Note: Descriptions are shown in the official language in which they were submitted.
CA 02697978 2012-05-15
LOWER DOSAGE STRENGTH IMIQUIMOD FORMULATIONS AND SHORT
DOSING REGIMENS FOR TREATING GENITAL WARTS
FIELD OF THE INVENTION
The present invention relates to pharmaceutical formulations and methods for
the topical
or transdermal delivery of 1-isobuty1-111-imidan[4,5-c-quinolin-4-amine, also
known as (a.k.a)
1-(2-methylpropy1)-1H-imidwo[4,5-elquinolin-4-arnine, aka imiquimod, to treat
genital and
perianal warts with shorter durations of therapy, than currently prescribed
for the commercially
available Aldara* 5% imiquimod cream, as now approved by the U.S. Food & Drug
Administration ("FDA"). More specifically, the present invention is directed
to lower dosage
strength imiquimod formulations to deliver an efficacious dose for treating
genital and perianal
warts with an acceptable safety profile, but with a dosing regimen that is
shorter and more
convenient for patient use than the dosing regimen currently approved by the
FDA for Aldara.
5% imiquimod cream.
BACKGROUND
External Genital Warts (EGW), or condylomata acuminate, are caused by
infection with
human papilloma virus (HPV), the most common sexually transmitted virus in the
Western
world (LAtle 1994, Mayeaux 1995, Shah 1990). Approximately 1% of the sexually
active
population between 15 and 49 years of age in the US is estimated to have EGW
(1Coutsky 1988,
Koutsky 1997). Most EGWs are associated with HPV types 6 and 11 (Phelps 1995).
In 1997, imiquimod 5% cream (Mara) was approved for the treatment of EGW and
perianal warts. Imiquimod, an immune response modifier that stimulates the
innate and adaptive
immune response, has been demonstrated to be an effective and safe treatment
for EOWs.
Stimulation of the immune response has been shown to decrease HPV viral load
(Kreuter 2006)
and may decrease the recurrence rate of visible warts, although observed rates
after treatments do
vary.
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CA 02697978 2012-05-15
Imiquimod, however, has no direct antiviral activity in cell culture. A study
in 22
patients with genital/perianal warts comparing Aldara 5% imiquimod cream and
vehicle shows
that Aldara 5% imiquirnod cream induces mRNA encoding cytokines including
interferon-a at
the treatment site. In addition, HF'VL1 mRNA and HPV DNA are significantly
decreased
following treatment. However, the clinical relevance of these findings is
unknown.
Specific antiviral therapy for the treatment of EGW is lacking, but drug and
other
therapies have been used. Ablative treatment modalities include procedures
such as surgical
excision, laser therapy, and cryotherapy. Other approaches include topical
treatments, such as
acetic acid, podophylline, podophyllotoxin, and 5-fluorouracil, which are
cytodestructive, and
sinecatechins, whose mechanism of action is unknown. Each of these therapies
has
disadvantages such as inconvenient regimens, pain or burning associated with
the therapy,
scarring, itching, or high recurrence rates.
Aldara' 5% imiquimod cream is approved for the treatment of external genital
and
perianal warts (condylomata acuminata) in individuals 12 years old and above
(Aldara Package
Insert). The approved dosing regimen is 3 times per week, for up to 16 weeks
of treatment.
The compound characterized as 1-isobuty1-1H-imidaz,o[4,5-ej-quinolin-4-amine
or 142-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine, and known as imiquirnod, is
disclosed in
U.S. Patent No. 4,689,338 and described therein as an antiviral agent and as
an interferon
inducer. A variety of formulations for topical administration of imiquimod are
also described
therein. This U.S. Patent No. 4,68,338.
U.S. Patent No. 4,751,087 discloses the use of a combination of ethyl oleate
and glyceryl
monolaurate as a skin penetration enhancer for nitroglycerin, with all three
components being
contained in the adhesive layer of a transdenTud patch.
U.S. Patent No. 4,411,893 disdoses the use of N,N-dimethyldodecylamine-N-oxide
as a
skin penetration enhancer in aqueous systems.
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CA 02697978 2012-05-15
U.S. Patent No. 4,722,941 discloses readily absorbable pharmaceutical
compositions that
comprise a pharmacologically active agent distributed in a vehicle comprising
an absorption-
enhancing amount of at least one fatty acid containing 6 to 12 carbon atoms
and optionally a
fatty acid monoglyceride. Such compositions are said to be particularly useful
for increasing the
absorption of pharmacologically active bases.
U.S. Patent No. 4,746515 discloses a method of using glyceryl monolaurate to
enhance
the transderrnal flux of a transdermally deliverable drug through intact skin,
U.S. Patent No. 5,238,944, U.S. Patent No. 7,038,051, U.S. Patent No.
6,693,113, U.S.
Patent No. 6,894,060, U.S. Patent No. 7,655,672, U.S. Patent Publication No.
2009/0093514 Al.
U.S. Patent Publication No. 2007/0123558, U.S. Patent Publication No.
2004/087614, U.S.
Patent Publication No, 2002/147210, pa Publication 'No. W02008082381 and PCT
Publication
No. W020081JS53522 disclose topical formulations and/or topical and iransdem-
tal delivery
systems containing 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine or 1-(2-
methylpropy1)-1/1-
imidazo[4,5-c]quinolin-4-amine
Currently, the FDA has approved a 5% imiquimod cream, commercially available
under
the brand name Aldare, to treat certain dermal and mucosal associated
conditions, such as (1)
the topical treatment of clinically typical, nonhyperkeratotic actinic
keratosis (AK) on the face or
scalp in inununocompetent adults, (2) topical treatment of biopsy confirmed,
primary superficial
basal cell carcinoma (sBCC) in immunocompetent adults, and (3) the topical
treatment of
external genital and perianal warts/condyloma acuminate (hereinafter,
individually or jointly
"EGWs") in patients 12 years or older.
Aldare is the brand name for an FDA-approved 5% imiquimod cream, which is an
immune response modifier. Each gram of the Mare 5% imiquimod cream contains 50
mg of
imiquimod in an off-white oil-in-water vanishing cream base consisting of
isostearic acid, cetyl
alcohol, stearyl alcohol, white petrolatum, polysorbate 60, sorbitan
monostearate, glycerin,
xanthan gum, purified water, benzyl alcohol, methylparaben, and propylparaben.
The Aldare
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CA 02697978 2010-03-30
5% imiquimod cream is packaged in single-use packets or sachets, each
containing 250 mg of
cream, equivalent to 12.5 mg of imiquimod.
Chemically, imiquimod, as indicated above, is known as 1-(2-methylpropy1)-1H-
imidazo
[4,5-c]quinolin-4- amine or 1 -isobuty1-1H-imidazo [4,5-c]-quinolin-4-amine .
Imiquimod has a
molecular formula of C14H161\14 and a molecular weight of 240.3. The chemical
structural
formula for imiquimod is as follows:
N H 2
ONN)
N\L......(eC H 3
C H 3
Notwithstanding FDA approval, Aldara 5% imiquimod cream treatment for EGWs is
not without limitation, including an unsimplified and lengthy dosing regimen
(administration
three times per week until total clearance of EGWs is achieved, or up to 16
weeks). According to
the FDA-approved label for Aldara 5% imiquimod cream, the median time to
complete wart
cleance is 10 weeks. The eccentric dosing schedule is not easy to remember,
which could lead to
reduced compliance with resulting reduced efficacy. If applied too thickly or
generously,
Aldara 5% imiquimod cream can cause site or local skin reactions, such as
erosions or
ulcerations, causing pain or dysfunction (e.g., of the foreskin or urethra).
In addition, efficacy of
treatment with Aldara 5% imiquimod cream may be limited, especially in men,
in patients with
longstanding or recurrent disease, or for treatment of keratinized areas
(e.g., inguinal). In some
cases, a rest period from scheduled dosing with Aldara 5% imiquimod cream may
be needed,
and consultation or reevaluation by healthcare provider may also be required.
Other symptoms,
such as perianal itching or systemic effects such as flu-like symptoms, may
also occur in some
cases after treatment with Aldara 5% imiquimod cream.
In view of the above, there is a need for improved EGW topical treatment that
overcomes
the current limitations associated with the current FDA-approved topical
treatment regimen for
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EGWs, i.e., administration until there is total clearance of the EGWs, for up
to 16 weeks, three
days per week, with FDA-approved Aldara 5% imiquimod cream.
SUMMARY OF THE INVENTION
The present invention addresses the above-mentioned limitations associated
with the
treatment of EGWs with FDA-approved Aldara 5% imiquimod cream through the
discovery of
novel and improved imiquimod treatment regimens of short duration, lower
dosage strength
imiquimod pharmaceutical formulations, and simplified dosing regimens to treat
EGWs.
Generally speaking, the present invention provides for new and improved
substantially
less-irritating lower dosage strength imiquimod pharmaceutical formulations,
which are suitable
for daily application in connection with substantially condensed treatment
regimens, for topical
and/or transdermal administration of an effective amount of imiquimod to treat
subjects who are
diagnosed with external genital and perianal warts/condyloma acuminate (EGWs).
In addition,
the present invention provides for new and improved EGW treatments, wherein:
(1) treatment
periods of the present invention are substantially shorter in duration, i.e.,
up to eight weeks and
preferably up to six weeks or four weeks, than the current FDA-approved up-to-
16-week
treatment regimen for EGWs treatment; (2) dosing regimens of the present
invention are
substantially simpler, i.e., one application daily each day for up to eight
weeks and preferably up
to six weeks or four weeks, than the current dosing regimen, as compared to
the once-a-day but
only three times per week for up to 16 weeks regimen for the current FDA-
approved Aldara 5%
imiquimod cream for EGWs treatment; (3) less-irritating imiquimod
pharmaceutical
formulations of the present invention are formulated with a lower dosage
strength, i.e., between
about 1% and about 4.25% imiquimod, than the current FDA-approved Aldara 5%
imiquimod
cream for EGWs treatment; and (4) lower subject incidence of application site
reactions is
experienced in accordance with the present invention, as compared with higher
subject incidence
of application site reactions experienced with the current FDA-approved Aldara
5% imiquimod
cream and treatment regimen for EGWs treatment.
In other words, the present invention provides for new and improved EGWs
treatments
that have short durations of therapies, use lower imiquimod dosage strengths,
have simplified
CA 02697978 2010-03-30
daily dosing regimens, and have a lower incidence of application site
reactions, as compared to
treatment of EGWs with Aldara 5% imiquimod cream, as currently approved by
the FDA.
The present invention thus provides numerous surprising advantages over
current FDA-
approved Aldara 5% imiquimod cream therapy for EGWs treatment. For example,
the present
invention provides for (1) a shortened treatment regimen, i.e., up to about 8
weeks, or preferably
up to about 6 weeks and preferably up to about 4 weeks, (2) a simplified
dosing regimen, i.e.,
once daily on each day of the treatment period, (3) low systemic imiquimod
blood levels even
though the dosing frequency is increased, and (4) a lower subject incidence of
application site
reactions during the topical treatment regimen of EGWs, than currently
associated with FDA-
approved Aldara 5% imiquimod cream therapy.
Thus, the present invention overcomes certain of the limitations associated
with the
treatment of EGWs with FDA-approved Aldara 5% imiquimod cream and addresses
current
medical needs for (1) a shorter treatment period, (2) a more intuitive dosing
regimen (daily
dosing vs. thrice weekly dosing for Aldara 5% imiquimod cream) and (3) less
or a lower
incidence of application site reactions.
The less-irritating lower dosage strength imiquimod pharmaceutical
formulations of the
present invention may comprise:
1. a lower dosage strength of 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine
or 1-(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine (imiquimod) for delivering an
effective
amount of imiquimod; and
2. a pharmaceutically acceptable vehicle for imiquimod, which vehicle
comprises a fatty
acid, such as isostearic acid, palmitic acid, stearic acid, linoleic acid,
unrefined oleic acid, refined
oleic acid, such as Super Refined oleic acid NF (e.g., a highly purified
oleic acid, i.e., an oleic
acid which has low polar impurities, such as peroxides, a low peroxide value
and is marketed by
CRODA; see e.g., www.crodausa.com) and a combination thereof, in a total
amount of about 3
percent to about 45 percent by weight based on the total weight of the
formulation.
The lower dosage strength imiquimod formulations of the present invention,
especially
those wherein the vehicle comprises an isostearic acid as the fatty acid, are
uniquely designed to
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CA 02697978 2010-03-30
have physical and chemical stability, solubility, emollient properties and
dose proportionate
delivery similar to or better than Aldara 5% imiquimod cream. More
specifically, the lower
dosage strength imiquimod formulations of the present invention, especially
those wherein the
vehicle comprises an isostearic acid as the fatty acid, are believed to
generally have similar or
improved skin emolliency at the application site and dose proportionate
release rates as to both
the release rates of the imiquimod and the total amount of imiquimod released,
relative to the
Aldara 5% imiquimod cream. In other words, the lower dosage strength
imiquimod
formulations of the present invention are concentration influenced and have
similar release rates
to the Aldara 5% imiquimod cream. Additionally, the greater the amount of
imiquimod in the
formulation, the faster and the greater the total amount of imiquimod is
released, evidencing that
the amount in and the rate of release from the formulations are imiquimod
concentration
dependent. Thus, while the lower dose strength imiquimod formulations of the
present invention
deliver different cumulative amounts to the stratum corneum and epidermis,
i.e., local skin
delivery, than the Aldara 5% imiquimod cream, such lower dosage strength
imiquimod
formulations are believed to have a proportional and linear relationship that
is similar with the
Aldara 5% imiquimod cream as to both the rate of imiquimod release and the
total amount of
imiquimod released and delivered locally to the skin over time, so that the
imiquimod
concentrations in the formulations of the present invention, the imiquimod
release rates and the
amount of imiquimod unabsorbed and delivered to the stratum corneum and
epidermis, which
has been released from the formulations, are generally proportional and linear
to the Aldara 5%
imiquimod cream.
In addition, the lower dosage strength imiquimod formulations of the present
invention,
especially those wherein the vehicle comprises an isostearic acid as the fatty
acid, are uniquely
designed to be stable and fall within the range of the specifications for the
commercially
available Aldara 5% imiquimod cream, such as to viscosity, pH, and stability,
including
microscopic and macroscopic stability. More specifically, the imiquimod
present in the lower
dosage strength imiquimod formulations of the present invention, especially
those wherein the
vehicle comprises an isostearic acid as the fatty acid, (monograph range: 90
to 110%) and
benzyl alcohol (monograph range: 50 to 105%) remain within limits at both
about 25 C and
about 40 C over about a one month period and within limits at both about 25 C
and about 40 C
over about a six month period. Furthermore, the lower dosage strength
imiquimod formulations
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of the present invention, especially those wherein the vehicle comprises an
isostearic acid as the
fatty acid, remain stabile for about six months at about 25 C and about 40 C,
and also remain
stable with respect to macroscopic and microscopic appearance, viscosity
(monograph range:
2,000 to 35000 cPs) and pH (monograph range 4.0 to 5.5). In addition, the
lower dosage strength
imiquimod formulations of the present invention are uniquely designed to meet
the requirements
specified in both United States Pharmacopeia ("USP") and the European
Pharmacopeia ("EP")
as to preservative efficacy and remain free of degradation products when
stored at about
25 C/60%RH, about 30 C/65%RH and about 40 C/75%RH over about one, about two,
about
three and about six months and analyzed at about 318 nm wavelength.
The present invention also contemplates lower dosage strength imiquimod
formulations
that have unique pharmacokinetic profiles when used, for example, in
connection with the short
durations of therapy to treat EGWs in accordance with the present invention.
By way of
example, a 3.75% imiquimod lower dosage strength formulation of the present
invention, when
approximately 250 mg of such a formulation (about 9.375 mg imiquimod) or less
is applied daily
for 21 days to EGWs in the genital/perianal area with a total wart area of
greater than or equal to
100 mm2, achieves steady state by about Day 7, and provides an in-vivo serum
profile selected
from one or more of the following:
(a) a Day 21 mean Trnax of about 9.7 hours with a standard deviation ("SD")
of about
4.0, a median Trnax of about 12 hours and a geometric mean Tmax of about 8.3
hours and a
coefficient of variation ("CV") of about 41%;
(b) a Day 21 mean Crnax of about 0.488 ng/ml with a standard deviation of
about
0.368, a median Cm ax of about 0.45 and a geometric mean Cm ax of about 0.39
ng/mL and a
coefficient of variation of about 75%;
(c) a Day 21 T. of from about 6.8 to about 54 hours and preferably a mean
Ty, of
about 24.1 hours with a standard deviation of about 12, a median T. of about
22.8 hours and a
geometric mean T1/2 of about 21 hours and a coefficient of variation of about
51%;
(d) a Day 21 AUC0_24 of from about 1.9 to about 14 ng-hr/mL and preferably
a mean
AUC0_24 of about 6.8 ng.hr/mL with a standard deviation of about 3.6, a median
AUC0_24 of
about 6.6 ng.hr/mL and a geometric mean AUC0_24 of about 5.8 ng-hr/mL and a
coefficient of
variation of about 53%;
(e) a Day 21 Az of from about 0.013 hfl to about 0.102 hi-4 and preferably
a mean
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CA 02697978 2010-03-30
Xz of about 0.037 hr-1 with a standard deviation of about 0.02, a median Az of
about 0.03 hr4 and
a geometric mean Az of about 0.03 hr4 and a coefficient of variation of about
60%;
a Day 21 Cam, of from about 0.025 to about 0.47 and preferably a mean Cmm of
about 0.158 with an SD of about 0.121, a median Cam, of about 0.14 and a
geometric mean Cma,
of about 0.11 and a coefficient of variation of about 77%;
(g) at Day 14/7 (a ratio of the trough concentration at Day 14 over the
trough
concentration at Day 7), a trough concentration geometric mean ratio of about
1.13 with a 90%
confidence interval ( "CI") within a range of between about 0.7 and about 1.7;
(h) at Day 21/14 (a ratio of the trough concentration at Day 21 over the
trough
concentration at Day 14), a trough concentration geometric mean ratio of about
0.84 with a 90%
confidence interval ("CI") within a range of between about 0.5 and about 1.3;
(i) at Day 22/21 (a ratio of the trough concentration at Day 22 over the
trough
concentration at Day 21) a trough concentration geometric mean ratio of about
1.12 with a 90%
confidence interval ("CI") within a range of between about0.7 and about 1.6;
(j) a mean peak imiquimod serum concentration of about 0.488 ng/mL at Day
21;
(k) a Day 21 RAUC of from about 0.6 to about 7 and preferably a mean RAUC
of
about 2.2 with a standard deviation of about 1.8, a median RAUC of about 1.8
and a geometric
mean RAUC of about 1.7 and a coefficient of variation of about 81%;
(1) a Day 21 RCmax of from about 0.5 to about 5 and preferably a mean
RCm of
about 2.3 with a standard deviation of about 1.6, a median RCmax of about 1.7
and a geometric
mean RCmax of about 1.8 and a coefficient of variation of about 70%;
(m) a Day 21 LAzeff of from about 0.006 hr-1 to about 0.09 hr-1 and
preferably a mean
LXzeff of about 0.04 hr-1 with a standard deviation of about 0.03, a median
LAzaff of about 0.03 hr-
1
and a geometric mean LAzeff of about 0.03 hr-1 and a coefficient of variation
of about 69%;
(n) a Day 21 'Oaf of from about 8 hr to about 111 hr and preferably a mean
TY2eff of
about 31 hr with a standard deviation of about 30, a median T14effof about 22
hr and a geometric
mean T1/2eff of about 23 hr-1 and a coefficient of variation of about 97%;
(o) a Day 21 Cm ax in female patients about 61% higher in female subjects
than in
male subjects (0.676 versus 0.420 ng/mL) and total systemic exposure AUC 0-24
8% higher in
female subjects than in male subjects (7.192 versus 6.651 ng-hr/mL) when data
is not dose
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normalized;
(p) a Day 21 Cmax in female patients about 35% higher than in male
subjects (0.583
versus 0.431 ng/mL) and AUC 0-24 about 6% lower in female subjects than in
male subjects
(6.428 versus 6.858 ng-hr/mL) when using dose normalization to adjust for
differences in
dosage and reported without subjects who missed an application of study drug
during the last
week of dosing; and/or
(q) a median Trnax occurring approximately twice as quickly in female subjects
(about
6.50 hours) as in male subjects (about 12.0 hours).
In accordance with the present invention, a mean peak serum concentration is
achieved
with a 3.75% lower dosage strength imiquimod formulation of Examples 23-26.
More
specifically, a mean peak serum concentration of about 0.488 ng/mL is achieved
with a 3.75%
lower dosage strength imiquimod formulation of Examples 23-26 after about 9.4
mg of
imiquimod is applied to the affected treatment area each day for up to 8
weeks.
Furthermore, this invention provides the following evidence of clinical
efficacy: The
wart area decreased by 45% from a mean of 108.3 mm 2 at baseline to 43.2 mm 2
at Day 21 (Table
14.1.2.1). The P value of <.0001 for this change from baseline indicated a
statistically significant
(<0.050) decrease in wart area after 3 weeks of treatment.
In accordance with the present invention, a mean peak serum concentration is
achieved
with a 3.75% lower dosage strength imiquimod formulation of Examples 23-26.
More
specifically, a mean peak serum concentration of about 0.488 ng/ml is achieved
with a 3.75%
lower dosage strength imiquimod formulation of Examples 23-26 after about 9.4
mg of
imiquimod is applied to the affected treatment area, i.e., the external
genital/perianal warts, each
day until completely cleared or for up to eight weeks.
In addition, the present invention contemplates lower dosage strength
formulations that
are pharmaceutically equivalent, therapeutically equivalent, bioequivalent
and/or
interchangeable, regardless of the method selected to demonstrate equivalents
or bioequivalence,
such as dermatopharmacokinetic and pharmacokinetic methodologies,
microdialysis, in vitro and
in vivo methods and/or clinical endpoints. Thus, the present invention
contemplates lower
dosage strength imiquimod formulations that are bioequivalent,
pharmaceutically equivalent
and/or therapeutic equivalent, especially, 2.5% and 3.75% lower dosage
strength imiquimod
CA 02697978 2010-03-30
formulations that are bioequivalent, pharmaceutically equivalent and/or
therapeutically
equivalent, when used daily in accordance with the short durations of therapy
of the present
invention to treat EGWs, e.g., used on treatment areas, on a daily basis until
complete wart
clearance or for up to about eight weeks, six weeks, or up to about 4 weeks,
optionally including
a rest (no drug application) period.
Thus, the present invention contemplates: (a) pharmaceutically equivalent
lower dosage
strength imiquimod formulations which contain the same amount of imiquimod in
the same
dosage form; (b) bioequivalent lower dosage strength imiquimod formulations
which are
chemically equivalent and which, when administered to the same individuals in
the same dosage
regimens, result in comparable bioavailabilities; (c) therapeutic equivalent
lower dosage strength
imiquimod formulations which, when administered to the same individuals in the
same dosage
regimens, provide essentially the same efficacy and/or toxicity; and (d)
interchangeable lower
dosage strength imiquimod formulations of the present invention which are
pharmaceutically
equivalent, bioequivalent and therapeutically equivalent.
By the term "lower dosage strength(s)", as used herein, it refers to a
pharmaceutical
formulation containing imiquimod in an amount of between about 1.0 percent and
about 4.25
percent by weight based on the total weight of the formulation and preferably
a pharmaceutical
formulation containing imiquimod in an amount of about 2.5% or about 3.75%.
By the term "short duration(s)" of therapy, as used herein, it refers to the
daily topical
application of an effective amount of imiquimod to a defined treatment area
diagnosed with
EGWs for a total on-treatment period of up to about 8 weeks, 6 weeks, or 4
weeks, depending
upon which lower dosage strength imiquimod formulation of the present
invention is selected for
daily application, and more preferably a total on-treatment period of up to
about 8, 6, or 4 weeks
to treat EGWs. In addition, the "short durations" of therapy may also include
an 8 week
examination period (no further treatment) following the treatment period.
As indicated above, when the short durations of therapy are used in
combination with the
lower dosage strength imiquimod formulations of the present invention, it is
surprisingly found
that (1) simplified daily dosing regimens can be used, (2) the therapy is
better tolerated than
standard therapy with 5% imiquimod (Aldara8), resulting in effective treatment
with lower
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dosage strength imiquimod formulations without inducing significant local skin
reactions or
irritation in the treatment area or treatment limiting adverse events which
could result in
premature therapy termination or significant voluntary rest periods of several
days that are
generally associated with higher concentrations of imiquimod therapy. It is
also surprisingly
found that as much as between about 250 mg of a low dosage strength imiquimod
formulation
may be used per application in accordance with the present invention,
especially when the short
durations of therapy are used in combination with the low dosage strength
imiquimod
formulations of the present invention.
Also quite surprisingly, the efficacy achieved by the lower dosage strength
imiquimod
formulations when used in either of the short durations of therapy, e.g., an
up to 8-week
treatment regimen, of the present invention for treatment of EGWs as to total
clearance, partial
clearance and a reduction in the number of warts is statistically significant
over placebo, e.g.,
when a 3.75% imiquimod cream is used.
It should be noted that the efficacy P value that is achieved for a percent
reduction in the
number of warts for a 3.75% lower dosage strength imiquimod formulation versus
a 2.5% lower
dosage strength imiquimod formulation that is utilized in accordance with a
treatment regimen of
the present invention is not always statistically significant.
It should be understood that the short durations of therapy and lower dosage
strength
imiquimod formulations of the present invention are believed to be optimized
to treat EGWs. By
"optimized", it is meant herein that the short durations of therapy and lower
dosage strength
imiquimod formulations of the present invention are designed to achieve
efficacy, stability and
release rates profiles that are at least essentially equivalent to and linear
with Aldara 5%
imiquimod cream, respectively, but with an improved acceptable safety profile.
In this context,
it should be appreciated that the primary efficacy variable used in the
studies of the short
durations of therapy and lower dosage strength imiquimod formulations of the
present invention
(complete clearance of all warts, both Baseline and newly emerged, in all
assessed anatomic
areas) was very conservative (see, e.g., Example 24), when compared to
reported studies of
Aldara 5% imiquimod cream.
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By the term "acceptable safety profile", it is meant herein to mean that
treatment of
EGWs with a short duration of therapy and a lower dosage strength imiquimod
formulation in
accordance with the present invention, does not cause treatment limiting side
effects or rest
periods in an appreciable number of subjects undergoing therapy for EGWs to a
level that causes
premature termination of treatment. The term "acceptable safety profile" also
refers to treatment
of EGWs with a short duration of therapy and a lower dosage strength imiquimod
formulation of
the present invention with a lower subject incidence of application site
reactions as compared
with treatment of EGWs with Aldara 5% imiquimod cream.
The salient elements of a pharmaceutical formulation according to the present
invention
are (a) imiquimod and (b) a fatty acid, e.g., isostearic, palmitic, stearic,
linoleic, unrefined oleic
acid or refined oleic acid, such as Super Refined oleic acid NF (e.g., a
highly purified oleic acid,
i.e., an oleic acid which has low polar impurities, such as peroxides, a low
peroxide value and is
marketed by CRODA; see e.g., www.crodausa.com) and mixtures thereof. A
pharmaceutical
formulation of the invention can be in any form known to the art, including
semi-solid dosage
forms, such as a cream, an ointment, a foam, a gel, a lotion or a pressure-
sensitive adhesive
composition, each form containing the necessary elements in particular amounts
and further
containing various additional elements.
A cream of the invention contains an effective amount of imiquimod, such as
between
about greater than 1 percent and about 4.25 percent by weight of imiquimod,
based on the total
weight of the cream; about 5 percent to about 30 percent by weight of fatty
acid, based on the
total weight of the cream; and optional ingredients such as emollients,
emulsifiers, thickeners,
and/or preservatives.
An ointment of the invention contains an ointment base in addition to
imiquimod and
fatty acid. An ointment of the invention contains an effective amount of
imiquimod, such as
between about greater than 1 percent and about 4.25 percent by weight of
imiquimod; about 3
percent to about 45 percent, more preferably about 3 percent to about 30
percent by weight fatty
acid; and about 40 percent to about 95 percent by weight ointment base, all
weights being based
on the total weight of the ointment. Optionally, an ointment of the invention
can also contain
emulsifiers, emollients and thickeners.
13
CA 02697978 2010-03-30
A pressure-sensitive adhesive composition of the invention contains imiquimod,
fatty
add, and an adhesive. The adhesives utilized in a pressure sensitive adhesive
composition of the
invention are preferably substantially chemically inert to imiquimod. A
pressure sensitive
adhesive composition of the invention preferably contains an effective amount
of imiquimod,
such as between about greater than 1 percent and about 4.25 percent by weight
of imiquimod;
about 10 percent to about 40 percent by weight, more preferably of about 15
percent to about 30
percent by weight, and most preferably about 20 percent to about 30 percent by
weight of fatty
acid; all weights being based on the total weight of the pressure sensitive
adhesive composition.
Optionally, pressure sensitive adhesive compositions of the invention can also
contain
one or more skin penetration enhancers. The total amount of skin penetration
enhancer(s)
present in a pressure sensitive adhesive composition of the invention is
preferably about 3
percent to about 25 percent by weight, and more preferably about 3 percent to
about 10 percent
by weight based on the total weight of the pressure sensitive adhesive
composition.
A pressure-sensitive adhesive coated sheet material of the invention can be
made from a
pressure-sensitive adhesive composition of the invention in the form of an
article such as a tape,
a patch, a sheet, or a dressing.
A lower dosage strength formulation of the present invention may be used to
topically
and/or transdermally administer an effective amount of imiquimod to
effectively treat EGWs
with short durations of therapy and with an acceptable safety profile. Thus,
lower dosage
strength formulations according to the present invention can be applied to any
suitable location,
for example, topically to dermal, lip and/or mucosal surfaces. In the case of
dermal application,
for example, depending on the concentration, formulation composition, and
dermal surface, the
therapeutic effect of imiquimod may extend only to the superficial layers of
the dermal surface
or to tissues below the dermal surface.
It should be understood that while lower dosage strength formulations of the
present
invention containing, by weight based on the total weight of the formulation,
between about 1%
and about 4.25% imiquimod are contemplated, preferably between about 1.5%,
1.75%, 2.0%,
2.25%, 2.5%, 2.75%, 3.0%, 3.25%, 3.5%, 3.75%, 4.0% and 4.25% (between about
1.5% and
about 4.25%), and even more preferably between about 2.0%, 2.25%, 2.5%, 2.75%,
3.0%,
14
CA 02697978 2010-03-30
3.25%, 3.5%, 3.75% and 4.0% (between about 2.0% and about 4.0%), and still
even more
preferably between about 2.5%, 2.75%, 3.0%, 3.25%, 3.5% and 3.75% (between
about 2.5% and
about 3.75%) are contemplated. Lower dosage strength formulations of the
present invention
that contain about 2.5% imiquimod or about 3.75% imiquimod by weight based on
the total
weight of the formulation are most preferred. It should also be understood
that lower dosage
strength imiquimod formulations of the present invention, which have dose
proportionate release
rates as to both the release rates of the imiquimod and the total amount of
imiquimod released,
relative to the Aldara 5% imiquimod cream, are also preferred.
Thus, it should be understood by those versed in this art that an amount of
imiquimod
present in a formulation of the present invention will be an effective amount
when a formulation
of the present invention is applied daily in accordance with a short duration
of therapy as
described herein to a targeted area diagnosed with EGWs and permitted
following each
individual application to remain in contact with the targeted area for a
sufficient time to allow an
effective amount of imiquimod to clear such a disease or warts of the disease,
to partially clear
the number of warts of such a disease, to reduce the number of warts, to
prevent the recurrence
of such a disease without inducing treatment limiting local skin reactions or
adverse events,
including unscheduled rest periods caused by such treatment limiting local
skin reactions or
adverse events, in an appreciable number of people undergoing treatment. For
example, when
treating EGWs in accordance with the present invention, an effective amount
will achieve a
partial clearance in warts as a targeted endpoint, e.g., at least about 40%
and preferably at least
about 50% and more preferably at least about 60% and still more preferably at
least about 70%
and most preferably at least about a 75% reduction in the number of warts in
the treatment area
compared with baseline, or at least about 60% and preferably at least about
70% and even more
preferably at least about 80% and most preferably at least about 90% median
reduction in the
number of warts in the treatment area compared with baseline as a secondary
endpoint, or at least
about 25% complete clearance and preferably at least about 30% complete
clearance and even
more preferably at least about 35% complete clearance and most preferably at
least about 45%
complete clearance of the warts as a primary endpoint. See, e.g., FIGS. 15-36.
By "complete
clearance", as used herein, the term means the absence of clinically visible
warts in the treatment
area.
CA 02697978 2010-03-30
Results from use of the lower dosage strength imiquimod formulations in
accordance
with the short durations of therapy of the present invention demonstrate that
lower dosage
strength imiquimod formulations dosed once daily until complete wart clearance
or for up to an
eight week treatment period is effective and well-tolerated treatments for
EGWs. The condensed
dosing regimens of the present invention allows for short treatment periods,
minimizing
exposure to imiquimod and further supporting an improved benefit-risk profile,
as compared
with FDA-approved Aldara 5% imiquimod cream 16 week, thrice-weekly therapy.
Benefits of treatment with the lower dosage strength imiquimod formulations in
accordance with the short durations of therapy of the present invention
include complete
clearance or partial clearance (>30%, preferably >40%, preferably >50%,
preferably >60%,
even more preferably >70% even more preferably >80% and even more preferably
>95%) of
EGWs for a majority of the subjects that are treated. See Example 24.
While the present invention has identified what it believes to be preferred
concentrations
of imiquimod formulations, numbers of applications per week and durations of
therapy, it should
be understood by those versed in this art that any effective concentration of
imiquimod in a
formulation that delivers an effective amount of imiquimod and any numbers of
application per
week during a short duration of therapy, as described herein, that can
effectively treat EGWs,
without causing treatment limiting local skin reactions or related adverse
events, including too
many rest periods, is contemplated by the present invention.
The above summary of the present invention is not intended to describe each
disclosed
embodiment or every implementation of the present invention. The description
that follows
more particularly exemplifies illustrative embodiments. In several places
throughout the
application, guidance is provided through lists of examples, which examples
can be used in
various combinations. In each instance, the recited list serves only as a
representative group and
should not be interpreted as an exclusive list.
BRIEF DESCRIPTION OF THE DRAWINGS
The foregoing and other objects, advantages and features of the present
invention, and the
manner in which the same are accomplished, will become more readily apparent
upon
16
CA 02697978 2010-03-30
consideration of the following detailed description of the invention taken in
conjunction with the
accompanying figure and examples, which illustrate an embodiment, wherein:
FIG. 1 shows a schematic representation of a Franz cell;
FIG. 2 shows a summary of microscope pictures of eight 2.5% w/w imiquimod
formulations, i.e., formulations 113, 246, 247, 248, 249, 251, 252 and 253
(the formulations
continued into the stability program are included for the 1 kg batches in
TABLE 18 and FIG. 9);
FIG. 3 shows a comparison of the mean cumulative amount of imiquimod released
(ps/cm2) after about 3 h for the membrane release studies (for all the
formulations selected for
Full thickness skin permeation and stability studies) (mean sd, where n=4);
FIG. 4 shows a comparison of the average total cumulative report released
(ig/cm2)
after 3 h for each concentration of imiquimod in the formulations that are
tested (mean sd,
where n=4 for 1%, n=16 for 2.5%, n=20 for 3.75% and n=12 for 5%);
FIG. 5 shows a total amount of imiguimod that is recovered following mass
balance for
each formulation (See also Tables 35-40 for statistical analysts) (mean sd,
refer to Table 34
for n numbers of each sample);
FIG. 6 shows a total amount of imiquimod recovered for each formulation in the
receiver
fluid, epidermis and dermis combined (mean sd, refer to Table 34 for n
numbers of each
sample);
FIG. 7 shows a total amount of imiquimod recovered for the averages of each
imiquimod
concentration from each of the skin matrices.
FIGS. 8A-C show microscopic depiction of 13 imiquimod formulations, i.e., 3M
Aldara imiquimod cream lkg batch, Graceway 3M Aldara imiquimod cream I kg
batch and
formulations 110, 123, 125, 126, 182, 183, 195, 197, 250, 256 and 257 (t=0,
I., 2, 3 and 6
months) - x400 magnification;
FIG. 9 shows microscopic depiction of placebo formulations Pbol-Pbo4 (t=0, 1,
2, 3 and
6 months) - x400 magnification;
FIGS. 10A-B show microscopic depiction of 10 imiquimod formulations, i.e.,
formulations, 116, 117, 254, 120, 235, 188, 189, 184, 255, 124, after 1 month
stability (t=0 and 1
month) - x400 magnification;
FIG. 11 shows a comparison of the mean amount of imiquimod that is released (
g/cm2)
over a 3 hour period for the 3M Aldara imiquimod cream lkg batch, the 3M
Aldara imiquimod
17
CA 02697978 2010-03-30
cream sachet, the Graceway 3M Aldara imiquimod cream 1 kg batch and
formulation 257, a
1% Imiquimod formulation (mean sd, where n=4);
FIG. 12 shows a comparison of the mean amount of imiquimod that is released
(ug/cm2)
over a 3 hour period for four 2.5% imiquimod formulations, i.e., formulations
110, 123, 125 and
250 (mean sd, where n=4).
FIG. 13 shows a comparison of the mean amount of imiquimod that is released
(pg/cm2)
over a 3 hour period for five 3.75% imiquimod formulations, i.e., formulations
182, 183, 195,
197 and 256 (mean sd, where n=4); and
FIG. 14 shows a comparison of the mean amount of imiquimod released (pg/cm2)
over a
3 hour period for the 2.5% ( = ), 3.75% (.), 3M Aldara imiquimod cream batch
(M), Graceway
Aldara imiquimod cream 1 kg batch (M) and formulation 257 Imiquimod
formulations
(mean sd, where n=4).
FIG. 15 shows complete clearance rates observed in the intent-to-treat (ITT)
population
at the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 16 shows complete clearance rates observed in the Per Protocol (PP)
population at
the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 17 shows complete clearance rates vs analysis week during the evaluation
period
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
FIG. 18 shows complete clearance rates vs analysis week during the evaluation
period
observed in the Per Protocol (PP) population in one study of a lower-dose
imiquimod treatment
of genital warts.
FIG. 19 shows partial (>75%) clearance rates observed in the intent-to-treat
(ITT)
population at the end of one study of a lower-dose imiquimod treatment of
genital warts.
FIG. 20 shows partial (>75%) clearance rates observed in the Per Protocol (PP)
population at the end of one study of a lower-dose imiquimod treatment of
genital warts.
FIG. 21 shows >50% clearance rates observed in the intent-to-treat (ITT)
population at
the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 22 shows >50% clearance rates vs analysis week during the evaluation
period
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
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CA 02697978 2010-03-30
FIG. 23 shows mean percent change from baseline in wart count vs. analysis
week
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
FIG. 24 shows mean local skin reaction sum score by analysis week, safety
population,
in one study of a lower-dose imiquimod treatment of genital warts.
FIG. 25 shows complete clearance rates observed in the intent-to-treat (ITT)
population
at the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 26 shows complete clearance rates observed in the Per Protocol (PP)
population at
the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 27 shows complete clearance rates vs analysis week during the evaluation
period
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
FIG. 28 shows complete clearance rates vs analysis week during the evaluation
period
observed in the Per Protocol (PP) population in one study of a lower-dose
imiquimod treatment
of genital warts.
FIG. 29 shows partial (>75%) clearance rates observed in the intent-to-treat
(ITT)
population at the end of one study of a lower-dose imiquimod treatment of
genital warts.
FIG. 30 shows partial (>75%) clearance rates observed in the Per Protocol (PP)
population at the end of one study of a lower-dose imiquimod treatment of
genital warts.
FIG. 31 shows >50% clearance rates observed in the intent-to-treat (ITT)
population at
the end of one study of a lower-dose imiquimod treatment of genital warts.
FIG. 32 shows >50% clearance rates vs analysis week during the evaluation
period
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
FIG. 33 shows mean percent change from baseline in wart count vs. analysis
week
observed in the intent-to-treat (ITT) population in one study of a lower-dose
imiquimod
treatment of genital warts.
FIG. 34 shows mean local skin reaction sum score by analysis week, safety
population,
in one study of a lower-dose imiquimod treatment of genital warts.
FIG. 35 shows mean serum concentrations of imiquimod and imiquimod metabolites
on
Day 1 (linear and semi-log scale).
19
CA 02697978 2012-05-15
FIG. 36 shows mean serum concentrations of imiquimod and imiquimod metabolites
on
Day 21 (linear and semi-log scale).
DETAILED DESCRIPTION OF TIIE INVENTION
By way of illustrating and providing a more complete appreciation of the
present
invention and many of the attendant advantages thereof, the following detailed
description and
examples are given concerning the novel methods and compositions.
In one aspect, the present invention relates to a pharmaceutical composition
comprising
imiquimod and a pharmaceutically acceptable vehicle for imiquimod, which
vehicle comprises a
fatty acid. While the present invention may be embodied in many different
forms, several
specific embodiments are discussed herein with the understanding that the
present disclosure is
to be considered only as an exemplification of the principles of the
invention, and it is not
intended to limit the invention to the embodiments described or illustrated.
As used in the specification and claims, the phrase "substantially less-
irritating"
designates formulations that do not cause unacceptable skin irritation in
conventional repeat skin
irritation tests in albino rabbits such as that described in Draize et al.,
"Appraisal of the Safety of
Chemicals in Food, Drugs and Cosmetics", prepared by the Division of
Pharmacology of the
Food and Drug Administration, published originally in 1959 by the Association
of Food and
Drug Officials of the United States, Topeka, Kans. (2nd printing 1965).
Unless otherwise indicated, all numbers expressing quantities, ratios, and
numerical
properties of ingredients, reaction conditions, and so forth used in the
specification and claims
are to be understood as being modified in all instances by the term "about".
All parts, percentages, ratios, etc. herein are by weight unless indicated
otherwise.
As used herein, the singular forms "a" or "an" or "the" are used
interchangeably and
intended to include the plural forms as well and fall within each meaning,
unless expressly stated
otherwise. Also as used herein, "at least one" is intended to mean "one or
more" of the listed
element. Singular word forms are intended to include plural word forms and are
likewise used
CA 02697978 2010-03-30
herein interchangeably where appropriate and fall within each meaning, unless
expressly stated
otherwise. Except where noted otherwise, capitalized and non-capitalized forms
of all terms fall
within each meaning.
By the term "bioequivalence or bioequivalent", as used herein, it refers to
lower dosage
strength formulations in which they are pharmaceutically equivalent and their
bioavailibilities
(rate and extent of absorption) after administration in the same molar dosage
or amount are
similar to such a degree that their therapeutic effects, as to safety and
efficacy, are essentially the
same. In other words, bioequivalence or bioequivalent means the absence of a
significant
difference in the rate and extent to which imiquimod becomes available from
such formulations
at the site of imiquimod action when administered at the same molar dose under
similar
conditions, e.g., the rate at which imiquimod can leave such a formulation and
the rate at which
imiquimod can either cross the stratum corneum and/or become available at the
site of action to
treat external genital or perineal warts (EGWs). In other words, there is a
high degree of
similarity in the bioavailabilities of two imiquimod pharmaceutical products
(of the same galenic
form) from the same molar dose, that are unlikely to produce clinically
relevant differences in
therapeutic effects, or adverse reactions, or both. The terms
"bioequivalence", as well as
"pharmaceutical equivalence" and "therapeutic equivalence" are also used
herein as defined
and/or used by (a) the FDA, (b) the Code of Federal Regulations ("C.F.R."),
Title 21, and/or (c)
Health Canada.
By the term "bioavailability or bioavailable", as used herein, it means
generally the rate
and extent of absorption of imiquimod into the systemic circulation and, more
specifically, the
rate or measurements intended to reflect the rate and extent to which
imiquimod becomes
available at the site of action or is absorbed from a drug product and becomes
available at the site
of action. In other words, and by way of example, the extent and rate of
imiquimod absorption
from a lower dosage strength formulation of the present invention as reflected
by a time-
concentration curve of imiquimod in systemic circulation.
By "pharmaceutical equivalence or pharmaceutically equivalent", as used
herein, it refers
to lower dosage strength imiquimod formulations of the present invention that
contain the same
amount of imiquimod, in the same dosage forms, but not necessarily containing
the same
21
CA 02697978 2010-03-30
inactive ingredients, for the same route of administration and meeting the
same or comparable
compendia or other applicable standards of identity, strength, quality, and
purity, including
potency and, where applicable, content uniformity and /or stability.
By "therapeutic equivalence or therapeutically equivalent", it is meant herein
to mean
those lower dosage strength imiquimod formulations which (a) will produce the
same clinical
effect and safety profile when practicing the short durations of therapy to
treat EGWs in
accordance with the present invention and (b) are pharmaceutical equivalents,
e.g., they contain
imiquimod in the same dosage form, they have the same route of administration;
and they have
the same imiquimod strength. In other words, therapeutic equivalence means
that a chemical
equivalent of an imiquimod lower dosage strength imiquimod formulation of the
present
invention (i.e., containing the same amount of imiquimod in the same dosage
form) when
administered to the same individuals in the same dosage regimen will provide
essentially the
same efficacy and toxicity.
By "Tmax", it is meant herein to mean the time when the maximum imiquimod
serum
concentration is reached at steady state following topical application of a
lower dosage strength
imiquimod formulation of the present invention, i.e., when the rate of
imiquimod absorption
equals the rate of imiquimod elimination. In other words, the time that Cm ax
is observed for
imiquimod.
By "Cmax", it is meant herein to refer to the maximum imiquimod serum
concentration
that is reached at steady state following topical application of a lower
dosage strength imiquimod
formulation of the present invention, i.e., when the rate of imiquimod
absorption equals the rate
of imiquimod elimination. In other words, it is the maximum serum
concentration; the highest
serum concentration observed during the imiquimod dosing or sampling interval.
By "Cmin", it is meant herein to refer to the minimum measurable imiquimod
serum
concentration; e.g., imiquimod serum concentration that is observed
immediately prior to dosing
on Days 7, 14, 21 and 22 (24 hours post-dose).
By "T112", it is meant herein to mean the time required for half of the
quantity of
maximum imiquimod serum concentration to be eliminated once steady state is
achieved
22
CA 02697978 2010-03-30
following topical application of a lower dosage strength imiquimod formulation
of the present
invention. For example, the apparent elimination half-life for imiquimod, that
is calculated as
about 0.693a7 in accordance with Example 24.
By "AUC0-24", it is meant herein to mean the area under the serum imiquimod
concentration versus a 24 hour time curve following topical application of a
lower dosage
strength imiquimod formulation of the present invention, i.e., a measure of
imiquimod exposure
over a 24 hour period. For example, the area under the imiquimod serum
concentration versus
time curve, from 0 to 24 hours, that is calculated using the linear trapezoid
rule or extrapolated to
24 hours in cases where reportable values are not obtainable up to that time
point.
By "AUCo_t", it is meant herein to mean the area under the imiquimod serum
concentration versus time curve, from 0 to the time of the last non-zero
concentration on Day 1;
that is calculated using the linear trapezoid rule.
By "RAuc", it is meant herein to mean the accumulation ratio; that are
calculated as the
AUC0_24 value during multiple-imiquimod dose administration divided by the
AUC0_24 value
following the first dose (i.e., Day 21/Day 1); or the accumulation ratios that
are calculated for an
imiquimod metabolite only if sufficient non-zero time points are available to
reasonably estimate
AUCo-24.
By "AUCo-inf", it is meant herein to mean the area under the imiquimod serum
concentration versus time curve, from 0 to infinity; AUCo-inf that is
calculated on Day 1 as
AUC(o-m0 = AUC(o_t) + Ct/Ket (where Ct = the fitted last non-zero
concentration, AUC04 = the
AUC from time zero to the time of the last non-zero concentration and Ket =
the elimination rate
constant).
By "Rcmax", it is meant herein to mean the accumulation ratio; calculated as
the Cm.
value during multiple-dose administration divided by the Cm ax value following
the first dose (i.e.,
Day 21/Day 1).
By "A, EFF", it is meant herein to mean the effective elimination rate
constant, calculated
as ¨In(1 -1 /RAuc)/tau.
23
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By "T112 EFF", it is meant herein to mean the effective half-life for
accumulation;
calculated as 0.693/X, EFF.
By "Xz", it is meant to refer to an elimination rate constant, i.e., the rate
at which
imiquimod disappears from the site of measurement once steady state is
achieved following
topical application of a lower dosage strength imiquimod formulation of the
present invention.
In other words, the apparent elimination rate constant; that is calculated
using linear regression
on the terminal portion of the In concentration versus time profile.
By "geometric mean", it refers a statistical average of a set of transformed
numbers often
used to represent a central tendency in highly variable data. It is calculated
from data
transformed using powers or logarithms and then transformed back to original
scale after
averaging.
By "geometric mean ratio", it refers to a ratio of two geometric means, where
the
"geometric LS mean test" is the numerator of the geometric mean ratio, and the
"geometric LS
mean reference" is the denominator of the geometric mean ratio.
By "RH", it refers herein to relative humidity.
By "cPs, it refers herein to centipoise.
By "h", it refers herein to hours.
By "ITT'", it refers to an intent-to-treat population.
By "Pbo, it refers to placebo.
By "EOS", it refers to End of Study.
By "V", it refers to vehicle.
By "AE", it refers herein to adverse events.
The present invention provides pharmaceutical formulations such as creams,
ointments,
foams, gels, lotions and adhesive coatings that contain imiquimod and a fatty
acid such as
24
CA 02697978 2010-03-30
isostearic, linoleic, unrefined oleic acid, refined oleic acid, such as Super
Refined oleic acid NF
(e.g., a highly purified oleic acid, i.e., an oleic acid which has low polar
impurities, such as
peroxides, a low peroxide value and is marketed by CRODA; see e.g.,
wwvv.crodausa.com) and
mixtures thereof The formulations of the invention provide desirable skin
penetrability of the
imiquimod.
The compound imiquimod is a known antiviral agent that is also known to induce
interferon biosynthesis. It can be prepared using the method disclosed in U.S.
Pat. No.
4,689,338, the disclosure of which is incorporated herein by reference in its
entirety. The
compound can be used to treat external genital and perineal wart (EGWs). The
amount of
imiquimod present in a formulation of the present invention will be an
effective amount to treat
EGWs to achieve total wart clearance or partial wart reduction or clearance,
to prevent the
recurrence of such a disease and/or to promote immunity against such a disease
with an
acceptable safety profile. An example of an effective amount of imiquimod in a
formulation of
the present invention is between about 1.0 percent and about 4.25 percent by
weight based on the
total weight of a formulation, more preferably between about 1.5%, 1.75%,
2.0%, 2.25%, 2.5%,
2.75%, 3.0%, 3.25%, 3.5%, 3.75%, 4.0% and 4.25%, even more preferably between
about 2.0%,
2.25%, 2.5%, 2.75%, 3.0%, 3.25%, 3.5%, 3.75% and 4.0%, and still even more
preferably
between about 2.5%, 2.75%, 3.0%, 3.25%, 3.5% and 3.75%. Imiquimod formulations
of the
present invention that contain about 2.5% imiquimod or about 3.75% imiquimod
by weight
based on the total weight of the formulation are most preferred.
Likewise, a shortened period or duration, as contemplated by the present
invention, will
be for reduced periods of time effective to treat EGWs as discussed herein
above, e.g., up to
eight weeks, again depending upon the lower dosage strength imiquimod
formulation of the
present invention that is selected for daily application, and preferably up to
six weeks or up to
four weeks. By way of example, short periods of treatment with lower dosage
strength
imiquimod formulations for treating EGWs, include:
applying an effective amount of imiquimod, such as via the lower dosage
strength
imiquimod formulations of the present invention to the area affected with
EGWs, as
follows: applying an effective amount once per day until complete clearance is
achieved,
CA 02697978 2010-03-30
for example, between about 28 doses and 56 doses applied once per day, such as
applying
an effective amount once per day up to about eight weeks or less, up to about
six weeks
or less, or up to about four weeks or less to thereby treat EGWs.
A fatty acid such as isostearic acid, palmitic acid, stearic acid, linoleic
acid, refined oleic
acid, such as Super Refined oleic acid NF (e.g., a highly purified oleic
acid, i.e., an oleic acid
which has low polar impurities, such as peroxides, a low peroxide value and is
marketed by
CRODA; see e.g., www.crodausa.com), an unrefined oleic acid blended with
effective amounts
of antioxidants or mixtures thereof are incorporated into formulations of the
present invention.
The total amount of fatty acid present in a formulation is preferably between
about 3 percent and
about 45 percent by weight based on the total weight of a formulation. It
should be understood
that when oleic acid is selected as a fatty acid, that stability may present
issue. Thus, stabilizers,
such as anti-oxidants and the like, may be required to preserve pharmaceutical
elegance and
stability over the life of the oleic acid formulation.
A pharmaceutical formulation of the invention can be in a form such as a
cream, an
ointment, a foam, a gel, a lotion, a pressure-sensitive adhesive composition,
or other forms
known to those skilled in the art, each particular form containing imiquimod
and fatty acid in
particular amounts, and optionally containing various additional elements. The
preferred
amounts of drug and fatty acid, and the amounts and types of optional elements
used in
formulations of the invention are discussed below with particular reference to
creams, ointments
and adhesive compositions.
A cream according to the invention contains 1-isobuty1-1H-imidazo[4,5-
c]quinolin-4-
amine and fatty acid.
The amount of 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine present in a cream
is
preferably about 0.5 percent to about 9 percent by weight, and more preferably
about 1 percent to
about 5 percent by weight, and more preferably about 2.5% to about 3.75%,
based on the total
weight of the cream.
26
CA 02697978 2010-03-30
The total amount of fatty acid present in a cream of the invention is
preferably about 3
percent to about 45 percent by weight, and more preferably about 5 percent to
about 25 percent
by weight, based on the total weight of the cream.
Optionally, a cream of the present invention can contain emollients,
emulsifiers,
thickeners, and/or preservatives.
Emollients such as long chain alcohols, e.g., cetyl alcohol, stearyl alcohol
and cetearyl
alcohol; hydrocarbons such as petrolatum and light mineral oil; or acetylated
lanolin can be
included in a cream of the invention. A cream can contain one or more of these
emollients. The
total amount of emollient in a cream of the invention is preferably about 5
percent to about 30
percent, and more preferably about 5 percent to about 10 percent by weight
based on the total
weight of the cream.
Emulsifiers such as nonionic surface active agents, e.g., polysorbate 60
(available from
ICI Americas), sorbitan monostearate, polyglycery1-4 oleate, and
polyoxyethylene(4)1auryl ether
or trivalent cationic a cream of the invention. A cream can contain one or
more emulsifiers.
Generally the total amount of emulsifier is preferably about 2 percent to
about 14 percent, and
more preferably about 2 percent to about 6 percent by weight based on the
total weight of the
cream.
Pharmaceutically acceptable thickeners, such as Xanthum gum, Guar gum, Veegum
gumTMK (available from R. T. Vanderbilt Company, Inc.), and long chain
alcohols (i.e. cetyl
alcohol, stearyl alcohol or cetearyl alcohol) can be used. A cream can contain
one or more
thickeners. The total amount of thickener present is preferably about 3
percent to about
12 percent by weight based on the total weight of the cream.
