Table 1. Characteristics of Scintigraphy PatientsSubject Number

Age (y) Gender NTM

Infection Chest CT Medical History FEV1% predicted

2363-218 62 Male Mabs Nodular Bronchiectasis 82%

2363-219 67 Female MAC Nodular and cavitary Bronchiectasis 66.3%

2363-220 51 Female MAC Nodular and cavitary Cystic fibrosis 36.4%

2363-222 20 Female Mabs Nodular Cystic fibrosis 33.8%

CT, computed tomography; FEV1, forced expiratory volume in 1 second; Mabs, Mycobacterium abscessus; MAC, Mycobacterium avium complex; NTM, nontuberculous mycobacteria.

Dosing and Imaging• Subjects initially underwent a seated transmission scan (using a cobalt-57 source) to serve as a template for

defining margins of ventilated lung.• Subjects then inhaled the 99mTc-LAI via the eFlow nebulizer using tidal breathing with a nose clip in place

(Figure 1). None of the patients used a bronchodilator prior to inhalation of the study drug or during the scanning period.

• Following inhalation, subjects immediately rinsed their mouth/throat with water and swallowed to wash the drug that was deposited into the oropharynx and esophagus into the stomach.

• Immediately after water ingestion, seated gamma scintigraphy imaging commenced.

Data Acquisition• Imaging during the first 2 minutes of each 10-minute period over 120 minutes was recorded to determine initial

deposition and retention.• Subjects returned approximately 24 hours post-dosing for a single 30-minute image to assess residual retention.• Radioactivity of the nebulizer system (reservoir, tubing, mouthpiece, and exhalation filter) was measured using

the dose calibrator after dosing and compared with pre-dosing radioactivity levels to assess the delivered dose as a percent of the total loaded dose.

Deposition and Retention• Pulmonary deposition of 99mTc radiolabel was calculated as the percent of loaded dose in the nebulizer that was

deposited in the lungs.• The percentage of initially deposited radiolabel remaining in the lungs at each scan period after correction for

radioactive decay was plotted over time to assess the retention rates of nebulized LAI.

Central-to-Peripheral Lung Distribution

• To assess central vs. peripheral deposition, 2 outline regions of interest were created over the right cobalt-57 transmission lung image: 1) a rectangular region around the entire right lung, and 2) a central (C) region of interest, positioned on the interior boundary of the lung. The peripheral region (P) is the area lying between the central and whole lung outline (Figure 2).

• These regions were displayed over the initial aerosol scans to determine the initial counts in each region. We then calculated the ratio of central-to-peripheral 99mTc counts as an index of relative deposition between the 2 regions. The 99mTc ratio was divided by the transmission scan ratio to obtain a C/P ratio normalized for lung volume.

RESULTS• Almost half (42.8% ± 5.6%) of the loaded dose and three-fourths (74.8 % ± 7.7%) of the emitted dose was

deposited in the lungs immediately after dosing (Figure 3). This corresponds to approximately 252 mg of LAI (of the 590 mg loaded into the nebulizer) deposited in the lungs. – In a similar study in healthy male subjects by Weers et al8 using a Pari LC Star jet nebulizer, only 14% of

the loaded dose and less than one-third (32.3% ± 3.4%) of the emitted dose was deposited in the lungs. – Only 12.8% ± 5.4% of the loaded dose was retained in the nebulizer compared with 57.8% ± 5.5% in the

Weers study.8

BACKGROUND• Nontuberculous mycobacteria (NTM) cause significant pulmonary disease in patients with cystic fibrosis (CF) or

non-CF bronchiectasis.1• A recent phase 2 clinical trial targeting treatment-refractory pulmonary NTM disease suggested that liposomal

amikacin for inhalation (LAI) 590 mg once daily added to a multidrug regimen may be associated with an enhanced rate of culture conversion.2,3

• The purpose of the present study is to assess the lung distribution and retention of LAI in patients with moderate to severe pulmonary NTM disease (Study TR02-112, ClinicalTrials.gov identifier: NCT 1315236).4

• Gamma scintigraphy imaging of radiotracers attached to study drugs for the noninvasive measurement of total and regional lung aerosol deposition and retention is well established in the literature, including the report of a study that investigated lung deposition and clearance of inhaled amikacin-loaded liposomes in healthy male volunteers.5-8

OBJECTIVES• The primary objective was to determine, by gamma scintigraphy, the pulmonary deposition and retention of

nebulized LAI in patients with treatment-refractory NTM lung disease.3• The secondary objective was to determine the pattern of radiolabel distribution in the lung in terms of deposition

in the central airways compared with that in the periphery of the lung.3

METHODSStudy Agent and Delivery System• Amikacin-loaded liposomes were radiolabeled by reacting LAI with sodium pertechnetate (Na+[99mTcO4

‒]) in the presence of stannous chloride (SnCl2) dissolved in ascorbic acid solution and purified by anion-exchange resin to yield a total of 590 mg amikacin with 7 millicurie (mCi) of technetium-99m (99mTc) in 8.5 mL for patient administration.9

• This liposomal surface labeling produced 99mTc-LAI with high labeling efficiency and stability9 that was delivered via a customized investigational eFlow® technology nebulizer (PARI Pharma GmbH).

