CA2625084A1

CA2625084A1 - Pth formulations and methods of use

Info

Publication number: CA2625084A1
Application number: CA002625084A
Authority: CA
Inventors: Henry R. Costantino; Steven C. Quay; Michael V. Templin; Ching-Yuan Li; Anthony Sileno
Original assignee: Individual
Current assignee: Marina Biotech Inc
Priority date: 2005-10-06
Filing date: 2006-04-10
Publication date: 2007-04-19
Also published as: JP2009511472A; KR20080059430A; IL190583A0

Abstract

What is described is an aqueous pharmaceutical formulation of PTH, comprising PTH(I -34) and a nonionic surface active agent, a dosage form comprising the formulation, a system of delivering PTH to a human, comprising exposing a layer of mucosal cells to the formulation, and a method of using such formulation for treating osteoporosis in a mammal, preferably wherein a time to maximum plasma concentration, Tmax, of PTH(I -34) following administration is less than 30 minutes. Also described is a method for treating osteoporosis in a mammal comprising administering intranasally a PTH formulation comprises a therapeutically effective amount of PTH(I -34) and one or more excipients selected from the group consisting of a solubilizing agent, a chelating agent, and one or more polyols. Comprising PTH(l-34) and a nonionic surface active agent. Also described is a use of PTH(l-34) in the manufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises a therapeutically effective amount of PTH(I -34) and one or more excipients selected from the group consisting of a nonionic surface active agent, a solubilizing agent, a chelating agent, and one or more polyols.

Description

PTH FORMULATIONS AND METHODS OF USE

Osteoporosis can be defined as a systemic skeletal disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and increased bone fragility and susceptibility to fracture. It most commonly affects older populations, primarily postmenopausal women.
The prevalence of osteoporosis poses a serious health problem. The National Osteoporosis Foundation has estimated that 44 million people are experiencing the effects of osteoporosis or osteopenia. By the year 2010, osteoporosis will affect more than 52 million people and, by 2020, more than 61 million people. The prevalence of osteoporosis is greater in Caucasians and Asians than in African-Americans, perhaps because African-Americans have a higher peak bone mass. Women are affected in greater numbers than men because men have a higher peak bone density.
Furthermore, as women age the rate of bone turnover increases, resulting in accelerated bone loss because of the lack of estrogen after menopause.
The goal of pharmacological treatment of osteoporosis is to maintain or increase bone strength, to prevent fractures throughout the patient's life, and to minimize osteoporosis-related morbidity and mortality by safely reducing the risk of fracture. The medications that have been used most commonly to treat osteoporosis include calcium, and vitamin D, estrogen (with or without progestin), bisphonates, selective estrogen receptor modulators (SERMs), and calcitonin.
Paratllyroid hormone (PTH) has recently emerged as a popular osteoporosis treatment. Unlike other therapies that reduce bone resorption, PTH increases bone mass, which results in greater bone mineral density (BMD). PTH has multiple actions on bone, some direct and some indirect. PTH increases the rate of calcium release from bone into blood. The chronic effects of PTH are to increase the number of bone cells both osteoblasts and osteoclasts, and to increase the remodeling bone.
These effects are apparent within hours after PTH is administered and persist for hours after PTH is withdrawn. PTH administered to osteoporotic patients leads to a net stimulation of bone formation especially in trabecular bone in the spine and hip resulting in a highly significant reduction in fractures. The bone formation is believed to occur by the stimulation of osteoblasts by PTH as osteoblasts have PTH
receptors.
Parathyroid hormone (PTH) is a secreted, 84 amino acid residue polypeptide having the amino acid sequence Ser-Val-Ser-Glu-Ile-Gln-Leu-Met-His-Asn-Leu-Gly-Lys-His-Leu-Asn-Ser-Met-Glu-Arg-Val-Glu-Trp-Leu-Arg-Lys-Lys-Leu-Gln-Asp-Val-His-Asn-Phe Val Ala Leu Gly Ala Pro Leu Ala Pro Arg Asp Ala Gly Ser Gln Arg Pro Arg Lys Lys Ghi Asp Asn Val Leu Val Glu Ser His Glu Lys Ser Leu Gly Glu Ala Asp Lys Ala Asn Val Asp Val Leu Tlir Lys Ala Lys Ser Gln (SEQ ID NO: 1).
Studies in humans with certain forms of PTH have demonstrated an anabolic effect on bone, and have prompted significant interest in its use for the treatment of osteoporosis and related bone disorders.
Using the N-terminal 34 amino acids of the bovine and human hormone Ser-Val-Ser-Glu-Ile-Gln-Leu-Met-His-Asn-Leu-Gly-Lys-His-Leu-Asn-S er-Met-Glu-Arg-Val-Glu-Trp-Leu-Arg-Lys-Lys-Leu-Gln-Asp-Val-His-Asn-Phe (SEQ ID NO: 2) for example, which by all published accounts are deemed biologically equivalent to the full length hormone, it has been demonstrated in humans that paratllyroid hormone enhances bone growth particularly when administered in pulsatile fashion by the subcutaneous route. A slightly different form of PTH, human PTH (1-38) has shown similar results.
PTH (1-34), also called teriparatide, is currently on the market under the brand name FORTEO , Eli Lilly, Indianapolis, Indiana for the treatment of postmenopausal women with osteoporosis who are at high risk of fracture. This drug is administered by a once daily subcutaneous injection of 20 g in a solution containing acetate buffer, mannitol, and m-cresol in water, pH 4. However, many people are adverse to injections, and thus become non-compliant with the prescribed dosing of the PTH.
Thus, there is a need to develop an intranasal formulation of a parathyroid hormone peptide that has suitable bioavailability such that therapeutic levels can be achieved in the blood to be effective to treat osteoporosis or osteopenia. FORTEO (Eli Lilly, U.S.), or FORSTEO (Eli Lilly, UK), is manufactured by recombinant DNA
technology using an Escherichia coli strain. PTH (1-34) has a molecular weight of 4117.87 daltons. Reviews on PTH (1-34) and its clinical uses are published, including, e.g., Brixen et al., 2004; Dobnig, 2004; Eriksen and Robins, 2004;

Quattrocchi and Kourlas 2004, are hereby incorporated by reference. FORTEO is currently licensed in the US and Europe (as FORSTEO). The safety of teriparatide has been evaluated in over 2800 patients in doses ranging from 5 to 100 g per day in short term trials. Doses of up to 40 g per day have been given for up to two years in long term trials. Adverse events associated with FORSTEO were usually mild and generally did not require discontinuation of therapy. The most commonly reported adverse effects were dizziness, leg cramps, nausea, vomiting and headache.
Mild transient hypercalcemia has been reported with FORSTEO which is usually self limiting within 6 hours.
Currently FORTEO is administered as a daily subcutaneous injection. The following Cmax and AUC values are described for various doses of FORTEO (20 ug is the commercially approved dose).

SC Dose ~ ~~ ~UCc~.t cmu f~r : ~rtm1 ~m~
22 '# 52*3 91.2 165 ~ 67.6 151.0*56.9 40 16 124,3 165.8 393 t 161 256,2:0 17:5 80 22 1 ID4,4 27.9 816 202e2 552 8 183.6 20 It would be preferable for patient acceptability if a non-injected route of administration were available, including nasal, bucal, gastrointestinal and dermal.
Teriparatide has previously been administered intranasally to humans at doses of up to 500 g per day for 7 days in one study (Suntory News Release). Suntory Establishes Large Scale Production of recombinant human PTH1_34 and obtains promising results from Phase 1 Clinical Trials using a Nasal Formulation. February 1999.
http://www.suntory.com/news/1999-02.litml accessed 15 April 2004) and in another study subjects received up to 1,000 g per day for 3 months (Matsumoto et al., Daily Nasal Spray of hPTH1_34 for 3 Months Increases Bone Mass in Osteoporotic Subjects (ASBMR 2004 presentation 1171, October 4, 2004, Seattle WA), no safety concerns were noted witlz this route.
Most PTH formulations are reconstituted from fresh or lyophilized hormone, and incorporate various carriers, excipients and vehicles. PTH formulations are often prepared in water-based vehicles such as saline, or water which is acidified typically with acetic acid to solubilize the hormone. Many reported forinulations also incorporate albumin as a stabilizer (see, for example, Reeve et al., Br. Med.
J., 1980, 280:6228; Reeve et al., Lancet, 1976, 1:1035; Reeve at al., Calcif. Tissue Res., 1976, 21:469; Hodsman et al., Bone Miner 1990, 9(2):137; Tsai et al., J. Clin.
Endocrinol Metab., 1989, 69(5):1024; Isaac et al., Horm. Metab. Res., 1980, 12(9):487;
Law et al., J. Clin Invest. 1983, 72(3):1106; and Hulter, J. Clin Hypertens, 1986, 2(4):360).
Other reported formulations incorporate an excipient such as mamitol with either lyopliilized hormone or in the reconstituted vehicle. Some formulations used for human studies include a human PTH (1-34) preparation consisting of mannitol, heat inactivated human serum albumin, and caproic acid (a protease inliibitor) as an absorption enliancer (see Reeve et al., 1976, Calcif. Tissue Res., 21, Suppl., 469-477);
a human PTH (1-38) preparation reconstituted into a saline vehicle (see Hodsman et al., 1991, 14(1), 67-83); and a bovine PTH (1-34) preparation in aqueous vehicle pH
adjusted with acetic acid and containing albumin. The International Reference preparation for human PTH (1-84) consists of 100 ng of hormone ampouled with g human serum albumin and 1.25 mg lactose (1981), and for bovine PTH (1-84) consists of 10 g lyophilized hormone in 0.01 M acetic acid and 0.1 % w/v mannitol (see Martindale, The Extra Pharmacoepia, The Pharmaceutical Press, London, 29th Edition, 1989 at p. 1338). A formulation aimed at improving the stability for a lyophilized preparation of h-PTH (1-34) is reported in EP 619 119 using a combination of sugar and sodium chloride. U.S. Pat. No. 5,496,801 describes a freeze-dried composition for the natural hormone, PTH (1-84), containing mannitol as an excipient and a citrate source as a non-volatile buffering agent.
U.S. Patent No. 6,770,623 describes stabilized teriparatide formulations. The '623 formulations require a buffer. The buffering agent includes any acid or salt combination which is pharmaceutically acceptable and capable of maintaining the aqueous solution at a pH range of 3 to 7, preferably 3-6, e.g., acetate, tartrate, or citrate sources. The concentration of buffer may be in the range of about 2 mM
to about 500 mM.

U.S. Patent No. 5,407,911 describes the use of dipotassium glycyrrhizate as an emulsifying agent for nasal administration of PTH. Polysorbate 80 was determined to 5 be inferior when used in the intranasal PTH formulations because it caused a precipitate and instability in the formulation.
Coinmercial exploitation of parathyroid hormone requires the development of a formulation that is acceptable in terms of storage stability and ease of preparation.
Because it is a protein and thus far more labile than traditional small molecular weight drugs, a parathyroid hormone formulation presents challenges not commonly encountered by the pharmaceutical industry. Furthermore, like other proteins that have been formulated successfully, PTH is particularly sensitive to oxidation, deamidation, and hydrolysis, and requires that its N-terminal and C-terminal sequences remain intact in order to preserve bioactivity.
Formulating proteins is generally more difficult that formulating small molecules, because proteins are more susceptible to degradation (see Arakawa et al.
(2001) Adv. Drug Del. Rev. 46:307-26, hereby incorporated by reference in its entirety). Thus, the stability of purified proteins is difficult to predict a priori and in general must be assessed on a case-by-case basis. FORTEO is a liquid pharmaceutical formulation of teriparatide that requires a buffer for its stability.
There remains a need for a storage-stable formulation of teriparatide that does not require a buffer, and is suitable for intranasal administration.
A potential issue with intranasal delivery of PTH or its analogs is local effect on nasal tissue. For example, Tanako and co-workers have described the effects of PTH locally administered to nasal cartilage cells in culture (see Takano T, et al., J
Dent Res. 1987 Jan;66(1):84-7; Takigawa M, et. al., J Dent Res. 1984 Jan;63(1):19-22.; Takano T, et.al., Nippon Kyosei Shika Gaklcai Zasshi. 1983 Sep;42(3):314-21).
Thus, there is a need to develop safe and effective intranasal formulations of PTH or PTH analogs that will be suitable for systemic delivery, but not cause significant local effects on the nasal tissue (i.e., not having an effect on nasal toxicity).
SUMMARY OF THE INVENTION
One aspect of the invention is an aqueous pharmaceutical formulation for intranasal delivery of PTH, comprising PTH(1-34) and a nonionic surface active agent. In one embodiment, the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol. In another embodiment, the surface active agent is polysorbate 80. In another embodiment, polysorbate 80 is present at less than about 50 mg/mL in the formulation. In another embodiment, polysorbate 80 is present at less than about 10 mg/mL in the formulation. In another embodiment, polysorbate 80 is present at less than about 1 mg/mL in the formulation. In another embodiment, the polyol is selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin, and polyethylene glycol. In another embodiment, the polyol is sorbitol. In another embodiment, a preservative is selected from the group consisting of chlorobutanol, methyl paraben, propyl paraben, butyl paraben, benzalkonium chloride, benzethonium chloride, sodium benzoate, sorbic acid, phenol, and ortho-, meta- or paracresol. In another embodiment, the formulation has a pH of about 3 to about 6. In another embodiment, the formulation has a pH of about 5.0 or less. In another embodiment, the formulation has a pH
of about 4.0 or less. In another embodiment, the aqueous solution is in the form of liquid droplets. In another embodiment, the liquid droplets have an average volume-mean particle size (Dv,50) between about 1 micron and 1000 microns. In another embodiment, the liquid droplets have an average volume-mean particle size (Dv,50) between about 5 microns and 500 microns. In another embodiment, the liquid droplets have an average volume-mean particle size (Dv,50) between about 10 microns and 100 microns. In another embodiment, administration in a human subject achieves a maximum serum concentration of PTH, post-dosing (Cmax), of at least pg/mL.

Another aspect of the invention is a method for treating osteoporosis in a mammal, comprising administering intranasally a therapeutically effective amount of a PTH formulation to the maxnmal wherein the formulation comprises PTH(1-34) and a nonionic surface active agent. In one embodiment, the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol. In another embodiment, the formulation has a pH of about 3-6. In another embodiment, a dose containing about 1 g to about 1000 g of a PTH(1-34) is administered to the mammal. In another embodiment, a dose containing about 20 g to about 400 g of PTH(1 -34) is administered to the mammal. In another embodiment, the mammal is a human. In another embodiment, administration of the PTH formulation results in an increase in plasma levels of calcium. In another embodiment, the increase in plasma levels of calcium are associated with the anabolic effects of PTH. In another embodiment, the increase in plasma levels of calcium are not the result of increased bone catabolism. In another embodinient, the increase in plasma levels of calcium are not the result of increased bone catabolism. In another embodiment, administration of the PTH formulation results in an increase in bone mass. In another embodiment, administration of the PTH formulation results in an increase in bone strength.
In another embodiment, administration of the PTH formulation results in an increased resistance to bone fracture. In another embodiment, administration of the PTH
formulation does not produce histological changes in nasal tissue.
Another aspect of the invention is a method for treating osteoporosis in a mammal comprising administering intranasally a therapeutically effective amount of a PTH formulation to the mammal, wherein the PTH formulation comprises PTH(1-34) and one or more excipients selected from the group consisting of a solubilizing agent, a chelating agent, and one or more polyols. In one embodiment, the formulation further coinprises a surface active agent. In another embodiment, the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, bile salts such, sodium glycocholate, deoxycholate, derivatives of fusidic acid, sodium taurodihydrofusidate, L-a-phosphatidylcholine didecanoyl (DDPC), polysorbate 80, polysoibate 20, a polyethylene glycol, cetyl alcohol, pplyvinylpyrolidone, a polyvinyl alcohol, lanolin alcohol, and sorbitan monooleate. In another embodiment, the surface-active agent is DDPC. In another embodiment, one or more polyols are selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin and polyethylene glycol. In another embodiment, the polyol is sorbitol. In another embodiment, the chelating agent is ethylene diamine tetraacetic acid (EDTA) or ethylene glycol tetraacetic acid (EGTA). In another embodiment, the chelating agent is EDTA. In another embodiment, the solubilizing agent is selected from the group consisting of a cyclodextran, hydroxypropyl-(3-cyclodextran, sulfobutylether-(3-cyclodextran, and methyl-(i-cyclodextran. In another embodiment, the solubilizing agent is a cyclodextran.
Another aspect of the invention is method for treating osteoporosis in a mammal comprising administering intranasally a therapeutically effective amount of a PTH formulation to the mammal, wherein the PTH formulation comprises PTH(1-34) and a nonionic surface active agent, and wherein a time to maximum plasma concentration, T,,,a,, of PTH(1-34) following administration of said formulation to the mammal is less than 30 minutes. In one embodiment, a Cm. greater than about pg/ml results from a single administration of said formulation.
Anotlier aspect of the invention is a dosage form of PTH, comprising an aqueous pharmaceutical formulation of PTH and a nonionic detergent for aerosolized intranasal delivery of PTH having a bioavailability of about 5% or greater, wherein the formulation comprises a therapeutically effective amount of PTH(1-34) and a polysorbate, and wherein least 90% of the PTH can be recovered after storage for 24 weeks at 5 C. In one embodiment, the PTH dosage form having greater than about 90% recovery of the PTH after at least six months at 5 C storage. In another embodiment, the PTH dosage form having greater than about 90% recovery of the PTH after one year at 5 C storage. In another embodiment, the PTH dosage form having greater than about 90% recovery of the PTH after two years at 5 C
storage. In another embodiment, the PTH dosage form having greater than about 80% recovery of the PTH after 24 weeks at 25 C storage. In another embodiment, the PTH
dosage form having greater than about 80% recovery of the PTH after at least six months at 25 C storage. In another embodiment, the PTH dosage form having greater than about 80% recovery of the PTH after one year at 25 C storage. In another embodiment, the PTH dosage form having greater than about 80% recovery of the PTH after two years at 25 C storage. In another embodiment, the PTH dosage form having greater than about 65% recovery of the PTH can be recovered after storage for at least 4 weeks at 40 C. In another embodiment, the PTH dosage form having greater than about 90% recovery of the PTH after being in use for greater than about five days. In another embodiment, the PTH dosage form having greater than about 90% recovery of PTH at 30 C/65% relative humidity between all sprays. In another embodiment, the pH is about 5.0 or less. In another embodiment, the pH is about 4.5 or less. In another embodiment, the pH is about 4.0 or less. In another embodiment, the pH is about 3.5 or less. In another embodiment, the concentration of PTH
is at least about 1 mg/ml. In another embodiment, the concentration of PTH is at least about 2 mg/ml. In another embodiment, the concentration of PTH is at least about 6 mg/ml. In another embodiment, the concentration of PTH is at least about 10 mg/ml.
In another embodiment, the dosage form is suitable for intra-nasal administration to achieve a dose of from about 2 g to about 1000 g of said PTH. In another embodiment, the dosage form is suitable for intra-nasal administration to achieve a dose of from about 100 g to about 600 g of said PTH. In another embodiment, the polysorbate is present at least about 1 mg/mL in the formulation. In another embodiment, the polysorbate is present at least about 10 mg/mL in the formulation.
In another embodiment, the polysorbate is present at least about 50 mg/mL in the formulation. In another embodiment, a preservative is present. In another embodiment, the preservative is chlorobutanol.
Another aspect of the invention is a dosage form of PTH, comprising an aqueous pharmaceutical formulation for aerosolized intranasal delivery of PTH
having a bioavailability of about 10% or greater, wherein the formulation comprises a therapeutically effective amount of PTH(1-34), methyl-p-cyclodextrin, didecanoylphosphatidyl choline, and ethylenediaminetetraacetic acid, and wherein least 90% of the PTH can be recovered after storage for 24 weeks at 5 C. In one embodiment, the PTH dosage form having greater than about 90% recovery of PTH
after at least six months at 5 C storage. In another embodiment, the PTH
dosage form having greater than about 90% recovery of PTH after one year at 5 C storage.
In another embodiment, the PTH dosage form having greater than about 90% recovery of PTH after two years at 5 C storage. In another embodiment, the PTH dosage form having greater than about 80% recovery of PTH after 24 weeks at 25 C storage.
In another embodiment, the PTH dosage form having greater than about 80% recovery of PTH after at least six months at 25 C storage. In another embodiment, the PTH
dosage form having greater than about 80% recovery of PTH after one year at 25 C
storage. In another embodiment, the PTH dosage form having greater than about 80%
recovery of PTH after two years at 25 C storage. In another embodiment, the PTH