Preservatives such as methylparaben, propylparaben and benzyl alcohol can be
present in
a cream of the invention. The appropriate amount of such preservative(s) is
known to those
skilled in the art.
Optionally, an additional solubilizing agent such as benzyl alcohol, lactic
acid, acetic
acid, stearic acid, salicylic acid, any alpha-hydroxy acid such as glycolic
acid, or hydrochloric
acid can be included in a cream of the invention.
27
CA 02697978 2010-03-30
If an additional solubilizing agent is used, the amount present is preferably
about
1 percent to about 12 percent by weight based on the total weight of the
cream.
Optionally, a cream of the invention can contain a humectant such as glycerin,
skin
penetration enhancers such as butyl stearate, and additional solubilizing
agents.
Generally, a cream consists of an oil phase and a water phase mixed together
to form an
emulsion. Preferably, the amount of water present in a cream of the invention
is about 45
percent to about 85 percent by weight based on the total weight of the cream.
The oil phase of a
cream of the invention can be prepared by first combining the 1-isobuty1-1H-
imidazo[4,5-
c]quinolin-4-amine or 1-(2-methylpropy1)-1H-imidazo [4,5-c]quinolin-4-amine
and the fatty acid
(if the cream contains benzyl alcohol it can also be added at this point) and
heating with
occasional stirring to a temperature of about 50 C. to 85 C. When the 1-
isobuty1-1H-
imidazo [4,5-c] quinolin-4- amine or 1-(2-methylpropy1)-1H-imidazo [4,5-c]
quinolin-4-amine
appears to be completely dissolved, the remaining oil phase ingredients are
added and heating is
continued until dissolution appears to be complete.
The water phase can be prepared by combining all other ingredients and heating
with
stirring until dissolution appears to be complete.
The creams of the invention are generally prepared by adding the water phase
to the oil
phase with both phases at a temperature of about 65 C to 75 C. The resulting
emulsion is mixed
with a suitable mixer apparatus to give the desired cream.
An ointment of the invention contains an ointment base in addition to 1-
isobuty1-1H-
itnidazo[4,5-c]quinolin-4-amine and fatty acid.
The amount of 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine present in an
ointment of
the invention is preferably about 0.5 percent to about 9 percent, and more
preferably about
0.5 percent to about 5 percent by weight based on the total weight of the
ointment.
The total amount of fatty acid present in an ointment of the invention is
preferably about
3 percent to about 45 percent, and more preferably about 3 percent to about 25
percent based on
the total weight of the ointment.
28
CA 02697978 2010-03-30
A pharmaceutically acceptable ointment base such as petrolatum or polyethylene
glycol
400 (available from Union Carbide) in combination with polyethylene glycol
3350 (available
from Union Carbide) can be used. The amount of ointment base present in an
ointment of the
invention is preferably about 60 percent to about 95 percent by weight based
on the total weight
of ointment.
Optionally, an ointment of the invention can also contain emollients,
emulsifiers and
thickeners. The emollients, emulsifiers, and thickeners and the preferred
amounts thereof
described above in connection with creams are also generally suitable for use
in an ointment of
the invention.
An ointment according to the invention can be prepared by combining 1-isobuty1-
1H-
imida7o[4,5-c]quinolin-4-amine with fatty acid and heating with occasional
stirring to a
temperature of about 65 C. When the 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-
amine or 1-(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine appears to be completely
dissolved, the
remaining ingredients are added and heated to about 65 C. The resulting
mixture is mixed with
a suitable mixer while being allowed to cool to room temperature.
A pressure-sensitive adhesive composition of the invention contains 1-isobuty1-
1H
imidazo [4,5-c]-quinolin-4-amine or 1-(2-methylpropy1)-1H-imidazo[4,5-
c]quinolin-4-amine,
fatty acid, and a pressure sensitive adhesive polymer.
The amount of 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine or 1-(2-
methylpropy1)-
1H-imidazo[4,5-c]quinolin-4-amine present in a pressure sensitive adhesive
composition of the
invention is preferably about 0.5 percent to about 9 percent by weight, and
more preferably about
3 percent to about 7 percent by weight based on the total weight of the
adhesive composition.
The amount of fatty acid present is preferably about 10 percent to about 40
percent by weight,
more preferably about 15 percent to about 30 percent by weight, and most
preferably about
20 percent to about 30 percent by weight, based on the total weight of the
adhesive composition.
Preferably, the adhesive polymer utilized in a pressure sensitive adhesive
composition of
the invention is substantially chemically inert to 1-isobuty1-1H-imidazo[4,5-0-
quinolin-4-amine
or 1-(2-methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine. The adhesive polymer
is preferably
29
CA 02697978 2010-03-30
present in an amount of about 55 percent to about 85 percent by weight based
on the total weight
of the composition. Suitable adhesive polymers include acrylic adhesives that
contain, as a
major constituent (i.e., at least about 80 percent by weight of all monomers
in the polymer), a
hydrophobic monomeric acrylic or methacrylic acid ester of an alkyl alcohol,
the alkyl alcohol
containing 4 to 10 carbon atoms. Examples of suitable monomers are those
discussed below in
connection with the "A Monomer". These adhesive polymers can further contain
minor amounts
of other monomers such as the "B Monomers" listed below.
Preferred adhesives include acrylic pressure-sensitive adhesive copolymers
containing A
and B Monomers as follows: Monomer A is a hydrophobic monomeric acrylic or
methacrylic
acid ester of an alkyl alcohol, the alkyl alcohol containing 4 to 10 carbon
atoms, preferably 6 to
carbon atoms, more preferably 6 to 8 carbon atoms, and most preferably 8
carbon atoms.
Examples of suitable A Monomers are n-butyl, n-pentyl, n-hexyl, isoheptyl, n-
nonyl, n-decyl,
isohexyl, 2-ethyloctyl, isooctyl and 2-ethylhexyl acrylates. The most
preferred A Monomer is
isooctyl acrylate.
Monomer B is a reinforcing monomer selected from the group consisting of
acrylic acid;
methacrylic acid; alkyl acrylates and methacrylates containing 1 to 3 carbon
atoms in the alkyl
group; acrylamide; methacrylamide; lower alkyl-substituted acrylamides (i.e.,
the alkyl group
containing 1 to 4 carbon atoms) such as tertiary-butyl acrylamide; diacetone
acrylamide; n-viny1-
2-pyrrolidone; vinyl ethers such as vinyl tertiary-butyl ether; substituted
ethylenes such as
derivatives of maleic anhydride, dimethyl itaconate and monoethyl formate and
vinyl perfluoro-
n-butyrate. The preferred B Monomers are acrylic acid, methacrylic acid, the
above-described
alkyl acrylates and methacrylates, acrylamide, methacrylamide, and the above-
described lower
alkyl substituted acrylamides. The most preferred B Monomer is acrylamide.
In one embodiment of a pressure-sensitive adhesive composition of the
invention, the
pressure-sensitive adhesive copolymer containing A and B Monomers as set forth
above
preferably contains the A Monomer in an amount by weight of about 80 percent
to about
98 percent of the total weight of all monomers in the copolymer. The A Monomer
is more
preferably present in an amount by weight of about 88 percent to about 98
percent, and is most
preferably present in an amount by weight of about 91 percent to about 98
percent. The B
CA 02697978 2010-03-30
Monomer in such a copolymer is preferably present in the pressure-sensitive
adhesive copolymer
in an amount by weight of about 2 percent to about 20 percent, more preferably
about 2 percent
to about 12 percent, and most preferably 2 to 9 percent of the total weight of
the monomers in the
copolymer.
In another embodiment of a pressure-sensitive adhesive composition of the
invention, the
adhesive copolymer comprises about 60 to about 80 percent by weight (and
preferably about 70
to about 80 percent by weight) of the above-mentioned hydrophobic monomeric
acrylic or
methacrylic acid ester of an alkyl alcohol (i.e., Monomer A described above)
based on the total
weight of all monomers in the copolymer; about 4 to about 9 percent by weight
based on the total
weight of all monomers in the copolymer of a reinforcing monomer selected from
the group
consisting of acrylic acid, methacrylic acid, an alkyl acrylate or
methacrylate containing 1 to 3
carbon atoms in the alkyl group, acrylamide, methacrylamide, a lower alkyl-
substituted
acrylamide, diacetone acrylamide and N-vinyl-2-pyrrolidone; and about 15 to
about 35 percent
by weight (and preferably about 15 to about 25 percent by weight) of vinyl
acetate based on the
total weight of all monomers in the copolymer. In this embodiment the
preferred acrylic or
methacrylic acid ester is isooctyl acrylate and the preferred reinforcing
monomer is acrylamide.
The above described adhesive copolymers are known, and methods of preparation
therefore are well known to those skilled in the art, having been described
for example, in U.S.
Pat. No. 24,906 (Ulrich), the disclosure of which is incorporated herein by
reference. The
polymerization reaction can be carried out using a free radical initiator such
as an organic
peroxide (e.g., benzoylperoxide) or an organic azo compound (e.g., 2,2'-
azobis(2,4-
dimethylpentanenitrile), available under the trade designation "Vazo 52" from
DuPont).
Since pressure-sensitive adhesives such as those described above are
inherently rubbery
and tacky and are suitably heat and light stable, there is no need to add
tackifiers or stabilizers.
However, such can be added if desired.
Optionally, a pressure sensitive adhesive composition of the invention can
also contain
one or more skin penetration enhancers such as glyceryl monolaurate, ethyl
oleate, isopropyl
myristate, diisopropyl adipate and N,N-dimethyldodecylamine-N-oxide, either as
a single
ingredient or as a combination of two or more ingredients. The skin
penetration enhancer(s)
31
CA 02697978 2010-03-30
preferably form a substantially homogeneous mixture with the pressure
sensitive adhesive
polymer or copolymer. The total amount of skin penetration enhancer(s) present
in a pressure
sensitive adhesive composition of the invention is preferably about 3 percent
to about 25 percent
by weight, more preferably about 3 percent to about 10 percent by weight based
on the total
weight of the adhesive composition.
When the skin penetration enhancer is a single ingredient, it is preferably a
skin
penetration enhancer such as isopropyl myristate, diisopropyl adipate, ethyl
oleate, or glyceryl
monolaurate.
When a combination skin penetration enhancer is used, it is preferably a
combination
such as: ethyl oleate with glyceryl monolaurate; ethyl oleate with N,N-
dimethyldodecylamine-
N-oxide; glyceryl monolaurate with N,N-dimethyldodecylamine-N-oxide; and ethyl
oleate with
both glyceryl monolaurate and N,N-dimethyldodecylamine-N-oxide.
A pressure-sensitive adhesive composition of the invention can be prepared by
combining dry adhesive, 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-amine, fatty
acid, and skin
penetration enhancer(s) with an organic solvent. The preferred organic
solvents are methanol
and ethyl acetate. The total solids content of the adhesive coating is
preferably in the range of
about 15 percent to about 40 percent, and more preferably in the range of
about 20 to about
35 percent based on the total weight of the adhesive coating. The resulting
mixture is shaken or
mixed for a period of about 20 to 72 hours. When this method is used it is
preferred that the
1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine be in micronized form (i.e.,
particle size of 1-2
microns in diameter). Optionally, the mixture can be heated during shaking.
In a preferred method, the 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine or 1-
(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine is combined with the fatty
acid and shaken at
40 C. until there appears to be complete dissolution. The remaining
ingredients are added and
the mixture is shaken for a period of about 20 to 72 hours.
The pressure-sensitive adhesive compositions described above are preferably
coated onto
one surface of a suitable backing of sheet material, such as a film, to form a
pressure-sensitive
adhesive coated sheet material. A pressure-sensitive adhesive coated sheet
material of the
32
CA 02697978 2010-03-30
invention can be prepared by knife coating a suitable release liner to a
predetermined uniform
thickness with a wet adhesive formulation. This adhesive coated release liner
is then dried and
laminated onto a backing using conventional methods. Suitable release liners
include
conventional release liners comprising a known sheet material, such as a
polyester web, a
polyethylene web, or a polystyrene web, or polyethylene-coated paper, coated
with a suitable
silicone-type coating such as that available under the trade designation
Daubert 164Z, from
Daubert Co. The backing can be occlusive, non-occlusive or a breathable film
as desired. The
backing can be any of the conventional materials for pressure-sensitive
adhesive tapes, such as
polyethylene, particularly low density polyethylene, linear low density
polyethylene, high
density polyethylene, randomly-oriented nylon fibers, polypropylene, ethylene-
vinylacetate
copolymer, polyurethane, rayon and the like. Backings that are layered, such
as polyethylene-
aluminum-polyethylene composites are also suitable. The backing should be
substantially
non-reactive with the ingredients of the adhesive coating. The presently
preferred backing is low
density polyethylene.
The pressure-sensitive adhesive coated sheet material of the invention can be
made in the
form of an article such as a tape, a patch, a sheet, a dressing or any other
form known to those
skilled in the art.
Preferably, an article in the form of a patch is made from an adhesive coated
sheet
material of the invention and applied to the skin of a mammal. The patch is
replaced as
necessary with a fresh patch to maintain the particular desired therapeutic
effect of the
1- isobuty1-1H-imidazo [4,5-c] quinolin-4-amine.
The inherent viscosity values reported in the examples below were obtained by
the
conventional method used by those skilled in the art. The measurement of the
viscosity of dilute
solutions of the adhesive, when compared to controls run under the same
conditions, clearly
demonstrates the relative molecular weights. It is the comparative values that
are significant;
absolute figures are not required. In the examples, the inherent viscosity
values were obtained
using a Cannon-Fenske #50 viscometer to measure the flow time of 10 ml of a
polymer solution
(0.2 g polymer/deciliter tetrahydrofuran, in a water bath controlled at 25
C.). The examples and
the controls were run under identical conditions. The test procedure followed
and the apparatus
33
CA 02697978 2012-05-15
used are explained in detail in the Textbook of Polymer Science, F. W.
Billmeyer, Wiley-
Interseience, 2nd Edition, 1971 under: Polymer chains and their
characterization, D. Solution
Viscosity and Molecular Size, pp 84-85,
As indicated herein above, and in accordance with the present invention, the
present
invention contemplates bioequivalent or interchangeable lower dosage strength
imiquimod
formulations By way of an example, bioequivalent or interchangeable 3.75%
lower dosage
strength imiquimod topical formulations, as contemplated by the present
invention, include those
3.75% imiquimod formulations that have comparable in-vivo serum profiles,
i.e., wherein the
following in-vivo parameters are either the same or may vary up to about +25%
or more, when
such 335% formulations are topically administered daily to the same
individuals in the same
dosage regimen in accordance with the short durations of therapy of the
present invention:
By way of example, a 3.75% imiquimod lower dosage strength formulation of the
present
invention, when approximately 250 mg of such a formulation (about 9.375 mg
imiquimod) or
less is applied daily for 21 days to EGWs in the genital/paianal area with a
total wart area of
greater than or equal to 100 rnm2, achieves steady state by about Day 7, and
provides an in-vivo
serum profile selected from one or more of the following:
(a) a Day 21 mean Tõ,õõ of about 9.7 hours with a standard deviation ("SD")
of about
4.0, a median T. of about 12 hours and a geometric mean Tinax of about 8.3
hours and a
coefficient of variation ("Cr) of about 41%;
(b) a Day 21 mean C, of about 0.488 rtg/m1 with a standard deviation of
about
0.368, a median Cõ,õõ of about 0.45 and a geometric Meall Cr. of about 0.39
zig/mL and a
coefficient of variation of about 75%;
(c) a Day 21
T1/2 of from about 6.8 to about 54 hours and preferably a mean T1/2 of -
about 24.1 hours with a standard deviation of about 12, a median T1/2 of about
22.8 hours and a
geometric mean T1/2 of about 21 hours and a coefficient of variation of about
51%;
(d) a Day 21 ALIC0.24 of from about 1.9 to about 14 tig-hrinth and
preferably a mean
AtiC0.24 of about 6.8 ng.hr/rnL with a standard deviation of about 3.6, a
median AUC0.24 of
about 6.6 ng.hr/mL and a geometric mean AUC0.24 of about 5.8 ng-hr/mL and a
coefficient of
variation of about 53%;
34
CA 02697978 2010-03-30
(e) a Day 21 Az of from about 0.013 hr-1 to about 0.102 hr-1 and
preferably a mean
Az of about 0.037 hr1 with a standard deviation of about 0.02, a median Az of
about 0.03 1111 and
a geometric mean Az of about 0.03 hr-1 and a coefficient of variation of about
60%;
(0 a Day 21 Cmm of from about 0.025 to about 0.47 and preferably a
mean Cmin of
about 0.158 with an SD of about 0.121, a median Cmin of about 0.14 and a
geometric mean Cmm
of about 0.11 and a coefficient of variation of about 77%;
(g) at Day 14/7 (a ratio of the trough concentration at Day 14 over the
trough
concentration at Day 7), a trough concentration geometric mean ratio of about
1.13 with a 90%
confidence interval ( "CI") within a range of between about 0.7 and about 1.7;
(h) at Day 21/14 (a ratio of the trough concentration at Day 21 over the
trough
concentration at Day 14), a trough concentration geometric mean ratio of about
0.84 with a 90%
confidence interval ("CI") within a range of between about 0.5 and about 1.3;
at Day 22/21 (a ratio of the trough concentration at Day 22 over the trough
concentration at Day 21) a trough concentration geometric mean ratio of about
1.12 with a 90%
confidence interval ("CI") within a range of between about0.7 and about 1.6;
(i) a mean peak imiquimod serum concentration of about 0.488 ng/mL at Day
21;
(k) a Day 21 RAUC of from about 0.6 to about 7 and preferably a mean
RAUC of
about 2.2 with a standard deviation of about 1.8, a median RAUC of about 1.8
and a geometric
mean RAUC of about 1.7 and a coefficient of variation of about 81%;
(1) a Day 21 RCmax of from about 0.5 to about 5 and preferably a mean
RCm of
about 2.3 with a standard deviation of about 1.6, a median RCmax of about 1.7
and a geometric
mean RCm of about 1.8 and a coefficient of variation of about 70%;
(m) a Day 21 LAzeff of from about 0.006 hr-1 to about 0.09 hr1 and
preferably a mean
LAzeff of about 0.04 hr-1 with a standard deviation of about 0.03, a median
LAzeff of about 0.03 hr-
and a geometric mean LAzeff of about 0.03 hr-1 and a coefficient of variation
of about 69%;
(n) a Day 21 tAeff of from about 8 hr to about 111 hr and preferably a mean
TY2eff of
about 31 hr with a standard deviation of about 30, a median TY2effof about 22
hr and a geometric
mean TIAeff of about 23 hr1 and a coefficient of variation of about 97%;
(o) a Day 21 Cm ax in female patients about 61% higher in female subjects
than in
male subjects (0.676 versus 0.420 ng/mL) and total systemic exposure AUC 0-24
8% higher in
CA 02697978 2010-03-30
female subjects than in male subjects (7.192 versus 6.651 ng-hr/mL) when data
is not dose
normalized;
(p) a
Day 21 Cmax in female patients about 35% higher than in male subjects (0.583
versus 0.431 ng/mL) and AUC 0-24 about 6% lower in female subjects than in
male subjects
(6.428 versus 6.858 ng-hr/mL) when using dose normalization to adjust for
differences in
dosage and reported without subjects who missed an application of study drug
during the last
week of dosing; and/or
(q) a median Tmax occurring approximately twice as quickly in female subjects
(about
6.50 hours) as in male subjects (about 12.0 hours).
In accordance with the present invention, a mean peak serum concentration is
achieved
with a 3.75% lower dosage strength imiquimod formulation of Examples 23-26.
More
specifically, a mean peak serum concentration of about 0.488 ng/mL is achieved
with a 3.75%
lower dosage strength imiquimod formulation of Examples 23-26 after about 9.4
mg of
imiquimod is applied to the affected treatment area each day for up to 8
weeks.
Furthermore, this invention provides the following evidence of clinical
efficacy: the wart
area decreased by about 45% from a mean of about 108.3 mm 2 at baseline to
about 43.2 mm 2 at
Day 21 (Table 14.1.2.1). The P value of <.0001 for this change from baseline
indicated a
statistically significant (<0.050) decrease in wart area after 3 weeks of
treatment.
While the lower dosage strength imiquimod pharmaceutical formulations of the
present
invention can be formulated into any form known to the art, such as a cream,
an ointment, a
foam, a gel, a lotion or a pressure-sensitive adhesive composition or patch,
it should be
understood that the creams, ointments, foams, gels and lotions may be packaged
into any suitable
container, such as unit-dose sachets or packets or multi-dose tubes or
containers. A packaged
amount of an imiquimod pharmaceutical formulation contemplated by the present
invention
includes any suitable amount, such as about 250 mg to about 500 mg or more,
and preferably
about 250 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg or about
500 mg
unit-dose sachets or packets.
Examples of various embodiments of the present invention will now be further
illustrated
with reference to the following examples. Thus, the following examples are
provided to
illustrate the invention, but are not intended to be limiting thereof. Parts
and percentages are by
weight unless otherwise specified. Examples of creams, ointments and pressure
sensitive
36
CA 02697978 2012-05-15
adhesive compositions contemplated by the present invention are described in
U.S. Patent No.
4,689,338 and U.S. Patent No. 5,238,944.
Percent modifications for, e.g., imiquimod and vehicle, to generate imiquimod
formulations as described herein are likewise contemplated by the present
invention. In addition,
the formulations described and disclosed in U.S. Patent No. 7,655,672, U.S.
Patent Publication
No. 2007/0123558, Serial No. 11/276,324, US. Patent Publication No.
2007/0264317, US.
Serial No. 11/433,471, and US2007/09005505 Publication No. W02008098232 (Al),
are also
contemplated by the present invention and are incorporated herein by reference
in their entireties.
PREPARATIVE METHOD I
Laboratory Scale Preparation of Isooetylacrylate/Acrylamide Copolymer
To a 114 gram narrow-mouth glass bottle were added: 18,6 g isooctyl acrylate,
1.4 g
acrylamide, 0.04 g benzoyl peroxide, 27.0 g ethyl acetate and 3.0 g methanol.
The solution was
purged for thirty five seconds with nitrogen at a flow rate of one liter per
minute. The bottle was
sealed and placed in a rotating water bath at 55 C for twenty-four hours to
effect essentially
complete polymerization. The polymer was diluted with ethyl acetate/methanol
(90/10) to 23.2
percent solids and had a measured inherent viscosity of 1.26 dl/g in ethyl
acetate.
PREPARATIVE METHOD 2
Pilot Plant Scale Preparation of lsooctylacrylate/Acrylamide Copolymer
155 kg isooetylacrylate, 11.6 kg acrylamide, 209.1 kg ethyl acetate and 23.2
kg methanol
were charged to a clean, dry reactor. Medium agitation was applied. The batch
was
deoxygenated vvith nitrogen while heating to an induction temperature of 55 C.
114 g LucidolTM
70 initiator (available from Pennwalt Corp.) mixed with 2.3 kg ethyl acetate
was charged to the
reactor. The temperature was maintained at 55 C. throughout the reaction.
After 5.5 hours
reaction time, 114 g Lucidoirm 70 mixed with 2.3 kg ethyl acetate were charged
to the reactor.
After 9.0 hours reaction time, an additional 114 g LucidolTm 70 initiator
mixed with 2.3 kg ethyl
acetate were charged to the reactor. The reaction was continued until the
percent conversion was
greater than 98 percent as measured by gas chromatographic evaluation of
residual monomer
concentration. The resulting polymer solution was diluted to 25-28 percent
solids with ethyl
37
CA 02697978 2010-03-30
acetate/methanol (90/10) and had a measured Brookfield viscosity of 17,000-
21,000 centipoises
using spindle #4 at 12 rpm. The polymer had a measured inherent viscosity of
1.3-1.4 dllg in
ethyl acetate.
The above-mentioned procedure was found to provide a pressure-sensitive
adhesive that
is equivalent in the practice of the present invention to a pressure-sensitive
adhesive prepared
according to Preparative Method 1.
A 25-30 percent solids solution of the isooctyl acrylate:acrylamide (93:7)
adhesive
copolymer in ethyl acetate/methanol (90:10) was coated onto a two-sided
release liner using a
knife-coater and coating at 0.5 mm in thickness. The adhesive-coated laminate
was dried first at
82 C for 3 minutes and then at 116 C for 3 minutes. The dried adhesive coating
was then
stripped off the release liner and placed in a glass bottle. The foregoing
procedure results in a
reduction of the amount of any residual monomer in the adhesive copolymer.
PREPARATIVE METHOD 3
Preparation of Isooctyl Acrylate: Acrylamide: Vinyl Acetate (75:5:20)
Copolymer
The procedure of Preparative Method 1 above acrylate, 8.0 g acrylamide, 32.0 g
vinyl
acetate, 0.32 g benzoyl peroxide, 216.0 g ethyl acetate and 24.0 g methyl
alcohol. The resulting
polymer was diluted with the ethyl acetate/methyl alcohol mixture to 21.52%
solids. The
adhesive polymer had a measured inherent viscosity of 1.40 dl/g in ethyl
acetate at a
concentration of 0.15 g/dl. Its Brookfield viscosity was 2,300 centipoise.
PREPARATIVE METHOD 4
Preparation of Isooctyl Acrylate Acrylamide: Vinyl Acetate (75:5:20) Copolymer
A master batch was prepared by combining 621.0 g of isooctyl acrylate, 41.4 g
of
acrylamide, 165.6 g of vinyl acetate, 1.656 g of 2,2'-azobis(2,4-
dimethylpentanenitrile)
(available from the DuPont Company as Vazo.TM.52), 884.52 g of ethyl acetate
and 87.48 g of
methanol. A 400 g portion of the resulting solution was placed in an amber
quart bottle. The
bottle was purged for two minutes with nitrogen at a flow rate of one liter
per minute. The bottle
was sealed and placed in a rotating water bath at 45 C for twenty-four hours
to effect essentially
38
CA 02697978 2010-03-30
complete polymerization. The copolymer was diluted with 250 g of ethyl
acetate/methanol
(90/10) to 26.05% solids and had a measured inherent viscosity of 1.27 dl/g in
ethyl acetate at a
concentration of 0.15 g/dl. Its Brookfield viscosity was 5580 centipoise.
EXAMPLE 1
A cream according to the present invention is prepared from the following
ingredients:
% by Weight Amount
Oil Phase
1 -i sobuty1-1H-imidazo [4,5-c] -quinolin-4-amine 1.0 40.0 g
Isostearic acid 10.0 400.0 g
Benzyl alcohol 2.0 80.0 g
Cetyl alcohol 2.2 88.0 g
Stearyl alcohol 3.1 124.0 g
Polysorbate 60 2.55 102.0 g
Sorbitan monostearate 0.45 18.0 g
Aqueous Phase Glycerin 2.0 80.0 g
Methylparaben 0.2 8.0 g
Propylparaben 0.02 0.8 g
Purified water 76.48 3059.2g
The materials listed above were combined according to the following procedure:
The glycerin, methylparaben, propylparaben and water were weighed into a 4
liter glass
beaker then heated on a hot plate with stirring until the parabens isostearic
acid and 1-isobuty1-
1H-imidazo[4,5-c]-quinolin-4-amine were weighed into an 8 liter stainless
steel beaker and
heated on a hot plate until the amine was in solution (the temperature reached
69 C.). The
benzyl alcohol, cetyl alcohol, stearyl alcohol, polysorbate 60 and sorbitan
monostearate were
added to the isostearic acid solution and heated on a hot plate until all
material was dissolved
(the temperature reached 75 C.). With both phases at approximately the same
temperature (65 -
75 C.), the water phase was added to the oil phase. The mixture was mixed with
a homogenizer
for 13 minutes then put into a cool water bath and mixed with a 3 inch
propeller for 40 minutes
(the temperature was 29 C.). The resulting cream was placed in glass jars.
EXAMPLES 2-9
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CA 02697978 2010-03-30
Using the general method of Example 1, the cream formulations shown in Tables
1 and
2 are prepared.
Table 1
% by Weight
Example Example Example Example 5
2 3 4
Oil Phase
1-isobuty1-1H-imidazo- [4,5- 1.0 1.0 1.0 1.0
c]quinolin-4-amine
Isostearic acid 10.0 10.0 5.0 5.0
Benzyl alcohol 2.0
Cetyl alcohol 1.7
Stearyl alcohol 2.3
Cetearyl alcohol 6.0 6.0 6.0
Polysorbate 60 2.55 2.55 2.55 2.55
Sorbitan monostearate 0.45 0.45 0.45 0.45
Brij lm 30a 10.0
Aqueous Phase
Glycerin 2.0 2.0 2.0 2.0
Methylparaben 0.2 0.2 0.2 0.2
Propylparaben 0.02 0.02 0.02 0.02
Purified water 77.78 77.78 82.78 72.78
a BrijTM 30 (polyoxyethylene(4) lauryl ether) is available from ICI Americas,
Inc.
Table 2
% by Weight
Example Example Example Example
6 7 8 9
Oil Phase
1-isobuty1-1H-imidazo-[4,5- 1.0 1.0 1.0 1.0
c]quinolin-4- amine
Isostearic acid 10.0 25.0 10.0 6.0
Benzyl alcohol 2.0 2.0
Cetyl alcohol 2.2 1.7
Stearyl alcohol 3.1 2.3
Cetearyl alcohol 6.0 6.0
Polysorbate 60 2.55 3.4 2.55 2.55
Sorbitan monostearate 0.45 0.6 0.45 = 0.45
CA 02697978 2010-03-30
BrijTM 3 Oa 10.0
Aqueous Phase
Glycerin 2.0 2.0 2.0 2.0
Methylparaben 0.2 0.2 0.2 0.2
Propylparaben 0.02 0.02 0.02 0.02
Purified water 67.78 60.48 79.78 79.78
BrijTM 30 (polyoxyethylene(4) lauryl ether) is available from ICI Americas,
Inc.
EXAMPLE 10
A cream according to the present invention is prepared from the following
ingredients in
the following Table 3:
Table 3
% by Weight Amount
Oil Phase
1-isobuty1-1H-imidazo[4,5- 1.0 3.00 g
c]quinolin-4-amine
Isostearic acid 5.0 15.0 g
White petrolatum 15.0 45.0 g
Light mineral oil 12.8 38.4g
Aluminum stearate 8.0 24.0 g
Cetyl alcohol 4.0 12.0 g
WitconolTM 14a 3.0 9.00 g
Acetylated lanolin 1.0 3.0 g
Propylparaben 0.063 0.19 g
Aqueous Phase
VeegumTM Kb 1.0 3.0 g
Methylparaben 0.12 0.36 g
Purified water 49.017 147.05g
a WitconolTM 14 (polyglycery14 oleate) is available from Witco Chemical Corp.
Organics
Division
VeegumTM K (colloidal magnesium aluminum silicate) is available from R. T.
Vanderbilt
Company Inc.
The materials listed above were combined according to the following procedure:
41
CA 02697978 2010-03-30
The 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-amine and the isostearic acid were
weighed
into a glass jar and heated with occasional stirring until the amine was
dissolved (the temperature
reached 68 C.). To this solution was added, the petrolatum, mineral oil,
aluminum stearate, cetyl
alcohol, WitconolTM 14, acetylated lanoline and propylparaben. The mixture was
heated to
75 C. In a separate beaker, the methylparaben and water were combined and
heated until the
paraben dissolved (the temperature reached 61 C.). The VeegumTM K was added
to the aqueous
solution and heated at 75 C. for 30 minutes while mixing with a homogenizer.
With both phases
at 75 C., the aqueous phase was slowly added to the oil phase while mixing
with a homogenizer.
Mixing was continued for 30 minutes while maintaining a temperature to about
80 C. The jar
was then capped and the formulation was allowed to cool.
EXAMPLE 11
An ointment according to the present invention is prepared from the
ingredients in the
following Table 4:
Table 4
% by Weight Amount
1-i sobutyl-1H- imidazo [4,5-c] quinolin-4- 1.0 0.20 g
amine
Isostearic acid 5.0 1.00 g
Mineral oil 12.8 2.56g
White petrolatum 65.2 13.04g
Cetyl alcohol 4.0 0.80g
Acetylated lanolin 1.0 0.20 g
WitconolTM 143.0 0.60 g
Aluminum stearate 8.0 1.60 g
The materials listed above are combined according to the following procedure:
The 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-amine and the isostearic acid were
placed in
a glass jar and heated with stirring until the amine was dissolved. The
remaining ingredients
were added and the resulting mixture was heated to 65 C. and then mixed while
being allowed to
cool to room temperature.
EXAMPLE 12
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CA 02697978 2010-03-30
Using the general procedure of Example 11 an ointment containing the
ingredients in the
following Table 5 is prepared.
Table 5
% by Weight Amount
1-Tsobutyl -1H-imidazo[4,5-c]quinolin-4- 1.0 0.20 g
amine
Isostearic acid 6.0 1.20 g
Polyethylene Glycol 400 55.8 11.16 g
Polyethylene Glycol 3350 32.6 6.52 g
Stearyl alcohol 4.6 0.92 g
EXAMPLES 13-15
Creams of the present invention are prepared using the ingredients shown in
Table 6.
The Example 1 except that benzyl alcohol was used with the isostearic acid to
dissolve the
1-isobuty1-1H-imidazo [4,5-c] quinolin-4- amine.
TABLE 6
Example 13 Example 14 Example 15
Amount % by Amount % by Amount % by
Oil Phase Weight Weight Weight
1-isobuty1-1H-imidazo[4,5-c]quinolin- 50 5.0 4.85
4-amine
Isostearic acid 25.0 25.0 24.3
Benzyl alcohol 2.0 2.0 1.94
Cetyl alcohol 2.2 2.2 1.16
Stearyl alcohol 3.1 3.1 1.75
Petrolatum 3.0 2.91
Polysorbate 60 3.4 3.4 4.13
Sorbitan monostearate 0.6 0.6 0.73
Stearic acid 9.71
Aqueous Phase
Glycerin 2.0 2.0 1.94
Methylparaben 0.2 0.2 0.19
Propylparaben 0.02 0.02 , 0.02
EXAMPLE 16
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CA 02697978 2010-03-30
A cream according to the present invention is prepared from the ingredients in
the
following Table 7:
Table 7
% by Weight % by Weight Amount
Amount
Oil Phase
1-isobuty1-1H-imidazo[4,5-c]quinolin-4- 4.0 0.80 g
amine
Isostearic acid 20.0 4.00 g
Benzyl alcohol 2.0 0.40 g
Cetyl alcohol 2.2 0.49 g
Stearyl alcohol 3.1 0.62 g
Polysorbate 60 3.4 0.68 g
Sorbitan monostearate 0.6 0.12 g
Aqueous Phase
1-isobuty1-1H-imidazo [4,5-c]quinolin-4- 1.0 0.2 g
amine
Glycerin 2.0 0.4 g
85% Lactic acid 1.0 0.22g
Methylparaben 0.2 0.04 g
Propylparaben 0.02 0.004 g
Purified water 60.48 12.0 g
The materials listed above are combined according to the following procedure:
The isostearic acid and 0.8 g of 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-amine
or 1-(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine were combined in a glass jar
and heated with
stirring until the amine had dissolved. The remaining oil phase ingredients
were added to this
solution and the mixture was heated to about 70 C. The aqueous phase
ingredients were
weighed into a separate beaker and heated with stirring until the amine and
the parabens had
dissolved. With both phases at about 70 C., the water phase was added to the
oil phase and
mixed with a propeller until the mixture cooled to room temperature.
EXAMPLE 17
A mixture of 5.9415 g of the 93:7 isooctyl acrylate:acrylamide adhesive
copolymer
prepared in PREPARATIVE METHOD 2 above, 1.5126 g isostearic acid, 2.0075 g
ethyl oleate,
0.3021 g glyceryl monolaurate, 0.2936 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-
amine
44
CA 02697978 2010-03-30
(micronized) and 23.7 g of 90:10 ethyl acetate: methanol was placed in a small
glass jar. The jar
was placed on a horizontal shaker and shaken at room temperature for about 13
hours. The
formulation was coated at a thickness of 20 mils onto a 5 mil Daubert 164Z
liner. The laminate
was oven dried for 3 minutes at 105 F., for 2 minutes at 185 F., and for 2
minutes at 210 F. The
resulting adhesive coating contained 59.1 percent 93:7 isooctyl
acrylate:acylamide adhesive
copolymer, 15.0 percent isostearic acid, 20.0 percent ethyl oleate, 3.0
percent glyceryl
monolaurate and 2.9 percent 1-isobuty1-1H-imidazo[4,5-c]quinolin-4-amine. The
material was
then laminated with 3 mil low density polyethylene backing and die cut into
2.056 cm2
patches.
EXAMPLES 18-20
Pressure-Sensitive Adhesive Coated Sheet Materials Prepared Using Unmicronized
1 -i sobuty1-1H-imidazo [4,5-c] quinolin-4-amine .
Using the general method of Example 17 the formulations shown below are
prepared. 1-
Isobuty1-1H-imidazo [4,5-c] quinolin-4-amine or 1 -(2-methylpropy1)-1H-imidazo
[4,5-c] quinolin-
4-amine that had been ground with a mortar and pestle was used. The adhesive
was the 93:7
isooctyl acrylate:acrylamide copolymer prepared in Preparative Method 1 above.
The solvent
was 90:10 ethyl acetate:methanol. All formulations in the following Table 8
were mixed at
room temperature.
Table 8
Example 18 Example 19 Example 20
1-isobuty1-1H-imidazo [4,5-c] quinolin- 5.0 3.0 3.0
4-amine
Ethyl oleate 5.1 5.0 8.0
Isostearic acid 10.0 10.0 6.0
Oleic acid 20.0 20.0 13.0
Glyceryl monolaurate 1.5 1.5 1.5
N,N-dimethyldodecylamine- 1.0 1.1 3.0
N-oxide Adhesive 57.4 59.3 65.4
EXAMPLE 21
CA 02697978 2010-03-30
A formulation with the same components in the same proportions as Example 18
is
prepared using a different method. The 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-
amine or 1-(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine was combined with the oleic
and isostearic
acids and shaken at 40 C. until there was complete dissolution of the 1-
isobuty1-1H-imidazo-
[4,5-c] quinolin-4-amine or 1-(2-methylpropy1)-1H-imidazo [4,5-c] quinolin-4-
amine . The
remaining ingredients were added and shaken a 40 C. for 72 hours. Patches
measuring 2.056
cm2 were prepared by the general method of Example 17.
EXAMPLE 22
A mixture of 2.4734 g 1-isobuty1-1H-imidazo[4,5-c]-quinolin-4-amine or 1-(2-
methylpropy1)-1H-imidazo[4,5-c]quinolin-4-amine, 3.3315 g isostearic acid and
6.6763 g oleic
acid is prepared. To 1.8738 g of the above mixture was added 2.8750 g of the
93:7 isooctyl
acrylate:acryamide adhesive copolymer prepared in Preparative Method 2 above,
0.2548 g of
ethyl oleate, 0.0510 g N,N-dimethyldodecylamine-N-oxide, 0.0820 g glyceryl
monolaurate (from
Lauricidin, Inc.) and 14.0457 g of 90:10 ethyl acetate/methanol. The above was
shaken for
30 hours at room temperature on a horizontal shaker. Transdermal patches were
then prepared
generally according to the procedures of Example 17.
EXAMPLE 23
Topical Imiquimod Pharmaceutical Cream Formulations
Creams are prepared in accordance with the present invention using the
ingredients
shown in this Example 23.
The materials listed below in this Example 23 are combined according to the
following
procedure to make cream formulations in the following Table 9 of this Example
23:
46
CA 02697978 2010-03-30
Table 9. Lower Dosage Strength Imiquimod Formulations
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 1 2 3 4 5 6
Fatty acid* 15.00 15.00 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 1.00 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Monostearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
Purified water 68.98 66.98 64.98 61.98 60.73 60.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.00 1.00 1.00 1.00 1.00 1.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 7 8 9 10 11 12
Fatty acid* 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 66.98 60.98 60.98 57.08 58.98 55.78
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
lmiquimod 1.00 1.00 1.00 1.00 1.00 1.00
Total 100.00 100.00 100.00 100.00 100.00
100.00
47
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 13 14 15 16 17 18
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 56.48 67.08 59.98 58.98 56.98 61.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.00 1.00 1.00 1.00 1.00 1.00
Total 100.00 100.00 100.00 100.00 100.00 , 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 19 20 21 22 23 24
Fatty acid* 15.00 15.00 , 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 1.00 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Mono stearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
Purified water 68.73 66.73 64.73 61.73 60.48 60.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.25 1.25 1.25 1.25 1.25 1.25
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CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 25 26 27 28 29 30
Fatty acid* 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 66.73 60.73 60.73 56.83 58.73 55.53
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.25 1.25 1.25 1.25 1.25 1.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 31 32 33 34 35 36
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Poly sorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 56.23 66.83 59.73 58.73 56.73 61.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.25 1.25 1.25 1.25 1.25 1.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
49
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 37 38 39 40 41 42
Fatty acid* 15.00 15.00 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 1.00 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Monostearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
,
Purified water 68.48 66.48 64.48 61.48 60.23 60.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.50 1.50 1.50 1.50 1.50 1.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 43 44 45 46 47 48
Fatty acid 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 . 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum . 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 66.48 60.48 60.48 56.58 58.48 55.28
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.50 1.50 1.50 1.50 1.50 1.50
Total 100.00 100.00 100.00 i 100.00 100.00 100.00
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 49 50 51 52 53 54
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
_
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 55.98 66.58 59.48 58.48 56.48 61.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.50 1.50 1.50 1.50 1.50 1.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 55 56 57 58 _ 59 60
Fatty acid* 15.00 15.00 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 1.00 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Mono stearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
Purified water 68.23 66.23 64.23 61.23 59.98 59.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.75 1.75 1.75 1.75 1.75 1.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
51
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 61 62 63 64 65 66
Fatty acid* 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 66.23 60.23 60.23 56.33 58.23 55.03
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.75 1.75 1.75 1.75 1.75 1.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 67 68 69 70 71 72
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 55.73 66.33 59.23 58.23 56.23 61.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 1.75 1.75 1.75 1.75 1.75 1.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
52
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 73 74 75 76 77 78
Fatty acid* 10.00 12.50 25.00 10.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.70 4.00 4.00 2.20
Stearyl alcohol 3.10 3.10 3.80 2.00 2.00 3.10
White petrolatum 5.00 5.00 3.00 3.40 2.80 3.00
Polysorbate 60 3.40 3.40 3.40 3.80 3.00 3.00
Sorbitan 0.60 0.60 0.60 1.00 1.00 1.00
Monostearate
Glycerin 5.00 5.00 2.00 1.00 3.00 3.00
Xanthan gum 0.50 0.50 0.50 0.30 0.70 0.75
Purified water 65.98 63.48 54.78 70.28 64.28 59.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.00 2.00 2.00 2.00 2.00 2.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 79 80 81 82 83 84
Fatty acid* 10.00 12.50 25.00 10.00 15.00 25.00
Cetyl alcohol 2.20 2.20 2.70 4.00 4.00 2.70
Stearyl alcohol 3.10 3.10 3.80 2.00 2.00 3.80
White petrolatum 5.00 5.00 3.00 3.40 2.80 3.00
Polysorbate 60 3.40 3.40 3.40 3.80 3.00 3.40
Sorbitan 0.60 0.60 0.60 1.00 1.00 0.60
Monostearate
_ Glycerin 5.00 5.00 2.00 1.00 3.00 2.00
Xanthan gum 0.50 0.50 0.50 0.30 0.70 0.50
Purified water 65.98 63.48 54.78 70.28 64.28 54.78
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.00 2.00 2.00 2.00 2.00 2.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
53
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 85 86 87 88 89 90
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 55.48 66.08 58.98 57.98 55.98 60.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.00 2.00 2.00 2.00 2.00 2.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 91 92 93 94 95 96
Fatty acid* 15.00 12.50 25.00 15.00 10.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.00 2.00 2.20
Stearyl alcohol 3.10 3.10 3.10 2.00 2.40 3.10
White petrolatum 6.00 5.00 3.00 3.40 2.80 3.00
Polysorbate 60 3.00 3.00 3.40 3.80 3.80 3.00
Sorbitan 1.00 1.00 0.60 0.20 1.00 1.00
Monostearate
Glycerin 5.00 5.00 2.00 3.00 3.00 3.00
Xanthan gum 1.00 0.50 1.00 0.30 0.30 0.75
Purified water 60.23 63.23 55.23 66.83 70.23 59.48
Benzyl alcohol 1.00 2.00 2.00 1.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.25 2.25 2.25 2.25 2.25 2.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
54
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w , %w/w %w/w %w/w
Formulation 97 98 99 100 101 102
Fatty acid* 15.00 12.50 25.00 15.00 10.00 25.00
Cetyl alcohol 2.20 2.20 2.20 2.00 2.00 2.70
Stearyl alcohol 3.10 3.10 3.10 2.00 2.40 3.80
White petrolatum 6.00 5.00 3.00 3.40 2.80 3.00
Polysorbate 60 3.00 3.00 3.40 3.80 3.80 3.40
Sorbitan 1.00 1.00 0.60 0.20 1.00 0.60
Monostearate
Glycerin 5.00 5.00 2.00 3.00 3.00 2.00
Xanthan gum 1.00 0.50 1.00 0.30 0.30 0.50
Purified water 60.23 63.23 55.23 66.83 70.23 54.53
Benzyl alcohol 1.00 2.00 2.00 1.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.25 2.25 2.25 2.25 2.25 2.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 103 104 105 106 107 108
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 55.23 65.83 58.73 57.73 55.73 60.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.25 2.25 2.25 2.25 2.25 2.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 109 110 111 112 113 114
Fatty acid* 15.00 15.00 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 2.50 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Monostearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
Purified water 65.98 65.48 63.48 60.48 59.23 59.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 115 116 117 118 119 120
Fatty acid* 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 65.48 59.48 59.48 55.58 57.48 54.28
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50
Total _ 100.00 100.00 100.00 100.00 100.00
100.00
56
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 121 122 123 124 125 126
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 54.98 65.58 58.48 57.48 55.48 60.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 127 128 129 130 131 132
Fatty acid* 15.00 18.00 15.00 20.00 12.50 20.00
Cetyl alcohol 2.00 2.00 2.00 2.00 2.20 2.20
Stearyl alcohol 2.00 2.00 2.40 2.40 3.10 3.10
White petrolatum 3.40 2.80 3.40 2.80 5.00 3.00
Polysorbate 60 3.00 3.80 3.00 3.00 3.40 3.00
Sorbitan 1.00 1.00 0.20 0.20 0.60 1.00
Monostearate
Glycerin 3.00 2.00 1.00 3.00 6.00 3.00
Xanthan gum 0.30 0.70 0.70 0.30 0.50 0.75
Purified water 65.08 62.48 67.08 61.08 61.48 58.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.00 3.00 3.00 3.00 3.00 3.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
57
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 133 134 135 136 137 138
Fatty acid* 15.00 18.00 15.00 20.00 12.50 25.00
Cetyl alcohol 2.00 2.00 2.00 2.00 2.20 2.70
Stearyl alcohol 2.00 2.00 2.40 2.40 3.10 3.80
White petrolatum 3.40 2.80 3.40 2.80 5.00 3.00
Polysorbate 60 3.00 3.80 3.00 3.00 3.40 3.40
Sorbitan 1.00 1.00 0.20 0.20 0.60 0.60
Monostearate
Glycerin 3.00 2.00 1.00 3.00 6.00 2.00
Xanthan gum 0.30 0.70 0.70 0.30 0.50 0.50
Purified water 65.08 62.48 67.08 61.08 61.48 53.78
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.00 3.00 3.00 3.00 3.00 3.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 139 140 141 142 143 144
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 54.48 65.08 57.98 56.98 54.98 59.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.00 3.00 3.00 3.00 3.00 3.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
58
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 145 146 147 148 149 150
Fatty acid* 15.00 20.00 15.00 20.00 10.00 20.00
Cetyl alcohol 2.00 2.00 4.00 4.00 2.20 2.20
Stearyl alcohol 2.00 2.40 2.40 2.40 3.10 3.10
White petrolatum 3.40 2.80 2.50 3.40 5.00 3.00
Polysorbate 60 3.00 3.00 3.00 3.80 3.40 3.00
Sorbitan 1.00 0.20 1.00 1.00 0.60 1.00
Monostearate
Glycerin 3.00 3.00 1.00 3.00 5.00 3.00
Xanthan gum 0.30 0.30 0.30 0.70 0.50 0.75
Purified water 64.83 60.83 65.33 57.23 64.73 58.48 _
Benzyl alcohol 2.00 2.00 2.00 1.00 2.00 2.00 .
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20 _
Propylparaben _ 0.02 0.02 0.02 0.02 0.02 0.02 _
Imiquimod 3.25 3.25 3.25 3.25 3.25 3.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 151 152 153 154 155 156
Fatty acid* 15.00 20.00 15.00 20.00 10.00 25.00
Cetyl alcohol 2.00 2.00 4.00 4.00 2.20 2.70
Stearyl alcohol 2.00 2.40 2.40 2.40 3.10 3.80 _
White petrolatum 3.40 2.80 2.50 3.40 5.00 3.00
Polysorbate 60 3.00 3.00 3.00 3.80 3.40 3.40
Sorbitan 1.00 0.20 1.00 1.00 0.60 0.60
Monostearate
Glycerin 3.00 3.00 1.00 3.00 5.00 2.00
Xanthan gum 0.30 0.30 0.30 0.70 0.50 0.50
Purified water 64.83 60.83 65.33 57.23 64.73 53.53
Benzyl alcohol , 2.00 2.00 2.00 1.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.25 3.25 3.25 3.25 3.25 3.25
Total 100.00 100.00 100.00 100.00 100.00
100.00
59
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 157 158 159 160 161 162
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 54.23 64.83 59.98 56.73 54.73 59.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.25 3.25 3.25 3.25 3.25 3.25
Total 100.00 100.00 100.00 100.00 100.00
100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
_ Formulation 163 164 165 166 167 168
Fatty acid* 15.00 10.00 12.50 19.00 20.00 20.00
Cetyl alcohol 2.00 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 2.40 3.10 3.10 3.10 3.10 3.10
White petrolatum 3.40 5.00 5.00 3.00 3.00 3.00
Polysorbate 60 3.00 3.40 4.00 3.40 3.40 . 3.00
Sorbitan 0.20 0.60 0.60 0.60 0.60 1.00
Monostearate
Glycerin 1.00 4.00 5.00 2.00 6.00 3.00
Xanthan gum 0.70 0.50 0.50 0.50 0.50 0.75
Purified water 66.58 65.48 61.38 60.48 56.48 58.23
Benzyl alcohol 2.00 2.00 2.00 2.00 1.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.50 3.50 3.50 3.50 3.50 3.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 169 170 171 172 173 174
Fatty acid* 15.00 10.00 12.50 19.00 20.00 25.00
Cetyl alcohol 2.00 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 2.40 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.40 5.00 5.00 3.00 3.00 3.00
Polysorbate 60 3.00 3.40 4.00 3.40 3.40 3.40
Sorbitan 0.20 0.60 0.60 0.60 0.60 0.60
Monostearate
Glycerin 1.00 4.00 5.00 2.00 6.00 2.00
Xanthan gum 0.70 0.50 0.50 0.50 0.50 0.50
Purified water 66.58 65.48 61.38 60.48 56.48 53.28
Benzyl alcohol 2.00 2.00 2.00 2.00 1.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.50 3.50 3.50 3.50 3.50 3.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 175 176 177 178 179 180
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 53.98 64.58 57.48 56.48 54.48 59.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.50 3.50 3.50 3.50 3.50 3.50
Total 100.00 100.00 100.00 100.00 100.00 100.00
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Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 181 182 183 184 185 186
Fatty acid* 20.00 20.00 25.00 18.75 2000 21.25
Cetyl alcohol 4.00 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 2.40 3.10 3.10 3.10 3.10 3.10
White petrolatum 2.80 3.00 3.00 5.00 5.00 3.75
Polysorbate 60 3.00 3.40 3.40 3.00 3.40 3.40
Sorbitan 1.00 0.60 0.60 1.00 0.60 0.60
Monostearate
Glycerin 1.00 2.00 2.00 5.00 5.00 5.00
Xanthan gum 0.30 0.50 0.50 0.50 0.50 0.50
Purified water 64.53 59.23 54.23 55.48 54.23 54.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.75 3.75 3.75 3.75 3.75 3.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 187 188 189 190 191 192
Fatty acid* 20.00 20.00 20.00 25.00 18.75 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan
Monostearate 0.60 0.60 1.00 0.50 1.00 0.60
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 59.23 53.23 53.23 54.33 55.48 53.03
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.75 3.75 3.75 3.75 3.75 3.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
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Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 193 194 195 196 197 198
Fatty acid* 25.00 20.00 20.00 20.00 20.00 21.00
Cetyl alcohol 2.20 4.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.40 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 5.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
,
Sorbitan 0.60 1.00 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 5.00
Xanthan gum 1.00 0.70 0.50 0.50 0.50 0.50
Purified water 53.73 55.73 57.23 56.23 54.23 53.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.75 3.75 3.75 3.75 3.75 3.75
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 199 200 201 202 203 204
Fatty acid* 20.00 25.00 22.50 20.00 20.00 22.50
Cetyl alcohol 2.20 2.70 , 2.20 4.00 2.20 2.20
Stearyl alcohol 3.10 3.80 3.10 2.40 3.10 3.10
White petrolatum 6.00 3.00 3.00 3.40 5.00 4.00
Polysorbate 60 3.00 3.40 3.40 3.80 3.40 3.40
Sorbitan 1.00 0.60 0.60 1.00 0.60 0.60
Monostearate
Glycerin 5.00 2.00 2.00 3.00 2.00 2.00
Xanthan gum 0.50 0.50 1.00 0.70 0.50 0.50
Purified water 52.98 52.78 55.98 55.48 56.98 55.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 4.00 4.00 4.00 4.00 4.00 4.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
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Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 205 206 207 208 209 210
Fatty acid* 20.00 25.00 22.50 20.00 20.00 22.50
Cetyl alcohol 2.20 2.70 2.20 4.00 2.20 2.20
Stearyl alcohol 3.10 3.80 3.10 2.40 3.10 3.10
White petrolatum 6.00 3.00 3.00 3.40 5.00 4.00
Polysorbate 60 3.00 3.40 3.40 3.80 3.40 3.40
Sorbitan 1.00 0.60 0.60 1.00 0.60 0.60
Monostearate
Glycerin 5.00 2.00 2.00 3.00 2.00 2.00
Xanthan gum 0.50 0.50 1.00 0.70 0.50 0.50
Purified water 52.98 52.78 55.98 55.48 56.98 55.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
lmiquimod 4.00 4.00 4.00 4.00 4.00 4.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 211 212 213 214 215 216
Fatty acid* 25.00 15.00 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.2 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 53.48 64.08 56.98 55.98 53.98 58.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 4.00 4.00 4.00 4.00 4.00 4.00
Total 100.00 100.00 100.00 100.00 100.00 100.00
64
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Excipient %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 217 218 219 220 221 222
Fatty acid* 15.00 15.00 15.00 20.00 15.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10
White petrolatum 1.00 3.00 2.00 3.00 6.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 3.00
Sorbitan 0.60 0.60 0.60 0.60 1.00 1.00
Monostearate
Glycerin 2.00 2.00 5.00 2.00 5.00 3.00
Xanthan gum 0.50 0.50 0.50 0.50 0.75 0.75
Purified water 65.73 63.73 61.73 58.73 57.48 57.48
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 4.25 4.25 4.25 4.25 4.25 4.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 223 224 225 226 227 228
Fatty acid* 15.00 15.00 15.00 25.00 18.0 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40
Sorbitan 0.60 0.60 1.00 0.50 1.00 0.60
Monostearate
Glycerin 2.00 5.00 5.00 2.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50
Purified water 63.73 57.73 57.73 53.83 55.73 52.53
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 4.25 4.25 4.25 4.25 4.25 4.25
Total 100.00 100.00 100.00 100.00 100.00 100.00
CA 02697978 2010-03-30
Excipients %w/w %w/w %w/w %w/w %w/w %w/w
Formulation 229 230 231 232 233 234
Fatty acid* 25.00 15.00 20.00 20.00 20.0 20.00
Cetyl alcohol 2.20 2.00 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 2.00 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.40 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.80 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.20 0.60 0.60 0.60 0.60
Monostearate
Glycerin 2.00 3.00 2.00 5.00 5.00 2.00
Xanthan gum 1.00 0.30 0.50 0.50 0.50 0.50
Purified water 53.23 63.83 56.73 55.73 53.73 58.73
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
_ Imiquimod 4.25 4.25 4.25 4.25 4.25 4.25
Total 100.00 100.00 100.00 100.00 100.00
100.00
*The Fatty acid referenced in this Table 9 can be, for example, linoleic acid
(la), stearic acid
(sa), palmitic acid (pa), isostearic acid (isa), unrefined oleic acid, (uoa),
refined oleic acid, such
as super refined oleic acid (roa), or mixtures thereof.
