Technology & Services Section

Effective Use of Ultrasound Skin Permeation

a report by

Sontra Medical Corporation

Sontra Medical Corporation is focused on the development of complete solutions for transdermal drug delivery and non-invasive transdermal diagnostics. The SonoPrep ultrasonic skin permeation instrument facilitates faster transdermal delivery and enables delivery of large molecular weight protein and carbohydrate drugs. SonoPrep treatment can be combined with low power iontophoresis to accelerate and/or control drug delivery rates. Sontras LC-Gel (liquid crystal gel) technology combines hydrophilic and lipophylic gel properties with unique flow characteristics to facilitate rapid transdermal drug transport through SonoPrep-treated skin.The first truly continuous non-invasive glucose monitoring is enabled by Sontras Glucose Flux Biosensor that is placed over SonoPrep-treated skin. The SonoPrep device delivers ultrasonic energy to the skin through an aqueous ultrasound conducting medium. The tip of the device includes a cylindrical ultrasonic horn inside a housing that positions the horn 7.5mm above the skin. The housing is filled with the coupling buffer, which consists of a phosphate buffered saline solution and 1% sodium dodecyl sulfate. The treated site is 0.8cm2 (1.0cm diameter). Energy (12 watts RMS) is delivered to the ultrasonic horn by an ultrasonic control system at a frequency of 55kHz.Axial ultrasonic motion at the tip creates cavitation bubbles that rapidly expand and contract in the coupling medium at the skin surface. High shear and jetting in the cavitation field disorganizes the lipid bi-layer and creates random 25125m crevices and pores in the stratum corneum. There are numerous variables relating to skin condition, location on the body and demographics that affect the ultrasonic skin permeation process.The stratum corneum layer varies in thickness, surface oils and water content. Because of these differences, the permeation process needs to be controlled in order to achieve consistent permeation at every location and across a variety of skin types and conditions. This is important to ensure adequate stratum corneum poration and avoid excessive penetration, which may result in pain and/or tissue damage. SonoPrep controls
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skin permeation by measuring increasing electrical conductivity during the application. Conductivity is measured between the coupling medium in the SonoPrep cavitation reservoir and a hand grip reference electrode. In a study on the volar forearm, ultrasonic power was delivered to skin sites for an average 9.0 seconds.1 The SonoPrep instrument is battery operated (rechargeable) and portable. The system consists of a control console, ultrasonic hand-piece, reference electrode, 12 volt battery charger, and a cleaning stand. SonoPrep treats a 1 cm diameter skin area over which drugs or biosensors may be applied. Prior to SonoPrep application, a locator ring is placed on the skin. A coupling medium cartridge is placed in the SonoPrep hand-piece and the patient grasps a reference sensor. When the hand-piece is deployed (pressed down) on the site locator ring, it automatically delivers the coupling medium and activates. The instrument automatically turns off when skin conductivity measurement identifies optimum skin permeation.The application takes five to 30 seconds, depending on skin condition and location. The coupling fluid is returned automatically to the cartridge for disposal when ultrasound administration ends. The SonoPrep tip is sanitized between patient uses by inserting a decontamination cartridge and inserting the instrument into the decontamination stand for one minute.
SonoPrep Applications in Dr ug Deliver y

Clinical and preclinical studies have been conducted to demonstrate the safety and effectiveness of SonoPrep treatment in transdermal drug delivery applications. The studies indicate that SonoPrep skin permeation can accelerate the delivery of topical drugs and facilitate the delivery of large molecular weight protein and carbohydrate drugs, such as insulin and heparin, respectively.
Rapid Skin Anesthesia

In a randomized, double-blind, placebo controlled, crossover trial of 42 volunteer subjects, investigators

Technology & Services Section

examined the speed of onset of skin anesthesia by a eutectic mixture of lidocaine and prilocaine (EMLA, AstraZeneca) after a brief (approximately nine seconds) pretreatment with ultrasound. Needle stick pain was assessed after EMLA applications of five, 10, and 15 minutes to skin pretreated with ultrasound and 60minute application to intact skin. Pain scores after fiveminute applications of EMLA to ultrasound pretreatment were equivalent to pain scores after 60 minute EMLA applications to intact skin.1 Ultrasound pretreatment followed by a five-minute application of LMX4 (Ferndale Laboratories), a 4% liposomal lidocaine cream, was compared with no skin anesthesia (standard of care) in the emergency department setting.2 The subjective pain scores were statistically significantly lower for patients who received ultrasound treatment followed by LMX4 application. Additional yet-to-bepublished studies of pediatric patients were completed in an emergency department and an out-patient phlebotomy clinic with the same results. In another recently completed study, topical anesthesia was accomplished in two minutes by pre-treating with ultrasound and actively delivering 2% lidocaine through the skin with low energy iontophoresis.
To p i c a l V a c c i n a t i o n

need optimization in future clinical trials. An analysis of T-cell proliferation data to tetanus toxoid and C. albicans verified the immune response to be consistent with skin induration results. Moving forward, clinical trials with Hepatitis A and influenza vaccines are planned for further determination of feasibility and optimization of topical vaccine delivery.
Tr a n s d e r m a l I n s u l i n