5 dosage form having greater than about 65% recovery of the PTH after storage for at least 4 weeks at 40 C. In another embodiment, the PTH dosage form having greater than about 90% recovery of the PTH after being in use for greater than about five days. In another embodiment, the PTH dosage form having greater than about 90%
recovery of PTH at 30 C/65% relative humidity between all sprays. In another 10 embodiment, the pH is about 5.0 or less. In another embodiment, the pH is about 4.5 or less. In another embodiment, the pH is about 4.0 or less. In another embodiment, the pH is about 3.5 or less. In another einbodiment, the concentration of PTH
is at least about 1 mg/ml. In another embodiment, the concentration of PTH is at least about 2 mg/ml. In another embodiment, the concentration of PTH is at least about 6 mg/ml. In another embodiment, the concentration of PTH is at least about 10 mg/ml.
In another embodiment, the dosage form is suitable for intra-nasal administration to achieve a dose of from about 2 g to about 1000 g of said PTH. In another embodiment, the dosage form is suitable for intra-nasal administration to achieve a dose of from about 100 g to about 600 g of said PTH. In another embodiment, a preservative is present. In another embodiment, the preservative is chlorobutanol.
Another aspect of the invention is a method of delivering PTH to a human, comprising exposing a layer of mucosal cells to a PTH solution comprising PTH(1-34) and a nonionic surface active agent. In one embodiment, the method utilizes a non-parenteral administration. In another embodiment, the method of administration is selected from the group consisting of intranasal, buccal, gastrointestinal, vaginal, and transdermal. In another embodiment, the method is an intranasal administration.
In another embodiment, the intranasal administration comprises delivering an aerosol comprising droplets of between about 1 and about 700 microns in size. In another embodiment, intranasal administration comprises delivering an aerosol comprising about about 0.7 to about about 25 g PTH per kg weight of the patient. In another embodiment, intxanasal administration comprises delivering an aerosol comprising about 50 to about 800 g PTH. In another embodiment, the method is an oral delivery. In another embodiment, oral delivery is a controlled release delivery wherein Tmax is less than about 40 minutes from the time of release.
Another aspect of the invention is a system for delivering PTH to a human by intranasal administration comprising an aqueous PTH solution comprising PTH(1-34) and a nonionic surface active agent in a bottle, and a droplet-generating actuator attached to said bottle and fluidly connected to the PTH solution in the container, wherein said actuator produces a spray of the PTH solution through a tip of the actuator when said actuator is engaged, wherein said PTH spray has a spray pattern ellipticity ratio of from about 1.0 to about 1.4 when measured at a height of 3.0 cm from the actuator tip. In one embodiment, the PTH spray is comprised of droplets of the PTH solution wherein less than about 5% of the droplets are less than 10 m in size. In another embodiment, the PTH spray is comprised of droplets of the PTH
solution wherein less than about 1% of the droplets are less than 10 m in size. In another embodiment, the PTH spray has a spray pattern major axis and minor axis of about 25 and about 40 mm, respectively. In another embodiment, the PTH spray is comprised of droplets of the PTH solution, wherein less than about 90% of the droplets are about 250 gm or less in size. In another embodiment, the PTH
spray is comprised of droplets of the PTH solution, wherein less than about 90% of the droplets are about 120 m or less in size. In another embodiment, the PTH
spray is comprised of droplets of the PTH solution wherein less than about 50% of the droplets are about 75 in or less in size. In another embodiment, the PTH
spray is comprised of droplets of the PTH solution wherein less than about 50% of the droplets are about 50 in or less in size. In another embodiment, the PTH
spray is comprised of droplets of the PTH solution, wherein less than about 10% of the droplets are about 30 gm or less in size. In another embodiment, the PTH spray is comprised of droplets of the PTH solution, wherein less than about 10% of the droplets are about 20 m or less in size. In another embodiment, the formulation is used in the treatment of osteoporosis or osteopenia.
Another aspect of the invention, is use of PTH(1-34) in the manufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises PTH(1-34) and a nonionic surface active agent. In one embodiment, the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol. In another embodiment, the formulation has a pH of about of about 3-6. In another embodiment, a dose containing 1 g to 1000 g of a PTH(1-34) is administered to the mammal. In another embodiment, a dose containing 20 g to 400 gg of PTH(1-34) is administered to the mammal. In another embodiment, the mammal is a human. In another embodiment, administration of the PTH
formulation results in an increase in plasma levels of calcium. In another embodiment, the increase in plasma levels of calcium are associated with the anabolic effects of PTH.
In another embodiment, the increase in plasma levels of calcium are not the result of increased bone catabolism. In another embodiment, the increase in plasma levels of calcium are not the result of increased bone catabolism. In another embodiment, administration of the PTH formulation results in an increase in bone mass. In another embodiment, administration of the PTH formulation results in an increase in bone strength. In another embodiment, administration of the PTH formulation results in an increased resistance to bone fracture. In another embodiment, administration of the PTH formulation does not produce histological changes in nasal tissue.
Another aspect of the invention is use of PTH(1-34) in the inanufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises a therapeutically effective amount of PTH(1-34) and one or more excipients selected from the group consisting of a solubilizing agent, a chelating agent, and one or more polyols. In one embodiment, the formulation further comprises a surface active agent. In another embodiment, the surface active agent is selected from the group consisting of nonionic polyoxyethylene etlier, bile salts such, sodium glycocholate, deoxycholate, derivatives of fusidic acid, sodium taurodihydrofusidate, L-a-phosphatidylcholine didecanoyl (DDPC), polysorbate 80, polysorbate 20, a polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, a polyvinyl alcohol, lanolin alcohol, and sorbitan monooleate. In another embodiment, the surface-active agent is DDPC. In another embodiment, one or more polyols are selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin and glycol. In another embodiment, the polyol is sorbitol. In another embodiment, the chelating agent is ethylene diamine tetraacetic acid (EDTA) or ethylene glycol tetraacetic acid (EGTA). In another embodiment, the chelating agent is EDTA. In another embodiment, the solubilizing agent is selected from the group consisting of a cyclodextran, hydroxypropyl-(3-cyclodextran, sulfobutylether-0-cyclodextran, and methyl-(3-cyclodextran. In another embodiment, the solubilizing agent is a cyclodextran.
Another aspect of the invention is use of PTH(1-34) in the manufacture of a medicainent for treating osteoporosis in a mammal, wherein the medicament comprises PTH(1-34) and a nonionic surface active agent, and wherein a time to maximum plasma concentration, T,,,a,,, of PTH(1-34) following administration of said formulation to the mainmal is less than 30 minutes. In one embodiment, a C,,,a, greater than 300 pg/ml results from a single administration of said forinulation.

BRIEF DISCRIPTION OF THE DRAWINGS
Figure 1: Mean Plasma Concentration versus Time for Periods 1-5: (Linear Graph).
Figure 2: Ratio of C,,,a, to Mean, Low Dose PTH Formulations versus FORTEO .
DISCLOSURE OF THE INVENTION
Preferably the honnone is parathyroid hormone and the mammal is a human.
In a most preferred embodiinent the parathyroid hormone peptide is PTH (1-34), also known as teriparatide. Tregear, U.S. Pat. No. 4,086,196, described human PTH
analogues and claimed that the first 27 to 34 amino acids are the most effective in terms of the stimulation of adenylyl cyclase in an in vitro cell assay. PTH
operates through activation of two second messenger systems, GS -protein activated adenylyl cyclase (AC) and Gq -protein activated phospholipase Cp. The latter system results in a stimulation of membrane-bound protein kinase C (PKC) activity.
The PKC activity has been shown to require PTH residues 29 to 32 (Jouishomme et al.
(1994) J. Bone Mineral Res. 9, (1179-1189). It has been established that the increase in bone growth, i.e. the effect which is useful in the treatment of osteoporosis, is coupled to the ability of the peptide sequence to increase AC activity. The native PTH
sequence, PTH (1-84) (SEQ ID NO: 1), has been shown to have all of these activities.
The above described forms of parathyroid hormone are embraced by the terins "parathyroid hormone" or "PTH" or "PTH peptide" as used generically herein.
The parathyroid hormones may be obtained by Icnown recombinant or synthetic methods, such as described in U.S. Pat. No. 4,086,196 incorporated herein by reference.

Thus, the present invention is a method for treating osteoporosis or osteopenia in a mammal comprising transmucosally administering a formulation comprised of a PTH peptide, such that when 50 g of the PTH is administered transmucosally to the mammal the concentration of the PTH peptide in the plasma of the mainmal increases by at least 5 pmol, preferably at least 10 pmol per liter of plasma.
Intranasal delivery-enhancing agents are employed which enhance delivery of PTH into or across a nasal mucosal surface. For passively absorbed drugs, the relative contribution of paracellular and transcellular pathways to drug transport depends upon the pKa, partition coefficient, molecular radius and charge of the drug, the pH of the luminal environment in which the drug is delivered, and the area of the absorbing surface. The intranasal delivery-enhancing agent of the present invention may be a pH control agent. The pH of the pharmaceutical forinulation of the present invention is a factor affecting absorption of PTH via paracellular and transcellular pathways to drug transport. In one embodiment, the pharmaceutical formulation of the present invention is pH adjusted to between about pH 3.0 to 7Ø In a further embodiment, the pharmaceutical formulation of the present invention is pH
adjusted to between about pH 3.0 to 6Ø In a further einbodiment, the pharmaceutical formulation of the present invention is pH adjusted to between about pH 4.0 to 5Ø
Generally, the pH is 4.0 0.3.
As noted above, the present invention provides improved methods and compositions for mucosal delivery of PTH peptide to mammalian subjects for treatment or prevention of osteoporosis or osteopenia. Examples of appropriate mammalian subjects for treatment and prophylaxis according to the methods of the invention include, but are not restricted to, humans and non-human primates, livestock species, such as horses, cattle, sheep, and goats, and research and domestic species, including dogs, cats, mice, rats, guinea pigs, and rabbits.
In order to provide better understanding of the present invention, the following definitions are provided:
According to the present invention a PTH peptide also includes the free bases, acid addition salts or metal salts, such as potassium or sodium salts of the peptides, and PTH peptides that have been modified by such processes as amidation, 5 glycosylation, acylation, sulfation, phosphorylation, acetylation, cyclization and other well known covalent modification methods.
The nasal spray product manufacturing process generally includes the preparation of a diluent for PTH (1-34) nasal spray, which includes -85% water plus the components of the nasal spray formulation without PTH. The pH of the diluent is 10 then measured and adjusted to pH 4.0 0.3 with sodium hydroxide or hydrochloric acid, if necessary. The PTH (1-34) nasal spray is prepared by the non-aseptic transfer of -85% of the final target volume of the diluent to a screw cap bottle. An appropriate amount of PTH (1-34) is added and mixed until completely dissolved.
The pH is measured and adjusted to pH 4.0 0.3 with sodium hydroxide or 15 hydrochloric acid, if necessary. , A sufficient quantity of diluent is added to reach the final target volume. Screw-cap bottles are filled and caps affixed. The above description of the manufacturing process represents a method used to prepare the initial clinical batches of drug product. This method may be modified during the development process to optimize the manufacturing process.
Currently marketed PTH requires sterile manufacturing conditions for compliance witli FDA regulations. Parenteral administration, including PTH for injection or infusion, requires a sterile (aseptic) manufacturing process.
Current Good Manufacturing Practices (GMP) for sterile drug manufacturing include standards for design and construction features (21 CFR 211.42 (April 1, 2005)); standards for testing and approval or rejection of components, drug product containers, and closures ( 211.84); standards for control of microbiological contamination ( 211.113); and other special testing requirements ( 211.167). Non-parenteral (non-aseptic) products, such as the intranasal product of the invention, do not require these specialized sterile manufacturing conditions. As can be readily appreciated, the requirements for a sterile manufacturing process are substantially higher and correspondingly more costly than those required for a non-sterile product manufacturing process. These costs include much greater capitalization costs for facilities, as well as a more costly manufacturing cost: extra facilites for sterile manufacturing include additional rooms and ventilation; extra costs associated with sterile manufacturing include greater manpower, extensive quality control and quality assurance, and administrative support. As a result, manufacturing costs of an intranasal PTH product, such as that of the invention, are far less than those of a parenterally administered PTH product. The present invention satisfies the need for a non-sterile manufacturing process for PTH.
"Mucosal delivery-enhancing agents" are defined as chemicals and other excipients that, when added to an aqueous PTH formulation results in a formulation that produces a significant increase in transport of PTH peptide across a mucosa as measured by the maximum blood, serum, or cerebral spinal fluid concentration (C,aX) or by the area under the curve, AUC, in a plot of concentration versus time. A
mucosa includes the nasal, oral, intestinal, buccal, bronchopulmonary, vaginal, and rectal mucosal surfaces and in fact includes all mucus-secreting membranes lining all body cavities or passages that communicate with the exterior. Mucosal delivery enhancing agents are sometimes called carriers.
As used herein, mucosal delivery-enhancing agents include agents which enhance the release or solubility (e.g., from a formulation delivery vehicle), diffusion rate, penetration capacity and timing, uptalce, residence time, stability, effective half-life, peak or sustained concentration levels, clearance and other desired mucosal delivery characteristics (e.g., as measured at the site of delivery, or at a selected target site of activity such as the bloodstream or central nervous system) of PTH
peptide or other biologically active compound(s). Enhancement of mucosal delivery can thus occur by any of a variety of mechanisms, for example by increasing the diffusion, transport, persistence or stability of PTH peptide, increasing membrane fluidity, modulating the availability or action of calcium and other ions that regulate intracellular or paracellular permeation, solubilizing mucosal membrane components (e.g., lipids), changing non-protein and protein sulfhydryl levels in mucosal tissues, increasing water flux across the mucosal surface, modulating epithelial junctional physiology, reducing the viscosity of mucus overlying the mucosal epithelium, reducing mucociliary clearance rates, and other mechanisms.
As used herein, a "mucosally effective amount of PTH peptide" contemplates effective mucosal delivery of PTH peptide to a target site for drug activity in the subject that may involve a variety of delivery or transfer routes. For example, a given active agent may find its way through clearances between cells of the mucosa and reach an adjacent vascular wall, while by another route the agent may, either passively or actively, be taken up into mucosal cells to act within the cells or be discharged or transported out of the cells to reach a secondary target site, such as the systemic circulation. The methods and compositions of the invention may promote the translocation of active agents along one or more such alternate routes, or may act directly on the mucosal tissue or proximal vascular tissue to promote absorption or penetration of the active agent(s). The promotion of absorption or penetration in this context is not limited to these mechanisms.
As used herein "peak concentration (C,,,,,,) of PTH peptide in a blood plasma", "area under concentration vs. time curve (AUC) of PTH peptide in a blood plasma", "time to maximal plasma concentration (t,,,~,x) of PTH peptide in a blood plasma" are pharmacokinetic parameters lcnown to one skilled in the art. Laursen et al., Eur. J
Endocrinology, 135: 309-315 (1996). The "concentration vs. time curve"
measures the concentration of PTH peptide in a blood serum of a subject vs. time after administration of a dosage of PTH peptide to the subject either by intranasal, intrainuscular, or subcutaneous route of administration. "Cm,,," is the maximum concentration of PTH peptide in the blood serum of a subject following a single dosage of PTH peptide to the subject. "tax" is the time to reach maximum concentration of PTH peptide in a blood serum of a subject following administration of a single dosage of PTH peptide to the subject.
A "buffer" is generally used to maintain the pH of a solution at a nearly consta.nt value. A buffer maintains the pH of a solution, even when small amounts of strong acid or strong base are added to the solution, by preventing or neutralizing large changes in concentrations of hydrogen and hydroxide ions. A buffer generally consists of a weak acid and its appropriate salt (or a weak base and its appropriate salt). The appropriate salt for a weak acid contains the same negative ion as present in the weak acid. (see Lagowski, Macmillan Encyclopedia of Chemistry, Vol. 1, Simon & Schuster, New Yorlc, 1997 at p. 273-4). The Henderson-Hasselbach Equation, pH = pKa + logio [A"]/[HA], is used to describe a buffer, and is based on the standard equation for weak acid dissociation, HA = H+ + K. Examples of commonly used buffer sources include the following: acetate, tartrate, or citrate.