The work area, all vessels and equipment is initially cleaned prior to
commencing
manufacture. A 2 L glass container and paddle stirrer blade are placed onto a
balance and the
weight is recorded. The paddle is then removed from the vessel. The isostearic
acid and benzyl
alcohol are weighed directly into the 2 L glass container. The imiquimod is
then weighed into
the 2 L glass container and a spatula is used to ensure the imiquimod is
wetted with the isostearic
acid and benzyl alcohol mixture. The 2 L container is then heated in a water
bath to about 55 5
C while stirring with a Heidolph mixer (Note: aluminum foil is placed around
the top of the
vessel and the paddle for the mixer, to limit evaporation). The solution is
visually inspected to
confirm the imiquimod has fully dissolved prior to mixing with cetyl alcohol,
stearyl alcohol,
white petrolatum, polysorbate 60 and sorbitan monostearate. Cetyl alcohol,
stearyl alcohol,
white petrolatum, polysorbate 60 and sorbitan monostearate are then weighed
directly into the
2 L container and mixing is continued at about 55 5 C until the oil phase
is completely in
solution. Separately, about 2 L of water are placed into a beaker and heated
to 55 5 C while
stirring with a magnetic follower. Briefly, about 500 ml of the heated water
is transferred into a
1 L beaker and placed into the water bath maintained at about 55 5 C. Half
of the amount of
66
CA 02697978 2010-03-30
glycerin required for the final formulation is then weighed into the beaker
along with the total
amount of methylparaben and propylparaben to the water (where both methyl and
propyl
paraben are weighed into weighing boats first, a pipette is used to remove a
portion of the heated
water to wash out the weighing boats to ensure total transfer of both the
propyl- and
methylparaben into the aqueous phase). The mixture is continuously stirred at
about 55 5 C
(this is the aqueous phase). The remaining glycerin is then added to a 28 ml
vial and the xanthan
gum is added and mixed using a small overhead mixer (1KA8-Werke Lab Egg) with
paddle
attachment for about 10 min. The glycerin and xanthan mixture are then added
slowly into the
vortex of the aqueous phase, and a further aliquot of about 20 ml of heated
water is used to rinse
the vessel out into the water phase to ensure complete transfer. The water
phase is then heated
and mixed at about 55 5 C until the xanthan gum mixture is fully and evenly
dispersed into
the aqueous phase. The temperatures of both the water phase and oil phase are
both maintained
at about 55 5 C. The aqueous phase is then transferred into the oil phase
and the speed of the
Heidolph mixer is increased during addition. The mixture is then homogenized
on high speed
for about 3 min and transferred immediately back to the Heidolph mixture;
however, the contents
of the homogenized sample, about 2 L, are mixed at about room temperature and
allowed to cool
to about 35 C. The container and contents and the paddle from the overhead
mixer are then
re-weighed and the weight of the paddle and 2 L beaker, as determined above,
are subtracted to
determine the total weight of the formulation remaining. The total weight
(about 1 kg) of the
cream is then made up to weight with heated water (Note: water evaporated
during heating,
which needs to be corrected at this point). The mixture is then transferred
back onto the
Heidolph mixer at about room temperature and mixed until the temperature of
the formulation is
below about 28 C. The lid of the container is then placed onto the vessel and
stored at room
temperature.
The lower dosage strength formulations of this Example 23 are believed to be
stable and
consistent with the specifications for the commercially available Aldara 5%
imiquimod cream.
More preferably, low dosage formulations of this Example 23, especially as to
those lower
dosage strength formulations wherein the vehicle comprises an isostearic acid
as the fatty acid,
are believed to have the following:
67
CA 02697978 2010-03-30
(1) Stability. The imiquimod formulations of the present invention, when
they are
measured on HPLC at 25 C/60%RH, 30 C/65%RH and 40 C/75%RH over, one, two,
three and
six months, demonstrate stability consistent with the Aldara 5% imiquimod
cream;
(2) Degradation Products. No degradation products are detected in the
formulations
of the present invention, at its current recommended storage temperatures of
about 4-25 C. In
addition, there are no degradation products detected at any of the
temperatures or time points
mentioned under "Stability" above, when analyzed at about 318 nm.
(3) Homogeneity. The amount of imiquimod that is recovered from the
formulations
at any of the above-mentioned temperatures and time points is between about 90
to about 110%
w/w thereby demonstrating good homogeneity;
(4) Benzyl Alcohol Content. The formulations of the present invention are
also
within specifications for the Aldara 5% imiquimod cream, i.e., between 1.0
%w/w and 2.1
%w/w, at any of the above-mentioned temperatures and time points as to benzyl
alcohol content.
(5) Microscopic Stability. There is no change in the particle size and no
crystals are
detected in the formulations of the present invention when they are stored at
25 C/60%RH and
analyzed over a six month period;
(6) Macroscopic Stability. There are no obvious physical changes in the
formulations
of the present invention when they are stored at 25 C/60%RH and analyzed over
a six month
period;
(7) Viscosity. The formulations of the present invention are within the
range of the
specifications for the Aldara 5% imiquimod cream, i.e., between 2000 cPs and
35,000 cPs,
when they are stored at 25 C/60%RH and analyzed over a six month period; pH
Stability. The
formulations of the present invention are within the range of the
specifications for the Aldara
5% imiquimod cream, i.e., between pH 4.0 and pH 5.5) when they are stored at
25 C/60 %RH
and analyzed over a six month period;
(8) Preservative Efficacy Test ("PET"). The formulations of the present
invention
demonstrate sufficient reductions in colony forming unit counts for each of
the organisms with
which the formulations are inoculated, i.e., S. aureus, E. coli, Ps.
Aeruginosa, C. albicans, and
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CA 02697978 2010-03-30
A. niger, at 2-8 C and 40 C over a 28 day test period and meet the
requirements specified in
both the USP and EP.
(9)
Imiquimod In vitro Release. The Aldara 5% imiquimod cream releases
statistically significant (p<0.05) higher amounts of imiquimod over a 3 hour
time period in
comparison to the lower dosage strength formulations of the present invention
through a
synthetic membrane, e.g., Microporous polyethylene film 3M No. 9711 CoTranTm.
There is no
statistical difference (p<0.05) in the total cumulative amount of imiquimod
that is released from
any of the 3.75% w/w imiquimod formulations. There is no statistical
difference (p<0.05) in the
total cumulative amount of imiquimod that is released from any of the 2.5% w/w
imiquimod
formulations. The Aldara 5% imiquimod cream also statistically significantly
(p<0.05) releases
imiquimod at a faster rate over a 3 hour time period in comparison to the
lower dosage strength
formulations of the present invention through a synthetic membrane, e.g.,
Microporous
polyethylene film 3M No. 9711 CoTranTm. There is no statistical difference
(p<0.05) between
the imiquimod release rates for any of the 3.75% w/w imiquimod formulations.
There is no
statistical difference (p<0.05) between the imiquimod release rates for any of
the 2.5% w/w
imiquimod formulations. Thus, the greater the amount of imiquimod in a
formulation, the faster
and greater the total amount of imiquimod that is released from such
formulation that the amount
and rate of release of imiquimod are concentration dependant and that the
rates and amounts of
release of imiquimod from the formulations of the present invention are linear
and dose
proportionate to the Aldara 5% imiquimod cream;
(10) Imiquimod In vitro Skin Permeation (Franz Cell Study). With respect to
statistical analyses, there is no statistical difference between the lower
dosage strength
formulations of the present invention and the Aldara 5% imiquimod cream as to
the amount of
imiquimod recovered from the receiver fluid, epidermis and dermis combined.
Nonetheless,
there is a statistically significant (p<0.05) dose proportionate difference
between the amount of
imiquimod recovered from each of the matrices with respect to the
concentration of imiquimod
in the lower dosage strength formulations of the present invention and the
Aldara 5%
imiquimod cream for both un-absorbed and stratum corneum. Thus there is a
linear dose release
between the amount of imiquimod that is applied and recovered in each of the
matrices, i.e.,
receiver fluid, unabsorbed dose, stratum corneum, epidermis and dermis.
69
CA 02697978 2012-05-15
ANOVA statistical analysis at 95% confidence level is used to analyze the
stability data
generated, including the data generated for the membrane and skin permeation
experiments.
It is also believed that the formulations of the present invention, including
the
formulations identified in this Example 23, have Hydrophilic-lipophilic
balance (HLB) values
between about 12 and 15, and more preferably between about 12.4 and about
13.4.
I Physical Characterization and Testing
The following is conducted for physical characterization of lower dosage
strength
imiquimod formulations, e.g, formulations identified in Table 12 and Table 18,
and for testing
lower dosage strength imiquimod formulations, e.g., imiquimod formulations
identified in
Tables 13-17.
(A) Analytical method-HPLC Assay
A summary of an HPLC method is provided in Table 10.
Table 10. Summary of HPLC Methodology
HPLC 9. Waters 265 (Alliance Separations module), Wati,996
(Photodiode array detector), CPU (Compaq), Software¨ Microsoft
HPLC System WindowtNT Version 4.00.1381 and Analysis
software -Millenium32 Version 4.00.00,00
.t
Column Supelcostl LC-8-DB (5nun, 15 x 0A6 cm)
Guard Column Supelguald LC-8-DB 2cm
Detection UV at 258 am
Sample Temperature 25 C
Column Temperature 25 C
Flow Rate 2 ml/min
Mobile Phase 72:28 aqueous:ACN (1% TEA solution, 0.2% Octyl Sodium
Sulfate,
adjusted to pH 2.0 with 113PO4
Injection Volume 20 ul
Run Time 12 min
Needle Wash 10:90 0.1N HC1:water
70 *Tradvaak
CA 02697978 2010-03-30
(B) Preparation of HPLC Reagents
Mobile Phase:
About 2.0 g octyl sodium sulfate (OSS) is weighed into a large beaker and is
mixed with
about 990 ml milli-Q ultrapure water and about 10.0 ml of triethylamine (TEA).
The mixture is
sonicated and stirred for about 5 min to dissolve the solids. A pH meter is
then placed in the
mixture and the pH of the OSS/TEA solution is adjusted to about 2.0 with
concentrated H3PO4,
stirring continuously during the adjusting procedure. The entire mixture is
then filtered through
a 0.2 gm filter. The filtrate is mixed with acetonitrile (HPLC grade) in the
ratio of about
72:28 aqueous: acetonitrile by volume.
Sample Diluent
About 250 ml acetonitrile (HPLC grade), about 740 ml purified water and about
10 ml of
concentrated HCI are mixed together in a 1 L volumetric flask.
Receiver Fluid
About 100 ml of a commercially available standardized 1N HCI solution is
diluted to
about 1000 ml with Milli-Q ultra pure water.
Standards
Imiquimod standards are prepared, as described under Sample Diluent and
Receiver
Fluid, for stability test and receiver for membrane release tests. Initially,
a stock solution of
imiquimod is prepared by dissolving about 25 mg of imiquimod into about 50 ml
of solvent
(either Sample Diluent or Receiver Fluid) to give a concentration of about 500
gg/ml in Sample
Diluent or Receiver Fluid.
A calibration range as shown in Table 11 is prepared for each HPLC run.
71
CA 02697978 2010-03-30
Table 11. Preparation of Calibration Standards
Volume of stock
Final concentration of Test
solution Volume of diluent
Item (ttg/m1)
(ml)
0 500
5 5 250
4 6 200
2 8 100
1 9 50
0.5 9.5 25
0.2 9.8 10
0.1 9.9 5
Combination Standard
The following combination standard solution is also prepared; whereby, about
500 mg of
methylparaben and about 50 mg propylparaben are weighed into a single 250 ml
volumetric flask
and is diluted to volume with sample diluent above, to form the parabens
solution. In addition,
about 500 mg of imiquimod and about 200 mg benzyl alcohol are also weighed
into a single
100 ml volumetric flask and about 10 ml of the parabens solution is then
transferred into the
imiquimod/benzyl alcohol volumetric which is made up to volume with diluent
and is sonicated
to dissolve fully.
Impurity standards
Impurity standards are prepared separately at a concentration of about 50
p.g/m1 in
Sample Diluent and are analyzed in each HPLC run. The impurity standards that
are included in
each HPLC run are as follows:
= N-propyl imiquimod
= N-methyl imiquimod
= 4-hydroxyimiquimod
= 4-chloro imiquimod
72
Table 12
2.5% Imiquimod Formulations 3.75% Imiquimod Formulations
235 236 237 238 239 240 241 242 243 244 181
245
%w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w
Excipients
Isostearic acid 15 10 15 10 15 15 15 20
15 20 15 20
Cetyl alcohol 2 4 4 2 2 4 2 2 2
2 4 4
Stearyl alcohol 2 2 2 2.4 2.4 2.4 2 2
2.4 2.4 2.4 , 2.4
White petrolatum 3.4 3.4 2.8 2.8 3.4 2.8 3.4 2.8
3.4 2.8 2.8 3.4
Polysorbate 60 3.8 3.8 3 3.8 3 3.8 3 3.8
3 3 3 3.8
Sorbitan
Monostearate 0.2 1 1 1 1 0.2 1 1
0.2 0.2 1 1 o
Glycerine 3 1 3 3 1 1 3 1 1
3 1 3 0
Xanthan gum 0.3 0.3 0.7 0.3 0.7 0.3 0.3 0.7
0.7 0.3 0.3 0.7 "
0,
Purified water 65.58 69.78 63.78 69.98 66.78 65.78
64.33 60.73 66.33 60.33 64.53 55.73 ko
.4
Benzyl alcohol 2 2 2 2 2 2 2 2 2
2 2 2 ko
.4
Methylparaben 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2
0.2 0.2 0.2 0.2 co
iv
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02 0.02
0.02 0.02 0.02 0.02 0.02 0
1-,
0
1
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50 3.75
3.75 3.75 3.75 3.75 3.75 0
w
1
w
Total amount (g) 100.00 100.00 100.00 100.00 100.00
100.00 100.00 100.00 100.00 100.00 100.00 100.00
0
HLB Values 14.4 12.8 12.4 12.8 12.4 14.4 12.4
12.8 14.3 14.3 12.4 12.8
73
In Table 13, fifteen 2.5% w/w imiquimod formulations are manufactured in 100 g
batches. Each of the fifteen formulations
are assessed for macroscopic and microscopic appearance, as discussed
hereinafter.
Table 13
Imiquimod 246 110 116 247 117 248 249 250 113
251 252 253 254 120 121
Formulations 'Yow/w , %w/w %w/w %w/w %w/w 'Yow/w %w/w %w/w %w/w 'Yow/w %w/w
'Yow/w 'Yow/w 'Yow/w 'Yow/w
Excipients
Isostearic acid 15.00 15.00 15.00 10.00 15.00 15.00
10.00 25.00 15.00 15.00 10.00 12.5 12.5 25.00 25.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.20 2.20 2.20
2.20 2.20 2.20 2.20 2.20 2.70 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.10 3.10
3.10 3.10 3.10 3.10 3.10 3.10 3.80 3.10
White petrolatum 15.50 3.00 6.00 8.50 6.00 6.00
_ 8.50 - 3.00 6.00 6.00 5.00 5.00 5.00 3.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.00 4.25 3.00
3.40 3.00 3.00 3.40 3.40 3.00 3.40 3.40
Sorbitan
0
Monostearate 0.60 0.60 0.60 0.60 1.00 0.75_ 1.00 0.60
1.00 1.00 0.60 0.60 1.00 0.60 0.60
Glycerine 2.00 2.00 5.00 5.00 5.00 5.00 5.00 2.00
5.00 5.00 5.00 5.00 5.00 2.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50 _ 0.50
0.50 0.75 1.00 0.50 0.50 0.50 0.50 1.00 co
Purified water 52.98 65.48 59.48 61.98 59.48 58.48 61.98 55.48 59.23 58.98
65.48 62.98 62.98 54.28 54.98
0
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00 2.00
2.00 2.00 2.00 2.00 2.00 2.00 2.00 2.00
0
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20 0.20
0.20 0.20 0
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02
0.02 0.02 0.02 0.02 0.02 0.02 0.02
0
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50
2.50 2.50 2.50 2.50 2.50 2.50 2.50
Total amount (g)
100.00 100.00 100.00 100.00 100.00 100.00 100.00
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
HLB Values 13.4 13.4 13.4 13.4 12.4 13.4 12.4 13.4
12.4 12.4 13.4 13.4 12.4 13.4 13.4
74
Table 14
2.5% Imiquimod 110 116 117 250 254 120 121 , 235 _
123 124 125 126
Formulations %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w
Excipients . _
Isostearic acid 15.00 15.00 15.00 25.00 12.5 25.00
25.00 15 20.00 20.00 20.00 20.00
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70 2.20 2
2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10_ 3.10 3.10 3.80 3.10 2
3.10 3.10 3.10 3.10
White petrolatum 3.00 6.00 6.00 3.00 5.00 3.00 3.00
3.4 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40 3.40
3.8 3.40 3.40 3.40 3.40
Sorbitan
Monostearate 0.60 0.60 1.00 0.60 1.00 0.60 0.60
0.2 0.60 0.60 0.60 0.60
Glycerine 2.00 5.00 5.00 2.00 5.00 2.00 2.00 3
2.00 5.00 5.00 2.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 0.50 1.00 0.3
0.50 0.50 0.50 0.50 o
Purified water 65.48 59.48 59.48 55.48 62.98 54.28
54.98 65.58 58.48 57.48 55.48 60.48 0
iv
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2
2.00 2.00 2.00 2.00 cl,
ko
Methylparaben 0.20 0.20 0.20 0.20 0.20 0.20 0.20
0.2 0.20 0.20 0.20 0.20 --3
ko
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02 0.02
0.02 0.02 0.02 0.02 0.02 --3
co
F..,
Imiquimod 2.50 2.50 2.50 2.50 2.50 2.50 2.50 2.50
2.50 2.50 2.50 2.50 0
1-,
0
1
0
Total
100.00 100.00 100.00 100.00 100.00 100.00 100.00
100.00 100.00 100.00 100.00 100.00 w
1
I-ILB Values 13.4 13.4 12.4 13.4 12.4 13.4 13.4
14.4 13.4 13.4 13.4 13.4 w
0
CA 02697978 2010-03-30
Table 15
3.75% Imiquimod 182 188 189 183 184 255 193 245 195
256 197
Formulations %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w
Excipients
Cetyl alcohol 2.20 2.20 2.20 2.20 2.20 2.70 2.20 4
2.20 2.20 2.20
Stearyl alcohol 3.10 3.10 3.10 3.10 3.10 3.80 3.10 2.4
3.10 3.10 3.10
White
petrolatum 3.00 6.00 6.00 3.00 . 5.00 3.00 3.00
3.4 . 5.00 3.00 5.00
Polysorbate 60 3.40 3.40 3.00 3.40 3.00 3.40 3.40 3.8
3.40 3.40 3.40
Sorbitan
0.60 0.60 1.00 0.60 1.00 0.60 0.60 1 0.60 0.60
0.60
Monostearate
Glycerine 2.00 5.00 5.00 2.00 5.00 2.00 2.00 3
2.00 5.00 5.00
Xanthan gum 0.50 0.50 0.50 0.50 0.50 1.00 1.00 0.7
0.50 0.50 0.50
Purified water 59.23 53.23 53.23 54.23 55.48 53.73
53.73 . 55.73 57.23 58.23 54.23
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00 2.00 2
2.00 2.00 2.00
Methylparaben 0.20 0.20 0.20 0.20 0.20 . 0.20 0.20
0.2 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.02
Imiquimod 3.75 3.75 3.75 3.75 3.75 3.75 3.75
3.75 3.75 3.75 3.75
Total
100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00
HLB Values 13.4 13.4 12.4 13.4 12.4 13.4 13.4
12.8 13.4 13.4 13.4
76
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In Table 16, compositions for Aldara 5% imiquimod cream and 1% imiquimod
cream
formulations are shown. Also shown in the Table 16, are four placebo
formulations Pbol, Pbo2,
Pbo3 and formulation Pbo4,
Table 16
3M 257 Placebos
Aldara (1%)
Formulations (5% Pbol Pbo2 Pbo3 Pbo4
Bulk)
%w/w %w/w %w/w %w/w %w/w %w/w
Excipients
Isostearic acid 25.00 25.00 20.00 20.00 20.00
20.00
Cetyl alcohol 2.20 2.40 2.20 2.20 2.20 2.20
Stearyl alcohol 3.10 3.40 3.10 3.10 3.10 3.10
White petrolatum 3.00 3.00 5.00 3.00 5.00 3.00
Polysorbate 60 3.40 3.40 3.40 3.40 3.40 3.40
Sorbitan 0.60 0.60 0.60 0.60 0.60 0.60
Mono stearate
Glycerin 2.00 ' 2.00 2.00 5.00 5.00 2.00
Xanthan gum 0.50 0.50 0.60 0.60 0.50 0.50
Purified water , 52.98 58.48 80.98 , 59.98 57.98
62.98
Benzyl alcohol 2.00 2.00 2.00 2.00 2.00 2.00
Methylparaben 0.20 , 0.20 0.20 0.20 0.20 0.20
Propylparaben 0.02 0.02 0.02 0.02 0.02 0.02
lmiquimod 5.00 1.00 0.00 0.00 0.00 0.00
Total 100.00 100.00
100.00 100.00 100.00 100.00
HLP Values 13.37 13.37 13.37 13.37 13.37
13.37
(C) Uniformity/homogeneity
Following a 1 kg batch manufacturing process as described in this Example 23,
3 x 150
mg samples (top, middle and bottom) are removed from each 1 kg bulk batch
using a positive
displacement pipette and are extracted and are analyzed as described in
Section, entitled
"Imiquimod Content" described hereinafter.
(D) Preparation of Stability Samples
77
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Each of the 1 kg batches are sub-aliquoted individually into 21 x 60 ml glass
powder jars,
where:
(B) 5 x 50 g (25 C/60%RH t= 0 h, 1 month, 2 months, 3 months, 6 months)
(C) 5 x 50 g (30 /65%RH -1= 0 h, 1 month, 2 months, 3 months, 6 months)
(D) 5 x 50 g (40 C/75% RH - t= 0 h, 1 month, 2 months, 3 months, 6 months)
(E) 1 x 60 g (PET sample, placed at 2-8 C)
(F) 1 x 20 g (placed at 2-8 C)
(G) 1 x 20 g (placed at -20 C)
(H) The remaining formulation, is divided into 3 additional aliquots and each
is
placed at 25 C/60%RH, 30 /65%RH and 40 C/75% RH.
All batches are characterised based on the protocols that are shown in Section
entitled
Protocol for the Assessment of Formulations. Once each aliquot is removed from
the relevant
stability conditions at each time point; the remaining aliquot from each
sample is placed in a
fridge at 2-8 C for future reference if required.
Following the 1 month stability time point, the benzyl alcohol content of the
formulations
are monitored; for all subsequent time points, the placebo formulations are
analyzed by HPLC.
Thus, there are no t=0 measurements for benzyl alcohol content for placebo
formulations Pbo 1 ,
Pbo2 and Pbo3.
(E) Protocol for the assessment of formulations
The protocols that are used for the assessment of the formulations are as
follows:
(1) Macroscopic Appearance
Macroscopic appearance is determined by visual examination of the physical
characteristics which include appearance and texture of each cream.
Macroscopic appearance is
performed at each time point (t = 0, 1, 2, 3 and 6 months) for the 25 C
stability samples, as
follows:
(A) Using a medium Granton pallet knife, a small aliquot of sample
(approximately 1
to 2 g) is removed from its container and is placed on the surface of a large
Granton pallet knife.
(B) The medium Granton pallet knife is then used to smooth the cream over
the
surface of the large Granton pallet knife, by using a backward and forward
78
CA 02697978 2012-05-15
motion of the spatula until a visually uniform layer of cream is obtained on
the
large Grantoe pallet knife.
(C) Visual observations of the cream are recorded which am based on, the
presence of
lumps, gradoRls or ease of spread over the surface of the spatula.
(2) Microscopic Appearance
Formulations are viewed under a light microscope (Leica DME FD198536 Light
Microscope), to determine particle size, uniformity and the absence of
particulates. Digital
images of each formulation are taken at each time point (t 0, 1, 2, 3 and 6
months) for the 25 C
stability samples, as follows:
-44
(A) The microscope is set up so that the camera (Nikkon Cool Pi x 4500
digital
camera) is attached to the relay lens of the microscope and the 40x objective
lens
is set into place to view the sample. Camera settings: Image size 1280 x 960
pixels, Image quality: Fine.
(B) A small droplet of the formulation to be viewed is placed onto a
microscope slide
(Fisher-brand microscope slides, Cat No. 7101) using a micro-spatula. The
microscope slide is then covered using a cover glass (Fisher-brand cover
glass,
width: 22 - 32 IBM, thickness: 0.13-0.17 nun).
(C) The microscope slide with the formulation is then placed under the 40x
objective.
Using the fine adjustment knob of the light microscope, the slide is brought
into
sharper focus to get a clear view.
(D) Once a clear distinct view is obtained, pictures are taken (x400
magnification).
(E) The particle sizes of formulations prepared arc determined using a
graticule
(Olympus, Objective Micrometer, 0.01 mm). Overall uniformity and particle size
are measured using the scale on a calibrated graticule. Five random locations
on
each slide for each formulation are chosen to assess uniformity and particle
size.
(3) Imiquimod Content
The imiquimod content of the formulations is measured at each time point (t 0,
1, 2, 3
and 6 months) for the 25 C and 40 C stability samples. The 30 C stability
samples are removed
from the stability cabinet at each time point and placed at about 2-8 C for
future reference, as
follows:
79 *Trademark
CA 02697978 2010-03-30
(2) About 150 mg of the formulation is removed from each sample and is
transferred
into a 50 ml volumetric flask.
(3) About 30 ¨ 40 ml of diluent (about 250 ml acetonitrile (HPLC grade),
about 740
ml purified water and about 10 ml of concentrated HCI are mixed together in a
1 L
volumetric flask) is then added to the volumetric flask containing the aliquot
of the
formulation.
(4) The sample is then vortex mixed for approximately 1 min or until the
formulation
has visibly completely dispersed into the diluent.
(5) The sample is then sonicated for about 5 min and then is left to cool to
room
temperature.
(6) The sample is then filled to volume with diluent and is mixed by inverting
the
volumetric flask.
(7) This step is followed by filtration through a 0.45 mm filter directly
into a 2 ml
HPLC vial and the cap crimped.
(8) The sample is then analysed on the HPLC using the method described in
Section
entitled Analytical Method ¨ HPLC Assay described above, with the standard
solutions as described above in Sections entitled Standards Combination
Standard
and Impurity Standard. This method also allows for the detection and
measurement of benzyl alcohol.
(4) Related Substances/ Degradation Products
Following the extraction and analysis, as described above under Imiquimod
Content, the
chromatograms for each formulation are compared to those generated for the
impurity standards,
as described above under Impurity Standards, to identify if there are any
degradation peaks
present. As the preservatives have similar retention times as the degradation
products, the
chromatograms are viewed at an absorbance of 318 nm wavelength at which the
preservatives do
not absorb to confirm the absence of degradation products.
(5) pH measurements
The pH of the formulations are measured at each time point (t = 0, 1, 2, 3 and
6 months).
The pH measurement protocol is as follows:
(4) A small sample of the formulation is applied on to the surface of a
strip of pH
paper (Fisher-brand pH paper: FB33045, Range pH 0.5-5.5) and is spread evenly
CA 02697978 2010-03-30
over the surface using a spatula.
(5) The pH paper with the formulation on it is then left for 10 min to
ensure that the
paper does absorb the cream (which is confirmed by a color change).
(6) The pH of the formulation is then determined by comparing the color on
the strip
of pH paper with a range of colors (color chart) that are provided with the
Fisher-
brand pH paper.
(6) Viscosity from Flow Curve (Rheology Bohlin CVO measurements)
The rheology of the formulations are measured at each time point (t = 0, 1, 2,
3 and 6
months) for the 25 C stability samples.
(7) Rheology Oscillation Methodology (Bohlin CVO)
The Crossover and GI values of the ICH stability samples are measured for all
the t=0
samples. See e.g., Tables 18 and 26. The 'crossover' point is an indication of
the elastic
structure of the formulation and a high cross over point indicates that more
force is required to
breakdown the formulation thus providing an indication for longer term
stability of the cream
formulations. The Gl value is a measurement of the elastic part of the
formulation, whereby a
high GI value indicates a more rigid formulation which 'recovers' more easily
from applied shear
stress.
(8) Viscosity (Brookfield) Measurements
The viscosity of the formulations is measured at each time point (t = 0, 1, 2,
3 and
6 months) for the 25 C stability samples.
(9) Preservative Efficacy Test Protocol
The preservative efficacy test is performed on formulations 110, 126, Pbo4 and
182
which are stored at about 2 - 8 C and about 40 C for about 3 months.
Preservative efficacy
testing is carried out according to the procedure described in line with the
methodology
described in the USP 2007 and EP 2007. The time points, at which the
inoculated samples are
tested are: Oh, 24h, 48h, 7 days, 14 days, 21 days and 28 days.
81
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Method validation is performed using Staphylococcus aureus cultures to confirm
the
neutralizing effect of DIE broth, for this purpose 110 and 182 are used to
confirm neutralization
of the preservatives.
II Test Item Release Studies through Synthetic Membranes
(A) In vitro screening of release profiles through synthetic membranes
The release of imiquimod from 13 formulations (n=4 for each) are compared
using
methodology based on the principles of the FDA, SUPAC-SS guidelines. The
formulations that
are tested included: 3M's Aldan. 5% imiquimod cream 1 kg bulk sample, Aldara
5%
imiquimod cream sachet (commercial product), Graceway's Aldara 5% imiquimod
cream 1 kg
batch, and formulations 257(1%), 123, 250, 125, 110, 182, 195, 256, 197 and
183. The protocol
for the investigation is as follows:
A synthetic membrane (Microporous polyethylene film 3M No. 9711 CoTranTm) is
mounted in a small Franz cell (refer to FIG. 1) with a receiver fluid (0.1 N
HCI) to ensure sink
conditions (is equilibrated for a minimum of 30 min prior to dosing). An
infinite dose of
formulation (230 to 250 p.1 is dispensed using a calibrated positive
displacement pipette) is
applied to the membrane (using the pipette tip to gently spread over the
surface) and the
diffusion of imiquimod that is measured over time (n=4 per formulation).
Briefly 200 1 of the
receiver fluid is removed using a 250 IA Hamilton syringe at each time point
(0, 15, 30, 60, 120
and 240 min) and is analysed on the HPLC using the method, as described under
Analytical
Method ¨ HPLC Assay. The sample of receiver fluid is removed at each time
point and is
replaced with fresh pre-warmed (32 C) receiver fluid.
III In vitro Skin Permeation Study
(A) Analytical Methods
(1) Liquid Scintillation Method Details
Samples are added to a scintillation vial and about 4 ml of scintillation
cocktail
(Hionic-fluor) is added. The vial is capped and is shaken using a vortex mixer
until the sample is
mixed with the scintillation cocktail. The scintillation vials are then loaded
into racks before
analysing on the scintillation counter, using the settings listed as follows.
82
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Model of scintillation counter: Beckman* LS 5000 CE
Isotope setting: C14
Counting time: 5 min
Calculation mode: SL DPM
Count samples: 1 times
Replicates:
Quench monitor: Yes
(B) Radioactive purity of Imiquiniod NC
(1) Preparation of Stock
The radio-labelled material is as follows:
Irniquimod stock (c14): Specific activity of about 57 maIrnmol with a
radiochemical
purity of about 99.2% is supplied as a powder in a borosilicate multi-dose
vial with additional
screw cap.
Working stock solutions are prepared by addition of I ml isostearic acid to
the imiquimod
powder using a needle and syringe inserted through the septum of the vial. The
screw cap is then
replaced securely and the vial shaken on a vortex mixer until all the
irniquimod dissolves in the
isostearic acid. The homogeneity is also confirmed. This results in a stock
solution containing
about 1000 Ciiml.
(C) Preparation of Formulations
= The method for the preparation of about a 100g radioactive batch is as
follows:
The glass container and mixer paddle attachment are placed onto a balance and
the
weight is recorded before the container and paddle are removed.
= The amount of imiquirnod required for the formulation is added by weight
and the
remaining isostearic acid (minus 1.38 g) and benzyl alcohol are added to the
container.
= The entire mixture is heated in a water bath at about 55 5 C while
stirring with a small
over head mixer (IKAO-Werke Lab Egg) and paddle attachment.
83 *Trademark
CA 02697978 2010-03-30
= Cetyl alcohol, stearyl alcohol, white petrolatum, polysorbate 60 and
sorbitan
monostearate are added into the beaker and mixed at about 55 5 C until the
oil phase is
completely in solution.
= Separately, about 200 ml of water is heated in a beaker to about 55 5
C while stirring
with a magnetic follower.
= About 50 ml of the heated water is transferred into a beaker and is
placed in a water bath
maintained at about 55 5 C and half the glycerine, methyl hydroxyparabens
and propyl
hydroxyparabens are added (where both methyl and propyl parabens are weighed
into
weighing boats first) to the water and is stirred at about 55 5 C (this is
the aqueous
phase).
= The remaining glycerine is added to a 28 mi vial with the xanthan gum and
is mixed
using a small over head mixer (IKAS-Werke Lab Egg) with paddle attachment for
about
min.
= The glycerine and xanthan mixture are then added into the vortex of the
aqueous phase,
using about a 5 ml aliquot of heated water to rinse the vessel out into the
water phase.
= Mixing of the water phase is continued for at least about 5 min.
= The aqueous phase is transferred into the oil phase, increasing the
stirring speed during
addition.
= The mixture is stirred on high speed maintaining the temperature at about
55 5 C for
30 min.
= The vessel is removed from the mixer and is homogenised using the 1 cm
head for about
3 min.
= Mixing is continued while cooling to about 35 C and the total weight of
the cream is
made up to weight with heated water. The mixture is transferred to the
overhead stirrer
and cooling and stirring is continued to about 25 C.
= The formulations are then aliquoted in to screw top vials and are sealed
with Parafilm
placed around the screw top lid.
= About 9.862 g of the formulation is weighed into a vial and is placed in
a water bath at
about 5 C. About 138 mg of radio-labelled working stock solution is then
added to the
formulation and the formulation is thoroughly mixed using a spatula while
cooling.
(D) Homogeneity Control
Following manufacturing of the formulations, the following test is performed:
For each of the formulations, three aliquots (top, middle and bottom of batch)
of
approximately 5 mg is exactly weighed directly into a scintillation vial,
where about 4 ml of
scintillation cocktail is added. All of the samples are then directly
quantified on the Liquid
Scintillation Counter ("LSC") to confirm homogeneity within 10%.
84
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(E) Franz cell study
The method involves the use of full thickness human skin that is mounted in a
Franz cell
with about a 0.01 N hydrochloric acid as receiver fluid to ensure sink
conditions. A dose of
formulation equivalent to about 10 mg/cm2 is applied to the membrane and the
diffusion of
imiquimod is measured over time. Human skin from cosmetic reduction surgery is
used.
Subcutaneous fat is removed mechanically prior to preparation of the skin
section for the study.
The formulations (61,t) are applied to the surface of the membrane using a
positive displacement
pipette. The investigation is performed in several experiments. Two skin
donors are used
randomly and are assigned across all experiments so that each formulation is
tested on both skin
donors. Each experiment consists of two randomly assigned formulations (n---.6
cells per
formulation) and two comparator formulations (n=6 cells per comparator). The
receptor
compartment of the Franz cells is then filled with the receiver fluid and the
cells are fixed in a
water bath maintained at about 37 C. The receptor compartment contents are
continuously
agitated by small magnetic followers. At t=1, 8 and 24 h, samples of receiver
fluid are taken
from the receptor compartment, and are replaced with fresh receiver fluid and
are assayed by
scintillation counting.
(F) Mass balance
At the end of the experiment, a mass balance experiment is carried out, where
the amount
of 14Cimiquimod remaining in the donor compartment, surface residue, Stratum
corneum (SC),
remaining epidermis, dermis and receiver compartment is quantified. This
method involves
removal of the SC by tape stripping and processing of the remaining epidermal
layer and dermis
using standard procedures. The protocol for the mass balance is as follows:
Unabsorbed dose: The surface of each Franz cell donor chamber is wiped gently
with a
cotton bud using 5 clockwise and anti-clockwise movements. This procedure is
repeated on 4
occasions using alternate wet (receiver fluid) and dry cotton buds. The cotton
buds are added to
scintillation cocktail before analysis. Two tape strips are removed from the
skin and these are
regarded as unabsorbed formulation and included in the total surface activity.
The Stratum
corneum) (SC) is removed by carefully tape stripping the membrane ten times
using Scotch
adhesive tape. Collectively, each tape is placed into a scintillation vial to
which 4 ml of
CA 02697978 2010-03-30
scintillation cocktail are added before analysis. Epidermal layer: The
remaining section of the
epidermis (following tape stripping) is carefully removed from the dermis with
a scalpel. The
epidermis is placed into a glass vial containing 2 ml of Soluene 350 and is
incubated at about
50 C for about 72 h before analysis by LSC. The remaining dermal layer is
placed in to a glass
vial containing about 2 ml of Soluene 350 and is incubated at about 50 C for
about 72 h before
analysis by LSC.
(G) Analysis of Data
ANOVA statistical analysis at a 95% confidence level is used to analyse the
data
generated for the membrane release and skin permeation experiments.
An example of the ANOVA statistical analysis is as follows:
Individual 95% Cis For Mean Base on
Pooled StDev
Level N Mean StDev
Formulation X 4 4605.5 626.9 (---*---)
Formulation Y 4 1862.8 185.9 (---*---)
Formulation Z 4 1845.6 206.4 (---*---)
0 1500 3000 4500
Whereby, no significance (p>0.05) is shown by two overlapping histograms (e.g.
Y and
Z), whereas a significant difference (P<0.05) can be identified by two
histograms which don't
overlap (e.g. X and Y and X and Z). The width of the each histogram is a
reflection of the
pooled standard deviation from all data sets.
IV Results and Discussion
(A) Degradation Product Analysis
It is discovered that the preservatives (benzyl alcohol, methylparaben and
propylparaben)
at about 318 in the imiquimod formulations can not be detected. Thus, by
analysing the
imiquimod formulations at this wavelength, it permits the detection of
degradation products, if
86
CA 02697978 2010-03-30
any, in the presence of preservatives. However, no degradation products are
identified at about
318 nm for any of the imiquimod formulations tested up to and including the 6
month stability
time point at about 25 C and about 40 C.
In Table 17 and FIG. 2, they show a summary of the findings, whereby simple
microscopic analysis of the imiquimod formulations identify formulations with
inconsistent
particle size and large aggregation of material. Summary and composition of
lower dosage
strength imiquimod formulations are listed in Table 13 and Table 14.
87
Table 17
246 110 116 247 117 248 249 250 113
251 252 253 254 120 121
%w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w
Viscosity
Medium- very medium-
high High high high high high high low
high high high high high high low
(visual)
Appearance slightly
matt, matt,
(spatula)
lumpy Smooth smooth smooth smooth
smooth smooth smooth textured Textured smooth smooth smooth smooth smooth p,
0
PH 5 5 5 5 4.5 4.5 5 4 5
5 5 5 5 4.5 4.5 N.)
0,
ko
.4
G1 (Pa) 3639 1150.5 1504 1093 1740.5 5235 1364.5
171.5 642 943 626.5 567 2285.5 5231 304.5 ko
.4
co
Crossover 29.5 14.5 20.5 16 21.5 nonc 21.5 13
21.5 29.25 19 15 21.5 20.5 29.75 <ND'
(01)
0
O
w
Microscope v. bad Ok good bad good v.bad bad good
bad bad ok bad ok ok good I
`8).
88
Table 18. Physical Characteristics of 12 Lower Dosage Strength Imiquimod
Formulations, i.e., Formulations 181, 235, 236,
237, 238, 239, 240, 241, 242, 243, 244 and 245.
235 236 237 238 239 240 241
242 243 244 181 245
_
-
%w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w %w/w
%w/w %w/w
Excipients
-
Isostearic acid 15 10 15 10 15 15 15
20 15 20 15 20
Cetyl alcohol 2 4 _ 4 2 2 4 2
2 2 2 , 4 4
_ - -
Stearyl alcohol 2 2 2 2.4 2.4 2.4 2
2 2.4 2.4 2,4 2.4
White petroleum 3.4 3.4 2.8 , 2.8 3.4 2.8
3.4 2.8- 3.4 2.8 2.8 3.4
-
Polysorbate 60 3.8 3.8 3 38 3 3.8 3
3.8 3 3 3 3.8
Sorbitan Monostearate 0.2 1 I 1 1 0.2
1 1 0.2 0.2 1 1
Glycerin 3 1 3 3 1 1 , 3
1 1 3 1 3
Xanthan gum 0.3 0.3 0.7 0.3 0.7 0.3 0.3
0.7 0.7 0.3 0.3 0.7
Purified water 65.58 69.78 63.78 69.98 66.78 65.78
64.33 60.73 66.33 60.33 86.53 55.73
Benzyl alcohol 2 2 2 2 2 2 2
2 2_ 2 2 2 0
Methylparaben 0.2 0.2 0.2 0.2 0.2 0.2 0.2
0.2 0.2 0.2 0.2 0.2 o
Propyiparaben 0.02 0.02 0.02 0,02 0.02 0.02 0.02
0.02 0.02 0.02 0.02 0.02 n.)
o)
l0
_
-4
Imiquimod I 2.50 I 2.50 I 2.50 I 2.50 I 2.50
I 2.50 I 3.75 I 3.75 I 3.75 T 3.75 I
3.75 I 3.75 l0
-4
CO
Total amount (g) 100.00 100.00 100.00
100.00 100.00 , 100.00 100.00 100.00 100.00 100.00 100.00
100.00
n.)
HLB Values 14.39 12.78 12.35 12.78 12.35 14.39
12.35 12.78 14.26 14.26 12.35 12.78 o
Modification: multi multi multi multi multi multi
multi multi multi multi multi multi
o
o1
Viscosity low/med high high medium med/high
high Medium-High Medium Medium-Low Medium-
high Very High _ High w
w1
1,1-1 , 4.7 4.7 4.7 6 4.7 _ 4.7
5.0 4.7 4.7 4.5 4.7 4.5
G 294.37 1527.65 639.345 467.78
552.61 924.075 116.18 416.65 8767 65.425 2514.25_
1280.05 o
crossover 9.5 , 25.25 10.5 17.75 12 25.5 13.75
18.5 none 11.75 36 22.5
microscope v. good ok, but bad good, but
bad bad - good with very good ok good very good
good
particles? particles? particles?
bubbles
-
Appearance/Spatula glossy, v slight
smooth, matt, slight texture, glossy, slightly glossy,
glossy, slightly glossy, very smooth with a glossy,
texture, matt, v. glossy & v.
slightly matt does glossy, smooth
smooth, matt textured with textured with textured, very
slightly matt smooth, with
does smooth smooth
aerated smooth out some
aeration some aeration aerated textured appearance some aeration
out
89
CA 02697978 2010-03-30
(B) Scale-up and ICH stability
(1) Homogeneity
In Table 19, formulations 245, 121 and 193 show signs of phase separation. All
the
other formulations in Table 19 show good homogeneity, and are subsequently sub-
aliquoted and
placed on stability as described above under Preparation of Stability Samples.
Table 19. Homogeneity Results from 1 kg batches, where Samples are Removed
from Top
Middle and the Bottom of the Batch for Comparison of Homogeneity.
Formulation % Recovery %CV
3M Aldaraw 5% Batch 102.69 2.29 2.23
257 (1%) 100.29 0.68 0.68
197 96.81 2.15 2.22
183 97.56 0.48 0.50
245 91.08 12.80 14.06
182 97.68 0.73 0.75
189 98.32 0.92 0.94
184 98.37 1.61 1.63
193 97.21 0.22 0.23
188 98.95 2.48 2.51
195 99.66 0.70 0.70
255 99.46 0.49 0.49
256 98.80 0.75 0.76
Graceway Aldare 5%
102.74 1.26 1.23
Imiquimod
110 101.43 0.63 0.62
116 100.39 0.18 0.18
117 100.49 0.64 0.64
250 99.98 0.37 0.37
254 98.70 0.21 0.21
120 100.02 0.34 0.34
121 106.22 0.09 0.09
235 101.04 0.21 0.21
123 101.75 0.28 0.28
124 95.00 0.32 0.34
125 101.12 0.12 0.12
126 102.37 0.58 0.57
Pbol N/A N/A
Pbo2 N/A N/A
Pbo3 N/A N/A
Pbo4 N/A N/A
CA 02697978 2010-03-30
(C) Stability
(1) Stability of Imiquimod in Formulations
In Table 20, imiquimod in the formulations is stable at both about 25 C and
about 40 C
over an about six month period, although the results for three and six months
at both about 25 C
and about 40 C look consistently higher than previous time points. This could
be attributed to a
small amount of water evaporation from the containers. In addition, all
samples are consistent
with the commercially supplied Aldara 5% imiquimod cream sample. There are no
degradation
products detected in any of the samples in Table 20 at any of the temperatures
and time points
when analyzed at about 318 nm. With reference to formulation specification,
the specification
amount of imiquimod that is recovered from the samples in Table 20 is between
about
90%-110% w/w, thereby confirming that the samples fall within their target
specification. In
other words, and by way of example, the specification amount of imiquimod that
is recovered
from preferred 2.5% imiquimod formulations of the present invention will fall
within between
about 2.25% and about 2.75% w/w and the amount of imiquimod that is recovered
from
preferred 3.7.5% imiquimod formulations of the present invention will fall
within between about
3.38% and about 4.12% w/w. Thus, in accordance with the present invention, the
amount of
imiquimod recovery from preferred formulations will fall within about the 100%
10% w/w
specification of their target concentrations.
91
Table 20. Percentage of Imiquimod that is Recovered from the Formulations as
Compared to Theoretical when the
Formulations are Stored at 25 C and 40 C over a 6 Month Period. Highlighted
Grey Areas Indicate Time Points Which Are
Not Tested Due To Rejection/Omission Of Formulations (n=3 sd).
,
_______________________________________________________________________________
__________________________
Imiquimod TO T-1 month 25 C T-1 month 40 C 1.2 months
25 C T-2 months 40 C 1-3 month 25 C 1-3 month 40 C T-6 month 25
C T-6 month 40 C
-
Formulations wan SD Mean SD Mean SD Mean SD Mean sp Mean Si) Mean Si)
_ Mean SD Mean Si)
Aldaral 5% 100.38 9 0.25 ' 100.60 ' 9 0.10 100.41 9
0.04 - 100.58 - 0.10 - 101.40 9 0.29- 104.12 9 . 0.23 104,12
9 0.79 106.78 - 4 - 4.64 105.41 9 0.60
3M
=,- __ _
. _
297(4%) 100.29 0.12 104.36 0.18 104.98 9 2.41 102.31 * 0,46 102.42 +
0.10 103.16 4 0.37 105.79 9 0,27 407.09 9 1.63 103.76 9 3.59
. - _
_ _
197 96.81 4 0.17 97.74 0.20 99.22 1 0.33 99.28 + 0.14 10147 4 0.22 102,69
9 092 102.69 0.92 100.39 1.04 101.11 2.66
1
183 97.69 9 021 9973 032 99.43 9 2.77 99.61
* 0.33 100.01 - 0.05-4 100.80 4 1.07 103.70
1.58 100.75 1.82 102.19 1.33
- . _ . . . -
245 *
-
182 96,76 9 0.25 102,01 4 0.01 98.46 9 0.15 99.00 4 0.12 98.07 0,10
101.48 0.27 104.39 1.55 102.91 1.16 99.21 4.25
_
189 98.73 9 0.19 , 100.72 4 017 99.20 9 0.25
, . .
.
. . - 0
184 100.09 0.08 101.71 4 0.14 9686 9 0.20
.
.
,.. .
- - .... -
193
.
-
. _
. = . 0
188 100.28 4 0.02 - 99.39
+ 0.17 97.04 . 6 0.21- N)_
ON
195 99.39 0.32 99.33 * 0.07 97.84 9 0.25
101.13 4 0.10 103.13 0.10 103.00 0.15
106.25 4 0.99 106.84 1.38 106.28 * 1.22 t.C.
- . .._
...1
255 98.87 9 0.42 100.67 0.02 98.73 * 0.13
- - tO
256 97.58 0,03 100.06 4 0.22 98.05 + 0.12 99.74 9 0.07 99.28 9 0.24
101,74 4 0.37 101,71 9 0.44 105.42 * 2.10 105.55 3.20
-
...1
- - CO
Graceway 98.62 4 0,11 102.32 4 028 96.66 9 0.18 101.65 4 0.06 101,02 9 0.10
103,58 9 0.19 103,64 9 0,15 101.70 4 0.79 103.20 1.85
Aldara 5%
tv
Imiquimod
0
-_
I-4
110 101.06 * 0.35 102.17 4 0.95 99.48 9 0.19
101.46 9 0.09 99.03 4 0.14 102.73 4 0.64
103.36 0.38 _ 102.42 1.16 102.38 9 2.82. 0
- - -, - .... -
I
116 98.63 0.25 99.15 * 0.13 96,87 9 0,09
.
.
.
, .,
- . _ 0
.
1 La
117 99.00 9 0.73 102,06 0.10
98.42 ._, . 0 - - ..... ..
.00 _
_ _ _
250 97.67 9 0.11 101.88 4 0,06 99.37 1.05
99.43 0.20 99.74 0.13 101 57 4 0.35 105.32
242 102.45 C150 101.14 4 2.23 (A)
..,
. -... 0
254 96.29 9 _ 0. ,
27 99.75 * 0.09
97,11 _ 0.25 .
- -
120 99.79 9 0,27 100.61 4 0.03 98.82 9 017
. .
_ , -= .. - , - . - = .-
121
'
'=
. .
235 99.25 9 0
= .25 102.80 4 0.20 1007s 4 0.11 . .
123 09,71 4 0.17 101.49 9 0,10 99.52 4 0.34 40208 9 0.34 101.11 4 0.27
103.27 4 0.31 102.35 4 0.47 105.49 9 1.11 103.34 4 1.44
124 93.17 4 0,07 94.26 0.04 92.93
0.14 _. .
125 98,37 4 0.23 102.33 _ 0.29 99.14 9 0.14
99.99 i 9 0.21 I 100.38 9 0.09 1 103.28 4 0,76 - 104.87 4
2,65 102.48 _- _ 1,27 103.87 . 9 , 1.37 .
126 102.37 0.58 102.84 4 0.45 104. /1 4 0.04
100.02 0.95 101.32 4 0.40 99.28 3.25 98.43 *
0.55 101.95 0.37 103.02 1 1.89
_
- -
Pbo4 0 0 0 9 0 0 4 0 0 -4 0 0 4
0 0 4 0 0 , 4 0 0 4 0 0 0
Pbol 0 4 0 o 9 o o + o o + o _ o + o o + o o + o
o + o o 9 o
Pbo2 It 4 0 o 9 0 o + o o 9 0 o +
0 , o 9 o 0 9 0 o 9 _ 0 o o
_
Pb03 o 9 o ..o 9 a o 4 0 ' o 9 o 0 + o 0 9 0 0 9
o o 9 0 0 4 0
_
*30 C sample analysed, as 40 C had shown signs of phase separation.
92
CA 02697978 2010-03-30
(2) Stability of Benzyl Alcohol in Formulations
In Table 21, Benzyl alcohol content is found to fall over the duration of the
stability tests.
The greatest loss observed is in the placebo's; Pbo4 (1.08 0.02% w/w), Pbo 1
(1.01
0.03%w/w), Pbo2 (1.04 0.08% w/w) and Pbo3 (1.11 0.00% w/w) and the active
formulation
257 (1%) (1.37 0.01% w/w) which shows a loss in benzyl alcohol at about 40 C
for about
6 months down from 2.0% w/w. The specified range for benzyl alcohol in the
Aldara 5%
imiquimod cream formulations (1.0 to 2.1% w/w), are within specification for
Aldara 5%
imiquimod cream. The decrease in benzyl alcohol content from the formulations
is possibly the
result of the formation of an ester (benzyl isostearate), whereby there is a
reaction between the
excipients of benzyl alcohol and isostearic acid.
93
Table 21. Amount of Benzyl Alcohol that is Recovered from the Formulations
when the formulations that are Stored at 25 C
and 40 C over a 6 Month Period. Highlighted Grey Areas Indicate Time Points
Which Are Not Tested Due To
Rejection/Omission Of Formulations (N=3 Sd).
Imiquimod T-0 T-1 month 25 C 1-1 month 40 C 1-2 months 25
C T-2 months 40 C T-3 month 25 C T-3 month 40 C T-6 month 25 C
T-6 month 40 C
Formulations Mean SD_ Mean SD Mean SD Mean _ SD
Mean SD Mean SD Mean SD Mean SD Mean SD
Aldarag 5% 2.11 0.02 204 0.01 1.86 0.01 2.04
0.01 1.84 0.06 1.88 0.02 1.67 0.02
1.76 4 0.05 1.41 0.00
3M
- -_
257(1%) 2.06 0.01 2.01 4 0.01 1.74 0.02 2.00
+ 0.04 1,07 4 0.03 1.74 0.01 1.37 4 0.01
1.58 ,. 4 0.01 1.02 0.08
_- -
197 2.06 0.00 2.06 0.01
1.86 0.01 2.05 + 0.00 1.91 0.02 1.85 0,01 1.70 0.02 1.74 4
0.05 1.47 4 0.02
183 205 0.01 201 4 0.01 1.85 4 0.12 2.00 _
0.01 1.81 0.00 1,78 + . 0.01 1.56 4 0.02 1.66
4 004 1.24 001
245 _
182 217 0.00 2.17 0.00 1.95 001 2.11 4 0,04 1.97 + 000 1.94 4 0.01
1.82 0.04 1.85 4 0.03 1.48 + 0.05
189 211 0.01 206
0.02 , 1.88 4 0.02 ..
