Effect of Poloxamer 188 vs Placebo on Painful Vaso-Occlusive Episodes in Children and Adults With Sickle Cell Disease: A Randomized Clinical Trial

IMPORTANCE

Although effective agents are available to prevent painful vaso-occlusive episodes of sickle cell disease (SCD), there are no disease-modifying therapies for ongoing painful vaso-occlusive episodes; treatment remains supportive. A previous phase 3 trial of poloxamer 188 reported shortened duration of painful vaso-occlusive episodes in SCD, particularly in children and participants treated with hydroxyurea.

OBJECTIVE

To reassess the efficacy of poloxamer 188 for vaso-occlusive episodes.

DESIGN, SETTING, AND PARTICIPANTS

Phase 3, randomized, double-blind, placebo-controlled, multicenter, international trial conducted from May 2013 to February 2016 that included 66 hospitals in 12 countries and 60 cities; 388 individuals with SCD (hemoglobin SS, SC, S-β0 thalassemia, or S-β+ thalassemia disease) aged 4 to 65 years with acute moderate to severe pain typical of painful vaso-occlusive episodes requiring hospitalization were included.

INTERVENTIONS

A 1-hour 100-mg/kg loading dose of poloxamer 188 intravenously followed by a 12-hour to 48-hour 30-mg/kg/h continuous infusion (n = 194) or placebo (n = 194).

MAIN OUTCOMES AND MEASURES

Time in hours from randomization to the last dose of parenteral opioids among all participants and among those younger than 16 years as a separate subgroup.

RESULTS

Of 437 participants assessed for eligibility, 388 were randomized (mean age, 15.2 years; 176 [45.4%] female), the primary outcome was available for 384 (99.0%), 15-day follow-up contacts were available for 357 (92.0%), and 30-day follow-up contacts were available for 368 (94.8%). There was no significant difference between the groups for the mean time to last dose of parenteral opioids (81.8 h for the poloxamer 188 group vs 77.8 h for the placebo group; difference, 4.0 h [95% CI, -7.8 to 15.7]; geometric mean ratio, 1.2 [95% CI, 1.0-1.5]; P = .09). Based on a significant interaction of age and treatment (P = .01), there was a treatment difference in time from randomization to last administration of parenteral opioids for participants younger than 16 years (88.7 h in the poloxamer 188 group vs 71.9 h in the placebo group; difference, 16.8 h [95% CI, 1.7-32.0]; geometric mean ratio, 1.4 [95% CI, 1.1-1.8]; P = .008). Adverse events that were more common in the poloxamer 188 group than the placebo group included hyperbilirubinemia (12.7% vs 5.2%); those more common in the placebo group included hypoxia (12.0% vs 5.3%).

CONCLUSIONS AND RELEVANCE

Among children and adults with SCD, poloxamer 188 did not significantly shorten time to last dose of parenteral opioids during vaso-occlusive episodes. These findings do not support the use of poloxamer 188 for vaso-occlusive episodes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01737814.

Evaluation of the activity of a chemo-ablative, thermoresponsive hydrogel in a murine xenograft model of lung cancer

BACKGROUND

Minimally invasive intratumoural administration of thermoresponsive hydrogels, that transition from liquid to gel in response to temperature, has been proposed as a potential treatment modality for solid tumours. The aim of this study was to assess the inherent cytotoxicity of a poloxamer-based thermoresponsive hydrogel in a murine xenograft model of lung cancer.

METHODS

In vitro viability assessment was carried out in a lung cancer (A549) and non-cancerous (Balb/c 3T3 clone A31) cell line. Following intratumoural administration of saline or the thermoresponsive hydrogel to an A549 xenograft model in female Athymic Nude-Foxn1nu mice (n = 6/group), localisation was confirmed using IVIS imaging. Tumour volume was assessed using callipers measurements over 14 days. Blood serum was analysed for liver and kidney damage and ex vivo tissue samples were histologically assessed.

