Вы находитесь на странице: 1из 88

Accepted Manuscript

Progress in brain targeting drug delivery system by nasal route

Abdur Rauf Khan, Mengrui Liu, Muhammad Wasim Khan,


Guangxi Zhai

PII: S0168-3659(17)30825-8
DOI: doi: 10.1016/j.jconrel.2017.09.001
Reference: COREL 8944
To appear in: Journal of Controlled Release
Received date: 3 May 2017
Revised date: 31 August 2017
Accepted date: 1 September 2017

Please cite this article as: Abdur Rauf Khan, Mengrui Liu, Muhammad Wasim Khan,
Guangxi Zhai , Progress in brain targeting drug delivery system by nasal route. The
address for the corresponding author was captured as affiliation for all authors. Please
check if appropriate. Corel(2017), doi: 10.1016/j.jconrel.2017.09.001

This is a PDF file of an unedited manuscript that has been accepted for publication. As
a service to our customers we are providing this early version of the manuscript. The
manuscript will undergo copyediting, typesetting, and review of the resulting proof before
it is published in its final form. Please note that during the production process errors may
be discovered which could affect the content, and all legal disclaimers that apply to the
journal pertain.
ACCEPTED MANUSCRIPT

PROGRESS IN BRAIN TARGETING DRUG DELIVERY SYSTEM


BY NASAL ROUTE

Abdur Rauf Khan, Mengrui Liu, Muhammad Wasim Khan, Guangxi Zhai*

Department of Pharmaceutics, College of Pharmacy, Shandong University, Jinan 250012, China

T
IP
CR
* Corresponding author:

Guangxi Zhai, Ph D

US
Professor AN
Department of Pharmaceutics

School of Pharmaceutical Sciences, Shandong University


M

44 Wenhua Xilu, Jinan 250012, China


ED

Tel.: (86) 531-88382015.


PT

E-mail: professorgxzhai@126.com
CE
AC
ACCEPTED MANUSCRIPT

Abstract

The blood–brain barrier (BBB) restricts the transport of potential therapeutic moieties to the
brain. Direct targeting the brain via olfactory and trigeminal neural pathways by passing the
BBB has gained an important consideration for delivery of wide range of therapeutics to brain.
Intranasal route of transportation directly delivers the drugs to brain without systemic absorption,
thus avoiding the side effects and enhancing the efficacy of neurotherapeutics. Over the last

T
several decades, different drug delivery systems (DDSs) have been studied for targeting the brain

IP
by the nasal route. Novel DDSs such as nanoparticles (NPs), liposomes and polymeric micelles

CR
have gained potential as useful tools for targeting the brain without toxicity in nasal mucosa and
central nervous system (CNS). Complex geometry of the nasal cavity presented a big challenge
to effective delivery of drugs beyond the nasal valve. Recently, pharmaceutical fir ms utilized

US
latest and emerging nasal drug delivery technologies to overcome these barriers. This review
aims to describe the latest development of brain targeted DDSs via nasal administration.
AN
Chemical compounds studied in this review article:
M

Carbopol 934p (PubChem CID: 6581); Carboxy methylcellulose (PubChem CID: 24748);
ED

Penetratin (PubChem CID: 101111470 ); Poly lactic-co-glycolic acid (PubChem CID:


23111554); Tween 80 (PubChem CID: 5284448).
PT

Keywords: Blood-brain barrier, Intranasal delivery, Nanoparticles, Liposomes, Polymeric


CE

micelles
AC
ACCEPTED MANUSCRIPT

1. INTRODUCTION:

Despite of the tremendous advancement in drug delivery systems (DDSs) for treatment of central
nervous system disorders like schizophrenia, migraine, Parkinson’s, Alzheimer′s disease and
brain tumors, still there is need of novel brain targeted DDSs. The major hurdle for targeting the

T
drug to brain is the presence of BBB. BBB is the delicate network of blood vessels having tightly

IP
packed endothelial cells which separates the brain from circulatory system. It protects brain from
entry of harmful substances such as toxin and bacteria. Hydrophilic substances, charged

CR
molecules, proteins and peptides are unable to cross this barrier, whereas lipophillic drugs such
as antidepressants, anxiolytics and many hormones can easily cross the endothelial cells [1].

US
Patients suffering from neurological disorders required chronic dosing, leading to side effects in
non targeted organs. It is considered that majority of drugs which are useful to treat the
AN
neurological disorders have lost their potential due to the BBB, resulting in limited treatment
options for the patients suffering from neurodegenerative diseases and brain cancer [2].
M

Therefore, non- invasive transport of drug to brain is highly needed for neurological disorders and
brain tumors requiring chronic therapy. Olfactory pathway is a reliable alternative to achieve
ED

desire therapeutic effects at lower doses for treating chronic diseases while minimizing the side
effects. Transmucosal delivery of drug through olfactory or trigeminal pathway to brain by
PT

passing the BBB is referred as the direct IN drug transportation to brain. This is the only route
through which brain is in connection with the outside environment [3]. This neural connection
CE

has gained attention for delivery of wide variety of drug molecules by the formulations ranging
from small molecules to large molecules such as nucleotides, peptides and proteins to brain by
AC

preventing the enzymatic degradation and enhancing the pharmacological effects without
systemic absorption and toxicity to the major peripheral organs. In animal and human studies, it
was investigated that different DDSs by improving the nasal permeability, increasing
mucoadhesion, providing constant or controlled release of drug or increasing deposition at
olfactory epithelium resulted in successful delivery of drug from direct nose to brain [4, 5].

This review highlights literatures regarding pathways and mechanisms of therapeutic agents
transporting across nasal mucosa and latest developments on novel DDSs using various
formulation strategies to improve the IN drug delivery to brain. Colloidal carriers such as various
ACCEPTED MANUSCRIPT

types of nanocarriers (NPs, micelles, nanogels, nanoemulsions and liposomes) and microspheres
as potential DDSs to brain are main focus of discussion. Patented technology based drug delivery
devices for efficient nasal delivery of drugs are highlighted in this review. Moreover, limitations
as well as future prospects of such brain targeted DDSs are also discussed in details.

2. Drug delivery strategies for brain targeting


Various drug delivery strategies to disrupt or overcome the BBB and potentiate the transport of

T
drug molecules across this barrier to the CNS have been studied. These strategies are divided

IP
into three main categories; invasive and non invasive strategies a nd recent techniques for BBB

CR
disruption.
2.1 Invasive strategies

US
2.1.1 Chemical disruption of BBB
Numerous invasive techniques are used to disrupt the BBB and enhance the delivery of drug to
AN
brain. Osmotic disruption of BBB is one of the invasive techniques involving temporarily
shrinkage of endothelial cells, opening of tight junctions and leakage of drug to the CNS [6, 7, 8].
M

On injecting intracarotid hypotonic solution of mannitol, tight junctions were opened and
subsequently promoted the delivery of chemotherapeutic agents to the brain. Os motic disruption
ED

enhanced 2.5-7.6 fold transport of methotrexate, aminoisobutyric acid and dextran 70 to CNS
[9]. This technique is less specific and inefficient and major drawbacks are transport of plasma
PT

protein to CNS, disturbed glucose uptake, microembolism, neurotoxicity of cerebral tissues,


altered brain functions and technicality related issues.
CE

Vasoactive agents such as bradykinin and histamine disturb the BBB and improve the
transportation of drugs to CNS [10, 11, 12]. Purpose mechanisms involved in BBB opening
AC

effects of bradykinin are the activation of B2 receptors, leakage of endothelial cells based on
modulation of caveolin-1 and caveolin-2 [13] and permeability enhancement of brain tumor
microvessels via (KATP) channels [14]. In preliminary clinical trials, intra arterial infusion of
RMP-7, agonist of bradykinin, resulted in 2.7 fold enhanced transport of carboplatin [15] but
phase II and III clinical trials had shown inefficiency of RMP-7 in the treatment of glioma [16,
17]. The Transient effect and unevenly distribution of receptors in the brain led to the poor
distribution of chemotherapeutic agents in brain [18]. Efficiency of vasoactive agents could be
maintained by conjugating onto the surface of NPs. A study has shown that coupling of
ACCEPTED MANUSCRIPT

methylmethacrylate-sulfopropylmethacrylate (MMA-SPM) NPs with RMP-7 resulted in


successful delivery of antiretroviral drug across BBB. This strategy of combining liposomes or
NPs encapsulating drugs with hyperosmotic agents has shown positive results in improving drug
delivery to brain and reducing systemic side effects [19]. Liposomes grafted with peptidase
inhibitors [20], bradykinin and etoposide [21] promoted the transport of encapsulated drugs
across BBB.
2.1.2 Focus Ultrasound enhanced delivery

T
IP
The use of ultrasound waves to reversibly and transiently open the BBB is another ve rsatile
approach for enhancing of drug transportation to the CNS [22]. Ultrasound based drug delivery

CR
utilized microbubbles (MBs) as a contrast agent [23, 24]. These bubbles were administered
systemically and worked on acoustic energy principle to exert pressure on endothelial cells and

US
open the tight junctions, resulted in increased permeability of BBB and improved de livery of
drug to the brain [25]. MBs have diameter of 1-10µm and are made of semi rigid lipid and
AN
albumin shells encapsulated with perfluorocarbon [26]. These MBs operate in collaboration with
low intensity Focus Ultrasound (FUS) and this combined system is called MB facilitated FUS.
M

MB-FUS system decreases the acoustic energy requirement, focusing the acoustic energy within
blood vessels. Different antitumor agents such as trastuzumab [27], temozolomide [28],
ED

methotrexate [29], neucleotides i.e. siRNA [30] and stem cells [31] have been successfully
delivered with the help of FUS. FUS-MB system is effectively used with other DDSs for brain
PT

targeted delivery. This system could be utilized in combination with PEGylated NPs to disrupt
the BBB for enhanced delivery, target the cancerous cell and increase penetration [32]. FUS
CE

technique coupled with liposomes had shown optimum effects o f doxorubicin in rat glioma [33].
FUS grafted gold NPs guided through MRI were delivered to brain tumor model. FUS system
AC

could be helpful for gene therapy of brain tumor [34]. Successful delivery of NPs encapsulating
reporter gene combined with MRI guided FUS to transfect the brain, is the clue for future
prospects of this technology for gene therapy [35].
High-Intensity Focused Ultrasound (HIFU) is effectively applied for reversible disturbance of
BBB and promotion of drug distribution to the brain in a précised and controlled way without
toxicity to brain parenchyma tissues. This technique is valuable for tumor targeted delivery of
drugs, genes and antibodies [36, 37, 38]. Interstitial fluid pressure limited the distribution of NPs
to the tumor. HFU increased the permeability of endothelial cells and NPs were moved from
ACCEPTED MANUSCRIPT

leaky endothelial cells to the tumor microenvironment resulting in improved distribution of


anticancer agents to the tumor targeted area.
2.1.3 Craniotomy-based drug delivery
Craniotomy-based drug delivery is the direct way of targeting the specific part of the brain
without exposure to peripheral organs via Intracerebral or intraventricular injection. In
intraventricular delivery, drug reservoir implanted in the scalp provided the controlled release of

T
a drug and is connected to the ventricles in the brain through catheter [39, 40]. Higher

IP
concentration of drugs is achieved without distribution to the interstitial fluid of brain.
Intraventricular system directly delivers the drug to the ventricles and subarachnoidal part of the

CR
brain and is suitable for therapy of meningioma and metastatic cells of CSF [41]. Intracerebral
system directly injects or infuses the drug into brain parenchyma through catheter [42] and

US
controlled devices maintain the delivery [43]. This system depends on the diffusion mechanism
and provides slow distribution of drugs within the brain, as diffusion decreases with the increase
AN
of distance. Hence, intracerebral delivery requires large doses of a drug to achieve desired
therapeutic response [44].
M

2.1.4 Convection-enhanced delivery (CED)


Convection-enhanced delivery (CED) overcomes the disadvantages of intracereberal delivery
ED

system. This diffusion system utilizes continuous infusion method and pressure gradient to
distribute large volume of drugs at target tissues via intracranial catheter. CED has certain
PT

limitations of drug exposure to surrounding tissue, difficulty in designing the optimum


formulations, instability of drug and subtherapeutic level of drug in the target area [45, 46, 47].
CE

Coupling of CED with liposomes improved the efficiency of CED for brain tumor targeting.
PEGylated liposomes encapsulating temozolomide (TMZ) were studied on rat bearing
AC

glioblastoma multiforme (GBM). Liposomal delivery, significantly, inhibited tumor volume and
increased the survival rate [48]. CED process was further improved using efflux-resistant
infusion cannula to increase the infusion rate and liposomal delivery was guided through MRI
[49]. PLGA NPs based on CED technology were investigated in animals bearing intracranial
tumor for targeted and controlled delivery. NPs distribution was comparable to that of healthy
animals but distribution to surrounding tissues was observed [50].
ACCEPTED MANUSCRIPT

2.1.5 Polymeric wafers and Microchip technology


Advancement in polymer technology led to development of polymeric devices for targeted and
controlled delivery of therapeutic moieties. Circumventing the BBB and providing the controlled
release of drug at intracranial tumor using polymer devices, is a big achievement in the field of
polymer nanotechnology. Wafers based on polyanhydride were implanted in tumor resection
area, crossed the BBB, gradually released and distributed the drug into the brain and targeted site

T
[51]. Gliadel® is effective for chemotherapy of recurrent and newly diagnosed glioblastoma

IP
followed by radiotherapy. FDA approved Gliadel® as adjunct to surgery for recurrent
glioblastoma patients and radiation and surgery for high grade malignant glioma patients [52, 53].

CR
Phase III clinical trials based on combination therapy of Gliadel®, radiation and oral
temozolomide increased median survival time upto 2 months [54]. Polymeric wafer was the first

US
clinically used local strategy to cross BBB and provided sustained release of carmustine at the
tumor targeted site. Clinical studies have proved useful potential of Gliadel® in newly diagnosed
AN
glioblastomas. Gliadel® wafers have gained importance in saving the therapeutic potential of
drugs that lost their efficiency due to systemic toxicity or BBB impermeability. Camptothecin
M

failed in clinical trials due to systemic side effects. Local delivery based on polyanhydride
polymers had shown efficacious results in animals without major organ toxicity [55]. Wafers
ED

have certain limitations of less penetration into deep brain tissue, cyst formation, meningitis,
impaired wound healing and abscess formation.
PT

Programmable microchips are intracranial devices implanted to control the release of drug at
targeted site. Two types of chips are microelectromechanical systems (MEMS) and the passive
CE

chip. Single and multiple doses could be delivered through chip technology. Active microchips
based on MEMS comprise drug filled reservoir on silicon chip and provide highly programmable
AC

release of drug at the targeted site [56]. Active chip technology enabled development of multiple
reservoirs containing separate drugs to be released at the same or different required time intervals.
Passive chips release the drug on gradual degradation of polymeric film surrounding
microreservoir. These chips also deliver multiple drugs on demand of the therapy. These active
and passive devices offer several advantages over polymeric drug delivery. Higher drug loading,
drug remained in contact with microchip, no interaction of drug with polymer and programmed
controlled release of drug made these devices superior to polymer delivery [57]. Preclinical
studies of temozolomide and carmustine using MEMS and the passive chip were conducted in
ACCEPTED MANUSCRIPT

rodent gliosarcoma model. Device effectively delivered the drug and increased survival t ime in
9L glioma model [58]. In another study, chemotherapeutic effect of 1,3-bis (2-chloroethyl)-1-
nitrosourea (BCNU) on Fischer gliosarcoma rat model using passive microchip device was
investigated. BCNU effectively reduced the tumor volume compared to empty device [59].

T
Chemical Disruption of
BBB

IP
Focus Ultrasound
Enhanced Delivery

CR
Craniotomy-Based Drug
Invasive Strategies Delivery
Convection Enhanced

US
Delivery
Polymeric Wafers and
Microchip Technology
AN
Efflux Pump
Inhibition
M

Prodrug Approach
Non Invasive
Cell Based Therapy
ED

Strategies
Drug Delivery Strategies
for Brain Targeting Nanocarriers as Drug
Delivery System
PT

Intranasal Drug
Delivery
CE

Antibodies Mediated
Drug Delivery
Recent Mfsd2a Based Drug
AC

Advancements in Delivery
Brain Targeted
Drug Delivery Facial Intradermal
Injection
Laser Light
Technology

Fig.1: Diagrametic presentation of drug delivery strategies for brain tageting.