,
184 2.13_ 0.01 2.09 + 0.01 .
1.86 + 0.01 =
193
188 2.15 0.02 2.05 + 0.02 1.84 + 0.01
'
_ -
195 2.12 4 002 2.04 0.01 , 1.85 + 0.02 2.07
4 0.03 1.95 0.03 1.88 0.01 1.74 0.02 1
80 4 0.01 1,48 4 0.01
255 2.09 0.01 , 2.04 4 , 0.00 1.81 + 0.02 -
256 2.07 _ + 0.01 2.05 0.00 1.85 + 0.00 2.06
+ 0.02 1.87 4 0.03 1.84 + 0.01 1.88 1.68 0.01
1.76 I 0.01 1.46 + 0.01
-
Graceway 2.06 0.01 2.06 0.00 1.80 4 0.00 2.05 +
0.00 1.91 0.02 1.87 ' 0.02 1.65 4 001
1.73 0.00 1.38 + 0.03 C)
Aldarag 5%
Imiquimod
110 2.09 0.01 2.04 0.01 1.84 4 0,01 2.04
0.02 1.91 0.02 1 97 4 , 0.02 1.75
001 1.78 004 1.72 + 0.02 IV
116 2.08 0.01 2.05 , . 0,01
1.87 + 0.01, C71
-
1.0
117 2,11 - + 0.01 2.06 + 0.01
1.82 0.05 , - . .,,,
.
-4
250 2.03 0.01 2.00 + 0.01 1.78 0.07 1.96
0.02 , 1.70 + 0.01 1.74 0.01 1.47 _ 4 0.03 1.59
4 002 1.12 , 0.02
1.0
-
254 2.07 4 0.01 2.04 + 0.01
1.89 0,01 .. .4-
. .
CO
120 211 0.00 .. 2.00 - +
0.01 , 1.77 0.02 .. ..
.
=
. - ,
121
= IV
-
, .
1
0
235 2.10 0.00 2.10 + 0.02
1.92 0.02 . = = = =
..
- - -
I-`
123 2.11 + 0.01 2,05 + 0.00 1.82 0,01 2.06_
. . + 001 1.85 0.01 1.84 + 0.01 1,59
0.00 1.73 - 0.02 1.34 + 0 01 0
- ,-
124 1.96 0.01 1.89 0.01
1.71 0.00 I
- -
0
125 2.08 ., 0.01 2.06 + 0.01 1.82 0.00 2.02+
0.01 1.82 + 0.01 1.85 0.00 1.63 , 0.04 1.73
0.02 1.32 + 0,02
,,,
_ W
126 2.00 + , 0.02 2.02 + 0.01 1.89 0.01 1.86
_ 0.02 1.65 0.02 2.00 + 0.04 1.70 +
0.04 2.01 , 0.03 1.55 0,02 1
PB04 1.93 0.02 1.83 0.08 1.90 + 0.03 1.91
+ 0.01 1.53 + 0.00 1.81 , 0.01 1.39 4
0.01 1.71 ., 0.01 1.08 4 0.02 W
-
PBOI 1.82 + 0.01
1.65 0.00 1.85 0.09 1.54 0.10 1.93 + 0.03 1.55 0.04 1.58 0.02
1.01 0.03 0
_ PB02 1.83 0.01 1.65 0 87 _ 0.19
.01 1
. 1.70 + 0.09 2.01 0.13 1.61 0.08 _ 1.65 4 0.05
1.04 0.08 PB03 _ 1,97 + 0.00 1.81 0.01 2.09 0.00 1.81
0.00 2.12 4 0.04 1.70 0.00 1.73 0.01 1.11 4 0.00
*30 C sample analysed, as 40 C had shown signs of phase separation
94
CA 02697978 2010-03-30
(D) Microscopic stability of the formulations
In Table 22, there is no change in the particle size in any of the
formulations tested at
about 25 C over about a 6 month period. In addition, and with reference to the
microscopic
photographs presented in FIGS. 8A-C and 9; no crystals are detected. For
completeness and
reference, the pictures of the formulations rejected after one month stability
are shown in
FIGS. 10A-B.
Table 22. Results of Particle Size of the Formulations when viewed under a
Microscope at
25 C over a 6 Month Period.
Particle size (AM)
Formulation T = 0 t=1 Month t=2 Months t=3 Months t=6
Months
3M Aldara 5% <10 <10 <10 <10 <10
GRACE WAY
Aldara 5% <10 <10 <10 <10 <10
257 (1%) <10 <10 <10 <10 <10
110 <10 <10 <10 <10 <10
250 <10 <10 <10 <10 <10
182 <10 <10 <10 <10 <10
195 10 10 10 10 10
123 10 10 10 10 10
125 10 10 10 10 10
256 10 10 10 10 10
197 10 10 10 10 10
183 10 10 10 10 10
126 <10 <10 <10 <10 <10
Pbol <10 <10 <10 <10 <10
Pbo2 <10 <10 <10 <10 <10
Pbo3 <10 <10 <10 <10 <10
Pbo4 <10 <10 <10 <10 <10
CA 02697978 2010-03-30
(E) Macroscopic stability of the
formulations
In Table 23, there are no obvious physical changes in the formulations that
are tested
over the six month stability program, with the exception of the placebos,
which become notably
less viscous. See also Tables 24-26.
Table 23. Macroscopic Appearance when Imiquimod Formulations are stored at
about
25 C over about a 6 Month Period.
Appearance spatula Test (25 C sample only) Visual Viscosity (25 C sample
only)
Imiquimod
Formulation
t = 0 t=1 month t=2 months t=3 months t=6 months t=0
t=1 month t=2 months t=3 months t=6 months
3M Alder? Medium- Medium-
5% Glossy, very Glossy, very Glossy, very Glossy, very
Glossy, very
Imiquimod smooth smooth smooth smooth smooth High High
Medium High Medium
Graceway
Aided' 5% Glossy, very Glossy, very Glossy, very
Glossy, very Glossy, very Medium-
Imiquimod smooth smooth smooth smooth smooth High High
High High Medium
Medium- and Glossy and Glossy, very Glossy, very Glossy,
very Me Medium- Medium-
Low
257(1%) smooth smooth smooth smooth smooth Medium
High High High viscosity
Glossy, very Glossy, very Glossy, Glossy, Glossy,
slightly slightly slightly slightly slightly
110 textured texturedtextured textured textured High
High High High Medium
Glossy and Glossy, Very Glossy, Very Glossy, Very
Medium-
smooth, some Glossy and slightly slightly
slightly Medium- Medium-
250 aeration textured textured textured textured
Medium High High High Medium
Medium- Medium-
Very glossy Very glossy Very glossy Very glossy
Very glossy Medium-
182 and smooth and smooth and smooth and smooth and
smooth High High High High High
Glossy, Glossy, Glossy, very Glossy,
Glossy, Medium-
slightly slightly slightly slightly
slightly Medium-
High
195
Glossy, Glossy, slightly Glossy, slightly Glossy,
Medium- Medium- Medium-
Glossy and slightly textured, textured, slightly
123 smooth textured smoothed out smoothed out textured
High High High High Medium
Glossy,
smooth with Glossy,
Glossy and Glossy and slight Glossy, slightly
Medium-
124 smooth smooth smooth textured Medium Medium
Medium High Low
aeration
Glossy, Glossy, Glossy, Glossy, Glossy,
Medium- Medium- Medium- Medium-
256
slightly slightly slightly slightly slightly
High High High High
High
textured textured textured textured textured
Glossy, Glossy, very Glossy and Glossy and
slightly slightly Glossy and slightly slightly
Medium-
197 textured textured Medium High
High High High
textured textured textured
Glossy,
smooth Glossy and Glossy and Glossy and Glossy and
Medium- Medium- Medium-
slight
183 smooth smooth smooth smooth High High
High High Low
aeration
Glossy, very Smooth,
126 Slightly
slightly slightly Glossy and
textured, Low
textured sheen
viscosity
,
Very glossy
Pbo 1 and smooth Very glossy Very glossy Glossy
and Low Medium- Medium- Low Low
Glossy and xrifl pnooth and cmnoth smooth 1 mu 1 ow
smooth
96
CA 02697978 2010-03-30
Imiquimod Appearance spatula Test (25 C sample only) Visual Viscosity
(25 C sample only)
Formulation
t = 0 1=1 month 1=2 months 1=3 months 1=6 months t=0
t=1 month t=2 months 1=3 months t=6 months
v
Glossy and Glossy and Glossy and Glossy,tlery slighy Glossy and
Medium- Medium- Medium-
Pbo2 smooth smooth smooth textured smooth Low Medium
Low low Low
Glossy, very Glossy, very
slightly textured slightly textured
but smoothed out but smoothed
Glossy and Glossy and Glossy and Medium- Medium-
Medium-
out
Pbo3 smooth smooth smooth Low Low Low Low
Medium
Smooth
Glossy and Glassy and Glossy and Glossy and cream high Medium-
Medium-
Pbo4 smooth smooth smooth smooth sheen Low Medium Low
Low Low
Table 24. Stability Data for 10 Formulations, i.e., Formulations 116, 117,
120, 124, 188,
184, 189, 235, 254 and 255, rejected after 1 Month Stability, with respect to
the Spatula
Test, Visual Viscosity and Particle Size (as determined by microscopy).
Formulation Spatula Test Visual Viscosity Majority of
particle
size ( M)
T= 0 T=1 T= 0 T=1 T= 0
T=1 Month
Month Month
116 Glossy, Glossy, Medium Medium- 10 10
textured textured High
117 Glossy, Glossy, Medium- Medium- <10 <10
slightly slightly High High
textured textured
254 Smooth with Smooth, High Medium-
<10 <10
matt matt High
appearance
120 Smooth, Smooth, Very High Very High <10 <10
matt matt
appearance,
some
aeration
235 Glossy, Glossy, Medium- Medium <50 <50
textured but very slightly Low
does textured but
smooth out does smooth
out
97
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Formulation Spatula Test Visual Viscosity
Majority of particle
size ( M)
T= 0 T=1 T= 0 T=1 T= 0 T=1 Month
Month Month
188 Glossy and Glossy Medium- High <10 <10
textured and Low
textured
189 Glossy, very Glossy, High Very High <10 <10
slightly slightly
textured textured
184 Glossy, Glossy, High High <10 <10
slightly slightly
textured textured
255 Glossy and Glossy High High 10 <10
smooth and
smooth
124 Glossy, very Glossy, very Medium- Medium- <10 <10
slightly slightly High High
textured textured
Table 25. pH Stability Data for 10 Imiquimod Formulations, i.e., Formulations
116, 117,
120, 124, 188, 184, 189, 235, 254 and 255, Rejected after 1 Month Stability.
pH
Formulation
Identity T = 0 T = 1 Month
116 5.0 4.7
117 4.5 4.5
254 4.7 4.7
120 4.5 4.5
235 4.5 4.5
188 4.7 4.7
189 4.7 4.7
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Formulation pH
Identity T = 0 T = 1 Month
184 4.7 4.7
255 4.5 4.5
124 4.5 4.5
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Table 26. Viscosity Stability Data for 10 Imiquimod Formulations, i.e.,
Formulations 116,
117, 120, 124, 188, 184, 189, 235, 254 and 255, Rejected after 1 Month
Stability
Crossover G' Brookfield (cps) Bohlin Viscosity
(cps)
Formulation
Identity T= 0 T= 0 T= 0 T= 1 T = 0 T = 1 Month
Month
116 9.0 478 601867 63500 15350 13300
117 14.0 1151 1216667 1281000
17250 15600
254 10.3 1399 1476667 1423000
19050 19000
120 15.3 884 1416667 1393000
20250 20900
235 6.0 134 245333 313000
6350 5700
188 14.0 708 1141333 1254000 20350 20750
189 34.8 1037 1344333 1463000
18700 18550
184 23.0 1054 1475667 1350000
20200 21600
255 16.0 1488 2483333 1334000
21150 25150
124 7.0 561 849000 663000
14400 14250
(F) Brookfield Viscosity Stability Results of Formulations
In Table 27, Brookfield viscosity measurements are notoriously variable and,
as such,
there are fluctuations in the measurements of the formulations over about a 6
month period when
stored at about 25 C. Variations in results are further observed if the
spindle or the speed of the
spindle rotation is altered. Although the majority of the formulations are
measured using the
same settings and spindle; the placebo formulations (Pbol, Pbo2, Pbo3 and
Pbo4) result in
torque measurements below the threshold required for accurate measurements and
subsequently
readings are inaccurate. Attempts are made to change the settings and
spindles; however, results
are vastly different and thus unreliable. See also Tables 24-26.
100
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Table 27. Viscosity and Rheology Measurements of Imiquimod Formulations stored
at
25 C over a 6 Month Period.
Crossover
G(Pa) , (ol Brookfield (cps Bohlin Viscosity (cPs)
(basedon3Mmethod)
Formulation t=1 t=2 t=3 t=6 t=1 t=2
1=3 t=6
Identity 1=0 t=0 t=0 Month Months Months Months t=0 Month Months
Months Months
3MAIdarag5% 507 123 660333 623000 337000 428833 166233
15700 17300 17600 13296 12833
Imiquimod
Graceay Aldarag 716 10.5 1108667 1109000 587667 768566
252033 18250 20250 19900 18697 15100
5% Imiquimod
257(1%) 352 10.52 642667 600000 220333 351566 . 13600
15050 11500 6075 3139
110 782 11.5 87100 119000 , 782333 619300 366067
16250 16400 18000 16368 14076
250 320 9 695333 816000 557333 394166 141400 13700
16400 14950 10587 , 5890
182 702 8.5 693067 1097000 904667 523033 273233
18050 17850 18550 16820 13691
195 692 15 1141333 ,1293000 779333 618133 381700 17000 17600
16500 16208 14696
123 510 10.8 804000 773000 386333 701500 199933
15800 16250 15200 13095 9587
125 485 8.5 603000 707000 429667 412133 127067
14900 17050 15300 12069 8301
256 667 7.3, 1126000 958000 697667 757523 249500 19400
18300 18750 15453 12379
197 646 14 1082667 1377000 613667 607366 274400 , 17750
17850 17600 15861 13524
183 719 10.3 693333 839000 596000 332900 188000
18700 19100 18600 15906 12120
126 AP -- 430100 235066 228104 212500 105720 16783
12739 14749 10856.5 8789.5
PBOI 306 11 85000 = = = 12100 14450 7500
7969 2508.3
PB02 263 13 79500 14200 13950 9100
6452.5 2617.6
PB03 305 11.5 117000 12200 13850 9000
8395 3256.5
PB04 227800 = 10350 7953 5511 3550
2247
results un-reliable and not presented as the torque was out of range (due to
low viscosity) for the Brookfield viscometer
using the settings and spindle used for all the other samples. Alternative
spindles and settings were investigated; however, the
results were vastly different than previous readings.
** no recorded measurements, as test was only required for initial
formulations choice and development.
101
CA 02 697978 2010-03-30
(G) Bohlin viscosity Results
Also as shown in Table 27, the Bohlin viscosity results are in contrast to the
results of the
Brookfield viscosity and appear to be more consistent for all formulations. A
fall in the viscosity
is observed for 257 (1%) and placebo formulations, Pbo 1 -4, over the 6 month
stability study,
whereby the viscosity falls by approximately 50%. All formulations are within
the range of the
specifications for the Aldara 5% imiquimod cream formulation (2000 to 35,000
cps). See also
Tables 24-26.
(H) pH Stability of Formulations
In Table 28, it reports that the specification for all formulations that are
tested, fall within
the Aldara 5% imiquimod cream specifications (pH 4.0 to 5.5). A slight
variation in pH is
observed over the 6 month period for all of the formulations. See also Tables
24-26.
Table 28. ph for Imiquimod Formulations when Stored at about 25 C and about 40
C over
a 6 Month Period. Grey Areas Indicate No Test Is Performed.
PH
Formulation t= 0 t=1 month t=-2 months t=3 months t=6 months
25 C 25 C 40 C 25 C 40 C 25 C 40 C 25 C
40 C
3M Aldara 5%
4.5 4.5 4.5 4.5 4.5 4.7 4.3 4.1
Imiquimod
Graceway Aldara
4.5 4.5 4.5 4.5 4.5 4.5 4.3 4.5
5% Imiquimod
257(1%) 4.2 4.5 4.5 4.5 4.5 4.1 4.1 3.9
'
110 5 4.7 4.7 4.7 4.7 4.4 4.5 4.3*
250 4.2 4.2 4.2 4.5 4.2 4 4.2 4.1
182 4.5 4.5 4.5 4.5 4.5 4.6 4.3 4.3
195 4.7 4.5 4.5 4.5 4.5 4.7 4.5 4.5
123 4.5 4.7 4.7 4.7 4.7 4.3 4.1 4.3
125 4.5 4.5 4.5 4.5 4.5 4.2 4.1 4.1
256 4.7 4.7 4.7 4.7 4.7 4.4 4.3 4.3
197 4.5 4.7 4.7 4.7 4.7 4.6 4.5 4.3
183 4.5 4.5 4.5 4.5 4.5 4.2 4.5 4.1
126 4.2 4.3 4.3 4.3 4.3 4.3 4.3 4.1 4.1
102
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PH
Formulation t= 0 t=1 month t=2 months t=3 months
t=6 months
25 C 25 C 40 C 25 C 40 C 25 C 40 C 25 C
40 C
Pbol 4.5 4.5 4.5 4.5 4.2 4.5 4.0
4.0
,
Pbo2 4.5 4.5 4.2 4.2 4.2 4.2 4.1 4.1
Pbo3 4.5 4.5 4.5 4.2 4.2 4.2 4.2
4.2
Pbo4 4.5 4.2 4.5 4.2 4.2 4.1 4.1 4.0
4.0
* 30 C sample analyzed as the 40 C sample had phase separated
(I) Preservative efficacy test
Table 29 reports final viable counts of organism inoculations that are added
to the
formulations.
Table 29. Total Viable Counts that are obtained for the Organism Inoculates
into the
Imiquimod Formulations
Mimi for 182 and Cfu/ml
for 126 and
Organism
110 Pbo4
Staphylococcus aureus 2.4E+08 3.1E+08
Escherichia coli 1.7E+08 2.1E+08
Pseudomonas
9.0E+07 1.1E+08
aeruginosa
Candida albicans 1.0E+08 1.1E+08
Aspergillus niger 1.7E+07 1.6E+08
Table 30 shows colony forming unit count (cfu) for Staphylococcus aureus after
PET
validation is performed on two formulations stored at about 2 - 8 C.
103
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Table 30. Viable counts that are obtained for Staphylococcus aureus that are
Inoculated
Formulations after PET Validation
Imiquimod Suspension
Dilution Viable count (cfu/m1)
Formulation fluid
1 ml in 9 ml 2.20E+08
DIE broth
0.1 ml in 0.9 ml 2.80E+08
110
1 ml in 9 ml 1.00E+03
Ringer's
solution 0.1 ml in 0.9 ml 1.50E+03
1 ml in 9 ml 2.30E+08
D/E broth
0.1 ml in 0.9 ml 2.60E+08
182
1 ml in 9 ml 1.00E+03
Ringer's
solution 0.1 ml in 0.9 ml 1.40E+03
The preservative efficacy test ("PET") is a procedure used to demonstrate
antimicrobial
activity of a formulation with respect to the preservative system used. In
Table 31, cell counts
that are recovered from the inoculated formulations at various time points are
reported. The data
shows that sufficient log reductions are present in the formulations at about
2-8 C and about
40 C and meet the requirements that are specified in both the USP and EP.
104
Table 31. Colony Forming Unit Counts that are recovered (Cfu/MI) for Each
Organism from the Imiquimod Formulations,
over 28 Days
Organisms recovered- (cfu/ml)
Pass/
Formulation Organism 0 h 24 h 48 h 7 days 19
days 21 days 28 days Fail
.. ,
S. aureus 3.10E+05 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
Pbo4 E. coil 5.00E+03 0.00E+00 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 PASS
STORAGE: Ps. aeruginosa 9.00E+03 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
2 - 8 C
a alhicans 5.00E+04 1.80E+03 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
A. niger 1.60E+05 6.00E+03 2.50E+03
0.00E+00 0.00E+00 ,.._ 0.00E+00 0.00E+00 PASS
S. aureus 1.70E+06 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
E. coil 6.00E+03 0.00E+00 G.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
Pbo4
STORAGE: 40 C Ps. aeruginosa 1.30E+04 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
_ C. albicans 2.60E+04 4.10E+03 1.30E+03
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
A niger 3.00E+05 1.70E+04 3.30E+03_
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS C1
S. aureus 5.70E+04 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
_
0
126 E. coil 1.20E+06 0.00E+00 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 PASS n.)
a)
STORAGE: Ps. aeruginasa 1.40E+04 0.00E+00 ,
0.00E+00 0.00E+00 , 0.00E+00 0.00E+00
0.00E+00 PASS lt7
2- 8 C
-.3
C. albicans 3.50E-W4 _ 5.00E+03 4.00E+02
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS l0
A. niger 1.00E+05 2.10E+04 2.50E+03
0.00E+00 0.00E+00 0.00E-F00 0.00E+00 PASS ---.3
CO
S. aureus 2.10E+04 0.00E+00 _ 0.00E+00
0.00E+00 _ 0.00E+00 0.00E+00 0.00E+00 PASS
n.)
E. coil 5.00E+05 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS 0
126 '
STORAGE 40 C Ps. aeruginosa 1.50E+04 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
0
:
i
C- albicans 3.80E+04 3.60E+03 2.50E+03
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS 0
W
A. niger 1.00E+05 2.90E+03 1.60E+03 ,
0.00E+00 , 0.00E+00 0.00E+00 0.00E+00 ,
PASS 1
.
W
S. aureus 1.00E+06 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS 0
110 E. soli 7.00E+05 0.00E+00 0.00E+00 0.00E+00
0.00E+00 , 0.00E+00 0.00E+00 PASS
STORAGE: Ps. aeruginosa 8.00E+04 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
2- FPG
C. albi cans 8.00E+05 2.60E+04 7.00E+03
7.00E+01 0.00E+00 0.00E+00 , 0.00E+00 PASS
A. niger 6.00E+04 9.00E+04 2.30E+04
7.00E+03 3.70E+02 0.00E+00 0.00E+00 , PASS
_
S. aureus 6.00E+05 0.00E+00 0.00E+00
0.00E+00 0.00E+00 ., 0.00E+00 0.00E+00 PASS
E. coil 8.00E+04 0.00E+00 0.00E+00
0.00E+00_ 0.00E+00 0.00E+00 0.00E+00 PASS
110
STORAGE: 40 C Ps. aeruginosa 7.00E+05 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
C. alhicans 1.60E+05 1.50E+04 4.00E+03
2.20E+02 0.00E+00 0.00E+00 0.00E+00 PASS
A. niger 7.00E+04 6.00E+04 2.50E+04
1.90E+04 1.90E+02 0.00E+00 0.043E+00 PASS
S. aureus 1.70E+06 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
182 E colt 1.70E+06 0.00E+00 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 PASS
STORAGE: Ps. aeruginosa 7.00E+05 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
2 - 8 C C. alhicans 3.00E+05 2.10E+04 1.90E+03 3.00E+03
0.00E+00 0.00E+00 0.00E+00 PASS
_
A. niger 4.00E+05 5.00E+03 2.40E+03
3.00E+03 0.00E+00 0.00E+00 0.00E+00 PASS
S aureus 1.50E+06 0.00E+00 0.00E+130
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
182
STORAGE.* 40 C E coil 1.10E+06 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+00 0.00E+00 PASS
105
Organisms recovered- (cfu/ml)
Pass/
Formulation Organism Oh 24 h 48 h 7 days 19 days
21 days 28 days Fail
Ps. aeruginosa 6.00E+05 0.00E+00 0.00E+00 0.00E+00
0.00E+00 0.00E+00 0.00E+OG PASS
C. albicans 7.00E+05 3.00E+04 3.00E+03 7.00E+03
0.00E+00 0.00E+00 0.00E+00 PASS
A. niger 7.00E+05 6.00E+03 2.70E+03 1.70E-4-03
1.20E+02 0.00E+00 0.00E+00 PASS
ci
n.)
IfCO
n.)
0
106
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(J) Test Item Release Studies through Synthetic Membranes
In FIG. 3, it indicates that there is a trend between the concentrations of
imiquimod
present in the formulation as compared to the amount that is released. This is
supported by the
results presented in FIG. 4 and the corresponding statistical analysis, where
it can be seen that
that the higher the imiquimod concentration in the formulation, the greater
the release of
imiquimod. However, formulation 183 (3.75% w/w imiquimod) gives a
statistically (at a 95%
confidence level) greater cumulative release of imiquimod when it is compared
to the 2.5% w/w
formulations. All of the 5% w/w formulations, i.e., Aldara 5% imiquimod cream
batch,
Aldara 5% imiquimod cream Graceway batch, and Aldara 5% imiquimod cream
Sachet),
result in significantly (p<0.05) higher amounts of imiquimod released over a 3
h time period in
comparison to 1%, 2.5% and 3.75% w/w imiquimod formulations. There is no
statistical
difference (p>0.05) in the total cumulative amount of imiquimod that is
released from any of the
3.75% w/w imiquimod formulations; likewise there is also no statistical
difference (p>0.05) from
the 2.5% w/w imiquimod formulations.
ANOVA statistical analysis (95% confidence level): mean total cumulative
amount that
is released ( /cm2) after 3 h (from results that are presented in FIG. 3):
Source DF SS MS
Formulation 12 86439222 7203268 19.40 0.000
Error 39 14484370 371394
Total 51 100923592
S = 609.4 R-Sq = 85.65% R-Sq (adj) = 81.23%
Individual 95% CIs For Mean Based on
Pooled StDev
Level N Mean St. Dev ---- +
Aldara 3M 5% 4 5332.8 734.2 (----*---)
Aldara sachet 4 4605.5 626.9 (---*---)
110 4 1862.8 185.9
250 4 1845.6 206.4
182 4 3161.3 774.9 (---*---)
195 4 3046.2 988.2 (---*---)
123 4 2094.9 674.6
107
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125 4 2134.1 369.0 (---*---)
256 4 2918.7 59.5 (---*----)
197 4 2766.0 929.1 (---*----)
183 4 3453.2 564.4 (---*---)
MedPharm Aldara 4 4813.3 660.7 (---*---)
257% 4 586.9 170.2 (---*---)
+ ---------------------------------------------- + ------- + ------- + --
0 1500 3000 4500
Pooled StDev = 609.4
ANOVA statistical analysis (95% confidence level): mean total cumulative
amount that
is released ( g/cm2) after 3 h for each concentration of imiquimod in the
formulations that are
tested (from results that are presented in FIG. 4):
Source DF SS MS F P
Formulation 3 83957708 27985903 79.18
0.000
Error 48 16965878 353456
Total 51 100923586
S = 594.5 R-Sq = 83.19% R-Sq (adj) = 82.14%
Individual 95% CIs For Mean Based on
Pooled StDev
Level N Mean St. Dev ---- + ------- + ------- + -- +
1% 4 586.9 170.2 (---*---)
2.50% 16 1984.4 389.9
3.75% 20 3069.1 702.3 (*-)
5.00% 12 4917.2 689.4 (--*-)
+ ---------------------------------------------- ------- ------- --
0 1500 3000 4500
Pooled StDev = 594.5
The result for the rate of release presented in Table 32, indicate that the
higher the
amount of imiquimod in the formulation, the faster the rate of release of
imiquimod. Similar to
the results of the cumulative amount permeated, there is no statistical
difference (p>0.05)
between the results for the 2.5% w/w imiquimod formulations (Table 32 and FIG.
12) and
108
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likewise for the 3.75% w/w imiquimod formulations (Table 32 and FIG. 13). See
also FIGS. 11
and 14.
Table 32. Comparison of Mean Flux of Imiquimod (pg/Cm2) over a 3 H Period for
Membrane Release Tests (Mean Sd, Where N=4) that are Presented as a Function
of
Time from 15 Min To 3 H.
Flux Vtime
Formulations Mean sd
Graceway Aldara 5%
3720.65 569.38
imiquimod
3M Aldara 5% Imiquimod
3873.38 479.64
Cream Bulk
3M Aldara 5% Imiquimod
3319.56 494.32
Cream sachet
257 (1%) 504.40 148.43
123 (2.5%) 1539.39 482.36
250 (2.5%) 1396.68 173.65
125 (2.5%) 1592.98 324.51
110(2.5%) 1518.29 151.17
182 (3.75%) 2410.03 599.08
195 (3.75%) 2310.06 597.59
256 (3.75%) 2424.87 28.09
197(3.75%) 2116.53 723.60
183 (3.75%) 2516.84 357.41
ANOVA statistical analysis (95% confidence level): mean amount of imiquimod
released
( g/cm2) over a 3 hour period for the membrane release studies (mean sd,
where n=4)
presented as a function of Vtime from 15 min to 3 h (from results presented in
Table 32):
Source DF SS MS F P
Formulation 12 45353042 3779420 19.05 0.000
Error 39 77392670 198443
Total 51 53092309
109
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S = 445.5 R-Sq = 85.42% R-Sq (adj) = 80.94%
Individual 95% Cls For Mean Based on
Pooled StDev
Level N Mean St. Dev --- + -------- + ----- + ---- +
3M Aldan. 5% 4 3873.4 479.6 (--*---)
Imiquimod Cream
Bulk
3M Aldara 5% 4 3319.6 494.3 (---*--)
Imiquimod Cream
Sachet
110 4 1518.3 151.2 (---*--)
250 4 1396.7 173.6 (---*--)
182 4 2410.0 599.1 (---*---)
195 4 2310.1 597.6 (---*---)
123 4 1539.4 482.4 (---*---)
125 4 1593.0 324.5 (--*----)
256 4 2424.9 28.1 (---*---)
197 4 2116.5 723.6 (---*--)
183 4 2516.8 357.4 (---*---)
Graceway 5% 4 3720.6 569.4 (---*----)
Imiquimod Cream
257 1% 4 504.4 148.4 (---*---)
+ --------------------------------------------- + -------- + ----- + ----
0 1200 2400 3600
Pooled StDev = 445.5
110
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ANOVA statistical analysis (95% confidence level): Comparison of the mean
amount of
imiquimod released ( g/cm2) over a 3 hour period for the 3M Aldan. 5%
imiquimod cream lkg
batch, the 3M Aldara 5% imiquimod cream sachet, the Graceway Aldara 5%
imiquimod
cream lkg batch and 257, 1% Imiquimod formulation (mean sd, where n=4) -
refer to FIG. 11:
Source DF SS MS F P
Formulation 3 57378855 19126285 54.74 0.000
Error 12 4192460 349372
Total 15 61571315
S = 591.1 R-Sq = 93.19% R-Sq (adj) = 91.49%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St.Dev + ---------------- + ------ + ------- + ---
3M Aldara 5% 4 5332.8 734.2 (---
* )
Aldara sachet 4 4605.5 626.9 (---
*---)
MedPharm Aldara 4 4813.3 660.7 (---
*---)
U2F 1% 4 586.9 170.2 (---*---)
+ ----------------------------------------------- + ------ + ------- + ---
0 1600 3200 4800
Pooled StDev = 591.1
ANOVA statistical analysis (95% confidence level): Comparison of the mean
amount of
imiquimod released (j.1g/cm2) over a 3 hour period for 2.5% imiquimod
formulations 123, 250,
125 and 110 (mean sd, where n=4) - refer to FIG. 12:
Source DF SS MS F P
Formulation 3 274778 91593 0.55 0.659
Error 12 2004990 167083
Total 15 2279769
S = 408.8 R-Sq = 12.05% R-Sq (adj) = 0.00%
Individual 95% Cls For Mean Based on Pooled
1 1 1
CA 02697978 2010-03-30
StDev
Level N Mean St.Dev -+ -- + -- + -- +
GW002 4 1862.8 185.9 -- ( ------ * )
GW008 4 1845.6 206.4 -- ( ------ * )
GW037 4 2094.9 674.6 -- ( ----- * )
GW039 4 2134.1 369.0 -- ( ------ * )
-+ -- + -- + --- + --
1500 1800 2100 2400
Pooled StDev = 408.8
ANOVA statistical analysis (95% confidence level): Comparison of the mean
amount of
imiquimod released ( g/cm2) over a 3 hour period for 3.75% imiquimod
formulations 182, 195,
256, 197 and 183 (mean sd, where n=4) - refer to FIG. 13:
Source DF SS MS F P
Formulation 4 1084063 271016 0.49 0.743
Error 15 8286917 552461
Total 19 9370981
S = 743.3 R-Sq = 11.57% R-Sq (adj) = 0.00%
Individual 95% Cis For Mean Based on Pooled
StDev
Level N Mean St.Dev -- + -- + -- + +-
GW030 4 3161.3 774.9 -- ( --- * )
GW033 4 3046.2 988.2 -- ( -- * )
GW040 4 2918.7 59.5 ( -- * ---- )
GW041 4 2766.0 929.1 -- ( ---- * )
GW042 4 3453.2 -------- 564.4 -- + -- + -- + +-
2400 3000 3600 4200
Pooled StDev = 743.3
As discussed under FIG. 14 in the Brief Description of the Drawings, FIG. 14
shows a
comparison of the mean amount of imiguimod released (p.g/cm2) over a 3 hour
period for the
112
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2.5% ( A), 3.75% (.), 3M Aldara imiquimod cream batch (a), Graceway Aldara
imiquimod
cream 1 kg batch (a) and formulation 257 Imiquimod formulations (a) (mean
sd, where n=4).
Based on the results; it appears that the greater the amount of imiquimod in
the
formulation, the faster and greater the total amount of imiquimod that is
released, suggesting that
the amount and rate of release are concentration dependant.
(K) In vitro Skin Permeation Study
(1) Homogeneity
Manufacture of the formulations (about 100g batches) is first performed, which
batches
are then mixed with the radioactive labelled material. The batches are
prepared by omitting
about 1.38g of isostearic acid which is added with the radio-labelled
imiquimod. The
homogeneity of the test formulations, see Table 33, is measured as described
in under
Homogeneity Control above and all compositions are confirmed to meet the
criterion (<10%
CV).
Table 33. Homogeneity of Radioactivity for Imiquimod Formulations
Formulation % CV
Graceway Aldara 5% Imiquimod Cream 0.93
3M Aldara 5% Imiquimod Cream 1.50
182 0.80
195 2.39
256 1.17
197 0.07
183 1.54
110 0.71
250 2.53
123 1.89
125 1.53
126 2.55
257 (1%) 2.30
(2) Franz cell study
The data that is shown in Table 34 is the actual amount of imiquimod that is
recovered
for each formulation from the various matrices, which is also represented
graphically in FIG. 5.
113
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FIG. 6 represents the total amount of imiquimod that is recovered for each
formulation in the
epidermis, dermis and receiver fluid combined.
114
Table 34. Amount of Imiquimod that is Recovered following Mass Balance
Investigation
Amount of imiquimod recovered SEM (4)
Percentage Replicate
Percentage total
Formulations . imiquimod s (n) Receiver Fluid Unabsorbed
Dose Stratum Comeum Epidermis Dennis recovered
Graceway
Aldara 5%
Imiquimod
Cream 5% 6 0.03 0.01 127.06 + 9.58 80.78
11.67 2.90 0.72 2.76 + 0.70 85.24 + 5.15
3M Aldara
5% Imiquimod +
Cream 5% 4 0.05 0.03 132.75 , 17.62 74.37 , +
10.59 6.60 + 1.91 . 3.96 0.41 86.92 + 4.16
1823.75% 3.75% 6 0.08 + 0.06 85.75 + 3.93 46.85 +
5.51 3.65 1 0.85 6.94 2.22 76.25 1.82
1953.75% 3.75% 4 0.08 0.07 74.19 6.90 57.41 +
11.46 7.06 2.29 2.47 0.87 75.16 5.12
0
2563.75% . 3.75% 5 0.16 0.06
71.73 7.22 33.41 +4.77 1.99 0.71 9.03 2.37 , 61.91 3.95
1973.75% 3.75% 5 0.06 + 0.03 110.54 6.22 41.61 + 6.54
2.21 + 0.36 2.53 + 0.91 83.54 + 3.92 o
N.)
cn
1833.75% 3.75% 4 0.02 0.01 113.84 11.63 40.99 6.99
3.26 0.53 5.11 2.32 86.88 6.68 l0
-4
l0
1102.5% 2.5% 6 0.00 0.00 52.92 3.96 33.96 3.43
3.25 0.70 2.32 *0.44 73.82 +4.64
co
250 2.5% 2.5% 5 0.00 + 0.00 82.46 + 2.94 28.30
3.67 2.35 0.68 1.17 + 0.30 91.25 + 3.93
N.)
, 123 2.5% 2.5% 5 0.01 + 0.01 68.33 3.18 35.93
+ 10.40 4.20 + 1.69 1.80 0.32 88.04 7.95
0
1-,
125 2.5% 2.5% 6 0.02 +0.01 72.82 3.92 28.88 4.41
1.12 0.42 1.52 0.42 83.32 2.44 0
o1
126 2.5% 2.5% 5 0.01 +0.00 64.00 5.27 29.59 4.97
2.36 0.40 4.44 1.62 80.15 6.61
w
w1
257 1% 1% 4 0.01 0.00 28.88 4.60 12.49
3.75 0.42 0:14 1.54 1.05 86.98 3.40
o
115
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The only data rejected from that presented in Table 34, FIG 5 and FIG. 6 are
obvious
outliers that are observed on the basis of cell failure.
The average data for the 5%, 1%, 3.75% and 2.5% w/w formulations showing the
amount
of imiquimod that is recovered from the unabsorbed fraction, in the Stratum
corneum and in the
epidermis, dermis and receiver fluid combined are shown in FIG. 7. This data
shows that there
is a linear dose release between the amount of imiquimod applied and recovery
in each of the
matrices. See also Table 35 for stability of calibration standards in spent
receiver fluid and
Tables 36-40-for statistical analysis.
Table 35. Stability of Calibration Standards in Spent Receiver Fluid (Stored
In HPLC
Crimp Top Vials at Each Temperature (Where Recovery was Compared To T=0)
48h % recovered in Spent
receiver fluid
Standard
(ug/ml) Spent receiver fluid: Fridge RT 37 C
105.5 88.242 88.546 91.704
84.4 84.561 84.421 85.629
52.75 91.776 92.027 93.779
42.2 Full thickness + placebo 83.976 84.144 86.439
21.1 84.584 85.162 88.000
10.55 88.307 86.897 90.798
5.275 90.260 87.973 86.134
105.5 90.545 92.275 92.278
84.4 98.841 99.790 101.010
52.75 92.317 92.152 95.282
42.2 Full thickness 95.103 95.805 95.939
21.1 91.876 91.968 93.847
10.55 94.989 93.522 97.826
5.275 94.586 95.232 90.611
105.5 83.833 84.515 84.903
84.4 95.620 96.033 98.178
52.75 85.635 88.169 86.906
42.2 Epidermal sheet + placebo 93.077 92.904 95.095
21.1 101.831 105.389 105.213
10.55 84.046 85.095 89.945
5.275 88.881 86.540 86.828
105.5 90.465 92.089 91.501
84.4 81.350 82.276 82.694
52.75 87.669 89.096 90.943
42.2 Epidermal sheet 85.716 86.340 89.641
21.1 95.828 97.098 97.470
10.55 93.180 94.971 97.099
5.275 88.938 91.447 85.995
116
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Tables 36-40. Statistical Analysis for Amount of Imiquimod that is Recovered
following
Mass Balance Test
ANOVA statistical analysis (95% confidence level): Amount of imiquimod that is
recovered following mass balance test from receiver fluid (from results that
are presented in
FIG. 5) is shown in Table 36:
Table 36
Source DF SS MS F P
Cl 14 0.12075 0.01006 1.84 0.066
Error 52 0.28455 0.00547
Total 64 0.40530
S = 0.07397 R-Sq = 29.79% R-Sq (adj) = 13.59%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St. Dev ----- + ---- + ---- + -- +
3M Aldara 5% 4 0.05250 0.05909 ( --- * ---- )
Imiquimod Cream
110 2.5% 6 0.00000 0.00000 ( -- * -- )
250 2.5% 5 0.00400 0.00894 ( -- * -- )
182 3.75% 6 0.07833 0.14400 ( --- * ---- )
195 3.75% 4 0.08250 0.14500 ( --- * --- )
123 2.5% 5 0.01200 0.01095 ( -- * -- )
125 2.5% 6 0.02333 0.02503 ( -- * -- )
256 3.75% 5 0.15600 0.14064 ( ---- * -- )
197 3.75% 5 0.05800 0.06611 ( --- * -- )
183 3.75% 4 0.01750 0.01708 ( -- * -- )
126 5 0.00600 0.00894 ( ---- * ---- )
Graceway Aldara 6 0.02833 0.03312 ( ---- * ---- )
5% Imiquimod
Cream
257 (1%) 4 0.00500 0.00577 ( -- * -- )
-------------------------------------------- + --- + ---- + -- +
0.000 0.080 0.160 0.240
Pooled StDev = 0.07397
117
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ANOVA statistical analysis (95% confidence level): Amount of imiquimod that is
recovered following mass balance test from unabsorbed dose (from results that
are presented in
FIG. 5) is shown in Table 37:
Table 37
Source DF SS MS F P
Cl 12 50777 4231 16.85 0.000
Error 52 13071 251
Total 64 63848
S = 15.85 R-Sq = 79.53% R-Sq (adj) = 74.80%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St. Dev -- + -- + ---- + ------ +-
3M Aldara 5% 4 132.75 35.25 ( -- *----)
Imiquimod Cream
1102.5% 6 52.93 9.69 (---*---)
250 2.5% 5 82.46 6.57 (----*---)
182 3.75% 6 85.75 9.63 (--*---)
195 3.75% 4 74.19 13.80 (---*----)
123 2.5% 5 68.33 7.10 (----*---)
125 2.5% 6 72.82 9.61 (---*---)
256 3.75% 5 71.73 16.15 (---*----)
1973.75% 5 110.54 13.91 (---*---)
183 3.75% 4 113.85 23.27 (----*---)
126 5 63.98 11.78 (---s---)
Graceway Aldara 6 127.06 23.46 (--*---)
5% Imiquimod
Cream
257 (1%) 4 28.88 9.20 (---*----)
-------------------------------------------- + ----- + ---- + ------ +-
35 70 105 140
Pooled StDev = 15.85
118
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ANOVA statistical analysis (95% confidence level): Amount of imiquimod that is
recovered following mass balance test from Stratum corneum (from results that
are presented in
FIG. 5) is shown in Table 38:
Table 38
Source DF SS MS F P
Cl 12 21479 1790 6.72 0.000
Error 52 13848 266
Total 64 35327
S = 16.32 R-Sq = 60.80% R-Sq (adj) = 51.75%
Individual 95% Cls For Mean Based on Pooled
StDev
Level N Mean St. Dev + ----- + ------ + ------ + -----
3M Aldara 5% 4 74.38 21.17 ( -- * -- )
Imiquimod Cream
1102.5% 6 33.96 8.41 (----*----)
250 2.5% 5 28.30 8.21 ( -- * -- )
182 3.75% 6 46.85 13.50 ( -- * -- )
195 3.75% 4 57.41 22.92 ( -- * -- )
123 2.5% 5 35.93 23.25 ( -- * -- )
125 2.5% 6 28.88 10.80 ( -- * -- )
256 3.75% 5 33.41 10.67 ( -- * -- )
197 3.75% 5 41.61 14.62 ( -- * -- )
183 3.75% 4 41.00 13.97 ( -- * -- )
126 5 29.59 11.11 ( -- * -- )
Graceway Aldara 6 80.78 28.60 ( -- * -- )
5% Imiquimod
Cream
257 (1%) 4 12.49 7.49 ( -- * -- )
-+ --------------------------------------------- + ------ + ------- + ----
0 25 50 75
Pooled StDev = 16.32
119
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ANOVA statistical analysis (95% confidence level): Amount of imiquimod that is
recovered following mass balance test from epidermis (from results that are
presented in FIG. 5)
is shown in Table 39:
Table 39
Source DF SS MS F P
Cl 12 187.78 15.65 3.26 0.002
Error 52 249.79 4.80
Total 64 437.57
S = 2.192 R-Sq = 42.91% R-Sq (adj) = 29.74%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St. Dev -- + ---- + --- + ---- +
3M Aldara 5% 4 6.600 3.823 ( -- * -- )
Imiquimod Cream
1102.5% 6 3.248 1.717 ( -- * -- )
250 2.5% 5 2.350 1.514 ( -- * -- )
182 3.75% 6 3.643 2.083 ( -- * -- )
195 3.75% 4 7.055 4.580 ( -- * -- )
123 2.5% 5 4.196 3.782 ( -- * -- )
125 2.5% 6 1.123 1.039 ( -- * -- )
256 3.75% 5 1.990 1.588 ( -- * -- )
197 3.75% 5 2.208 0.797 ( -- * -- )
183 3.75% 4 3.260 1.053 ( -- * -- )
126 5 2.360 0.903 ( -- * -- )
Graceway Aldara 6 2.895 1.752 ( -- * -- )
5% Imiquimod
Cream
257 (1%) 4 0.415 0.273 ( -- * )
-------------------------------------------- + ----- + --- + --- +-
0.0 3.0 6.0 9.0
Pooled StDev = 2.192
120
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ANOVA statistical analysis (95% confidence level): Amount of imiquimod that is
recovered following mass balance test from dermis (from results that are
presented in FIG. 5) is
shown in Table 40:
Table 40
Source DF SS MS F P
Cl 12 340.72 28.39 3.29 0.001
Error 52 448.34 8.62
Total 64 789.06
S = 2.936 R-Sq = 43.18% R-Sq (adj) = 30.07%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St. Dev -- + ---- + ----- + ------ +-
3M Aldara 5% 4 3.960 0.825 ( --- * -- )
Imiquimod Cream
1102.5% 6 2.323 1.068 ( -- * -- )
250 2.5% 5 1.164 0.663 ( -- * -- )
182 3.75% 6 6.937 5.445 ( -- * -- )
195 3.75% 4 2.473 1.733 ( --- * -- )
123 2.5% 5 1.796 0.715 ( -- * -- )
125 2.5% 6 1.518 1.020 ( -- * -- )
256 3.75% 5 9.030 5.305 ( -- * -- )
197 3.75% 5 2.532 2.036 ( --- * -- )
183 3.75% 4 5.110 4.638 ( -- * -- )
126 5 4.436 3.626 ( -- * -- )
Graceway Aldara 6 2.758 1.721 ( -- * -- )
5% Imiquimod
Cream
257 (1%) 4 1.533 2.099 ( -- * )
------------------------------------------- + ---- ----- + --- +-
0.0 3.5 7.0 10.5
Pooled StDev = 2.936
121
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The results that are presented in FIG. 6, indicate that the delivery of the
imiquimod into
the receiver fluid, epidermis and dermis combined from formulations 182, 195
and 256 are
similar to the Aldara 5% imiquimod cream formulation when comparing averages.
With
respect to the statistical analysis, there is no statistical difference
(p>0.05) between 110 (2.5%),
126 (2.5%), 123 (2.5%), 182, (3.75%), 195 (3.75%), 256 (3.75%), 197 (3.75%)
and 183 (3.75%)
when compared to Aldara 5% imiquimod cream formulation in the amount of
imiquimod that is
recovered from the receiver fluid, epidermis and dermis combined.
In Table 41, ANOVA statistical analysis (95% confidence level) are presented:
Total
amount of imiquimod that is recovered for each formulation in the receiver
fluid, epidermis and
dermis combined (from the results that are presented in FIG. 6:
Table 41
Source DF SS MS
Cl 12 340.72 28.39 3.29 0.001
Error 52 448.34 8.62
Total 64 789.06
S = 3.819 R-Sq = 43.05% R-Sq (adj) = 29.91%
Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean --------------------------- St. Dev +-
257 (1%) 4 1.958 2.357 -- ( -- * )
1102.5% 6 5.572 2.706 --- * -- )
250 2.5% 5 3.524 1.445 -- * -- )
123 2.5% 5 6.010 4.296 ---- * -- )
125 2.5% 6 2.663 0.837 -- ( -- * )
126 2.5% 5 6.804 3.538 ------ * -- )
182 3.75% 6 10.662 -------------------- 6.441 -- * -- )
195 3.75% 4 9.608 5.392 --------- * -- )
256 3.75% 5 11.180 --------------------- 5.770 -- * -- )
197 3.75% 5 4.800 1.749 --- * -- )
183 3.75% 4 8.388 3.666 -------- * -- )
122
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Individual 95% CIs For Mean Based on Pooled
StDev
Level N Mean St. Dev ---------------- -+ +-
Graceway Aldara 6 5.682 2.671
5% Imiquimod
Cream
257(1%) 4 10.613 4.211
-+ --------------------------------------------
0.0 5.0 10.0 15.0
Pooled StDev = 3.819
The results that are presented in FIG. 7 and statistical analysis in Tables 42-
46 indicate
that there is a distinct dose proportionate trend between the amount of
imiquimod that is
recovered from each of the matrices with respect to the concentration of
imiquimod in the
formulation for both unabsorbed and Stratum comeum. The trend in this data, is
also observed
for the epidermis (with respect to average values in the statistical
analysis).
In Tables 42-46, statistical analysis for the total amount of imiquimod
recovered from
each of the matrices (1%, 2.5%, 3.75% and 5% w/w formulations)
ANOVA statistical analysis (95% confidence level): Total amount of imiquimod
that is
recovered for imiquimod concentration combined from each of the matrices from
unabsorbed
dose (from results presented in FIG. 7) in Table 42:
Table 42
Source DF SS MS
Cl 3 44198 14733 35.53 0.000
Error 61 25293 415
Total 64 69491
S = 20.36 R-Sq = 63.60% R-Sq (adj) = 61.81%
123
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Individual 95% Cls For Mean Based on Pooled
StDev
Level N Mean St. Dev -- + ---- + ---- + ----- +-
1% 4 28.88 9.20 -- ( -- * )
2.5% 27 64.08 16.24 (-*--)
3.75% 24 90.75 22.48 (-*-)
5% 10 129.33 26.99 (---*---)
---------------------------------------------- + ----- + ---- + ----- +-
35 70 105 140
Pooled StDev = 20.36
ANOVA statistical analysis (95% confidence level): Total amount of imiquimod
that is
recovered for imiquimod concentration combined from each of the matrices from
Strateum
corneum (from results presented in FIG. 7) in Table 43:
Table 43
Source DF SS MS F P
Cl 3 19744 6581 25.76 0.000
Error 61 15583 255
Total 64 35327
S = 15.98 R-Sq = 55.89% R-Sq (adj) = 53.72%
Individual 95% C1s For Mean Based on
Pooled StDev
Level N Mean St. Dev --- -+ ---- + ---- + ----- +
1% 4 12.49 7.49 -- ( -- * )
2.5% 27 3L34 12.57 (--*-)
3.75% 24 43.74 15.85 (-*--)
5% 10 78.22 24.79 (---*---)
-+ --------------------------------------------- + ---- + ---- + -----
0 25 50 75
Pooled StDev = 15.98
124
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ANOVA statistical analysis (95% confidence level): Total amount of imiquimod
that is
recovered for imiquimod concentration combined from each of the matrices from
epidermis
(from results presented in FIG. 7) in Table 44:
Table 44
Source DF SS MS F P
Cl 3 55.25 18.42 2.94 0.040
Error 61 382.32 6.27
Total 64 437.57
S = 2.504 R-Sq = 12.63% R-Sq (adj) = 8.33%
Individual 95% Cls For Mean Based on
Pooled StDev
Level N Mean St. Dev -- + -- + --- + -- +-
1% 4 0.415 0.273 ---- ( ---- * )
2.5% 27 2.621 2.137 (--*---)
3.75% 24 3.505 2.729 (---*---)
5% 10 4.37 3.200 ( -- * -- )
-------------------------------------------- + --- + ---- + -- +
0.0 2.5 5.0 7.5
Pooled StDev = 2.504
ANOVA statistical analysis (95% confidence level): Total amount of imiquimod
that is
recovered for imiquimod concentration combined from each of the matrices from
dermis (from
results presented in FIG. 7) in Table 45:
Table 45
Source DF SS MS F P
Cl 3 147.4 49.1 4.67 0.005
Error 61 641.7 10.5
Total 64 789.1
S = 3.243 R-Sq = 18.68% R-Sq (adj)= 14.68%
125
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Individual 95% CIs For Mean Based on
Pooled StDev
Level N Mean St. Dev -- + ----- + ---- + --- +-
1% 4 1.533 2.099 ------ ( -------- * )
2.5% 27 2.223 1.974 (----*----)
3.75% 24 5.407 4.694 ( -- * --)
5% 10 3.239 1.502 ( -- * -- )
------------------------------------------ + ------ + ---- + --- +-
0.0 2.5 5.0 7.5
Pooled StDev = 3.243
ANOVA statistical analysis (95% confidence level): Total amount of imiquimod
that is
recovered for imiquimod concentration combined from each of the matrices from
receiver fluid
(from results presented in FIG. 7) in Table 46:
Table 46
Source DF SS MS F P
CI 3 0.07047 0.02349 4.28 0.008
Error 61 0.33483 0.00549
Total 64 0.40530
S = 0.07409 R-Sq = 17.39% R-Sq (adj) = 13.32%
Individual 95% Cls For Mean Based on
Pooled StDev
Level N Mean St. Dev -+ -- + -- + -- +
1% 4 0.00500 0.00577 ---- ( -------- * )
2.5% 27 0.00926 0.01542 ( -- * -- )
3.75% 24 0.08083 0.11632 ( -- * -- )
5% 10 0.03800 0.04392 ( -- * -- )
---------------------------------------- + ------- + --- + --- +-
-0.050 0.000 0.050 0.100
Pooled StDev = 0.07409
126
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The following Tables 47-59 summarize results for formulations 126, 182 and
Pbo4.
Table 47. Stability of Imiquimod in the Formulations. Percentage of imiquimod
that is
recovered from each formulation compared to theoretical when stored at 25 C
and 40 C
over a 6 month period.
t = 1 month t = 2 months t = 3 months t
= 6 months
Formulations t = Oh 25 C 40 C 25 C 40 C 25 C 40 C
25 C 40 C
96.76 0 102.01 98.46 99.00 98.07
101.48 104.39 102.91
182 25 0.01 0.15 0.12 0.10 0.27 1.55 1.16 99.12
0.45
PB04 0 0 0 0 0 0 0 0 0
102.37 102.84 104.11 100.02 101.32
99.28 98.43 101.95 + 0
126 0.58 0.45 0.04 0.95 040 3.25 0.55 37
103.02 1.89
Table 48. Stability of Imiquimod in the Formulations. Identification of
Imiquimod when
the formulations are stored at 25 C and 40 C over a 6 month period (confirmed
by HPLC).