The "buffer capacity" means the amount of acid or base that can be added to a buffer solution before a significant pH change will occur. If the pH lies within the range of pK-l and pK+l of the weak acid the buffer capacity is appreciable, but outside this range it falls off to such an extent as to be of little value.
Therefore, a given system only has a useful buffer action in a range of one pH unit on either side of the pK of the weak acid (or wealc base). (see Dawson, Data for Biochemical Research, Third Edition, Oxford Science Publications, 1986 at p. 419).
Generally, suitable concentrations are chosen so that the pH of the solution is close to the pKa of the weak acid (or weak base). (see Lide, CRC Handbook of Chemistry and Physics, 86t" Edition, Taylor & Francis Group, 2005-2006 at p. 2-41). Further, solutions of strong acids and bases are not normally classified as buffer solutions, and they do not display buffer capacity between pH values 2.4 to 11.6.
"Non-infused administration" means any method of delivery that does not involve an injection directly into an artery or vein, a method which forces or drives (typically a fluid) into something and especially to introduce into a body part by means of a needle, syringe or otlier invasive method. Non-infused administration includes subcutaneous injection, intramuscular injection, intraparitoneal injection and the non-injection methods of delivery to a mucosa.
Osteoporosis is a systemic slceletal disease characterized by low bone mass, microarchitectural deterioration of bone tissue, and increased bone fragility and susceptibility to fracture. Osteopenia is a decreased calcification or density of bone, a descriptive term applicable to all skeletal systems in which the condition is noted.
Osteoporosis or osteopenia therapies and medical diagnosis include the administration of a clinically effective dose of PTH for the prevention and/or treatment of osteoporosis or osteopenia. As noted above, the instant invention provides improved and useful methods and compositions for nasal mucosal delivery of a PTH peptide to prevent and treat osteoporosis or osteopenia in mammalian subjects. As used herein, prevention and treatment of osteoporosis or osteopenia means prevention of the onset or lowering the incidence or severity of clinical osteoporosis by reducing increasing bone mass, decreasing bone resporption, or reducing the incidence of fiactured bones in a patient.

The PTH peptide can also be administered in conjunction with other therapeutic agents such as bisphonates, calcium, vitamin D, estrogen or estrogen-receptor binding compounds, selective estrogen receptor modulators (SERMs), bone morphogenic proteins, or calcitonin.
Improved methods and compositions for mucosal administration of PTH
peptide to mammalian subjects optimize PTH peptide dosing schedules. The present invention provides mucosal delivery of PTH peptide, formulated with one or more mucosal delivery-enhancing agents such as a nonionic surface active agent, wherein PTH peptide dosage release is substantially normalized and/or sustained for an effective delivery period of PTH peptide release ranging from approximately 0.1 to 2.0 hours; 0.4 to 1.5 hours; 0.7 to 1.5 hours; or 0.8 to 1.0 hours; following mucosal administration. The sustained release of PTH peptide may be facilitated by repeated administration of exogenous PTH peptide utilizing methods and compositions of the present invention.

Improved coinpositions and methods for mucosal administration of PTH
peptide to mammalian subjects optimize PTH peptide dosing schedules. The present invention provides improved mucosal (e.g., nasal) delivery of a formulation comprising PTH peptide in combination with one or more mucosal delivery-enhancing agents and an optional sustained release-enhancing agent or agents.
Mucosal delivery-enhancing agents of the present invention yield an effective increase in delivery, e.g., an increase in the maximal plasma concentration (C,,,ax) to enhance the therapeutic activity of mucosally-administered PTH peptide. A
second factor affecting therapeutic activity of PTH peptide in the blood plasma and CNS is residence time (RT). Sustained release-enhancing agents, in combination with intranasal delivery-enhancing agents, increase Ca,, and increase residence time (RT) of PTH peptide. Polymeric delivery vehicles and other agents and methods of the present invention that yield sustained release-enhancing formulations, for example, polyethylene glycol (PEG), are disclosed herein. The present invention provides an improved PTH peptide delivery method and dosage form for treatment or prevention of osteoporosis or osteopenia in mammalian subjects.

Within the mucosal delivery compositions and methods of the invention, various delivery-enhancing agents are employed which enhance delivery of PTH

5 peptide into or across a mucosal surface. In this regard, delivery of PTH
peptide across the mucosal epithelium can occur "transcellularly" or "paracellularly."
The extent to wlZich these pathways contribute to the overall flux and bioavailability of the PTH peptide depends upon the environment of the mucosa, the physico-chemical properties the active agent, and the properties of the mucosal epitheliuin.
Paracellular 10 transport involves only passive diffusion, whereas transcellular transport can occur by passive, facilitated, or active processes. Generally, hydrophilic, passively transported, polar solutes diffuse tlirough the paracellular route, while more lipophilic solutes use the transcellular route. Absorption and bioavailability (e.g., as reflected by a permeability coefficient or physiological assay), for diverse, passively and actively 15 absorbed solutes, can be readily evaluated, in terms of both paracellular and transcellular delivery components, for any selected PTH peptide within the invention.
For passively absorbed drugs, the relative contribution of paracellular and transcellular pathways to drug transport depends upon the pKa, partition coefficient, molecular radius and charge of the drug, the pH of the luminal envirorunent in which 20 the drug is delivered, and the area of the absorbing surface. The paracellular route represents a relatively small fraction of accessible surface area of the nasal mucosal epithelium. In general terms, it has been reported that cell membranes occupy a mucosal surface area that is a thousand times greater than the area occupied by the paracellular spaces. Thus, the smaller accessible area and the size- and charge-based discrimination against macromolecular permeation suggest that the paracellular route is a generally less favorable route than transcellular delivery for drug transport.
Surprisingly, the methods and compositions of the invention provide for significantly enhanced transport of biotherapeutics into and across mucosal epithelia via the paracellular route. Therefore, the methods and compositions of the invention successfully target both paracellular and transcellular routes, alternatively, or within a single method or composition.
While the mechanism of absorption promotion may vary with different mucosal delivery-enhancing agents of the invention, useful reagents in this context will not substantially adversely affect the mucosal tissue and is selected according to the physicochenlical characteristics of the particular PTH peptide or other active or delivery-enhancing agent. In this context, delivery-enhancing agents that increase penetration or permeability of mucosal tissues will often result in some alteration of the protective permeability barrier of the mucosa. For such delivery-enhancing agents to be of value within the invention, it is generally desired that any significant changes in permeability of the mucosa be reversible within a time frame appropriate to the desired duration of drug delivery. Furthermore, there should be no substantial, cumulative toxicity, nor any permanent deleterious changes induced in the barrier properties of the mucosa with long-term use.

Within certain aspects of the invention, delivery-enhancing agents for coordinate administration or combinatorial formulation with PTH peptide of the invention are selected from absorption promoting small hydrophilic molecules, including but not limited to, dimethyl sulfoxide (DMSO), dimethylformamide, ethanol, propylene glycol, and the 2-pyrrolidones. Alternatively, long-chain amphipathic molecules, for example, deacylmethyl sulfoxide, azone, sodium laurylsulfate, oleic acid, and the bile salts, may be employed to enhance mucosal penetration of the PTH peptide. Additionally, surfactants (e.g., nonionic surface active agents such as polysorbates) may be employed as adjunct compounds, processing agents, or formulation additives to enliance intranasal delivery of the PTH
peptide. Agents such as DMSO, polyethylene glycol, and ethanol can, if present in sufficiently high concentrations in delivery environment (e.g., by pre-administration or incorporation in a tlierapeutic formulation), enter the aqueous phase of the mucosa and alter its solubilizing properties, thereby enhancing the partitioning of the PTH
peptide from the vehicle into the mucosa.
Additional mucosal delivery-enhancing agents that are useful within the coordinate administration and processing methods and combinatorial formulations of the invention include, but are not limited to, mixed micelles; enamines;
nitric oxide donors (e.g., S-nitroso-N-acetyl-DL-penicillamine, NORl, NOR4--which are preferably co-administered with an NO scavenger such as carboxy-PITO or doclofenac sodium); sodium salicylate; glycerol esters of acetoacetic acid (e.g., glyceryl-1,3-diacetoacetate or 1,2-isopropylideneglycerine-3-acetoacetate);
and other release-diffusion or intra- or trans-epithelial penetration-promoting agents that are physiologically compatible for mucosal delivery. Other delivery-enhancing agents are selected from a variety of carriers, bases and excipients that enhance mucosal delivery, stability, activity, or trans-epithelial penetration of the PTH
peptide. These include, inter alia, cyclodextrins and (3-cyclodextrin derivatives (e.g., 2-hydroxypropyl-(3-cyclodextrin and heptakis(2,6-di-O-methyl-(3-cyclodextrin).
These compounds, optionally conjugated with one or more of the active ingredients and further optionally formulated in an oleaginous base, enhance bioavailability in the mucosal formulations of the invention. Yet additional delivery-enhancing agents adapted for mucosal delivery include medium-chain fatty acids, including mono-and diglycerides (e.g., sodium caprate--extracts of coconut oil, Capmul), and triglycerides (e.g., amylodextrin, Estaram 299, Miglyol 810).
The mucosal therapeutic and prophylactic compositions of the present invention may be supplemented with any suitable delivery-enhancing agent that facilitates absorption, diffusion, or penetration of PTH peptide across mucosal barriers. The penetration promoter may be any promoter that is pharmaceutically acceptable. Thus, in more detailed aspects of the invention compositions are provided that incorporate one or more delivery-enhancing agents that promote penetration selected from sodium salicylate and salicylic acid derivatives (acetyl salicylate, choline salicylate, salicylamide.); amino acids and salts thereof (e.g.
monoaminocarboxlic acids such as glycine, alanine, phenylalanine, proline, hydroxyproline; hydroxyainino acids such as serine; acidic amino acids such as aspartic acid, glutamic acid; and basic amino acids such as lysine-inclusive of their alkali metal or alkaline eartli metal salts); and N-acetylamino acids (N-acetylalanine, N-acetylphenylalanine, N-acetylserine, N-acetylglycine, N-acetyllysine, N-acetylglutamic acid, N-acetylproline, N-acetylhydroxyproline.) and their salts (alkali metal salts and alkaline earth metal salts). Also provided as delivery-enhancing agents that promote penetration within the methods and compositions of the invention are substances which are generally used as emulsifiers (e.g. sodium oleyl phosphate, sodium lauryl phosphate, sodium lauryl sulfate, sodium myristyl sulfate, polyoxyethylene allcyl ethers, polyoxyethylene alkyl esters.), caproic acid, lactic acid, malic acid and citric acid and alkali metal salts thereof, pyrrolidonecarboxylic acids, allcylpyrrolidonecarboxylic acid esters, N-alkylpyrrolidones, proline acyl esters, and the like.

Within various aspects of the invention, improved nasal mucosal delivery formulations and methods are provided that allow delivery of PTH peptide and other therapeutic agents within the invention across mucosal barriers between administration and selected target sites. Certain formulations are specifically adapted for a selected target cell, tissue or organ, or even a particular disease state.
In other aspects, formulations and methods provide for efficient, selective endo- or transcytosis of PTH peptide specifically routed along a defined intracellular or intercellular pathway. Typically, the PTH peptide is efficiently loaded at effective concentration levels in a carrier or other delivery vehicle, and is delivered and maintained in a stabilized form, e.g., at the nasal mucosa and/or during passage througli intracellular compartments and membranes to a remote target site for drug action (e.g., the blood stream or a defined tissue, organ, or extracellular compartment). The PTH peptide may be provided in a delivery vehicle or otherwise modified (e.g., in the form of a prodrug), wherein release or activation of the PTH
peptide is triggered by a physiological stimulus (e.g. pH change, lysosomal enzymes).
Often, the PTH peptide is pharmacologically inactive until it reaches its target site for activity. In most cases, the PTH peptide and other formulation components are non-toxic and non-immunogenic. In this context, carriers and other formulation components are generally selected for their ability to be rapidly degraded and excreted under physiological conditions. At the same time, formulations are chemically and physically stable in dosage form for effective storage.
Various additional preparative components and methods, as well as specific formulation additives, are provided herein which yield formulations for mucosal delivery of aggregation-prone peptides and proteins, wherein the peptide or protein is stabilized in a substantially pure, unaggregated form using a solubilization agent. A
range of components and additives are contemplated for use within these methods and formulations. Exemplary of these solubilization agents are cyclodextrins (CDs), which selectively bind hydrophobic side chains of polypeptides. These CDs have been found to bind to hydrophobic patches of proteins in a manner that significantly inhibits aggregation. This inhibition is selective with respect to both the CD
and the protein involved. Such selective inhibition of protein aggregation provides additional advantages within the intranasal delivery methods and compositions of the invention.

Additional agents for use in this context include CD dimers, trimers and tetramers with varying geometries controlled by the linlcers that specifically block aggregation of peptides and protein. Yet solubilization agents and methods for incorporation within the invention involve the use of peptides and peptide mimetics to selectively block protein-protein interactions. In one aspect, the specific binding of hydrophobic side chains reported for CD multimers is extended to proteins via the use of peptides and peptide mimetics that similarly bloclc protein aggregation. A wide range of suitable methods and anti-aggregation agents are available for incorporation within the compositions and procedures of the invention.
Effective delivery of biotherapeutic agents via intranasal administration must take into account the decreased drug transport rate across the protective mucus lining of the nasal mucosa, in addition to drug loss due to binding to glycoproteins of the mucus layer. Normal mucus is a viscoelastic, gel-like substance consisting of water, electrolytes, mucins, macromolecules, and sloughed epitllelial cells. It serves primarily as a cytoprotective and lubricative covering for the underlying mucosal tissues. Mucus is secreted by randomly distributed secretory cells located in the nasal epithelium and in other mucosal epithelia. The structural unit of mucus is mucin.
This glycoprotein is mainly responsible for the viscoelastic nature of mucus, although other inacromolecules may also contribute to this property. In airway mucus, such macromolecules include locally produced secretory IgA, IgM, IgE, lysozyme, and bronchotransferrin, which also play an important role in host defense mechanisms.
The coordinate administration methods of the instant invention optionally incorporate effective mucolytic or mucus-clearing agents, which serve to degrade, thin, or clear mucus from intranasal mucosal surfaces to facilitate absorption of intranasally administered biotherapeutic agents. Within these methods, a mucolytic or mucus-clearing agent is coordinately administered as an adjunct compound to enhance intranasal delivery of PTH. Alternatively, an effective amount of a mucolytic or mucus-clearing agent is incorporated as a processing agent within a multi-processing method of the invention, or as an additive within a combinatorial formulation of the invention, to provide an improved formulation that enhances intranasal delivery of biotherapeutic compounds by reducing the barrier effects of intranasal mucus.

5 A variety of mucolytic or mucus-clearing agents are available for incorporation within the methods and compositions of the invention. Based on their mechanisms of action, mucolytic and mucus clearing agents can often be classified into the following groups: proteases (e.g., pronase, papain) that cleave the protein core of mucin glycoproteins; sulfhydryl compounds that split mucoprotein disulfide 10 linkages; and detergents (e.g., Triton X-100, Tween 20) that break non-covalent bonds within the mucus. Additional compounds in this context include, but are not limited to, bile salts and surfactants, for example, sodium deoxycholate, sodium taurodeoxycholate, sodium glycocholate, and lysophosphatidylcholine.
The effectiveness of bile salts in causing structural breakdown of mucus is in 15 the order: deoxycholate > taurocholate > glycocholate. Other effective agents that reduce mucus viscosity or adhesion to enhance intranasal delivery according to the methods of the invention include, e.g., short-chain fatty acids, and mucolytic agents that worlc by chelation, such as N-acylcollagen peptides, bile acids, and saponins (the latter function in part by chelating Caa+ and/or Mg2+ which play an important role in 20 maintaining mucus layer structure).