ACCEPTED MANUSCRIPT

2.2 Non-Invasive strategies


Non invasive approaches exploit the endogenous mechanisms for transport of drug across the
BBB. These strategies include prodrug approach, chemical modulation of BBB, efflux pump
inhibition, alternative route of administration and nanocarriers based drug delivery to the brain.
2.2.1 Efflux pump inhibition
Another barrier for effective drug transportation to the brain is the presence of efflux pump in the

T
BBB. Efflux by the active P-glycoprotein (P- gp) presents on the apical membrane of the

IP
endothelial cells of BBB results in poor drug availability at the targeted brain tissues. P- gp has
more association with lipophillic and cationic drugs [60]. Most of the low molecular weight

CR
drugs such as nitrosoureas are substrate for P-gp and are restricted to enter the brain. Inhibition
of P-gp efflux is the useful approach to save the therapeutic efficacy of potent drugs. Pazopanib

US
is candidate for P-gp efflux. Administration with elacridar, P-gp inhibitors, significantly
enhanced the brain uptake of pazopanib [61]. First generation P-gp inhibitors, verapamil and
AN
cyclosporine A, associated with cytochrome P450 3A (CYP3A) enzymes inhibitions and are
toxic. Valspodar is second- generation strong P-gp inhibitor with less toxicity related issues.
M

Elacridar, zosuquidar, and tariquidar are third generation inhibitors with proved safety and have
no effect on CYP3A enzymes inhibitions [62, 63]. To avoid serious side effects associated with
ED

efflux inhibitors, dual therapy of efflux inhibitors with NPs was explored. Verapamil was
delivered in combination with paclitaxel micelles to investigate paclitaxel toxicity in multi drug
PT

resistant (MDR) cancer cells. Combination therapy exhibited toxicity of paclitaxel in MDR
tumor cells [64]. Patil et al. conducted a study and reported that paclitaxel encapsulated NPs
CE

were unable to exhibit antitumor effect on drug resistant tumor model. NPs encapsulated with
tariquidar and paclitaxel had shown antitumor effect on mouse model [65]. In vitro studies of
AC

PEGylated liposomes encapsulated with Ariquidar/paclitaxel and PEG-PE micelles containing


elacridar-/paclitaxel revealed positive results [66, 67].
In addition to P-gp, multidrug resistance-associated protein (MRP) family located on the
endothelial cells involved in the efflux of cationic molecules. MRP is responsible for multi drug
resistance of cancer to chemotherapeutic agents. The basic function of P- gp and MRP is to
protect the brain from entry of harmful chemical substances resultantly inhibit the entry of drugs
to the brain. Inhibition of P-gp and MRP simultaneously could be beneficial for brain targeted
delivery [68].
ACCEPTED MANUSCRIPT

2.2.2 Prodrug Approach


Increasing the lipophilic characteristics of a drug facilitates the BBB permeation ability. Prodrug
approach is the chemical modification of active molecule to modulate its lipophilic behavior,
increase permeability and water solubility [69]. Targeted prodrugs contain chemical entity along
with parent drugs designed to approach enzymes or transport system at the targeted site to be
converted to active moiety. Targeted prodrug approach based on redox chemical delivery to save

T
the chemotherapeutic potential of mustard alkylating agents was applied. Redox derivative of

IP
alkylating agent crossed the BBB and retained in the brain for longer time. Pharmacokinetic
studies demonstrated enhanced lipophilicity and improved efficacy of alkylating agents [70].

CR
Enkephalins are alternative options to avoid serio us side effects related with morphine and other
opoids but have limited permeability to BBB and underwent peptidase degradation. Tyr-D-Ala-

US
Gly-Phe-D-Leu (DADLE) is prodrug of enkephalins but unable to cross BBB due to hydrophilic
nature. To solve this problem, 1, 4-dihydrotrigonellyl chemical entity was attached to the parent
AN
drug via spacer. This targeted prodrug system retained the prodrug in the brain for longer period
of time. Peptidase enzymes in the brain removed the spacer and released the active drug [71].
M

Prodrug approach has been successfully utilized for delivery of neurotherapeutics to treat
neurological disorders. Dopamine, pharmacologically effective for the treatment of Parkinson′s
ED

disease, is unable to cross BBB disease. L-dopa is transported through L-amino acid transporter
crossed BBB and converted to dopamine in the brain [72].
PT

2.2.3 Cell based therapy


Cell based therapy has gained attraction for effective delivery of variety of drugs to treat
CE

neurological disorders and brain tumors. This therapy involves macrophages and many types of
stem cells as carriers for delivery to brain [73]. Macrophages are migrated to brain through
AC

paracellular and transcellular transport mechanisms [74, 75]. They have natural ability of
phagocytosis, enables them to enter brain as Trojan horses. During brain tumor and
inflammatory conditions macrophages are attracted and infiltrated towards brain. Macrophages
are suitable candidates for targeted delivery of NPs and diagnostic and imaging agents to the
brain tumor and neurodegenerative diseases. In in vitro studies, gold nanoshells carrying
macrophages for photothermal therapy were infiltrated glioma spheroids [76]. Exosomes are
nanovesicles, cargo large number of drugs and biological molecules [77]. Protein and lipidic
nature of exosomes facilitate them to be fused with the recipient cells and deliver the therapeutic
ACCEPTED MANUSCRIPT

agents. Ligands such as peptides are attached to target the exosomes and macrophages at specific
site in the brain. Rabies virus glycopeptides, tet-1 peptide and EGFRvIII-specific antibodies for
glioblastomas are ligands for exosomes brain targeting delivery [78, 79, 80]. Stem cells could be
used as vector for delivery of cytokines, oncolytic viruses, and suicide genes to brain [81, 82, 83].
Stem cells could be effective cargo for oncolytic virus to treat the glioma. In a study,
Mesenchymal Stem Cells carrying oncolytic herpes simplex virus exhibited efficacious results in
glioma-bearing mice [84].

T
2.2.4 Nanocarriers as drug delivery system

IP
Nanocarriers have gained importance and interest as permeation enhancement nanovehicles of

CR
therapeutic molecules across BBB. Nanocarriers have capability of targeted and site specific
delivery of anticancer, anti-Alzheimer`s and anti-parkinson′s drugs and protease inhibitors, made

US
them suitable candidates as carriers for neurological disorders and brain tumor targeted delivery.
Most of the research over last several years was focused on polymeric NPs based on poly (lactic
AN
acid) (PLA), poly (D.L- lactide-co-glycolide) (PLGA) and poly (glycolic acid) (PGA) for brain
targeted delivery [85]. Surface coating of polymeric NPs with PEG, chitosan, lectin and D-α-
M

tocopherol polyethylene glycol 1000 succinate (TPGS) conferred stealth and site specific
targeting abilities to the NPs. Chitosan NPs were synthesized and encapsulated with nucleotide
ED

(Bcl-2 siRNA-) and doxorubicin separately. In vivo pharmacokinetic and biodistribution studies
had shown similar results irrespective of different nature of two drugs [86]. Conjugation of NPs
PT

with cell penetrating peptides such as RGD, RVG and CDX potentiated the brain uptake of
nanocarriers. A study was performed to evaluate the effect of CDX on BBB permeation ability of
CE

NPs. compared to unmodified NPS, paclitaxel loaded NPs modified with CDX, significantly,
enhanced the median survival time and exhibited improved antitumor efficacy. In addition to
AC

polymeric NPs, solid lipids NPs (SLNs) are also efficient nanovehicles to increase the brain
targeting efficiency of drugs. Ligand conjugated SLNs are efficient carriers for site specific
therapy. SLNs could be effective cargo for neucleotide delivery to brain. Conjugation of SLNs
with cationic angiopep and encapsulation of SiRNA efficiently de livered SiRNA to the glioma
[87]. 5- fluoro-2,-deoxyuridine (FUdR) have restricted ability to enter the brain. Wang et al.
synthesized 3′, 5-dioctanoyl-5-fluoro-2-deoxyuridine (DO-FUdR) and incorporated in SLN.
They observed that SLN improved brain uptake up to two folds compared to FUdR [88].
ACCEPTED MANUSCRIPT

Liposomal delivery of cereberal ischemic agents, opoid peptides and antitumor agents has
proved therapeutic importance of these nanocarriers for brain targeting delivery. Cationic
liposomes are positively charged vesicles bind with negatively charged endot helium and
delivered through adsorptive- mediated endocytosis or phagocytosis [89]. PEGylated liposomes
functionalized with glutathione were encapsulated with doxorubicin and inhibited tumor growth
in animal bearing glioblastoma [90]. Monoclonal antibodies (mAbs) bind to transferrin receptor
OX26 and conjugation of PEGylated liposomes with mAbs directed liposomal de livery to the

T
targeted site [91]. Various brain tumor targeting chemotherapeutic agents based on liposomal

IP
delivery have been approved for therapeutic purposes. These are DaunoXome® (Lipoplatin),

CR
DepoCyt® (cytarabine), Ambisome®, Visudyne® and Doxil/Caelyx® (doxorubicin) [92].
The therapeutic and diagnostic potentials of magnetic NPs in brain tumor targeted delivery have

US
been explored in the recent years. Superparamagnetic iron oxide nanoparticles, or SPIONS could
be directed to the target site and distinguish tumor affected tissue from healthy tissues. External
AN
magnetic field is applied to target them into the brain tumor and also used in combination with
radiotherapy for brain tumor. Endothelial vascular cell adhesion molecule-1 (VCAM-1) is
M

detection indicator of brain metastasis and combination of SPIONS with VCAM-1 helped in
early detection of brain tumor [93]. SPIONS have been used for tracking the therapy and act as
ED

MRI contrast agent. Magnetoliposomes are liposome encapsulating magnetic NPs and are
conjugated with transferrin protein to facilitate brain uptake through trasferrin receptor mediated
PT

delivery. Magnetoliposomes of paclitaxel modified with anti-GPNMB antibodies increased 4


fold brain uptake of paclitaxel. Liposomal delivery provided sustained release concentration of
CE

paclitaxel in animals compared to unmodified delivery [94].


2.2.5 Intranasal drug delivery
AC

Drug administered through nasal route of administration is absorbed into the systemic
circulation. Drug absorption through nasal respiratory epithelium follows transcellular and
paracellular absorption, carrier-mediated transport, and absorption through trancytosis
mechanism [95]. Nasal drug delivery to the brain posed a big challenge of BBB- mediated
restriction. Administration of drug deep into the nasal cavity approached nasal mucosa, led to
direct transmission of drug into brain via olfactory pathway. Olfactory pathway consists of
olfactory neurons that carry drugs from olfactory mucosa to the brain and is slow process of drug
transmission. Olfactory epithelium pathway is faster way of drug transportation [96]. Drug is
ACCEPTED MANUSCRIPT

passed through olfactory epithelium via paracellular mechanism into perineural space and
transferred directly to the brain [97]. Detailed description about intranasal brain targeting is the
main focus of this review.
Table 1: List of FDA approved marketed products for brain targeting delivery
Product Name Active ingredients Year of approval Indication

Amyotrophic Lateral
Radicava Edaravone 2017

T
Sclerosis (ALS)

IP
Ingrezza Valbenazine 2017 Tardive dyskinesia

CR
Austedo Deutetrabenazine 2017 Huntington’s disease

US
Ocrevus Ocrelizumab 2017 Multiple Sclerosis
AN
Xadago Safinamide 2017 Parkinson’s disease

Spinal Muscular
Spinraza Nusinersen 2016
M

Atrophy (SMA)

Zinbryta Daclizumab 2016 Multiple Sclerosis


ED

Hallucinations and
Nuplazid Pimavanserin 2016 delusions associated
PT

with psychosis

Aristada Aripiprazole lauroxil 2015 Schizophrenia


CE

Schizophrenia and
Vraylar Cariprazine 2015
bipolar disorder
AC

Rexulti Brexpiprazole 2015 Schizophrenia

Relapse of multiple
Plegridy Peginterferon beta-1a 2014
sclerosis

Eslicarbazepine Epilepsy associated


Aptiom 2013
acetate seizures.

Flutemetamol F 18 Radioactive
Vizamyl 2013
injection diagnostic drug for
ACCEPTED MANUSCRIPT

Alzheimer's disease

Major depressive
Brintellix Vortioxetine 2013
disorder

Relapse of multiple
Tecfidera 2013
Dimethyl fumarate sclerosis

T
Gadoterate MRI based brain
Dotarem 2013

IP
meglumine imaging

CR
2.3 Recent advancements in brain targeted drug delivery

US
2.3.1 Antibodies mediated drug delivery
Antibodies based therapy became famous over last decade. However, restriction posed by the
AN
BBB and low brain permeability of the antibodies limited the potential of antibody mediated
therapy for neurological diseases. mAbs are much large in size and unlike small molecules,
M

unable to cross BBB and approach target sites in the brain [98, 99]. Although, no mAb has been
approved for brain targeted therapy but several mAbs are under clinical trials especially for the
ED

treatment of Alzheimer’s disease [100]. Alzheimer’s disease is accompanied by the abnormal


folding and deposition of amyloid beta (Aβ) peptide and tau protein in the brain. Anti- Aβ mAbs,
PT

bapineuzumab and solanezumab failed to achieve optimal level in brain and caused imaging
related abnormalities in clinical trials [101]. Recently, clinical trials conducted on aggregated
CE

mAbs peptide, significantly decreased amyloid plaque in the brain. Trials on large number of
population are desired to further evaluate clinical benefits. mAbs such as solanezumab recognize
AC

and bind with soluble form of Aβ whereas, aducanumab and gantenerumab target the insoluble
and aggregated Aβ plaques in the brain and ultimately remove it from brain (102). Another class
of novel Abs is single domain antibodies (VHHs), depleted of light chain and have only fully
functional heavy chain to recognize the target site in brain. Camelid is VHH recognizes the
amyloid peptide and tau neurofibrillary tangles (NFTs) involved in Alzheimer′s disease. These
Abs are transported across BBB non- invasively and useful transmigrating agents for BBB
mediated therapy. Anti-Aβ and anti-tau VHHs were formulated and administered I.V. in mouse
to probe the plaque and NFTs in brain. In vivo imaging technique had shown that V VH
ACCEPTED MANUSCRIPT

transmigrated across BBB more efficiently than conventional IGg, bound to Aβ plaques and
recognized tau tangles. These finding suggested that VHSS could be therapeutically and
diagnostically important for targeting neurological diseases [103].
Multiple sclerosis (MS) is another CNS disease characterized by impaired connection between
the brain and rest of the body. Myelin is the protective sheath to insulate the axons and damaging
of this sheath leads to MS. Strategic treatment of MS based on mAbs involves depletion of B
cells, facilitation of remyelination and inhibition of immune-cell trafficking [102]. Natalizumab

T
depletes the B cells and T cells in the CNS. It prevents the entry of T cells via alpha 4- integrin

IP
blockade in the BBB [104]. Novel therapy of MS involves reduction of lymphocytes count and is

CR
emerging approach for MS targeting. Ofatumumab is the latest mAb that binds CD20 on B
lymphocytes and depleted B cells via complement-dependent cytotoxicity and antibody-

US
dependent cell- mediated cytotoxicity in phase II study [105]. Ocrelizumab is in final stage
development, reduced the relapse rate for extended period of time in phase II and phase III
AN
studies and significantly, decreased number of lesions in the brain in phase III study [106, 107].
Facilitation of myelin repair is another latest approach for MS therapy. BIIB033, anti- LINGO-1
M

mAb, is the first mAb that antagonizes LINGO-1, have shown efficacy in myelin repairing
model and safety in phase I safety study [108, 109].
ED

Bispecific antibody (bsAb) is newly designed Ab with two different binding specificities. bsAbs
are introduced for chemotherapy with one binding specificity targets the tumor cell and other
PT

targets the antigen on immune cells [110]. Recent application of bsAbs is the targeted delivery
across BBB. bsAbs constructed with one specificity to promote transportation across BBB via
CE

receptor mediated transport and second specificity to target the specific site in the brain for
desired therapeutic effect. Several BBB crossing bsAbs were formulated and evaluated for brain
AC

targeted delivery such as bsAb with transferrin receptor (TfR) binding domain to cross BBB and
single-chain variable region fragments (scFv) specificity against amyloid beta peptide. mAb-
scFv injected subcutaneously in amyloid precursor protein transgenic mice, 60% reduced
amyloid plaque. TfR and BACE1 targeting bsAbs were designed through “knobs- into- holes
technique. TfR binding domain of bsAbs had shown low binding affinity with TfR, minimally
altered normal function of receptors and enhanced BBB penetration of BACE1 [111]. Whereas,
high affinity binding Abs were trapped in vascular compartment resulted in poor penetration of
BACE1to the target site.
ACCEPTED MANUSCRIPT

Lipocalin-2 (LCN2) is a lipocalin protein secreted by the astrocytes and microglia during brain
hemorrhage, ischemic stroke and brain injury. Astrocytes and microglia secreted LCN2
facilitates the inflammation during brain injuries. Various studies on multiple carcinoma reported
higher level of LCN2 expression in different tumors. Animal and cell culture studies strongly
recommended the involvement of LCN2 in the progress of stroke, cerebral ischemia and brain
injury. LCN2 gene is modulated at transcription and translation level. Research on LCN2
explored that LCN2 is the target for drug therapy of neuroinflammatry conditions. In near future,

T
it is expected that scientists should focus on the development of LCN2 inhibitors and LCN2

IP
targeted neutralizing Abs for brain ischemia, stroke and cerebral hemorrhage therapy [112].