T = 1 month T = 2 months T = 3 months T = 6 months
Formulations T = 0
25 C 40 C 25 C 25 C 40 C 40 C 25
C 40 C
182 Complies Complies
Complies Complies Compiles Complies Complies Compiles Complies
126 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
GWO3OP Complies Complies
Complies Complies Complies Complies Complies Complies Complies
Table 49. Stability of Benzyl Alcohol in the Formulations. Amount of benzyl
alcohol that
is recovered from each of the formulations when the formulations are stored at
25 C and
40 C over a 6 month period.
i = 1 month t = 2 months t = 3 months t = 6
months
Formulations t = 0 h
25 C 40 C 25 C 40 C 25 C 40 C 25 C
40 C
182 2.17 + 0.00 2.17 0.00 1.95 0.01 2.11 0.04
1.97 0.00 1.94 0.01 , 1.82 + 0.04 1.85 + 0.03 1.48 + 0.05 _
PB04 1.93 0.02 1.83 0.06 1.90 0.03 1.91 + 0.01 1.53
0.00 1.81 + 0.01 1.39 0.01 1.71 0.01 1.08 0.02
126 2.00 0.02 2.02 + 0.01 1.89 + 0.01 1.86 + 0.02
1.65 0.02 2.00 + 0.04 1.70 + 0.04 2.01 0.03 1.55 + 0.02
Table 50. Stability of Benzyl Alcohol in the Formulations. Identification of
Benzyl alcohol
when the formulations are stored at 25 C and 40 C over a 6 month period
(confirmed by
HPLC).
T = 1 month T = 2 months T = 3 months T = 6 months
Formulations T = 0
25 C 40 C 25 C 25 C 40 C 40 C 25
C 40 C
182 Complies Complies
Complies Complies Compiles Complies Complies Compiles Complies
126 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
PB04 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
127
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Table 51. Stability of Methylparabens in the Formulations. Amount of
Methylparabens
that are recovered from each of the formulations when the formulations are
stored at 25 C
and 40 C over a 6 month period.
t = 1 month t = 2 months t = 3 months t =
6 months
Formulations t = 0 h
25 C 40 C 25 C 40 C 25 C 40 C 25 C UPC
182 0.18 0.18 0.19 0.20 0.20 0.19 0.20
0.19 0.19 0.001
0.001 0.000 0.001 0.001 0.000 0.000 0.004
0.002
PB04 0.19 0.00 0.19 0.18 0.20 0.20 0.20 0.20
0.20 0.20 0.002
0.003 0.002 0.001 0.000 0.001 0.001 0.001
126 0.20 0.20 0.19 0.19 0.21 0.00 0.21
0.20 0.20 0.20 0.001
0.002 0.001 0.000 0.001 0.001 0.001
0.001
Table 52. Stability of Methylparabens in the Formulations. Identification of
Methylparabens when the formulations are stored at 25 C and 40 C over a 6
month
period (confirmed by HPLC).
T = 1 month T = 2 months T = 3 months T
= 6 months
Formulations T = 0
25 C 40 C 25 C 25 C 40 C 40 C
25 C 40 C
182 Complies Complies
Complies Complies Compiles Complies Complies Compiles Complies
126 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
PB04 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
Table 53. Stability of Propylparabens in the Formulations. Amount of
Propylparabens
that are recovered from each of the formulations when the formulations are
stored at 25 C
and 40 C over a 6 month period.
t = 1 month t = 2 months I t = 3
months t = 6 months
Formulations
t = Oh 25 C 40 C 25 C 40 C 25 C 40 C 25 C
40 C
0.019 0.020 0.018 0.018 0.018 0.021 0.022
0.019
182
0.019 0.0010
0.000 0.001 0.000 0.000 0.000 0.002 0.001
0.000
0.018 0.018 0.16 0.19 0.020 0.020 0.020
0.018
PB04
0020 0.001
0.001 0.001 0.001 0.000 0.000 0.002 0.002
0.000
0.018 0.019 0021 0.018 0.019 0.020
0010 0.020
126
0020 0.001
0.000 0.001 0.001 0.000 0.001 0.001 0.001
0.000
Table 54. Stability of Propylparabens in the Formulations.
Identification of
Propylparabens when the formulations are stored at 25 C and 40 C over a 6
month period
(confirmed by HPLC).
T = 1 month T = 2 months T = 3 months T
= 6 months
Formulations T = 0
25 C 40 C 25 C 25 C 40 C 40 C
25 C 40 C
182 Complies Complies
Complies Complies Compiles Complies Complies Compiles Complies
126 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
P804 Complies Complies
Complies Complies Complies Complies Complies Complies Complies
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Table 55. Microscopic Stability of the Formulations. The results of the
particle size for
each formulation which is determined by optical microscopy at 25 C over a 6
month
period.
Particle size ( M)
Formulation
t = 0 t=1 Month
t=2 Months t=3 Months t=6 Months
182 <10 <10 <10 <10 <10
PB04 <10 <10 <10 <10 <10
126 <10 <10 <10 <10 <10
Table 56. pH stability of the Formulations. The results of the pH test for
each of the
formulations when the formulations are stored at 25 C and 40 C over a 6 month
period.
Grey area indicate no test was performed.
pH
Formulation t=0 t=1 month I t=2 months t=3
months t=6 months
25 C 25 C 40 C 25 C 40 C 25 C 40 C 25 C 40 C
182 4.5 4.5 4.5 4.5 4.5 4.6 4.3
4.3
PB04 4.5 4.2 4.5 I 4.2 4.2 4.1 4.1
4.0 4.0
126 4.2 4.3 4.3 4.3 4.3 4.3 4.3 4.1 4A
Table 57. Macroscopic stability of the Formulations. The results of the
macroscopic
appearance test when the formulations are stored at 25 C over a 6 month
period.
Appearance spatula Test (25 C sample only) Visual Viscosity (25 C sample
only)
Formulation
t=0 1=1 t=2 1=3 1=6 1=1 1=2 t= 1=6 month
months months months t = 0month months months months
Very
Very Very Very Very
glossy Medium- Medium- Medium-
182 glossy and glossy and glossy and glossy and
High High
and High High High
smooth smooth smooth smooth
smooth
Glossy, Smooth,
very slightly Glassy Slightly
126
and textured, Glossy Medium Medium Medium Medium .Low.
slightly textured,
viscosity
smooth sheen
textured glossy
Smooth
Glossy Glossy Glossy Glossy
cream Medium Medium-
PB04 and and and and Medium Low
Low
smooth smooth smooth smooth high - Low Low
sheen
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Table 58. Brookfield and Bohlin Viscosity. The results of the viscosity and
rheology
measurements for the formulations that are stored at 25 C over a 6 month
period.
Crossover
G*(Pa ) Brookfield (cps) Bohlin Viscosity (cps) (based on 3M method)
(0*)
Formulation
Identity t=2 t-3
t=-6
t=1 t=1 t=2 t=3 t=6
1--3 1-:) t=0 Month Month Month t=0
Month Month Months Months Months
S s s
109700 90466 52303 27323 1805 1785
182 702 8.5 693067 18550 16820
13691
0 7 3 3 0 0
126 ** 430100 235066
22810 21250 10572 1678 1273 14749 10856. 8789.
**
4 0 0 3 9 5 5
p 4** ** 227800 * * * * 1035 7953 5511
3550 2247
0
* Results not presented as the torque is out of range (due to low viscosity)
for the Brookfields
viscometer based on the setting and spindle that are used for all the other
samples. Alternative
spindles and settings are investigated; however, the results are vastly
different compared to
previous readings.
** no recorded measurements.
Table 59. Identification of 4-hydroxy Imiquimod when the formulations are
stored at 25 C
and 40 C over a 6 month period (confirmed by HPLC at 318 nm).
1=13 t=1 month 1=2 months 1=3 months
1=6 months
Formulations
25 C 25 C 40 C 25 C 40 C 25 C 40 C 25 C
40 C
182 NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT
0.1% NMT 0.1% NMT 0.1%
w/w w/w w/w w/w w/w w/w w/w w/w
w/w
NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT
0.1% NMT 0.1% NMT 0.1%
PB04
w/w w/w w/w w/w w/w w/w w/w w/w
w/w
NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT 0.1% NMT
0.1% NMT 0.1% NMT 0.1%
126
w/w w/w w/w w/w w/w w/w w/w w/w
w/w
EXAMPLE 24
Two Phase 3, Randomized, Double-blind, Placebo-controlled, Multi-center,
Efficacy and Safety
Studies of 2.5% and 3.75% lmiquimod Creams in the Treatment of External
Genital Warts
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This Example 24 will study a shorter duration treatment regimen utilizing
lower
concentrations of imiquimod to allow for more frequent dosing. The lower
concentrations of
imiquimod should permit daily dosing such that the overall short treatment
regimen (up to 8
weeks of treatment) could still provide adequate clearing of external
genital/perianal warts.
The clinical development program for the formulations of lower strengths of
imiquimod
will investigate a patient population similar to that evaluated in the
development program for
Aldara . In addition to lower strengths, the key modification is to the
treatment regimen itself,
as the treatment with the 2.5% and 3.75% imiquimod creams will be once daily
for a maximum
of 8 weeks, rather than the currently approved regimen of 3 times per week
with Aldara for up to
16 weeks. Each strength will be evaluated vs. placebo to determine the benefit-
risk profile with
each of these treatment regimen.
STUDY OBJECTIVE
The primary objective of this Example is to compare the efficacy and safety of
2.5%
imiquimod cream and 3.75% imiquimod cream to placebo cream, applied once daily
for up to 8
weeks, in the treatment of external genital warts (EGW).
The secondary objective of this study is to provide information on recurrence
of EGW.
DESCRIPTION OF STUDY
This is a randomized, double-blind, placebo-controlled, multicenter Phase 3
study of
2.5% and 3.75% imiquimod creams in the treatment of EGW. Two investigational
treatments
will be studied: 2.5% imiquimod cream once-a-day application for a maximum of
8 weeks and
3.75% imiquimod cream once-a-day for a maximum of 8 weeks. The study will
consist of a
Screening visit and an Evaluation Period including a maximum 8-week Treatment
Period and a
maximum 8-week No-treatment Period. Subjects with complete clearance at the
end of study
(EOS) will be followed for a maximum of 12 weeks for recurrence. During the
Evaluation
Period, subjects will be followed until they have achieved complete clearance
of all warts. Any
subject determined to have achieved complete wart clearance at any time
through the Week 16
visit will enter the maximum 12-week Follow-up Period for evaluation of
recurrence. The total
study duration is a maximum of 28 weeks from randomization.
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Approximately 450 subjects with at least 2 and up to 30 external genital /
perianal warts
will be randomized. Subjects will be screened for study eligibility during the
4 weeks prior to
randomization. During the Screening Period, the medical history, including
genital / perianal
wart history and wart treatment history, and demographic information,
including sex, age, and
race will be recorded. In addition, a physical examination, including vital
signs and clinical
safety laboratory tests, will be performed for each subject. If clinically
indicated, a sexually
transmitted diseases (STD) screen may be performed. Subjects with a positive
screen for STD
may participate in the study if they otherwise meet the required
Inclusion/Exclusion Criteria.
For female subjects, a pelvic exam/Pap smear will be performed unless a normal
(negative) Pap
smear result is available and was performed within 6 months of enrollment.
Qualified subjects will be randomized to receive one of 3 treatments: 2.5%
imiquimod
cream, 3.75% imiquimod cream, or placebo cream. Subjects will apply study
cream once daily
for a maximum of 8 weeks. Subjects will be stratified by gender and will be
randomized to
treatment with an allocation ratio of 2:2:1 in favor of the active treatments.
All subjects will be
seen every 2 weeks for up to 16 weeks, depending on complete clearance of all
baseline and new
warts.
In the Evaluation Period, subjects will apply investigative cream to the
identified
treatment area for a maximum of 8 weeks. If the subject has not achieved
complete wart
clearance by the Week 8 visit (end of treatment, EOT), the subject will be
followed for an
additional maximum of 8 weeks. Subjects determined to have achieved clearance
of all warts at
any time through Week 16 will complete procedures for the EOS visit and will
immediately
enter the Follow-up Period for determination of recurrence. In the Follow-up
Period, subjects
will be followed every 4 weeks for up to 12 weeks or until the recurrence of
warts. The 2.5%
and 3.75% imiquimod creams that will be used this Example 24 have the same
formulations as
the 2.5% and 3.75% imiquimod creams that were used in the EGWs studies
reported in
Examples 23-26, which are described in application for U.S. patent, Serial
No._12/636,613 filed
December 11, 2009, which is incorporated herein by reference in its entirety.
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Clinical evaluations, including count of warts and assessment of local skin
reactions, and
recording of adverse events (AEs) and concomitant medications will be
performed. Safety
laboratory tests will also be performed prior to treatment and at the EOS
visit.
Study Number: GW01-0805
Objectives: The primary objective of this study was to compare the efficacy
and safety
of 2.5% imiquimod cream and 3.75% imiquimod cream with that of placebo cream,
applied once
daily for up to 8 weeks, in the treatment of EGW. The secondary objective of
this study was to
provide information on the recurrence of EGW.
Methodology: This was a randomized, double-blind, placebo-controlled,
multicenter study that
compared the efficacy and safety of 2.5% imiquimod cream and 3.75% imiquimod
cream with
that of placebo in the treatment of EGW. The study consisted of a screening
visit and an
evaluation period that included a maximum 8-week treatment period and a
maximum 8-week no-
treatment period. Subjects who achieved complete clearance at End of Study
(EOS) entered a
maximum 12-week follow-up period for evaluation of recurrence. The total study
duration was a
maximum of 28 weeks from randomization.
Subjects determined to be eligible during the screening period were stratified
by gender and
randomized in a 2:2:1 ratio to 2.5% imiquimod cream, 3.75% imiquimod cream, or
placebo
cream. Subjects were scheduled for 1 prestudy screening visit, and then were
scheduled for
visits every 2 weeks for up to 16 weeks during the evaluation period,
depending on complete
clearance of all baseline and new warts. During the evaluation period,
subjects applied
investigative cream to the identified treatment area for a maximum of 8 weeks.
If the subject did
not achieve complete wart clearance by the Week 8 visit (End of Treatment,
EOT), the subject
was monitored for an additional maximum of 8 weeks. Subjects determined to
have achieved
clearance of all warts at any time through Week 16 completed procedures for
the EOS visit and
were eligible to immediately enter the follow-up period for determination of
recurrence. During
the follow-up period, subjects were monitored every 4 weeks for up to 12 weeks
or until the
recurrence of warts.
Clinical evaluations included counts of the number of warts, assessments of
local skin reactions
(LSRs), and recordings of adverse events (AEs) and concomitant medications. At
selected
centers, photography was performed at designated visits. Laboratory tests were
also performed
prior to treatment and at the EOS visit to assess safety.
The study design is presented schematically in Tables 60 and 61 below.
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Table 60 Study Design ¨ Evaluation Period
Screening Treatment Period No-treatment Period
Week Week Week 2 Week 4 Week 6 Week Week Week Week Week
-4 to 0 0 8/ 10 12 14 16/
Day 1 EOT EOS
Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6
Visit 7 Visit 8 Visit 9 Visit 10
Note: At any time during the Evaluation Period (ie, any time after Visit 2), a
subject who achieved clearance of all
warts concluded the evaluation period and was eligible to enter the Follow-up
for Recurrence Period.
Table 61 Study Design ¨ Follow-up for Recurrence Period
Follow-up Period
(Only in subjects with clearance of all warts)
Week 4 Week 8 Week 12
Post-EOS Post-EOS Post-EOS
Follow-up Visit 1 Follow-up Visit 2 Follow-up Visit 3
Discussion of Study Design, Including the Choice of Control Groups
This was a randomized, double-blind, placebo-controlled, multicenter study. In
order to assess
the effect of imiquimod in the treatment of EGW, a placebo-control group was
included in the
study design. The study medications were identical with the exception of the
absence of
imiquimod in the placebo cream and the concentration of imiquimod (2.5% or
3.75%) in the
active formulations.
The double-blind study design, in which the treatment assignment was concealed
from the
subjects, investigators, and all individuals involved in study execution,
monitoring, and data
collection, was chosen to provide an unbiased evaluation of the study
medications. Comparison
of each imiquimod group to the placebo group provides an unbiased test of the
effect of
imiquimod.
The 8-week treatment period was selected based on market experience of the use
of Aldara to
treat EGW, in which treatment duration greater than 8 weeks appears to be
rare. Subjects who
did not experience clearance during the treatment period were observed for an
additional no-
treatment period of up to 8 weeks. Once clearance was achieved at any time
during the study,
subjects were observed during a 12-week follow-up period to determine if the
EGW recurred.
Selection of Study Population
It was planned to enroll approximately 450 subjects in a 2:2:1 ratio:
approximately 180 in each
active-treatment group and 90 in the placebo group. Forty-five investigative
study centers in the
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United States (US) participated in the study, although 2 centers did not
enroll any subjects.
Study centers could enroll a maximum of 30 subjects per center. Enrollment was
stopped at all
centers when the study enrollment goal was reached.
Inclusion Criteria
Subjects could participate in the study if they met the following inclusion
criteria:
1. Were willing and able to give informed consent -- for subjects under 18,
the parent/legal
guardian was required to give written informed consent and the subject was
required to
provide written assent in accordance with local regulations;
2. Were at least 12 years of age at the time of initial screening;
3. Were willing and able to participate in the study as outpatients, making
frequent visits to
the study center during the treatment and follow-up periods, and to comply
with all study
requirements;
4. Had a diagnosis of external genital / perianal warts with at least 2
warts and no more than
30 warts located in one or more of the following anatomic locations:
= In both sexes: inguinal, perineal, and perianal areas;
= In men: over the glans penis, penis shaft, scrotum, and foreskin;
= In women: on the vulva;
5. Had total wart areas of at least 10 mm2;
6. Were judged to be in good health based upon the results of a medical
history, physical
examination, and safety laboratory profile;
7. If female and of childbearing potential, had a negative serum pregnancy
test at Screening
and a negative urine pregnancy test prior to randomization and were willing to
use
effective contraception; and
8. If male or a male partner of a female subject, were willing to use
condoms for sexual
activities during the study.
Exclusion Criteria
Subjects were excluded from the study if they met any of the following
criteria:
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9. Had received any topical and/or destructive treatments for external genital
warts within
4 weeks (within 12 months for imiquimod, and within 12 weeks for
sinecatechins) prior
to enrollment (ie, the randomization visit);
10. Had received any of the following treatments within the indicated time
intervals prior to
enrollment:
Medication/Treatment Washout
Interval
Any marketed or investigational HPV vaccines 12 months
Imiquimod 12 months
Sinecatechins (Veregen ) 12 weeks
Interferon/ Interferon inducer 4 weeks
Cytotoxic drugs 4 weeks
Immunomodulators or immunosuppressive therapies 4 weeks
Oral antiviral drugs (with the exception of oral 4 weeks
acyclovir and acyclovir related drugs for suppressive
or acute therapy herpes; or oseltamivir for prophylaxis
or acute therapy of influenza)
Topical antiviral drugs (including topical acyclovir and 4 weeks
acyclovir related drugs) in the wart areas
Podophyllotoxin / Podofilox in the wart areas 4 weeks
Oral and parenteral corticosteroids (inhaled/intranasal 4 weeks
steroids are permitted)
Any topical prescription therapy for any conditions in 4 weeks
the wart areas
Dermatologic/cosmetic procedures or surgeries in the 4 weeks
wart areas
11. Had any evidence (physical or laboratory) of clinically significant or
unstable disease
and/or any condition that might have interfered with the response to the study
treatment
or altered the natural history of EGW;
12. Were currently participating in another clinical study or had completed
another clinical
study with an investigational drug or device within the past 4 weeks;
13. Had known or active chemical dependency or alcoholism as assessed by the
investigator;
14. Had known allergies to study drug or any excipient in the study cream;
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15. Were currently immunosuppressed or had a history of immunosuppression;
16. Had a planned surgery that would cause an interruption of study treatment;
17. Had sexual partners currently in treatment with an approved or
investigational treatment
for EGW;
18. Had any current or recurrent malignancies in the genital or treatment
area;
19. Had any untreated or unstable genital infections (other than genital
warts);
20. Had any of the following conditions:
= known human immunodeficiency virus (HIV) infection;
= current or past history of high risk HPV infection (eg, HPV 16, 18, etc);
= an outbreak of herpes genitalis in the wart areas within 4 weeks prior to
enrollment;
= internal (rectal, urethral, vaginal/cervical) warts that required or were
undergoing
treatment;
= a dermatological disease (eg, psoriasis) or skin condition in the wart
areas which
may have caused difficulty with examination;
21. If female, had clinically significant abnormalities on pelvic examination
or had laboratory
test results showing high-grade pathology (eg, high-grade squamous
intraepithelial
lesion, moderate or severe dysplasia, squamous cell carcinoma);
22. If female, were nursing or pregnant or planned to become pregnant during
the study.
Removal of Patients from Therapy or Assessment
Subjects could withdraw from the study or be withdrawn by the investigator at
any time without
prejudice to their future medical care. Any subject who did not comply with
the
inclusion/exclusion criteria could be withdrawn from further participation in
the study.
Subjects could also be discontinued if the investigator determined that LSRs
or AEs were of such
severe intensity, serious events, or of a duration sufficient to warrant
discontinuation, or if a
subject required treatment for a suspected malignancy or other condition
within the treatment or
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surrounding area. If a subject discontinued due to an LSR, the LSR was
recorded as an AE, and
the subject was monitored until the AE resolved to the investigator's
satisfaction.
Any subject who received study drug and discontinued prematurely from the
study was to return
to the study center for EOS procedures. Subjects who discontinued prematurely
from the study
for any reasons were not replaced.
Treatments Administered
The test products were 2.5% imiquimod cream and 3.75% imiquimod cream. The
reference therapy was placebo cream. Subjects applied the study drug in a thin
layer once daily
to each wart identified at Baseline and any new wart that appeared during the
treatment period.
A maximum of 1 packet (250 mg) of study drug was applied for a given dose (250
mg of 3.75%
cream is equivalent to 9.375 mg imiquimod, and 250 mg of 2.5% cream is
equivalent to 6.25 mg
imiquimod). Study drug was applied prior to normal sleeping hours and removed
approximately
8 hours later with mild soap and water. Subjects were to continue to apply
study cream to all
identified wart/wart areas until all warts were cleared.
The investigational products, 2.5% imiquimod cream and 3.75% imiquimod cream,
contained imiquimod, isostearic acid, benzyl alcohol, cetyl alcohol, stearyl
alcohol, polysorbate
60, sorbitan monostearate, white petrolatum, glycerin, methyl paraben, propyl
paraben, purified
water, and xanthan gum. The placebo cream contained the same ingredients as
the active
formulations with the exception of imiquimod.
Method of Assigning Patients to Treatment Groups
Subjects were randomly assigned to study treatments in a 2:2:1 ratio (2.5%
imiquimod
cream: 3.75% imiquimod cream: placebo cream).
Selection of Doses in the Study
The approved dosing regimen for Aldara (imiquimod) Cream, 5% for EGW is 3
times
per week until warts are cleared, up to 16 weeks of treatment. This protocol
studied a treatment
regimen shorter in duration, and used lower concentrations of imiquimod to
allow for more
frequent dosing. The lower concentrations of imiquimod used in this study were
chosen to
permit daily dosing such that the overall shortened treatment regimen (8 weeks
compared with a
16-week treatment regimen for Aldara) could still provide adequate clearing of
EGW.
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Selection and Timing of Dose for Each Patient
Subjects meeting all inclusion and no exclusion criteria were randomly
assigned in a
2:2:1 ratio to 1 of the 3 treatment groups (2.5% imiquimod cream: 3.7%
imiquimod cream : or
placebo cream).
Each dose of study drug was to be applied by the subject at approximately the
same time
of day. To reduce the risk of study drug removal from daily hygienic or
physical activities, study
drug was to be applied just prior to the subject's normal sleeping hours.
Subjects were to wash the treatment area with mild soap and water before
applying the
study medication, allow the area to dry thoroughly, and then apply the study
medication once
daily. Subjects were to apply a thin layer of study cream to each wart
identified at Baseline and
any new wart that appeared during the treatment period. Only up to one packet
of study cream
was to be applied per application.
The subjects were encouraged to leave study cream on for approximately 8
hours,
preferably during normal sleeping hours, and were not to wash the treatment
area, swim, shower
or bathe, or have sexual contacts while the study medication was on the skin.
Subjects could
wash the study cream off with soap and water any time after approximately 8
hours of
application. Subjects were to continue applying the study cream for a maximum
of 8 weeks or
until the investigator determined that they had achieved complete clearance of
all (baseline and
new) warts. Subjects were not to make up any missed doses.
Rest periods, or temporary interruptions of dosing due to intolerable local
skin reactions,
were allowed during the study if the investigator or subject (or legal parent
or guardian) decided
that study drug application should be interrupted. Subjects who were placed on
a rest period
were to be seen by the investigator prior to resuming treatment with study
drug in order to assess
if the recovery of the treatment site was sufficient. Doses missed due to a
rest period were not
counted as missed doses in the assessment of subject compliance with the
treatment regimen.
The study visit schedule and procedures were not to be altered due to missed
doses or rest
periods. If a subject experienced a strong local reaction in one treatment
area but not in other
treated areas, the subject could temporarily stop applying study cream in that
affected area while
continuing study treatment in the other areas.
Treatment of New Warts
During treatment period, any new warts appearing in any of the protocol-
defined
anatomic locations were treated with the study cream. Neither the warts
present at Baseline nor
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new warts were allowed to be treated during the no-treatment period (ie, from
the Week 8/EOT
visit to the Week 16 visit).
Blinding
This study was conducted as a double-blind study, ie, the treatment assignment
was
concealed from the subjects, the investigators and their staff, and the
clinical research team.
Treatment supplies for each subject included treatment kits for 8 weeks of
treatment.
Each treatment kit contained 4 supply boxes of study cream and one emergency
box, each box
containing a 2-week supply of study cream. At the randomization/Day 1 visit, a
randomization
number was assigned to each subject. Each subject was assigned the next
available treatment kit
number available at the site, starting from the lowest number for each gender
and proceeding in
numerical order to the highest number.
The randomization code for each subject could be accessed via the double-blind
tear-off
label, but was to be broken for an individual subject only in an emergency
situation such as a
serious adverse event (SAE). The study monitor or project manager was to be
informed prior to
any emergency unblinding. If the code for a subject was broken, the
investigator was to
document promptly the premature unblinding of the investigational product in
the electronic case
report form (eCRF) system.
No premature unblinding was performed. The treatment assignments were
unblinded
approximately 3 months after the last subject contact after all data queries
had been answered
and the database had been locked.
Prior and Concomitant Therapy
At each visit, prior and concomitant medications and therapies were reviewed.
The name
of the medication (trade or generic name), indication for use, and start and
stop dates were
recorded for any medication used.
Restricted Medications/Treatments. The following medications, preparations,
and treatments
that could potentially affect the study results were prohibited during the
study:
1. Imiquimod 5% cream (Aldara8);
2. Any marketed or investigational HPV vaccines;
3. Sinecatechins (Veregen);
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4. Interferon or interferon inducers;
5. Cytotoxic drugs;
6. Immunomodulators or immunosuppressive therapies;
7. Oral or parenteral corticosteroids (inhaled/intranasal steroids are
permitted);
8. Oral antiviral drugs (with the exception of oral acyclovir and acyclovir
related drugs for
suppressive or acute therapy herpes; or oseltamivir for prophylaxis or acute
therapy of
influenza);
9. Topical antiviral drugs (including topical acyclovir and acyclovir related
drugs) in the
treatment areas;
10. Podophyllotoxin/Podofilox in the treatment areas;
11. Any topical prescription medications in the treatment areas;
12. Dermatologic/cosmetic procedures or surgeries in the treatment areas.
Treatment Compliance
Study center personnel carefully queried each subject and reviewed the study
diary at
each treatment study visit to make sure the subject was dosing with study drug
as indicated. The
numbers of returned used and unused study packets were counted and recorded,
and any
discrepancies were discussed with the subject. During the treatment period,
the study center
personnel continued to instruct the subject on dosing procedures until the
subject demonstrated
compliance with study drug application. If at any time the investigator felt
that a subject had
missed a significant number of doses (exclusive of rest periods) or was not
compliant with the
study requirements, the investigator was to contact the project manager or
study monitor to
review the subject's compliance status and to determine a course of action.
Efficacy and Safety Variables
Efficacy and Safety Measurements Assessed
A schedule of study visits and procedures is presented in the Table below.
Source
documentation was completed at each subject's visit, and the data captured in
the source
documents was subsequently entered into eCRFs by the investigator or designee.
The evaluator
who performed the EGW count and LSR assessment at Baseline was to perform
these
assessments at the subsequent visits if possible.
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Photographs were taken of the treatment area at selected centers, for
informational
purposes only. Only subjects who had signed a photographic consent form were
to be
photographed. No subjects under the age of 18 years (19 in Nebraska, Alabama,
Alaska, or
Wyoming) were photographed. The majority of subjects who participated in this
trial did not
have photographs of the treatment area taken. Cameras, detailed instructions
on taking the
photographs, and related items for photography were provided to the study
centers by Canfield
Scientific, Inc.
Criteria for evaluation:
Efficacy Assessments
COUNT OF EXTERNAL GENITAL/PERIANAL WARTS (EGWS)
In order to qualify for this study, subjects had to have at least 2 warts and
no more than 30 warts
in the genital/perianal area at the screening and randomization /Day 1 visits.
At each study visit
including Screening, the number of warts, including new warts, was documented
on the source
documents and eCRF for each of the following anatomic locations:
= In both sexes: inguinal, perineal, and perianal areas;
= In men: over the glans penis, penis shaft, scrotum, and foreskin (if
circumcised, the
foreskin area was marked as "not applicable");
= In women: on the vulva.
Any warts that were visible to the naked eye were included in the lesion count
as separate
lesions.
In the event that the margins or boundaries of some warts could not be
discerned due to local
skin reactions obscuring the field, the best estimate by clinical assessment
of the number of warts
in each anatomic location was made and the count included.
If possible, the same investigator who counted the warts at Baseline completed
wart counts at
subsequent study visits.
MEASUREMENT OF BASELINE WART AREA
At the screening and randomization/Day 1 visits, the size of each wart or wart
cluster was
measured by length and width. The total wart areas were to equal at least 10
mm2 in order to
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qualify for this study. The investigator measured the total baseline wart area
to be treated in
mm2. The total baseline wart area was the sum of individual areas for each
wart or cluster of
warts. It was preferred that each subject's wart areas be measured by the same
investigator at
both visits. If the wart areas were not continuous, the total areas were to be
calculated and
recorded on the source documents and eCRF.
TREATMENT OF NEW WARTS
During the treatment period, any new warts that appeared in any of the
protocol-defined
anatomic locations were treated with study cream. Treatment for any warts,
Baseline or new,
was not allowed during the no-treatment period (ie, from the EOT visit to the
Week 16 visit).
Safety Assessments
Safety assessments included visual assessments of local skin reactions (LSRs)
at each study visit
after the screening visit, including any temporary interruptions of dosing
(ie, rest periods)
required in response to LSRs; all reports of AEs and SAEs, with their severity
and relationship to
study drug; results of clinical laboratory tests (including urine pregnancy
tests for women of
childbearing potential); pelvic examinations with Pap smears in women;
findings of a general
physical examination at the screening visit, and intercurrent dermatologic
conditions occurring
within or outside of the treatment area.
Full information about the definition of AEs and SAEs, the procedure for
reporting them, and the
assessment of other safety parameters is given in the protocol.
ADVERSE EVENTS
Subjects were queried indirectly regarding AEs during each study visit. All
AEs that occurred
during the study period were recorded on the appropriate eCRF. The description
of the AE
included the dates of onset and resolution (duration), severity, relationship
to study treatment or
other therapy, action taken (if any), and outcome. If the investigator
considered it necessary, he
or she was to contact the sponsor with regard to any AE that occurred after a
subject ended study
participation. Any treatment-related AEs or LSRs that were ongoing at the end
of the study were
followed to the investigator's satisfaction. The study period for the purpose
of AE reporting was
defined as the period from the prestudy screening or the initiation of any
study procedures to the
end of the follow-up period.
An adverse event was defined as any untoward medical occurrence in a patient
or clinical
investigation subject that was temporally related to protocol procedures,
including the
administration of a pharmaceutical product at any dose, but that did not
necessarily have a causal
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relationship with the treatment. Laboratory values or results of other
diagnostic procedures
considered by the investigator to be clinically significant were captured as
AEs and summarized
accordingly.
Local skin reactions were not recorded as AEs unless they extended beyond the
anatomic
treatment area, if they required any medical interventions, or if the LSR
resulted in subject
discontinuation from the study. Application site reactions other than those
described as LSRs
(eg, vesicles, burning, itching, bleeding, soreness, and induration) were
recorded as AEs.
Severity: Terms used to describe the severity of an AE were mild, moderate,
and severe. These
terms were defined as follows:
= Mild ¨ The subject was aware of the signs and symptoms but the signs and
symptoms were easily tolerated.
= Moderate ¨ The signs and symptoms were sufficient to restrict, but did
not
prevent, usual daily activity for the subject.
= Severe ¨ The subject was unable to perform usual daily activity.
Serious Adverse Events: An SAE was any AE that, at any dose, resulted in any
of the
following outcomes: death, life-threatening AE, inpatient hospitalization or
prolongation of
existing hospitalization, persistent or significant disability/incapacity, or
a congenital
anomaly/birth defect.
An event was considered serious when, based upon appropriate medical judgment,
it jeopardized
the subject and may have required medical or surgical intervention to prevent
one of the
outcomes listed above.
A life-threatening AE was any AE that, at any dose, placed the subject, in the
view of the
investigator, at immediate risk of death from the reaction as it occurred. It
did not include a
reaction or event that, had it occurred in a more severe form, might have
caused death.
LOCAL SKIN REACTIONS
Local skin reactions in the treatment and/or immediate surrounding area were
clinically
identified by the following categories: erythema, edema, weeping/exudate,
flaking/scaling/dryness, scabbing/crusting, and erosion/ulceration. At each
study visit after the
screening visit, the investigator visually assessed the treatment and
immediate surrounding areas
and graded the intensity of each LSR category using the scales in Tables 62
and 63.
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Table 62 Local Skin Reaction Scale
Local Skin Severity Definitions
Reaction 0 1 (Mild) 2 (Moderate) 3
(Severe)
Erythema None Faint to mild redness Moderate redness
Intense redness
Edema Mild visible or barely
Easily palpable Gross
None palpable
swelling/induration
swelling/induration
swelling/induration
Weeping/exudate None Minimal exudate Moderate exudate Heavy
exudate
Flaking/scaling/dryness Moderate
None Mild dryness/flaking aking Severe
dryness/flaking
dryness/fl
Scabbing/crusting None Crusting Serous scab Eschar
Table 63 Local Skin Reaction Scale (erosion/ulceration)
Local Skin Severity Definitions
Reactions 0 2 3
Erosion/ ulceration None Erosion Ulceration
Erosion/ulceration intensity was originally collected as 0 = None, 1 =
Erosion, and 2 =
Ulceration. For consistency in the analysis of LSR intensities and sum score,
these were recoded
as 0 = None, 2 = Erosion, and 3 = Ulceration.
Local skin reactions were assessed independently from AEs, and were recorded
as AEs only if
they extended beyond the immediate surrounding area, if they required any
medical
interventions, or if the LSR resulted in subject discontinuation from the
study. Other application
site reactions not listed above (eg, vesicles, burning, itching, bleeding,
soreness, and induration)
were recorded as AEs.
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INTERCURRENT DERMATOLOGICAL CONDITIONS
Occurring Within the Treatment Area
= Dermatological Conditions ¨ Subjects who experienced dermatological
conditions
within the treatment area that were unrelated to or may have been exacerbated
by
study cream could be discontinued from the study if these conditions impaired
wart count and LSR assessments. In such a circumstance, the EOS procedures
were to be completed.
= Herpes Genitalis - A subject who had an outbreak of herpes genitalis that
required
treatment during the study in the genital wart areas could remain in the study
but
was to stop dosing with study cream. If the outbreak of herpes was distal from
the wart areas and did not interfere with study drug application or wart
evaluation,
the subject was to remain in the study and could continue dosing with study
cream. Subjects could receive treatment for herpes genitalis with oral
acyclovir,
famciclovir, and valaciclovir.
Occurring Outside the Treatment Area
= Dermatological Conditions ¨ Subjects who experienced dermatological
conditions
outside the treatment area or area immediately surrounding the treatment area
could receive treatments for these conditions with the exception of treatments
listed above.
= Vaginal and/or Cervical Warts ¨ During the study, subjects who developed
vaginal
and/or cervical warts were to be monitored by the investigator throughout the
treatment period. These diseases could be treated after the subject exited the
study.
= Vulvar Intraepithelial Neoplasia or Vaginal Intraepithelial Neoplasia ¨
If vulvar or
vaginal intraepithelial neoplasia was diagnosed during the study, the
investigator
was to consult with the medical monitor regarding the subject's continued
participation in the study.
= Rectal Mucosal or Urethral Warts - Rectal and urethral warts could be
treated with
conventional therapy only after the subject exited the study.
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REST PERIODS
A rest period was a temporary interruption of dosing due to intolerable LSRs.
Doses that were
missed due to a subject's noncompliance with the treatment regimen were not
considered a rest
period. Rest periods from daily treatment were instituted by the investigator
as needed, with
resumption of treatment at the investigator's discretion.
CLINICAL LABORATORY TESTS
Laboratory Tests: Subjects had samples taken at the prestudy screening visit
and at the EOS
visit for analysis of the following parameters:
= Hematology: hemoglobin, hematocrit, red blood cell count (RBC), white
blood count
(WBC) with differential, and platelet count;
= Serum chemistry: glucose (non-fasting), blood urea nitrogen (BUN),
creatinine,
cholesterol, total bilirubin, aspartate aminotransferase (AST), alanine
aminotransferase
(ALT), lactate dehydrogenase (LDH), alkaline phosphatase (AP), potassium,
sodium,
calcium, chloride, total protein, albumin, and phosphorous;
= Serum pregnancy test: females of childbearing potential underwent a serum
pregnancy
test at the screening visit, and the test result had to be negative for the
subject to
participate in the study;
= Urinalysis: color/appearance, glucose, pH, ketones, specific gravity,
microscopic
examination, and protein;
The samples were analyzed at a central laboratory, Covance Central Laboratory
Services, 8211
Scicor Drive, Indianapolis, Indiana 46214. Any laboratory test result that the
investigator
considered to be clinically significant was recorded as an AE.
Urine Pregnancy Tests: Females of childbearing potential underwent a urine
pregnancy test
(UPT) at Screening (in addition to a serum pregnancy test), the
randomization/Day 1 visit, every
4 weeks during the evaluation period, and at the EOT visit. If either the UPT
or the serum
pregnancy test was positive prior to randomization, the subject was not
permitted to enroll in the
study. Any subject who became pregnant during treatment was discontinued from
further
treatment. If there was a suspicion of pregnancy at any time during the
treatment period, a urine
sample was obtained and tested. All pregnancies were to be immediately
reported to the medical
monitor and followed through to resolution. Subjects were to continue with
follow-up visits.
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Sexually transmitted disease (STD) Screen: If applicable or if clinically
indicated, an STD
screen was performed at the screening visit. This was not considered part of
the protocol.
GENERAL PHYSICAL EXAMINATION
At the screening visit, the investigator completed a general physical
examination that included
measurement of blood pressure, pulse rate, temperature, weight, and
respiration rate.
PELVIC EXAMINATION AND PAP SMEAR
For female subjects, a pelvic examination including a Pap smear was performed
at the screening
visit unless a normal (negative) Pap smear result was available and had been
performed within 6
months of enrollment. Subjects with Pap smear results which were negative
(normal) could be
enrolled. Subjects with atypical squamous cells of undetermined significance
(ASCUS) or low
grade squamous intraepithelial lesion (LSIL) may have been eligible for
enrollment if per usual
clinical follow-up there was no suspicion of high grade pathology. Subjects
with results showing
high-grade pathology were not to be enrolled in the study and were to be
followed appropriately
or referred to their primary care physician for further care. The ThinPrep
Pap (ie,
Papanicolaou) test was the only test that was performed in this study.
The samples were analyzed at a central laboratory, South Bend Medical
Foundation, Inc., 530 N.
Lafayette Blvd., South Bend, IN 46601. Subjects with a (negative/normal) Pap
smear result
obtained within 6 months prior to enrollment did not need to have the test
repeated.
Appropriateness of Measurements
External genital warts are clinically diagnosed and treated in North America
and elsewhere. A
count of the number of clinically visible EGWs by a qualified investigator is
an appropriate
measurement of the efficacy of a treatment for EGW. The safety assessments,
which included
AE monitoring and clinical laboratory testing and which followed standard
medical practice
guidelines, are accepted measures that provide general health assessments.
Because imiquimod
therapy has been known to be associated with LSRs, the type and severity of
these were
monitored separately from other AEs. These measures are generally recognized
as appropriate
for the purposes of this study.
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Efficacy Analyses
PRIMARY EFFICACY VARIABLE
The primary efficacy variable was the subject status with respect to complete
clearance of all
warts (baseline and new) in all anatomic areas at EOS (Week 16), as determined
by the
investigator.
SECONDARY AND TERTIARY EFFICACY VARIABLES
Secondary efficacy variables were the following:
= Subject status with respect to partial clearance of baseline warts,
defined as at least a 75%
reduction in the number of baseline warts, at EOS/Week 16.
= Percent change from Baseline to EOS in the total number of warts.
= Subject status with respect to complete clearance of all warts at EOS and
remained
cleared in all anatomic areas, as determined by the investigator, through the
end of the
follow-up for recurrence period.
= Time from Baseline to complete clearance of all warts, as determined by
the investigator.
The tertiary efficacy variables are the following:
= Subject status with respect to complete clearance of all warts (baseline
and new) in all
anatomic areas, at EOT/Week 8.
= Subject status with respect to at least a 50% reduction in the number of
baseline warts at
EOS/Week 16.
STATISTICAL METHODS FOR EFFICACY ANALYSES
Efficacy analyses were conducted on the ITT population and on the PP
population. For the
primary efficacy variable, imputations were made for missing data points using
last observation
carried forward (LOCF, primary analysis), taking all missed observations as
failure (sensitivity
analysis), and using observed cases (supportive analysis). For the ITT
population, subjects who
had no post-baseline data were included in the analysis carrying forward the
baseline data. The
PP population analysis used observed cases, except for complete clearance and
for recurrence.
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Analysis of the Primary Efficacy Variable
The primary efficacy endpoint, complete clearance rate at the EOS, was
analyzed using Cochran-
Mantel-Haenszel (CMH) statistics, stratifying by gender and site.
All pairwise comparisons of active treatment versus placebo were made using
Hochberg's
modified Bonferroni procedure. If either test was significant at a 0.025 level
of significance,
then that test was considered significant. Otherwise, if both tests were
significant at 0.05, then
both tests were considered significant. The 3.75% and 2.5% treatment groups
were compared to
each other at the 0.05 level of significance if at least one of these
treatment groups was found to
be different than the placebo using the Hochberg's test.
In the primary analysis of complete clearance rate, the Breslow-Day statistic
was tested at the
10% level for heterogeneity of the odds ratios across analysis sites. A
finding of statistical
significance in this test was followed by exploratory analyses to characterize
the source of the
heterogeneity.
Analysis of Secondary Efficacy Variables
The secondary efficacy variable partial clearance rate was analyzed using
Cochran-Mantel-
Haenszel (CMH) statistics, stratifying by gender and site. The percent change
from baseline to
EOS in wart count was analyzed using analysis of covariance (ANCOVA),
controlling for
baseline wart count, gender, and analysis site. The proportion of subjects who
were clear prior to
or at EOS and remained clear at the end of the follow-up for recurrence period
was summarized
by frequency count and 95% confidence interval. The time to complete clearance
was analyzed
using the log rank test in the context of a Kaplan-Meier survival analysis.
For analysis of secondary efficacy variables, only the LOCF method was used
for the ITT
population, and observed cases for the PP population. All data from interim
visits were analyzed
using visit windows.
The secondary efficacy variables were compared pairwise using Hochberg's
modified Bonferroni
procedure.
= If at least one of the active arms was found to be superior to placebo in
the primary
efficacy variable of complete clearance according to Hochberg's modified
Bonferroni
procedure, the secondary efficacy variable of partial (>75%) clearance was
compared
between each of the active arms and placebo.
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= If the secondary efficacy variable of partial (>75%) clearance was found
to be superior to
placebo in either of the active treatment groups, then the secondary efficacy
variable of
percent change from Baseline to EOS in wart count was tested.
= If the secondary efficacy variable of percent change from Baseline to EOS
in wart count
was found to be superior to placebo in either of the active treatment groups,
then the
secondary efficacy variable of complete clearance at EOS and remained clear at
the end
of follow-up for recurrence period was tested.
= If the secondary efficacy variable of complete clearance at EOS and
remained clear at the
end of follow-up for recurrence period was found to be superior to placebo in
either of
the active treatment groups, then the secondary efficacy variable of time from
Baseline to
complete clearance was tested.
The percent change from Baseline in EGW count at each post-baseline visit was
summarized by
mean, standard deviation, median, and range by treatment group. The recurrence
rate of warts
was summarized by treatment group and study visit using visit windows.
Analysis of Tertiary Efficacy Variables
The tertiary efficacy endpoints, complete clearance rate at EOT and subject
status with respect to
at least a 50% reduction in baseline wart count, were analyzed using Cochran-
Mantel-Haenszel
(CMH) statistics, stratifying on gender and site.
Visit Windows
For the analysis of wart counts, the data were summarized by analysis visits.
Analysis visits
were assigned according to the actual study day of the evaluation as
illustrated in Table 64.
Table 64 Visit Windows
Evaluation Period Target
Analysis Visit Study Day Day Range
Baseline 1 Study Day 1
Week 2 15 1 < Study Day < 22
Week 4 29 22 < Study Day < 36
Week 6 43 36 < Study Day < 50
Week 8 57 50 < Study Day < 64
End of Treatment (EOT) Study Day 64
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Week 10 71 64 < Study Day 78
Week 12 85 78 < Study Day 92
Week 14 99 92 < Study Day < 106
Week 16 113 106 < Study Day < 127
End of Study (EOS) Study Day 127
Follow-up Period Target
Analysis Visit Study Day Day Range
Post EOS
Follow-up Week 4 29 1 < Study Day 43
Follow-up Week 8 57 43 < Study Day 71
Follow-up Week 12 85 71 < Study Day 99
All visits (scheduled or unscheduled) were mapped to an analysis visit. If
more than 1
evaluation was assigned to an analysis visit, the evaluation with the lowest
wart count within the
window was used for analysis. Study day was calculated as the date of
evaluation minus the date
of randomization plus one except for the follow up visits. For the follow up
visits, study day was
calculated as the date of evaluation minus the date of End of Study (EOS)
visit plus one.
Safety Analyses
All safety variables were analyzed using the safety population. Safety
variables included the
following:
= Local skin reactions.
= Rest periods during the treatment period:
o The number and percentage by treatment group of subjects who required a
rest
period (1 or more).
o The number of dosing days missed due to rest periods.
o The number of dosing days prior to the beginning of the first rest
period.
= Adverse events.
= Clinical laboratory test results.
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ADVERSE EVENTS
Adverse events were coded using Medical Dictionary for Regulatory Activities
(MedDRA,
version 11.0) terminology. A treatment-emergent AE was defined as an AE that
began or
worsened in severity after Day 1 and no more than 30 days after the last
application of study
drug. If an AE had a completely missing start date, it was considered a
"treatment emergent"
event, unless the stop date was prior to the date of randomization.
Treatment-emergent AEs and all AEs were summarized for each treatment group by
the overall
incidence of at least one event, incidence by system organ class, and
incidence by system organ
class and preferred term. Each subject contributed only once to each of the
rates, regardless of
the number of occurrences (events) the subject experienced.
Treatment-emergent AEs were summarized by severity (mild, moderate, or severe)
and by
relationship to study product (related, not related). Events were considered
not related to study
product if the relationship was "not related" or "probably not related".
Similarly, related events were those that were "probably related" or
"related". An AE was
assumed to be related to study drug if the relationship to study drug was
unknown. For AEs that
occurred more than once, the AE that was most related to study drug in that
period was used in
the summary of AEs by relationship to study drug categories. Similarly, the AE
with the
maximum intensity in that period was used in the summary of AEs by severity.
If severity was
missing or unknown, it was assumed to be severe.
The incidence of AEs was summarized for subgroup analysis by gender, by age
subgroup, and
by number of anatomic locations (ie, one location versus multiple). Serious
AEs (SAEs) and
AEs that led to discontinuation from the study were listed by subject.
LOCAL SKIN REACTIONS
The LSR intensities were summarized by frequency counts and mean score by
treatment group
and study visit for each LSR type. The LSRs were graded as follows:
= Erythema (0¨None, 1¨Faint to mild redness, 2=Moderate redness, 3¨Intense
redness),
= Edema (0¨None, 1¨Mild visible or barely palpable swelling/ induration,
2¨Easily
palpable swelling/indurationõ 3=Gross swelling/induration),
= Weeping/Exudate (0¨None, 1¨Minimal exudate, 2=Moderate exudate, 3¨Heavy
exudate),
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= Flaking/Scaling/Dryness (0=None, 1=Mild dryness/flaking, 2=Moderate
dryness/flaking,
3=Severe dryness/flaking),
= Scabbing/Crusting (0=None, 1=Crusting, 2=Serous scab, 3=Eschar),
= Erosion/Ulceration (0=None, 2=Erosion, 3=Ulceration).
Erosion/ulceration intensity was originally collected as 0 = None, 1 =
Erosion, and 2 ¨
Ulceration. For consistency in the analysis of LSR intensities and sum score,
these were recoded
as 0 = None, 2 = Erosion, and 3 = Ulceration.
The most intense reaction (post-baseline) and incidence of any reaction (post-
baseline) for each
LSR type were also presented by frequency distribution and mean score by
treatment group.
Data were analyzed using visit windows.
The LSR sum score (addition of 6 scores) was computed and summarized by
treatment group at
each study visit.
REST PERIODS
A rest period was a temporary interruption of dosing due to intolerable LSRs
or other AEs.
Doses missed due to a subject's noncompliance with the treatment regimen were
not considered
a rest period. The start of a rest period was the first date on which the
study medication was not
applied for the reason of "rest period". The end of the rest period was the
first date of
application following the start of the rest period. The number and percentage
of subjects who
required a rest period (1 or more) were analyzed by treatment group using CMH
statistics. The
number of dosing days missed due to rest periods and the number of dosing days
prior to the
beginning of the first rest period were analyzed using the Wilcoxon test. In
this analysis, only
subjects who experienced a rest period were included.
STUDY PATIENTS
Disposition of Subjects
Evaluation Period
Subject disposition for the evaluation period is displayed in Table 65 below.
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Table 65 Subject Disposition - Evaluation Period (ITT Population)
Imiquimod Cream
Total Subjects, n (%) 3.75% 2.5% Placebo
Overall
Randomized 204 202 105 511
Completed evaluation perioda 149 (73.0) 139 (68.8) 77
(73.3) 365 (71.4)
Not Cleared 89 (43.6) 90 (44.6) 68 (64.8) 247
(48.3)
Cleared, Ended Study 7 (3.4) 6 (3.0) 2 (1.9) 15
(2.9)
Cleared, Entered Follow-up 53 (26.0) 43 (21.3) 7 (6.7) 103
(20.2)
Discontinued evaluation 55 (27.0) 63 (31.2) 28 (26.7) 146
(28.6)
period
Reasons for discontinuation
during evaluation period,
n (%)
Safety reasons (AEs) 3(1.5) 4(2.0) 0
7(1.4)
Investigator's request 2 (1.0) 0 1(1.0) 3
(0.6)
Subject's request (not AE) 11(5.4) 10 (5.0) 4 (3.8) 25
(4.9)
Lack of efficacy 0 0 0 0
Noncompliance 2 (1.0) 3 (1.5) 3 (2.9) 8
(1.6)
Use of concomitant therapy 0 1(0.5) 0
1(0.2)
Lost to follow-up 35 (17.2) 40 (19.8) 19 (18.1) 94
(18.4)
Other (not AE)b 2(1.0) 5(2.5) 1(1.0)
8(1.6)
AE = adverse event.
a Based on investigator assessment (CRF page 31), includes subjects who (1)
cleared prior to or at EOS/Week 16,
(2) not cleared at Week 16.
One subject in 2.5% treatment group had a wart count of zero at EOS but reason
for discontinuation was 'Subject's
request' due to concomitant cryotherapy. Another subject in the 2.5% treatment
group had a wart count of zero at
Week 8 visit but not cleared at EOS. One subject was randomized to the 2.5%
treatment group, but included in the
3.75% group for safety analysis.
One subject in the 2.5% imiquimod group, who discontinued from the study at
the subject's request was also
recorded as discontinued from the study due to an adverse event.
Of 911 subjects who were screened, 511(56.1%) were randomized and 400 (43.9%)
failed screening. The most frequent reason for screen failure (194 subjects
[48.5% out of
400 screen failures]) was that the subject did not have a clinical diagnosis
of external
genital/perianal warts and did not have between 2 and 30 warts located in the
inguinal, perineal
and perianal areas.
Two hundred and four (204) subjects were randomized into the 3.75% imiquimod
treatment group, 202 subjects were randomized into the 2.5% imiquimod
treatment group, and
105 subjects were randomized into the placebo group. Overall, 71.4% of the
subjects completed
the evaluation study, and in the individual treatment groups 73.0%, 68.8%, and
73.3% in the
3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively, completed
the study.
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Lost to follow-up, was the most common reason for discontinuation from the
evaluation
period and accounted for withdrawal of at least 17% of the subjects in each
treatment group.
There was no appreciable difference in the percentages of subjects who were
lost to follow-up or
the times at which they became lost to follow-up. Of the subjects who withdrew
from the study,
a sizable number of subjects discontinued early, ie, had no post-Baseline
visit: 16 of 55 (29.1%)
in the 3.75% imiquimod group, 21 of 63 (33.3%) in the 2.5% imiquimod group,
and 7 of 28
(25%) in the placebo group. No subjects were discontinued from the study due
to lack of
efficacy.
Of the 511 subjects randomized into treatment groups, 222 were male and 289
were
female. Similar percentages of subjects of males and females in each treatment
group completed
the evaluation period. With the exception of subjects showing EGW clearance (a
higher
percentage of females compared with males cleared of EGW), disposition
characteristics within
genders were similar to those in the overall population.
Follow-up for Recurrence Period
Subject disposition for the follow-up period is displayed in Table 66 below.
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Table 66 Subject
Disposition ¨ Follow-Up Period (ITT Population)
Imiquimod Cream
Total Subjects, n (/0) 3.75% 2.5% Placebo
Overall
Entered follow-up period 53 (100) 43 (100) 7 (100) 103
(100)
Completed study, no recurrence 36 (67.9) 30 (69.8) 7
(100) 73 (70.9)
Subjects with EGW recurrence 11 (20.8) 8(18.6) 0
19 (18.4)
Discontinued follow-up perioda
Reasons for discontinuation
during follow-up, n (c/o)
Subject's request (not AE) 1(1.9) 1(2.3) 0 2
(1.9)
Lost to follow-up 5 (9.4) 3 (7.0) 0 8
(7.8)
Other (not AE) b 0 1 (2.3) 0 1
(1.0)
AE = adverse event.
a Excludes subjects discontinued due to recurrence of external genital
warts.