Additional mucolytic agents for use within the methods and compositions of the invention include N-acetyl-L-cysteine (ACS), a potent mucolytic agent that reduces both the viscosity and adherence of bronchopulmonary mucus and is reported to modestly increase nasal bioavailability of human growth hormone in anesthetized 25 rats (from 7.5 to 12.2%). These and other mucolytic or mucus-clearing agents are contacted with the nasal mucosa, typically in a concentration range of about 0.2 to 20 mM, coordinately with administration of the biologically active agent, to reduce the polar viscosity and/or elasticity of intranasal mucus.
Still other mucolytic or mucus-clearing agents may be selected from a range of glycosidase enzymes, which are able to cleave glycosidic bonds within the mucus glycoprotein. a-amylase and 13-amylase are representative of this class of enzymes, although their mucolytic effect may be limited. In contrast, bacterial glycosidases which allow these microorganisms to permeate mucus layers of their hosts may have a stronger effect.
For combinatorial use witli most biologically active agents within the invention, including peptide and protein therapeutics, non-ionogenic detergents are generally also useful as mucolytic or mucus-clearing agents. These agents typically will not modify or substantially impair the activity of therapeutic polypeptides.
Because the self-cleaning capacity of certain mucosal tissues (e.g., nasal mucosal tissues) by mucociliary clearance is necessary as a protective function (e.g., to remove dust, allergens, and bacteria), it has been generally considered that this function should not be substantially impaired by mucosal medications.
Mucociliary transport in the respiratory tract is a particularly important defense mechanism against infections. To achieve this function, ciliary beating in the nasal and airway passages moves a layer of mucus along the mucosa to removing iiihaled particles and microorganisms.
Ciliostatic agents, within the metllods and compositions of the invention, increase the residence time of mucosally (e.g., intranasally) administered PTH. In particular, within the methods and compositions of the invention, delivery is significantly enhanced in certain aspects by the coordinate administration or combinatorial formulation of one or more ciliostatic agents that function to reversibly inliibit ciliary activity of mucosal cells, to provide for a temporary, reversible increase in the residence time of the mucosally administered active agent(s). For use within these aspects of the invention, the foregoing ciliostatic factors, either specific or indirect in their activity, are all candidates for successful employment as ciliostatic agents in appropriate amounts (depending on concentration, duration and mode of delivery) such that they yield a transient (i.e., reversible) reduction or cessation of mucociliary clearance at a mucosal site of administration to enhance delivery of PTH
peptide, analogs and mimetics, and other biologically active agents disclosed herein, without unacceptable adverse side effects.
Certain surface active agents (surfactants) are readily incorporated within the mucosal delivery formulations and methods of the invention as delivery-enhancing agents. These agents, which may be coordinately administered or combinatorially formulated with PTHand other delivery-enhancing agents disclosed herein, may be selected from a broad assemblage of known surface active agents. Examples of surface-active agent are nonionic polyoxyethylene ether, bile salts, sodium glycocholate, deoxycholate, derivatives of fusidic acid, sodiuin taurodihydrofusidate, L-a-phosphatidylcholine didecanoyl (DDPC), polysorbate 80, polysorbate 20, a polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, a polyvinyl alcohol, lanolin alcohol, and sorbitan monooleate. The mechanisms of action of these various classes of surface active agents typically include solubilization of a biologically active agent.
For proteins and peptides which often form aggregates, the surface active properties of these delivery-enhancing agents can allow interactions with proteins so that smaller units, such as surfactant coated monomers, may be more readily maintained in solution. These monomers are presumably more transportable units than aggregates.
A nonionic surface active agent has no charge group in its head. Examples of nonionic surface active agents are nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F 127, and lanolin alcohol.
Another potential mechanism of surface active agents is the protection of the peptide or protein from proteolytic degradation by proteases in the mucosal environment. Both bile salts and some fusidic acid derivatives reportedly inhibit proteolytic degradation of proteins by nasal homogenates at concentrations less than or equivalent to those required to enhance protein absorption. This protease inhibition may be especially important for peptides with short biological half-lives.
The present invention provides a pharmaceutical composition that contains PTH in combination with delivery-enhancing agents disclosed herein formulated in a pharmaceutical preparation for mucosal delivery.
In certain aspects of the invention, the combinatorial forinulations and/or coordinate administration methods herein incorporate an effective amount of PTH
which may adhere to charged glass thereby reducing the effective concentration in the container. Silanized containers, for example, silanized glass containers, are used to store the finished product to reduce adsorption of the PTH to a glass container.
In yet additional aspects of the invention, a kit for treatment of a manunalian subject comprises a stable pharmaceutical composition of PTH formulated for mucosal delivery to the mammalian subject wherein the composition is effective for treating or preventing osteoporosis or osteopenia. The kit further comprises a pharmaceutical reagent bottle to contain the PTH. The pharmaceutical reagent bottle is composed of pharmaceutical grade polymer, glass or other suitable material.
The pharmaceutical reagent bottle is, for example, a silanized glass bottle. The kit further comprises an aperture for delivery of the composition to a nasal mucosal surface of the subject. The delivery aperture is composed of a pharmaceutical grade polymer, glass or other suitable material. The delivery aperture is, for example, a silanized glass.
A silanization technique combines a special cleaning technique for the surfaces to be silanized with a silanization process at low pressure. The silane is in the gas phase and at an enhanced temperature of the surfaces to be silanized.
The method provides reproducible surfaces with stable, homogeneous and functional silane layers having characteristics of a monolayer. The silanized surfaces prevent binding to the glass of polypeptides or mucosal delivery enhancing agents of the present invention.
The procedure is useful to prepare silanized pharmaceutical reagent bottles to hold PTH peptide compositions of the present invention. Glass trays are cleaned by rinsing with double distilled water (ddH2O) before using. The silane tray is then be rinsed with 95% EtOH, and the acetone tray is rinsed with acetone.
Pharmaceutical reagent bottles are sonicated in acetone for 10 minutes. After the acetone sonication, reagent bottles are washed in ddHZO tray at least twice. Reagent bottles are sonicated in 0.1 M NaOH for 10 minutes. While the reagent bottles are sonicating in NaOH, the silane solution is made under a hood. (Silane solution: 800 mL of 95% ethanol;

of glacial acetic acid; 25 mL of glycidoxypropyltrimethoxy silane). After the NaOH
sonication, reagent bottles are washed in ddHZO tray at least twice. The reagent bottles are sonicated in silane solution for 3 to 5 minutes. The reagent bottles are washed in 100% EtOH tray. The reagent bottles are dried with prepurified N2 gas and stored in a 100 C oven for at least 2 hours before using.
Within the compositions and methods of the invention, PTH may be administered to subjects by a variety of mucosal administration modes, including by oral, rectal, vaginal, intranasal, intrapulmonary, or transdermal delivery, or by topical delivery to the eyes, ears, skin or other mucosal surfaces.
Compositions according to the present invention are often administered in an aqueous solution as a nasal or pulmonary spray and may be dispensed in spray form by a variety of methods known to those skilled in the art. Preferred systems for dispensing liquids as a nasal spray are disclosed in U.S. Patent No.
4,511,069, hereby incorporated by reference. The formulations may be presented in multi-dose containers, for example in the sealed dispensing system disclosed in U.S.
Patent No.
4,511,069. Additional aerosol delivery forms may include, e.g., compressed air-, jet-, ultrasonic-, and piezoelectric nebulizers, which deliver the biologically active agent dissolved or suspended in a pharmaceutical solvent, e.g., water, ethanol, or a mixture thereof.
Nasal and pulmonary spray solutions of the present invention typically coinprise PTH, formulated with a surface active agent, such as a nonionic surfactant (e.g., polysorbate-80), and water. Another embodiment of the present invention comprises PTH, forinulated with metliyl-(3-cyclodextrin, EDTA, didecanoylphosphatidyl choline (DDPC), and water. In some embodiments of the present invention, the nasal spray solution fuxther comprises a propellant.
The pH of the nasal spray solution is optionally between about pH 3.0 and 6.0, preferably 4.0 0.3. Other components may be added to enhance or maintain chemical stability, including preservatives, surfactants, dispersants, or gases. Suitable preservatives include, but are not limited to, phenol, methyl paraben, paraben, m-cresol, thiomersal, chlorobutanol, benzylalkonimum chloride, and the like. Suitable surfactants include, but are not limited to, oleic acid, sorbitan trioleate, polysorbates, lecithin, phospliotidyl cholines, and various long chain diglycerides and phospholipids.
Suitable dispersants include, but are not limited to, ethylenediaminetetraacetic acid, and the like. Suitable gases include, but are not limited to, nitrogen, helium, chlorofluorocarbons (CFCs), hydrofluorocarbons (HFCs), carbon dioxide, air, and the like.
To formulate compositions for mucosal delivery within the present invention, the biologically active agent can be combined with various pharmaceutically acceptable additives, as well as a base or carrier for dispersion of the active agent(s).
In addition, local anesthetics (e.g., benzyl alcohol), isotonizing agents (e.g., sodium chloride, mannitol, sorbitol), adsorption inhibitors (e.g., Tween 80), solubility enhancing agents (e.g., cyclodextrins and derivatives thereof), stabilizers (e.g., serum albumin), and reducing agents (e.g., glutathione) can be included. When the composition for mucosal delivery is a liquid, the tonicity of the formulation, as measured with reference to the tonicity of 0.9% (w/v) physiological saline solution 5 taken as unity, is typically adjusted to a value at which no substantial, irreversible tissue damage is induced in the nasal mucosa at the site of administration.
Generally, the tonicity of the solution is adjusted to a value of about 1/3 to 3, more typically 1/2 to 2, and most often 3/4 to 1.7.
To further enhance mucosal delivery of pharmaceutical agents within the 10 invention, PTH formulations may also contain a hydrophilic low molecular weight compound as a base or excipient. Such hydrophilic low molecular weight compounds provide a passage medium through which a water-soluble active agent, such as PTH, may diffuse through the base to the body surface where PTH is absorbed. The hydrophilic low molecular weight compound optionally absorbs moisture from the 15 mucosa or the administration atmosphere and dissolves the water-soluble active peptide. The molecular weight of the hydrophilic low molecular weight compound is generally not more than 10000 and preferably not more than 3000. Exemplary hydrophilic low molecular weight compound include polyol compounds, such as oligo-, di- and monosaccarides such as sucrose, mannitol, sorbitol, lactose, L-20 arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin, and polyethylene glycol. Other examples of liydrophilic low molecular weight compounds useful as carriers within the invention include N-methylpyrrolidone, and alcohols (e.g. oligovinyl alcohol, etllanol, ethylene glycol, and propylene glycol) These hydrophilic low molecular weight 25 compounds can be used alone or in combination with one another or with other components of the intranasal formulation.
The compositions of the invention may alternatively contain as pharmaceutically acceptable carriers substances as required to approximate physiological conditions, such as tonicity adjusting agents, wetting agents and the 30 like, for example, sodium lactate, sodium chloride, potassium chloride, calcium chloride, sorbitan monolaurate, and triethanolamine oleate. Conventional nontoxic pharmaceutically acceptable carriers can be used which include, for example, pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharin, talcum, cellulose, glucose, sucrose, magnesium carbonate, and the like.
Therapeutic compositions for administering PTH can also be formulated as a solution, microemulsion, or other ordered structure suitable for high concentration of active ingredients. The carrier can be a solvent or dispersion medium containing, for example, water, ethanol, polyol (for example, glycerol, propylene glycol, and liquid polyethylene glycol, and the like), and suitable mixtures thereof. Proper fluidity for solutions can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of a desired particle size in the case of dispersible formulations, and by the use of surfactants. In many cases, it is desirable to include isotonic agents, for example, sugars, polyalcohols such as mannitol, sorbitol, or sodium chloride in the composition. Prolonged absorption of the biologically active agent can be brought about by including in the composition an agent which delays absorption, for example, monostearate salts, and gelatin.
Mucosal administration according to the invention allows effective self-administration of treatment by patients, provided that sufficient safeguards are in place to control and monitor dosing and side effects. Mucosal administration also overcomes certain drawbacks of other administration forms, such as injections, that are painful and expose the patient to possible infections and may present drug bioavailability problems. For nasal and pulmonary delivery, systems for controlled aerosol dispensing of therapeutic liquids as a spray are well known. In one embodiment, metered doses of active agent are delivered by means of a specially constructed mechanical pump valve, U.S. Patent No. 4,511,069.
For prophylactic and treatment purposes, PTH may be administered to the subject intranasally once daily. In this context, a therapeutically effective dosage of the PTH may include repeated doses within a prolonged prophylaxis or treatment regimen that will yield clinically significant results to alleviate or prevent osteoporosis or osteopenia. Determination of effective dosages in this context is typically based on animal model studies followed up by human clinical trials and is guided by determining effective dosages and administration protocols that significantly reduce the occurrence or severity of targeted disease symptoms or conditions in the subject. Suitable models in this regard include, for example, murine, rat, porcine, feline, dog, non-human primate, and other accepted animal model subjects known in the art. Alternatively, effective dosages can be determined using in vitro models (e.g., immunologic and histopathologic assays). Using such models, only ordinary calculations and adjustments are typically required to determine an appropriate concentration and dose to administer a therapeutically effective amount of the biologically active agent(s) (e.g., amounts that are intranasally effective, transdermally effective, intravenously effective, or intramuscularly effective to elicit a desired response).
The actual dosage of biologically active agents will of course vary according to factors such as the disease indication and particular status of the subject (e.g., the subject's age, size, fitness, extent of symptoms, and susceptibility factors), time and route of administration, other drugs or treatments being administered concurrently, as well as the specific pharmacology of the biologically active agent(s) for eliciting the desired activity or biological response in the subject. Dosage regimens may be adjusted to provide an optimum prophylactic or therapeutic response. A
therapeutically effective amount is also one in which any toxic or detrimental side effects of the biologically active agent are outweiglied in clinical terms by therapeutically beneficial effects. A non-limiting range for a therapeutically effective amount of a PTH peptide within the methods and formulations of the invention is 0.7 g/kg to about 25 g/kg. To treat osteoporosis or osteopenia, an intranasal dose of PTH peptide is administered at dose high enough to promote the increase in bone mass but low enough so as not to induce any unwanted side-effects such as nausea. A
preferred intranasal dose of PTH (1-34) is about 1 to about 10 g/lcg weight of the patient, most preferably about 6 g/kg weight of the patient. In a standard dose a patient will receive about 1 to about 1000 g, more preferably about between 20 to 800 g, most preferably 100 g to about 600 g with 300 g being a dose that is considered to be highly effective.
Alternatively, a non-limiting range for a therapeutically effective amount of a biologically active agent within the methods and formulations of the invention is between about 0.001 pmol to about 100 pmol per kg body weight, between about 0.01 pmol to about 10 pmol per kg body weight, between about 0.1 pmol to about 5 pmol per kg body weight, or between about 0.5 pmol to about 1.0 pmol per kg body weight.
Per administration, it is desirable to administer at least one microgram of PTH, more typically between about 10 g and 5.0 mg, and in certain embodiments between about 100 g and 1.0 or 2.0 mg to an average human subject. For certain oral applications, doses as high as 0.5 mg per kg body weight may be necessary to achieve adequate plasma levels. It is to be further noted that for each particular subject, specific dosage regimens should be evaluated and adjusted over time according to the individual need and professional judgment of the person administering or supervising the administration of the permeabilizing peptide(s) and other biologically active agent(s).
An intranasal dose of a parathyroid hormone will range from 1 g to 1000 g of parathyroid hormone, preferably 20 g to 800 g, more preferably 100 g to g with 300 g being a dose that is considered to be highly effective. Repeated intranasal dosing with the formulations of the invention, on a schedule ranging from about 0.1 to 24 hours between doses, preferably between 0.5 and 24 hours between doses, will maintain normalized, sustained therapeutic levels of PTH peptide to maximize clinical benefits while minimizing the risks of excessive exposure and side effects. The goal is to mucosally deliver an amount of the PTH peptide sufficient to raise the concentration of the PTH peptide in the plasma of an individual to promote increase in bone mass.
Dosage of PTH agonists such as parathyroid hormone may be varied by the attending clinician or patient, if self administering an over the counter dosage form, to maintain a desired concentration at the target site.
In an alternative embodiment, the invention provides compositions and methods for intranasal delivery of PTH peptide, wherein the PTH peptide is repeatedly administered through an intranasal effective dosage regimen that involves multiple administrations of the PTH peptide to the subject during a daily or weekly schedule to maintain a therapeutically effective elevated and lowered pulsatile level of PTH peptide during an extended dosing period. The compositions and method provide PTH peptide that is self-administered by the subject in a nasal formulation between one and six times daily to maintain a therapeutically effective elevated and lowered pulsatile level of PTH peptide during an 8 hour to 24 hour extended dosing period.
The instant invention also includes kits, packages and multicontainer units containing the above described pharmaceutical compositions, active ingredients, and/or means for administering the same for use in the prevention and treatment of diseases and other conditions in mammalian subjects. Briefly, these kits include a container or formulation that contains PTH in combination with mucosal delivery enhancing agents disclosed herein formulated in a pharmaceutical preparation for mucosal delivery.
The intranasal formulations of the present invention can be administered using any spray bottle (i.e., a bottle with an actuator, spray pump). An example of a nasal spray bottle is the, "Nasal Spray Pump w/ Safety Clip", which delivers a dose of 0.1 mL per squirt and has a diptube length of 36.05 mm (Pfeiffer of America, Princeton, NJ). Intranasal doses of a PTH peptide such as parathyroid hormone can range from 0.1 gg/lcg to about 1500 g/kg. When administered in an intranasal spray, it is preferable that the particle size of the spray is between 10 - 100 m (microns) in size, preferably 20 - 100 m in size.
We have discovered that the parathyroid hormone peptides can be administered intranasally using a nasal spray or aerosol. This is surprising because many proteins and peptides have been shown to be sheared or denatured due to the mechanical forces generated by the actuator in producing the spray or aerosol.
In this area the following definitions are useful.
1. Aerosol - A product that is packaged under pressure and contains therapeutically active ingredients that are released upon activation of an appropriate valve system.
2. Metered aerosol - A pressurized dosage form comprised of metered dose valves, which allow for the delivery of a uniform quantity of spray upon each activation.
3. Powder aerosol - A product that is packaged under pressure and contains therapeutically active ingredients in the form of a powder, which are released upon activation of an appropriate valve system.
4. Spray aerosol - An aerosol product that utilizes a compressed gas as the propellant to provide the force necessary to expel the product as a wet spray;
it generally applicable to solutions of medicinal agents in aqueous solvents.
5. Spray - A liquid minutely divided as by a jet of air or steam. Nasal spray drug products contain therapeutically active ingredients dissolved or suspended in solutions or mixtures of excipients in nonpressurized dispensers.

5 6. Metered spray - A non-pressurized dosage forn consisting of valves that allow the dispensing of a specified quantity of spray upon each activation.
7. Suspension spray - A liquid preparation containing solid particles dispersed in a liquid vehicle and in the form of course droplets or as finely divided solids.
10 The fluid dynamic characterization of the aerosol spray emitted by metered nasal spray pumps as a drug delivery device ("DDD"). Spray characterization is an integral part of the regulatory submissions necessary for Food and Drug Administration ("FDA") approval of research and development, quality assurance and stability testing procedures for new and existing nasal spray pumps.
15 Thorough characterization of the spray's geometry has been found to be the best indicator of the overall performance of nasal spray pumps. In particular, measurements of the spray's divergence angle (plume geometry) as it exits the device;
the spray's cross-sectional ellipticity, uniformity and particle/droplet distribution (spray pattern); and the time evolution of the developing spray have been found to be 20 the most representative performance quantities in the characterization of a nasal spray pump. During quality assurance and stability testing, plume geometry and spray pattern measurements are key identifiers for verifying consistency and conformity with the approved data criteria for the nasal spray pumps.
Definitions 25 Plume Height - the measurement from the actuator tip to the point at which the plume angle becomes non-linear because of the breakdown of linear flow.
Based on a visual examination of digital images, and to establish a measurement point for width that is consistent with the farthest measurement point of spray pattern, a height of 30 mm is defined for this study 30 Major Axis - the largest chord that can be drawn within the fitted spray pattern that crosses the COMw in base units (mm) Minor Axis - the smallest chord that can be drawn within the fitted spray pattern that crosses the COMw in base units (mm) Ellipticity Ratio - the ratio of the major axis to the minor axis Dlo - the diameter of droplet for which 10% of the total liquid volume of sample consists of droplets of a smaller diameter ( m) D50 - the diameter of droplet for which 50% of the total liquid volume of sample consists of droplets of a smaller diameter ( m), also known as the mass median diameter D90 - the diameter of droplet for wliich 90% of the total liquid volume of sample consists of droplets of a smaller diameter ( m) Span - measurement of the width of the distribution, the smaller the value, the narrower the distribution. Span is calculated as (Dso - D,o) D5o % RSD - percent relative standard deviation, the standard deviation divided by the mean of the series and multiplied by 100, also known as % CV.
A nasal spray device can be selected according to what is customary in the industry or acceptable by the regulatory health authorities. One example of a suitable device is described in described in U.S. Application No. 10/869,649 (S. Quay and G.
Brandt: Compositions and methods for enhanced mucosal delivery of Y2 receptor-binding peptides and methods for treating and preventing obesity).
To treat osteoporosis or osteopenia, an intranasal dose of a PTH peptide parathyroid hormone is administered at dose high enough to promote an increase in bone mass, but low enough so as not to induce any unwanted side-effects such as nausea. A preferred intranasal dose of a PTH is about 1 g - 10 g/kg weight of the patient, most preferably about 6 gg/kg weight of the patient. In a standard dose a patient will receive 1 g to 1000 g, more preferably about between 20 g to 800 g, most preferably 100 g to about 600 gg with 300 g being the dose that is considered to be highly effective. A PTH peptide such as parathyroid hormone (1-34) is preferably administered once a day.
The following examples are provided by way of illustration, not limitation.