• The eFlow nebulizer was equipped with one-way exhalation valves and filter to limit radiation exposure (Figure 1), and the apparatus was pre-tested in vitro for delivery efficiency of particle sizes in the respirable range.

• Inertial impaction tests using an Anderson cascade impactor revealed that 65% of the nebulized 99mTc-LAI was deposited in the middle stages of the impactor in the 2.1-3.3 µm range.9

• These particles were larger than previously reported for similarly labeled amikacin-loaded liposomes using a jet nebulizer with a reported mass median aerodynamic diameter (MMAD) of 1.6 µm and a geometric standard deviation (GSD) of 2.0.8

Figure 1. Setup for seated drug inhalation. Contained system with one-way exhalation valve and filter allowed capture of emitted radiolabel. eFlow® technology nebulizer (PARI Pharma GmbH).

PARTICIPANTS• Four adult subjects (2 with CF, 2 with non-CF bronchiectasis) with treatment-refractory Mycobacterium avium

complex (n = 2) or Mycobacterium abscessus (n = 2) were screened using the same criteria as for the phase 2 LAI placebo-controlled clinical trial, which included a non-contrasted chest computed tomography (CT) scan (Table 1).

• Subjects were studied in a stable disease state with no prior use of inhaled aminoglycosides for 28 days before drug inhalation.

Poster presented at the American Thoracic Society 2016 International Conference, May 13-18, San Francisco, CA, USA.

Airway Deposition and Retention of Liposomal Amikacin for Inhalation in Patients With Pulmonary Nontuberculous Mycobacterial Disease

Kenneth N. Olivier1, Roberto Maass-Moreno2, Millie Whatley2, Kenneth T. Cheng2, Jae-ho Lee2, Les Folio2, Charles Fiorentino3, Robyn Shaffer3, Sandra MacDonald1, Renu Gupta4, Timothy Corcoran5, Vladimir Malinin6, Gina Eagle6, Walter R. Perkins6, Chang H. Paik2, Clara C. Chen2

1Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, Bethesda, MD, USA; 2Nuclear Medicine Section, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA; 3Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA; 4Global Biopharma, Moorestown, NJ, USA; 5Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; 6Insmed Incorporated, Bridgewater, NJ, USA

(A) Chest computed tomography (CT) coronal image with multiplanar volume reformation, demonstrating posterior right upper lobe cavity (c), an area of air trapping (at) in the left upper lobe, and scoliosis of the spine in the center of the image. (B) Cobalt-57 transmission scan used for delineating margins of lungs to determine central-to-peripheral distribution of tracer deposition. Initial deposition and subsequent retention images of 99mTc-LAI at the following time points: (C) 0 minutes, (D) 120 minutes, and (E) 24 hours post-inhalation. Note the poor deposition into cavitary (c) and air-trapped (at) areas noted on CT image (A). Significant radiolabel remains in the lung at 120 minutes and at 24 hours post-inhalation. All images are oriented anteroposteriorly, with stomach (s) deposition noted on image (C) immediately after inhalation.

CONCLUSIONS• 99mTc-LAI was delivered to the lungs via the investigational eFlow device with higher efficiency compared with the jet nebulizer utilized by Weers et al.8 • 99mTc-LAI was distributed to both central and peripheral compartments of the lung. The more proximal deposition and larger particle size relative to prior studies may better target bronchiectatic airways.• Deposition of 99mTc-LAI in areas of cavitation and air trapping was not apparent. • Lung retention of the radiolabeled LAI over time in patients with treatment-refractory NTM lung disease was

comparable to that seen with radiolabeled LAI 120 mg in 3 healthy male subjects.8

REFERENCES1. Rose SJ, Neville ME, Gupta R, Bermudez LE. PLoS One. 2014;9(9):e108703.

2. Olivier KN, Eagle G, McGinnis JP II, et al. Randomized, double-blind (DB), placebo-controlled study and open-label (OL) extension of liposomal amikacin for inhalation (LAI) in patients with refractory nontuberculous mycobacterial (NTM) lung disease (LD). Poster presented at the 38th European Cystic Fibrosis Conference; June 10-13, 2015; Brussels, Belgium.

3. Olivier KN, Griffith DE, Wallace RJ. Arikayce Protocol TR02-112. A randomized, double-blind, placebo-controlled study of liposomal amikacin for inhalation (Arikayce) in patients with recalcitrant nontuberculous mycobacterial lung disease. IND Sponsor: Insmed Incorporated. Final Amendment 3: 2 April 2015. Data on file. Insmed incorporated, Bridgewater, NJ, USA.