Overall, 103 subjects entered the follow-up for recurrence period, 53 subjects
in the
3.75% imiquimod treatment group, 43 subjects in the 2.5% imiquimod treatment
group, and
7 subjects in the placebo group.
Overall, 11 subjects were discontinued from the follow-up period. Of the 6
(11.3%)
subjects in the 3.75% imiquimod treatment group, 5 (9.4%) subjects were lost
to follow-up and
1 (1.9%) was due to the subject's request. Five subjects were discontinued
from the follow-up
period in the 2.5% imiquimod treatment group, 3 (7.0%) subjects were lost to
follow-up, and 1
(2.3%) each were due to the subject's request or 'other' (both non-AE). No
subjects in the
placebo group discontinued from the follow-up period.
Protocol Deviations
Final determination of each subject's status with respect to inclusion in the
PP evaluation
was made in a joint data review by clinical and statistical staff prior to
unblinding the treatment
codes.
A total of 142 subjects had major protocol deviations and were excluded from
the PP
population; 60 in the 3.75% imiquimod treatment group, 58 in the 2.5%
imiquimod treatment
group, and 24 in the placebo group). A total of 140 subjects were excluded due
to lost to follow-
up (accounting for approximately two-thirds of the subjects excluded from the
PP population)
and treatment noncompliance. Three subjects who were noncompliant were also
excluded from
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the PP population for additional reasons: one subject (2.5% imiquimod group)
had taken
exclusionary medication, one subject (3.75%) had a wart area <10 mm2 and one
subject
(placebo) had used imiquimod as a prior EGW treatment within the exclusionary
period. One
subject was excluded from the PP population because the subject received kits
from each of the
imiquimod treatment groups and 1 subject was excluded because they had taken
exclusionary
medication.
A total of 4 subjects (all females) received study medication kits from the
incorrect
gender strata. Subject 10-001 received study medication kit # M5341 (2.5%),
Subject 10-009
received study medication kit # M5426 (placebo), Subject 10-011 received study
medication kit
M5427 (3.75%), and Subject 22-013 received study medication kit M5314 (3.75%)
instead of
the next available female kit. For all analyses, these 4 subjects were
analyzed according to their
actual gender (female).
EFFICACY EVALUATION
Datasets Analyzed
The number of subjects in each analysis population is presented in Table
67below.
Table 67 Number (%) of Subjects in Analysis Populations
Imiquimod Cream
Populations 3.75% 2.5% Placebo Overall
ITT population 204 202a 105 511
PP population 144 144 81 369
Safety population 205a 201a 105 511
Follow-up for 53 43 7 103
Recurrence
population
a Subject 04/025 was originally randomized to the 2.5% imiquimod treatment
group; however, at Week 2, the
subject incorrectly received a 3.75% imiquimod treatment group kit assigned to
another subject. For the safety
analysis the highest dose received (3.75%) is used and for the efficacy
analysis, the original randomized
treatment of 2.5% is used.
A total of 511 subjects were included in the ITT and safety population. Of
these, 369 subjects
were included in the PP population. A total of 103 subjects elected to enter
the follow-up period
and comprised the follow-up for recurrence population.
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Demographic and Other Baseline Characteristics
Prestudy/Baseline Demographics
Demographic and baseline characteristics for the ITT population are presented
in Table 68 below.
Table 68 Demographic Summary by Treatment Group - ITT Population
Imiquimod Cream
3.75% 2.5% Placebo
Overall
(N=204) (N=202) (N=105)
(N=511)
Age in years
Mean (SD) 32.8 (11.0) 33.1 (10.1)
33.3 (10.8) 33.1 (10.6)
Median 29.5 31.0 30.0 30.0
Minimum, Maximum 15.0, 70.0 18.0, 60.0
19.0, 66.0 15.0, 70.0
Sex, n (%)
Male 88 (43.1) 85 (42.1) 49 (46.7) 222
(43.4)
Female 116 (56.9) 117 (57.9) 56
(53.3) 289 (56.6)
Race, n (%)
White 141 (69.1) 133 (65.8) 76
(72.4) 350 (68.5)
Black/African American 55 (27.0) 66 (32.7) 27 (25.7) 148
(29.0)
Other 8(4.0%) 3(1.5%) 2(2.0%) 13
(2.5%)
Ethnicity, n (%)
Hispanic 12 (5.9) 21 (10.4) 8 (7.6)
41(8.0)
Non-Hispanic 192 (94.1) 181 (89.6) 97
(92.4) 470 (92.0)
SD = standard deviation.
Demographic characteristics were similar among the 3 treatment groups.
Slightly more
than half of the subjects were female. Overall, 68.5% of the subjects were
White and more than
89% of the subjects in every treatment group were non-Hispanic. The mean age
ranged from
32.8 years in the 3.75% imiquimod treatment group to 33.3 years in the placebo
group.
Demographic characteristics in the PP population were similar to those in the
ITT population.
Medical History
The most frequently reported conditions were hypertension (53 subjects),
depression (42
subjects), and seasonal allergies (35 subjects).
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External Genital Warts Treatment History
Previous EGW treatment was reported by 50.5%, 52.5%, and 47.6% of subjects in
the
3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively.
Cryotherapy, the most
frequently reported treatment, had been performed in 51(25.0%) subjects in the
3.75%
imiquimod treatment group, in 46 (22.8%) of the subjects in the 2.5% treatment
group, and in 22
(21.0%) of the subjects in the placebo group. Other treatments included
imiquimod (in a total of
45 subjects), acetic acid (in a total of 33 subjects), laser therapy (in a
total of 29 subjects),
"other" treatments (in 24 subjects), podophyllin (in 23 subjects),
podophyllotoxin (in 21
subjects) and surgical excision (23 subjects), and electrodessication (13
subjects).
Prior and Concomitant Medications
Seventeen subjects (8.3%) in the 3.75% imiquimod treatment group, 20 subjects
(9.9%)
in the 2.5% treatment group, and 6 subjects (5.7%) in the placebo group were
taking prior
medications, ie, medications that were discontinued prior to the date of
randomization. The most
common prior medications were antibacterials for systemic use in 2.9% of the
3.75% imiquimod
treatment group, 2.5% of the 2.5% imiquimod treatment group, and 3.8% of the
placebo group.
One hundred thirty-four (65.4%) subjects in the 3.75% imiquimod treatment
group, 121
(60.2%) subjects in the 2.5% imiquimod treatment group, and 63 (60.0%)
subjects in the placebo
group received one or more concomitant medications during this study. The
following classes of
concomitant medication were received by more than 10% of the subjects in one
or more of the
treatment groups:
= Analgesics, received by 20.5% of the 3.75% imiquimod treatment group,
20.4% of
the 2.5% imiquimod treatment group, and 20.0% of the placebo group;
= Antibacterials for systemic use, received by 15.1% of the 3.75% imiquimod
treatment
group, 17.4% of the 2.5% imiquimod treatment group, and 14.3% of the placebo
group;
= Anti-inflammatory and anti-rheumatic products, received by 14.1% of the
3.75%
imiquimod treatment group, 11.9% of the 2.5% imiquimod treatment group, and
13.3% of the placebo group;
= Sex hormones and modulators of the genital system, received by 12.7% of
the 3.75%
imiquimod treatment group, 10.0% of the 2.5% imiquimod treatment group, and
12.4% of the placebo group;
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= Psychoanaleptics, received by 10.2% of the 3.75% imiquimod treatment
group, 8.0%
of the 2.5% imiquimod treatment group, and 8.6% of the placebo group.
Baseline Number of External Genital Warts
A summary of the external genital wart counts at Baseline and other baseline
data relevant to
subjects' EGW are presented in the Table 69 for the ITT population.
Table 69 Baseline External Genital Warts Data by Treatment Group -
ITT
Population
Imiquimod Cream
3.75% 2.5% Placebo
Overall
(N=204) (N=202) (N=105)
(N=511)
Total wart area (mm2)
Mean (SD) 150.2 (321.9) 161.1 (367.4) 200.7
(374.9) 164.9 (351.4)
Median 61 53 61 57
Minimum, Maximum 9, 3419 10, 4000 10, 1950 9,
4000
Total wart count
Mean (SD) 8.7 (7.5) 7.7 (6.3) 7.7 (6.3)
8.1 (6.8)
Median 6 5 6 6
Minimum, Maximum 2, 48 2, 30 2, 29 2, 48
Years Since Diagnosis
Mean 4.9 5.8 5.5 5.4
Standard Deviation 7.4 7.6 7.9 7.6
Median 2.0 2.3 2.2 2.2
Minimum, Maximum 0.0, 39.4 0.0, 33.4 0.0, 33.4
0.0, 39.4
Anatomic location, Malesa, n 88 85 49 222
Inguinal 24 (27.3) 17 (20.0) 19 (38.8) 60
(27.0)
Perineal 6 (6.8) 8 (9.4) 3 (6.1) 17
(7.7)
Perianal 8(9.1) 6(7.1) 5(10.2)
19(8.6)
Glans Penis 9(10.2) 11 (12.9) 5 (10.2) 25
(11.3)
Penis Shaft 71 (80.7) 76 (89.4) 39 (79.6) 186
(83.8)
Scrotum 19 (21.6) 16 (18.8) 14 (28.6) 49
(22.1)
Foreskin 0 2(2.4) 2(4.1)
4(1.8)
Anatomic location, Females", n 116 117 56 289
Inguinal 11(9.5) 19 (16.2) 4(7.1) 34
(11.8)
Perineal 61 (52.6) 53 (45.3) 29 (51.8) 143
(49.5)
Perianal 53 (45.7) 51 (43.6) 26 (46.4) 130
(45.0)
Vulva 86 (74.1) 78 (66.7) 31 (55.4) 195
(67.5)
Number of treatment anatomic
areas, n (%)--Malesa
Total Males 88 (100) 85 (100) 49 (100) 222
(100)
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Table 69 Baseline External Genital Warts Data by Treatment Group -
ITT
Population
imiquimod Cream
3.75% 2.5% Placebo
Overall
(N=204) (N=202) (N=105)
(N=511)
1 49 (55.7) 48 (56.5) 25 (51.0)
122 (55.0)
2 30 (34.1) 25 (29.4) 12 (24.5) 67
(30.2)
3 8(9.1) 10 (11.8) 10 (20.4) 28
(12.6)
4 1(1.1) 2(2.4) 2(4.1)
5(2.3)
(Continued)
Number of treatment anatomic
areas, n (%)--Femalesb
Total Females 116 (100) 117 (100) 56 (100)
289 (100)
1 47 (40.5) 53 (45.3) 28 (50.0)
128 (44.3)
2 46 (39.7) 48 (41.0) 23 (41.1)
117 (40.5)
3 20 (17.2) 12 (10.3) 4 (7.1)
36 (12.5)
4 3 (2.6) 4(3.4) 1(1.8) 8
(2.8)
SD = standard deviation.
a Denominator based on the number of males in treatment group.
b Denominator based on the number of females in treatment group.
The mean total wart area was 164.9 mm2 overall, and ranged from 150.2 mm2 in
the
3.75% imiquimod treatment group to 200.7 mm2 in the placebo group. The mean
total wart
count was 8.1 overall, and ranged from 7.7 in the 2.5% imiquimod treatment
group and placebo
to 8.7 in the 3.75% imiquimod treatment group.
In males, the most commonly affected areas were the penis shaft (83.8%), the
inguinal
area (27.0%), and the scrotum (22.1%). In females, the most commonly-affected
areas were the
vulva (67.5%), the perineal area (49.5%), and the perianal area (45.0%). More
than 50% of
subjects in the female subgroup and more than 40% of subjects in the male
subgroup had two or
more anatomic locations affected with warts at Baseline.
Measurements of Treatment Compliance
Compliance was based on the number of applications received (where a rest
period day
was counted as an application) divided by the number of intended applications,
or by the number
of packets used (where a rest period day was counted as a packet used) divided
by the number of
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packets intended to be used per the protocol-defined treatment regimen,
whichever was greater.
Noncompliance with the treatment regimen was defined as compliance less than
75% or greater
than 125%.
The overall mean treatment compliance was 83.2% in the 3.75% imiquimod
treatment
group, 86.5% in the 2.5% imiquimod treatment group, and 91.1% in the placebo
group). Of the
142 subjects excluded from the PP population, 140 were the result of
noncompliance with the
treatment regimen, including many subjects who were lost to follow-up.
Compliance rates were
slightly higher in subjects who cleared their EGW during the study (87.7%,
91.8%, and 97.8% in
the 3.75% imiquimod, 2.5% imiquimod, and placebo group, respectively) compared
with
subjects who did not clear (81.1%, 84.5%, and 90.4% in the 3.75% imiquimod,
2.5% imiquimod,
and placebo group, respectively).
Analysis of Efficacy
Complete Clearance Rate of All Warts
COMPLETE CLEARANCE RATES AT END OF STUDY
The primary efficacy variable in this study was the proportion of subjects
with complete
clearance of all warts (those present at Baseline and new warts) at EOS (ie, 8
weeks after EOT).
The primary analysis was performed on the ITT population with imputation
(LOCF) for missing
data points. The PP population analysis used observed cases only. The results
of these analyses
for the ITT population are shown in Table 70. Results are presented
graphically for the ITT
population in Figure 15.
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Table 70 Proportion of Subjects with Complete Clearance of Warts at
the Week
16/End of Study Visit
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF)
n/Na (%)
60/204 (29.4) 50/202 (24.8) 9/105 (8.6)
95% CI 23.3, 36.2 19.0,31.3
4.0,15.6
P value vs placebo <0.001** <0.001**
P value vs 2.5% imiquimod cream 0.187
Males
rilNa (%)
15/88(17.0) 13/85(15.3) 2/49(4.1)
95% CI 9.9, 26.6 8.4, 24.7 0.5,
14.0
P value vs placebo 0.019** 0.034**
P value vs 2.5% imiquimod cream 0.639
Females
niNzi (%)
45/116 (38.8) 37/117 (31.6) 7/56 (12.5)
95% CI 29.9,48.3 23.3, 40.9 5.2,
24.1
P value vs placebo <0.001** 0.012**
P value vs 2.5% imiquimod cream 0.204
LOCF = last observation carried forward, 95% CI = 95% confidence interval
a: n/N=number of subjects with complete clearance at end of study divided
by the number of subjects analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups, taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated
using the exact binomial statistics.
Breslow-Day P values for ITT Population (LOCF,) males, are 3.75% Imiquimod
Cream vs Placebo = 0.933, 2.5%
Imiquimod Cream vs Placebo = 0.691, and 3.75% Imiquimod Cream vs 2.5%
Imiquimod Cream = 0.773.
Breslow-Day P values for ITT Population (LOCF), females, are 3.75% Imiquimod
Cream vs Placebo = 0.731, 2.5%
Imiquimod Cream vs Placebo = 0.757, and 3.75% Imiquimod Cream vs 2.5%
Imiquimod Cream = 0.942.
In the ITT population, the rate of complete clearance of EGW at EOS was
significantly
higher (P<0.001) in the active treatment groups; 29.4% in the 3.75% imiquimod
group and
24.8% in the 2.5% imiquimod group, compared with placebo (8.6%). As shown in
the Table
above, subjects in the 3.75% imiquimod group had a higher rate of complete
clearance than
subjects in the 2.5% imiquimod group. However, the difference between the 2
active treatment
groups was not statistically significant (P=0.187).
Results were similar in the by-gender analyses. The complete clearance rates
at EOS
were statistically significantly higher in the 2 active treatment groups
compared with placebo for
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both genders. In all treatment groups, the complete clearance rates were
consistently higher in
females than in males.
Due to deviations from GCP, an additional analysis was run in which 2 study
sites (Sites
13 and 18) were excluded from the primary analysis. Removal of the efficacy
data from these 2
sites does not materially impact the results: the primary analyses, complete
clearance rates of
actives compared to placebo are numerically increased.
Rates of complete clearance at EOS in the ITT population are illustrated in
Figure 15.
The primary efficacy variable was analyzed for the PP population, overall and
by gender,
using observed cases (OC). Results for the PP population are shown in Table
71.
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Table 71
Proportion of Subjects with Complete Clearance of Warts at the Week
16 /End of Study Visit -PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP population (OC), at EOS
niNa (%) 49/144(34.0) 43/144(29.9) 9/81
(11.1)
95% confidence interval 26.3, 42.4 22.5, 38.0 5.2,
20.0
P value vs placebo <0.001** <0.001**
P value vs 2.5% imiquimod cream 0.243
Males
n/Na (%) 12/59 (20.3) 12/64 (18.8) 2/36
(5.6)
95% confidence interval 11.0, 32.8 10.13, 30.5 0.7,
18.7
P value vs placebo 0.026** 0.011**
P value vs 2.5% imiquimod cream 0.568
Females
niNa (%) 37/85(43.5) 31/80(38.8)
7/45(15.6)
95% confidence interval 32.8, 54.7 28.1, 50.3 6.5,
29.5
P value vs placebo 0.002** 0.009**
P value vs 2.5% imiquimod cream 0.424
95% Cl = 95% confidence interval, OC=observed cases.
a:
n/N = number of subjects with complete clearance at end of study divided by
the number of subjects analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups, taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated
using the exact binomial distribution.
Complete clearance was carried forward once achieved.
In the PP population, overall, the complete clearance rates at EOS were higher
than those
in the ITT population for all treatment groups: 34.0% in the 3.75% imiquimod
group, 29.9% in
the 2.5% imiquimod group, and 11.1% in the placebo group. The larger responses
in the active
treatment groups were statistically significant compared with placebo (P
<0.001 for the active
treatment groups). As was the case in the ITT population, the rate of complete
clearance was
larger in the 3.75% imiquimod group than in the 2.5% imiquimod group, but the
difference
between the 2 active treatment groups was not statistically significant.
Results were similar in the by-gender analyses. In all treatment groups in the
PP
population, the complete clearance rates at EOS were consistently higher in
females than in
males. Complete clearance rates were statistically significantly higher in the
2 active treatment
groups compared with placebo for both genders.
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Rates of complete clearance at EOS in the PP population are illustrated in
Figure 16.
COMPLETE CLEARANCE RATES AT END OF TREATMENT
A summary of the complete clearance rate at EOT for the ITT population,
overall and by gender,
is provided in Table 72.
Table 72 Proportion of Subjects with Complete Clearance of Warts at
End of
Treatment--ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF)
n/Na (%) 32/204 (15.7) 28/202 (13.9) 4/105
(3.8)
95% CI 11.0, 21.4 9.4, 19.4
1.0,9.5
P value vs placebo 0.002** 0.012**
P value vs 2.5% imiquimod cream 0.460
Males
niNa (%) 8/88(9.1) 6/85(7.1)
1/49(2.0)
95% CI 4.0, 17.1 2.6, 14.7 0.1,
10.9
P value vs placebo 0.092 0.222
P value vs 2.5% imiquimod cream 0.547
Females
niNa (%) 24/116(20.7) 22/117 (18.8) 3/56
(5.4)
95% CI 13.7, 29.2 12.2,27.1 1.1,
14.9
P value vs placebo 0.009** 0.028**
P value vs 2.5% imiquimod cream 0.616
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a: n/N=number of subjects with complete clearance at end of treatment
divided by the number of subjects
analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated
using the exact binomial distribution.
At Week 8/EOT, 15.7% of subjects in the 3.75% imiquimod group, 13.9% of
subjects in
the 2.5% imiquimod group, and 3.8% of subjects in the placebo group had
attained complete
clearance. The overall complete clearance rate at EOT was significantly higher
in the 3.75%
imiquimod group (P = 0.002) and in the 2.5% imiquimod group (P = 0.012)
compared with the
placebo group. The clearance rate in the 3.75% imiquimod group was slightly
higher than in the
2.5% imiquimod group; however, the difference was not statistically
significant.
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The complete clearance rate at EOT was significantly higher in the active
treatment
groups compared with placebo only in the female subgroup. In all treatment
groups, the
complete clearance rates were consistently higher in females than in males.
Slightly higher
percentages of males in the 3.75% imiquimod group achieved complete clearance
than those in
the 2.5% imiquimod group.
A summary of the complete clearance at EOT for the PP population is provided
in Table
73.
Table 73 Proportion of Subjects with Complete Clearance of Warts at
End of
Treatment - PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC), at EOT
niNa (0/0) 26/144(18.1) 24/144(16.7) 4/81
(4.9)
95% CI 12.1, 25.3 11.0, 23.8 1.4,
12.2
P value vs placebo 0.010** 0.019**
P value vs 2.5% imiquimod cream 0.602
Males
(%) 7/59 (11.9) 6/64 (9.4) 1/36
(2.8)
95% CI 4.9, 22.9 3.5, 19.3 0.1,
14.5
P value vs placebo 0.206 0.250
P value vs 2.5% imiquimod cream 0.400
Females
niNa (%) 19/85 (22.4) 18/80 (22.5) 3/45
(6.7)
95% CI 14.0,32.7 13.9, 33.2 1.4,
18.3
P value vs placebo 0.024** 0.041**
P value vs 2.5% imiquimod cream 0.934
95% CI = 95% confidence interval, OC=observed cases
a: n/N=number of subjects with complete clearance at end of treatment
divided by the number of subjects
analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated
using the exact binomial distribution.
Complete clearance was carried forward once achieved.
In the PP population, the EOT complete clearance rate was significantly higher
in both
active treatment groups compared with placebo (P=0.010 for 3.75% imiquimod vs
placebo; and
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P=0.019 for 2.5% imiquimod vs placebo). The difference between the active
treatment groups
was not statistically significant.
In the PP population, complete clearance rates for males and females were
higher than
those in the ITT population. Complete clearance rates in the female subgroup
in both active
treatment groups were essentially the same and were significantly higher
compared with those in
the placebo group. A slightly higher percentage of males in the 3.75%
imiquimod group
achieved complete clearance than those in the 2.5% imiquimod group. In both
treatment groups
in males, the difference in clearance rate was not statistically significant
when compared to
placebo. In all treatment groups, the complete clearance rates were
consistently higher in
females than in males.
COMPLETE CLEARANCE RATES BY VISIT WEEK
A by-visit summary of complete clearance rates in the ITT population during
the
evaluation period is shown graphically in Figure 17.
As shown in Figure 17, the complete clearance rate was higher in the imiquimod
treatment
groups compared with placebo at all assessment time points after Week 4, and
the differences
were statistically significant at Week 8 (EOT) and thereafter. This includes
the Week 8/end of
treatment assessment and the Week 16/end of study assessment.
In female subjects, the complete clearance rate was significantly higher in
the 3.75%
imiquimod group compared with placebo at all assessment time points after Week
6. The
complete clearance rate was significantly higher in the 2.5% imiquimod group
compared with
placebo at Weeks 8, 10 and 16. The difference between the active treatment
groups was not
statistically significant at any time point during the evaluation period. In
male subjects, the
complete clearance rate was significantly higher in the 3.75% group compared
with placebo at
all assessment time point from Week 10 to Week 16. The complete clearance rate
was
significantly higher in the 2.5% imiquimod group compared with placebo at
Weeks 14 and 16.
The difference between the active treatment groups was not statistically
significant at any time
point during the evaluation period.
A by-visit summary of complete clearance rates in the PP population during the
evaluation period is shown in Figure 18.
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Results in the PP population were similar to those in the ITT population. The
complete
clearance rate was significantly higher in the active treatment groups
compared with placebo at
all assessment time points after Week 6. The difference in clearance rate
between the 2 active
treatments was not statistically significant.
In female subjects, the complete clearance rate was significantly higher in
the 3.75% and
2.5% imiquimod groups compared with placebo at Week 8 and Week 16. The
difference
between the active treatment groups was not statistically significant at any
time point during the
evaluation period. In male subjects, the complete clearance rate was
significantly higher in the
3.75% group compared with placebo at Week 10, Week 14 and Week 16. The
complete
clearance rate was significantly higher in the 2.5% imiquimod group compared
with placebo at
Week 16. The difference between the active treatment groups was not
statistically significant at
any time point during the evaluation period.
Partial Clearance Rates
PARTIAL (>75%) CLEARANCE RATES AT END OF STUDY
The proportion of subjects, overall and by gender, who had a partial clearance
(>75%
reduction from Baseline in wart count) during the study is summarized in Table
74 for the ITT
population. Partial clearance was defined as at least a 75% reduction in the
number of warts in
the treatment area compared with Baseline.
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Table 74 Proportion of Subjects with Partial (>75%) Clearance at End
of
Study, ITT Population
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF) at EOS
iilNa (%) 79/204 (38.7) 63/202 (31.2)
11/105(10.5)
95% CI 32.0, 45.8 24.9, 38.1 5.3,
18.0
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod Cream 0.078
Males
niNa (%) 21/88 (23.9) 19/85 (22.4) 3/49
(6.1)
95% CI 15.4, 34.1 14.0, 32.7 1.3,
16.9
P value vs Placebo 0.008** 0.013**
P value vs 2.5% Imiquimod Cream 0.776
Females
58/116(50.0) 44/117(37.6) 8/56(14.3)
95% CI 40.6, 59.4 28.8, 47.0 6.4,
26.2
P value vs Placebo <0.001** 0.002**
P value vs 2.5% Imiquimod Cream 0.050**
95% CI = 95% confidence interval
a: nJN=number of subjects with complete clearance at end of study divided
by the number of subjects analyzed.
Partial clearance was defined as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (gender
subgroups), or stratified by analysis site (gender subgroups) taking 2
treatment groups at a time. The P values
marked with ** are statistically significant using Hochberg's modified
Bonferroni procedure. Confidence intervals
were calculated using the exact binomial distribution.
In the ITT population, the difference in the partial (>75%) clearance rate at
EOS between
each of the imiquimod treatment groups and placebo was statistically
significant (P<0.001). The
partial (>75%) clearance rate was higher in the 3.75% imiquimod group than in
the 2.5%
imiquimod group, but the difference between the 2 active treatment groups was
not statistically
significant.
In the by-gender analyses, the >75% clearance rate at EOS was significantly
higher in
both of the active treatment groups compared with placebo for both males and
females. The
>75% clearance rate in the female subgroup was significantly higher in the
3.75% imiquimod
group than in the 2.5% imiquimod group. In all treatment groups, the >75%
clearance rates were
consistently higher in females than in males.
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Rates of partial (>75%) clearance at EOS in the ITT population are illustrated
in Figure
19.
A summary of the partial (>75%) clearance rate at EOS for the PP population,
overall and
by gender, is presented in Table 75. The >75% clearance rates at EOS are
presented graphically
in Figure 20 for the PP population.
Table 75 Proportion of Subjects with Partial (>75%) Clearance at End
of
Study¨PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC), at EOS
iilNa (%) 65/144 (45.1) 55/144 (38.2) 11/81
(13.6)
95% CI 36.8, 53.6 30.2, 46.7 7.0,
23.0
P value vs placebo <0.001** <0.001**
P value vs 2.5% imiquimod cream 0.128
Males
niNa (%) 16/59(27.1) 18/64(28.1)
3/36(8.3)
95% CI 16.4,40.3 17.6, 40.8 1.8,
22.5
P value vs placebo 0.011** 0.014**
P value vs 2.5% imiquimod cream 0.696
Females
niNa (%) 49/85 (57.6) 37/80 (46.3) 8/45
(17.8)
95% CI 46.4, 68.3 35.0, 57.8 8.0,
32.1
P value vs placebo <0.001** 0.001**
P value vs 2.5% imiquimod cream 0.112
95% CI = 95% confidence interval, OC = observed cases
a: n/N¨number of subjects with complete clearance at end of study divided
by the number of subjects analyzed.
Partial clearance was defmed as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. P values marked
with ** are statistically significant using Hochberg's modified Bonferroni
procedure. Confidence intervals were
calculated using the exact binomial distribution statistics.
In the PP population, the partial (>75%) clearance rate at EOS was higher in
the active
treatment groups than in the placebo group. The difference between each of the
imiquimod
treatment groups and placebo was statistically significant (P<0.001). There
was no statistically
significant difference in partial (>75%) clearance rate between the active
treatment groups. The
partial (>75%) clearance rates were statistically significantly higher in the
3.75% imiquimod
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group compared with placebo at all analysis time points after Week 4; results
of the analysis over
time are presented below.
As in the overall PP population, the 275% clearance rate was significantly
higher with
3.75% imiquimod and with 2.5% imiquimod versus placebo in either gender. There
was no
statistically significant difference between the active treatment groups in
either gender.
Rates of partial (275%) clearance at EOS in the PP population are illustrated
in Figure
20.
PARTIAL (275%) CLEARANCE RATES AT END OF TREATMENT
The proportion of subjects who had a 75% or greater reduction from Baseline in
wart
count at EOT is summarized in Table 76 for the ITT population.
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Table 76 Proportion of Subjects with Partial (>75%) Clearance at End
of
Treatment ¨ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF) at EOT
n/Na (%) 60/204 (29.4) 44/202 (21.8) 8/105
(7.6)
95% CI 23.3, 36.2 16.3, 28.1 3.3,
14.5
P value vs placebo <0.001** 0.003**
P value vs 2.5% imiquimod cream 0.054
Males
n/Isla (%) 19/88(21.6) 11/85(12.9)
1/49(2.0)
95% CI 13.5, 31.6 6.6, 22.0 0.1,
10.9
P value vs placebo 0.002** 0.029**
P value vs 2.5% imiquimod cream 0.134
Females
"a (%) 41/116 (35.3) 33/117 (28.2) 7/56
(12.5)
95% CI 26.7,44.8 20.3,37.3
5.2,24.1
P value vs placebo 0.001** 0.027**
P value vs 2.5% imiquimod cream 0.193
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a: n/N=number of subjects with complete clearance at end of treatment
divided by the number of subjects
analyzed.
Partial clearance was defmed as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. P values marked
with ** are statistically significant using Hochberg's modified Bonferroni
procedure. Confidence intervals were
calculated using the exact binomial statistics.
In the overall ITT population, the >75% clearance rate at EOT was
significantly higher in
the active treatment groups than in the placebo group. The difference between
the active
treatment groups was not statistically significant.
The >75% clearance rate at EOT was significantly higher with both active
treatment
groups compared with placebo in either gender. There was no significant
difference between
3.75% and 2.5% imiquimod in either gender subgroup.
The partial (>75%) clearance rate at EOT for the PP population is provided in
Table 77.
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Table 77
Proportion of Subjects with Partial (275%) Clearance at End of
Treatment-PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC), EOT
niNa (%) 51/144 (35.4) 39/144 (27.1) 8/81
(9.9)
95% CI 27.6, 43.8 20.0, 35.1 4.4,
18.5
P value vs placebo <0.001** 0.003**
P value vs 2.5% imiquimod cream 0.047**
Males
"a (%) 16/59(27.1) 11/64(17.2)
1/36(2.8)
95% CI 16.4, 40.3 8.9, 28.7 0.1,
14.5
P value vs placebo 0.007** 0.031**
P value vs 2.5% imiquimod cream 0.090
Females
n/Na (%) 35/85 (41.2) 28/80 (35.0) 7/45
(15.6)
95% CI 30.6, 52.4 24.7, 46.5 6.5,
29.5
P value vs placebo 0.003** 0.036**
P value vs 2.5% imiquimod cream 0.220
95% CI = 95% confidence interval, OC=observed cases, EOT = end of treatment
a:
n/N=number of subjects with complete clearance at end of treatment divided by
the number of subjects
analyzed.
Partial clearance was defmed as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. The P values
marked with ** are statistically significant using Hochberg's modified
Bonferroni procedure. Confidence intervals
were calculated using the exact binomial distribution statistics.
In the overall PP population, the >75% clearance rate at EOT was significantly
higher in
the active treatment groups than in the placebo group. The partial (>75%)
clearance rate in the
3.75% imiquimod group was significantly higher (P=0.047) than that in the 2.5%
imiquimod
treatment group.
The >75% clearance rate at EOT was significantly higher with both active
treatment
groups compared with placebo for both genders. There was no significant
difference between
3.75% and 2.5% imiquimod groups in either gender.
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PARTIAL (>75%) CLEARANCE RATES BY ANALYSIS VISIT
Over the course of the study, the partial (>75%) clearance rates were
statistically
significantly higher in the 3.75% and 2.75% imiquimod group compared with
placebo at all
analysis time points after Week 6, and were significantly higher for 3.75%
compared with 2.5%
imiquimod at Weeks 6, 12, and 14.
In both genders, the difference between each of the imiquimod treatment groups
and
placebo was statistically significant at Week 16. In the female subgroup, the
difference between
the active treatment groups was statistically significant (P = 0.050).
The partial (>75%) clearance rates were statistically significantly higher in
the 3.75% and
2.75% imiquimod groups compared with placebo at all analysis time points after
Week 8, and
were significantly higher for 3.75% imiquimod group compared with 2.5%
imiquimod at Weeks
6 and 10.
SUBJECTS WITH AT LEAST A 50% REDUCTION IN WART COUNT AT END OF
STUDY
Table 78 provides a summary of the >50% clearance rate at EOS for the ITT
population
(overall and by gender). The results are presented graphically in Figure 21.
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Table 78 Proportion of Subjects with 250% Clearance at End of Study-
ITT
Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF) at EOS
n/I=la (%) 101/204 (49.5) 87/202 (43.1)
21/105 (20.0)
95% CI 42.5, 56.6 36.1, 50.2 12.8,
28.9
P value vs placebo <0.001** <0.001**
P value vs 2.5% imiquimod cream 0.154
Males
nThr (%) 27/88 (30.7) 29/85 (34.1) 5/49
(10.2)
95% CI 21.3,41.4 24.2,45.2 3.4,22.2
P value vs placebo 0.007** 0.002**
P value vs 2.5% imiquimod cream 0.617
Females
niNa (%) 74/116(63.8) 58/117 (49.6) 16/56
(28.6)
95% Cl 54.4, 72.5 40.2, 59.0 17.3,
42.2
P value vs placebo <0.001** 0.009**
P value vs 2.5% imiquimod cream 0.027**
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a: n/N¨number of subjects with complete clearance at end of study divided
by the number of subjects
analyzed.
50% clearance is defined as at least a 50% reduction in the number of warts in
the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. P values marked
with ** are statistically significant using Hochberg's modified Bonferroni
procedure. Confidence intervals were
calculated using the exact binomial distribution statistics.
In the overall ITT population, the rate of >50% clearance of EGW at EOS was
significantly higher in each of the imiquimod treatment groups compared with
placebo. The
>50% clearance rate was higher in the 3.75% imiquimod group than in the 2.5%
imiquimod
group, but the difference between the 2 active treatment groups was not
statistically significant.
The >50% clearance rate at EOS was significantly higher with both active
treatment
groups compared with placebo for both genders. The >50% clearance rate at EOS
was
significantly higher in the 3.75% imiquimod group compared with the 2.5%
imiquimod group
for females only. In males, the >50% clearance rate was higher in the 2.5%
imiquimod group
than in the 3.75% imiquimod group. However, the difference was not
statistically significant.
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Results in the PP population (overall and by gender) were similar to results
in the ITT
population.
SUBJECTS WITH >50% REDUCTION IN WART COUNT AT END OF TREATMENT
Table 79 provides a summary of the >50% clearance rate at EOT for the ITT
population
(overall and by gender).
Table 79
Proportion of Subjects with >50% Clearance at End of Treatment--
ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF) at EOT
nnsia (%) 89/204 (43.6) 74/202 (36.6)
18/105 (17.1)
95% CI 36.7, 50.7 30.0, 43.7 10.5,
25.7
P value vs placebo <0.001** <0.001**
P value vs 2.5% imiquimod cream 0.103
Males
niNa (%) 31/88 (35.2) 25/85 (29.4) 5/49
(10.2)
95% CI 25.3, 46.1 20.0, 40.3 3.4,
22.2
P value vs placebo <0.001** 0.012**
P value vs 2.5% imiquimod cream 0.412
Females
n/Na (%) 58/116 (50.0) 49/117 (41.9) 13/56
(23.2)
95% CI 40.6, 59.4 32.8, 51.4 13.0,
36.4
P value vs placebo <0.001** 0.016**
P value vs 2.5% imiquimod cream 0.152
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a:
n/N=number of subjects with complete clearance at end of treatment divided by
the number of subjects
analyzed.
50% clearance was defined as at least a 50% reduction in the number of warts
in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. The P values
marked with ** are statistically significant using Hochberg's modified
Bonferroni procedure. Confidence intervals
were calculated using the exact binomial distribution statistics.
In the overall ITT population, the >50% clearance rate at EOT was
significantly higher in
the active treatment groups than in the placebo group. The difference between
the active
treatment groups was not statistically significant. The >50% clearance rate at
EOT was
significantly higher with both active treatment groups compared with placebo
for both gender
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subgroups. There was no significant difference between 3.75% and 2.5%
imiquimod in either
gender. In all treatment groups, the >50% clearance rates at EOT were higher
in females than in
males.
Results were similar in the PP population. In the overall PP population, the
rate of >50%
clearance of EGW at EOT was significantly higher in the active treatment
groups compared to
placebo. In both the male and female subgroups, the >50% clearance rate was
significantly
higher in both of the active treatment groups compared with placebo.
SUBJECTS WITH > 50% REDUCTION IN WART COUNT BY ANALYSIS WEEK
As shown in Figure 22 for the overall ITT population, the difference between
each of the
imiquimod treatment groups and placebo was statistically significant at Week
16 (P<0.001 for
3.75% imiquimod and 2.5% imiquimod vs placebo), and at all post-Baseline
assessment time
points after Week 4. The >50% clearance rate in the 3.75% imiquimod group was
higher than
that in the 2.5% imiquimod treatment group at End of Study however the
difference was not
statistically significant.
In both genders, the difference between each of the imiquimod treatment groups
and
placebo was statistically significant at Week 16. In the female subgroup, the
difference between
the active treatment groups was statistically significant (P = 0.027).
Results in the PP population were similar to those in the ITT population.
Compared with
placebo, the >50% clearance rate was significantly higher in both active
treatment groups at all
analysis time points after Week 4. The >50% clearance rate in the 3.75%
imiquimod group was
higher than that in the 2.5% imiquimod treatment group at End of Study however
the difference
was not statistically significant.
Wart Counts and Change and Percent Change from Baseline in Wart Counts
Summaries of the EGW counts, change from Baseline in EGW counts, and percent
change from Baseline in EGW counts over the course of the study are presented
in Table 80
below. The mean percent changes in EGW counts over time are presented
graphically in Figure
23.
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Table 80 Summary of External Genital Wart Count from Baseline to End
of
Treatment/End of Study-ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
(N = 204) (N = 202) (N = 105)
Baseline
Mean 8.7 (7.5) 7.7 (6.3) 7.7 (6.3)
Median 6 5 6
Min, Max 2, 48 2, 30 2, 29
P value vs Placebo 0.180 0.727
P value vs 2.5% Imiquimod 0.158
Week 8/EOT
Mean 5.5 (7.2) 5.3 (5.6) 7.2 (6.6)
Median 3 3 5
Min, Max 0, 51 0, 25 0, 30
Week 16/EOS
Mean 5.0 (7.3) 4.7 (5.7) 7.1 (6.8)
Median 3 3 4
Min, Max 0, 65 0, 29 0, 31
Change from Baseline to EOS
Mean -3.7 (7.1) -3.0 (4.9) -0.6 (3.7)
Median -2 -1 0
Min, Max -43, 40 -30, 7 -15, 11
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod 0.643
Percent Change from Baseline to EOS
Mean -40.9 (56.9) -37.7 (46.2) -7.8 (46.8)
Median -46.8 -19.1 0.0
Min, Max -100,160 -100,67 -100,183
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod 0.641
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site, taking 2 treatment groups at a time.
Change from Baseline is calculated as the post-Baseline value minus the
Baseline value. Change from Baseline P values are
from analysis of covariance (ANCOVA), controlling for Baseline wart count,
gender, and analysis site. The P values marked
with ** are statistically significant using Hochberg's modified Bonferroni
procedure.
The mean EGW count at Baseline was similar between all the treatment groups
for the
ITT population. At EOT the EGW counts were lowest in the 3.75% imiquimod group
and
highest in the placebo group. At EOS the EGW counts were lowest in the 2.5%
imiquimod
group and highest in the placebo group. At EOS, the mean change from Baseline
was
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significantly greater in the active treatment groups compared with placebo.
The difference in
mean change between the active treatment groups was not statistically
significant.
In the gender subgroups, the Baseline EGW counts were higher in the 3.75%
imiquimod
group and 2.75% imiquimod group in both genders compared with placebo however
the
difference was not statistically significant. The mean change and mean percent
change from
Baseline in EGW count was significantly larger for both active treatment
groups versus placebo
in males and in females.
As shown in Figure 23 for the ITT population, the mean percent decrease from
Baseline
in wart count in the 2 active treatment groups was consistently larger than
placebo, and the
differences between the 2 active treatment groups compared with placebo were
statistically
significant at all post-Baseline analysis time points after Week 4. The
differences between the
3.75% imiquimod and 2.5% imiquimod groups were not statistically significant
at any time
during the study.
For the PP population, summaries of the EGW counts, change from Baseline in
EGW
counts, and percent change from Baseline in EGW counts over the course of the
study are
presented in Table 81.
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Table 81 Summary of External Genital Wart Count from Baseline to End
of
Treatment and End of Study-PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5%
Placebo
Baseline
N 144 144
81
Mean 8.4 (7.2) 7.6 (6.4) 7.8
(6.3)
Median 6 5 6
Min, Max 2, 32 2, 30 2, 29
P value vs Placebo 0.174 0.726
P value vs 2.5% Imiquimod 0.340
End of Treatment (EOT)
N 119 125 72
Mean 5.3 (7.7) 4.7 (5.2) 7.3
(6.3)
Median 3 3 5
Min, Max 0, 51 0, 25 0, 23
End of Study (EOS)
N 87 93 65
Mean 6.4 (9.0) 5.2 (5.8) 7.8
(7.0)
Median 4 3 6
Min, Max 0, 65 0, 29 0, 31
Change from Baseline at EOS
N 87 93 65
Mean -3.1 (7.3) -3.0 (5.5) 0.2
(3.7)
Median -2 -1 0
Min, Max -25, 40 -30, 5 -15,
11
P value vs Placebo 0.024** <0.001**
P value vs 2.5% Imiquimod 0.208
Percent Change from Baseline at EOS
N 87 93 65
Mean -30.6 (56.2) -28.9 (40.8) 2.9
(45.9)
Median -33.3 -20.8 0.0
Min, Max -100, 160 -100, 67 -100,
183
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod 0.346
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site, taking 2 treatment groups at a time.
Change from Baseline is calculated as the post-Baseline value minus the
Baseline value. Change from Baseline P values are
from analysis of covariance (ANCOVA), controlling for Baseline wart count,
gender, and analysis site. The P values marked
with ** are statistically significant using Hochberg's modified Bonferroni
procedure.
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The mean EGW count at Baseline was similar across the treatment groups for the
PP
population. At both EOT and EOS, the EGW counts were lowest in the 2.5%
imiquimod group
and highest in the placebo group in the PP population. At EOS, the mean change
and mean
percent change from Baseline in EGW count was significantly greater in the
active treatment
groups compared with placebo, however the difference between the active
treatment groups was
not statistically significant.
In the female subgroup only, the mean change and mean percent change from
Baseline in
EGW count at EOS was significantly lower in both active treatment groups
compared with
placebo, and there was no significant difference between the active treatment
groups. In males,
the mean change and mean percent change was lower in both active treatment
groups compared
with placebo; the difference in mean change was significant only for the 2.5%
imiquimod group,
but the difference in mean percent change was significant for both the 3.75%
and 2.5%
imiquimod groups.
The mean percent decrease from Baseline in wart count in the 2 active
treatment groups
was consistently larger than placebo. The differences between the active
treatment groups and
placebo were statistically significant at all post-Baseline time points after
Week 4 with the
exception of the 2.5% imiquimod group at Week 12. The differences between the
3.75%
imiquimod and 2.5% imiquimod groups were not statistically significant at any
analysis time
point.
Time to Complete Clearance
Summaries of the time to complete clearance are shown in Table 82 below.
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Table 82 Time to Clearance (days) for the ITT population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=204) (N=202)
(N=105)
All Subjects (Kaplan-Meier)
204 202 105
1st Quartile 71.0 101.0 >57
Median time to complete clearance, including all 123.0 >101
>112.0
subjects, days
P value vs Placebo <0.001 <0.001
P value vs 2.5% imiquimod cream 0.474
Only Subjects Who Attained Clearance
60 50 9
1st Quartile 47.0 43.0 34.0
Median time to complete clearance, including only 60.0 63.0
71.0
subjects who attained clearance, days
3rd Quartile 81.5 100.0 91.0
P values are from the log rank test comparing survival curves in the Kaplan-
Meier framework, taking 2 treatment
groups at a time.
Although the median time to complete clearance for the ITT treatment group was
not
reached, the median time to complete clearance in the ITT population was
statistically
significantly shorter in the 2 active treatment groups compared with placebo
(P<0.001 using the
log-rank test). The difference between the 2 imiquimod treatment groups was
not statistically
significant (P=0.474).
For those subjects who attained complete clearance, the median time to
complete
clearance was 60 days in the 3.75% imiquimod group, 63 days in the 2.75%
imiquimod group,
and 71 days in the placebo group.
Results in the PP population were similar to those in the ITT population.
Among the
subset of subjects who achieved complete clearance in the PP population, the
median time to
clearance was 64 days in the 3.75% imiquimod group, 63 days in the 2.5%
imiquimod group,
and 71 days in the placebo group.
Complete clearance was achieved more rapidly in female subjects compared with
males
in both the ITT and PP populations.
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Sustained Complete Clearance Rate at Week 12 of the Follow-up for Recurrence
Period
The numbers of subjects who remained clear in the follow-up period or who had
a recurrence of
EGW are presented in Table 83 below.
Table 83 Wart
Recurrence Rate ¨ Follow-up for Recurrence Population
(LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
(N=53) (N=43) (N=7)
Recurrence Follow-up - Week 12
Subjects who remained clear a, n/N (%) 34/53 (64.2) 29/43 (67.4)
7/7 (100.0)
Subjects who had a recurrence, n/N (%) 10/53 (18.9) 7/43 (16.3) 0
Missed at Week 12 Visit 9/53 (17.0) 7/43 (16.3) 0/7
(0.0)
95% Confidence interval 9.4, 32.0 6.8, 30.7
a Includes those who had a visit within window with no warts
Thirty-four subjects (64.2%) in the 3.75% imiquimod group, 29 subjects (67.4%)
in the
2.5% imiquimod group, and 7 subjects (100%) in the placebo group achieved
complete clearance
at EOS that was sustained throughout the 12-week follow-up period. Data were
missing for 9
subjects (17.0%) in the 3.75% imiquimod group and 7 subjects (16.3%) in the
2.5% imiquimod
group, so their recurrence status was not known, but at least 18.9% of the
3.75% imiquimod
group and 16.3% of the 2.5% imiquimod group in the follow-up for recurrence
population are
known to have shown recurrence of EGW within 12 weeks of the initial
clearance.
Statistical/Analytical Issues
Adjustments for Covariates
The primary efficacy analysis was based on a CMH test, stratified by gender
and analysis
site. Secondary analyses were performed in a number of subgroups. No other
adjustments for
covariates were planned.
Handling of Dropouts or Missing Data
For the primary ITT analysis, missing observations due to early
discontinuation were
imputed using the LOCF. Screening data were carried forward if no baseline
data existed for the
subject. Baseline data were carried forward if no post-baseline data existed
for the subject.
Additional analyses of the primary efficacy variable were performed in which
(1) all missing
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observations were considered as failures and (2) using only observed cases,
without imputations.
The results of these additional analyses are presented in the Table 84 below.
Table 84
Proportion of Subjects with Complete Clearance at End of Study
(Sensitivity and Supporting Analyses) ¨ ITT Population
Imiquimod Cream
3.75% 2.5% Placebo
(N =204) (N =202) (N = 105)
ITT Population (all subjects with
missing data were counted as failures)
n/Na (%) 60/204 (29.4) 51/202 (25.2) 9/105
(8.6)
95% CI 23.3, 36.2 19.4, 31.8 4.0,
15.6
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod Cream 0.231
ITT Population (observed cases)
niNa (%) 60/204 (29.4) 50/202 (24.8) 9/105
(8.6)
95% CI 23.3, 36.2 19.0,31.8 4.0,
15.6
P value vs Placebo <0.001** 0.001**
P value vs 2.5% Imiquimod Cream 0.231
95% CI = 95% confidence interval
a n/N=number of subjects with complete clearance at end of study divided by
the number of subjects analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site, taking 2 treatment groups at
a time. P-values marked with ** are statistically significant using Hochberg's
modified Bonferroni procedure.
Confidence intervals were calculated using the exact binomial distribution.
Results of these additional analyses are identical to those obtained based
upon LOCF for
all treatment groups.
Multicenter Studies
In order to obtain at least 6 subjects per site per active treatment group,
investigational
sites yielding fewer than 15 subjects were combined in order of geographic
proximity. The exact
composition of these "analysis sites" was determined and documented prior to
breaking the study
blind. The stratification for CMH analyses was based on the analysis sites,
not on the actual
investigational sites.
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Multiple Comparison/Multiplicity
The primary efficacy endpoint, complete clearance rate at the End of Study,
was analyzed
using Cochran-Mantel-Haenszel (CMH) statistics, stratifying on gender and
site. As mentioned
above, all pairwise comparisons of active treatment versus placebo were made
using Hochberg's
modified Bonferroni procedure. If either test was significant at a 0.025 level
of significance,
then that test was considered significant. Otherwise, if both tests were
significant at 0.05, then
both tests were considered significant. The 3.75% and 2.5% treatment groups
were compared to
each other at the 0.05 level of significance if at least one of these
treatment groups was found to
be different than the placebo using the Hochberg's test.
The 4 secondary efficacy variables were to be tested hierarchically using
Hochberg's
modified Bonferroni procedure to conserve Type 1 error. First, only if the
primary endpoint
showed statistical significant could the first secondary efficacy variable be
tested. If the prior
secondary efficacy variable showed statistical significance then the next
secondary efficacy
variable could be tested, etc.
Use of an "Efficacy Subset" of Subjects
Efficacy variables were analyzed for a Per Protocol (PP) subset of subjects.
The PP
population included all subjects in the ITT population who had no major
protocol violations: 144
subjects in the 3.75% imiquimod treatment group, 144 subjects in the 2.5%
imiquimod treatment
group, and 81 subjects in the placebo group. The demographic and baseline
characteristics in the
PP population were similar to those in the ITT population, although the mean
total wart area
decreased in the 3.75% imiquimod group.
In the analysis of the primary efficacy variable, the results in the PP
population were
similar to those in the ITT population. The proportion of subjects with
complete clearance at
Week 16/EOS was statistically significantly greater in the active treatment
groups compared with
placebo.
Results in the PP population for the other efficacy variables were also
similar to those
from the ITT population.
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Examination of Subgroups
The primary efficacy variable was summarized without statistical testing by,
investigator
site, by analysis site, by investigator medical specialty, by gender, by age
subgroup, by race
subgroup, by baseline EGW count subgroup, by baseline wart areas, by anatomic
locations
(inguinal, perineal, perianal, glans penis, penis shaft, scrotum, foreskin, or
vulva), by number of
anatomic locations affected by EGW (ie, one location versus multiple), by
whether first EGW
episode, by duration from first diagnosis of EGW, by rest periods (yes or no),
and by previous
treatment with imiquimod (yes or no).
In general, the complete clearance rates increased in a dose-dependent manner
regardless
of subgroup. The most striking subgroup effect was observed in the analysis by
gender.
Complete clearance at EOS was attained by 17.0%, 15.3%, and 4.1% of male
subjects, and by
38.8%, 31.6%, and 12.5% of females in the 3.75%, 2.5%, and placebo groups,
respectively.
The complete clearance tended to be higher in the following subgroups:
= Females;
= Lower baseline wart count (<7 compared with >7);
= Baseline wart area <70mm2;
= Subjects with baseline warts in the perianal, perineal and glans penis;
= Subjects who took a rest period (noted in the imiquimod groups but not
placebo);
= No previous imiquimod treatment (noted in the imiquimod groups but not
placebo).
In the 3.75% imiquimod group, the complete clearance rate was higher in older
subjects (>35 years) compared with younger subjects.
When analyzed by analysis site or investigative site subgroups, the complete
clearance
rate was highest in the 3.75% imiquimod group at 12/24 analysis sites and
17/43 investigative
sites.
When analyzed by investigator site specialty subgroups, the highest overall
complete
clearance rates were observed at sites specializing in gynecology (sites where
more females were
enrolled) or infectious disease. At sites specializing in dermatology and
urology, the clearance
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rates decreased with increasing imiquimod dose. Few subjects in any treatment
group attained
complete clearance at sites specializing in dermatology or urology (sites at
which only male
subjects were enrolled) or infectious disease.
Additional analysis by Gender
Additional analyses of the data were performed to explore the possible effect
of gender
on efficacy. Of the 511 subjects randomized into the trial, 222 (43.4%) were
male and 289
(56.6%) were female. Similar percentages of males and females completed the
evaluation
period. Lost to follow-up and subject's request were the most common reasons
for study
discontinuation in both genders. The time to loss of follow-up was similar in
the active
treatment groups for both genders. However, in males, the highest percentage
of subjects lost to
follow-up were in the 3.75% imiquimod group, and in females, the highest
percentage of
subjects lost to follow-up were in the 2.5% imiquimod group.
As in the overall population, the response with 3.75% imiquimod cream was
significantly
superior to that with placebo in both genders. The complete clearance rates
were consistently
higher in females compared with males in all treatment groups for both the ITT
and PP
populations, including the sensitivity and supporting analyses of the ITT
population.
A summary of complete clearance of all anatomic sites at EOS by baseline
involvement
of anatomic locations is presented in Table 85 below. Of note, a majority of
subjects of each
gender had involvement of more than one anatomic site at baseline.
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Table 85 Complete Clearance at End of Study by Baseline Anatomic
Location, -
-ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
Baseline anatomic location (N=204) (N=202) (N=105)
Both genders- n/N (%)a
Inguinal 3/35 (8.6) 7/36 (19.4) 1/23 (4.3)
Perineal 26/67 (38.8) 18/61 (29.5)
2/32 (6.3)
Perianal 28/61 (45.9) 19/57 (33.3)
4/31 (12.9)
Males- n/N (Na
Inguinal 1/24(4.2) 2/17(11.8) 1/19(5.3)
Perineal 1/6 (16.7) 1/8 (12.5) 0/3 (0.0)
Perianal 3/8 (37.5) 0/6 (0.0) 0/5 (0.0)
Glans Penis 4/9 (44.4) 3/11(27.3) 0/5 (0.0)
Penis Shaft 10/71 (14.1) 12/76(15.8)
2/39(5.1)
Scrotum 0/19 (0.0) 1/16 (6.3) 0/14 (0.0)
Foreskin 0/2 (0.0) 0/2 (0.0)
Females- n/N (%)a
Inguinal 2/11 (18.2) 5/19(26.3) 0/4(0.0)
Perineal 25/61 (41.0) 17/53 (32.1)
2/29 (6.9)
Perianal 25/53 (47.2) 19/51 (37.3)
4/26 (15.4)
Vulva 31/86 (36.0) 22/78 (28.2)
5/31 (16.1)
a: Subjects with complete clearance are included in the numerator.