RESULTS

The thermoresponsive hydrogel demonstrated a dose-dependent cancer cell-specific toxicity in vitro and was retained in situ for at least 14 days in the xenograft model. Tumour volume increase was statistically significantly lower than saline treated control at day 14 (n = 6, p = 0.0001), with no associated damage of hepatic or renal tissue observed.

CONCLUSIONS

Presented is a poloxamer-based thermoresponsive hydrogel, suitable for intratumoural administration and retention, which has demonstrated preliminary evidence of local tumour control, with minimal off-site toxicity.

Poloxamer bioadhesive hydrogel for buccal drug delivery: Cytotoxicity and trans-epithelial permeability evaluations using TR146 human buccal epithelial cell line

A salbutamol sulfate (SS)-Poloxamer bioadhesive hydrogel specially developed for buccal administration was investigated by studying interactions with TR146 human buccal epithelium cells (i.e. cellular toxicity (i) and trans-epithelial SS diffusion (ii)). The assessment of cell viability (MTT, Alamar Blue), membrane integrity (Neutral Red), and apoptosis assay (Hoechst 33342), were performed and associated to Digital Holographic Microscopy analysis. After the treatment of 2h, SS solution induced drastic cellular alterations that were prevented by hydrogels in relation with the concentrations of poloxamer and xanthan gum. The formulation containing P407 19%/P188 1%/Satiaxane 0.1% showed the best tolerance after single and multiple administrations and significantly reduced the trans-epithelial permeability from 5.00±0.29 (×10(3)) (SS solution) to 1.83±0.22 cm/h. Digital Holographic Microscopy images in good agreement with the viability data confirmed the great interest of this direct technique. In conclusion, the proposed hydrogels represent a safe and efficient buccal drug delivery platform.

Preventing neuronal damage and inflammation in vivo during cortical microelectrode implantation through the use of poloxamer P-188

OBJECTIVE

The aim of this study was to test the efficacy of Poloxamer P188 to reduce cell death and immune response associated with mechanical trauma to cells during implantation of a chronic recording electrode.

APPROACH

Ceramic multi-site recording electrodes were implanted bilaterally into 15 adult male Long-Evans rats. One of each pair was randomly assigned to receive a coating of Poloxamer while the other was treated with saline. The extent of neuron loss, and glial cell recruitment were characterized at 2, 4 and 6 weeks post-implantation by stereologic analysis.

MAIN RESULTS

At 2 and 4 weeks post-implantation, Poloxamer-coated implants showed significantly fewer glial cells and more neurons in the peri-electrode space than controls; however, this significance was lost by 6 weeks.

SIGNIFICANCE

These findings are the first to suggest that Poloxamer has neuroprotective effects in vivo; however, at a fixed loading dose, these effects are limited to approximately 1 month post-implantation.

Facilitated nanoscale delivery of insulin across intestinal membrane models

The effect of nanoparticulate delivery system on enhancing insulin permeation through intestinal membrane was evaluated in different intestinal epithelial models using cell cultures and excised intestinal tissues. Multilayered nanoparticles were formulated by encapsulating insulin within a core consisting of alginate and dextran sulfate nucleating around calcium and binding to poloxamer, stabilized by chitosan, and subsequently coated with albumin. Insulin permeation through Caco-2 cell monolayer was enhanced 2.1-fold, facilitated by the nanoparticles compared with insulin alone, 3.7-fold through a mucus-secreting Caco-2/HT29 co-culture, and 3.9-fold through excised intestinal mucosa of Wistar rats. Correlation of Caco-2/HT29 co-culture cells with the animal-model intestinal membrane demonstrates that the mucus layer plays a significant role in determining the effectiveness of oral nanoformulations in delivering poorly absorbed drugs. Albumin was applied to the nanoparticles as outermost coat to protect insulin through shielding from proteolytic degradation. The effect of the albumin layering on insulin permeation was compared with albumin-free nanoparticles that mimic the result of albumin being enzymatically removed during gastric and intestinal transport. Results showed that albumin layering is important toward improving insulin transport across the intestinal membrane, possibly by stabilizing insulin in the intestinal conditions. Transcellular permeation was evidenced by internalization of independently labeled insulin and nanoparticles into enterocytes, in which insulin appeared to remain associated with the nanoparticles. Transcellular transport of insulin through rat intestinal mucosa may represent the predominant mechanism by which nanoparticles facilitate insulin permeation. Nanoformulations demonstrated biocompatibility with rat intestinal mucosa through determination of cell viability via monitoring of mitochondrial dehydrogenases. Insulin permeation facilitated by the biocompatible nanoparticles suggests a potential carrier system in delivering protein-based drugs by the oral route.