Low frequency ultrasonic skin permeation facilitated topical vaccination by enhancing delivery of tetanus toxoid in animal studies.3 These studies demonstrated that ultrasound skin permeation generated a potent systemic and mucosal immune response without using toxin adjuvant, and suggested that the ultrasound treatment acted as its own potent physical adjuvant. The potential of vaccine delivery into the epidermis to evoke an immune response was evaluated with recall antigens in a human clinical study.4 This study evaluated the immune response induced by using the SonoPrep skin permeation device to facilitate the delivery of the antigenic proteins, tetanus toxoid, and Candida albicans into the epidermis. In this study, the antigenic proteins, tetanus toxoid and C. albicans were applied topically to SonoPrep-treated skin sites. A 10patient control group received the standard intradermal injection of the same antigenic protein. A delayed-type hypersensitivity (DTH) skin immune response was induced in 90% of the SonoPrep-treated patients and the extent and duration of the DTH skin reaction was similar in the treatment group versus the control group. The kinetics of appearance and disappearance of DTH responses were not markedly different between the intradermal and SonoPrep groups. However, the magnitude of the DRH response to tetanus toxoid and C. albicans appeared lower in the SonoPrep group compared with intradermal needle injection, indicating that the parameters for SonoPrep-mediated vaccine delivery

A feasibility study was performed to evaluate the use of SonoPrep ultrasound pretreatment for enhancing skin permeability and to allow the passive transdermal delivery of human recombinant insulin using an in vivo model. Four healthy non-diabetic pigs were treated with a brief application of ultrasound using SonoPrep. After ultrasound treatments, insulin in solution was applied to 15 to 20 treated sites (1cm diameter) on each pig. Over a five-hour period, pig blood glucose was monitored using a One Touch Glucose meter (LifeScan) to evaluate the pharmacological response of insulin. Three pigs showed significant drops in blood glucose, from approximately 90mg per dL to 40mg per dL, and rises of insulin in systemic circulation. Dextran was injected into one pig to prevent excessive hypoglycemia. One pig showed no changes in blood glucose due to inadequate device contact and leakage of insulin solution applied to skin, but did show a moderate increase in plasma insulin levels during the experiment. The study conclusively demonstrated that it is feasible to treat skin in a non-invasive manner using ultrasound for enabling the passive delivery of a large protein (hexamer insulin, MW- 36kDa at pH 7) into systemic circulation as to allow the protein to express biological activities in an in vivo swine model.
Tr a n s d e r m a l H e p a r i n

The feasibility of low molecular weight heparin (LMWH) delivery through SonoPrep treated skin was demonstrated in in vitro studies with porcine skin and in vivo studies in a rat model.An in vitro experiment on pig skin demonstrated that ultrasound pretreatment and iontophoresis combined facilitated delivery of large molecules and resulted in greater flux than either modality alone for transdermal heparin delivery.5 Also, the combination of ultrasound and iontophoresis has the potential to actively control transdermal vaccine transport. In vivo studies in which LMWH was delivered transdermally through ultrasonically pretreated skin demonstrated significant antifactor-X activity (aXa) well beyond five hours after a two-hour lag time. In comparison, subcutaneous injection controls showed immediate activity that declined rapidly during the five-hour period. Transdermal LMWH delivery exhibited prolonged activity similar to intravenous delivery.6
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Sontra Medical Corporation

Conclusions

Ultrasonic skin permeation has the potential to change the paradigms of transdermal drug delivery that limit applications to small molecules, chronic applications and potent drugs. SonoPrep enables the delivery of large MW drugs (MW>500 Da) and
References:

accelerates the delivery of current transdermal drugs tenfold. Effective use of ultrasound skin permeation to facilitate transdermal drug delivery depends also on the application transdermal drug formulation technologies and can be improved by combining with active transport technologies.

1. Katz N P, Shapiro D E, Herrmann T E, Kost J, Custer L, Rapid Onset Of Cutaneous Anesthesia With Emla Cream After Pretreatment With A New Ultrasound-Emitting Device, Anesth. Analg. (2004), 98: pp. 371376. 2. Becker B, Helfrich S, Baker E, Lovgren K, Minugh A, Machan J T, Ultrasound with Topical Anesthetic Rapidly Decreases Pain of Intravenous Cannulation, Acad. Emergency Medicine (2005), 12 (4): pp. 289295. 3. Tezel A, Paliwal S, Zancorg S, Mitragotri S,Low frequency ultrasound as a transcutaneous immunization adjuvant for generation of systemic and mucosal immunity, Infection & Immunity (2005), in press. 4. Libraty D, Barman S, Needle-Free Delivery of Antigens to Ultrasound Pre-treated Skin Demonstrated in Feasibility Clinical Trial, Submitted for presentation at the Controlled Release Society meeting, 2005. 5. Long Le, Kost J, Mitragotri S,Combined Effect Of Low-Frequency Ultrasound And Iontophoresis:Applications For Transdermal Heparin Delivery, Pharm. Res. (2000), 17 (9): pp. 1,1511,154. 6. Mitragotri S, Kost J,Transdermal delivery of heparin and low-molecular weight heparin using low-frequency ultrasound, Pharm. Res. (2001), 18 (8): pp. 1,1411,146.

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