polymer–protein conjugates and antibodies are all classified as nanomedicines. Nanomedicines can be designed to: protect the therapeutic agent from degradation, remain in blood circulation longer, be tailored for macrophage uptake or targeted to certain receptors and permeate through certain diseased tissues as interendothelial cell gaps are generally 1–2 nm in healthy tissues, but can be up to 600 nm in diseased tissues, such as inflamed joints.

WHY NANO-PARTICLES?
• Decreased fed/fasted variability
• Decreased patient-to-patient variability
• Enhanced solubility
• Increased oral bioavailability
• Increased rate of dissolution
• Increased surface area
• Less amount of dose required
• More rapid onset of therapeutic action
• Better safety profile
Different components which come under nanotechnology are:
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CLASSIFICATION:
• ONE DIMENSION NANOPARTICLES:
One dimensional system (thin film or manufactured surfaces) has been used for decades. Thin films (sizes 1–100 nm) or monolayer is now common place in the field of solar cells offering, different technological applications, such as chemical and biological sensors, information storage systems, magneto-optic and optical device, fiber-optic systems.

• TWO DIMENSION NANOPARTICLES:
Carbon nano-tubes
• THREE DIMENSION NANOPARTICLES:
Dendrimers, Quantum Dots, Fullerenes (Carbon 60), (QDs)

METHODS OF PREPARATION:
The selection of appropriate method for the preparation of nano-particles depends on
The physicochemical character of the polymer and
The drug to be loaded.

Nano-particles have been usually prepared by three methods:
• Dispersion of preformed polymers
• Ionic gelation or coacervation of hydrophilic polymers
• Polymerization of monomers
However, other methods such as supercritical fluid technology and particle replication in non-wetting templates have also been described in the literature for production of nanoparticles.
DISPERSION OF PREFORMED POLYMERS:
This technique is based on the preparation of biodegradable nanoparticles via dispersion of biodegradable polymers such as PLA, PCA, and PLGA.

Dispersion of preformed polymers to prepare the nanoparticles can be used in various ways:
SOLVENT EVAPORATION:
This method involves two steps:
Emulsification of the polymer solution into an aqueous phase.

Evaporation of polymer solvent, inducing polymer precipitation as nanospheres.

The size can be controlled by adjusting the stirring rate, type and amount of dispersing agent, viscosity of organic and aqueous phases and temperature. Polymers used are PLGA, PLA, cellulose acetate phthalate, EC, Poly (? -hydroxybutyrate) (PHB), Poly (?-caprolactone) (PCL).

2. SPONTANEOUS EMULSIFICATION OR SOLVENT DIFFUSION:
This method is developed from solvent evaporation method, in which the water miscible solvent along with a small amount of the organic solvent (water immiscible) is used as an oil phase. This method can be used for hydrophobic or hydrophilic drugs. In the case of hydrophilic drug, a multiple w/o/w emulsion needs to be formed with the drug dissolved in the internal aqueous phase.

3. DOUBLE EMULSION AND EVAPORATION METHOD:
Most of the emulsion and evaporation based methods suffer from the limitation of poor entrapment of hydrophilic drugs. Therefore to encapsulate hydrophilic drug the double emulsion technique is employed, which involves the addition of aqueous drug solutions to organic polymer solution under vigorous stirring to form w/o emulsions. This w/o emulsion is added into second aqueous phase with continuous stirring to form the w/o/w emulsion. The emulsion then subjected to solvent removal by evaporation and nano particles can be isolated by centrifugation at high speed.

4. SALTING OUT:
During the initial process polymer and drug are dissolved in a solvent which is subsequently emulsified into an aqueous gel containing the salting out agent and a colloidal stabilizer. Various types of salting out agents (electrolytes, such as magnesium chloride and calcium chloride, or non- electrolytes such as sucrose) and colloidal stabilizer (such as polyvinylpyrrolidone or hydroxyethylcellulose) have been used. This lead to formation of oil/water emulsion which is further diluted with a suffi cient volume of water or aqueous solution to enhance the diffusion of solvent into the aqueous phase, ultimately induce the formation of nanospheres.

5 EMULSIONS-DIFFUSION METHOD:
The encapsulating polymer is dissolved in a partially water-miscible solvent (such as propylene carbonate, benzyl alcohol), and saturated with water to ensure the initial thermodynamic equilibrium of both liquids. Subsequently, the polymer-water saturated solvent phase is emulsifi ed in an aqueous solution containing stabilizer, leading to solvent diffusion to the external phase and the formation of nanospheres or nanocapsules, according to the oil-to-polymer ratio. Finally, the solvent is eliminated by evaporation or fi ltration, according to its boiling point.