In the anatomic areas common to both genders, perineal and perianal
involvements were
relatively common in females: few males had baseline disease in those areas.
Females with
perineal or perianal EGW at Baseline demonstrated relatively high rates of
complete clearance at
EOS. The third most common anatomic site, the inguinal area, was present in
more males in the
3.75% imiquimod and placebo groups but comparable in both genders in the 2.5%
imiquimod
group. Females in the active treatment groups had a higher rate of complete
clearance than
males. The lowest clearance rates occurred in subjects with inguinal area
involvement (at
Baseline) in all treatment groups. The complete clearance rates at EOS by
baseline anatomic
location for each gender are shown in Table 85.
The anatomic areas most commonly affected with EGW at Baseline in males were
the
penis shaft, inguinal, and scrotum area. The complete clearance rates were
highest in the
subjects whose EGW at Baseline was in the glans penis and perianal area for
the 3.75%
imiquimod group compared with the 2.5% imiquimod group and placebo. In
females, the vulva,
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perineal, and perianal areas were the areas most commonly affected with EGW at
Baseline. The
complete clearance rates were highest with 3.75% imiquimod for all baseline
anatomic areas
with the exception of the inguinal area in females.
In both genders, complete clearance rates were higher in subjects who took a
rest period
from imiquimod treatment compared with those who did not take a rest period.
The complete
clearance rates in males and females were higher for subjects >35 years of age
than in younger
subjects. Females with a first EGW diagnosis within one year had higher
clearance rates than
those with a longer EGW history. Males with a first EGW diagnosis after one
year had higher
clearance rates than those with a shorter EGW history.
Exploratory Analysis of Anatomic Specific Complete Clearance
In this study, subjects applied study medication to individual warts in
various anatomic
areas identified at Baseline. Some subjects developed new warts during the
study. These new
warts may have appeared within anatomic areas already displaying EGW at
Baseline and/or
these new warts may have appeared in 'new' anatomic areas that had not been
exposed to study
medication at initiation of treatment. New warts were treated with study
medication when they
appeared, but received less than a full course of treatment, because treatment
was not extended
beyond 8 weeks from randomization.
An exploratory analysis of complete clearance within the specific anatomic
areas affected
with EGW at Baseline was performed for the overall ITT population and by
gender.
Drug Dose, Drug Concentration, and Relationships to Response
This study examined the efficacy of 2.5% imiquimod cream and 3.75% imiquimod
cream, that was applied once daily for a maximum of 8 weeks. Subjects self-
applied a maximum
of 1 packet (250 mg) of study drug per application. No sample collection for
pharmacokinetic
determinations was planned in this study; therefore, no analysis of drug
concentration was done.
A dose response was observed in this study. The 3.75% imiquimod cream
consistently
demonstrated higher efficacy rates compared with the 2.5% imiquimod cream for
all primary and
secondary efficacy measures, in both the ITT and PP populations. The
difference between the 2
active treatment groups was not statistically significant for primary efficacy
analysis, secondary
and tertiary efficacy variables.
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Efficacy Conclusions
The investigational products 3.75% imiquimod cream and 2.5% imiquimod cream
met
the criteria for efficacy as defined in this protocol.
= For the primary endpoint (the rate of complete clearance of EGW at Weekl
6/E0S),
results with 3.75% imiquimod cream and 2.5% imiquimod cream were statistically
significantly superior to results with the placebo cream (P<0.001). This
effect was
observed in both the ITT and PP populations. In the ITT population, the
complete
clearance rates were 29.4% and 24.8%, respectively, in the 3.75% and 2.5%
imiquimod treatment groups, compared with 8.6% in the placebo group. Results
in
the 3.75% imiquimod group were numerically but not statistically higher than
in the
2.5% imiquimod group.
= The complete clearance rate at end of treatment (EOT) was statistically
significantly
superior with both active treatment groups compared with placebo overall and
in the
female subgroup in both the ITT and PP populations.
= Over the course of the study, the complete clearance rates were
significantly superior
with both active treatment groups compared with placebo at every analysis time
point
after Week 8 in both the ITT and PP populations. Clearance rates were higher
in the
3.75% imiquimod group than in the 2.5% imiquimod group however the difference
was not statistically significant at any time point during the evaluation
period.
= The partial (>75%) clearance rate in both active treatment groups was
statistically
significantly superior to the placebo cream at Week 16/EOS for the ITT
population
and PP population (overall and in both genders). Results were significantly
higher for
the active treatment groups at all analysis time points after Week 4 for the
ITT and PP
populations.
= Over the course of the study, the partial (>75%) clearance rates were
significantly
superior with both active treatment groups at every analysis time point after
Week 6
(ITT population) and Week 8 (PP population). Results were significantly higher
for
the 3.75% imiquimod vs 2.5% imiquimod at Weeks 6, 12, and 14.
= The >50% clearance rate at EOS was significantly greater in both active
treatment
groups compared with placebo in both the ITT and PP populations. Results were
higher in the 3.75% imiquimod group vs 2.5% imiquimod however the difference
was
not statistically significant.
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= Over the course of the study, the >50% clearance rates were significantly
superior
with both active treatment groups compared with placebo at every analysis time
point
after Week 4 in both the ITT and PP populations.
= The complete and partial clearance rates were consistently higher in the
female
subgroup compared with the male subgroup in all treatment groups. Mean change
and percent change from Baseline in EGW counts were consistently higher in
females
compared with males in the active treatment groups.
= At EOS, the mean percent change from Baseline in wart count with 3.75%
imiquimod
cream and 2.5% imiquimod cream was statistically significantly greater than
with
placebo (P<0.001) in the ITT and PP populations.
= Although the median time to complete clearance for the ITT treatment
group was not
reached, the median time to complete clearance in the ITT population was
statistically
significantly shorter in the 2 active treatment groups compared with placebo
(P<0.001
using the log-rank test). The difference between the 2 imiquimod treatment
groups
was not statistically significant (P=0.474). For those subjects who attained
complete
clearance, the median time to complete clearance was 60 days in the 3.75%
imiquimod group, 63 days in the 2.75% imiquimod group, and 71 days in the
placebo
group.
= Thirty-four of 53 subjects (64.2%) in the 3.75% imiquimod group remained
completely clear of EGW through the 12-week follow-up period, while 10/53
subjects
had wart recurrence. The status is unknown for 9/53 subjects. Twenty-nine of
43
subjects (67.4%) in the 2.5% imiquimod group (with 7 missing subjects), and 7
of 7
subjects in the placebo group remained clear through the follow-up period.
Thus, at
least 64.2% of the 3.75% imiquimod group and 67.4% of the 2.5% imiquimod group
in the follow-up for recurrence population are known to have sustained
clearance of
all anatomic sites for at least 12 weeks from initial clearance.
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SAFETY EVALUATION
Extent of Exposure
An overall summary of study drug exposure for the ITT population is presented
in Table
86 below. One subject was originally randomized to the 2.5% imiquimod
treatment group;
however, at Week 2, the subject incorrectly received a 3.75% imiquimod
treatment group kit
assigned to another subject. For the safety analysis the highest dose received
(3.75% imiquimod)
was used and the subject was considered as part of the safety population
instead of the ITT
population.
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Table 86 Overall Study Drug Exposure - ITT Population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=204) (N=202)
(N=105)
Treatment duration, days' - All subjects
172 163 89
Mean SD 50.0 (15.6) 50.8 (15.3) 54.7
(10.9)
Median 56 56 56
MM, Max 1,89 3,97 13,73
Total number of packets used
164 159 86
Mean SD 43.8 (14.4) 45.1 (14.2) 52.7
(9.5)
Median 48 51 56
Min, Max 6,72 3,65 13,76
Number of days treated'
172 163 89
Mean SD 43.7 (15.4) 45.6 (15.5) 52.0
(10.9)
Median 50 52 55
Min, Max 1,74 3,92 13,69
Percent of Treatment Compliance c
191 180 97
Mean SD 83.2 (26.7) 86.5 (23.2) 91.1
(20.8)
Median 95 96 98
Min, Max 0,116 13, 118 25,
123
SD=standard deviation, min=minimum, max-maximum.
a
Duration of treatment is date of last dose minus date of first dose plus 1.
Last dose is defined as last date
on study medication.
b Days treated is the
duration of treatment minus rest period days and missed doses.
c Based on either packet use compliance or treatment days compliance
whichever is greater.
The mean treatment duration, number of study medication packets, and number of
days
were numerically highest in the placebo group compared with the 3.75% and 2.5%
imiquimod
treatment groups.
Based on the available data, on average, the subjects used 43.8 packets of
3.75%
imiquimod, 45.1 packets of 2.5% imiquimod, and 52.7 packets of placebo. Mean
treatment
duration was 50.0 days in the 3.75% imiquimod treatment group, 50.8 days in
the 2.5%
imiquimod treatment group, and 54.7 days in the placebo group. When rest
periods and missed
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doses were subtracted, the total number of days treated was reduced to 43.7,
45.6, and 52.0 days
in the 3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively.
The mean number of packets used, number of days treated, and percent treatment
compliance were higher in the males than in females in the active treatment
groups in the ITT
and safety populations. Mean treatment duration was higher in males than in
females for the
2.5% imiquimod group in the ITT population. There was no difference between
genders in the
placebo group.
Adverse Events (AEs)
Brief Summary of Adverse Events
A summary of the overall incidence of AEs is provided in Table 87 below for
the safety
population.
Table 87 Summary of Adverse Events-Safety Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201) (N=105)
Subjects with any AE, n (%) 103 (50.2) 101 (50.2) 43 (41.0)
Number of AEs 286 227 75
Subjects with any:
Treatment-relatecr AE, n (%) 40 (19.5) 37 (18.4) 3 ( 2.9)
SAE, n (%) 7 ( 3.4) 2 ( 1.0) 1 ( 1.0)
AEs of severe intensity, n (%) 15 ( 7.3) 10 ( 5.0) 4 ( 3.8)
AE leading to study 3 ( 1.5) 5 ( 2.5) 0
discontinuation, n (%)
AE=adverse event, SAE=serious adverse event
a: Includes "Probably related" and "Related" AEs.
Counts reflect numbers of subjects in each treatment group reporting one or
more adverse events that map to
the MedDRA system organ class. A subject may be counted once only in each row
of the table. A treatment-
emergent AE is an AE that began or worsened in severity after Day 1 and no
more than 30 days after the last
application of study drug.
Subject 03/012 in the 2.5% imiquimod group, who discontinued from the study at
the subject's request (CRF
page 31) was also recorded as discontinued from the study due to an adverse
event.
The number of subjects who experienced any AE (including those not considered
treatment emergent) was similar in the active treatment groups (103 [50.2%]
and 101 [50.2%] in
the 3.75% and 2.5% imiquimod groups, respectively) and lower in the placebo
group
(43, [41.0%]). The number of subjects with AEs considered treatment-related or
severe in
intensity was similar in the active treatment groups and lower in the placebo
group. Seven
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(3.4%) of subjects in the 3.75% imiquimod group experienced an SAE. The number
of subjects
with an SAE or who withdrew from the study due to an AE was low in the other 2
treatment
groups.
An overall summary of the incidence of treatment-emergent AEs is provided in
Table 88 below.
Table 88 Summary of Treatment-Emergent Adverse Events - Safety
Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201) (N=105)
Subjects with any AE, n (%) 91 (44.4) 82 (40.8) 34 (32.4)
Number of AEs 216 167 51
Subjects with any:
Treatment-relateda AE, n (%) 40 (19.5) 37 (18.4) 3 (2.9)
Application site AE, n (%) 35 (17.1) 33 (16.4) 3 ( 2.9)
SAE, n (%) 6(2.9) 2(1.0) 1(1.0)
AEs of severe intensity, n (%) 14 (6.8) 9 (4.5) 3 (2.9)
AE leading to study 3 (1.5) 5(2.5) 0
discontinuation, n (%)
AE=adverse event, SAE=serious adverse event
a: Includes "Probably related" and "Related" AEs.
Counts reflect numbers of subjects in each treatment group reporting one or
more adverse events that map to
the MedDRA system organ class. A subject may be counted once only in each row
of the table. A treatment-
emergent AE is an AE that began or worsened in severity after Day 1 and no
more than 30 days after the last
application of study drug.
The number of subjects with treatment-emergent AEs was similar in the active
treatment
groups (91 [44.4%] and 82 [40.8%] in the 3.75% and 2.5% imiquimod groups,
respectively) and
lower in the placebo group (34, [32.4%]). The number of subjects with AEs
considered
treatment-emergent or severe in intensity was similar in the active treatment
groups and lower in
the placebo group. A higher percentage of subjects in the active treatment
groups had application
site reactions compared with placebo. The number of subjects with an SAE or
who withdrew
from the study due to an AE was relatively low in all treatment groups.
Most Frequent Adverse Events
A treatment-emergent AE was defined as an AE that began or worsened in
severity after
the first application of the study drug and no more than 30 days after the
last application of the
study drug. The incidence of the most commonly-occurring treatment-emergent
AEs is
presented by preferred term in Table 89 below.
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Table 89 Number (%) of Subjects with Most Frequent Treatment-Emergent
Adverse Events (>1 /0 in any active treatment group) - Safety
Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201) (N=105)
Subjects with any AE, n (%) 91 (44.4) 82 (40.8) 34 (32.4)
Application site pain 17 (8.3) 8 (4.0) 0
Application site pruritus 8 (3.9) 14 (7.0) 1(1.0)
Application site irritation 12 (5.9) 8 (4.0) 1(1.0)
Nasopharyngitis 4 (2.0) 7 (3.5) 6 (5.7)
Upper respiratory tract infection 5 (2.4) 4 (2.0) 2
(1.9)
Urinary tract infection 4 (2.0) 3 (1.5) 2 (1.9)
Vaginal candidiasis 1(0.5) 7 (3.5) 1(1.0)
Nasal congestion 2 (1.0) 5 (2.5) 1(1.0)
Headache 3 (1.5) 3 (1.5) 1(1.0)
Pruritus genital 4 (2.0) 2 (1.0) 1(1.0)
Scrotal erythema 2 (1.0) 5 (2.5) 0
Influenza 1(0.5) 3 (1.5) 2 (1.9)
Application site rash 2 (1.0) 3 (1.5) 0
Application site ulcer 2 (1.0) 3 (1.5) 0
Nausea 3 (1.5) 1(0.5) 1(1.0)
Rash 3 (1.5) 1(0.5) 1(1.0)
Scrotal ulcer 2 (1.0) 3 (1.5) 0
Sinusitis 3 (1.5) 0 2 (1.9)
Application site infection 1(0.5) 3 (1.5) 0
Application site vesicles 3 (1.5) 1 (0.5) 0
Sinus congestion 3 (1.5) 1(0.5) 0
Anxiety 3(1.5) 0 0
Influenza like illness 0 3 (1.5) 0
Musculoskeletal pain 3 (1.5) 0 0
Scrotal pain 3(1.5) 0 0
AE-adverse event
Counts reflect numbers of subjects in each treatment group reporting one or
more adverse events that map to
the MedDRA system organ class. A subject may be counted once only in each row
of the table.
A treatment-emergent AE is an AE that began or worsened in severity after the
first application of the study
drug and no more than 30 days after the last application of the study drug.
The AE reported with the greatest overall incidence was application site pain,
reported in
8.3% of subjects in the 3.75% imiquimod group, 4.0% of subjects in the 2.5%
imiquimod group,
and 0.0% of subjects in the placebo group.
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Application site pruritus occurred with a higher frequency in the 2.5%
imiquimod group
(7.0%) compared with the 3.75% imiquimod group (3.9%) and placebo 0.0% groups.
Nasopharyngitis occurred with a higher frequency in the placebo group (5.7%)
compared with
the 3.75% imiquimod group (2.0%), and 2.5% imiquimod group (3.5%). With these
exceptions,
the incidence of the individual AEs was similar in the 2 active treatment
groups and lower in the
placebo group.
Flu-like symptoms and certain other systemic effects have been reported with
5%
imiquimod treatment. The incidence of these AEs was very low in the current
study. These
events were reported in this study in the 3.75% imiquimod, 2.5% imiquimod, and
placebo
groups, respectively, as follows:
= nausea was reported in 3 (1.5%), 1 (0.5%), and 1 (0.5%) subjects;
= influenza was reported in 1(0.5%), 3 (1.5%), and 2 (1.9%) subjects;
= influenza-like illness was reported in 0, 3 (1.5%), and 0 subjects;
= myalgia was reported in 1 (0.5%), 1 (0.5%), and 0 subjects;
= pyrexia was reported in 1 (0.5%), 1 (0.5%), and 0 subjects;
= chills were reported in 0, 1 (0.5), and 0 subjects.
Adverse Events by System Organ Class
The incidence of AEs is presented by system organ class in Table 90 below.
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Table 90 Number ("/0) of Subjects with Treatment-Emergent Adverse
Events by
System Organ Class - Safety Population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=205) (N=201)
(N=105)
General disorders and administration site disorders 42 (20.5) 37
(18.4) 5 (4.8)
Infections and infestations 36 (17.6) 37 (18.4) 20
(19.0)
Respiratory, thoracic, and mediastinal disorders 11(5.4) 10
(5.0) 4 (3.8)
Gastrointestinal disorders 11(5.4) 6 (3.0) 3
(2.9)
Skin and subcutaneous tissue disorders 11(5.4) 3 (1.5) 2
(1.9)
Reproductive system and breast disorders 10 (4.9) 13 (6.5) 2
(1.9)
Musculoskeletal and connective tissue disorders 7 (3.4) 4
(2.0) 1 (1.0)
Injury, poisoning, and connective tissue disorders 6 (2.9) 3
(1.5) 4 (3.8)
Psychiatric disorders 4 (2.0) 1(0.5)
1(1.0)
Nervous system disorders 3 (1.5) 5 (2.5)
1(1.0)
Investigations 2 (1.0) 0 1
(1.0)
Renal and urinary disorders 2 (1.0) 0 1
(1.0)
Neoplasms benign, malignant, and unspecified (incl 2 (1.0) 0 0
cysts and polyps)
Immune system disorders 1(0.5) 1(0.5)
1(1.0)
Surgical and medical procedures 1(0.5) 1(0.5)
1(1.0)
Endocrine disorders 1 (0.5) 0 0
Metabolism and nutrition disorders 1 (0.5) 0 0
Vascular disorders 1 (0.5) 0 0
Blood and lymphatic disorders 0 2 (1.0) 0
AE-adverse event
Counts reflect numbers of subjects in each treatment group reporting one or
more AEs that map to the MedDRA
system organ class. A subject was counted only once in each row of the table.
System organ classes in which AEs were reported with an incidence of >5% in at
least
one treatment group were general disorders and administrative site disorders,
infections and
infestations, gastrointestinal disorders, reproductive system and breast
disorders, respiratory,
thoracic, and mediastinal disorders, and skin and subcutaneous tissue
disorders.
Adverse Events by Intensity
Most of the AEs were of mild or moderate intensity. Four AEs were rated as
severe in at
least 2 subjects in any treatment group:
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= application site pruritus, reported in 1 subject (0.5%) in the 3.75%
imiquimod
treatment group, 2 subjects (1.0%) in the 2.5% imiquimod treatment group, and
0
subjects in the placebo group;
= application site irritation, reported in 2 subjects (1.0%) in the 3.75%
imiquimod
treatment group, 2 subjects (1.0%) in the 2.5% imiquimod treatment group, and
0
subjects in the placebo group;
= application site rash, reported in 2 subjects (1.0%) in the 3.75%
imiquimod treatment
group, 0 subjects in the 2.5% imiquimod treatment and placebo groups;
= scrotal erythema, reported in 2 subjects (1.0%) in the 3.75% imiquimod
treatment
group, 1 subject (0.5%) in the 2.5% imiquimod treatment group, and 0 subjects
in the
placebo group.
Adverse Events by Relationship to Treatment
Treatment-emergent AEs are summarized by treatment group and relationship to
study
treatment in Table 91 below.
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Table 91 Number (%) of Subjects with Treatment-Emergent Adverse Events
Related
to Treatment - Safety Population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=205) (N=201)
(N=105)
Subjects with any treatment-related:
SAE, n (%) 0 0 0
AE of severe intensity, n (%) 9 ( 4.4) 9 ( 4.5) 1 (
1.0)
AE leading to study drug discontinuation, 1 ( 0.5) 3 ( 1.5) 0
n (%)
Application site pain 16 ( 7.8) 8 ( 4.0) 0
Application site pruritus 7 ( 3.4) 14 ( 7.0) 1 (
1.0)
Application site irritation 11 ( 5.4) 8 ( 4.0) 1 (
1.0)
Application site rash 2 ( 1.0) 3 ( 1.5) 0
Application site ulcer 2 ( 1.0) 3 ( 1.5) 0
Application site bleeding 2 ( 1.0) 1 ( 0.5) 1 (
1.0)
Application site vesicles 3 ( 1.5) 1 ( 0.5) 0
Secretion discharge 2 ( 1.0) 2 ( 1.0) 0
Application site reaction 1 ( 0.5) 2 ( 1.0) 0
Application site dermatitis 1 ( 0.5) 1 ( 0.5) 0
Application site discharge 1 ( 0.5) 1 ( 0.5) 0
Application site erythema 0 2 ( 1.0) 0
Application site erosion 0 1 ( 0.5) 0
Application site paraesthesia 0 0 1 (
1.0)
Application site swelling 1 ( 0.5) 0 0
Scrotal erythema 2 ( 1.0) 4 ( 2.0) 0
Scrotal ulcer 2 ( 1.0) 3 ( 1.5) 0
Scrotal oedema 2 ( 1.0) 2 ( 1.0) 0
Pruritus genital 2 ( 1.0) 1 ( 0.5) 0
Scrotal pain 3 ( 1.5) 0 0
Genital rash 0 1 ( 0.5) 0
Pelvic pain 0 1 ( 0.5) 0
Penis disorder 0 1 ( 0.5) 0
Prostatitis 1 ( 0.5) 0 0
Scrotal irritation 1 ( 0.5) 0 0
Vulval disorder 0 1 ( 0.5) 0
Vulval ulceration 0 1 ( 0.5) 0
Vulvovaginal pruritus 1 ( 0.5) 0 0
(Continued)
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Table 91 Number (%) of Subjects with Treatment-Emergent Adverse Events
Related
to Treatment - Safety Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201) (N=105)
Application site infection 1 ( 0.5) 3 ( 1.5) 0
Application site cellulitis 1 ( 0.5) 0 0
Application site pustules 0 1 ( 0.5) 0
Cellulitis 0 1 ( 0.5) 0
Folliculitis 0 1 ( 0.5) 0
Fungal infection 1 ( 0.5) 0 0
Influenza 1 ( 0.5) 0 0
Scrotal infection 1 ( 0.5) 0 0
Staphylococcal abscess 0 1 ( 0.5) 0
Haemorrhoidal haemorrhage 1 ( 0.5) 0 0
Haemorrhoids 0 1 ( 0.5) 0
Nausea 0 1 ( 0.5) 0
Groin pain 0 1 ( 0.5) 0
Myalgia 1 ( 0.5) 0 0
Pain in extremity 0 1 ( 0.5) 0
Rash 1 ( 0.5) 0 0
Scab 0 1 ( 0.5) 0
Skin exfoliation 1 ( 0.5) 0 0
Lymph node pain 0 1 ( 0.5) 0
Burning sensation 0 1 ( 0.5) 0
Dysuria 1 ( 0.5) 0 0
AE¨adverse event
Counts reflect numbers of subjects in each treatment group reporting one or
more AEs that map to the MedDRA
system organ class. A subject was counted only once in each row of the table.
Treatment-related includes Probably
Related and Related.
Adverse events considered to be treatment-related were reported in 40 subjects
(19.5%)
in the 3.75% imiquimod treatment group, 37 (18.4%) in the 2.5% imiquimod
treatment group,
and 3 (2.9%) in the placebo group. The most frequently reported treatment-
related AEs were
application site pain and application site pruritus. Application site AEs were
the most frequently
reported treatment-related AEs followed by AEs involving the scrotum.
Application site pruritus,
application site irritation, application site bleeding and paraesthesia, each
in 1 subject (1.0%),
were the only treatment-related AEs reported in the placebo group.
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Treatment-related AEs of severe intensity were reported by 9 subjects in the
3.75%
imiquimod group, 9 subjects in the 2.5% imiquimod group, and 1 subject in the
placebo group.
The majority of the AEs were application site reactions and all resolved
without sequelae.
Adverse Events by Subgroup
Treatment-emergent AEs were analyzed by gender, by age, by number of anatomic
areas
affected by EGW, and by baseline wart count. As in the overall population,
application site
reactions were the most commonly-reported AEs and treatment-related AEs in all
subgroups for
all treatment groups.
Adverse Events by Gender: Summaries of the analysis by gender are provided in
the Table
below (table 92).
Table 92
Treatment-emergent Adverse Events by Gender-Safety Population
Male Female
3.75% 2.5% 3.75% 2.5%
Imiquimod Imiquimod Placebo Imiquimod Imiquimod Placebo
n=88 n=85 n=49 n=117 n=116 n=56
Subjects with any AE, n (%) 37 (42.0) 28 (32.9) 8 (16.3)
54 (46.2) 54 (46.6) 26 (46.4)
Number of AEs 104 60 11 112 107 40
Number (%) of subjects with:
Any Treatment-related AE 16 (18.2) 13 (15.3) 0 ( 0.0) 24
(20.5) 24 (20.7) 3 ( 5.4)
Any SAE 2 ( 2.3) 1 ( 1.2) 0 ( 0.0) 4 ( 3.4) 1
( 0.9) 1 ( 1.8)
Any Severe AE 10 (11.4) 2 ( 2.4) 0 ( 0.0) 4
( 3.4) 7 ( 6.0) 3 ( 5.4)
Any AE leading to Study 1 ( 1.1) 2 ( 2.4) 0 ( 0.0) 2
( 1.7) 3 ( 2.6) 0 ( 0.0)
Discontinuation
Any Application site 14 (15.9) 9 (10.6) 0 ( 0.0)
21 (17.9) 24 (20.7) 3 ( 5.4)
Reaction
The overall incidence of AEs was higher in females than in males in all
treatment groups.
Treatment-related AEs and SAEs were reported in a higher percentage of females
than in males
in the 3.75% imiquimod and placebo treatment groups but not in the 2.5%
imiquimod group.
Severe AEs were reported in a higher percentage of females in the 2.5%
imiquimod and placebo
groups, but not in the 3.75% imiquimod group. The incidence of SAEs and AEs
leading to study
discontinuation was low in all treatment groups regardless of gender.
Application site reactions
were the most commonly reported AEs in the 2 imiquimod treatment groups.
Severe AEs and
application site reactions were each reported in 3 female subjects (5.4%) in
the placebo group.
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Adverse Events by Age:
As in the overall population, application site reactions were the most
commonly-reported
treatment-emergent AEs in both age groups for the 2 imiquimod treatment
groups.
In the active treatment groups, the incidence of treatment-emergent AEs was
similar in
younger 35 years) and older (> 35 years) subjects within each treatment group.
Treatment-
emergent AEs were reported in 45.1%, 40.8%, and 31.8%, respectively, of
younger subjects in
the 3.75% imiquimod, 2.5% imiquimod, and placebo groups compared with 43.1%,
40.8%, and
33.3%, respectively, of the older subjects in the 3.75% imiquimod, 2.5%
imiquimod, and placebo
groups.
In the active treatment groups, the incidence of treatment-related AEs and
application site
reactions was slightly higher in younger subjects than in older subjects;
however, within each age
subgroup, there was little difference between the active treatments. Few
treatment-related AEs
or application site reactions were reported in subjects in either age subgroup
who received
placebo.
Adverse Events by Number of Anatomic Areas:
As in the overall population, the most commonly-reported treatment-emergent
AEs and
treatment-related AEs in both subgroups for all treatment groups were
application site reactions.
In the 2 active treatment groups, similar percentages of subjects in the
single-area and
multiple-area subgroups reported a treatment-emergent AE. In the placebo
group, subjects in the
multiple-area subgroup reported a higher percentage of treatment-emergent AEs
than those in the
single-area subgroup (36.5% versus 28.3%, respectively). For treatment-related
AEs and
application site reactions, there was little difference in AE incidence
between the subgroups in
any of the treatment groups.
Adverse Events by Baseline Wart Count:
In the subjects with 7 or fewer warts at Baseline, the incidence of AEs was
43.9%,
39.5%, and 32.8%, respectively, in the 3.75% imiquimod, 2.5% imiquimod, and
placebo groups,
whereas in subjects with more than 7 warts at Baseline, the incidence of AEs
was 45.1%, 42.9%,
and 31.6%, respectively, in the 3.75% imiquimod, 2.5% imiquimod, and placebo
groups.
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In the subjects with 7 or fewer warts at Baseline, the incidence of treatment-
related AEs
was 19.5%, 16.9%, and 4.5%, respectively, in the 3.75% imiquimod, 2.5%
imiquimod, and
placebo groups, whereas in subjects with more than 7 warts at Baseline, the
incidence of
treatment-related AEs was 19.5%, 20.8%, and 0%, respectively, in the 3.75%
imiquimod, 2.5%
imiquimod, and placebo groups.
There was little difference in the incidence of treatment-emergent AEs,
treatment-related
AEs, and application site reactions between the subgroups in any of the active
treatment groups.
In the placebo group, subjects with 7 or fewer warts had a higher incidence of
application site
reactions than subjects with more than 7 warts.
Local Skin Reactions
Local skin reactions were assessed by the investigator at each visit including
Baseline
(pretreatment). At Baseline, 5.4%, 6.0%, and 8.6% of subjects in the 3.75%
imiquimod, 2.5%
imiquimod, and placebo groups, respectively, had at least one LSR reaction
(LSR intensity score
>0). The most intense post-Baseline LSRs (ie, those with the highest intensity
rating) in the
treatment area that were assessed by the investigator over the course of the
study are summarized
in the Table below (Table 93). The potential maximum sum of LSR scores was 18
(six types of
LSRs each with maximum potential score of 3).
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Table 93
Frequency Distribution of Most Intense Post-baseline Local Skin
Reactions in the Treatment Area - Safety Population
Number (%) of Subjects
Imiquimod
3.75% 2.5%
Placebo
Type of Reaction Intensity
(N=205) (N=201)
(N=105)
Erythema N 189 (100) 180 (100) 98
(100)
0=None 50 (26.5) 64 (35.6) 67
(68.4)
1=Faint to mild redness 49 (25.9) 49 (27.2) 19
(19.4)
2-Moderate redness 71 (37.6) 47 (26.1) 11
(11.2)
3-Intense redness 19 (10.1) 20 (11.1)
1(1.0)
>0 (any reaction) 139 (73.5) 116 (64.4) 31
(31.6)
Mean score (SD) 1.31 (0.97) 1.13 (1.02)
0.45 (0.73)
Edema N 189 (100) 180 (100) 98
(100)
0=None 108 (57.1) 111 (61.7) 89
(90.8)
1-Mild visible/barely palpable swelling/ 59 (31.2) 47 (26.1) 8
(8.2)
induration
2-Easily palpable swelling/induration 19 (10.1) 16 (8.9)
1(1.0)
3-Gross swelling/induration 3 (1.6) 6 (3.3) 0
>0 (any reaction) 81 (42.9) 69 (38.3) 9
(9.2)
Mean score (SD) 0.56 (0.74) 0.54 (0.79)
0.10 (0.34)
Weeping/Exudate N 189 (100) 180
(100) 98 (100)
0=None 124 (65.6) 125 (69.4) 95
(96.9)
1=Minimal exudate 49 (25.9) 41 (22.8) 3
(3.1)
2=Moderate exudate 12 (6.3) 12 (6.7) 0
3-1-leavy exudate 4(2.1) 2(1.1) 0
>0 (any reaction) 65 (34.4) 55 (30.6) 3
(3.1)
Mean score (SD) 0.45 (0.71) 0.39 (0.66)
0.03 (0.17)
Flaking/Scaling/ N 189 (100) 180
(100) 98 (100)
Dryness 0=None 129 (68.3) 144 (80.0) 87
(88.8)
1=Mild dryness/flaking 52 (27.5) 28 (15.6) 11
(11.2)
2=Moderate dryness/flaking 8 (4.2) 6 (3.3) 0
3=Severe dryness/flaking 0 2 (1.1) 0
>0 (any reaction) 60 (31.7) 36 (20.0) 11
(11.2)
Mean score (SD) 0.36 (0.56) 0.26 (0.57)
0.11(0.32)
(Continued)
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Table 93
Frequency Distribution of Most Intense Post-baseline Local Skin
Reactions in the Treatment Area - Safety Population
Number (1)/0) of Subjects
Imiquimod
3.75% 2.5%
Placebo
Type of Reaction Intensity (N=205) (N=201)
(N=105)
Scabbing/Crusting N 189 (100) 180
(100) 98 (100)
0=N one 141 (74.6) 141 (78.3) 93
(94.9)
1-Crusting 41 (21.7) 30 (16.7) 5
(5.1)
2=Serous scab 6 (3.2) 8 (4.4) 0
3-Eschar 1 (0.5) 1 (0.6) 0
>0 (any reaction) 48 (25.4) 39 (21.7) 5
(5.1)
Mean score 0.30 (0.55) 0.27 (0.57)
0.05 (0.22)
Erosion/Ulceration N 189 (100) 180
(100) 98 (100)
0=None 116 (61.4) 118 (65.6) 92
(93.9)
2=Erosion 51 (27.0) 40 (22.2) 5
(5.1)
3=Ulceration 22 (11.6) 22 (12.2)
1(1.0)
>0 (any reaction) 73 (38.6) 62 (34.4) 6
(6.1)
Mean score (SD) 0.89 (1.16) 0.81 (1.16)
0.13 (0.53)
SD = Standard deviation.
Note: For purposes of analysis, 'Erosion' is categorized as 2 = Moderate, and
'Ulceration is categorized as 3 = Severe.
Denominator for the most intense reaction is the number of subjects with at
least one post-baseline assessment.
As displayed in the Table above, the incidence of each type of LSR was higher
in the
active treatment groups compared with placebo. For each LSR, the percentage of
subjects with
any reaction and the mean intensity score were highest in the 3.75% imiquimod
treatment group,
somewhat lower in the 2.5% imiquimod group, and lowest in the placebo group.
The incidence
of severe LSRs was similar between the active treatment groups within each LSR
category, and
lower in the placebo group.
Erythema was the LSR reported with the greatest frequency and the greatest
mean
intensity in all 3 treatment groups. Severe erythema was reported in 10.1% of
subjects in the
3.75% imiquimod group, 11.1% of subjects in the 2.5% imiquimod group, and 1.0%
of subjects
in the placebo group. The mean intensity score was higher in the active
treatment group (1.31
and 1.13 in the 3.75% and 2.5% imiquimod groups, respectively) compared with
placebo.
Edema rated as severe was reported in 1.6% and 3.3% of subjects in the 3.75%
and 2.5%
imiquimod groups, respectively, compared with no subjects in the placebo
group. The mean
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intensity scores were higher in the active treatment groups (0.56 and 0.54 in
the 3.75% and 2.5%
imiquimod groups, respectively) compared with 0.10 in the placebo group.
For erosion/ulceration severe reactions (ulceration) were in reported in 11.6%
and 12.2%
of subjects in the 3.75% and 2.5% imiquimod groups, respectively, compared
with 1.0% of
subjects in the placebo group. The mean intensity scores were higher in the
active treatment
groups (0.89 and 0.81 in the 3.75% and 2.5% imiquimod groups, respectively)
compared with
0.13 in the placebo group.
The majority of cases of weeping/exudate, flaking/scaling, and
scabbing/crusting were
mild in intensity. Few subjects in any treatment group had a reaction
considered to be severe.
A summary of subjects who had any post-baseline local skin reaction is
presented in
Table 94 below.
Table 94 Summary of Subjects Who Had Any Local Skin Reaction During
the
Study - Safety Population
Number (%) of Subjects
Imiquimod
3.75% 2.5%
Placebo
Most Intense Reaction (post-Baseline)
(N=205) (N=201) (N=105)
189 180 98
0=None 41 (21.7) 57 (31.7) 57
(58.2)
1=Mild 41 (21.7) 42 (23.3) 26
(26.5)
2=Moderate 74 (39.2) 48 (26.7) 13
(13.3)
3=Severe 33 (17.5) 33 (18.3) 2
(2.0)
>0 (any reaction) 148 (78.3) 123 (68.3) 41
(41.8)
Mean score (SD) 1.5 (1.0) 1.3 (1.1) 0.6
(0.8)
SD = Standard deviation.
Note: For purposes of analysis, 'Erosion' is categorized as 2 = Moderate, and
'Ulceration is categorized as 3 = Severe.
Denominator for the most intense reaction is the number of subjects with at
least 1 post-baseline assessment.
As noted for the individual LSRs, the percentage of subjects reporting an LSR
at each
intensity category was higher in the active treatment group compared with
placebo, and was
somewhat higher with 3.75% imiquimod than with 2.5% imiquimod. Severe
reactions were
reported by 17.5% of subjects in the 3.75% imiquimod group and 18.3% of
subjects in the 2.5%
imiquimod group compared with 2.0% of subjects in the placebo group. The mean
score for the
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most intense LSR reaction was slightly higher in the 3.75% imiquimod group
(1.5) than in the
2.5% imiquimod group (1.3).
The mean LSR sum score is shown by study week in Figure 24
Erythema was the major contributor to the LSR sum score in all treatment
groups, as
determined by visual inspection. In the imiquimod treatment groups, the mean
LSR sum score
peaked at Week 2, decreased slightly during the treatment period, and rapidly
decreased when
treatment was discontinued. Mean LSR scores in the placebo group were highest
at Week 4 but
were considerably lower than those seen with active treatment.
Rest Periods
Summaries of the rest periods for the safety population are presented in Table
95 below.
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Table 95 Summary of Rest
Periods - Safety Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201)
(N=105)
Subjects requiring rest period, n/N (%)* 67 (32.7) 55
(27.4) 3 (2.9)
P value vs Placebo <0.001 <0.001 NA
P value vs 2.5% imiquimod cream 0.234 NA NA
No. of dosing days missed due to rest
period"
67 55 3
Mean (SD) 10.3 (8.1) 9.3 (6.7) 6.7
(4.7)
Median 7 7 5
P value vs Placebo 0.522 0.526 NA
P value vs 2.5% cream 0.714 NA NA
No. of dosing days prior to the beginning of
the first rest period"
67 55 3
Mean (SD) 18.3 (11.5) 18.9 (13.7) 25.7 (4.0)
Median 14 14 28
P value vs Placebo 0.151 0.192 NA
P value vs 2.5% cream 0.924 NA NA
No. = number; SD=standard deviation; NA=not applicable
a P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site, taking 2
treatment groups at a time.
P values are from the Wilcoxon Rank Sum test, taking 2 treatment groups at a
time.
Significantly larger percentages of subjects in the active treatment groups
compared with
placebo took a rest period during the study (P <0.001). There was no
significant difference
between the active treatments in the percentage of subjects who took a rest
period (32.7% and
27.4% in the 3.75% and 2.5% imiquimod groups, respectively). There were no
statistically
significant differences between the treatment groups in the mean duration of
rest periods or the
mean number of dosing days prior to the rest periods.
Analysis of Adverse Events
Application site reactions are commonly reported for topically applied
products. An
additional analysis of these events is presented below.
Application site reactions reported in this study are displayed in Table 96
below.
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Table 96 Number (%) of Subjects with Treatment-Emergent Application
Site
Adverse Events - Safety Population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=205) (N=201)
(N=105)
Subjects with any application site reaction, 35 (17.1) 33
(16.4) 3 ( 2.9)
n (%)
Number of application site reactions 59 54 4
Number (%) of subjects with any:
Related Application Site Reaction a, n (%) 33 (16.1) 32 (15.9) 3 (
2.9)
Serious Application Site Reaction, n (%) 0 0 0
Severe Application Site Reaction, n (%) 6 ( 2.9) 6 ( 3.0) 1 (
1.0)
Application Site Reaction Leading to Study 1 ( 0.5) 3 (
1.5) 0
Discontinuation, n (%)
General disorders and administration site 35 (17.1) 32
(15.9) 3 ( 2.9)
conditions, n (%)
Application site pain 17 ( 8.3) 8 ( 4.0) 0
Application site pruritus 8 ( 3.9) 14 ( 7.0) 1 (
1.0)
Application site irritation 12 ( 5.9) 8 ( 4.0) 1 (
1.0)
Application site rash 2 ( 1.0) 3 ( 1.5) 0
Application site ulcer 2 ( 1.0) 3 ( 1.5) 0
Application site bleeding 2 ( 1.0) 1 ( 0.5) 1 (
1.0)
Application site vesicles 3 ( 1.5) 1 ( 0.5) 0
Application site reaction 1 ( 0.5) 2 ( 1.0) 0
Application site dermatitis 1 ( 0.5) 1 ( 0.5) 0
Application site discharge 1 ( 0.5) 1 ( 0.5) 0
Application site erythema 0 2 ( 1.0) 0
Application site dryness 1 ( 0.5) 0 0
Application site erosion 0 1 ( 0.5) 0
Application site hypersensitivity 0 1 ( 0.5) 0
Application site oedema 1 ( 0.5) 0 0
Application site paraesthesia 0 0 1 (
1.0)
Application site swelling 1 ( 0.5) 0 0
Infections and infestations, n (%) 2 ( 1.0) 4 ( 2.0) 0
Application site infection 1 ( 0.5) 3 ( 1.5) 0
Application site cellulitis 1 ( 0.5) 0 0
Application site pustules 0 1 ( 0.5) 0
a: Includes 'Probably related' and
'Related' adverse events.
Note: Counts reflect numbers of subjects in each treatment group reporting 1
or more AEs that map to the MedDRA
system organ class. A subject may be counted once only in each row of the
table.
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The incidence of application site AEs and treatment-related application site
AEs was
similar in the 3.75% and 2.5% imiquimod treatment study groups. Few subjects
in any of the
treatment groups reported severe application site events or application site
events that led to
study withdrawal. No serious application site reactions were reported in any
study group.
Listing of Deaths, Other Serious Adverse Events and Other Significant Adverse
Events
Deaths
There was one death in the study (a 28-year old White male randomized to the
3.75%
imiquimod group). The subject was undergoing treatment for EGW on the glans
penis and penis
shaft and in the inguinal area. At the time of the event (gunshot wound to the
chest) the subject
had applied an unknown number of packets of 3.75% imiquimod cream. The fatal
gunshot
wound to the chest occurred on Study Day 40. The subject was receiving
paracetamol 650 mg
po pm and topical Benzamycing 90 g qhs at the time he was hospitalized.
Other Serious Adverse Events
Serious adverse events are presented in Table 97 below.
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Table 97 Number (Y0) of Subjects with Serious Adverse Events - Safety
Population
Imiquimod Cream
3.75% 2.5%
Placebo
(N=205) (N=201)
(N=105)
Subjects with any serious adverse event, n (%) 7(3.4) 2
(1.0) 1(1.0)
Subjects with any treatment-emergent SAE, n (%) 6 (2.9) 2
(1.0) 1(1.0)
Subjects with any treatment-related SAE, n (%) 0 0
0
Serious adverse events
Malignant melanoma 2 ( 1.0) 0 0
Anxiety 1 ( 0.5) 0 0
Suicidal ideation 0 1 ( 0.5) 0
Chest pain 1 ( 0.5) 0 0
Diverticulitis 1 ( 0.5) 0 0
Gun shot wound 1 ( 0.5) 0 0
Diabetes mellitus inadequate control 1 ( 0.5) 0 0
Arthritis 0 0 1
( 1.0)
Dyspnoea 1 ( 0.5) 0 0
Ovarian cystectomy 0 1 ( 0.5) 0
Gall bladder disorder' 1 ( 0.5) NA NA
Pancreatic carcinoma' 1 ( 0.5) NA NA
Ovarian epithelial cancer' 1 ( 0.5) NA NA
Bile duct obstruction' 1 ( 0.5) NA NA
Abdominal pain' 1 ( 0.5) NA NA
Abdominal distension' 1 ( 0.5) NA NA
Pneumothoraxa 1 ( 0.5) NA NA
Catheter related infection' 1 ( 0.5) NA NA
Obstruction gastric' 1 ( 0.5) NA NA
Counts reflect numbers of subjects in each treatment group reporting one or
more adverse events that map to the
MedDRA system organ class. A subject was counted only once in each row of the
table.
a:
Subject 03/014 was diagnosed with cancer during screening. All events reported
for this subject were
classified as non treatment-emergent SAEs.
Few SAEs were reported during the study. The overall incidence of SAEs was
higher in
the 3.75% imiquimod group than in the 2.5% imiquimod and placebo groups.
Treatment-
emergent SAEs occurred in 6 subjects (2.9%) in the 3.75% imiquimod group, 2
subjects (1.0%)
in the 2.5% imiquimod group, and 1 subject (1.0%) in the placebo group. No
trends were
evident. No treatment-related SAEs were reported by subjects in any of the
treatment groups.
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Two SAEs (anxiety and suicidal ideation) were recorded as ongoing, 2 SAEs
(diabetes and
ovarian cystectomy) resolved with sequelae, and all other SAEs resolved
without sequelae.
Other Significant Adverse Events
Treatment-emergent AEs that led to discontinuation from the study are
presented in Table 98.
Table 98 Number (%) of Subjects with Treatment-Emergent Adverse
Events
Leading to Study Discontinuation - Safety Population
Imiquimod Cream
3.75% 2.5% Placebo
(N=205) (N=201) (N=105)
Subjects with an AE leading to study 3 (1.5) 5 (2.5) 0
discontinuation, n (%)
Subjects with a treatment-related AE 1(0.5) 3 (1.5) 0
leading to study discontinuation, n (%)
Adverse events leading to discontinuation,
n (%)
Application site pain 1(0.5) 2 (1.0) 0
Gunshot wound 1 (0.5) 0 0
Malignant melanoma right breast 1 (0.5) 0 0
Malignant melanoma right lower lateral 1 (0.5) 0 0
extremity
Hypersensitivity
Application site erythema 0 1 (0.5) 0
Application site irritation 0 1 (0.5) 0
Application site pruritus 0 1 (0.5) 0
Scrotal erythema 0 1 (0.5) 0
Scrotal ulcer 0 1 (0.5) 0
Lymph node pain 0 1 (0.5) 0
Pelvic pain 0 1(0.5) 0
Groin pain 0 1 (0.5) 0
Application site ulcer 0 1 (0.5) 0
Cellulitis 0 1 (0.5) 0
Application site infection 0 1 (0.5) 0
Suicidal ideation 0 1 (0.5) 0
Counts reflect numbers of subjects in each treatment group reporting one or
more adverse events that map to the
MedDRA system organ class. A subject was counted only once in each row of the
table.
A treatment-emergent AE is an AE that began or worsened in severity after the
first application of the study drug
and no more than 30 days after the last application of the study drug.
Treatment-related includes Probably Related
and Related.
The incidence of AEs that led to study discontinuation was low in all
treatment groups.
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The number of subjects with any AE leading to study discontinuation was higher
in the 2.5%
imiquimod group than in the 3.75% imiquimod group. No subjects in the placebo
group
discontinued the study because of AEs. Only 1 subject in the 3.75% imiquimod
group and 3
subjects in the 2.5% imiquimod group reported treatment-related AEs that led
to study
discontinuation. Subject 06/021 (3.75% imiquimod) discontinued the study
because of
application site pain. In the 2.5% imiquimod treatment group, Subject 04/022
discontinued the
study because of application site pain, Subject 12/010 discontinued the study
because of
application site erythema, application site irritation, application site pain
and application site
pruritus, and Subject 18/016 discontinued the study because of scrotal
erythema and scrotal ulcer
in a non-treatment area, lymph node pain, pelvic pain, groin pain, and
application site ulcer. All
(except scrotal erythema and scrotal ulcer in a non-treatment area) were
application site
reactions. All of these AEs resolved without sequelae.
Analysis and Discussion of Serious Adverse Events, and Other Significant
Adverse Events
One death (3.75% imiquimod group) occurred among the subjects in this study.
The
incidence of SAEs was low in this study. No SAE was considered related to
study treatment.
Few subjects discontinued the study as a result of an AE. Treatment-related
application site
reactions accounted for less than half of the AEs leading to study withdrawal.
Only two SAEs
(anxiety and suicidal ideation) were noted as ongoing and 2 SAEs (diabetes and
ovarian
cystectomy) resolved with sequelae.
Clinical Laboratory Evaluation
For most of the hematological, chemistry, and urinalysis variables, the
majority of the
subjects were normal at Screening and at EOS. Occasional shifts from normal at
Screening to
above or below the limits of the normal range were observed; however, no dose-
response
relationship was evident.
For the clinical chemistry determinations, shifts from normal to high were
most
frequently recorded for ALT (15/155 in the 3.75% imiquimod group, 11/146 in
the 2.5%
imiquimod group, and 2/80 in the placebo group), AST (11/155 in the 3.75%
imiquimod group,
4/144 in the 2.5% imiquimod group, and 3/79 in the placebo group), and glucose
(8/156 in the
3.75% imiquimod group, 10/146 in the 2.5% imiquimod group, and 4/79 in the
placebo group).
Low cholesterol was noted in 6/156 in the 3.75% imiquimod group, 8/146 in the
2.5%
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imiquimod group, and 5/82 in the placebo group. High cholesterol was also
noted in 9/156 in the
3.75% imiquimod group, 6/146 in the 2.5% imiquimod group, and 6/82 in the
placebo group.
Shifts from normal to low were most frequently recorded for cholesterol (9/156
in the 3.75%
imiquimod group, 7/146 in the 2.5% imiquimod group, and 3/82 in the placebo
group).
In the hematology analyses, shifts from normal to high were most frequently
reported for
neutrophils (5/155 in the 3.75% imiquimod group, 7/147 in the 2.5% imiquimod
group, and 6/80
in the placebo group). Shifts from normal to low were most frequently reported
for WBCs
(6/155 in the 3.75% imiquimod group, 6/147 in the 2.5% imiquimod group, and
4/80 in the
placebo group).
The most commonly-reported shift observed in the study was a shift from normal
to high
in urine protein (37/156 in the 3.75% imiquimod group, 35/143 in the 2.5%
imiquimod group,
and 17/79 in the placebo group). However, at screening, 24.4%, 20.3%, and
16.5% in the 3.75%
imiquimod group, 2.5% imiquimod group, and placebo group, respectively, had
high
concentrations of urinary protein. Other findings from urinalysis included
shifts from normal to
high for leukocyte esterase (12/156 in the 3.75% imiquimod group, 13/143 in
the 2.5%
imiquimod group, and 2/79 in the placebo group) and blood in the urine (11/156
in the 3.75%
imiquimod group, 6/143 in the 2.5% imiquimod group, and 2/79 in the placebo
group).
Pregnancies and Outcome
Five women became pregnant during the study, 2 in the 3.75% imiquimod group, 2
in the
2.5% imiquimod group, and 1 in the placebo group. All of the pregnancies were
discovered after
the subject had taken her last dose of study medication. The exposure to study
medication was
45 packets and unknown of 3.75% imiquimod cream, unknown and 24 packets of
2.5%
imiquimod cream, and 55 packets of placebo cream. The outcomes of the
pregnancies are to be
determined.
In addition, one subject in the 2.5% group reported that she was pregnant,
just after a
negative urine test result was reported at the Week 8 visit. The exposure to
study medication was
55 packets.
Safety Conclusions
= Mean exposure to study medication was approximately 44 packets, 45
packets, and
53 packets of study medication in the 3.75% imiquimod, 2.5% imiquimod, and
placebo groups respectively. Mean treatment duration was similar among the
study
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groups and ranged from 50.0 days in the 3.75% imiquimod group to 54.7 days in
the
placebo group.
= Treatment-emergent AEs were reported in 44.4%, 40.8%, and 32.4% of
subjects in
the 3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively. Most
AEs
were mild or moderate in intensity. Application site reactions were the most
frequently reported AEs. Adverse events of the system organ classes "general
disorders and administration site conditions" and "infections and
infestations" were
the most frequently reported. Incidences of these events were similar in the
active
treatment groups.
= The incidence of systemic symptoms (ie, flu-like symptoms, etc)
previously noted
with 5% imiquimod was low (<1%) in this study.
= Treatment-emergent SAEs were reported in 6 subjects in the 3.75%
imiquimod group,
2 subjects in the 2.5% imiquimod group, and 1 subject in the placebo group.
None of
the SAEs were considered treatment-related.
= Treatment-emergent AEs that led to study discontinuation were reported in
3 subjects,
subjects, and no subjects in the in the 3.75% imiquimod, 2.5% imiquimod, and
placebo groups, respectively. Of those TEAEs leading to discontinuation, 4
subjects
withdrew from the study for TEAEs considered treatment-related: 1 subject in
the
3.75% imiquimod group and 3 subjects in the 2.5% imiquimod group. All (except
scrotal erythema and scrotal ulcer in a non-treatment area) were application
site
reactions.
= The incidence of TEAEs and severe AEs was higher in females than in males
across
all treatment groups, and the incidence of application site reactions was
higher in
females than in males in the active treatment groups.
= Adverse events leading to study discontinuation were rare in all
treatment groups
regardless of gender.
= Local skin reactions were reported in 78.3%, 68.3%, and 41.8% of subjects
in the in
the 3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively. The
incidence and severity of LSRs was higher in the active treatment groups than
in the
placebo group. Erythema was the LSR reported with the greatest frequency and
the
greatest mean intensity in all treatment groups. Local skin reactions were
coincident
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with the treatment period and rapidly decreased when treatment was concluded.
Severe intensity LSRs were similar in the active groups.
= Rest periods were taken by 67 subjects (32.7%), 55 subjects (27.4%), and
3 subjects
(2.9%) in the 3.75% imiquimod, 2.5% imiquimod, and placebo groups,
respectively.
The frequency, duration, and number of dosing days prior to the rest period
were
similar in the active treatment group and lower in the placebo group.
= There was no evidence of clinically meaningful trends in vital sign
measurements or
clinical laboratory measurements. One subject in the placebo group reported
laboratory AEs that were considered clinically significant, the AEs were
considered
not related to treatment.
DISCUSSION AND OVERALL CONCLUSIONS
Discussion
In this double-blind, placebo controlled clinical study, 511 subjects with EGW
diagnosed
by clinical examination were randomized to receive treatment with 3.75%
imiquimod cream,
2.5% imiquimod cream, or a matching placebo cream. During the evaluation
period, subjects
applied study medication once daily to the identified treatment area(s) for a
maximum of 8
weeks. If the subject did not achieve complete wart clearance by the Week 8
visit (end of
treatment [E0T1), the subject was monitored for an additional maximum 8 weeks
of no
treatment. Subjects determined to have achieved complete clearance of all
warts at any time
until Week 16 (end of study [E0S]) completed procedures for the end-of-study
visit and were
eligible to immediately enter the follow-up period for determination of wart
recurrence. During
the follow-up period, subjects were monitored every 4 weeks for up to 12 weeks
or until the
recurrence of warts. The 3.75% imiquimod cream and 2.5% imiquimod cream
demonstrated
efficacy and tolerability as compared with placebo for treatment of EGW.