CR
High Mobility Group Box 1 protein (HMGBI) is actively or passively secreted in trauma,
chronic inflammatory disorders, autoimmune diseases and cancer. HMGB1 initiates and

US
maintains cytokine induced inflammation and plays a role in variety of diseases. Strategies
focused on HMGB1 targeted delivery are most promising for neuroinflammatory conditions.
AN
Several mAbs and polyclonal Abs inhibit HMGB1 and useful in the therapy of brain
inflammatory medical diseases such as stroke and hemorrhagic shock. In a study, rats were
M

immunized with HMGB1/HMGB2 and anti HMGB1 mAbs were achieved. In rat ischemic
model, HMGB1 mAbs decreased BBB permeability and remediated brain infarction. Anti
ED

HMGB1mAbs relieved the neuropathic pain in sciatic nerve ligated rats. Sasaki et al desc ribed
that mAbs provided neuroprotection in mouse Parkinson′s model. HMGB1 like bsAbs have two
PT

domains, A and B Box. Box B mediates inflammation and Box A is competitor of HMGB1. Box
A is the beneficial and has antitumor effects. It provides protection in cereberal ischemia,
CE

epilepsy and acute pancreatitis. It is suggetsed that Box A might be bind with HMGB1 and
compete with HMGB1 binding ligands [113].
AC

2.3.2 Mfsd2a-based drug delivery strategy


Mfsd2a-based drug delivery strategy is the novel approach to target the brain. Mfsd2a presents
on the endothelial cells surface in the BBB, prevents the transmission of molecules through
trancytosis [114] and facilitates the transport of specific lysophosp hatidyl-choline (LPC)
derivatives [115]. Mfsd2a worked on two principles. One approach is inhibition of Mfsd2a
promotes the trancytosis in endothelium, resultantly enhances BBB permeation. Tunicamycin
and anti-Mfsd2a antibodies are most probably reversible inhibitors of Mfsd2a [116]. Mfsd2a is
transporter of LPC and derivatives of LPC such as LPC-DHA. Mutation of mfsd2a blocks the
ACCEPTED MANUSCRIPT

transport of LPC to brain [117]. LPC act as carrier for small molecules and transported through
mfsd2a across BBB. Second approach involves LPC mediated delivery resembling the glucose
transporter (GluT1) and L-type amino acid transporter (LAT1) based transport [118, 119].
Acquired immunodeficiency syndrome (AIDS) induced encephalopathy was treated using this
strategy. Efavirenz loaded nanocarriers functionalized with phenylalanine were transported
through LAT-1, similar to LPC, inhibited reverse transcription of HIV into CNS [120]. LPC
based delivery has several limitations and is not applicable for all small molecular weight drugs.

T
Drugs transported through LPC must have one carboxylic group for coupling with LPC.

IP
2.3.3 Facial intradermal injection

CR
In addition to intranasal brain targeting, facial intradermal injection overcomes the BBB through
trigeminal neural connection. Trigeminal pathway consists of vasculature, perineurium and

US
epineurium interlinks facial skin with brain. This pathway is involved in facial intradermal
targeting of brain. Yu XC et al. compared intranasal delivery with intradermal injection for brain
AN
targeting in the rats. Compared to intranasal injection, intradermal injection into the rat mystacial
pad, significantly, enhanced brain targeting efficiency, direct transport percentage and brain
M

concentration of Evans blue (EB). Transport of EB from mystacial pad and nasal mucosa to brain
was mediated through lymphatic system. Facial dermal delivery explored epineurium,
ED

perineurium, neurons and Schwann cells for brain targeting [121].


2.3.4 Laser light based technology
PT

Laser light based technology could be beneficial in BBB disruption and helpful in glioma
targeted delivery. Laser light causes defects in membrane of endothelial cells and endothelial
CE

cells become leaky, allow transport of therapeutic agents to parenchymal tissues [122]. 5-
aminolevulinic acid (5-ALA), prodrug approved for photodynamic therapy, is exciting molecule
AC

for glioma treatment. Combination therapy of laser with 5-ALA opened the tight junctions
between the endothelial cells for longer period of time. Laser could be combined with other
strategies to potentiate BBB disruption. Nanoparticles combination with laser is appealing
approach for glioma targeting. Ultrashort laser pulses were applied and successfully transported
nanoparticles, genetically engineered viruses and numerous therapeutic agents to the brain [123].
ACCEPTED MANUSCRIPT

Table 2: Summary of antibodies mediated brain targeting drug delivery.


Antibiody Recognition site/ Neurological Outcomes Reference
Biomarker condition

Bapineuzumab Soluble form of Reduction of


Alzheimer′s disease [101]
and Solanezumab Aβ plaque amyloid plaque

insoluble and
Aducanumab and Reduction of

T
aggregated Aβ Alzheimer′s disease [102]
Gantenerumab amyloid plaque

IP
plaque

amyloid peptide Transmigration

CR
and tau across BBB,
Camelid –VHHs Alzheimer′s disease [111]
neurofibrillary recognition of Aβ
tangles and NFT

US
Enhanced BBB
transferrin penetration of
AN
Bispecific
receptor and Aβ Alzheimer′s disease BACE1 and [110]
antibodies
peptide reduced amyloid
M

plaque

Depletion of B
Natalizumab Alpha 4-integrin Multiple Sclerosis [103]
ED

and T cells

CD 20 on
Ofatumumab Multiple Sclerosis B cell depletion [104]
PT

lymphocytes

BIIB033, anti-
LINGO-1 Multiple Sclerosis Myelin repairing [107, 108]
CE

LINGO-1 mAb,

Cerebral Ischemia, Reduced


LCN2 targetting
AC

LCN2 stroke and brain Inflammatory [112]


Abs
injury response

Reduced
HMGB1 targeting Neuroinflammatory inflammation
HMBG1 [113]
mAbs diseases and Enhanced
neuroprotection
ACCEPTED MANUSCRIPT

2.4 Comparison of current approaches for CNS drug delivery


BBB is a major challenge in brain targeting. Invasive and noninvasive approaches to disrupt the
protective BBB were explored for effective therapy of neurological disorders. Invasive
approaches involve hyperosmotic and vasoactive agents that transiently disrupt the BBB. This
disruption results in opening of tight junction between the endothelial cells and promotes
transport of drugs to brain. However, chemical disruption has drawbacks of neurotoxicity and

T
disturbance in brain functions. Alternative invasive approach is FUS delivery involve MBs to

IP
increase BBB permeability. FUS combined with NPs and liposomal delivery for direct targeting
the brain tumor. HIFU enhances the transport of chemotherapeutic agents to the brain tumor.

CR
Intracerebral and intraventricular injection directly deliver drug to brain parenchyma through
catheter. This technology requires very precise mapping of the injection or implantation site to

US
achieve maximum targeting of the drug to the tumor. Convention enhanced delivery utilized
catheter linked reservoir to provide slow delivery and reduce toxicity of chemotherapeutic agents.
AN
One study reported toxicity of paclitaxel while using CED and this delivery strategy is not more
beneficial than other strategies in improving survival rate. Wafers and microchips are polymeric
M

devices implanted to provide controlled delivery of drugs to brain. Wafers are useful therapy in
recurrent and newly diagnosed glioblastoma. Wafers technology is unable to deliver drug into
ED

deep brain tissues and brain injuries involving impaired wound healing and abscess formation
limited their potential. Despite of therapeutic importance of invasive approaches in brain
PT

disorders, invasive techniques are limited to well define brain tumors. These techniques involve
surgical procedures and have risk of brain infections. Mechanical instruments might cause brain
CE

injuries including thrombosis.


Keeping in view of risks associated with invasive strategies, non invasive approaches were
AC

designed to treat life threatening brain disorders. P-gp efflux prohibits lipophillic and low
molecular weight drugs to enter the brain. Cyclosporine A, valspodar, elacridar and zosuquidar
inhibit P- gp efflux and facilitate brain delivery. Toxicity has been reported with efflux inhibitors
especially with first generation inhibitors. Prodrug was introduced to modulate lipophilic
characteristic of drugs. Prodrug approach is based on reducing the number of polar groups of
hydrophobic drug or linking it with lipophilic moiety. This conversion requires challenging
engineering skills and not fruitful. Stem cells could be cargo for brain delivery. Multiple stem
cell types have been shown to exhibit inherent tropism toward brain tumors. Stem cells have
ACCEPTED MANUSCRIPT

been used to cargo suicidal genes, cytokines and oncolytic viruses. Stem cells based brain
delivery failed to produce positive results in clinical trials. Non availability of standardized
protocol led to difficulty in interpretation of in vivo results from in vitro data and lack of skills in
engineering of oncolytic virus loaded stem cells restricted stem cell based delivery. Colloidal
carriers promote the transportation of therapeutic moieties for neurological disorders.
Combination of nanoparticles with other strategies provided fruitful results. Biligands targeted
nanocarriers for dual targeting of BBB and brain parenchyma have gained attention of scientists

T
now a days. Diffusion of nanocarriers to the parenchyma is uncertain and depends on their

IP
surface characteristics.

CR
All invasive and non invasive approaches have limitations in brain targeting. Most of the
approaches disrupt the BBB or promote BBB delivery and not bypass the BBB. IN delivery is

US
non invasive, bypass the BBB without absorption to blood and direct target the brain. Intranasal
delivery is useful approach and reliable alternative CNS delivery. Various colloidal carriers
AN
successfully explored IN neural pathway for brain delivery. This route avoids exposure of drugs
to the peripheral organs and non toxic to them. IN route requires small amount of drug to
M

produce therapeutic response. Recently, patients operated nasal drug delivery devices to deliver
drugs deep into the nasal cavity have been introduced. Direct brain targeting IN approach is safe
ED

and not alter normal physiological functions of brain and avoids injuries to brain.
3. Nasal drug delivery to brain
PT

Nasal route has been explored for decades for systemic delivery of drugs which can’t be given
via oral route but now it has gained attraction and potential for direct IN delivery of
CE

neurotherapeutics to brain by circumventing the blood circulation, thus reducing the systemic
exposure and hepatic/renal clearance [124,125]. This pathway involving olfactory and trigeminal
AC

nerves is gained an important consideration for delivery of wide range of therapeutic agents even
plasmids can be delivered to brain safely and effectively [126, 127].
3.1 Pathways of nasal drug delivery

3.1.1 Olfactory pathway

The possible mechanism by which drugs are transported from nose to brain has not yet clear but
olfactory pathway contributes a vital role. This pathway consists of olfactory epithelium, lamina
propria and olfactory bulb. Olfactory epithelium contains three types of cells; neuronal cell,
ACCEPTED MANUSCRIPT

progenitor cells and supporting cells, and all are connected by tight junctions. Neuronal cells
start from olfactory bulb in CNS to olfactory epithelium in nasal cavity and provide information
to brain [128]. Basal cells and neural cells replace each other during their constant motion and
due to this constant motion and replacement nasal mucosa becomes permeable resulting in
enhanced delivery of drug to brain [129]. Nasal epithelium protects the brain from entry of
harmful substances which are entrapped by the mucus layer on epithelium and cleared by cilia.
Lamina propria lying on nasal epithelium has blood vessels, mucus secreting glands, olfactory

T
axons and maxillary branch of trigeminal nerve [130, 131]. Olfactory axons are separated into

IP
group of 20′s and are surrounded by the sheath o f Schwann cells restricting perineural transport

CR
by decreasing space between axons. This feature of ensheathing the axons is called filia
olfactoria [132]. Olfactory bulb is projected to different regions of brain such as piriform cortex,

US
amygdale and hypothalamus, thus helpful for direct nasal delivery of drugs to brain.
AN
M
ED
PT
CE
AC

Fig.2: Pathways of IN delivery of drugs. Reprinted from [135]

3.1.2 Trigeminal pathway


Trigeminal pathway also plays an important role in IN delivery of drug. Respiratory region
occupies major portion of nasal cavity and innervated by trigeminal nerves. Trigeminal nerve is
fifth (V) cranial nerve having three branches; ophthalmic nerve, maxillary nerve and mandibular
nerve and is responsible for sensation in nasal cavity. Ophthalmic and ma xilla r y ner ves
inner vate the nasa l muco sa a nd carr y the necessa r y infor matio n fro m na sa l ca vity to
ACCEPTED MANUSCRIPT

CNS.Var io us DDSs tar ge t these two b ra nc hes for tra nspo rt o f dr ug to d iffer e nt pa rts
of bra in [133]. Trigeminal nerve innervating nasal cavity enters to brainstem through pons,
whereas it enters to forebrain through cribriform plate, thus promoting the entrance of drug to
caudal and rostral parts of brain and are main focus for IN transport of drugs to brain. Olfactory
pathway delivers drug to rostal area of brain, whereas trigeminal pathway not only targets rostal
but also caudal area of brain, making it difficult to differentiate whether intranasally
administered drug is translocated to rostal area by olfactory or trigeminal pathway [134]. As a

T
result, when drug is intranasally administered to brain, it may be transported via olfactory or

IP
trigeminal pathway as depicted in fig-2.

CR
3.2 Mechanism of nasal drug delivery to brain

When the drug is administered to nasal cavity, it has to cross the mucous layer and constantly

US
beat cilia. Ciliated columnar cells in the nasal epithelium control the movement of cilia. These
cilia are immobile in olfactory region, not having dynein arms required for motility, whereas
AN
they motile in respiratory region. After crossing this barrier, drug is transported across nasal
mucosa either transcellularly or paracellularly as depicted in fig-3.
M
ED
PT
CE
AC

Figure 3: Possible mechanisms for IN delivery of drugs to brain. Reproduced from [5].
ACCEPTED MANUSCRIPT

3.2.1 Transcellular transport

Receptor mediated endocytosis is the transport pathway of molecule through different BBB
endogenous receptors. Clathrin-dependent or independent mechanisms of receptor mediated
endocytosis are involved for transcellular transport [136]. Nicotinic acetylcholine receptors are
present in the olfactory epithelium, bulb and trigeminal ganglions and these receptors are
involved in the receptor mediated endocytosis. Particle size is important in deciding the

T
mechanism of endocytosis, for example, particles having size less than 200 nm are followed

IP
through clathrin-dependent endocytosis whereas, particles in the range of 100-200 nm are

CR
transported through caveolae- mediated endocytosis [137]. Other factors which contribute to
endocytosis pathway are cell type, surface charge and concentration of the particles applied to
the cells [138]. Transport of molecules through transcellular mechanism is slow and time taking

US
process.
AN
3.2.2 Paracellular transport

In nasal epithelium, cells are connected with each other through different junctions such as tight
M

junction, zonula adherens and macular adherens [139]. These junctions are impermeable to large
ED

molecule drugs but due to continuous turnover of neuronal and basal cells become permeable
[140]. Opening of these junctions promotes the paracellular transport. It has been reported by
PT

different studies that various DDSs by opening these junctions are rapidly transported through
nasal mucosa to brain as depicted in fig-3.
CE

3.3 Factors affecting nasal drug delivery to brain


AC

3.3.1 Physiochemical properties of drugs

Physiochemical properties of the drugs alter drug transportation across nasal mucosa.
Transmigration of low molecular weight drugs is not affected by the physiochemical
characteristics of drugs. Transportation of drugs with molecular weight of more than 300Da is
dependent on their physiochemical properties [141]. Molecular size of product decides about the
rate of permeation through mucosa. Macromolecular drugs such as protein, peptides and genes
achieved low level of drug in brain due to high molecular we ight and hydrophobic nature [142].
Particle size and surface properties of drug particles play a vital role in nasal drug delivery. Very
ACCEPTED MANUSCRIPT

fine particles are deposited in the lungs and are not considered in nasal products. Particle size in
the range of 5-10µ is an ideal for designing nasal formulations. Particle size and morphological
characteristics of particles must be considered with respect to nasal mucosa irritation and feel of
grittiness [143]. Polymorphic forms of a drug have different nasal membrane permeation
abilities. Polymorphism affects the delivery of drug across nasal epithelial membrane. Stability
and purity of polymorphic forms should be focused for nasal formulations preparation.