Microhardness evaluation of in situ vital bleaching and thickening agents on human dental enamel

Bleaching systems and thickening agents lead to changes in the tooth enamel matrix as a result of an unspecific oxidation of the bleaching gel in the enamel. This reaction may result in a loss of mineral content and a decrease in microhardness. The aim of this study was to evaluate the effects of different bleaching systems and their thickening agents on the microhardness of human enamel in situ. Two dental slabs (3 x 3 x 2 mm) obtained from third molars were fixed on the buccal facial aspects of the maxillary first molars in a group of 45 volunteers. The volunteers were treated with 10% carbamide peroxide gel with carbopol as the thickening agent (group 1), 2% carbopol gel (group 2), 10% carbamide peroxide paste with poloxamer as the thickening agent (group 3), poloxamer (group 4), or 6.5% hydrogen peroxide strips for 21 days (group 5) (experimental treatment factor). The effects of the experimental treatment were evaluated by microhardness tests performed both before and after treatment (time factor). Data were submitted to split-plot analysis of variance and Tukey tests. Only time showed a statistically significant difference (P < .0001). All treatments reduced the enamel microhardness during treatment. Clinically, a reduction in microhardness can be expected after dental bleaching.

Peribulbar poloxamer for ocular drug delivery

PURPOSE

The use of biopolymers in peribulbar injection for controlled drug delivery provides alternative options to eyedrops and intravitreal or surgical methods. Polymerizable biopolymers are especially likely to have a role because of their particular properties. In liquid form, they can be easily injected into the target site and, after polymerization, they provide a prolonged and controlled release of the drug. This study was undertaken to demonstrate the suitability of a thermopolymerizable biopolymer poloxamer (Lutrol F127) for peribulbar injections and controlled drug release.

METHODS

The toxicity of injected poloxamer compounds was evaluated by visual inspection and histological and immunohistochemical tissue evaluation. The release of marker substances such as 5(6)-carboxyfluorescein (376 Da) or fluorescein isothiocyanate-dextran (FITC-dextran) (4-40 kDa) from poloxamer was used to simulate drug release and penetration into the eye using in vivo fluorometry.

RESULTS

According to our clinical and pathological analyses, poloxamer was well tolerated in peribulbar injections and did not cause acute toxicity at the site of injection. The marker compounds were released from the site of injection during the first 24 hours.

CONCLUSIONS

Although poloxamer appears to be suitable for peribulbar injections, a more prolonged period of dissolution is desirable for clinical purposes.

Oxidation of low-density lipoprotein cholesterol following administration of poloxamer 407 to mice results from an indirect effect