EXAMPLES

Reagents and Cells The effect of various permeation enhancers on PTH formulations was measured in a MatTek cell model (MatTek, Corp. Ashland, MA). Three permeation enhancers (EDTA, ethanol, and polysorbate 80 (Tween 80)) were evaluated individually or in combination with one another. Sorbitol was used as a tonicifier to adjust the osmolarity of formulations to 220 inOsm/lcg whenever applicable.
The formulation pH was adjusted to -4Ø The permeation enhancer combination of 45 mg/ml M-(3-CD, 1 mg/ml DDPC, and 1 mg/ml EDTA at pH 4.5 served as the positive control. The formulation containing sorbitol only was used as the negative control.
Each formulation was evaluated in the presence and absence of preservative.
For all initial formulations tested, sodium benzoate was used as the preservative.
The MatTek cell line is normal, human-derived tracheal/bronchial epithelial cells (EpiAirwayTM Tissue Model). Cells were cultured for 24-48 hours before using to produce a tissue insert.

Each tissue insert was placed in an individual well containing 1 ml media. On the apical surface of the inserts, 100 l of test formulation was applied, and the samples were shaken for 1 h at 37 C. The underlying culture media samples were taken at 20, 40, and 60 minutes and stored at 4~ C for up to 48 hours for lactate dehydrogenase (LDH, cytotoxicity) and sample penetration (PTH HPLC
evaluations).
The 60-min samples were used for lactate deliydrogenase (LDH, cytotoxicity).
Transepithelial electrical resistance (TER) was measured before and after the 1-h incubation. Following the incubation, the cell inserts were analyzed for cell viability via the mitochondrial dehydrogenase (MDH) assay.
A reverse phase high pressure liquid chromatography method was used to determine the Teriparatide concentration in the tissue permeation assay.

Transepithelial Electrical Resistance TER measurements were accoinplished using the Endohm-12 Tissue Resistance Measurement Chamber connected to the EVOM Epithelial Voltohmmeter (World Precision Instruments, Sarasota, FL) with the electrode leads. The electrodes and a tissue culture blank insert were equilibrated for at least 20 minutes in MatTek medium with the power off prior to checking calibration. The background resistance was measured with 1.5 ml Media in the Endohm tissue chamber and 300 l Media in the blank insert. The top electrode was adjusted so that it was close to, but not in contact with, the top surface of the insert membrane. Baclcground resistance of the blank insert was about 5-20 ohms. For each TER determination, 300 l of MatTek medium was added to the insert followed by placement in the Endohm chamber.
Resistance was expressed as (resistance measured - blank) X 0.6 cm2.
The formulations tested for TER reduction are described in Table 1.

Table 1. Description of formulations containing GRAS permeation enhancers Sample Conc. (ing/ml) Sorbitol p H
# PTH M-(3-CD DDPC EDTA Ethanol Tween 80 NaBz (mg/ml) 1 7.5 45 1 0 0 0 28.8 4.5 2 7.5 45 1 0 0 4.75 16.8 4.5 3 7.5 0 0 0 0 0 34.2 4.0 4 7.5 0 0 0 0 3 26.7 4.0 5 7.5 0 0 0 0 0 0 35.9 4.0 6 7.5 0 0 0 0 0 3 28.3 4.0 7 7.5 0 0 0 10 0 0 0 4.0 8 7.5 0 0 10 0 0 0 4.0 9 7.5 0 0 10 10 0 0 0 4.0 10 7.5 0 0 0 10 0 3 0 4.0 11 7.5 0 0 10 0 3 0 4.0 12 7.5 0 0 10 10 0 3 0 4.0 13 7.5 0 0 0 0 0 35.7 4.0 14 7.5 0 0 0 0 3 28.1 4.0 15 7.5 0 0 10 0 0.0 4.0 16 7.5 0 0 10 3 0.0 4.0 17 Media 18 Triton X

The results show that the TER reduction was observed with all formulations.
Media applied to the apical side did not reduce TER whereas Triton X treated group showed significant TER reduction as expected.

Cell Viability and C otoxicitX
Cell viability was assessed using the MTT assay (MTT-100, MatTek kit).
Thawed and diluted MTT concentrate was pipetted (300 l) into a 24-well plate.
Tissue inserts were gently dried, placed into the plate wells, and incubated at 37 C for 3 hours. After incubation, each insert was removed fiom the plate, blotted gently, and placed into a 24-well extraction plate. The cell culture inserts were immersed in 2.0 ml of the extractant solution per well (to completely cover the sample). The extraction plate was covered and sealed to reduce evaporation of extractant.
After an overnight incubation at room temperature in the darlc, the liquid within each insert was decanted back into the well from which it was taken, and the inserts discarded.
The extractant solution (200 l in at least duplicate) was pipetted into a 96-well microtiter plate, along with extract blanks. The optical density of the samples was measured at 550 nm on a plate reader.
The amount of cell death was assayed by measuring the loss of lactate dehydrogenase (LDH) from the cells using a CytoTox 96 Cytoxicity Assay Kit (Promega Corp., Madison, WI). LDH analysis of the apical media was evaluated.
The appropriate amount of media was added to the apical surface in order to total 250 L, taking into consideration the initial sample loading volume. The inserts was shaken for 5 minutes. 150 L of the apical media was removed to eppendorf tubes and centrifuged at 10000 rpm for 3 minutes. 2 gL of the supernatant was removed and added to a 96 well plate. 48 uL of media was used to dilute the supernatant to make a 25x dilution. For LDH analysis of the basolateral media, 50 L of sample was loaded into a 96-well assay plates. Fresh, cell-free culture medium was used as a blanlc.
Fifty microliters of substrate solution was added to each well and the plates incubated for 30 minutes at room temperature in the darlc. Following incubation, 50 l of stop 5 solution was added to each well and the plates read on an optical density plate reader at 490 nm.

The results of the MTT assays showed no significant reduction of cell viability when cells were treated with all formulations. Media applied to the apical side did not show an effect on cell viability whereas the Triton X treated group showed significant 10 reduction of cell viability, as expected. The results of the LDH assays showed no significant cytotoxicity was observed when cells were treated with all formulations.
Media control applied to the apical side did not show cytotoxicity whereas Triton X
treated group showed significant cytotoxicity, as expected.

Permeation The ability of various permeation enhancers to improve delivery of PTH
transmucosally was tested. To this end, 7.5 mg/ml PTH was coinbined with various permeation enliancers at pH -4.0 and osmolarity 220-280 mOsm/kg.
20 The results of measurements of the PTH permeation in the presence of permeation enhancers showed that PTH permeation significantly increases in the presence of 45 mg/ml M-P-CD, 1 mg/ml DDPC, and 1 mg/inl EDTA. Various degrees of PTH permeation enhancement were observed in the presence of permeation enhancing excipients. The preservative had no significant impact on PTH
25 permeation.
A preferred formulation containing non-GRAS enhancers is exemplified by the combination of 45 mg/ml M-(3-CD, 1 mg/ml DDPC, and 1 mg/ml EDTA. It is also preferred that the formulation contain a suitable solvent such as water, a preservative, such as sodium benzoate, chlorobutanol or benzalkonium chloride, and a 30 tonicifiers such as a sugar or polyol such as trehalose or a salt such as sodium chloride. Alternatively, the formulation could contain other enhancers including alternative solubilizers, surface-active agents and chelators.
A preferred formulation containing GRAS enhancers is exemplified by the combination of 1 mg/mL Tween-80, 100 mg/mL ethanol and 1 mg/ml EDTA. It is 35 also preferred that the formulation contain a suitable co-solvent such as water, a preservative, such as sodium benzoate, chlorobutanol or benzalkonium chloride, and a tonicifiers such as a sugar or polyol such as trehalose or a salt such as sodium chloride. Alternatively, the formulation could contain other GRAS enhancers including alternative surface-active agents, co-solvents, and chelators.
Yet anotlier preferred formulation containing GRAS enhancers is exemplified by inclusion of 1 mg/mL Tween-80 (polysorbate 80). It is also preferred that the formulation contain a suitable co-solvent such as water, a preservative, such as sodium benzoate, chlorobutanol or benzalkonium chloride, and a tonicifiers such as a sugar or polyol such as trehalose or a salt such as sodium chloride.
Alternatively, the formulation could contain otlier GRAS enhancers such as alternative surface-active agents.

Stabili A PTH formulation will be supplied as a liquid in a bottle for intranasal administration via an actuator. Formulations containing 1-10 mg/mL PTH at pH
4.0-4.5 were tested for "as-sold" stability. "As-sold" stability studies are defined as those studies involving formulation stored within a closed (i.e., capped) bottle, placed at specific storage or accelerated temperature conditions for specified amounts of time.
Formulation excipients were selected from the group consisting of PTH; methyl-(3-cyclodextrin (M-(3-CD); ethylenediaininetetraacetic acid (EDTA);
didecanoylphosphatidyl choline (DDPC); chlorobutanol (CB); sodium benzoate (NaBZ), polysorbate 80, and sorbitol. The initial pH of the formulations was adjusted to pH 4.0 or 4.5 with sodium hydroxide or hydrochloric acid, as necessary. The formulations that were tested are shown in Table 2.

Table 2. Composition of various intranasal PTH formulations Formulation Composition #

1 1 mg/mL PTH, 5 mg/mL preservative (CB), 45 mg/mL M-0-CD, 1 mg/mL
DDPC, 1 mg/mL EDTA, 26 mg/mL sorbitol, pH - 4.0 2 1.5 mg/mL PTH, 5 mg/mL preservative (CB), 45 mg/mL M-(3-CD, 1 mg/mL DDPC, 1 mg/mL EDTA, 26 mg/mL sorbitol, pH - 4.0 3 2 mg/mL PTH, 5 mg/mL preservative (CB or NaBz), 45 mg/mL M-(3-CD, 1 mg/mL DDPC, 1 mg/mL EDTA, 16.7 mg/mL sorbitol, pH - 4.0 or 4.5 4 3 mg/mL PTH, 5 mg/mL preservative (CB), 1 mg/mL polysorbate 80, 31 mg/mL sorbitol, pH - 4.0 5 4 mg/mL PTH, 5 mg/mL preservative (CB), 1 mg/mL polysorbate 80, 31 mg/mL sorbitol, pH - 4.0 6 5 mg/mL PTH, 5 mg/mL preservative (CB or NaBz), 1 mg/mL
polysorbate 80, 27.2 mg/mL sorbitol, pH - 4 7 10 mg/mL PTH, 5 mg/mL preservative (CB or NaBz), 1 mg/mL
polysorbate 80, 27.2 mg/mL sorbitol, pH - 4 The reported storage conditions for injectable FORTEO (ingredients:
teriparatide, glacial acetic acid, sodium acetate, mannitol, m-cresol, and water) is 2-8 C for up to 28 days (four weeks). The storage stability of PTH formulations #
1, # 3, # 4, and # 7 was monitored at regular intervals by determining the remaining percentage of PTH relative to initial using HPLC. All four forinulations used in the stability studies included CB as preservative and were at a pH of 4Ø The results in Tables 3 and 4 show PTH intranasal formulations # 1, # 3, # 4, and # 7 may be safely stored at 5 C and 25 C for at least four weeks without a significant decrease in stability. Formulations # 1, # 3, # 4, and # 7 remained stable for at least 24 weeks when stored at 5 C. Formulation #7 was the most stable of the tested formulations at 5 C and 25 C. Storage conditions of PTH intranasal formulations at 5 C for at least 24 weeks is longer than the current recommended storage conditions for injectable FORTEO.

Table 3. Percent Stability of PTH Formulations at 5 C
Formulation # (5 C) Time (weeks) 1 3 4 _ 7 Initial 100 1.6 100 2.3 100 0.4 100 2.2 2 101.5 1.1 99.8 1.9 97.5 0.7 100.5 1.3 4 98.1 0.9 96.5 3.0 100 0.6 99.3 2.0 8 96.5- 3.2 98.2- 1.7 95.7 1.0 95.1 6.6 12 97.4:L4.1 98.8 -2.5 97.7 1.5 103.3 2.3 24 95.2 0.9 94.8:L1.2 97.3 0.5 100.6 2.5 Table 4. Percent Stability of PTH Formulations at 25 C

Formulation # (25 C) Time (weeks) 1 3 4 7 Initial 100:L1.6 100 2.3 100 0.4 100 2.2 2 98.3zL1.1 98.2 2.3 97.5 0.2 99.7 1.3 4 96.4 1.6 93.2 2.2 96.2 2.3 97.7 1.3 8 91.1 5.2 89.6 8.3 90.010.4 92.8~2.8 12 85.4 7.8 89.8 4.0 94.5 1.0 97.1 1.5 24 80.9 1.0 81.7 1.2 83.9 1.1 87.7+1.6 Further characterization of the stability of PTH formulations without buffer was conducted at 30 C (Table 5), 40 C (Table 6), and 50 C (Table 7). The percent PTH remaining from initial was determined at 1, 2, 3, and 4 week timepoints.
The 30 C data without buffer is compared to the injectable formulation data containing buffer from U.S. Pat. No. 6,770,623 (the '623 formulation). The '623 formulation contained 0.1 mg/mL rhPTH (1-34), 50 mg/mL mannitol, 2.5 ing/mL m-cresol, 0.52 mg/mL acetic acid and 0.12 mg/mL sodium acetate. Formulations # 1 and # 4 without a buffer at 30 C had stability similar to the '623 formulation with buffer at 30 C. At 50 C, Formulations # 1, # 3, # 4 and # 7 have a greater stability than the '623 formulation. Formulation # 7 was the most stable compared to other formulations tested at 40 C and 50 C.

Table 5. Percent Stability with and without buffer at 30 C

With buffer Without buffer Time (weeks) 20mM 10mM '623 1'623 2 Formulation Formulation acetate acetate # 1 # 4 ('623) ('623) Initial 100 100 100 100 100 100 1 96 94 100 --- 101 4.5 114 1.5 2 94 92 96 100 73.7 2.0 105.514.3 3 90 93 97 --- 94.7=L1.8 106.211.5 4 --- 81 96 96 93.8 101.6 Table 6. Percent Stability of PTH formulations at 40 C
Formulation # (40 C) Time (weeks) 1 3 4 7 Initial 100 1.6 100 2.3 100 0.4 100~2.2 1 90.2j:1.3 92.9 1.5 93.9 0.8 96.5 1.6 2 80.7 2.8 86.1 1.1 83.9 0.8 88.0 1.3 4 66.911.8 70.9 1.6 70.3+2.1 71.7 2.2 Table 7. Percent Stability with and without buffer at 50 C

Formulations Formulation #
With buffer 20mM 10mM 0.9% Water 1 3 4 7 Time acetate acetate NaCI ('623) (weeks) (1623) ('623) ('623) Initial 100 100 100 100 100 1.6 100 2.3 100f0.4 100J:2.

1 84 80 81 74 88.912.4 89.6 3.0 88.6+0.2 91.6+1 .6 2 67 71 58 55 76.6 1.8 75.9 2.2 73.5 0.5 76.7 2 .9 4 --- --- --- --- 54.3 1.2 54.5 4.4 52.0 0.9 56.7=L0 .8 5 PTH formulations # 1 and # 4 were also tested for in-use and spray stability at both 5 C and 30 C storage temperatures over a 29-day period. Results include %
Peptide Recover and % Total Peptide Impurity. "In-use" studies are those in which an actuator is present and the bottles were primed five times initially, and then actuated once daily by hand after subjecting to the storage temperatures. All bottles 10 were returned to the 5 C and 30 C stability chamber after 30 minute exposure to room teinperature. All bottles were actuated daily, and the actuated samples were collected and stored at -20 C until sclzeduled for HPLC measurements. HPLC
measurements are scheduled for in-use (i.e., in the bottle with an actuator present) and spray (i.e., measured from the spray produced by the actuator in the bottle) samples at 15 Day 0, Day 8, Day 15, Day 22 and Day 29. The HPLC measurements for stability are shown in Table 8 (% Peptide Recovery) and Table 9 (% Total Impurity).