T
pH of nasal mucosa and formulation and pKa of the drugs are important to be considered while

IP
formulating a DDS. Nasal irritation, mucosal damage and bacterial growth are prevented when
pH of formulation is adjusted to 4.5 to 6.5 [143]. Size of the nasal cavity is limited and it

CR
accommodates 25mg/dose and 25 to 200µL per nostril. Nasal mucosa facilitates the permeation
of non- ionized portion of a drug. Permeation of electrolytes and polar drugs depends on their

US
degree of ionization and pKa, respectively. Nasal mucosa promotes the transmigration of
lipophilic and low molecular weight drugs. High molecular weight and hydrophilic drugs are
AN
easily removed by the mucociliary clearance and unable to cross nasal mucosa. Nasal mucosa
also has hydrophilic components and highly lipophilic drugs do not cross nasal epithelium and
M

are cleared from nasal cavity. Various techniques used to enhance hydrophilic characters of
drugs. Prodrug approach is used to design inactive hydrophilic moiety of active lipophilic drug.
ED

Prodrugs of L-Dopa were designed and reported to significantly, enhanced penetration through
nasal membrane than active drug. Prodrugs of highly lipophilic drugs promote transmemberane
PT

nasal delivery of drug. Peptides and protein based drugs underwent enzymatic degradation in
nasal cavity. Prodrug has successfully protected them from peptidal degradation and facilitated
CE

nasal drug delivery. L-aspartate- β-ester prodrug of acyclovir was designed and resulted in
enhanced permeability across nasal epithelium and protection from enzymatic degradation than
AC

parent drug. Chemical form of a drug decides its fate of mucosal permeation. Salt or ester form
of a drug is easily permeated through membrane.

3.3.2 Formulation factors

Targeting of drugs deep into nasal mucosa is the utmost requirement of targeted nasal drug
delivery to brain. Nasal drops and traditional sprays are unable to deposit drug in olfactory
epithelium. These traditional devices are useless for targeting brain through olfactory pathway.
Computational fluid dynamics (CFD) study using spray device was conducted to investigate drug
ACCEPTED MANUSCRIPT

deposition at olfactory region. This study revealed that spray devices were failed to deposit drug
in olfactory region [144]. Standard spray bottles are not ideal candidates for olfactory deposition.
Oxytocin was delivered through nasal spray and produced variable response in different
treatment groups [145]. Compared to tradational spray pumps, droplets produced from nebulizer,
upon nasal inhalation deposited to the upper posterior region of the nasal cavity, thus promoted
nose to brain targetting. IN drug delivery to brain dependent upon the dosage forms, formulation
systems and delivery device. Physical form of a formulation affect IN delivery. Liquid

T
formulations are washed out with mucociliary clearance more easily than powder form. Powder

IP
formulations stick to moist surface of nasal mucosa and retained for prolong time.

CR
Tonicity of formulation is contributing factor in mucosal permeation. Hypertonic solution
shrinks the nasal epithelial cells and facilitates nasal mucosal permeation. Hypertonic solution

US
and low pH prevent the movement of cilia and enhance the transmucosal delivery by reducing
mucociliary clearance. IN delivery demands prolong contact of drug with nasal mucosa. Visosity
AN
enhancing, mucoadhesive and gelling agents increase contact time with mucosa.These agents
decrease mucociliary clearance and increase permeation through mucosa. DDSs such as
M

polymeric NPs, mucoadhesive microspheres and nanogels work through these mechanisms and
provide sustained release of drug over prolong period of time. Excipients used in nasal
ED

formulations should be non toxic and selected according to their functions.Excipients have been
reported to cause nasal irritation. In liquid nasal formulaitions glycol, alcohol and glycerides are
PT

used as solublizer to enhance the solubility. Surfactants and cyclodextrins, solublizers and
stabilzers are alternative to alcohols. Liquid formulations contain parabens, benzalkonium
CE

chloride, phenyl ethyl alcohol, EDTA and benzoyl alcohol as perservatives. Preservatives based
on mercury irreversibly inhibit ciliary actions and are prohibited for nasal delivery. Allergic
AC

rhinitis and chronic nasal conditions lead to dryness of nasal mucosa. Nanogels for IN delivery
contain humectants to keep mucosa humid and prevent mucosal damage. These are glycerin,
sorbitol and mannitol.

3.3.3 Physiological and anatomical considerations

Movement of cilia and mucus are natural defense mechanism to protect respiratory system from
invading foreign bodies including bacteria. Mucus entrapping foreign particle is cleared with
action of continuous beating cilia. Mucociliary clearance removes the drug and formulation
ACCEPTED MANUSCRIPT

systems from nasal cavity and decreases the contact time with the mucosa, ultimately leading to
decrease drug delivery to brain [146]. Nasal clearance half life of the formulations is about 12-15
minutes [147]. Pathological conditions, hormones and viscosity enhancing agents reduce the
mucociliary clearance and promote transmucosal delivery. Physiological conditions of mucosa
alter drug transportation. There are various conditions of mucosa such as dry, bleeding,
rhinorrhea, sinitis, or nasal infection. In allergic or excess mucus secretion conditions, drugs are
washed away from nasal mucosa before permeation to neural pathways [148]. Pathological

T
diseases such as cystic fibrosis, Kartagener’s syndrome or Sjogrens syndrome decrease mucosal

IP
clearance.

CR
Various enzymes exist in nasal cavity and alter nasal drug delivery to brain. Cytochrome P-450
is oxidizing enzymes present in nasal cavity. Other forms of CYP 450 are hydrolases,

US
oxidoreductase, lactate dehydrogenase, acid phosphatase and esterase. Oxidative Phase 1 and
conjugative phase II enzymes have also been reported in nasal cavity. Peptidase and proteases
AN
present in the nasal cavity restrict nasal delivery of peptide and protein based drugs to brain
[149]. Metabolic activity of these enzymes is less than hepatic enzymes but their importance in
altering pharmacokinetic and pharmacodynamic profile of drugs can’t be ignored. Enzyme
M

inhibition and prodrug design are effective approaches to save the therapeutic efficacy of nasal
ED

products from metabolic degradation.


Inner of the nasal cavity is covered with respiratory epithelium which lies interior to nasal valve
PT

and not target for IN delivery. Nasal valve is a narrow opening in the nasal cavity, created a
barrier for delivery of drug to brain. It is located 2-3cm from nostril with cross sectional area of
CE

0.5 to 0.6 cm2 [150]. Posterior part of the nasal cavity houses neural connection to brain.
Targeting the drug to the posterior and upper part of the nasal cavity beyond the nasal valve is
AC

demanded for effective IN neural delivery. Nanoformulations failed to target this part of the
nasal cavity, whereas latest nasal drug delivery devices have got potential to deliver drug deep
into the nasal cavity housing neural connection to brain. Erectile tissues of medial and lateral
walls of the nasal cavity control the physiological nasal cycle. Normal nasal cycle is associated
with alternating congestion and decongestion of nostrils [150]. Nasal cycle lasts for 1-4hr and
accompanies with congestion of one nostril and flow of air through other nostril. During
alternating cycle nasal delivery of drug through congested nostril beyond nasal valve is
prohibited. Various factors alter normal nasal cycle such as physical activity, sexual and
ACCEPTED MANUSCRIPT

emotional behaviors and inflammatory conditions. Shape of the plumes produced by nebulizers,
spray pumps and metered dose inhalers does not match with the triangular shaped nasal vestibule
and labyrinthine geometry beyond the nasal valve. Particles present in the periphery of the plume
penetrate to lower part of nasal cavity and pass to lower part but requirement of efficient nasal
delivery to brain is targeting the drug to upper part of the nasal valve.
Venous vasculature and lymphatic system drain the nasal cavity. Venous drainage comprises of
external jugular veins and cavernous venous sinuses. External jugular veins drain the anterior

T
region of the nasal cavity, whereas cavernous venous sinuses drain the region beyond the nasal

IP
valve, the part of nasal cavity housing olfactory olfaction. Nasal cavity has not true lymphatic

CR
drainage, the perivascular spaces along the olfactory and trigeminal nerves and alongside
cerebral arteries and veins, may act as lymphatic drainage between the nasal cavity and brain.

US
Lymphatic system plays its role in the transport of drug molecules between nose and brain.
3.4 Therapeutic applications of nasal drug delivery to brain
AN
IN delivery is emerging as an efficient and effective method of delivering a variety of drug
molecules such as growth factors, hormones, neuropeptides, stem cells and chemotherapeutic
M

agents to brain (summarized in table-3). It represents a promising therapeutic strategy for the
treatment of diseases with CNS involvement, such as obesity, Alzheimer’s disease, Parkinson’s
ED

disease, Huntington’s disease, depression, anxiety, autism spectrum disorders, seizures and
stroke [127].
PT

3.4.1 Nasal delivery of proteins based drugs


CE

Peptides and proteins based drugs administered via oral route underwent enzymatic metabolism
and are unable to enter the brain due to large molecular size. Nasal administration of such
AC

compounds targets them to the specific region of brain [151]. Usually peptide and protein drugs
are administered via parentral route because of physiochemical instability and first pass
elimination but IN delivery seems to be promising option. Different studies on human and
animals resulted in successful IN delivery of large number of protein based molecules to brain,
such as corticotropin-releasing hormone (CRH), neurotrophic factors, insulin and MSH/ACTH
[152]. Therapeutic role of Insulin- like growth factor (GF-1) in stroke was evaluated by IN
ACCEPTED MANUSCRIPT

administration in rats with middle cerebral artery occlusion (MCAO). IN administration of IGF-1
not only helped in decreasing stroke volume but also improved neurological function [153].

3.4.2 Nasal delivery of stem cells


Danielyan L et al. studied IN delivery of stem cells and suggested that stem cells administered by
the nasal route followed olfactory pathway and reached olfactory bulb and other parts of brain
including brain parenchyma. They also investigated that stem cell transplantation in Parkinson′s

T
disease was complicated surgical procedure and nasal delivery of stem cell was reliable

IP
alternative to surgical procedure [154]. Neural stem/progenitor cells (NSPC) have recently gain

CR
potential for treatment of intracerebral glioma by IN delivery. IN delivered NSPC was reported
to rapidly migrate to malignant glioma via olfactory pathway [155]. Genetically modified NSPC

US
are under phase-I clinical trial in humans, they have ability to carry an enzyme which converts
prodrug 5-flurouracil to active drug flurouracil during surge ry when administered through
AN
intracerebral route [5]. NSPC have useful potential to carry biological active genes products
targeting tumor, as well as reversal of other pathological and inflammatory process or deficiency
in the brain with reduced systemic exposure. IN delivery of NSPC provides non- invasive and
M

chronic therapy for treating gliomas and other CNS disorders [155, 156].
ED

3.4.3 Nasal delivery of chemotherapeutic agents


Administration of anticancer drugs by parenteral or oral route to target the brain tumors not only
PT

limited the efficacy of these agents by BBB but also caused serious side effects on other organs;
CE

therefore, the nasal route of drug delivery has been explored by researchers. Many
chemotherapeutic agents such as Perillyl alcohol (POH) [157], NSPCs [155], glioma-adapted
vesicular stomatitis virus strain (VSVrp30) [158], methotrexate [159] and telomerase inhibitors
AC

(GRN163) [160] have been successfully delivered to target brain tumors by nasal route. It was
reported from animal and human studies that IN delivery of drugs for treatment of brain tumor
has a bright future. To design a new molecule for treating brain metastatic breast tumor, Dr.
Thomas Chen and NeOnc Technologies conjugated temozolomide (TMZ) with POH for IN
delivery and the computer modeling results demonstrated the successful delivery to brain of this
moiety [161]. By utilizing this concept, Schonthal investigated the effect of this TMZ-POH
conjugate by IN inhalation in animals with breast cancer induced brain metastasis. It was
ACCEPTED MANUSCRIPT

observed that IN delivered conjugate not only enhanced the chemotherapeutic effects on breast
cancer cell lines but also increased the half life of TMZ without observable side effects and
increased the survival time of treated animals than control animals [162]. Brain tumor causes
damage to BBB and helpful for transport of drug across BBB but systemic exposure by nasal
delivery is very less suggesting this route of delivery may provide different and more efficient
route of accessing tumor.

T
Table 3: Potential therapeutic agents for nasal drug delivery to brain.

IP
Therapeutic Disease Outcomes Reference

CR
Agent
Insulin Alzheimer′s disease, Improve verbal memory and 163, 164
Cognitive impairment reduce general cognitive

US
decline
Oxytocin Autism spectrum Pro-social effects. 165
disorders
Orexin-A Narcolepsy Improve CNS hypocretin 166
AN
signaling and also olfactory
dysfunction
M

Leptin Obesity Reduce appetite and induce 167, 168


weight loss
Benzodiazepine Seizures Replacement of rectal and 169, 170
ED

i.e. Midazolam IV administration as


cheaper, easy to use and
more efficacious.
PT

Naloxone Opioid overdose Reverse the effects of opioid 171


overdose more effectively
Perillyl Alcohol Brain metastasis Increase efficacy and less 172
CE

side effects
AC

4. IN brain targeting novel DDSs


The DDS is designed to transport the drug at particular site in the body, attain desired therapeutic
drug level and maintain plasma drug concentration within therapeutic window. The DDSs
release the drug at predetermined rate and maintain the drug plasma concentration for desired
duration. Colloidal carriers such as NP, liposomes and microspheres have got potential to
achieve desired therapeutic level in target tissues for required duration for optimal therapeutic
efficacy by controlling the drug release rate [173]. The scope of these colloidal carriers for nose
ACCEPTED MANUSCRIPT

to brain targeted DDSs is focus of discussion in this review. Drugs and carriers which are used as
DDSs to explore direct nose to brain pathways are summarized in Table 5.

T
IP
CR
US
AN
M
ED
PT
CE
AC

Fig. 4: Schematic presentation of nasal drug delivery to brain.


ACCEPTED MANUSCRIPT

4.1 Critical attributes of IN DDSs for brain targeting


Nanoparticulate systems provide controlled and BBB circumvented delivery for effective therapy
of neurological disorders. IN nanovehicles reduce the dose related side effects in non targeted
tissues and improve patient’s compliance. Desired properties of nasal drug delivery formulations
are summarized as under:

 Polymers used for colloidal delivery should be non toxic, biodegradable and

T
biocompatible.