Atherosclerosis is an inflammatory response to accumulation of cholesterol in the artery wall. Low-density lipoproteins (LDL) accumulate and are oxidized to proinflammatory compounds in the arterial intima during hypercholesterolemia, leading to activation of endothelial cells, macrophages, and T cells. We sought to define the role of oxidized LDL (oxLDL) in the poloxamer 407 (P-407)-induced mouse model of dose-dependent hyperlipidemia and atherosclerosis developed in our laboratory. The hyperlipidemic agent P-407 was evaluated for its ability to oxidize native LDL in vitro as determined by measuring the rate of formation of conjugated dienes, as well as malondialdehyde (MDA) production using the thiobarbituric acid reactive substances assay. Additionally, plasma obtained from C57BL/6 mice treated with P-407 for 100 days and maintained on either a normal diet or a diet supplemented with 0.5% w/w cholic acid was assayed for both MDA and lipid hydroperoxide content. Lastly, plasma from these same groups of mice was analyzed for the presence of immunoglobulin (Ig) G and IgM autoantibodies against oxLDL. Our results indicate that P-407 is unable to directly oxidize native LDL in vitro. However, plasma obtained from P-407-treated mice demonstrated a significant (P < 0.05) increase in the content of oxidized lipids, but showed a significant (P < 0.05) decrease in the concentration of lipid hydroperoxides when compared to controls. Both plasma IgG and IgM antibodies to MDA-modified LDL (MDA-LDL) were significantly (P < 0.05) elevated in P-407-treated mice, as was IgG1 anti-MDA-LDL, whereas the titer of IgG2a anti-MDA-LDL was significantly (P < 0.05) reduced. We suggest that P-407 causes oxidation of LDL in vivo by an indirect mechanism and we further conclude that P-407-induced hypercholesterolemia in C57BL/6 mice is associated with T cell-dependent (IgG) and T cell-independent (IgM) B-cell responses to MDA-LDL.

Formulation and in vitro characterization of an in situ gelable, photo-polymerizable Pluronic hydrogel suitable for injection

Utilizing the existence of a sufficiently long induction period during photo-polymerization, defined as the time required to initiate macroscopic gelation after UV irradiation, we propose a new injection method of making a photo-polymerized hydrogel made of thermo-sensitive di-acrylated Pluronic F 127 (DA-PF 127). First, the photo-polymerization of DA-PF 127 solution at the molecular level is initiated by UV irradiation, and this solution is injected into a target site by macroscopic gelation before it becomes viscous. This method can overcome the problems of the existing methods to make an injectable and stable hydrogel by photo-polymerization, reducing the potential damage to normal tissue around the injection site due to direct UV exposure, and the requirement of special equipment for UV crosslinking after injection. By controlling photo-polymerization variables, we found the condition for making an injectable system, where the induction time is equal to or longer than the UV irradiation time. The feasibility of the proposed method was demonstrated in vitro, and the enhanced stability of the produced hydrogels by photo-polymerization was verified. We also characterized the cytotoxicity of the present method using cell cultures and cell encapsulation with the present method, and found minimal cytotoxicity.

Enhancement of drug absorption by noncharged detergents through membrane and P-glycoprotein binding

Noncharged detergents are used as excipients in drug formulations. Until recently, they were considered as inert compounds, enhancing drug absorption essentially by improving drug solubility. However, many detergents insert into lipid membranes, although to different extents, and change the lateral packing density of membranes at high concentrations. Moreover, they bind to the efflux transporter P-glycoprotein (P-gp) and most likely to related transporters and metabolising enzymes with overlapping substrate specificities. If their affinity to P-gp is higher than that of the coadministered drug they act as modulators or inhibitors of P-gp and enhance drug absorption. Inhibition of P-gp and related proteins can, however, cause severe side effects. This paper first reviews the membrane binding propensity of different noncharged detergents (including poloxamers) and discusses their ability to bind to P-gp. Second, literature data on drug uptake enhancement by noncharged detergents, obtained in vivo and in vitro, are analysed at the molecular level. The present analysis provides the tools for an approximate and simple prior estimate of the membrane and P-gp binding ability of noncharged detergents based on a modular binding approach.

Phase I dose escalation and pharmacokinetic study of pluronic polymer-bound doxorubicin (SP1049C) in patients with advanced cancer

SP1049C is a novel anticancer agent containing doxorubicin and two nonionic pluronic block copolymers. In preclinical studies, SP1049C demonstrated increased efficacy compared to doxorubicin. The objectives of this first phase I study were to determine the toxicity profile, dose-limiting toxicity, maximum tolerated dose and pharmacokinetic profile of SP1049C, and to document any antitumour activity. The starting dose was 5 mg m⁻² (doxorubicin content) as an intravenous infusion once every 3 weeks for up to six cycles. A total of 26 patients received 78 courses at seven dose levels. The dose-limiting toxicity was myelosuppression and DLT was reached at 90 mg m⁻². The maximum tolerated dose was 70 mg m⁻² and is recommended for future trials. The pharmacokinetic profile of SP1049C showed a slower clearance than has been reported for conventional doxorubicin. Evidence of antitumour activity was seen in some patients with advanced resistant solid tumours. Phase II trials with this agent are now warranted to further define its antitumour activity and safety profile.