Overall, 71.1% of
subjects completed the evaluation period, and the discontinuation rates were
similar in all
treatment groups. Compliance with the daily treatment regimen ranged from
83.2% in the 3.75%
imiquimod group to 91.1% in the placebo group.
Imiquimod has been demonstrated to be a safe and effective treatment for EGW.
The
dosing regimen for the currently approved product, 5% imiquimod cream, is 3
times per week
for up to 16 weeks. Clinical experience has shown compliance with this regimen
is challenging,
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as the treatment duration is long and the application schedule is non-
intuitive. The current study
was designed to evaluate imiquimod cream in lower concentrations to permit a
more intuitive
daily-dosing regimen and a shortened treatment regimen (up to 8 weeks) .
Efficacy
Efficacy was demonstrated for the primary efficacy measure as well as for the
secondary
and tertiary efficacy measures for the 3.75% imiquimod cream and 2.5%
imiquimod cream.
Results for all efficacy measures for which statistical testing was performed
were highly
statistically significant in the both of the active treatment groups as
compared with placebo in
both the ITT and PP populations.
Measures of wart reduction showed pronounced treatment effects for the higher
concentration product (complete clearance rates of 29.4%, 24.8% and 8.6%; >75%
clearance
rates of 38.7%, 31.2%, and 10.5%; mean percent change in wart count of -40.9%,
-37.7%, and -
7.8%; and at least 50% reduction in wart count in 49.5%, 43.1%, and 20.0% of
subjects in the
3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively, in the ITT
population).
It should be noted that the primary efficacy variable used in this study
(complete
clearance of all warts, both Baseline and newly emerged, in all assessed
anatomic areas) was
very conservative. Warts were counted in all assessed anatomic areas without
distinction as to
those warts identified at baseline or those newly identified. In this study,
subjects applied study
medication to individual warts in various anatomic areas identified at
Baseline. Some subjects
developed new warts during the study, and these new warts may have appeared in
anatomic areas
involved at Baseline as well as in newly involved anatomic areas. New warts
were treated with
study medication when they appeared, but received less than a full course of
treatment, because
treatment was not extended beyond 8 weeks from randomization/Day 1 visit.
Subjects who did
not completely clear all warts by the Week 8/EOT visit were followed for a
maximum 8 week no
treatment period. As with evaluations during the daily treatment phase,
subjects were evaluated
for the presence of EGW in all anatomic areas, and no distinction was made
between baseline
and newly evident warts. As efficacy measures were based on complete clearance
of all warts,
not just warts presented at Baseline, development of new warts would
potentially lower the
complete and partial clearance rates.
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Subgroup analyses were performed for the primary efficacy variable. In
general, the
complete clearance rates increased in a dose-dependent manner regardless of
subgroup. The
most striking subgroup effect was observed in the analysis by gender; the
complete clearance
rates were consistently higher in females than in males in all treatment
groups. The higher
absolute clearance rates in females than in males have been seen previously
with 5% imiquimod
cream as well as with other topical treatments and may be due in part to the
distribution of warts
on females (eg, less keratinized skin).
In addition to gender subgroup, the complete clearance rates tended to be
higher in
subjects with <7 warts at Baseline, in subjects with a Baseline wart area <70
mm2, in subjects
who took a rest period, in subjects with no previous imiquimod treatment, in
subjects whose
EGW was first diagnosed within 1 year, and in subjects with baseline warts in
the anatomic areas
with less keratinized skin such as the (perianal area, the perineal area, on
the glans penis, or on
the vulva). Of note, baseline demographics for the population as a whole
suggest that EGWs in
this study cohort were of relatively longstanding duration (mean/median years
since diagnosis of
5.4/2.2 years).
Safely
Daily application of 3.75% or 2.5% imiquimod cream was generally well
tolerated in this
study. Few subjects discontinued the study due to adverse events. Very few
serious adverse
events were reported, and none were considered treatment related. The
proportion of subjects
with treatment-related AEs was higher in the active treatment groups (19.5%
and 18.4% in the
3.75% and 2.5% imiquimod, respectively) than with placebo (2.9%), but there
was no difference
in the incidence rates between imiquimod groups. Most AEs were mild or
moderate in intensity,
and resolved without sequelae.
The majority of AEs considered treatment-related occurred in the system organ
class
"General Disorders and Administrative Site Conditions", and are not
unanticipated with
imiquimod. For the most part, these represented various application site
reaction symptoms such
as pain, irritation, and pruritus. The proportion of subjects with any
application site reaction was
similar in the active treatment groups.
Anticipated reactions in the application area were also captured separately as
local skin
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reactions (LSRs). The frequency and intensity of LSRs were higher in the
active treatments
compared with placebo. Erythema was the LSR reported with the greatest
frequency and the
greatest mean intensity in all treatment groups. Severe intensity LSRs were
similar between the
active groups. Local skin reactions were coincident with the treatment period
and rapidly
decreased when treatment was concluded.
There was no evidence of clinically meaningful trends in vital sign
measurements or
clinical laboratory measurements.
Conclusion
The 3.75% and 2.5% cream formulations of imiquimod demonstrated substantial
efficacy
for the treatment of EGW. All efficacy measures for which statistical testing
was performed
were significantly superior in the 3.75% and 2.5% imiquimod treatment groups
compared with
placebo in both the ITT and PP populations. The difference between 3.75%
imiquimod and
2.5% imiquimod did not reach statistical significance at any time during the
study. Treatment
with either imiquimod formulation resulted in greater increases in local skin
reactions compared
with the placebo cream: erythema was the LSR reported with the greatest
frequency and the
greatest mean intensity in all treatment groups. For both active creams, the
number and severity
of local skin reactions decreased rapidly after the completion of treatment.
The most frequently
reported adverse events were application site reactions observed in the active
treatment groups;
however, few subjects discontinued the study as a result of adverse events,
indicating that these
events were manageable and generally well tolerated.
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Study Number: GW01-0801
Objectives: The primary objective of this study is to compare the efficacy and
safety of 2.5%
imiquimod cream and 3.75% imiquimod cream to placebo cream, applied once daily
for up to 8
weeks, in the treatment of external genital warts (EGW). The secondary
objective of this study is
to provide information on recurrence of EGW.
Methodology: This was a randomized, double-blind, placebo-controlled,
multicenter study that
compared the efficacy and safety of 2.5% imiquimod cream and 3.75% imiquimod
cream with
that of placebo in the treatment of EGW. Subjects determined to be eligible
during the screening
period were stratified by gender and randomized in a 2:2:1 ratio to 2.5%
imiquimod cream,
3.75% imiquimod cream, or placebo cream. Subjects were scheduled for 1
prestudy screening
visit, and then were scheduled for visits every 2 weeks for up to 16 weeks
during the evaluation
period, depending upon clearance of all baseline and new warts. During the
evaluation period,
subjects applied investigative cream to the identified treatment area for a
maximum of 8 weeks.
If the subject did not achieve complete wart clearance by the Week 8 visit
(end of treatment,
EOT), the subject was monitored for an additional maximum of 8 weeks. Subjects
determined to
have achieved clearance of all warts at any time until Week 16 completed
procedures for the end -
of -study (EOS) visit and were eligible to immediately enter the follow-up
period for
determination of recurrence. During the follow-up period, subjects were
monitored every 4
weeks for up to 12 weeks or until the recurrence of warts.
Clinical evaluations included counting of warts and assessment of local skin
reactions
(LSRs), and recording of adverse events (AEs) and concomitant medications. At
selected
centers, photography was performed at designated visits. Laboratory tests were
also performed
prior to treatment and at the EOS visit to assess safety.
Number of Subjects (total and for each treatment):
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It was planned to enroll approximately 450 subjects in a 2:2:1 ratio. Actual
enrollment
was 470 subjects, and the ITT population and safety population comprised 470
subjects (195
imiquimod 3.75%, 178 imiquimod 2.5%, and 97 placebo). The per protocol (PP)
population
comprised 347 subjects (137 imiquimod 3.75%, 134 imiquimod 2.5%, and 76
placebo).
Inclusion criteria:
Subjects could participate in the study if they met the following inclusion
criteria:
1. Were willing and able to give informed consent -- for subjects under 18,
the parent/legal
guardian was required to give written informed consent and the subject was
required to
provide written assent in accordance with local regulations;
2. Were at least 12 years of age at the time of initial screening;
3. Were willing and able to participate in the study as outpatients, making
frequent visits to
the study center during the treatment and follow-up periods, and to comply
with all study
requirements;
4. Had a diagnosis of external genital / perianal warts with at least 2 warts
and no more than
30 warts located in one or more of the following anatomic locations:
= In both sexes: inguinal, perineal, and perianal areas;
= In men: over the glans penis, penis shaft, scrotum, and foreskin;
= In women: on the vulva;
5. Had total wart areas of at least 10 mm2;
6. Were judged to be in good health based upon the results of a medical
history, physical
examination, and safety laboratory profile;
7. If female and of childbearing potential, had a negative serum pregnancy
test at Screening
and a negative urine pregnancy test prior to randomization and were willing to
use
effective contraception; and
8. If male or a male partner of a female subject, were willing to use condoms
for sexual
activities during the study.
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Exclusion criteria:
Subjects were excluded from the study if they met any of the following
criteria:
1. Had received any topical and/or destructive treatments for external genital
warts within
4 weeks (within 12 months for imiquimod and within 12 weeks for sinecatechins)
prior to
enrollment (ie, the randomization visit);
2. Had received any of the following treatments within the indicated time
intervals prior to
enrollment:
Medication/Treatment Washout
Interval
Any marketed or investigational HPV vaccines 12 months
Imiquimod 12 months
Sinecatechins (Veregen ) 12 weeks
Interferon/ Interferon inducer 4 weeks
Cytotoxic drugs 4 weeks
Immunomodulators or immunosuppressive therapies 4 weeks
Oral antiviral drugs (with the exception of oral 4 weeks
acyclovir and acyclovir related drugs for suppressive
or acute therapy herpes; or oseltamivir for prophylaxis
or acute therapy of influenza)
Topical antiviral drugs (including topical acyclovir and 4 weeks
acyclovir related drugs) in the wart areas
Podophyllotoxin / Podofilox in the wart areas 4 weeks
Oral and parenteral corticosteroids (inhaled/intranasal 4 weeks
steroids are permitted)
Any topical prescription therapy for any conditions in 4 weeks
the wart areas
Dermatologic/cosmetic procedures or surgeries in the 4 weeks
wart areas
3. Had any evidence (physical or laboratory) of clinically significant or
unstable disease
and/or any condition that might have interfered with the response to the study
treatment or
altered the natural history of EGW;
4. Were currently participating in another clinical study or had completed
another clinical
study with an investigational drug or device within the past 4 weeks;
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5. Had known or active chemical dependency or alcoholism as assessed by the
investigator;
6. Had known allergies to study drug or any excipient in the study cream;
7. Were currently immunosuppressed or had a history of immunosuppression;
8. Had a planned surgery that would cause an interruption of study treatment;
9. Had sexual partners currently in treatment with an approved or
investigational treatment
for EGW;
10. Had any current or recurrent malignancies in the genital or treatment
area;
11. Had any untreated or unstable genital infections (other than genital
warts);
12. Had any of the following conditions:
= known human immunodeficiency virus (HIV) infection;
= current or past history of high risk HPV infection (eg, HPV 16, 18, etc);
= an outbreak of herpes genitalis in the wart areas within 4 weeks prior to
enrollment;
= internal (rectal, urethral, vaginal/cervical) warts that required or were
undergoing
treatment;
= a dermatological disease (eg, psoriasis) or skin condition in the wart
areas which
may have caused difficulty with examination;
13. If female, had clinically significant abnormalities on pelvic examination
or had laboratory
test results showing high-grade pathology (eg, high-grade squamous
intraepithelial lesion,
moderate or severe dysplasia, squamous cell carcinoma);
14. If female, were nursing or pregnant or planned to become pregnant during
the study.
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Test product, dose and mode of administration:
The test products were 2.5% imiquimod cream and 3.75% imiquimod cream. The
reference therapy was placebo cream. Subjects applied the study drug in a thin
layer once daily
to each wart identified at Baseline and any new wart that appeared during the
treatment period.
A maximum of 1 packet (250 mg) of study drug was applied for a given dose (250
mg of
3.75% cream is equivalent to 9.375 mg imiquimod, and 250 mg of 2.5% cream is
equivalent to
6.25 mg imiquimod). Study drug was applied prior to normal sleeping hours and
removed
approximately 8 hours later with mild soap and water. Subjects were to
continue to apply study
cream to all identified wart/wart areas until all warts were cleared.
The investigational products, 2.5% imiquimod cream and 3.75% imiquimod cream,
contained imiquimod, isostearic acid, benzyl alcohol, cetyl alcohol, stearyl
alcohol, polysorbate
60, sorbitan monostearate, white petrolatum, glycerin, methyl paraben, propyl
paraben, purified
water, and xanthan gum. The placebo cream contained the same ingredients as
the active
formulations with the exception of imiquimod.
Subjects meeting all inclusion and no exclusion criteria were randomly
assigned in a 2:2:1
ratio to 1 of the 3 treatment groups (2.5% imiquimod cream: 3.7% imiquimod
cream: or placebo
cream).
Each dose of study drug was to be applied by the subject at approximately the
same time
of day. To reduce the risk of study drug removal from daily hygienic or
physical activities, study
drug was to be applied just prior to the subject's normal sleeping hours.
Subjects were to wash the treatment area with mild soap and water before
applying the
study medication, allow the area to dry thoroughly, and then apply the study
medication once
daily. Subjects were to apply a thin layer of study cream to each wart
identified at Baseline and
any new wart that appeared during the treatment period. Only up to one packet
of study cream
was to be applied per application.
The subjects were encouraged to leave study cream on for approximately 8
hours,
preferably during normal sleeping hours, and were not to wash the treatment
area, swim, shower
or bathe, or have sexual contacts while the study medication was on the skin.
Subjects could
wash the study cream off with soap and water any time after approximately 8
hours of
application. Subjects were to continue applying the study cream for a maximum
of 8 weeks or
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until the investigator determined that they had achieved complete clearance of
all (baseline and
new) warts. Subjects were not to make up any missed doses.
Rest periods, or temporary interruptions of dosing due to intolerable local
skin reactions,
were allowed during the study if the investigator or subject (or legal parent
or guardian) decided
that study drug application should be interrupted. Subjects who were placed on
a rest period were
to be seen by the investigator prior to resuming treatment with study drug in
order to assess if the
recovery of the treatment site was sufficient. Doses missed due to a rest
period were not counted
as missed doses in the assessment of subject compliance with the treatment
regimen. The study
visit schedule and procedures were not to be altered due to missed doses or
rest periods. If a
subject experienced a strong local reaction in one treatment area but not in
other treated areas, the
subject could temporarily stop applying study cream in that affected area
while continuing study
treatment in the other areas.
During treatment period, any new warts appearing in any of the protocol-
defined anatomic
locations were treated with the study cream. Neither the warts present at
Baseline nor new warts
were allowed to be treated during the no-treatment period (ie, from the Week
8/EOT visit to the
Week 16 visit).
Criteria for evaluation:
Primary Efficacy Variables:
The primary efficacy variable was subject status with respect to complete
clearance of all warts
(baseline and new) in all anatomic areas at Week 16 (End of Study, EOS), as
determined by the
investigator.
Secondary and Tertiary Efficacy Variables
Secondary efficacy variables were the following:
= Subject status with respect to partial clearance of baseline warts,
defined as at least 75%
reduction in the number of baseline warts at EOS/Week 16.
= Percent change from Baseline to EOS in total number of warts.
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= Subject status with respect to complete clearance of all warts at EOS,
remaining cleared in
all anatomic areas, as determined by the investigator, through the end of the
follow-up for
recurrence period, and
= Time from Baseline to complete clearance of all warts, as determined by
the investigator.
Tertiary efficacy variables were the following:
= Subject status with respect to complete clearance of all warts (baseline
and new) in all
anatomic areas at EOT/Week 8,
= Subject status with respect to at least 50% reduction in the number of
baseline warts at
EOS/Week 16.
Statistical Methods For Efficacy Analyses
Efficacy analyses were conducted on the ITT population and on the PP
population. For
the primary efficacy variable, imputations were made for missing data points
using last
observation carried forward (LOCF, primary analysis), taking all missed
observations as failure
(sensitivity analysis), and using observed cases (supportive analysis). For
the ITT population,
subjects who had no post-baseline data were included in the analysis carrying
forward the
baseline data. The PP population analysis used observed cases except for
complete clearance and
recurrence.
Analysis of the Primary Efficacy Variable
The primary efficacy endpoint, complete clearance rate at the EOS, was
analyzed using
Cochran-Mantel-Haenszel (CMH) statistics, stratifying by gender and site.
All pairwise comparisons of active treatment versus placebo were made using
Hochberg's
modified Bonferroni procedure. If either test was significant at a 0.025 level
of significance, then
that test was considered significant. Otherwise, if both tests were
significant at 0.05, then both
tests were considered significant. The 3.75% and 2.5% treatment groups were
compared to each
other at the 0.05 level of significance if at least one of these treatment
groups was found to be
different than the placebo using the Hochberg's test.
In the primary analysis of complete clearance rate, the Breslow-Day statistic
was tested at
the 10% level for heterogeneity of the odds ratios across analysis sites. A
finding of statistical
significance in this test was followed by exploratory analyses to characterize
the source of the
heterogeneity.
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Analysis of Secondary Efficacy Variables
The secondary efficacy variable partial clearance rate was analyzed using
Cochran-
Mantel-Haenszel (CMH) statistics, stratifying by gender and site. The percent
change from
baseline to EOS in wart count was analyzed using analysis of covariance
(ANCOVA), controlling
for baseline wart count, gender, and analysis site. The proportion of subjects
who were clear
prior to or at EOS and remained clear at the end of the follow-up for
recurrence period was
summarized by frequency count and 95% confidence interval. The time to
complete clearance
was analyzed using the log rank test in the context of a Kaplan-Meier survival
analysis.
For analysis of secondary efficacy variables, only the LOCF method was used
for the ITT
population, and observed cases for the PP population. All data from interim
visits were analyzed
using visit windows.
The secondary efficacy variables were to be compared pairwise using Hochberg's
modified Bonferroni procedure.
= If at least one of the active arms was found to be superior to placebo in
the primary
efficacy variable of complete clearance according to Hochberg's modified
Bonferroni
procedure, the secondary efficacy variable of partial (>75%) clearance was
compared
between each of the active arms and placebo.
= If the secondary efficacy variable of partial (>75%) clearance was found
to be superior to
placebo in either of the active treatment groups, then the secondary efficacy
variable of
percent change from Baseline to EOS in wart count was tested.
= If the secondary efficacy variable of percent change from Baseline to EOS
in wart count
was found to be superior to placebo in either of the active treatment groups,
then the
secondary efficacy variable of complete clearance at EOS and remained clear at
the end of
follow-up for recurrence period was tested.
= If the secondary efficacy variable of complete clearance at EOS and
remained clear at the
end of follow-up for recurrence period was found to be superior to placebo in
either of the
active treatment groups, then the secondary efficacy variable of time from
Baseline to
complete clearance was tested.
The percent change from Baseline in EGW count at each post-baseline visit was
summarized by mean, standard deviation, median, and range by treatment group.
The recurrence
rate of warts was summarized by treatment group and study visit using visit
windows.
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Analysis of Tertiary Efficacy Variables
The tertiary efficacy endpoints, complete clearance rate at EOT and subject
status with
respect to at least a 50% reduction in baseline wart count, were analyzed
using Cochran-Mantel-
Haenszel (CMH) statistics, stratifying on gender and site.
Visit Windows
For the analysis of wart counts, the data were summarized by analysis visits.
Analysis
visits were assigned according to the actual study day of the evaluation as
illustrated in Table
98below.
Table 98 Visit Windows
Evaluation Period Target
Analysis Visit Study Day Day Range
Baseline 1 Study Day 5_ 1
Week 2 15 1 < Study Day 22
Week 4 29 22 < Study Day 36
Week 6 43 36 < Study Day 50
Week 8 57 50 < Study Day 64
End of Treatment (EOT) Study Day 64
Week 10 71 64 < Study Day < 78
Week 12 85 78 < Study Day < 92
Week 14 99 92 < Study Day 5_ 106
Week 16 113 106 < Study Day < 127
End of Study (EOS) Study Day < 127
Follow-up Period Target
Analysis Visit Study Day Day Range
Post EOS
Follow-up Week 4 29 1 < Study Day 43
Follow-up Week 8 57 43 < Study Day 71
Follow-up Week 12 85 71 < Study Day 99
All visits (scheduled or unscheduled) were mapped to an analysis visit. If
more than 1
evaluation was assigned to an analysis visit, the evaluation with the lowest
wart count within the
window was used for analysis. Study day was calculated as the date of
evaluation minus the date
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of randomization plus one except for the follow up visits. For the follow up
visits, study day was
calculated as the date of evaluation minus the date of End of Study (EOS)
visit plus one.
Safety Analyses
All safety variables were analyzed using the safety population. Safety
variables included the
following:
= Local skin reactions.
= Rest periods during the treatment period:
o The number and percentage by treatment group of subjects who required a
rest
period (1 or more).
o The number of dosing days missed due to rest periods.
o The number of dosing days prior to the beginning of the first rest
period.
= Adverse events.
= Clinical laboratory test results.
Adverse Events
Adverse events were coded using Medical Dictionary for Regulatory Activities
(MedDRA, version 11.0) terminology. A treatment-emergent AE was defined as an
AE that
began or worsened in severity after Day 1 and no more than 30 days after the
last application of
study drug. If an AE had a completely missing start date, it was considered a
"treatment
emergent" event, unless the stop date was prior to the date of randomization.
Treatment-emergent AEs and all AEs were summarized for each treatment group by
the
overall incidence of at least one event, incidence by system organ class, and
incidence by system
organ class and preferred term. Each subject contributed only once to each of
the rates,
regardless of the number of occurrences (events) the subject experienced.
Treatment-emergent AEs were summarized by severity (mild, moderate, or severe)
and by
relationship to study product (related, not related). Events were considered
not related to study
product if the relationship was "not related" or "probably not related."
Similarly, related events
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were those that were "probably related" or "related." An AE was assumed to be
related to study
drug if the relationship to study drug was unknown. For AEs that occurred more
than once, the
AE that was most related to study drug in that period was used in the summary
of AEs by
relationship to study drug categories. Similarly, the AE with the maximum
intensity in that
period was used in the summary of AEs by severity. If severity was missing or
unknown, it was
assumed to be severe.
The incidence of AEs was summarized for subgroup analysis by gender, by age
subgroup,
and by number of anatomic locations (ie, one location versus multiple).
Serious AEs (SAEs) and
AEs that led to discontinuation from the study were listed by subject.
Local Skin Reactions
The LSR intensities were summarized by frequency counts and mean score by
treatment
group and study visit for each LSR type. The LSRs were graded as follows:
= Erythema (0=None, 1=Faint to mild redness, 2¨Moderate redness, 3=Intense
redness),
= Edema (0=None, 1=Mild visible or barely palpable swelling/ induration,
2=Easily
palpable swelling/indurationõ 3=Gross swelling/induration),
= Weeping/Exudate (0¨None, 1=Minimal exudate, 2=Moderate exudate, 3=Heavy
exudate),
= Flaking/Scaling/Dryness (0=None, 1=Mild dryness/flaking, 2¨Moderate
dryness/flaking,
3=Severe dryness/flaking),
= Scabbing/Crusting (0=None, 1=Crusting, 2=Serous scab, 3=Eschar),
= Erosion/Ulceration (0=None, 2=Erosion, 3=Ulceration).
Erosion/ulceration intensity was originally collected as 0 = None, 1 =
Erosion, and 2 ¨
Ulceration. For consistency in the analysis of LSR intensities and sum score,
these were recoded
as 0 = None, 2 = Erosion, and 3 = Ulceration.
The most intense reaction (post-baseline) and incidence of any reaction (post-
baseline) for
each LSR type were also presented by frequency distribution and mean score by
treatment group.
Data were analyzed using windows.
The LSR sum score (addition of 6 scores) was computed and summarized by
treatment
group at each study visit.
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Rest Periods
A rest period was a temporary interruption of dosing due to intolerable LSRs
or other
AEs. Doses missed due to a subject's noncompliance with the treatment regimen
were not
considered a rest period. The start of a rest period was the first date on
which the study
medication was not applied for the reason of "rest period" on CRF page 20. The
end of the rest
period was the first date of application following the start of the rest
period. The number and
percentage of subjects who required a rest period (1 or more) were analyzed by
treatment group
using CMH statistics. The number of dosing days missed due to rest periods and
the number of
dosing days prior to the beginning of the first rest period were analyzed
using the Wilcoxon test.
In this analysis, only subjects who experienced a rest period were included.
Disposition of subjects
The disposition of subjects for the evaluation period is shown in Table 99
below:
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Table 99 Subject Disposition - Evaluation Period (ITT Population)
lmiquimod Cream
Total Subjects, n (%) 3.75% 2.5% Placebo
Overall
Randomized 195 178 97 470
Completed evaluation perioda 136 (69.7) 121 (68.0) 66
(68.0) 323 (68.7)
Not Cleared 82 (42.1) 87 (48.9) 56 (57.7) 225
(47.9)
Cleared, Ended Study 4(2.1) 3 (1.7) 4(4.1)
11(2.3)
Cleared, Entered Follow-up 50 (25.6) 31 (17.4) 6(6.2) 87
(18.5)
Discontinued evaluation period 59 (30.3) 57 (32.0) 31 (32.0) 147
(31.3)
Reasons for discontinuation
during evaluation period, n (%)
Safety reasons (AEs) 3(1.5) 2(1.1) 1(1.0)
6(1.3)
Investigator's request 1 (0.5) 0 0 1
(0.2)
Subject's request (not AE) 10(5.1) 8(4.5) 7(7.2)
25(5.3)
Lack of efficacy 0 1(0.6) 0
1(0.2)
Noncompliance 1(0.5) 4(2.2) 0 5
(1.1)
Use of concomitant therapy 0 0 0 0
Lost to follow-up 39 (20.0) 37 (20.8) 19 (19.6) 95
(20.2)
Other (not AE) 5(2.6) 5(2.8) 4(4.1)
14(3.0)
AE = adverse event.
a Based on investigator assessment (CRF page 31), includes subjects who (1)
cleared prior to or at
EOS/Week 16, (2) not cleared at Week 16.
Of the 794 subjects who were screened, 470 (59.2%) were randomized and 324
(40.8%)
were screen failures. The most frequent reason for screen failure (170
subjects [52.5%} out of
324 screen failures) was that subjects did not have a clinical diagnosis of
EGW with at least 2
warts and no more than 30 warts in one or more of the protocol-specified
anatomic locations.
One hundred ninety five (195) subjects were randomized into the 3.75%
imiquimod
treatment group, 178 subjects were randomized into the 2.5% imiquimod
treatment group, and 97
subjects were randomized into the placebo group. Overall, 68.7% of subjects
completed the
study, and in the individual treatment groups, 69.7%, 68.0%, and 68.0% in the
3.75% imiquimod,
2.5% imiquimod, and placebo groups, respectively, completed the study. Lost to
follow-up was
the most common reason for discontinuation from the evaluation period, and
accounted for
withdrawal of approximately 20% of subjects in each treatment group. Among the
treatment
groups, there was no appreciable difference in the percentages of subjects who
were lost to
follow-up or the times at which they became lost to follow-up. A sizeable
number of subjects
discontinued early, ie, had no post-Baseline visit: 15 of 59 (25.4%) in the
3.75% imiquimod
group, 16 of 57 (28.1%) in the 2.5% imiquimod group, and 5 of 31(16.1%) in the
placebo group.
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Follow-up for Recurrence Period
Subject disposition for the follow-up period is shown in Table 100 below:
Table 100 Subject Disposition ¨ Follow-up Period (ITT Population)
Imiquimod Cream
Total Subjects, n (%) 3.75% 2.5% Placebo
Overall
Entered follow-up period 50(100) 31(100) 6(100) 87
(100)
Completed study, no recurrence 41 (82.0) 20 (64.5) 6
(100) 67 (77.0)
Subjects with EGW recurrence 7 (14.0) 7 (22.6) 0 14
(16.1)
Discontinued follow-up perioda 2 (4.0) 4 (12.9) 0
6 (6.9)
Reasons for discontinuation
during follow-up, n (%)
Subject's request (not AE) 0 1(3.2) 0
1(1.1)
Lost to follow-up 2 (4.0) 3 (9.7) 0 5
(5.7)
Other (not AE) 0 0 0 0
AE = adverse event.
a Excludes subjects discontinued due to recurrence of external genital
warts.
Overall, 87 subjects entered the follow-up for recurrence period; 50 from the
3.75%
imiquimod treatment group, 31 from the 2.5% imiquimod treatment group, and 6
from the
placebo group. Only 6 subjects (2 and 4 in the 3.75% and 2.5% imiquimod
groups, respectively)
discontinued the follow-up for evaluation period. Of these, 5 subjects were
lost to follow-up and
1 subject was discontinued at his request.
EFFICACY EVALUATION
Datasets Analyzed
The number of subjects in each analysis population is presented in Table 101
below.
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Table 101 Number (%) of Subjects in Analysis Populations
Imiquimod Cream
Populations 3.75% 2.5% Placebo
Overall
ITT population 195 178 97 470
PP population 137 134 76 347
Safety population 195 178 97 470
Follow-up for Recurrence
population 50 31 6 87
A total of 470 subjects were included in the ITT and safety populations. Of
these, 347
subjects were included in the PP population. A total of 87 subjects elected to
enter the follow-up
period and comprised the follow-up for recurrence population.
Demographic and Other Baseline Characteristics
Prestudy/Baseline Demographics
Demographic and baseline characteristics for the ITT population are shown in
Table 102 below.
Table 102 Demographic Summary by Treatment Group - ITT Population
Imiquimod Cream
3.75% 2.5% Placebo
Overall
(N=195) (N=178) (N=97) (N=470)
Age in years
Mean (SD) 32.5(11.6) 32.7(11.3)
30.5(10.6) 32.2(11.3)
Median 29.0 30.0 27.0 29.0
Minimum, Maximum 18.0, 81.0 17.0, 78.0
18.0, 75.0 17.0, 81.0
Sex, n (%)
Male 95 (48.7) 83 (46.6) 47
(48.5) 225 (47.9)
Female 100 (51.3) 95 (53.4) 50
(51.5) 245 (52.1)
Race, n (%)
White 147 (75.4) 122 (68.5) 66
(68.0) 335 (71.3)
Black/African American 41 (21.0) 47 (26.4) 28
(28.9) 116 (24.7)
Other 7(3.6) 9(5.1) 3 (3.1)
19(4.0)
Ethnicity, n (%)
Hispanic 31 (15.9) 25 (14.0) 11
(11.3) 67 (14.3)
Non-Hispanic 164 (84.1) 153 (86.0) 86
(88.7) 403 (85.7)
SD = standard deviation.
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Demographic characteristics were similar among the 3 treatment groups.
Slightly more
than half of the subjects were female. Overall, 71.3% of subjects were White,
and more than
84% of subjects in every treatment group were non-Hispanic. The mean age
ranged from 30.5
years in the placebo group to 32.7 years in the 2.5% imiquimod treatment
group.
Medical History
The most frequently-reported concomitant medical conditions were
hypertension/high
blood pressure (42 subjects), seasonal allergies (27 subjects), and depression
(21 subjects).
External Genital Warts Treatment History
Previous EGW treatment was reported by 49.7%, 42.7%, and 33.0% of subjects in
the
3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively. Cryotherapy
was the most
frequently reported treatment, and had been performed in 28.2% of the subjects
in the 3.75%
imiquimod treatment group, 18.5% of subjects in the 2.5% imiquimod treatment
group, and
13.4% of subjects in the placebo group. Other treatments included acetic acid
(in a total of 42
subjects), imiquimod (in 33 subjects), podophyllotoxin (in 23 subjects), laser
therapy (in 22
subjects), "other" treatments (in 20 subjects), surgical excision (in 12
subjects), podophyllin (in 9
subjects), and electrodessication (in 3 subjects).
Prior and Concomitant Medications
Sixteen subjects (8.2%) in the 3.75% imiquimod treatment group, 12 subjects
(6.7%) in
the 2.5% imiquimod treatment group, and 4 subjects (4.1%) in the placebo group
were taking
prior medications, ie, medications that were discontinued prior to the date of
randomization. The
most common prior medications were antibacterials for systemic use in 3.6% of
the 3.75%
imiquimod treatment group, 3.9% of the 2.5% imiquimod treatment group, and
2.1% of the
placebo group.
Ninety-two subjects (47.2%) in the 3.75% imiquimod treatment group, 94
subjects
(52.8%) in the 2.5% imiquimod treatment group, and 45 subjects (46.4%) in the
placebo received
one or more concomitant medications during the study. The following classes of
concomitant
medications were received by more than 10% of the subjects in one or more
treatment groups:
= Analgesics, received by 18.5% of the 3.75% imiquimod treatment group,
13.5% of
the 2.5% imiquimod treatment group, and 20.6% of the placebo group;
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= Anti-inflammatory and anti- rheumatic products, received by 10.3% of the
3.75%
imiquimod treatment group, 13.5% of the 2.5% imiquimod treatment group, and
12.4% of the placebo group;
= Sex hormones and modulators of the genital system, by 7.7% of the 3.75%
imiquimod treatment group, 10.1% of the 2.5% imiquimod treatment group, and
9.3% of the placebo group.
Baseline Number of External Genital Warts
A summary of the external genital wart counts at Baseline and other baseline
data relevant to
subjects' EGW are presented in Table 103 below
Table 103
Baseline External Genital Warts Data by Treatment Group - ITT
Population
lmiquimod Cream
3.75% 2.5% Placebo
Overall
(N=195) (N=178) (N=97) (N=470)
Total wart area (mm2)
Mean (SD) 150.9 (458.7) 160.2 (334.8) 140.7
(248.6) 152.3 (377.0)
Median 52 68 73 61
Minimum, Maximum 10, 5579 10, 3212 6, 1969 6,5579
Total wart count
Mean (SD) 8.6 ( 6.4) 9.2 ( 6.7) 11.6 ( 8.8)
9.4 (7.1)
Median 7 7 8 7
Minimum, Maximum 2, 30 2, 30 2, 30 2, 30
Years Since Diagnosis
Mean 4.2 4.8 3.6 4.3
Standard Deviation 6.6 7.8 6.1 7.0
Median 1.4 1.5 1.3 1.4
Minimum, Maximum 0.0, 33.3 0.0, 53.7 0.0, 33.7 0.0,
53.7
Continued
Anatomic location, Males a, n 95 83 47 225
Inguinal 29 (30.5) 20 (24.1) 13 (27.7) 62
(27.6)
Perineal 7 (7.4) 6 (7.2) 4 (8.5) 17
(7.6)
Perianal 6(6.3) 8(9.6) 2(4.3) 16(7.1)
Glans penis 9 (9.5) 6 (7.2) 5 (10.6) 20
(8.9)
Penis shaft 77 (81.1) 71 (85.5) 42 (89.4) 190
(84.4)
Scrotum 27 (28.4) 29 (34.9) 8 (17.0) 64
(28.4)
Foreskin 3 (3.2) 4 (4.8) 1(2.1) 8 (3.6)
Anatomic location, Females b, n 100 95 50 245
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Table 103
Baseline External Genital Warts Data by Treatment Group - ITT
Population
Imiquimod Cream
3.75% 2.5% Placebo
Overall
(N=195) (N=178) (N=97) (N=470)
Inguinal 17 (17.0) 11 (11.6) 6(12.0) 34
(13.9)
Perineal 48 (48.0) 43 (45.3) 22 (44.0) 113
(46.1)
Perianal 44 (44.0) 52 (54.7) 22 (44.0) 118
(48.2)
Vulva 59 (59.0) 60 (63.2) 32 (64.0) 151
(61.6)
Number of treatment anatomic areas, n (%)-- Males'
Total Males 95 (100) 83 (100) 47 (100) 225
(100)
1 47 (49.5) 38 (45.8) 25 (53.2) 110
(48.9)
2 34 (35.8) 31 (37.3) 16 (34.0) 81
(36.0)
3 13 (13.7) 12 (14.5) 6(12.8) 31
(13.8)
4 1(1.1) 2(2.4) 0
3(1.3)
Number of treatment anatomic areas, n (%) --Females b
Total Females 100 (100) 95 (100) 50 (100) 245
(100)
1 49 (49.0) 40 (42.1) 26 (52.0) 115
(46.9)
2 36 (36.0) 40 (42.1) 17 (34.0) 93
(38.0)
3 13 (13.0) 14 (14.7) 6 (12.0) 33
(13.5)
4 2(2.0) 1(1.1) 1(2.0)
4(1.6)
SD = standard deviation.
a: Denominator based on the number of males in treatment group
b: Denominator based on the number of females in treatment group.
The mean total wart area was 152.3 mm2 overall, and ranged from 140.7 mm2 in
the
placebo group to 160.2 mm2 in the 2.5% imiquimod treatment group. The mean
total wart count
was 9.4 warts overall, and ranged from 8.6 warts in the 3.75% imiquimod
treatment group to 11.6
warts in the placebo group. In males, the most commonly affected anatomic
areas were the penis
shaft (84.4%), the scrotum (28.4%), and the inguinal area (27.6%). In females,
the most
commonly affected anatomic areas were the vulva (61.6%), the perianal area
(48.2%), and the
perineal area (46.1%). The anatomic distribution of warts was fairly
consistent across the
treatment groups. More than 50% of subjects in both gender subgroups had two
or more
anatomic locations affected with warts at Baseline.
Measurements of Treatment Compliance
Treatment compliance data was collected and analyzed. Compliance was based on
the
number of applications received (where a rest period day was counted as an
application) divided
by the number of intended applications, or by the number of packets used
(where a rest period
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day was counted as a packet used) divided by the number of packets intended to
be used per the
protocol-defined treatment regimen, whichever was greater. Noncompliance with
the treatment
regimen was defined as compliance less than 75% or greater than 125%.
The overall mean treatment compliance was 84.3% in the 3.75% imiquimod group,
84.7%
in the 2.5% imiquimod group, and 86.8% in the placebo group. Of the 123
subjects excluded
from the PP population in this study, 122 exclusions were the result of
noncompliance with the
treatment regimen, including many subjects who were lost to follow-up.
Compliance rates were
slightly higher in subjects who cleared their EGW during the study (90.9%,
88.5%, and 87.2% in
the 3.75% imiquimod, 2.5% imiquimod, and placebo groups, respectively)
compared with
subjects who did not clear (81.5%, 83.8%, and 86.8% in the 3.75% imiquimod,
2.5% imiquimod,
and placebo groups, respectively).
Efficacy Results
Complete Clearance of All Warts
COMPLETE CLEARANCE RATES AT END OF STUDY
The primary efficacy variable in this study was the proportion of subjects
with complete
clearance of all warts (those present at Baseline and new warts) at EOS (ie, 8
weeks after EOT).
The primary analysis was performed on the ITT population with imputation
(LOCF) for missing
data points. The results of the analyses on the ITT population, overall and by
gender, are shown
in Table 104 below. Results are presented graphically for the ITT population
in Figure 25.
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Table 104
Proportion of Subjects with Complete Clearance of Warts at the Week
16 /End of Study (EOS) Visit
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF)
niNa (%) 53/195 (27.2) 34/178 (19.1) 10/97
(10.3)
95% Cl 21.1, 34.0 13.6, 25.7 5.1,
18.1
P value vs placebo <0.001** 0.065
P value vs 2.5% imiquimod cream 0.061
Males
niNa (%) 19/95 (20.0) 11/83 (13.3) 2/47
(4.3)
95% confidence interval 12.5, 29.5 6.8, 22.5 0.5,
14.5
P value vs Placebo 0.015** 0.110
P value vs 2.5% Imiquimod Cream 0.236 , --
Females
n INa (%) 34/100 (34.0) 23/95 (24.2) 8/50
(16.0)
95% confidence interval 24.8, 44.2 16.0, 34.1 7.2,
29.1
P value vs Placebo 0.017** 0.255
P value vs 2.5% Imiquimod Cream 0.147
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a:
n/N=number of subjects with complete clearance at end of study divided by the
number of subjects analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. The P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals are calculated using
exact binomial statistics.
Breslow-Day P values for ITT Population (LOCF), males, are 3.75% Imiquimod
Cream vs Placebo = 0.357, 2.5%
Imiquimod Cream vs Placebo = 0.245, and 3.75% Imiquimod Cream vs 2.5%
Imiquimod Cream = 0.708.
Breslow-Day P values for ITT Population (LOCF), females, are 3.75% Imiquimod
Cream vs Placebo = 0.358, 2.5%
Imiquimod Cream vs Placebo = 0.310, and 3.75% Imiquimod Cream vs 2.5%
Imiquimod Cream = 0.178.
In the ITT population, the rate of complete clearance of EGW at EOS was
significantly
higher (P<0.001) in the 3.75% imiquimod group (27.2%) compared with placebo
(10.3%); the
difference in rate of complete clearance between the 2.5% imiquimod group
(19.1%) and the
placebo group (10.3%) did not attain statistical significance (P=0.065). The
3.75% imiquimod
group had a higher rate of complete clearance than the 2.5% imiquimod group,
but the difference
between the 2 active treatment groups was not statistically significant (P =
0.061).
Results were similar in the by-gender analyses. Complete clearance rates at
EOS were
statistically significantly higher with 3.75% imiquimod than with placebo in
both genders. There
was no significant difference in complete clearance rates at EOS between 2.5%
imiquimod and
placebo in either gender. In all treatment groups, the complete clearance
rates were consistently
higher in females than in males.
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Rates of complete clearance at EOS in the ITT population are illustrated in
Figure 25.
The primary efficacy variable was analyzed for the PP population, overall and
by gender,
using observed cases (OC). Results for the PP population are shown in Table
105 below.
Table 105 Proportion of Subjects with Complete Clearance of Warts at
the Week
16 /End of Study (EOS) Visit - PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC), at EOS
N 137 134 76
n/N a (%) 46/137 (33.6) 32/134 (23.9) 9/76
(11.8)
95% Cl 25.7, 42.1 16.9, 32.0 5.6,
21.3
P value vs placebo <0.001** 0.044** --
P value vs 2.5% imiquimod cream 0.060 -- --
Males
niNa (%) 17/69 (24.6) 10/63 (15.9) 2/34
(5.9)
95% confidence interval 15.1, 36.5 7.9, 27.3 0.7,
19.7
P value vs Placebo 0.023** 0.161 --
P value vs 2.5% Imiquimod Cream 0.286 -- --
Females
n/Na (%) 29/68 (42.6) 22/71 (31.0) 7/42
(16.7)
95% confidence interval 30.7, 55.2 20.5, 43.1 7.0,
31.4
P value vs Placebo 0.005** 0.140 --
P value vs 2.5% Imiquimod Cream 0.121 -- --
95% Cl = 95% confidence interval, OC=observed cases.
a: n/N-number of subjects with complete clearance at end of study divided
by the number of subjects analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated using
the exact binomial distribution.
Complete clearance was carried forward once achieved.
In the PP population, the complete clearance rates at EOS were higher than
those in the
ITT population for all treatment groups: 33.6% in the 3.75% imiquimod group,
23.9% in the
2.5% imiquimod group, and 11.8% in the placebo group. The larger responses in
the active
treatment groups were statistically significant compared with placebo (P<0.001
for 3.75%
imiquimod vs placebo; P=0.044 for 2.5% imiquimod vs placebo). As was the case
in the ITT
population, the complete clearance rate was larger in the 3.75% imiquimod
group than in the
2.5% imiquimod group, but the difference between the 2 active treatment groups
was not
statistically significant.
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Results were similar in the by-gender analyses. Complete clearance rates at
EOS were
statistically significantly higher with 3.75% imiquimod than with placebo in
both genders. There
was no significant difference in complete clearance rates at EOS between 2.5%
imiquimod and
placebo in either gender. In all treatment groups, the complete clearance
rates were consistently
higher in females than in males.
Rates of complete clearance at EOS in the PP population are illustrated in
Figure 26.
COMPLETE CLEARANCE RATES AT END OF TREATMENT
A summary of the complete clearance at EOT for the ITT population, overall and
by
gender, is provided in Table 106.
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Table 106 Proportion of Subjects with Complete Clearance of Warts at
End of
Treatment - ITT Population (LOCF)
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF)
niNa (%) 43/195 (22.1) 20/178 (11.2) 5/97
(5.2)
95% CI 16.4, 28.5 7.0, 16.8 1.7,
11.6
P value vs placebo <0.001** 0.090
P value vs 2.5% imiquimod cream 0.004**
Males
rilNa (v.) 14/95 (14.7) 6/83 (7.2) 1/47
(2.1)
95% CI 8.3, 23.5 2.7, 15.1 0.1,
11.3
P value vs placebo 0.027 0.227
P value vs 2.5% imiquimod cream 0.123
Females
n/Na (%) 29/100 (29.0) 14/95 (14.7) 4/50
(8.0)
95% Cl 20.4, 38.9 8.3, 23.5 2.2,
19.2
P value vs placebo 0.003** 0.215
P value vs 2.5% imiquimod cream 0.017**
LOCF = last observation carried forward, 95% CI = 95% confidence interval.
a: n/N=number of subjects with complete clearance at end of treatment
divided by the number of subjects
analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using liochberg's modified Bonferroni procedure.
Confidence intervals were calculated using
the exact binomial distribution.
At Week 8/EOT, 22.1% of subjects in the 3.75% imiquimod group, 11.2% of
subjects in
the 2.5% imiquimod group, and 5.2% of subjects in the placebo group had
attained complete
clearance. The overall complete clearance rate at EOT was significantly higher
in the 3.75%
imiquimod group compared with placebo (P<0.001) and compared with 2.5%
imiquimod
(P=0.004). The difference between 2.5% imiquimod and placebo was not
statistically significant.
The complete clearance rate at EOT was significantly higher in the 3.75%
imiquimod
group compared with placebo and compared with 2.5% imiquimod only in the
female subgroup.
The difference between 2.5% imiquimod and placebo was not statistically
significant in either
gender subgroup. In all treatment groups, the complete clearance rates were
consistently higher
in females than in males.
A summary of the complete clearance at EOT for the PP population, overall and
by
gender, is provided in Table 107.
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Table 107 Proportion of Subjects with Complete Clearance of Warts at
End of
Treatment -PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC) at EOT
niNa (%) 36/137 (26.3) 19/134 (14.2) 4/76
(5.3)
95% CI 19.1, 34.5 8.8, 21.3 1.5,
12.9
P value vs placebo <0.001** 0.038**
P value vs 2.5% imiquimod cream 0.015**
Males
IN (%) 12/69 (17.4) 6/63 (9.5) 1/34
(2.9)
95% CI 9.3, 28.4 3.6, 19.6 0.1,
15.3
P value vs placebo 0.069 0.267
P value vs 2.5% imiquimod cream 0.290
Females
niNa (%) 24/68(35.3) 13/71 (18.3)
3/42(7.1)
95% CI 24.1, 47.8 10.1, 29.3 1.5,
19.5
P value vs placebo <0.001** 0.079
P value vs 2.5% imiquimod cream 0.025**
95% CI = 95% confidence interval, OC=observed cases.
a: n/N=number of subjects with complete clearance at end of treatment
divided by the number of subjects
analyzed.
P values are from Cochran-Mantel-Haenszel test, stratified by gender and
analysis site (overall population) or
stratified by analysis site (gender subgroups), taking 2 treatment groups at a
time. P values marked with ** are
statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated using
the exact binomial distribution.
Complete clearance was carried forward once achieved.
In the PP population, the EOT complete clearance rate was significantly higher
in both
active treatment groups compared with placebo (P<0.001 for 3.75% imiquimod vs
placebo; and
P=0.038 for 2.5% imiquimod vs placebo). The complete clearance rate at EOT was
significantly
greater with 3.75% imiquimod than with 2.5% imiquimod (P=0.015).
In the female subgroup, the complete clearance rate at EOT was significantly
higher in the
3.75% imiquimod group compared with placebo and compared with 2.5% imiquimod.
In the
male subgroup, there was no significant difference between any of the
treatment groups. In all
treatment groups, the complete clearance rates were consistently higher in
females than in males.
COMPLETE CLEARANCE RATES BY VISIT WEEK
A by-visit summary of complete clearance rates in the ITT population during
the
evaluation period is shown graphically in Figure 27.
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As shown in Figure 27, the complete clearance rate was significantly higher in
the 3.75%
imiquimod group compared with placebo at all assessment time points after Week
2; this includes
the Week 8/end of treatment assessment and the Week 16/end of study
assessment. The complete
clearance rate was significantly higher in the 2.5% imiquimod group compared
with placebo at
Weeks 6, 10, 12, and 14. The clearance rate was higher in the 3.75% imiquimod
group than in
the 2.5% imiquimod group and the difference was statistically significant at
Week 8 (end of
treatment), and at Weeks 10, 12, and 14.
In female subjects, the complete clearance rate was significantly higher in
the 3.75%
imiquimod group compared with placebo at all assessment time points after Week
2, and was
significantly higher compared with 2.5% imiquimod at Weeks 4, 6, 8, 12, and
14. In male
subjects, the complete clearance rate was significantly higher in the 3.75%
imiquimod group
compared with placebo at Weeks 10, 12, 14, and 16. There was no statistically
significant
difference in complete clearance rate between 2.5% imiquimod and placebo in
either gender.
A by-visit summary of complete clearance rates in the PP population during the
evaluation
period is shown in Figure 28.
Results in the PP population were similar to those in the ITT population. The
complete
clearance rate was significantly higher in the 3.75% imiquimod and 2.5%
imiquimod groups
compared with placebo at all assessment time points after Week 2. The
clearance rate was higher
in the 3.75% imiquimod group than in the 2.5% imiquimod group and the
difference was
statistically significant at Weeks 8, 12, and 14.
In female subjects, the complete clearance rate was significantly higher in
the 3.75%
imiquimod group compared with placebo at all assessment time points after Week
2, and was
significantly higher compared with 2.5% imiquimod at Weeks 8 and 12. In male
subjects, the
complete clearance rate was significantly higher in the 3.75% imiquimod group
compared with
placebo at Weeks 10, 12, 14, and 16. The only significant difference in
complete clearance rate
between 2.5% imiquimod and placebo occurred in females at Week 10.
Partial Clearance Rates
PARTIAL (>75%) CLEARANCE RATES AT END OF STUDY
The proportion of subjects, overall and by gender, who had a partial clearance
(>75%
reduction from Baseline in wart count) during the study is summarized in Table
108 and Figure
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29 for the ITT population. Partial clearance was defined as at least a 75%
reduction in the
number of warts in the treatment area compared with Baseline.
Table 108 Proportion of Subjects with Partial (>75%) Clearance at End
of Study
¨ ITT Population
Imiquimod Cream
3.75% 2.5% Placebo
ITT Population (LOCF) at EOS
n/Na (%) 74/195 (37.9) 48/178 (27.0) 13/97
(13.4)
95% Cl 31.1, 45.2 20.6, 34.1 7.3,
21.8
P value vs Placebo <0.001** 0.010**
P value vs 2.5% Imiquimod Cream 0.023**
Males
nnsia (%) 29/95 (30.5) 15/83 (18.1) 3/47
(6.4)
95% Cl 21.5,40.8 10.5,28.0 1.3,
17.5
P value vs Placebo 0.001** 0.060
P value vs 2.5% Imiquimod Cream 0.067
Females
niNa (%) 45/100 (45.0) 33/95 (34.7) 10/50
(20.0)
95% Cl 35.0, 55.3 25.3, 45.2 10.0,
33.7
P value vs Placebo 0.002** 0.071
P value vs 2.5% imiquimod Cream 0.150
95% Cl = 95% confidence interval.
a: n/N=number of subjects with complete clearance at end of study divided
by the number of subjects analyzed.
Partial clearance was defined as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall population)
or stratified by analysis site (gender subgroups), taking 2 treatment groups
at a time. The P values marked with **
are statistically significant using Hochberg's modified Bonferroni procedure.
Confidence intervals were calculated
using the exact binomial distribution.
In the ITT population, the difference in the partial (>75%) clearance rate at
EOS between
each of the imiquimod treatment groups and placebo was statistically
significant. The partial
(>75%) clearance rate in the 3.75% imiquimod group was significantly higher
than that in the
2.5% imiquimod treatment group.
In the by-gender analyses, the >75% clearance rate at EOS was significantly
higher in the
3.75% imiquimod group compared with placebo for both males and females. There
was no
significant difference between 2.5% imiquimod and placebo, or between the
3.75% and 2.5%
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imiquimod groups. In all treatment groups, the >75% clearance rates were
consistently higher in
females than in males.
A summary of the partial (>75%) clearance rate at EOS for the PP population,
overall and
by gender, is presented in Table 109. The >75% clearance rates at EOS are
presented graphically
in Figure 30.
Table 109 Proportion of Subjects with Partial (>75%) Clearance at End
of Study
- PP Population (Observed Cases)
Imiquimod Cream
3.75% 2.5% Placebo
PP Population (OC), at EOS
niNa (%) 64/137 (46.7) 46/134 (34.3) 10/76
(13.2)
95% CI 38.1, 55.4 26.3, 43.0 6.5,
22.9
P value vs Placebo <0.001** <0.001**
P value vs 2.5% Imiquimod Cream 0.048**
Males
niNa 27/69 (39.1) 14/63 (22.2) 2/34
(5.9)
95% CI 27.6, 51.6 12.7, 34.5 0.7,
19.7
P value vs Placebo <0.001** 0.041**
P value vs 2.5% Imiquimod Cream 0.090
Females
n/Na (%) 37/68 (54.4) 32/71 (45.1) 8/42
(19.0)
95% CI 41.9, 66.5 33.2, 57.3 8.6,
34.1
P value vs Placebo <0.001** 0.009**
P value vs 2.5% Imiquimod Cream 0.257
95% Cl = 95% confidence interval, OC = observed cases.
a: n/N=number of subjects with complete clearance at end of study divided
by the number of subjects
analyzed.
Partial clearance was defmed as at least a 75% reduction in the number of
warts in the treatment area compared with
Baseline. P values are from Cochran-Mantel-Haenszel test, stratified by gender
and analysis site (overall
population) or stratified by analysis site (gender subgroups), taking 2
treatment groups at a time. The P values
marked with ** are statistically significant using Hochberg's modified
Bonferroni procedure. Confidence intervals
were calculated using the exact binomial statistics.
In the PP population, the partial (>75%) clearance rate at EOS was higher in
the active
treatment groups than in the placebo group. The difference between each of the
imiquimod
treatment groups and placebo was statistically significant (P<0.001). The
partial (>75%)
clearance rate in the 3.75% imiquimod group was significantly higher (P=0 .0
48) than that in the
2.5% imiquimod treatment group. The partial (>75%) clearance rates were
statistically
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significantly higher in the 3.75% imiquimod group compared with placebo at all
analysis time
points after Week 0.
As in the overall PP population, the >75% clearance rate was significantly
higher with
3.75% imiquimod and with 2.5% imiquimod versus placebo in either gender. There
was no
statistically significant difference between the active treatment groups in
either gender.
PARTIAL (>75%) CLEARANCE RATES AT END OF TREATMENT
The proportion of subjects who had a 75% or greater reduction from Baseline in
wart
count at EOT is shown in Table 110.
250