IP
 In vitro and in vivo stability of the nanoconstructs is utmost important. Size of the

CR
nanocarriers is deriving factor for efficient delivery. Intranasally administered colloidal
NPs with 20nm diameter are transported extracellularly to the brain. Olfactory pathway

US
demands NPs with diameter less than olfactory neurons for intracellular transport to
brain. Particle size is important in deciding the mechanism of endocytosis, for example,
AN
particles having size less than 200 nm are followed through clathrin-dependent
endocytosis whereas, particles in the range of 100-200 nm are transported through
caveolae-mediated endocytosis
M

 In addition to size, charge on the NPs is also an important consideration while designing
ED

formulation. Zeta potential is measure of stability of the resultant nanocarriers. NPs must
have ˃± 30 electrical potential to induce static repulsion on reproach and facilitate NPs –
PT

cells interaction.
 There should be minimum interactions between polymer, drug and excipients such as
CE

emulsifiers and surfactants to avoid chemical degradation, alteration or protein


translation.
AC

 It is likely to prolong stay of drug carriers at nasal mucosa by using various


mucoadhesive agents. Nanoformulations should be able to reduce mucociliary clearance.
Avoiding of NPS aggregation on interaction with mucus is desirable for effective
delivery. Liposomes and other lipid based DDSs reduce mucociliary clearance. Viscosity
enhancing and gelling agents provide sustained release properties to the carriers and
prolong stay at nasal mucosa.
 Non toxic and appropriate concentrations of the excipients are required for designing
colloidal carriers. Nanocarriers should not cause irritation and damage to nasal mucosa.
ACCEPTED MANUSCRIPT

 DDSs should have excellent drug loading and release the drug at desired rate. However,
high loading delays the release of drug from DDSs. NPs storage stability is mandatory to
be ensured.
 DDSs open the tight junctions between nasal epithelial cells and promote the drug
delivery through these junctions. Paracellular transport is slow process. Various
endocytic transport mechanisms are involved in IN drug delivery to brain. DDSs rapidly
deliver drug molecules via transcellular transport to brain.

T

IP
Combination of IN DDSs with vasoconstrictors supplements the drug delivery to brain.
Phenylephrine inhibited absorption of drug to systemic circulation across respiratory

CR
epithelium and promoted drug transportation through olfactory epithelium.

4.2 Nanocarriers as nose to brain DDSs


4.2.1 Nanoparticles (NPs)
US
AN
Among various available formulations, NPs provide an excellent platform for direct transport of
drug to brain by protecting drug from biological and chemical hazards and preventing the efflux
M

of drug to enhance drug brain concentration [3]. NPs with particle size of 10-300 nm are
designed to encapsulate and deliver wide variety of therapeutic agents across olfactory pathway
ED

to brain [174]. Various human and animal studies have shown that IN delivered NP may enhance
brain uptake, improve pharmacological activity or therapeutic efficacy and reduce s ide effect of
PT

drugs compared to conventional DDSs as depicted in table-5.


CE

From literatures, it is obvious that the mechanism of transport of NPs from nose to brain via
olfactory pathway is still unclear. Scientists have not explored whether drug is released in nasal
AC

cavity and transported to brain or NPs carrying drugs are directly delivered via neural connection
[3]. Most research was focused on increase in drug concentration in brain, and improvement in
efficacy and not on evaluating mechanism of drug transports [175, 176, 177]. Transport of NPs
depends on morphology and surface characteristics [178]. NPs having hydrophilic characteristics
are transported paracellularly and those with hydrophobic characteristics are transported
transcellularly [179]. Various types of novel NP with different potential applications are
discussed in this section.
ACCEPTED MANUSCRIPT

4.2.1.1 Polymeric NPs


Various biodegradable and biocompatible polymers have been studied for lN drug delivery of
NP to the brain. Among them, chitosan is reported to exhibit additional benefits of bioadhesive
properties, reduce mucocilliary clearance, increase residence time on olfactory region and
enhance permeation through mucosa by opening of the tight junction between epithelial cells,
gaining potential for transmucosal drug delivery [180, 181]. Chitosan NPs can be used to deliver

T
wide variety of drugs and nucleotides for treatment of neurological disorders and brain tumors.

IP
For example, Woensel MV et al. used chitosan NPs to deliver small interfering RNA (siRNA) to
CNS in mice for studying its effect on Gal-1 for treatment of glioblastoma multiforme and

CR
observed that after IN administration, siRNA were detected in hindbrain by rapidly passing
through olfactory pathway. They concluded that chitosan NP is an excellent formulation for

US
delivery of biological active agents to target the brain tumor [5]. Similarly Mittal et al.
incorporated rasagiline in chitosan glutamate NPs (RAS-CG-NPs) for IN delivery to brain. They
AN
observed, significantly, higher drug concentration of IN (RAS-CG-NPs) than that of free drug
solution and IV administered (RAS-CG-NPs) in brain. This study indicated the potential of
M

chitosan NPs in the treatment of Parkinson′s disease via direc t intranasal brain targeting [182].
Another neurological study supporting the role of chitosan NPs for treatment of Parkinson's
ED

disease was conducted by Md et al. Stable chitosan NPs were designed and encapsulated with
bromocriptine. Intranasally administered CS NP exhibited higher brain/blood ratio of drug
PT

compared with IV administered CS NPs and IN drug solution. The increase in drug
concentration in CNS and enhanced clinical responses were proof of direct nose to bra in
CE

transport of chitosan NPs [183].


In addition to chitosan NPs, other polymeric NPs such as poly lactic-co-glycolic acid (PLGA)
AC

have also been studied for exploring neural connection between nose and brain. PLGA is also a
biocompatible and biodegradable polymer and is important in improving drug stability like
polyethylene glycol (PEG) and polylactic acid (PLA) [184, 185]. The uptake of PLGA NPs on
olfactory ensheathing cells was studied and compared with PLA and chitosan NPs by loading
rhodamine using confocal microscopy. Higher level of rhodamine incorporated PLGA NPs was
found in olfactory cells than that of PLA and chitosan NPs. Treated cells had shown higher value
of zeta potential than that of control cells, whereas unloaded PLGA NPs had shown highest
value, confirming microscopy data. This study concluded that PLGA NPs could be preferred
ACCEPTED MANUSCRIPT

over other polymeric NPs for brain targeted d elivery via olfactory neurons [186]. PLGA NPs
could improve the brain uptake of encapsulated drug when administered by nasal route. For
example, olanzapine, used for psychosis, underwent enzymatic metabolism and also had less
uptake of brain due to P-gp efflux which led to poor bioavailability [187]. When incorporated in
PLGA NPs, the brain uptake efficacy of olanzapine loaded NPs increased by 6.35- fold for IV
administration and 10.86-fold after IN administration compared with free drug solution. Md et al.
further studied PLGA NPs for their brain uptake efficiency. PLGA NPs were synthesized by

T
solvent emulsification diffusion-evaporation technique and in vitro and in vivo parameters were

IP
evaluated. When donezepil was administered in PLGA NPs by nasal route, brain uptake of drug

CR
by PLGA NPs was enhanced, significantly, compared with free drug solution, as confirmed by
the biodistribution studies [188]. PEG is another versatile polymer, as a better choice for

US
construction of NP for IN delivery, possessing mucus penetration abilities. PEG-PLGA NPs
constructed by coupling PEG with PLGA and are useful tools to target the brain via nasal
AN
mucosal. Most research is now focused on PEG-PLGA NPs and many protein molecules are
conjugated onto these NPs and studied for enhancement of IN drug delivery for brain targeting.
M

For example, lectins are proteins or glycoproteins that recognize and bind specific carbohydrates
on the cell surface and thereby improve attachment to the mucus and cilia. Lectin could be bound
ED

to N-acetylglucosamine and s ia lic ac id res id ues on the nasal epithelial membrane.


Researchers utilized this potential to conjugate it with PEG-PLGA NPs to improve IN transport
PT

to brain. Zhang et al. conjugated PEG-PLGA NPs with Solanum tuberosum lectin (STL) and
entrapped fibroblast growth factor (I-bFGF) in it. Intranasally administered modified NPs
CE

exhibited significantly higher area under the concentration time curve (AUC) in different parts of
the brain than IV administered STL NPs and IN drug solution. Furthermore, Conjugated
AC

nanocarriers improved memory function, as shown by water maze test. These results revealed
that STL conjugated PEG-PLGA NPs were promising DDSs for delivery of peptide and protein
based drugs to brain via nasal route [189]. PEG-PLA NPs could be functionalized with wheat
germ agglutinin (WGA) for transmembrane delivery of drugs. Liu et al. explored pathways for
delivery of WGA-NPs to brain after IN administration. They formulated PEG-PLA NPs and
functionalized with WGA. Coumarin was incorporated in NPs to track the florescent intensity of
NPs in various parts of the brain. WGA-NPs were transferred to olfactory bulb via olfactory
neural connection by transcellular mechanism. Trigeminal pathway played a role for transport of
ACCEPTED MANUSCRIPT

NPs to caudal brain area, whereas transfer of NPs to brain via cerebrospinal fluid was minimal
[190]. Traditional lectins were immunogenic and induced immune response therefore; newer
lectins with less immunogenicity were needed to improve the delivery of NPs via nasal route.
Wen Z et al. conjugated odorranalectin (OL), smallest and less immunogenic lectin, to PEG–
PLGA NPs. To investigate the direct IN transport of conjugated NP to brain, NPs were loaded
with urocortin peptide (UCN) and distribution to various regions of CNS was determined.
Surface modification of NPs with OL potentiated the level of UCN in brain and enhanced the in

T
vivo efficacy of UCN. Fluorescent intensity of OL NPs in the brain region increased gradually

IP
within 8h, whereas it was decreased from 2h afterwards for unmodified NPs (fig-5),

CR
demonstrated enhanced uptake of OL NPs by the brain. It was suggested that NPs might be
transported to brain through olfactory pathway due to binding of OL to L- focuse on the olfactory

US
epithelium [191]. From these studies, it was obvious that lectin conjugated NPs protected peptide
and protein based drugs from peptidase degradation and improved their pharmacological activity,
AN
when administered in animals for brain targeting via nasal route. Lactoferrin is another protein
which could be conjugated onto PEG-PLGA NPs. Lactoferrin receptors are present on the
M

respiratory epithelium cells and neurons [192]. These receptors could be targeted by the
lactoferrin conjugated NPs for nasal drug delivery to brain. Recently, lactoferrin modified PEG-
ED

PLGA NPs (Lf-NPs) were investigated to successfully deliver rotigotine to brain via nasal route
for the treatment of Parkinson′s disease. It was reported that Lf-NPs delivered higher
PT

concentration of drug in olfactory bulb, striatum and other brain regions compared to unmodified
NPs. These results declared that conjugation of PEG-PLGA NPs with lactoferrin enhanced the
CE

delivery of rotigotine to brain via olfactory and trigeminal pathway by interaction of lactoferrin
with lactoferrin-receptors [193].
AC

Dendrimers are three dimensional polymers which are being utilized to design NPs. NPs based
on dendrimers have gained attention now a day for transcellular and paracellular delivery of
drugs and hence better choice for IN brain targeting. While developing a drug formulation, low
aqueous solubility is a major concerning problem. Dendrimers due to their unique structural
characteristics enhance the solubility by forming a drug complex. These nanocarriers have small
size and positive charge which enable them to increase transmucosal delivery and cellular uptake
of drug. Polyamidoamine (PAMAM) dendrimers were studied to enhance the aqueous solubility
and improve delivery of haloperidol to brain. Compared to intraperitoneal injection, IN delivery
ACCEPTED MANUSCRIPT

resulted in significantly higher distribution of drug to brain and plasma. 6.7 times lower doses of
IN dendrimers produced same behavioral response as induced by the intraperitoneal injection,
indicated the efficiency of dendrimers as potential IN DDSs to target the brain [194]. PAMAM
dendrimers had ability to deliver nucleotides and nucleic acid to brain via nasal route. In this
context, siRNA were attached onto PAMAM dendrimers to target against high mobility group
box 1 (HMGB1). Upon IN administration, it was observed that siRNA were distributed in
different regions of brain and depleted the target gene in peripheral cortex and striatum.

T
Moreover, HMGBI siRNA decreased the infarct volume in brain when intranasally administered

IP
to stroke induced rats. These positive findings potentiated the future role of dendr imers for IN

CR
brain targeting [195]. In addition to therapeutic potential, dendrimers also had diagnostic
applications. Effects of PAMAM dendrimers on neurological biomarkers in mouse brain via

US
nasal route were investigated. After 24 hours of single dose of PAMAM administration to mice,
significant modification of level of gene expression related to brain derived neurotrophic factor
AN
signaling pathway was observed. However, it was not clear whether these dendrimers delivered
to brain through systemic circulation or translocated via olfactory pathway by transce llular or
M

paracelluler route [196].


ED
PT
CE
AC

Fig. 5: Comparison of florescent intensity of OL-NPs in brain region with unmodified NPs
ACCEPTED MANUSCRIPT

4.2.1.2 Peptide Surface modified NPs


Bioactive peptides such as cell-penetrating peptides (CPPs) modify the surface of NPs and
mediate delivery of drugs across nasal mucosa. They promote transport of drugs via olfactory
pathway to brain. Among CPPs, low molecular weight protamine (LMWP) is therapeutically
important in transmucosal delivery of attached molecules. LMWP is not a ntigenic or mutagenic
and exhibits low toxicity, thus safer than protamine. The LMWP-CPPs could be utilized to

T
enhance IN transport of proteins to brain. It was studied that conjugates of LMWP–proteins were

IP
effectively penetrated into the brain by noninvasive IN administration. To strengthen this
concept, LMWP was conjugated with bovine serum albumin (BSA, Sigma–Aldrich) protein and

CR
administered intranasally to mice. In vivo imaging had shown that LWMP-protein conjugate was
significantly distributed to olfactory bulb and brain tissues. Absorption of drug to the systemic

US
circulation and distribution in major organs was very less. This study concluded that LWMP
opened the tight junction of nasal epithelial cells and promoted neural transport to brain [197].
AN
LWMP could be functionalized onto the surface of drug loaded NPs. CPP surface modified NPs
provide safe and effective noninvasive delivery of drugs to brain. PEG-PLA NPs were
M

conjugated with LWMP through maleimide linkage and incorporated with coumarin to
determine their brain uptake efficiency. Cellular uptake studies had shown that level of modified
ED

NPs in the cells was significantly higher than unmodified NPs. In vivo experiments in rats
revealed that conjugation of NPs with MWMP enhanced the transport of NPs to brain as
PT

confirmed by the microscopic data. It was investigated that coumarin loaded LWMP NPs after
IN administration were effectively delivered to brain along both olfactory and trigeminal
CE

pathways [198]. CPP surface modified NPs might be helpful for future development of peptides
and proteins based products to target the brain through nasal delivery. Potential of
AC

macromolecular drugs in neuroprotective therapy by IN administration is limited due to low


nasal absorption. Co-administration of macromolecular drugs with CPPs potentiates their IN
transport to brain. Insulin was co-administered with Penetratin, a CPP, to the rats and its
distribution in different brain regions was measured. Insulin was found in distal brain regions
including cerebral cortex, cerebellum and brain stem without systemic exposure [199].
Enhancement of IN macromolecular drug delivery to brain through peptide surface modified NPs
is another useful approach. CPP modified PLGA NPs were fabricated and evaluated for IN
delivery of insulin to treat the Alzheimer’s disease. In vivo studies demonstrated that peptide
ACCEPTED MANUSCRIPT

modified NPs effectively delivered insulin to brain with total bra in delivery efficiency of 6%
[200].
4.2.1.3 Lipid based NPs
In addition to polymeric NPs, lipid based NPs are also important for rapid IN transport of drug to
brain. Solid lipids NPs (SLNs) are biodegradable, biocompatible and have no toxicity on nasal
mucosa. These NPs have controlled release properties and increase the stability of encapsulated

T
drugs. In this context, hydrophilic drug rivastigmine (RHT) loaded SLNs were studied using

IP
quality by design (QbD) approach for IN administration. SLNs were designed by
homogenization and ultrasonication technique using lipids, surfactant and stabilizers. Ex-vivo

CR
permeation studies indicated that RHT SLNs showed higher drug diffusion compared to drug
solution. RHT SLNs were safer for delivery of drugs to nasal mucosa as no nasocilliary damage

US
and/or cell necrosis were observed [201]. Similarly, phospholipid-based gelatins NPs (GNLs)
were compared with gelatin NPs (GNs) for IN delivery of basic fibroblast growth factor (bFGF)
AN
to brain. The GNLs with particle size 143 ± 1.14 nm and Zeta potential − 38.2 ± 1.2 mV showed
better profile than GNs. The level of bFGF was significantly increased in olfactory bulb and
M

striatum by the IN administration of bFGF-GNLs. Compared to bFGF-GNs, more bFGF-GNLs


were found in the striatum without causing damage to nasal mucosa. These results depicted that
ED

NPs were transported through olfactory pathway and released the drug in striatum. Thus, GNLs
were efficient for delivery of macromolecular drug to brain through direct nasal pathwa y without
PT

causing toxicity [202].