Causative factors behind poloxamer 188 (Pluronic F68, Flocor™)-induced complement activation in human sera

Poloxamer 188 is a complex polydisperse mixture of non-ionic macromolecules. Adverse non-IgE-mediated hypersensitivity reactions occur in some individuals following intravenous injection of poloxamer 188-based pharmaceuticals, presumably via complement activation. Here we have delineated potential causal chemical and biological interactive factors behind poloxamer 188-induced complement activation in human serum specimens. We identified the molecular constituents inherent in poloxamer 188 preparations and studied their effect on generation of the two complement split products, SC5b-9 and Bb. Poloxamer 188 activated complement at sub-micellar concentrations and the results indicated the potential involvement of all three known complement activation pathways. The poloxamer-induced rise of SC5b-9 in human sera was abolished in the presence of a recombinant truncated soluble form of complement receptor type 1, thus confirming the role of C3/C5 convertases in the activation process. Poloxamer 188-mediated complement activation is an intrinsic property of these macromolecules and was independent of the degree of sample polydispersity, as opposed to other non-polymeric constituents. Poloxamer 188 preparations also contained unsaturated chains of diblock copolymers capable of generating SC5b-9 in human sera; this effect was terminated following the removal of double bonds by catalytic hydrogenation. By quasi-elastic light scattering, we established interaction between poloxamer and lipoproteins; interestingly, poloxamer-induced rise in SC5b-9 was significantly suppressed when serum HDL and LDL cholesterol levels were increased above normal to mimic two relevant clinical situations. This observation was consistent with previously reported data from patients with abnormal or elevated lipid profiles where no or poor complement activation by poloxamer 188 occurred. Our findings could provide the basis of novel approaches to the prevention of poloxamer-mediated complement activation.

Purified Poloxamer 188 for Sickle Cell Vaso-Occlusive Crisis

OBJECTIVE

To review available literature on the pharmacology, pharmacokinetics, efficacy, toxicology, adverse effects, drug interactions, and dosage guidelines for purified poloxamer 188, a product in Phase III trials.

DATA SOURCES

Reviewers searched the following databases for English-language studies: MEDLINE (1966–November 2003), International Pharmaceutical Abstracts (1970–November 2003), and the Cochrane Library Database (3rd quarter 2003). Key search terms included purified poloxamer 188, Flocor, CRL-5861, poloxamer 188, RheothRx, and pluronic F-68.

STUDY SELECTION AND DATA EXTRACTION

Data on efficacy, adverse effects, and pharmacokinetics were obtained from randomized, open-label, and blinded clinical trials. Toxicology data were obtained from unpublished studies with purified poloxamer 188 and from available data on poloxamer 188 (nonpurified form).

DATA SYNTHESIS

Purified poloxamer 188 is a highly purified form of the nonionic block copolymer poloxamer 188. It lowers blood viscosity, decreases red blood cell (RBC) aggregation, and decreases friction between RBCs and vessel walls to increase microvascular blood flow and decrease cell injury. In clinical trials, purified poloxamer 188 demonstrated safety, but little efficacy for the treatment of sickle cell vaso-occlusive crisis. Increased efficacy has been shown in patients on concurrent hydroxyurea therapy and those <15 years of age.

CONCLUSIONS

Purified poloxamer 188 represents a new approach to the management of the sickle cell vaso-occlusive crisis. Children and patients on hydroxyurea may benefit most from purified poloxamer 188 therapy. Further studies are needed to confirm its efficacy and to determine whether the drug decreases sickle cell disease severity and complications.