4. Olivier KN. Protocol: TR02-112. A randomized double-blind, placebo-controlled study of liposomal amikacin for inhalation (LAI) in patients with recalcitrant nontuberculous mycobacterial lung disease. Clinical Study Report. October 20, 2014. Errata sheet: October 21, 2014. Sponsor: Insmed Incorporated. Data on file. Insmed Incorporated, Bridgewater, NJ, USA.

5. Snell NJ, Ganderton D. Respir Med. 1999;93(2):123-133.

6. Berridge MS, Lee Z, Heald D. Curr Pharm Des. 2000;6(16):1631-1651.

7. Smaldone GC. J Aerosol Med. 2001;14(2):135-137.

8. Weers J, Metzheiser B, Taylor G, et al. J Aerosol Med Pulm Drug Deliv. 2009;22(2):131-138.

9. Lee JH, Cheng KT, Malinin V, et al. J Liposome Res. 2013;23(4):336-342.

ACKNOWLEDGMENTSThe authors acknowledge Connexion Healthcare (Newtown, PA) for providing editorial, layout, and design support. Insmed Incorporated (Bridgewater, NJ) provided funding to Connexion Healthcare for these services. The research was funded by Insmed Incorporated and supported in part by the intramural research programs of the National Institute of Allergy and Infectious Diseases (NIAID) and the National Heart, Lung, and Blood Institute (NHLBI), and the National Institutes of Health (NIH).

DISCLOSURESKenneth.N. Olivier is supported by the Division of Intramural Research of the NHLBI-NIH and had a Cooperative Research and Development Agreement between Insmed Incorporated and NIAID/NIH.

Roberto Maass-Moreno, Millie Whatley, Kenneth T. Cheng, Jae-ho Lee, Les Folio, Charles Fiorentino, Robyn Shaffer, Sandra MacDonald, Chang H. Paik, and Clara C. Chen are employees of the National Institutes of Health.

Renu Gupta is a former employee of Insmed Incorporated.

Vladimir Malinin, Gina Eagle, and Walter R. Perkins are employees of Insmed Incorporated.

Timothy Corcoran reports that neither he, nor the department(s) with which he is affiliated, have received anything of value from a commercial or other party related directly or indirectly to the subject of this presentation.

Poster #: A3732

• In general, more proximal initial deposition of radiolabel was seen in these NTM patients, as reflected by a C/P ratio of 2.05 ± 0.68, relative to the prior study in healthy males with a C/P ratio of 1.63 ± 0.48. Retention of the radiolabel over time was comparable to prior studies, with 79% ± 7% retained at 1 hour compared with 87% ± 9% retained at 1 hour in healthy males from the Weers et al study.8 Similarly, 53% ± 3% was retained at 24 hours in this study compared with 60% ± 7% in the Weers study8 (Table 2 and Figure 4). The more rapid clearance may reflect the larger particle size and more proximal deposition in this study.

Table 2. Retention Over Time of 99mTc Liposomal Amikacin for Inhalation in Patients With Nontuberculous Mycobacterial Lung Infection Relative to Prior Study in Healthy Malesa

SubjectsTime

0 min 60 min 24 h

Patients with NTM infection (n = 4)

100%(C/P = 2.05)

79% ± 7% 53% ± 3%

Healthy males (n = 3)a

100%(C/P = 1.63)

87% ± 9% 60% ± 7%

C/P, central lung region/peripheral lung region ratio; NTM, nontuberculous mycobacteria. aWeers et al study.8

• Expected radiographic abnormalities were noted on chest computed tomography (CT) in these patients, such as bronchiectasis, cavities, and areas of mosaic attenuation consistent with air trapping. The radiolabel did not appear to distribute well to areas of significant structural changes such as cavities or air trapping (Figure 5).

99mTc-LAI remaining in nebulizer, tubing, filter

99mTc-LAI deposited in oropharynx, esophagus, stomach

43%42% 15%99mTc-LAI deposited in lungs

B

120 min

D

24 h

E

0 min

C

S

A

C

at

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100 110 120 24 h

% L

abel

Ret

aine

d in

Lun

g

Time (minutes)

Figure 4. Right whole lung retention over time

Figure 5. Deposition, distribution, and retention of 99mTc liposomal amikacin for inhalation (99mTc-LAI) in Subject 2363-220

R L

C C P P

Figure 2. Central (C) and peripheral (P) regions of the right (R) and left (L) lungs

Figure 3. Distribution of total dose of technetium-99m liposomal amikacin for inhalation (99mTc-LAI) loaded into the nebulizer

Exhalation filter

eFlow nebulizer

Nose clips

One-way valve