Table 8. In-use and Spray % Peptide Recovery at 5 C and 30 C

In-use 5 C Spray 5 C
Time Point Formulation #1 Formulation #4 Formulation #1 Formulation (days) #4 0 100.0 100.0 100.0 100.0 15 94.2 97.8 93.9 97.3 22 93.8 100.1 103.0 107.9 29 99.3 105.3 32.9 106.0 In-use 30 C Spray 30 C
Time Point Formulation #1 Forinulation #4 Formulation #1 Formulation (days) #4 0 100.0 100.0 100.0 100.0 8 103.3 107.0 109.7 110.6 15 84.7 99.3 130.8 103.8 22 98.8 103.0 99.6 101.9 29 94.3 97.8 34.7 102.3 Table 9. In-use and Spray Total Peptide Impurity at 5 C and 30 C

As-sold 5 C In-use 5 C Spray 5 C
Time Formulation Formulation Formulation Formulation Formulation Formulation Point #1 #4 #1 #4 #1 #4 (days) 0 0.9 0.4 0.5 0.3 0.5 0.5 8 0.9 0.7 0.7 0.5 1.1 0.7 0.9 0.4 0.7 0.5 0.8 0.5 22 0.8 0.6 1.1 1.4 1.6 1.3 29 1.7 0.7 2.0 1.3 3.8 1.6 As-sold 30 C In-use 30 C Spray 30 C
Time Formulation Fomlulation Formulation Formulation Formulation Formulation Point #1 #4 #1 #4 #1 #4 (days) 0 0.9 0.3 0.5 0.3 0.5 0.5 8 1.7 1.5 2.0 1.5 3.0 1.5 15 1.8 1.5 1.8 1.5 3.5 2.0 22 4.6 3.2 4.5 3.2 5.0 3.7 29 6.2 5.0 6.5 5.0 15.4 5.1 As-sold, in-use and spray stability studies showed that Formulation # 4 (containing polysorbate 80) was more stable than Formulation # 1(containing EDTA). Further studies confirmed that EDTA alone or in combination with 10 polysorbate 80 was inferior to PTH formulations without EDTA. Formulations with EDTA alone caused precipitation and gelling. When EDTA was added in combination with other excipients an increased instability was observed.
Stability studies showed that polysorbate 80 alone and in combination with other excipients enhanced stability. Addition of ethanol to the PTH formulations did not enhance 15 stability. NaBz contributed to turbidity of the PTH formulations while results showed that CB was the preferred preservative for a stable PTH formulation.

pH Stability The following formulations were tested for pH stability (Table 10).
Table 10. pH Stability Formulations Conc. (mg/ml) Diluent A pV, ~.~., o pa ~ =~ ~ ~ ~ pH
ao ~ .~ cl t ' =~~ A W o ~ ~ u FORTEO 0 0 0 0 0 0 0.41 0.1 45.4 3 4.0 MBCD 45 1 1 0 2.5 29 0 0 0 0 4.0 Tween 0 0 0 1 2.5 36 0 0 0 0 4.0 Solutions without PTH were first tested by pH titration. All three diluents had a pH
value of 4.0 before the pH titration. The pH shifts resulting from the addition of base to the FORTEO , MBCD and Tween formulations containing 1-4 mg/mL PTH and stored without buffer maintain a pH of 4.0 to 4.2 after at least 8 weeks of storage at 5 C and 25 C (Table 11). These data show that the PTH formulation composition stably maintains pH without a buffer.

Table 11. pH stability for MBCD and Tween Formulations at 5 C and 25 C
pH
Formulations 5 C 25 C
Initial 4 weeks 8 weeks Initial 2 weeks 4 weeks 8 weeks lmg/mL PTH 4.0 4.1 4.0 4.0 4.0 4.1 4.1 MBCD*
2mg/mL PTH 4.0 4.0 4.0 4.0 4.0 4.1 4.0 MBCD*
2mg/mL PTH 4.0 4.2 4.1 4.0 4.1 4.1 4.1 Tween*
4mg/mL PTH 4.0 4.1 4.1 4.0 4.1 4.1 4.1 Tween*
*CB at 2.5 mg/mL

Pharmacolcinetics (PK) in Human Subjects The absorption and safety of the PTH nasal spray formulations (see Example 5, Table 2) of the invention were evaluated at two dose levels. The bioavailability of FORSTEO (Eli Lilly UK) given subcutaneously was compared with that of two PTH
nasal spray forinulations of the invention at two dose levels. PTH Nasal Spray will be supplied to the clinic as a liquid in a bottle for intranasal administration via an actuator. For the PK studies, Formulations # 3, # 6, and # 7 included NaBz as the preservative. Formulation # 3 had a pH of 4.5, while all other formulations were at pH 4Ø

The PTH solution is provided in a multi-unit dose container to deliver a metered dose of 0.1 mL of drug product per actuation. Hydrochloric acid is added for pH adjustment to meet target pH of 4.0 0.2 or 4.5 0.2, as appropriate. The stability of the formulations was monitored at regular intervals.
This study was a single-site, open-label, active controlled, 5 period crossover, dose ranging study involving 6 healthy male and 6 healthy female volunteers.
The commercially available formulation of teriparatide, FORSTEO was the active control.
The five study periods were as follows:
Period 1: All subjects received FORSTEO
(injection) 20 g subcutaneously.
Period 2: All subjects received 500 g intranasal dose of teriparatide, 100 microliter spray of intranasal formulation as described in Example 5, Formulation #6, Table 2.
Period 3: All subjects received 200 g intranasal dose of teriparatide, 100 microliter spray of intranasal formulation as described in Example 5, Formulation #3 Table 2.
Period 4: All subjects received a 1000 g intranasal dose of teriparatide, 100 microliter spray of intranasal formulation as described in Example 5, Formulation #7 Table 2.

Period 5: All subjects received a 400 g intranasal dose of teriparatide, 2 X
100 microliter spray of intranasal formulation as described in Example 5, Formulation #3 Table 2.

Blood samples for PK were collected at 0 (i.e., pre-dose), 5, 10, 15, 30, 45, 60, 90 minutes and 2, 3, and 4 hours post-dose and analyzed using a validated method.
Because the bioassay is fully cross reactive with endogenous PTH(1-84), all data was corrected for pre-dose values. When this correction resulted in a negative post-dose value, all such negative values were set to 'missing'. Values reported as <LLOQ
were set to half LLOQ in order to evaluate PK and change from baseline.
Standard pharmacokinetic parameters, including AUCIast, AUC;,,f, Cmax, tii2, tmax, and Ke were calculated using WinNonlin. Intra-subject variability of the pharmacokinetic profiles was evaluated for the test versus the reference using analysis of variance methods.
An analysis of variance (ANOVA) was performed based on a 2-period design and incorporating a main effect term for each of the two products under consideration (Snedecor GW and Cochran WG, One-Way Classifications -- Analysis of Variance.
In: Statistical Methods, 6t' ed.: Iowa State University Press, Ames, IA, (1967) pp.
258-98). (Subject (Sequence) was a random effect in the model with all others fixed.) A separate model was created for each dose of teriparatide nasal spray versus the reference. The 90% confidence intervals were generated for the ratio of test dose/reference with respect to Cmax, AUCiast, and AUC;,,f. These values were natural log (hl)-transforined prior to analysis. The corresponding 90% confidence intervals for the geometric mean ratio were obtained by taking the antilog of the 90%
confidence intervals for the difference between the means on the log scale.
These analyses were not performed to demonstrate bioequivalence but were for informational purposes only. As a result, no adjustinent to the confidence level for each of the paired comparisons was made to account for multiplicity of analysis. This study is hypothesis-generating only. For tm,,, the analyses were run using Wilcoxon's signed-rank test (Steinijans VW and Diletti E (1983) Eur J Clin Pharmacol.
24:127-36) to determine if differences existed between a given test group and the reference group.

5 For each subject, the following PK parameters were calculated, whenever possible, based on the plasma concentrations of teriparatide for each test article, according to the model independent approach:
C,,,a,, Maximum observed concentration t,,,a,, Time to maximum concentration 10 AUCIast Area under the concentration-time curve from time 0 to the time of last measurable concentration, calculated by the linear trapezoidal rule.
The following parameters were calculated when the data permited accurate estimation of these paranieters:
AUCiõf Area under the concentration-time curve extrapolated to infinity, 15 calculated using the formula:
AUCinf = AUCiast + Ct/Ke where Ct is the last measurable concentration and K. is the apparent terminal phase rate constant.
Ke Apparent terminal phase rate constant, where Ke is the magnitude of the slope of the linear regression of the log concentration versus time profile during the 20 terminal phase.
t1i2 Apparent terminal phase half-life (whenever possible), where t1/2 =
(ln2)/Ke.
All data was corrected for pre-dose values. When this correction resulted in a negative post-dose value, all such negative values were set to 'missing'.
Values 25 reported as <LLOQ were set to half LLOQ in order to evaluate pK and change from baseline. Actual (not nominal) sampling times were used in the calculation of all PK
parameters.
Figures 1 and 2 show the mean plasma concentration versus time for periods 1-5, and the ratio of C,,,~,, to mean, low dose forinulations versus Forsteo, respectively.
30 A summary of arithmetic mean pharmacokinetic parameters for each formulation and dose of teriparatide are presented in Table 12. The mean t,,,a,, was 0.68 versus 0.57 and 0.17 hours for the FORSTEO and low dose nasal formulations of Formulation # 6 and # 3, respectively. The C,,,,., was 1.6 and 2.4 fold higher than FORSTEO for each low dose formulation. The AUClast was 1.23 and 1.45 fold higher 35 than FORSTEO for each low dose formulation.

Table 12. Arithmetic Mean Pharmacokinetic Parameters by Formulation and Dose Dose Tmax Cmax AUClast AUCinf t1/2 Ke Formulation (gg) (hr) ( /mL hr* /mL hr* /mL (hr) (1/hr) FORSTEO 20 0.68 70.80 85.92 132.12 1.57 0.638 (injection) Formulation 500 0.57 112.72 106.08 195.69 1.38 0.610 #6 Formulation 1000 0.46 405.57 335.20 412.47 1.03 0.782 #7 Formulation 200 0.17 172.72 125.07 269.60 3.10 0.720 #3 Formulation 400 0.18 349.62 206.02 238.26 1.12 1.097 In addition, the t,,,,,, results for each formulation were compared to the FORSTEO control using a simple Wilcoxon signed-rank test. The results (as p-values) are given in Table 13.

Table 13. Comparison of T,,,a,, - FORSTEO and Nasal Formulations p-value from Wilcoxon Signed-Comparison of Tmax Rank Test FORSTEO vs. Formulation #6, 500 g 0.75 FORSTEO vs. Formulation #7, 1000 g 0.53 FORSTEO vs. Formulation #3, 200 g 0.10 FORSTEO vs. Formulation #3, 400 g 0.24 Thus, there does not appear to be differences in the tma, values among the formulations with respect to FORSTEO. ' The 90% confidence intervals for the comparison of the given formulation and the FORSTEO control for the ratios of Cma,,, AUCiast and AUCiõf was calculated. The coinparisons of each product with FORSTEO were done on a pairwise basis, but no adjustment for multiple testing was included because of the nature of this study.
A summary of clearance rates using the non-compartmental model are presented in Table 14:

Table 14. Summary of Clearance Rates Formulation Dose Mean mL/hr SD
Formulation #3 200 1366234.334 988398.4 Formulation #3 400 2527292.583 1701658 FORSTEO 20 267446.6298 263855.3 Formulation #6 500 4793716.136 4380229 Formulation #7 1000 3359436.634 1665618 A summary of percent coefficient of variation for each formulation and dose of teriparatide are presented in Table 15. Based on C,,,~ and AUCIast, the %CV
is lower for Formulation # 3 than Formulation # 6, Formulation # 7 or FORSTEO.
Table 15. Percent Coefficient of Variation by Formulation and Dose Dose Tmax Cmax AUClast Formulation (ug) (hr) /mL hr* mL AUCinf (hrl- g/mL) FORSTEO 20 165.29 51.76 66.46 62.30 Formulation #6 500 142.48 78.71 92.76 83.41 Formulation #7 1000 176.56 67.06 75.55 71.56 Formulation #3 200 24.72 38.78 61.55 82.28 Formulation #3 400 21.20 48.78 55.98 68.04 A summary of percent relative bioavailability comparing each formulation to the FORSTEO product based on AUCIast are presented in Table 16. The bioavailability of the Formulation # 3 (low and high dose) is 12-15%, whereas Formulations # 6 and # 7 are approximately 5-8 %.

Table 16. Relative Bioavailability Compared with FORSTEO by Formulation and Dose Dose Formulation (ug) % Bioavailability Formulation #6 500 4.9 Formulation #7 1000 7.8 Formulation #3 200 14.6 Formulation #3 400 12.0 An exploratory compartmental analysis using WinNonLin 5.0 was conducted to compare the absorption coefficient and elimination coefficient for each formulation. A mixed model analysis of variance on both the Ka and the Ke data, where the subject was included as the random variable was performed, and these results were subanalyzed using the Tukey-Kramer multiple comparison procedure.
The individual Ka and Ke data are presented in Table 17. The nasal absorption rates were not significantly different compared to FORSTEO (p=0.50), however the elimination rate for high dose nasal Formulation #3 was significantly faster (p=0.02) than FORSTEO. This is also observed when looking at the ratio of mean Cma, to each individual time point per low dose formulation.

Table 17. Absorption Coefficient and Elimination Coefficient for Each Formulation Dose Mean Coefficient Formulation ( ) N (1/hr) SD CV%
Ka FORSTEO 20 11 11.99 7.00 58.34 Ka Formulation #6 500 8 6.95 4.83 69.46 Ka Formulation #7 1000 7 10.43 7.49 71.81 Ka Formulation #3 200 6 11.02 5.29 48.05 Ka Formulation #3 400 7 8.81 3.19 36.27 Ke FORSTEO 20 11 1.04 0.86 83.50 Ke Formulation #6 500 8 1.40 1.70 121.57 Ke Formulation #7 1000 7 1.83 2.50 136.49 Ke Formulation #3 200 6 2.74 2.24 81.85 Ke Formulation #3 400 7 4.08 2.35 57.69 Based on the pharmacokinetic paraineters, both nasal formulations had a greater Cmax and AUC as compared to FORSTEO. The tmax occurred sooner after dosing for the nasal formulations, particularly for Formulation # 3. The absorption rates were not significantly different among the nasal and subcutaneous formulations (p=0.5), but elimination rates were faster particularly for the low dose Formulation #
3 (p=0.02). However, a t1i2 of approximately 1 hour was very similar for the nasal formulations compared to FORSTEO, except for the low dose Formulation # 3, where there may be an apparent outlier for subject numbers 1 and 5. If the two subjects are removed the t1i2 is 1.5 hours, the same as FORSTEO. The apparent difference in elimination rates may reflect slower wash-in for the subcutaneous product and Formulations # 6 and # 7 when compared with Formulation # 3.
Both nasal formulations have very similar t1/2 compared to FORSTEO.
Formulation # 3 also showed good dose linearity from 200 to 400 g dose based on the clearance rate and regression analysis. In addition, Formulation # 3 was less variable than Formulations #6 and # 7 and FORSTEO based on % coefficient of variation. Accordingly, the intranasal formulations of the invention exceed the C,,,ax 5 and AUC values for the currently marlceted subcutaneous product. This demonstrates that the levels of the marketed product can be exceeded by a nasally administered product, and also that the concentrations of PTH in nasal formulations can be decreased if it is desired to more closely approximate the plasma concentrations of the currently approved product.

Droplet Size and Spray Characterization The droplet size and spray characterization of two teriparatide intranasal forinulations (see Example 5, Table 2) were evaluated using the Pfeiffer 0.1 ml Nasal Spray Pump 65550 with 36 mm dip tube. The droplet size distribution is characterized by laser diffraction using a Malvern MasterSizer S modular particle size analyzer and a MightyRunt automated actuation station. Single spray droplet distribution is volume weighted measurement. The Spray Pattern is characterized using a SprayVIEW NSP Higli Speed Optical Spray Characterization System and SprayVlEW NSx Automated Actuation System. The data are shown in Table 18.
The diameter of droplet for which 50% of the total liquid volume of sample consists of droplets of 30 micron and 294 micron for formulation # 5 and # 2, respectively.
There are 3% and 1 10 of the total liquid volume for formulation # 5 and # 2, respectively, where the droplet size is less than 10 micron. The ellipticity ratio is 1.3 and 1.4 for formulation # 5 and # 2, respectively.

Table 18. Droplet Size and Ellipticity Ratio for Teriparatide Intranasal Formulations %<10 micromete Ellipticity D(v,0.1) D(v,0.5) D(v,0.9) r Ratio Formulation #5 14 30 65 3 1.3 Formulation #2 25 294 676 1 1.4 The spray characteristics and drug purity of PTH formulations were compared as actuated from two nasal pump models made by two manufacturers [Pfeiffer (SAP
#65550) vs. Valois (Model EquadelTM 100)]. Two formulations were tested in this study, Formulations # 2 and # 5 (Example 5, Table 2). A set of placebos (without drug) was included in all spray experiments as controls. Six vials for each group were provided for spray characterization tests. These vials were prepared and held at 5 C
until ready for the tests. Three of the six vials from each group were concurrently tested and evaluated for Droplet Size Distribution and Pump Delivery parameters.
The results of the comparison are shown in Tables 19 and 20.
Table 19. Comparison of Droplet Size for Different Actuators Actuator system D10 D50 D90 Span %< 10 m Formulation # 5 Pfeiffer 14 30 65 2 3.15 Valois 20 52 114 2 0.72 Formulation #5 w/o PTH 0 mg/ml PTH) Pfeiffer 14 29 62 2 3.55 Valois 20 50 108 2 0.79 Formulation # 2 Pfeiffer 25 294* 676* 2 1.06 Valois 24 67 255 3 0.85 Formulation #2 w/o PTH 0 m/ml PTH) Pfeiffer 26 252* 610* 3 1.09 Valois 24 67 244 3 0.94 * actuation produced bubbles that interfered with the measurement Table 20. Comparison of Ellipticity Ratio for Different Actuators Ellipticity Ratio Pfeffier Valois Formulation # 5 1.3 1.1 Formulation #5 w/o PTH 1.1 1.1 (0 m /ml PTH) Formulation # 2 1.4 1.1 Formulation #2 w/o PTH 1.4 1.1 0 m /ml PTH) Administration of Synthetic and Recombinant PTH1_34 Increases Bone Mass in Rats The anabolic effects of synthetic human PTH1_34 and recombinant PTHI_34 (Forteo , Eli Lilly U.S.) were studied in male rats. A common vehicle (composed of glacial acetic acid, m-cresol, sterile water, sodium acetate and mannitol) was used for each treatment Group and Vehicle control.
Experimentally naive, 5 week old, male Sprague Dawley rats received either vehicle or one of two dose levels (16 g/kg/d or 80 g/kg/d) of synthetic or recombinant PTH1_34 via subcutaneous (SQ) administration. The animals were randomized into treatment groups (10 rats/group) based on body weight. Each animal was given once daily subcutaneous injections of vehicle or test PTHI-34 treatment, starting on Day 1 and continuing for 21 consecutive days. Cage side observations were performed twice daily, and weekly body weight measurements were taken throughout the study. Animals were given a total of two doses of calcein, one dose six (6) and one dose two (2) days prior to scheduled necropsy. On Day 21, blood samples for pharmacokinetic analysis were collected from animals in select treatment groups. At the conclusion of the treatment period and after blood collection on Day 21, the animals were eutllanized and bone specimens collected. The treatment groups are shown in Table 21.
Table 21. Treatment groups for bone mass study Group Treatment Dose Level Route and Days of Group Size ( g/kg/d) Dosing 1 Vehicle 0 SQ, 1X/d, Days 1-21 10 2 Synthetic PTHI-34 16 SQ, 1X/d, Days 1-21 10 3 Recombinant PTHI-34 16 SQ, lX/d, Days 1-21 10 4 Synthetic PTHI-34 80 SQ, 1X/d, Days 1-21 10 5 Recombinant PTH1_34 80 SQ, 1X/d, Days 1-21 10 Bone in the distal and midshaft regions of the right femur were analyzed using peripheral quantitative computed tomography (pQCT) and bone strength was determined via three-point bending at the femoral mid-shaft and in the marrow cavity of the distal femur. The entire right tibia was subject to dual X-ray absorptiometry scan (DXA).
All animal weights increased over the course of the study. There was no statistically significant difference in body weight between the treatment groups. Bone mineral content, area, and density of four areas of the tibia were analyzed separately (whole tibia and distal, midshaft and proximal tibia) by DXA.
Administration of both forms of human PTHI-34 resulted in significant increases in bone mineral content and density at each of the sites examined compared to vehicle control. The increases in bone mineral density were accompanied by increased bone strength at the femoral shaft and trabecular bone in the marrow cavity of the distal femur. The increases in bone mass and strength were dose-dependent.
There was no significant difference in bone response between synthetic and recombinant forms of PTHI-34 at either of the two doses tested, 16 and 80 g/kg/d.
These studies confirm that synthetic and recombinant forms of human PTHI-34 exhibited comparable anabolic action on bone.