Effect of sodium chloride on the release, absorption and safety of diclofenac sodium delivered by poloxamer gel

Poloxamer solutions prepared with poloxamers and sodium chloride were previously reported to undergo a phase transition to bioadhesive gels at body temperature. For the development of a thermosensitive diclofenac sodium-loaded poloxamer gel, here we investigated the effect of sodium chloride on the release, safety and rectal absorption in rats of diclofenac sodium delivered by the poloxamer gels. P 188 delayed the release rates of diclofenac sodium from poloxamer gels. However, sodium chloride showed no significant effect on the release rates of diclofenac sodium from poloxamer gels. Release mechanism analysis showed the release of diclofenac sodium was proportional to the time. The initial plasma concentrations of diclofenac sodium in the rectal formulation [diclofenac sodium/poloxamer 407 (P 407)/poloxamer 188 (P 188)/sodium chloride (2.5/15/17/0.8%)] were significantly higher compared with those in semi-solid suppository. Furthermore, it gave significantly faster Tmax of diclofenac sodium than did semi-solid suppository, indicating that the diclofenac sodium from poloxamer gel could be absorbed faster than that from semi-solid one in rats. It did not cause any morphological damage to the rectal tissues. These results suggested that poloxamer gel with sodium chloride could be a more effective and safe rectal delivery system of diclofenac sodium.

Poloxamer 407-mediated alterations in the activities of enzymes regulating lipid metabolism in rats

PURPOSE

Recently, the P-407-treated mouse was established as a useful animal model of hyperlipidemia and atherosclerosis. The present study was aimed to determine whether P-407-induced hyperlipidemia in the rat is associated with alterations in the activities of enzymes responsible for lipid metabolism.

METHODS AND RESULTS

Rats were made hyperlipidemic by i.p. injection of 1.0 g/kg P-407 and blood samples collected 24 h after administration of P-407. Plasma from P-407-treated rats demonstrated 7- and 13-fold increases in cholesterol and triglycerides, respectively (p < 0.001). The plasma lecithin cholesterol acyl transferase (LCAT) activity in these animals was 4-5-fold greater than control animals (p < 0.05). Further, the plasma cholesteryl ester transfer protein (CETP) activity in P-407-treated rats was increased by approximately 25%, which was inhibited by > 50% in the presence of TP2, a monoclonal anti-CETP antibody (27.03 +/- 3.16 vs. 10.87 +/- 3.23; p < 0.05). The plasma CETP protein levels were also increased by 5-6-fold in P-407-treated animals (control 0.35 +/- 0.17 vs. P-407 treated 1.87 +/- 0.35 ug/ml, p < 0.05). However, the plasma hepatic lipase (HL) (control 49.2 +/- 3.1 vs. P-407-treated 2.0 +/- 0.38 umol/ml/h; p < 0.001) and lipoprotein lipase (LPL) (control 45.9 +/- 0.09 vs. P-407-treated 2.03 +/- 0.38 mol/ml/hr; p<0.001) activities in these animals were significantly inhibited.

CONCLUSIONS

In summary, P-407-induced hyperlipidemia in rats is associated with alterations in plasma LCAT, CETP, HL and LPL activities.

Enhanced efficacy by percutaneous absorption of piroxicam from the poloxamer gel in rats

The pharmacokinetics and anti-inflammatory activity of piroxicam from the poloxamer 407 gel were determined to investigate percutaneous absorption of piroxicam from poloxamer gels in rats. The poloxamer 407 gel containing 1% piroxicam showed significant inhibition of carragenin-induced rat foot swelling when compared to the control group. The extent of inhibition of swelling (%) showed a linear relationship with the logarithm of piroxicam dose within approximately 0.4-3.2 mg/kg. The enhancing effect of polyoxyethylene-2-oleyl ether, non-ionic surfactant on the percutaneous absorption of piroxicam from poloxamer 407 gel was evaluated in rats. The piroxicam gel containing polyoxyethylene-2-oleyl ether increaesd the relative bioavailability approximately 1.8-fold compared with the gel without enhancer. Percutaneous administration of piroxicam gel containing polyoxyethylene-2-oleyl ether to rats showed a relatively constant, sustained blood concentration with minimal fluctuation.