Nanostructured lipid carriers (NLCs) are also lipid based NPs containing liquid lipid in addition
CE

to solid lipid contents. NLCs overcome the entrapment efficiency and storage related problems
of SLNs. In NLCs, liquid lipid contents improve the drug loading capacity by creating imperfect
AC

structure within the lipid matrix. Likewise SLNs, these nanocarriers also have sustained release
properties [203]. For efficient IN delivery of O ndansetron hydrochloride (OND) to brain, Devkar
et al. investigated mucoadhesive NLCs. NLCs were formulated using Delonix regia gum as a
mucoadhesive polymer and administered intranasally and intravenously to the rats. Compared to
IV administered NLCs, IN NLCs had shown higher drug targeting efficiency and direct transport
percentage. It was observed that mucoadhesive NLCs promoted absorption and enhanced
residence time of OND in the nasal cavity, resulted in optimized transport to CNS. These NLCs
delivered OND to brain through olfactory neural connection via transcellular mechanism [204].
ACCEPTED MANUSCRIPT

New technology is needed to enhance the brain uptake of intranasa lly delivered peptides without
degradation by nasal peptidase. For this purpose, chitosan coated NLCs (CS-NLCs) were
designed and investigated for IN administration of proteins to brain. The resultant nanocarriers
were biocompatible and no cellular toxicity was appeared in the nasal mucosa of mice. Higher
accumulation of CS-NLCS in the cerebral cortex than in the cerebellum and hippocampus
indicated that nanocarriers were transported through olfactory and trigeminal pathway [205].

T
IP
CR
US
AN
M
ED
PT
CE
AC

Fig. 6: Pictorial representation of nanoformulations for nose to brain drug delivery.


ACCEPTED MANUSCRIPT

4.2.2 Nanoemulsions
Recently, animal studies have shown that nanoemulsions enhanced the permeability across nasal
epithelial cells and promoted nasal delivery of small molecular weight hydrophobic drugs to
brain. For example, IN delivery system of cyclosporine-A (CsA) based on Oil- in-water
nanoemulsion was fabricated and studied. Upon IN and IV administration of nanoemulsion
(CsA-NE) and solution (CsA-s) of CsA to the Sprague–Dawley rats, it was observed that IN

T
CsA-NE resulted in highest brain accumulation compared to IN solution and IV administered

IP
CsA-NE. The brain/blood ratio was also highest for CsA-NE and CsA-NE reduced the major
organ exposure. These observations indicated that CsA-NE was capable of directing nose-to-

CR
brain transport without systemic absorption [206]. Similarly, water in oil NE loaded with
Ginsenoside, basic component of Panax notoginseng saponins (PNS), was investigated for direct

US
IN transport to brain. IN delivery of NE exhibited higher level of drug in the brain than orally
administered PNS. The values of percentage of drug targeting efficiency (%DTE) and direct
AN
transport percentage (%DTP) were also higher for IN NE. The author concluded that NE is
preferred DDS to target the brain via nasal pathway [207]. Many studies have been conducted to
M

evaluate the effect of mucoadhesive agents on NE for direct nose to brain drug delivery. Sood et
al. optimized the poorly soluble curcumin loaded NE using chitosan as mucoadhesive agent.
ED

Different concentrations of oil, surfactant and co-surfactant were used to construct nanocarriers.
They investigated that mucoadhesive NE was highly diffused across sheep nasal mucosa
PT

compared to curcumin solution. Additionally, NE resulted in higher release compared to the


control and no ciliotoxicity was observed, indicated that mucoadhesive NE formulation was safer
CE

and efficient for direct IN delivery of drug to brain [208]. Future prospect of NE in nasal drug
delivery is to deliver genes and nucleotides to treat neuronal disorders. In this connection, NEs
AC

incorporating anti- TNFα siRNA were evaluated for their therapeutic potential in the treatment of
neuroinflammatory disorders. SiRNA was complexed with cationic NE of omega-3 fatty acids
and investigated for down regulation of target gene in the CNS. IN administration of these NEs
demonstrated enhanced uptake of siRNA in brain compared to uptake by the blood. Non-viral
cationic lipid based NEs efficiently knocked down the TNFα gene transcript levels
in lipopolysaccharide -stimulated macrophages. It was concluded that cationic NEs protected
nucleic acid from enzymatic degradation, enhanced its exposure to nasal mucosa and directly
delivered to brain to down regulate TNFα in experimental neuroinflammation [209].
ACCEPTED MANUSCRIPT

Amyotrophic Lateral Sclerosis is another neurodegenerative disease and riluzole is the only drug
available for its treatment. Riluzole belongs to biopharmaceutical class II system has low
bioavailability and hence its therapeutic potential is lost. NE was explored to improve the
delivery of riluzole to brain. NE was prepared by titration method using sefsol, tween 80 and
carbitol. IN administration of drug loaded NE demonstrated, significantly, enhanced brain uptake
than orally administered NE in rats without causing nasal ciliotoxicity [210].

T
4.2.3 Micelles

IP
Polymeric micelles as block copolymers are most promising drug delivery platforms to enhance

CR
the delivery of drugs and genes vial nasal rout to brain. These are nanoscale drug carriers with
ability to incorporate wide range of drugs including protein based drugs. A study was conducted

US
to investigate micellar nanocarriers for the efficient delivery of zolmitriptan to brain. It was
observed that nanocarriers were transported to brain in significantly higher concentration
AN
compared to IN and IV administered solution of zolmitriptan. The micellar formulation was
delivered to olfactory bulb through olfactory and trigeminal pathway but to midbrain and
M

cerebellum, nanocarriers were transported by trigeminal pathway only [211]. CPP-modified


block copolymer micelles as IN DDSs for brain targeting were studied. TAT conjugated
ED

amphiphillic block copolymers were constructed and loaded with coumarin for biodistribution
studies. CPP conjugated methoxy poly (ethylene glycol) (MPEG)/poly (caprolactone) (PCL)
PT

micelles exhibited higher cell uptake compared with unmodified micelles and distribution to
peripheral organs was also less. These observations declared that IN administration of CCP
CE

conjugated micelles followed direct neural transport to CNS without absorption into blood and
distribution to peripheral organs [212]. Newer drug delivery technologies in clinical and
AC

pharmaceutical fields are of the great interest for efficient transport of nucleotides to brain. To
enhance the therapeutic efficacy of small interfering RNA (siRNA), while treating the brain
disorders, Kanazawa et al. explored the neural connection between nose and brain. They loaded
MPEG–PCL–Tat micelles with siRNA and evaluated for their brain uptake efficiency. Compared
to intravenous delivery, intranasally delivered MPEG–PCL–Tat significantly enhanced the
nucleic acid concentration in brain. These modified micelles utilized both olfactory and
trigeminal nerve pathways. The distribution of nucleic acid to rostral brain tissue was the result
of olfactory transport, whereas in caudal brain tissue and brainstem nucleic acid was transported
ACCEPTED MANUSCRIPT

by trigeminal connection [213]. Similarly, potential of MPEG-PCL-TAT micelles in brain tumor


therapy was investigated. Camptothecin (CPT), an anticancer drug, was encapsulated in TAT-
modified micelles and administered intranasally to the rat. Compared to unmodified micelles,
TAT- modified micelles significantly increased median survival time of rats bearing intracranial
glioma tumors. CPT loaded MPEG-PCL-TAT had shown higher cellular accumulation due to
interaction with c6 cells and inhibited the tumor growth [214]. These findings were big hope for
gene therapy, brain tumors and neuropsychiatric disorders.

T
IP
4.2.4 Nanogels

CR
To enhance the deposition of drug at nasal epithelium by increasing the viscosity is a versatile
approach to improve IN delivery of drug to brain. Gels with three dimensional structure increase

US
the residence time in nasal cavity by increasing the viscosity, favor nasal delivery to brain.
Naratriptan hydrochloride is effective against migraine headache but frequent doses are required
AN
due to hepatic metabolism and low bioavailability. It was reported that direct IN delivery to brain
by thermoreversible gel overcame the bioavailability related problems of naratriptan. Poloxamer
M

407 based thermoreversible Nanogels were constructed using Carbopol 934 to confer
mucoadhesive properties. Researchers investigated that release of drug from gel was delayed and
ED

dependent on the concentration of Carbopol. Histopathological studies confirmed safet y profile


of nanoformulations [215]. siRNA dendriplexes loaded in situ- forming mucoadhesive gel
PT

formulations were tested for IN brain targeting. In situ forming gels were construc ted by
blending thermosensitive poloxamer with mucoadhesive chitosan or Carbopol and loaded with
CE

siRNA dendriplexes. It was observed that IN dendriplexes in gel delivered, significantly, higher
amount of radioactivity to the brain than IV administered dendriplexes and IN naked siRNA
AC

within gel. In situ gel maintained the stabilize structure of dexdriplexes and enhanced their
uptake by olfactory neurons. The author concluded that finding of radioactivity in the brain could
not lead to assume the presence of intact siRNA molecules or siRNA dendriplexes in the brain.
However, it was first time reported that in situ forming mucoadhesive gel enhanced the IN
delivery of radioactive nucleotide to the brain [216]. In situ gel formulation consisting of
resveratrol nanoparticulates and an ionic-triggered deacetylated gellan gum (DGG) matrix for
direct IN delivery to brain was studied. The markedly increased concentration of resveratrol in
the brain by in situ gel formulation demonstrated direct nose to brain transport. This combined
ACCEPTED MANUSCRIPT

formulation of nanosuspensions and the DGG in situ gel solution with properties of both
nanoparticles and ionic sensitive gel overcame the bioavailability related problems of
conventional nasal drops. In conclusion, this composite system enhanced the permeability of
nasal mucosa and increased residence time in nasal cavity [217]. Khan et al. incorporated
ropinirole, a dopamine D2 agonist in chitosan and hydroxyl propyl methyl cellulose gel.
Compared to IV administration, these gel on IN administration resulted in 8.5 time higher
concentration in brain and 3 times higher than intranasally administered ropinirole solution

T
[218]. Polymeric gel suspensions using PEG, Carbopol and carboxymethyl cellulose were

IP
designed and evaluated for IN delivery of melatonin. 6.77-and 9.22-fold increased brain levels of

CR
drug by CMC and carbopol suspension, respectively, than IV drug solution were found.
Microdialysis studies showed that polymeric gel suspensions delivered melatonin to brain

US
through olfactory pathway [219].

4.2.5 Liposomes
AN
Liposomes, as a drug delivery carrier, have been studied for more than 30 years [220, 221]. In
recent years, liposomes are under rapid development to target the brain by nasal route of
M

administration. Liposomes encapsulate proteins, improve their lipophilic characteristics, prevent


enzymatic degradation and increase uptake by the cells. Further, cationic liposomes increase
ED

residence time in the nasal cavity and promote transport of proteins across nasal mucosa. H102
peptide- loaded liposomes were tested on Calu-3 cell monolayers for IN brain delivery to treat
PT

Alzheimer’s disease. AUC of H102 liposomes in the hippocampus was 2.92- fold larger than that
of H102 solution. H102 might be delivered by olfactory pathway or trigeminal pathway to brain.
CE

Improved memory function at lower doses of peptide liposomes was reflected by the increased
concentration of peptide in hippocampus [222]. Surface modified liposomes for delivery of
AC

risperidone to brain via nasal route were studied by Narayan at al. Risperidone loaded liposomes
were synthesized using thin film hydration method and surface was modified with stearylamine
and MPEG-DSPE for efficient penetration to brain. Stearylamine liposomes prolonged the
release of drug whereas; PEGylated liposomes improved bioavailability and showed higher mean
residential time than conventional formulations. IN liposomes de livered, significantly, higher
concentration of drug to brain compared to IV bolus injection of drug. High value of BTE index
indicated that PEGylated liposomes were directly transported to brain bypassing the BBB.
However author suggested conducting further preclinical and clinical studies in larger group to
ACCEPTED MANUSCRIPT

evaluate these results are necessary [223]. Similarly, xanthan gum coated mucoadhesive
liposomes for delivery of curcumin were prepared and administered via nasal route. The
liposomes showed higher drug distribution (1240ng) in brain compared to drug solution (65ng).
However mechanism of drug transport to brain was not studied [224]. To improve rivastigmine
distribution in brain and enhance pharmacodynamics, intranasally administered rivastigmine
liposomes (Lp) and CPP modified liposomes (CPP-Lp) were optimized. Intranasally
administered rivastigmine liposomes enhanced distribution of drug to brain and retained the drug

T
for adequate time. In addition, there was very mild nasal toxicity of liposomal formulations.

IP
Liposomes especially CPP-Lp improved pharmacodynamic profile of rivastigmine delivered via

CR
olfactory pathway to brain [225].

4.2.6 Nanoemulsomes

US
Nanoemulsomes are nanocarriers with solid fat cores surrounded by phospholipids bilayer and
AN
stabilized by cholesterol and soya lecithin [226]. They are lipid based DDSs with properties of
liposomes and emulsions [227] and are better choice for delivery of poorly soluble drugs.
M

Emulsomes due to unique properties and smaller size were explored for IN drug delivery to brain
[228]. To avoid peripheral toxicity of orally administered oxcarbazepine (OX), emulsomes of
ED

OX were studied as nanocarriers for IN brain targeting. Emulsomes were prepared using
different triglycerides cores in different ratios and soya phosphatidylcholine and administered
PT

intranasally to the rats. The higher value of AUC, DTP% and DTE % for emulsomes than IV
administered drug solution and oral product indicated direct nose to brain transport of
CE

emulsomes via olfactory pathway. Pharmacokinetic studies revealed that emulsomes delivered
drug both through direct nasal transport and systemic delivery of drug from nasal mucosa to
AC

brain [229]. Another study was conducted to compare the emulsomes of OX with emulsomes
cryo-and-themogels, aimed to deliver nanocarriers for brain targeting. Poly ethylene glycol
diacrylate (PEGDA) cryogels were fabricated with varying concentration of PEGDA and
emulsomes were sequestered in gels. Similarly, thermoreversible thermosensitive PLGA-PEG-
PLGA triblock copolymer was synthesized and emulsomes were sequestered in thermogel. After
IN administration it was observed that emulsomes had shown highest drug targeting efficiency
and direct nose to brain transport and delivered, significantly, higher concentration of OX in
brain than cryo-and-themogels. Emulsomal cryo-and-themogels transported drug through
ACCEPTED MANUSCRIPT

systemic delivery with minimum involvement of direct transport to brain but in case of
emulsomes, direct transport prevailed. The aim of IN delivery is to target the brain through
trigeminal or olfactory pathway and to limit systemic exposure of drug. Hence, more studies are
required to investigate emulsomes for targeting the brain through nasal route without absorption
through respiratory epithelium.

Table 4: Pros and cons of nanocarriers for nose to brain delivery.

T
Delivery Systems Pros Cons

IP
Polymeric NPs Reduce mucocilliary clearance, Mucosal damage, nasal
increase residence time on irritation, toxicity associated

CR
olfactory region and enhance with lectin conjugated NPs and
permeation through mucosa mechanism of NPs neuronal
and conjugation with variety of uptake is unclear.