Anabolic Actions and Toxicity Results for Intranasal Administration of PTHI-34 in Rats Toxicity alid toxicokinetics of PTH1-34 formulations were evaluated in male and female Crl:CD(SD) rats. PTH1-34 (synthetic form) was administered once daily via intranasal instillation to rats for at least 13 weeks. For comparison, one group received commercially available recombinant PTH1_34 via subcutaneous injection.
Assessment of toxicity was based on mortality, clinical observations, ophthalmic examinations, body weights, food consumption, clinical and anatomic pathology, and toxicokinetic evaluations. Two synthetic PTH1-34 formulations were used in the study, PTH-072-1 and PTH-074 at low and high doses (formulations are shown in Table 22).
Table 22. Intranasal formulations for PTH-072-1 and PTH-074-1 Formulation ID PTH(1-34) M-B-CD DDPC EDTA Sorbitol Polysorbate 80 CB
(mg/mL) (mg/mL) (mg/mL) (mg/mL) (mg/mL) (mg/mL) (mg/m L) Low-PTH-072-1 2.0 45 1 1 26 0 5 High-PTH-072-1 4.0 45 1 1 26 0 5 Low-PTH-074-1 4.0 0 0 0 31 1 5 High-PTH-074-1 10.0 0 0 0 31 1 5 Doses in rats were determined for body weight, body surface area, and nasal surface area. Representative concentrations of PTH1_34 for clinical studies were considered to be 1.5 mghnL and 3.0 mg/mL (and a dose volume of 100 L). For the lower concentration, a 701cg human would receive a dose of 2.1 g/lcg based on body weight. At the higher dose a human would receive a dose of 4.3 g/lcg based on body weight. The rat study groups are shown in Table 23.

Table 23. Study groups for rat toxicity and toxiokinetic studies Group No. of Dose Level Mode of Administration Animals ( g/lcg/day) Male/Female Toxicity Animals 1 Control (placebo)t 10/10 0 Intranasal 50 L/kg/dose 2 Low - PTH-072-1 10/10 100 Intranasal 50 L/kg/dose 3 High - PTH-072-1 10/10 200 Intranasal 50 L/lcg/dose 4 Low - PTH-074-1 10/10 200 Intranasal 50 L/lcg/dose 5 High - PTH-074-1 10/10 500 Intranasal 50 L/lcg/dose 6 PTH1_34Injection 0/10 25 Subcutaneous 0.312 mL/kg Toxicokinetic Animals 7 High - PTH-072-1 10/10 200 hitranasal 50 L/kg/dose 8 High - PTH-074-1 10/10* 500 Intranasal 50 gL/lcg/dose PTH1_34Injection 0/10 25 Subcutaneous 0.312 mL/kg Placebo was 0.9% Sodium Chloride, USP (sterile saline).
$Four animals/sex from Groups 7 and 8 and four females in Group 9 received Calcein (10mg/lcg via intraperitoneal injection) on Days 86 and 90.

The t1/2 for PTH1_34 when administered in the PTH-072-1 formulation ranged from 14 to 21 minutes in male and female rats; Tm. ranged from 5 to 15 minutes for 5 both males and females. Cm,,, ranged from 5,041 pg/mL to 12,911 pg/mL in male rats and from 3,044 pg/mL to 5106 pg/mL in female rats. AUCiast ranged firom 100,038 pg-min/mL to 457,644 pg-min/mL in males and 58,890 pg-min/mL to 73,444 pg-min/mL in females. In comparison to a clinical study with PTH-072-1 formulation, the AUCIt values for male and female rats exceeded that in humans by 10 80-fold and 13-fold, respectively.
The t1i2 for PTHI-34 when administered in the PTH-074-1 formulation ranged from 12 to 24 minutes; T,,,a, ranged from 5 to 30 minutes for both male and female rats. C,,,,,, ranged from 12,251 pg/mL to 35,964 pg/mL in male rats and from 3,679 pg/mL to 17,175 pg/mL in female rats. AUClast ranged from 252,790 pg-min/mL to 15 1,010,348 pg-min/mL in males and 78,059 pg-min/mL to 377,278 pg-min/mL in females. In comparison to a clinical study with PTH-074-1 formulation, the AUClast values for male and female rats exceeded that in humans by 71-fold and 27-fold, respectively.
The t1i2 for PTHI-34 when administered by injection ranged from 15 to 23 20 minutes; T,,,a,, was 5 minutes for female rats. Cma., and AUClast ranged from 7,721 pg/mL to 12,200 pg/mL and from 140,945 pg-min/mL to 296,908 pg-min/mL, respectively.
The t112 and Tmax for PTHI-34 was similar among the intranasal groups and subcutaneous dose group. Cma, and AUCiast were higher in male rats than female rats, 25 which was an anticipated result for PTH1_34. Bioavailability appeared slightly greater in the PTH-072-1 formulation. The highest dose for each formulation exceeded the doses anticipated for clinical evaluation of PTHI-34 via intranasal administration in humans. For nasal surface area, the dose multiples were approximately 5-fold or greater in the rat. Based on body surface area or body weight, dose multiples in the 30 rat were approximately 17-fold or 95-fold or greater, respectively. These pharniacolcinetics results confirm that the doses selected were sufficient to evaluate the nasal and systemic toxicology of PTHI-34 when administered via intranasal instillation.
No PTHI-34 related clinical signs, ophthalmic observations, body weight 35 changes, or food consumption changes were observed, regardless of route of administration, dose level, or formulation. No changes considered to be attributable to the intranasal administration of PTH1_34 were observed in the nasal turbinate tissues from any animal in the study. The nasal cavity was sectioned such that meaningful regions of the cavity were represented, and the soft (epithelial lining) or hard (bone and cartilage based structures) tissues of the nasal cavity were examined.
Evaluation of trabecular bone in sternum and femur did not reveal any effects that were considered to be adverse. Rather, changes in trabecular bone revealed observations consistent with the anabolic actions of PTH1_34. Observations of thickened trabecular bone in the feinur and sternum were noted for females dosed with 25 g/kg/day SQ and 200 g/kg/day PTH-072-1 or 500 g/lcg/day PTH-074-1 intranasally. Females in the low dose intranasal PTH1_34 groups, 100 and 200 g/kg/day PTH-072-1 and PTH-074-1 were similar to control females. Trabecular bone in femur and sternum was thickened in male animals dosed intranasally with either PTH1_34 formulation. The tliickening was observed in males given PTH1_34 at 500 ~Lg/kg/day and 200 g/kg/day in the PTH-074-1 formulation; and males given 200 g/kg/day in the PTH-072-1 formulation. The low dose (100 g/lcg/day) males for PTH-072-1 were similar to controls. The anabolic effect was greater in males compared to females at the corresponding intranasally administered dose.
Summary No observations in animal health, clinical pathology, or tissue/organ morphology were found that indicate unexpected toxicologic results for the intranasal instillation of PTH1_34. There were no observational differences between the animals that received PTH1_34 via intranasal instillation compared to those dosed via subcutaneous injection. Examination of multiple sections representing the entire cavity and representative tissue types indicated once daily intranasal administration of PTHI_34 at high doses (and concentrations) was well tolerated. Further, changes in trabecular bone following intranasal PTH1_34 administration showed observations consistent with the anabolic actions of PTHI_34.

Anabolic Actions and Toxicity Results for Intranasal Administration of PTH1_34 in Dogs Toxicity and toxiokinetics of PTH1_34 was studied after administration of PTH1_34 once daily by intranasal instillation to dogs for at least 13 weeks.
One additional group received recombinant PTH1_34 by subcutaneous injection for comparison.
Male and female beagles were assigned among six study groups. Animals assigned to groups 1 through 5 received an intranasal installation of a negative control (0.9% Sodium Chloride for Injection, USP), 40 or 80 g/lcg of body weight/day ( g/lcg/day) PTH1_34 (synthetic form) in the PTH-072 formulation (Exa.inple 10, Table 22), or 80 or 200 g/kg/day PTH1_34 (synthetic form) in the PTH-074-1 formulation (Example 10, Table 22). The dog study groups are shown in Table 24.

Table 24. Study groups for dog toxicity and toxiokinetic studies Group No. of Dose Level Mode of Administration Animals ( g/kg/day) Male/Female 1 Control (placebo) 4/4 0 Intranasal 0.020mL/kg/dose 2 Low - PTH-072-1 4/4 40 Intranasa10.020mL/kg/dose 3 High - PTH-072-1 4/4 80 Intranasa10.020mL/kg/dose 4 Low - PTH-074-1 4/4 80 Intranasa10.020mL/kg/dose 5 High - PTH-074-1 4/4 200 Intranasal 0.020mL/kg/dose 6 PTH1_34Injection 4/4 6 Subcutaneous 0.081 mL/kg (Days 1-40) or 0.075 mL/kg (Days 41-92) For PTH-072-1 formulations, Tmax for PTH1_34 ranged from 8 to 26 minutes.
C,,,aX and AUCIast showed dose-dependence. For PTH-074-1 formulations, T,,,ax for PTH1_34 ranged from 8 to 24 minutes. Following subcutaneous injection of PTHI_34 T,,,a, for PTH1_34 ranged from 13 to 26 minutes. Systemic exposure for subcutaneous injection, as determined by Ca,, AUCI.t, and AUC;,,f, were intermediate between the low and high doses of PTHI-34 following intranasal administration.
The relative bioavailability for PTHI-34 was greater at the higher concentration dose for both intranasal formulations. The relative bioavailability for PTHI-34 was greater in the PTH-072-1 formulation. The C,,,., and AUCIast for PTHI-34 in each formulation were consistent with achieving peak levels soon after dosing and returning to baseline within a few hours post-dose; this general profile is desired for induction of anabolic actions of PTH1_34.
In comparison to clinical doses, for the low dose intranasal formulations nasal surface doses were approximately 0.9-fold for Day 1 and at least 1.5-fold by the end of the study. For the high dose intranasal formulations, nasal surface area doses were at least 1.0-fold on Day 1 and 3.8-fold or greater by the end of the study.
Cmax and AUCiast for PTH1_34 were at least 7-fold and 10-fold, respectively, greater in the dog than that found in humans at representative doses.
Results were collected for mortality, clinical signs, gross nasal passage observations, ophthalmic findings, electrocardiogram measurements, blood pressure and heart rate differences, body weiglzts, food consumption, clinical and anatomic pathology, and toxicokinetic evaluations. All animals in the study survived to scheduled necropsy. No PTHI-34 related clinical signs, ophthalmic findings, electrocardiograin differences, blood pressure and heart rate differences, body weights, or food consumption changes were noted. The nasal cavity was sectioned such that meaningful regions of the cavity were represented, and the soft (e.g., epithelial lining) or hard tissues (e.g., bone and cartilage based structures) of the nasal cavity were examined. There were no histologic changes in nasal tissues that were considered to be attributable to the intranasal administration of PTHI_34.
Anabolic effects considered to be associated with administration of PTHI-34 were reported in dogs administered PTH1_34 either intranasally or subcutaneously.
The mean total serum calcium for males and females is shown in Table 25.
Intranasal administration of PTHI-34 in the PTH-072-1 formulations, PTH-074-1 formulations, and subcutaneous injection resulted in a minimal to moderate (>12mg/dL) increase in serLun calcium, which is an expected physiological effect of PTH1_34.
Increased serum calcium was noted at 2, 4, and 6 hours post-dose with the pealc level at 2 or 4 hour time point. PTH1_34 injection, but not the intranasal formulations, produced elevated seruin calcium levels at the pre-dose time point. The absolute level for group mean serum calcium and the frequency of statistically significant elevation was similar for the injection group and the two high does intranasal formulations, but slightly higher for the injection group. The magnitude of change for the intranasal formulations was dose-dependent. Serum ionized calcium followed the same general pattern as total calcium.
The time and magnitude of the observed effect precludes the likelihood of catabolic effects. Instead, the biodynainic effect is one of an anabolic drug.
Such anabolic effects in animals are predictive of resistance to fracture in humans and used as predictors by the FDA.
Transiently elevated serum calcium is an expected action of PTHI_34, and there were no adverse clinical observations noted in association witli the transient elevation in serum calcium.

5 Table 25. Mean Total Serum Calcium * P< or =0.05 Group Pre- Dosing) Dosing Dosing Dosing Pre- Dosing Dosing Dosing dose (d2 (d27) (d27) (d27) dose (d89) (d89) (d89) (d7) 6hrs 2hrs 4hrs 6hrs (d89) 2hrs 4hrs 6hrs Males (mg/dL) 1 11.6 11.7 11.7 11.7 11.5 11.7 11.3 11.6 11.8 Control 0.29 0.15 0.13 0.10 0.17 0.21 0.18 0.24 0.49 (placebo 2 Low - 11.7 11.8 12.6 12.6 11.8 11.2 12.1 12.1 11.3 PTH- 0.26 0.31 0.71 0.53 0.51 0.13 0.45 0.45 0.22 3 High 11.5 11.8 13.2* 13.4* 12.4 11.6 12.7* 12.7* 12.1 - PTH- 0.36 0.28 1.02 1.33 0.49 0.38 0.45 0.54 1.35 .4 Low - 11.6 11.9 13.1* 13.0 12.1 11.7 12.3* 12.0 11.5 PTH- 0.30 0.13 0.48 0.66 0.31 0.48 0.40 0.50 0.49 5 High 11.8 12.3 14.0* 13.8* 12.4 11.8 13.1* 13.1* 12.1 - PTH- 0.58 0.85 0.99 0.73 0.27 0.30 0.67 0.97 0.60 6 PTH1_39 11.3 13.4* 13.9* 14.6* 13.4* 12.0 13.5* 14.3* 13.5 Injecti 0.29 0.92 -1-0.66 1.00 0.88 0.51 0.39 0.70 0.61 on Females (mg/dL) 1 11.5 11.4 11.3 11.6 11.3 11.1 11.2 11.2 11.2 Control 0.38 0.24 0.15 0.10 0.15 0.24 0.25 0.13 0.14 (placebo 2 Low - 11.5 11.5 12.6* 12.2 11.6 11.1 11.9 11.6 11.0 PTH- 0.13 0.25 0.46 0.25 0.29 0.33 0.29 0.17 0.38 3 High 11.7 11.8 13.4* 13.2* 12.2* 11.5 12.3* 12.4* 11.6 - 9TH- 0.29 0.22 0.13 0.38 0.30 0.26 0.29 0.54 0.67 4 Low - 11.4 11.3 13.0 12.7* 11.9 11.4 12.0 11.7 11.2 PTH- 0.26 0.17 0.69 0.54 0.40 0.22 0.37 0.30 0.17 5 High 11.1 11.9 13.2* 13.5* 12.5* 11.6 12.6 12.5* 11.9 - PTH- 0.38 0.44 0.39 0.79 0.34 0.29 0.64 0.57 0.42 6 PTH1_34 11.5 13.1* 14.1* 14.7* 13.3* 12.1* 13.3* 13.8* 12.6*
Injecti 0.06 0.46 0.12 0.37 0.34 0.19 0.25 0.21 0.41 on The (gross) nasal passage examination showed an increased incidence of erytllema in PTH1_34 treated animals (both subcutaneous and intranasal administration) compared to placebo control. PTH1_34 is known to have actions on vascular tone, and erythema is likely a reflection of the pharmacology of PTH1_34.
An attenuation of the normal age-related decrease in serum alkaline phosphatase activity is another effect of PTH1_34. Mean serum alkaline phosphatase activity dropped approximately 47% and 48% on Day 93 for placebo control males and females, respectively. None of the PTH1_34 treated groups (both subcutaneous and intranasal administration) showed a drop of greater than 30% in alkaline phosphatase activity. Attenuation of serum alkaline phosphatase activity was statistically significant in male dogs in both high dose intranasal groups as well as the males in the injection group.
Evaluation of trabecular bone in sternum and femur did not reveal any effects that were considered to be adverse. Rather, changes in trabecular bone revealed observations consistent with the anabolic actions of PTH1_34. PTH1_34 related changes of minimally thickened trabecular bone in the femur and sternum were observed in dogs dosed subcutaneously or intranasally at the high dose for PTH-072-1 and PTH-074-1.