Eg: doxorubicin-loaded PLGA nano particles, and cyclosporine(cy-A-); loaded sodium glycolate nanoparticles.

6. SOLVENT DISPLACEMENT/PRECIPITATION METHOD:
In this method preformed polymer is precipitated in an organic solution and organic solvent is diffused in the aqueous medium. Diffusion of organic solvent can be achieved in the presence or absence of surfactant. Semi polar water miscible solvent such as acetone or ethanol can be used to dissolve the polymers, drug, and or lipophilic surfactant. After their complete dissolution, solution is then poured or injected into an aqueous solution containing stabilizer under magnetic stirring. Nano particles are formed immediately by the rapid solvent diffusion. This step is followed by the removal of solvent from the suspensions under reduced pressure.

II. COACERVATION OR IONIC GELATION METHOD:
Used for preparing hydrophilic polymer based nanoparticles.

Existence of strong electrostatic interaction between two aqueous phases leads to the formation of coacervates.
In contrast ionic gelation involves the material undergoing transition from liquid to gel due to ionic interaction conditions at room temperature.

III. POLYMERIZATION METHOD:
Polymerization of monomers to form nanoparticles in an aqueous solution.

Drug is incorporated either by being dissolved in the polymerization medium or by adsorption onto the nanoparticles after polymerization completed.

Ultracentrifugation is used for purification
Desirable size of nanocapsule can be achieved by optimization of concentration of the surfactants and stabilizers.

CHARACTERIZATION OF NANODRUG DELIVERY SYSTEMS:

NANODRUG DELIVERY SYSTEMS IN TREATMENT OF RA:

SOME PRECLINICAL STUDIES:
Targeted Chemo-Photothermal Treatments of Rheumatoid Arthritis Using Gold Half-Shell Multifunctional Nanoparticles.

Folate-targeted nanoparticles show efficacy in the treatment of inflammatory arthritis

Tnf-? gene silencing using polymerized siRNA/ thiolated glycol chitosan nanoparticles for rheumatoid arthritis

Nanocomplex of polymerized siRNA (poly-siRNA) targeting TNF-? with thiolated glycol chitosan (tGC) polymers for the treatment of RA. The primary amine groups of glycol chitosan (GC) polymers used as a carrier for poly-siRNA.
The effect of curcumin and its nanoformulation on adjuvantinduced arthritis in rats:
Nanoemulsions, with their ability to enhance solubility, stability, and bioavailability of drugs, are potent nanocarriers for oral delivery of insoluble drugs.

?-Methylprednisolone conjugated cyclodextrin polymer-based nanoparticles for rheumatoid arthritis therapy:
A glycinate derivative of ?-methylprednisolone (MP) was prepared and conjugated to a linear cyclodextrin polymer (CDP) with a loading of 12.4% w/w. The polymer conjugate (CDP-MP) selfassembled into nanoparticles with a size of 27 nm.

FDA APPROVED MARKETED FORMULATION:
CIMZIA®/ CERTOLIZUMAB PEGOLCIMZIA is a prescription biologic medication that is injected under the skin(SC) and works to prevent inflammation that may result from an overactive immune system. A novel TNF inhibitor which is a combination of a humanized Fab’ fused to a 40 kd PEG moiety. It is the first and only PEGylated biologic treatment for moderate to severe rheumatoid arthritis. PEGylation increases the half life to ? 14 days. It got approval in 2009.

Certolizumab pegol (CDP870), is a recombinant, humanized Fab’ antibody fragment (CDP870 Fab’) covalently bound to a maleimido terminated bis-methoxypoly(ethylene glycol) modified lysine, PEG2MAL40K, through a thioether linkage. The CDP870 Fab’ is directed against TNF (alpha) and neutralizes the biological activity of TNF ?. A single molecule of PEG2MAL40K is covalently bound to each Fab’ molecule. The resulting CDP870 Fab’- PEG2MAL40K conjugate is further purified and formulated in acetate buffer at acidic pH to yield the Certolizumab pegol drug substance which is converted into a nanoformulation.

Figure3. Humanised monoclonal antibody: CERTOLIZUMAB PEGOL structure

DOSAGE FORMS AND STRENGTHS:
Cimzia is a clear to opalescent, colourless to yellow STERILE SOLUTION for injection(pre-filled syringes) containing 200 mg certolizumab pegol in one ml. Excipients are sodium acetate, sodium chloride and water for injections; the pH of the solution is approximately 4.7.

200 mg LYOPHILIZED POWDER FOR RECONSTITUTION in a single use vial, with 1 mL of sterile Water for Injection

4 5 6
Figure 4: Lyophilized powder for reconstitution before use
Figure 5& 6: Prefilled syringe with Cimzia solution