US
ligands for targeted delivery

Peptide modified NPs Targeted delivery of Toxicity associated with CPPs


AN
macromolecular drug such as mediated delivery
insulin
M

Solid lipid NPS Non toxic to nasal mucosa, Low entrapment efficiency and
controlled release properties, storage related problems
increase the stability of
ED

encapsulated drugs and deliver


peptides and macromolecular
drugs
PT

Nanoemulsions Enhance the permeability High concentration and a narrow


across nasal epithelial cells, range of physiologically
promote nasal delivery of acceptable surfactants and co-
CE

small molecular weight surfactants and concentration in


hydrophobic drugs, nucleotides different parts of brain varies
and genes with each agents
AC

Micelles
Ligand based targeted delivery Surfactants related complications
of nucleic acids and genes have been reported

Enhance the deposition of drug Mechanism of enhanced drug


Nanogels at nasal epithelium and transport to brain is unclear. It
residence time in nasal cavity, may be due to prolonged stay at
delay release of drugs, nasal mucosa or altered
overcome the bioavailability permeability of nasal epithelium
related problems, deliver
radioactive nucleotides and
combined with other DDSs.
ACCEPTED MANUSCRIPT

Liposomes Encapsulation of small and Liposomal delivery is passively


large molecules with a wide targeted rather than active
range of hydrophilicity and targeting
pKa values, prevent enzymatic
degradation and mucosal
membrane disruption,
sustained release of drug and
mild toxicity.
Microcarriers Provide mucoadhesion and Patient′s position during and

T
combined with other DDSs for after delivery influences the

IP
delayed release of drugs clearance of microparticles

CR
4.3 Microcarriers as DDS

US
Besides nanocarriers, microspheres could also be suitable candidates for direct nose to brain
targeting via integrated nerve pathways. Mucoadhesive microspheres were investigated for brain
AN
targeted delivery of zolmitriptan via nasal route. Mucoadhesive IN formulations based on
chitosan glutamate and hydroxypropyl methylcellulose (HPMC) were designed and compared
M

with IV infusion and nasal aqueous suspension of drugs for their brain uptake efficiency.
Compared to IV and oral administration, intranasally administered suspension produced CNS
ED

effects with lower peripheral toxicity. Chitosan glutamate microcarriers showed highest brain
uptake efficiency than HPMC microcarriers and nasal suspensio n of drug. Chitosan delivered
PT

drug through permeation enhancement mechanism across the olfactory mucosa. These
microspheres exhibited less exposure of drug to periphery as a result of direct transport of drug
CE

to the CNS [230]. Deferoxamine (DFO) has diverse neuroprotective effects and direct brain
targeting of DFO could be beneficial for the treatment of central nervous system disorders
AC

related to iron dysregulation such as Huntington's disease [231, 232], Alzheimer's disease [233]
and Parkinson’s disease [234]. Rassu et al. investigated intranasally administered spherical
chitosan chloride and methyl-β-Cyclodextrins microparticles loaded with DFO for nose to brain
permeation. Microparticles were prepared via spray drying and compared with nasally
administered free drug solution. These carriers were rapidly delivered to cerebrospinal fluid
(CSF) and CNS in rats, whereas no drug CSF uptake of DFO water solution was detected.
Moreover, cyclodextrins based microparticles regarding delivery of drug through olfactory
mucosa were superior to chitosan microparticles. These results suggested direct IN delivery of
ACCEPTED MANUSCRIPT

encapsulated DFO to brain [235]. A study was conducted to evaluate noninvasive transport of
midazolam microspheres into CSF via integrated nerve pathway. Ge latin-chitosan based
mucoadhesive microspheres were designed and administered intranasally to the rats. Midazolam
microspheres had shown significantly higher level in CSF than IV administered midazolam
solution. Drug toxicity index and drug targeting percentage indicated direct transport of drug
loaded microspheres to CSF [236]. Similarly, Jose et al. studied the effect of gel on the release
characteristics of microspheres. They formulated thermo-sensitive gel using puluronics and

T
loaded with mucoadhesive microspheres. Chitosan microspheres loaded thermosensitive

IP
poloxamer-based gel when administered intranasally to the rats, provided sustained release of

CR
lorazepam over a time period of 24h, whereas lorazepam microspheres in PBS (pH 6.2) and
lorazepam powder loaded in poloxamer gels released drug over 9 and 15 h, respectively. These

US
results suggested that loading of microspheres in a gel enhanced the residence time of drug in
nasal epithelium and hence beneficial for drug delivery to CNS through nasal mucosa [237].
AN
Table 5: Drugs and DDSs for direct nose to brain targeting.
M

Therapeutic Drug Delivery Problems Therapeutic Ref.


agent System Benefits
Less cytotoxicity, Improved
ED

Tat modified 214


Camptothecin less efficacy cytotoxicity and
Micelle
efficacy.
phytochemicals i.e. Mesoporous Poor solubility, Improved brain
PT

curcumin and silica NP 238


less brain uptake uptake
chrysin
Increased brain
Less brain uptake,
CE

Nucleotide Nucleotide NP uptake, improved 239


low efficacy
efficacy
Polymeric Low brain Enhanced Drug
Olanzapine 240
AC

micelle permeability targeting to brain


Poor oral
bioavailability, High brain uptake,
Risperidone Polymeric NP 241
non targeted high bioavailability
delivery
Poor oral
Quick onset of
bioavailability,
Venlafaxin Polymeric NP action, high brain 242
slow onset of
uptake
action
Lipid Neuronal Increased in drug
GDF-5 243
microemulsion degeneration targeting
Zonisamide Microemulsion Limited uptake High brain uptake, 244
ACCEPTED MANUSCRIPT

across BBB, High high bioavailability


first pass
metabolism
Enhanced drug
Less brain uptake
entrapment,
Midazolam PLGA NP and less targeting 245
stability and
of drug
controlled release.
Limited uptake High targeting
across brain, low efficiency,
Ropinirole In situ gel 218
oral enhanced brain

T
bioavailability uptake

IP
High P-gP efflux, High therapeutic
Olanzapine Nanoemulsion high first pass efficacy, high 246

CR
metabolism bioavailability
Enhanced brain
Less efficacy, less
Valporic acid Solid Lipid NP uptake, improved 247
brain uptake
efficacy

US
Improved brain
delivery and 225
Rivastigmine CPP-Liposomes Less brain uptake.
enhanced
AN
pharmacodynamics
Low permeability,
High brain uptake,
Estradiol Polymeric NP nasal mucocilliary 248
M

enhanced retention
clearance
Insulin Solution Cognitive deficits Improved memory 249
ED

4.4 Diagnostic applications of IN nanocarriers


Development in nanotechnology led the focus of scientists in designing and exploring potential
PT

of NPs in diagnosis and treatment of brain disorders. Mostly IN nanoformulations were designed
for therapeutic purposes. The therapeutic nanocarriers were aimed to transport drug at targeted
CE

site in the brain without accumulation to nontargeted tissues. Recently, nanocarriers are designed
for dual purposes; single nanocarrier has diagnostic and therapeutic applications. Dendrimers are
AC

the nanocarriers have diagnostic applications along with therapeutic potential. Effects of
PAMAM dendrimers on neurological biomarkers in mouse brain via nasal route were
investigated. After 24 hours of single dose of PAMAM administration to mice, significant
modification of level of gene expression related to brain derived neurotrophic factor signaling
pathway was observed. However, it was not clear whether these dendrimers delivered to brain
through systemic circulation or translocated via olfactory pathway by transce llular or
paracelluler route [192]. NPs carrying image guiding agents have been introduced for nose to
brain delivery. Curcumin is obtained from naturally occurring plant Curcuma longa and acts as
ACCEPTED MANUSCRIPT

florescent marker in Alzheimer′s disease. It has binding affinity with Aβ peptide and decreases
aggregation of Aβ. Liposomes were constructed containing curcumin. Postmortem studies shown
significant deposition of labeled Aβ peptide in brain tissues of Alzheimer′s patient [250].
Rhodamine is another florescent marker and biodistribution studies of NPs carrying rhodamine
were conducted. Positively charged chitosan NPs and negatively charged PLGA NPs were
constructed and administered intranasally in animals. Negative NPs shown florescence at early
time point and strong florescence of positive NPs after 48 hrs were detected. Rhodamine had

T
shown florescence in different parts of the brain and is useful to detect distribution of NPs in

IP
brain [251]. Fluorescein is used to determine the pathway of nanocarriers’ transportation after IN

CR
administeration. Fluorescein labeled dextran (FD3) IN solution was administered to the rats.
Fluorescence in the olfactory epithelium and olfactory bulb was detected within 15 minutes

US
[252]. Polymeric micelles based on MPEG-PCL were designed and loaded with coumarin
(fluoroscein model drug). After IN administration in rats, biodistribution in brain using
AN
fluorescent microscopy was studied. Coumarin concentration was used as florescent marker and
smaller size micelles delivered more concentration of coumarin than larger size micelles [253].
M

4.5 Toxicological studies of nanocarriers


Various polymeric formulations for nose to brain delivery were accessed for toxicity. Mostly
ED

polymeric nanoconstructs have cationic polymers such as chitosan and PEG. Catio nic polymers
have interaction with negatively charged surface of mucosal membrane and cause toxicity.
PT

Negatively charged carriers are repelled by the cell membrane result in low uptake and
unsuitable for transmucosal delivery. A study was conducted to evaluate pharmacokinetic,
CE

toxicity and safety profile of chitosan solution. Toxicity of chitosan was related to deacetylation
degree and not depends on molecular weight of chitosan [254]. In vitro and in vivo studies
AC

represented cytocompatibility of chitosan. Intranasally administered chitosan formulations


(0.25% w/v) to guinea pigs for 28 day [255] and single dose of 0.125%, 0.25% and 1% chitosan
hydrochloride to rats had shown no observable toxicity to nasal tissues [256]. Similarly
intranasally administered chitosan solution for 4 days was safe and had not shown any sign of
apoptosis of glial cells, inflammatory infiltrates or glial scars [257]. Microemulsion formulations
were investigated for toxicological screening in rats. Nasal mucosa and cartilage were found to
maintain their normal histological structure and no cytopathological abnormalities were reported
[258].
ACCEPTED MANUSCRIPT

Polymeric and lipid based nanovehicles are widely used for nose to brain targeting and toxicity
profile of NPs should be evaluated for deciding about risks associated with attractive drug
delivery. NPs suspensions resulted in higher cell viability than polymeric solution. NPs had
shown concentration dependent viability of Calu-3 cells. NPs augmented local inflammation of
nasal mucosal membrane without appearance of systemic inflammatory response [259]. NPs
cross olfactory epithelium and reach different brain regions. Md and collaborators administered
BRC loaded NPs in mice and examined brain for toxicity. There was no difference of treated

T
brain with normal brain. Smaller size and few eosinophilic lesions were found than mice treated

IP
with haloperidol [260]. Lectins are considered to be toxic to the mammalian cells and induce

CR
nasal ciliotoxicity and oxidative stress. WGA conjugated PEG-PLA NPs were constructed via
maleimide linkage and loaded with coumarin for IN administration. WGA-NPs and

US
unconjugated NPs exhibited negligible ciliotoxicity [261]. Tat- mediated nose-to-brain delivery
may induce cargo-dependent cytotoxicity [262]. LMWP, which is claimed to be non-cytotoxic,
AN
may still harm the normal tissue due to its lack of cell type selectivity [263].
Micellar nanocarriers based on PEG were designed and incorporated with zolmitriptan.
M

Toxicological studies of intranasally administered micelles for 28 days were performed and no
toxicity was found [264]. IN Pluronic based block copolymer micelles loaded with olanzapine
ED

were formulated and investigated for toxicological studies. Ex vivo toxicological analysis in
sheep nasal mucosa reported minor histopathological changes in nasal mucosa [265]. siRNA
PT

dendriplexes loaded in situ- forming mucoadhesive gel formulations were tested for IN brain
targeting. In situ forming gels were constructed by blending thermosensitive poloxamer with
CE

mucoadhesive chitosan or Carbopol and loaded with siRNA dendriplexes. It was observed that
IN dendriplexes in gel had not shown any toxicity [216]. Liposomes are consist of naturally
AC

occurring lipids and thought to be nontoxic. Liposomes for intranasal brain delivery were
examined for toxicological screening. Liposomes encapsulating quetiapine were formulated via
thin film hydration method and diffusion across sheep nasal mucosa was observed. Ciliotoxicity
studies reported no histopathological changes with liposomal delivery in nasal mucosa whereas,
isopropyl alcohol, positive control, damaged nasal epithelium and deep tissues alongwith
necrosis [266]. Few studies were published regarding toxicity of microparticles constructed for
nose to brain delivery. Ex vivo studies of microsphe res imbibed in gels in bovine nasal tissues
were conducted and signs of toxicity in bovine tissues were reported [267].
ACCEPTED MANUSCRIPT

5. Nasal Drug Delivery Devices for brain targeting


In addition to DDSs, another strategy for direct transport of drug from nose to brain is to deposit
the drug on olfactory epithelium or region of nose innervated by trigeminal nerves so that more
drug is transported to brain via olfactory /trigeminal pathway. For this purpose, many effective
and efficient novel nasal drug delivery devices were studied by the researchers and some were
patented. Among these devices, pressurized olfactory delivery devices, nebulizers, atomizers,

T
pressurized meter dose inhalers and Breathe Powered Bi-directional nasal devices gained access

IP
in the clinical settings. Nasal drug delivery devices were categorized into three classes, liquid,
powder and semisolid formulations containing devices for brain targeted devices.

CR
5.1 Powder devices
Powder based formulations are more suitable for IN drug delivery. Powder particles are not

US
easily dissolved in the nasal mucosa and remained in contact with mucosa for long period of
time. Powder dosage forms are free from preservatives, enab le large doses of drug
AN
administration, prevent microbial contamination and improve patient compliance, made them
potential candidates for nasal delivery. Powder formulations of macromolecular drugs such as
M

peptide and non peptide-based drugs have been designed and successfully investigated for nasal
delivery. Metered dose insufflators containing mucoadhesive powder polymers delivered
ED

polymers in nasal cavity. Polymers formed thick gel on contact with mucosa and decreased
mucociliary clearance.
PT

5.1.1 Insufflators/ Syringe with tube


Insufflator consists of straw or tube containing drugs and connected with syringe. This device
CE

directly delivers drugs to the olfactory region in the absence of pathological condition.
Rhinologist examines olfactory region located beyond the nasal valve before insufflations. Local
AC

anesthetics or decongestants are applied before insufflations facilitate delivery to olfactory


region. Devices fall in this category are described below.
5.1.1.1 Trimel/ Direct HalerTM
Direct Haler, Danish company, designed a device to deliver very fine particles into nasal cavity
with lungs exposure. This prefilled, pre- metered disposable device is unit or bidose system,
proved tolerability and acceptability in clinical studies. Trimel device has benefit of utilizing
patients own exhalation force for convenient delivery. One end of the tube is inserted in nasal
ACCEPTED MANUSCRIPT

vestibule and patient blows in the other end. Corrugations in the mid of the device provides
flexion and turbulence to spread the particles. Patient exhalation force expels the particles from
the tube to the nostril. Rhynal catheter elevates soft palate and the nasal cavity is isolated from
the rest of respiratory system, avoiding respiratory deposition. After successful delivery, nasal
and oral passages retain their normal functions. Many complications are associated with
commonly used liquid drops, sprays and inhaler such as chance of liquid dose to come out of
nose after delivery [268], swallowing of drug after delivery may lead to bitter taste and poor

T
mucosal penetration [269], necessity of preservatives in multidose containers results in

IP
unacceptability to patient and need of priming. Direct haler devices overcome these problems.