Summary No observations in animal health, clinical pathology, or tissue/organ morphology indicated toxicologic results for the intranasal instillation of PTH1_34 with formulations PTH-072-1 or PTH-074-1.
Elevated serum calcium was observed with intranasal doses of PTH1_34. The elevated serum calcium is an anabolic effect of PTH. Higher alkaline phosphatase activity in intranasal and subcutaneous PTH1_34 treated animals was suggestive of osetoblast activity. A higher incidence of minimally thickened trabecular bone was noted in femur and sternum of PTH1_34 treated animals.
The anabolic actions and toxicity studies in both rats and dogs demonstrate that the intranasal route of administration is an effective means for the administration of PTH1_34. These results show the safety and efficacy of intranasal administration of the described PTH1_34 formulations. Further, the transient increase in serum calcium, higher alkaline phosphatase activity, and thickening of trabecular bone are predictive of the ability of intranasal PTH to increase bone mass, increase bone strength, and decrease the incidence of bone fracture in humans.

Although the foregoing invention has been described in detail by way of example for purposes of clarity of understanding, it is apparent to the artisan that certain changes and modifications are compreliended by the disclosure and may be practiced without undue experimentation within the scope of the appended claims, which are presented by way of illustration, not limitation.

Claims

1. An aqueous pharmaceutical formulation for intranasal delivery of PTH, comprising PTH(1-34) and a nonionic surface active agent.

2. The pharmaceutical formulation of claim 1, wherein the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol.

3. The pharmaceutical formulation of claim 2, wherein the surface active agent is polysorbate 80.

4. The pharmaceutical formulation of claim 3, wherein polysorbate 80 is present at less than about 50 mg/mL in the formulation.

5. The pharmaceutical formulation of claim 3, wherein polysorbate 80 is present at less than about 10 mg/mL in the formulation.

6. The pharmaceutical formulation of claim 3, wherein polysorbate 80 is present at less than about 1 mg/mL in the formulation.

7. The pharmaceutical formulation of claim 1, wherein the polyol is selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin, and polyethylene glycol.

8. The pharmaceutical formulation of claim 7, wherein the polyol is sorbitol.

9. The pharmaceutical formulation of claim 1, further comprising a preservative selected from the group consisting of chlorobutanol, methyl paraben, propyl paraben, butyl paraben, benzalkonium chloride, benzethonium chloride, sodium benzoate, sorbic acid, phenol, and ortho-, meta- or paracresol.

10. The pharmaceutical formulation of claim 1, wherein the formulation has a pH
of about 3 to about 6.

11. The pharmaceutical formulation of claim 1, wherein the formulation has a pH
of about 5.0 or less.

12. The pharmaceutical formulation of claim 1, wherein the formulation has a pH
of about 4.0 or less.

13. The pharmaceutical formulation of claim 1, wherein the aqueous solution is in the form of liquid droplets.

14. The pharmaceutical formulation of claim 13, where in the liquid droplets have an average volume-mean particle size (Dv,50) between about 1 micron and 1000 microns.

15. The pharmaceutical formulation of claim 13, where in the liquid droplets have an average volume-mean particle size (Dv,50) between about 5 microns and 500 microns.

16. The pharmaceutical formulation of claim 13, where in the liquid droplets have an average volume-mean particle size (Dv,50) between about 10 microns and 100 microns.

17. The pharmaceutical formulation of claim 1, wherein administration in a human subject achieves a maximum serum concentration of PTH, post-dosing (Cmax), of at least 10 pg/mL.

18. A method for treating osteoporosis in a mammal, comprising administering intranasally a therapeutically effective amount of a PTH formulation to the mammal wherein the formulation comprises PTH(1-34) and a nonionic surface active agent.

19. The method of claim 18, wherein the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol.

20. The method of claim 18, wherein the formulation has a pH of about 3 to about 6.

21. The method of claim 18, wherein a dose containing about 1 µg to about µg of a PTH(1-34) is administered to the mammal.

22. The method of claim 18, wherein a dose containing about 20 µg to about µg of PTH(1-34) is administered to the mammal.

23. The method of claim 18, wherein the mammal is a human.

24. The method of claim 18, wherein administration of the PTH formulation results in an increase in plasma levels of calcium.

25. The method of claim 24, wherein the increase in plasma levels of calcium are associated with the anabolic effects of PTH.

26. The method of claim 24, wherein the increase in plasma levels of calcium are not the result of increased bone catabolism.

27. The method of claim 24, wherein the increase in plasma levels of calcium are not the result of increased bone catabolism.

28. The method of claim 18, wherein administration of the PTH formulation results in an increase in bone mass.

29. The method of claim 18, wherein administration of the PTH formulation results in an increase in bone strength.

30. The method of claim 18, wherein administration of the PTH formulation results in an increased resistance to bone fracture.

31. The method of claim 18, wherein administration of the PTH formulation does not produce histological changes in nasal tissue.

32. A method for treating osteoporosis in a mammal comprising administering intranasally a therapeutically effective amount of a PTH formulation to the mammal, wherein the PTH formulation comprises PTH(1-34) and one or more excipients selected from the group consisting of a solubilizing agent, a chelating agent, and one or more polyols.

33. The method of claim 32, wherein the formulation further comprises a surface active agent.

34. The method of claim 32, wherein the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, bile salts such, sodium glycocholate, deoxycholate, derivatives of fusidic acid, sodium taurodihydrofusidate, L-.alpha.-phosphatidylcholine didecanoyl (DDPC), polysorbate 80, polysorbate 20, a polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, a polyvinyl alcohol, lanolin alcohol, and sorbitan monooleate.

35. The method of claim 34, wherein the surface-active agent is DDPC.

36. The method of claim 34, wherein one or more polyols are selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin and polyethylene glycol.

37. The method of claim 36, wherein the polyol is sorbitol.

38. The method of claim 32, wherein the chelating agent is ethylene diamine tetraacetic acid (EDTA) or ethylene glycol tetraacetic acid (EGTA).

39. The method of claim 38, wherein the chelating agent is EDTA.

40. The method of claim 32, wherein the solubilizing agent is selected from the group consisting of a cyclodextran, hydroxypropyl-.beta.-cyclodextran, sulfobutylether-.beta.-cyclodextran, and methyl-.beta.-cyclodextran.

41. The method of claim 40, wherein the solubilizing agent is a cyclodextran.

42. A method for treating osteoporosis in a mammal comprising administering intranasally a therapeutically effective amount of a PTH formulation to the mammal, wherein the PTH formulation comprises PTH(1-34) and a nonionic surface active agent, and wherein a time to maximum plasma concentration, T max, of PTH(1-34) following administration of said formulation to the mammal is less than 30 minutes.

43. The method of claim 42, wherein a C max greater than about 300 pg/ml results from a single administration of said formulation.

44. A dosage form of PTH, comprising an aqueous pharmaceutical formulation of PTH and a nonionic detergent for aerosolized intranasal delivery of PTH having a bioavailability of about 5% or greater, wherein the formulation comprises a therapeutically effective amount of PTH(1-34) and a polysorbate, and wherein least 90% of the PTH can be recovered after storage for 24 weeks at 5°C.

45. The PTH dosage form of claim 44, having greater than about 90% recovery of the PTH after at least six months at 5°C storage.

46. The PTH dosage form of claim 44, having greater than about 90% recovery of the PTH after one year at 5°C storage.

47. The PTH dosage form of claim 44, having greater than about 90% recovery of the PTH after two years at 5°C storage.

48. The PTH dosage form of claim 44, having greater than about 80% recovery of the PTH after 24 weeks at 25°C storage.

49. The PTH dosage form of claim 44, having greater than about 80% recovery of the PTH after at least six months at 25°C storage.

50. The PTH dosage form of claim 44, having greater than about 80% recovery of the PTH after one year at 25°C storage.

51. The PTH dosage form of claim 44, having greater than about 80% recovery of the PTH after two years at 25°C storage.

52. The PTH dosage form of claim 44, having greater than about 65% recovery of the PTH can be recovered after storage for at least 4 weeks at 40°C.

53. The PTH dosage form of claim 44, having greater than about 90% recovery of the PTH after being in use for greater than about five days.

54. The PTH dosage form of claim 53, having greater than about 90% recovery of PTH at 30°C/65% relative humidity between all sprays.

55. The PTH dosage form of claim 44, wherein the pH is about 5.0 or less.

56. The PTH dosage form of claim 44, wherein the pH is about 4.5 or less.

57. The PTH dosage form of claim 44, wherein the pH is about 4.0 or less.

58. The PTH dosage form of claim 44, wherein the pH is about 3.5 or less.

59. The PTH dosage form of claim 44, wherein the concentration of PTH is at least about 1 mg/ml.

60. The PTH dosage form of claim 44, wherein the concentration of PTH is at least about 2 mg/ml.

61. The PTH dosage form of claim 44, wherein the concentration of PTH is at least about 6 mg/ml.

62. The PTH dosage form of claim 44, wherein the concentration of PTH is at least about 10 mg/ml.

63. The PTH dosage form of claim 44, wherein said dosage form is suitable for intra-nasal administration to achieve a dose of from about 2 µg to about 1000 µg of said PTH.

64. The PTH dosage form of claim 44, wherein said dosage form is suitable for intra-nasal administration to achieve a dose of from about 100 µg to about 600 µg of said PTH.

65. The PTH dosage form of claim 44, wherein the polysorbate is present at least about 1 mg/mL in the formulation.

66. The PTH dosage form of claim 44, wherein the polysorbate is present at least about 10 mg/mL in the formulation.

67. The PTH dosage form of claim 44, wherein the polysorbate is present at least about 50 mg/mL in the formulation.

68. The PTH dosage form of claim 44, further comprising a preservative.

69. The PTH dosage form of claim 68, wherein the preservative is chlorobutanol.

70. A dosage form of PTH, comprising an aqueous pharmaceutical formulation for aerosolized intranasal delivery of PTH having a bioavailability of about 10% or greater, wherein the formulation comprises a therapeutically effective amount of PTH(1-34), methyl-.beta.-cyclodextrin, didecanoylphosphatidyl choline, and ethylenediaininetetraacetic acid, and wherein least 90% of the PTH can be recovered after storage for 24 weeks at 5°C.

71. The PTH dosage form of claim 70, having greater than about 90% recovery of PTH after at least six months at 5°C storage.

72. The PTH dosage form of claim 70, having greater than about 90% recovery of PTH after one year at 5°C storage.

73. The PTH dosage form of claim 70, having greater than about 90% recovery of PTH after two years at 5°C storage.

74. The PTH dosage form of claim 70, having greater than about 80% recovery of PTH after 24 weeks at 25°C storage.

75. The PTH dosage form of claim 70, having greater than about 80% recovery of PTH after at least six months at 25°C storage.

76. The PTH dosage form of claim 70, having greater than about 80% recovery of PTH after one year at 25°C storage.

77. The PTH dosage form of claim 70, having greater than about 80% recovery of PTH after two years at 25°C storage.

78. The PTH dosage form of claim 70, having greater than about 65% recovery of the PTH after storage for at least 4 weeks at 40°C.

79. The PTH dosage form of claim 70, having greater than about 90% recovery of the PTH after being in use for greater than about five days.

80. The PTH dosage form of claim 79, having greater than about 90% recovery of PTH at 30°C/65% relative humidity between all sprays.

81. The PTH dosage form of claim 70, wherein the pH is about 5.0 or less.

82. The PTH dosage form of claim 70, wherein the pH is about 4.5 or less.

83. The PTH dosage form of claim 70, wherein the pH is about 4.0 or less.

84. The PTH dosage form of claim 70, wherein the pH is about 3.5 or less.

85. The PTH dosage form of claim 70, wherein the concentration of PTH is at least about 1 mg/ml.

86. The PTH dosage form of claim 70, wherein the concentration of PTH is at least about 2 mg/ml.

87. The PTH dosage form of claim 70, wherein the concentration of PTH is at least about 6 mg/ml.

88. The PTH dosage form of claim 70, wherein the concentration of PTH is at least about 10 gag/ml.

89. The PTH dosage form of claim 70, wherein said dosage form is suitable for intra-nasal administration to achieve a dose of from about 2 µg to about 1000 µg of said PTH.

90. The PTH dosage form of claim 70, wherein said dosage form is suitable for intra-nasal administration to achieve a dose of from about 100 µg to about 600 µg of said PTH.

91. The PTH dosage form of claim 70, further comprising a preservative.

92. The PTH dosage form of claim 91, wherein the preservative is chlorobutanol.

93. A method of delivering PTH to a human, comprising exposing a layer of mucosal cells to a PTH solution comprising PTH(1-34) and a nonionic surface active agent.

94. The method of delivering PTH of claim 93, wherein said method utilizes a non-parenteral administration.

95. The method of delivering PTH of claim 94, wherein said method of administration is selected from the group consisting of intranasal, buccal, gastrointestinal, vaginal, and transdermal.

96. The method of delivering PTH of claim 95, wherein said method is an intranasal administration.

97. The method of delivering PTH of claim 96, wherein said intranasal administration comprises delivering an aerosol comprising droplets of between about 1 and about 700 microns in size.

98. The method of delivering PTH of claim 96, wherein said intranasal administration comprises delivering an aerosol comprising about about 0.7 to about about 25 µg PTH per kg weight of the patient.

99. The method of delivering PTH of claim 96, wherein said intranasal administration comprises delivering an aerosol comprising about 50 to about 800 µg PTH.

100. The method of delivering PTH of claim 94, wherein said method is an oral delivery.

101. The method of delivering PTH of claim 100, wherein said oral delivery is a controlled release delivery wherein Tmax is less than about 40 minutes from the time of release.

102. A system for delivering PTH to a human by intranasal administration comprising an aqueous PTH solution comprising PTH(1-34) and a nonionic surface active agent in a bottle, and a droplet-generating actuator attached to said bottle and fluidly connected to the PTH solution in the container, wherein said actuator produces a spray of the PTH solution through a tip of the actuator when said actuator is engaged, wherein said PTH spray has a spray pattern ellipticity ratio of from about 1.0 to about 1.4 when measured at a height of 3.0 cm from the actuator tip.

103. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution wherein less than about 5% of the droplets are less than 10 µm in size.

104. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution wherein less than about 1% of the droplets are less than 10 µm in size.

105. The system of claims 102, wherein the PTH spray has a spray pattern major axis and minor axis of about 25 and about 40 mm, respectively.

106. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution, wherein less than about 90% of the droplets are about 250 µm or less in size.

107. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution, wherein less than about 90% of the droplets are about 120 µm or less in size.

108. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution wherein less than about 50% of the droplets are about 75 µm or less in size.

109. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution wherein less than about 50% of the droplets are about 50 µm or less in size.

110. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution, wherein less than about 10% of the droplets are about 30 µm or less in size.

111. The system of claims 102, wherein the PTH spray is comprised of droplets of the PTH solution, wherein less than about 10% of the droplets are about 20 µm or less in size.

112. The formulation of claim 1 for use in the treatment of osteoporosis or osteopenia.

113. A use of PTH(1-34) in the manufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises PTH(1-34) and a nonionic surface active agent.

114. The use of PTH of claim 113, wherein the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, polysorbate 80, polysorbate 20, polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, polyvinyl alcohol, poloxamer F68, poloxamer F127, and lanolin alcohol.

115. The use of PTH of claim 113, wherein the formulation has a pH of about of about 3-6.

116. The use of PTH of claim 113, wherein a dose containing 1 µg to 1000 µg of a PTH(1-34) is administered to the mammal.

117. The use of PTH of claim 113, wherein a dose containing 20 µg to 400 µg of PTH(1-34) is administered to the mammal.

118. The use of PTH of claim 113, wherein the mammal is a human.

119. The use of PTH of claim 113, wherein administration of the PTH
formulation results in an increase in plasma levels of calcium.

120. The use of PTH of claim 119, wherein the increase in plasma levels of calcium are associated with the anabolic effects of PTH.

121. The use of PTH of claim 120, wherein the increase in plasma levels of calcium are not the result of increased bone catabolism.

122. The use of PTH of claim 120, wherein the increase in plasma levels of calcium are not the result of increased bone catabolism.

123. The use of PTH of claim 113, wherein administration of the PTH
formulation results in an increase in bone mass.

124. The use of PTH of claim 113, wherein administration of the PTH
formulation results in an increase in bone strength.

125. The use of PTH of claim 113, wherein administration of the PTH
formulation results in an increased resistance to bone fracture.

126. The use of PTH of claim 113, wherein administration of the PTH
formulation does not produce histological changes in nasal tissue.

127. A use of PTH(1-34) in the manufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises a therapeutically effective amount of PTH(1-34) and one or more excipients selected from the group consisting of a solubilizing agent, a chelating agent, and one or more polyols.

128. The use of a PTH formulation of claim 127, wherein the formulation further comprises a surface active agent.

129. The use of a PTH formulation of claim 128, wherein the surface active agent is selected from the group consisting of nonionic polyoxyethylene ether, bile salts such, sodium glycocholate, deoxycholate, derivatives of fusidic acid, sodium taurodihydrofusidate, L-.alpha.-phosphatidylcholine didecanoyl (DDPC), polysorbate 80, polysorbate 20, a polyethylene glycol, cetyl alcohol, polyvinylpyrolidone, a polyvinyl alcohol, lanolin alcohol, and sorbitan monooleate.

130. The use of a PTH formulation of claim 129, wherein the surface-active agent is DDPC.

131. The use of a PTH formulation of claim 127, wherein one or more polyols are selected from the group consisting of sucrose, mannitol, sorbitol, lactose, L-arabinose, D-erythrose, D-ribose, D-xylose, D-mannose, trehalose, D-galactose, lactulose, cellobiose, gentibiose, glycerin and glycol.

132. The use of a PTH formulation of claim 131, wherein the polyol is sorbitol.

133. The use of a PTH formulation of claim 127, wherein the chelating agent is ethylene diamine tetraacetic acid (EDTA) or ethylene glycol tetraacetic acid (EGTA).

134. The use of a PTH formulation of claim 133, wherein the chelating agent is EDTA.

135. The use of a PTH formulation of claim 127, wherein the solubilizing agent is selected from the group consisting of a cyclodextran, hydroxypropyl-.beta.-cyclodextran, sulfobutylether-.beta.-cyclodextran, and methyl-.beta.-cyclodextran.

136. The use of a PTH formulation of claim 135, wherein the solubilizing agent is a cyclodextran.

137. A use of PTH(1-34) in the manufacture of a medicament for treating osteoporosis in a mammal, wherein the medicament comprises PTH(1-34) and a nonionic surface active agent, and wherein a time to maximum plasma concentration, T max, of PTH(1-34) following administration of said formulation to the mammal is less than 30 minutes.

138. The use of a PTH formulation of claim 137, wherein a C max greater than pg/ml results from a single administration of said formulation.