CR
Direct Haler device is free from contamination and ultimately preservatives. It is free from
priming and cleaning. Pressurized metered dose inhalers (pMDI) have poor patient acceptability

US
due to “cold-blow” and “hard-blow” of medication from inhaler but trimol utilized patient own
exhalation force at normal temperature and preferred over pMDI. The current focus of Direct
AN
Haler is nose to brain delivery, demands drug targeting beyond the nasal valve. Smaller particles
below 5µ are required for olfactory deposition. Reduction of particle size increases chance of
M

drug deposition to lungs. Scientists are now working to find a new delivery method for
successful olfactory delivery without lungs exposure. Bi-dose device deliver two doses, one in
ED

each nostril. Direct Haler Nasal devices can be “clicked” together to constitute such a compact
bi-dose. In addition, firm has designed special caps to keep contents with different sensitivity to
PT

humidity and temperature. These devices are cost effective and easy to manufacture.
Manufacturing process resembles drug capsule design. Device comprises of tube and cap. Tube
CE

is manufactured using extrusion and roll forming technique, whereas cap is designed by injection
molding. Powdered drug is filled in tube with high speed capsule filling machine. Simplicity and
AC

straightforward manufacturing process make this device attractive for future delivery of
combination therapy.
5.1.1.2 Breathe Powered Bi-Directional TM Technology.
Bi-Directional Breath Powered drug delivery technology exploits the normal breath process of
the body to deposit the drug on nasal epithelium [270]. This Bi-Directional™ technology could
be utilized to any type of dispersion technologies related to liquid and powder. When delivery of
drug is required, a user exhaled into the mouthpiece of device, soft palate is elevated and the
nasal cavity is isolated from the rest of respiratory system. The patient exhaled force emitted the
ACCEPTED MANUSCRIPT

medication from device into nostril while closure of the soft palate prevented the entry of drug to
the lungs. Expended nasal passage delivered medication deep into the targeted area of the nasal
cavity. When medicine is delivered to the targeted sites, air following “Bi- Directional™ flow
path” flowed around to the opposite side of the nasal cavity and exit through the other side of the
nose rather than into the throat or lungs, as depicted in fig-7 [271, 272]. Nasal valve is a narrow
opening in the nasal cavity, created a barrier for delivery of drug to brain. Neural connection to
brain is located posterior to this valve. Traditional nasal devices deliver drug in or anterior to this

T
valve. Optinose is a biopharmaceutical company, patented closed-palate Bi-Directional™ Breath

IP
Powered® DDSs. This technology used exhale device to target the dr ug to upper posterior part

CR
of the nasal cavity, beyond this valve [272]. Role of oxytocin has already been explored in the
treatment of autism spectrum. Higher doses of oxytocin are required for IN spray delivery, led to

US
adverse effects. Bidirectional technology is highly effective for IN delivery of powder form of
oxytocin in small doses. In this regard, a randomized four-way crossover trial was conducted by
AN
Quintana et al. to study the dose dependent effect of oxytocin on social cognition using Breath
Powered Optinose device (OPN). Oxytocin (OT) was delivered with an Optinose exhaler device
M

to healthy volunteers and direct nose to brain transport activity of OT was studied. Although,
similar plasma concentration was achieved with IV administered and OPN delivered OT but
ED

specific social-cognitive response was observed with OPN delivered OT, indicated OPN directly
transported drug across nasal mucosa to brain utilizing neural connection. Moreover, a lower
PT

dose of OPN-OT was more efficacious than higher dose of OPN-OT in producing cognitive
response, as previously reported [273]. Research Council of Norway has granted USD $1.8
CE

million to OptiNose AS, Norwegian affiliate of OptiNose Inc., to study IN efficacy of Orexin-A
in the treatment of narcolepsy using OptiNose Bi-Directional Breath Powered delivery
AC

technology [274]. Optinose devices are highly versatile in delivering wide range of therape utics
(from small molecules to vaccines) to brain. Single device could be used for multiple dosing.
ACCEPTED MANUSCRIPT

T
IP
CR
US
AN
Fig.7: Cross sectional view of human nose with normal dimension during soft palate elevation
and bidirectional flow of the air with Bi-Directional™ device. Reproduced from [270]
M

5.1.2 Dry powder inhaler


ED

Dry powder inhalers (DPI) enable powdered drug delivery via nasal route. They are single use
devices containing drug particles suspended or dissolved in propellant or drug is dissolved when
PT

come in contact with nasal mucosa. Very small doses in milligram are delivered to avoid cough
associated with large size particles. Unit and multi-dose powder inhalers ensure accurate dosing
CE

of drug. Mono-dose inhaler resembles single unit syringe. DPIs are used in asthmatic, bronchitis,
COPD patients and also effective in the therapy of diabetes mellitus. Patients hold mouthpie ce in
AC

the mouth after actuation. Patients inhale deeply and hold breath for 5-10seconds. Teijin Puvlizer
Rhinocort® is oldest dry powder inhaler and available in the world market. Rhinocort
Turbohaler®, Rhinicort Puvlizer ® and Erizas® are three nasal dry powder based inhalers
available for local treatment of rhinitis [275]. Rhinocort use capsule filled device and Erizas use
multidose device activated by the patient′s breath. Pulvizer works on the airflow generated by the
squeeze bottle or patient activated pump. It consists of capsule inserted stem and lower body is
soft plastic bulb. Body is pressed to generate air blow, forces the powder particles to expel from
capsule into nasal cavity through stem. Eight inhalations are required to empty the capsule [275].
ACCEPTED MANUSCRIPT

DPI should deliver constant amount of drug to the airstream that depends on total contents in
container and discharge during exhalation. DPIs are cheap and compatible with MDI. They have
commercial access to capsule filing equipments and availability o f novel technology to formulate
dry powder form of potent drugs. DPIs are not effective for high doses due to cohesive forces
between particles. Twin caps are DPI devices suitable for delivering high doses and chronic
dosing. It has simple design and automatically operating without medical supervision especially
in emergency conditions. It has two capsule shaped cavities filled with dose range from µg to

T
mg.

IP
5.1.3 Nasal powder sprayers

CR
Shin Nippon Biomedical Laboratories designed novel drug delivery technology, μco™ System,
based on mucoadhesive powder drug carrier. μco™ Carrier technology promotes drug absorption

US
and Fit Lizer is nasal device for dry powder formulation delivery. μco™ Carriers increase drug
absorption, decrease dose requirement and provide quick onset of action. It could be applied for
AN
local and systemic delivery, low molecular weight and high molecular weight drugs. It works
without absorption enhancers and proven safety in clinical trials. Powder carriers prolong contact
M

time with mucosa and enhance drug absorption [276]. Fit-lizer is patient operated device for
delivery of dry powder formulations. In multiple-use capsule device, single dose capsule is
ED

loaded at each use and alternative to multiple dose capsules of DPI for therapy of chronic
diseases. Capsule chamber is pulled to open and filled with capsule and chamber is closed. Pump
PT

is squeezed and air blown through capsule delivered the drug. Portable and light weight single
use device is effective technology for acute conditions. Tab is pinched and broken. Pump is
CE

squeezed to deliver prefilled drug to the nozzle and nasal cavity [277].
Bespak developed Unidose-DP™ resembling Flit Lizer technology. This device comprises
AC

sealed container capable of delivering single shot of drug. Unidose device has consistency
between doses. Among 95% of the dose delivered to the nasal passage, 60-70% reached to nasal
vestibular region limited use of this device for IN brain targeted delivery [278]. Upon actuation
compressed air in the container forced the pin to rupture the membrane and drug is released.
Antibody IgG has been delivered via Unidose device a nd guided through MRI imaging
technique.
SoluVent™- is powder based delivery device comprises a plunger that exerts pressure on
membrane and forces the powdered drug to come out of device into nasal cavity. Vaccines have
ACCEPTED MANUSCRIPT

been delivered through this device [279]. Monopowde device designed by the Aptar group
worked on the same mechanism of SoluVent™. When plunger is pushed, positive p ressure is
created that ruptured the membrane and drug is emitted. Animal studies using this device were
conducted but clinical studies on human are not available.
5.2 Liquid based Devices
Liquid formulations are widely used for nasal delivery. Liquid based devices mostly contain

T
liquid solution, suspension or emulsion formulations of drug. Nasal drops, sprays and metered

IP
dose nebulizer deliver drug solutions. Liquid formulations act as humectants and prevent dryness
of mucosa in pathological conditions. Liquid formulations are unstable due to microbial growth

CR
and chronic use requires preservatives. Preservatives may cause mucosal irritation and allergy.
Liquid formulations have drawbacks of less stability of drug dissolved in formulation and

US
mucociliary action easily washed them away from nasal mucosa. Construction of delivery
device, physiochemical properties of drug and administration mode decide about the site of drug
AN
deposition in nasal cavity and pattern of deposition.
5.2.1 Instillation and rhinyle catheter
M

Catheter delivers drugs to specific region of the nasal cavity. The simplest way of drug delivery
to nasal cavity is to insert catheter or squirt tube in nostril and deliver liquid in defined site under
ED

visual supervision. This technique is commonly used to anesthetize or sedate the animals.
Human mucosa is sensitive to mechanical injury and deposition site and inconsistency in dosing
PT

are major concerning issues. One side of the tube is inserted in the nostril and air is blown in the
other end through mouth to expel solution filled in the tube to the nostril [280]. Although this
CE

technique is valid only for experimental purposes but desmopressin rhinyle catheters are
available in some countries for treatment of diabetes inspidus, nocturnal enuresis and Von
AC

Willebrand disease.

5.2.2 Drops
Drops are being used from decades for nasal drug delivery of liquid formulations. They are cost
effective and have easy manufacturing process. Drops have risk of microbial contamination and
chemical instability. Mode of administration is important factor to decide fate of formulations in
nasal cavity. Previously, glass dropper with elongated neck was used to administer liquid drop
formations. Dropper filled with liquid is inserted in nostril and rubber top is pressed to release
ACCEPTED MANUSCRIPT

the drug in nostril. Dropper is feasible for single dose administration and metered-dose spray
pumps have taken their place for multidose administration. Spray pumps are expensive and
replaced by economical disposable pipette for some clinical conditions. Pipettes are
manufactured through “blow-fill-seal” methodology and commonly used for nasal decongestion
and irrigation purposes. Fluticasone nasal delivery based on spray pump is ineffective for
treatment of nasal polyps. Nasal drops formulations of fluticasone administered through pipette
had got place in European market. Nasal drop should deposit drug to the middle meat us, region

T
where polyps emerge [281]. Nasal drops delivered through pipette have uncontrollable volume

IP
of administration and risk of contamination. Head is downed during drops administration and

CR
large volume is rapidly cleared to the laryngopharynx [282]. Drops have limitations of
discomfort, unacceptable to the patient and cause headache.

US
5.2.3 Squeeze bottle
Importance of squeeze bottles is in local nasal drug delivery of topical decongestants. It consists
AN
of partly air filled plastic bottles with nozzle and jet outlet. On pressing the smooth bottle
specific volume is emitted through nozzle and delivered to the nasal cavity. On releasing the
M

pressure, air is filled again in the bottle. Squeeze bottle are not efficient in delivering drugs to the
deep region of the nasal cavity, hence not effective for systemic or brain targeted delivery. This
ED

device is not safe as delivery process contaminates the remaining volume with microorganisms
and nasal secretions [283]. Administration of calculated volume and deposition at particular site
PT

is difficult to control with this delivery device. Force applied to press the device decides about
the dose and droplet size.
CE

5.2.4 Metered-dose spray pumps and Pressurized MDIs


Mostly nasal products in the market deliver liquid formulations through metered-dose spray
AC

pumps. This system made easy delivery of doses with consistency and reproducibility. Spray
pumps usually used for local delivery of nasal decongesta nts, antihistamines and corticosteroids
or systemic administration of some drugs. Spray pump consists of container, actuator and pump
with valve. Operation of this system is based on generation of fine mist by the hand operated
pump and instillation into the nasal cavity. Design of spray device, viscosity, droplet size and
plume geometry influence the deposition [283]. Targeting of drugs to the nasal vestibule and
nasal valve region is specialty of conventional spray devices. However, only small volume is
delivered with metered-dose spray pump system and 2.5% of the administered volume reaches
ACCEPTED MANUSCRIPT

olfactory region, made them unsuitable for nose to brain targeting. Traditional spray pumps
replace emitted liquid with air lead to contaminations. Alteration in spray system design with the
help of novel technology negated preservative requirements and prevented contamination
associated with old spray pumps. Novel system comprises of collapsible bag, a movable piston,
or a compressed gas to replace emitted liquid. Preservative free system is alternative to above
piston pump and involve filtration of air that replaces emitted liquid through aseptic filter. This
system is costly and complex and now a day human friendly preservatives minimized the need of

T
preservative free system [284]. Recently spray pumps are modified with side actuation and

IP
shorter tip to avoid mucosal damage. Fluticasone furoate has been delivered with this novel

CR
system for seasonal rhinitis [280]. Modification in pump system negated the need for priming,
provided dose counter and lock-out mechanisms for controlled and safe delivery. Metered dose

US
spray pumps have disadvantage of priming and not control over dosing. They are used for
administration of wide therapeutic range drugs and not suitable for potent drugs. Single-dose or
AN
duo-dose spray devices are reliable alternative to them. They deliver single dose of costly drugs
with accurate dosing. These devices comprise of vial, piston and swirl chamber. Actuator is
M

pressed with thumb while holding device in second and third fingers. Liquid is passed through
chamber with pressure and spray is formed. Currently marketed products for migraine therapy
ED

are Imitrex and Zomig and FluMist is the marketed influenza vaccine [285]. The filling process
is sterilized, emitted the need of preservatives but overfill is required like metered-dose spray
PT

pump.
pMDIs are famous in nasal market for chronic respiratory disorders such as asthma, COPD and
CE

bronchitis. Micronized particles are suspended in liquid propellants and aerosol droplets are
produced upon actuation. Commonly used chlorofluorocarbon (CFC) propellants depleted the
AC

ozone layer and limited the potential of pMDI in the chronic respiratory disorders and were
withdrawn from market [286]. Now CFC free propellants such as hydrofluoroalkane 134a have
replaced CFC and saved therapeutic advantages of pMDIs. pMDIs deliver bronchodilator,
corticosteroid and cromoglicate or nedocromil as mast cell stabilizers. pMDIs provide aerosol
droplets with small size, accurate, consistent and calculated dose. pMDI comprises of plastic
case with mouth piece, cap for mouthpiece protection and pressurized metal canister containing
drug and propellants. Canister is pressed, upon actuation fine mist of measured dose of a drug is
passed though valve. Propellants are evaporated and fine particles are inhaled [287]. Propellants
ACCEPTED MANUSCRIPT

cause irritation in the nasal cavity and dryness of mucus membrane. Upon actuation pressurized
aerosol droplets strike the mucus layer from short distance with pressure and cause irritation.
This phenomenon is called ′cold Freon effect′. pMDIs deposit drug into anterior part of the nasal
cavity and not able to target upper posterior region beyond the nasal valve.
5.2.5 Pressurized olfactory device (POD)
The olfactory epithelium located between nose and brain accounts for only 3-10% of the surface

T
area of the nasal cavity in human. Its location in the upper part of the nose with turbinate

IP
restriction made consistent delivery of therapeutic molecules to this region challenging [288,
289]. POD has the ability to deposit a majority of drug at olfactory region. These devices contain

CR
suitable tank, compressed air or nitrogen, chlorofluorocarbon (CFC) or hydrofluoroalkane (HFA)
as propellant and air chamber as shown in fig-8. The air chamber is in connection with the device

US
via an internal compartment. Air chamber discharged an aerosol spray into the nasal cavity
through an applicator with an orifice. When patient took the dose, the pneumatic solenoid is
AN
activated and the compressed air is distributed through tubing to the air chamber and then from
chamber into the gas inlet of the housing. Pressurized gas is rotated inside the spin chamber with
M

circumferential helical velocity or vortex- like velocity [290]. When the solenoid is triggered, the
elongated needle is displaced from the orifice to allow the fluid within the fluid reservoir to
ED

escape. Pressurized gas passed through the orifice created partial vacuum to force the fluid out of
the reservoir through the orifice [290].
PT

POD device of the Impel NeuroPharma (Seattle, Washington) had the ability to target the drug
on the olfactory part of the nasal cavity. Hoekman and Ho, developed the POD and compared
CE

with nasal drops (to target respiratory region) and intraperitonea l injection (IP) to deliver
morphine to rat. Experimental results showed that POD delivered drug to brain via olfactory
AC

pathway and pain was relieved. No direct drug distribution to CNS was reported by IP injection
through systemic circulation and nasal drop through respiratory region. In addition to direct drug
delivery to brain, POD also resulted in systemic absorption of drug but not more than IP and
nasal drop [290]. POD technology is particularly exciting with molecules such as small peptides
and biologic agents, which are so rapidly destroyed in the blood and are ineffective if given
orally or intravenously. Interfering peptide disrupted the interaction between the D1 and D2
dopamine receptors for treating Major depressive disorder (MDD) and could be delivered to
relevant brain areas using the POD. Impel NeuroPharma IN POD delivered interfering peptide
ACCEPTED MANUSCRIPT

was studied for disruption of interaction between D1 and D2 receptors. It was reported that
interfering peptide showed antidepressant- like effect up to 2 h after IN administration of POD.
Strong antidepressant-like effect induced by Interfering peptide was comparable to that of
imipramine, as confirmed by forced swimming test (FST). It was also observed that interfering
peptide disrupted the D1–D2 interaction and were detected in the prefrontal cortex [291]. Nasal
drops are conventional DDSs for delivery to nasal epithelium. POD device was compared with
nasal drop for nose to brain access. POD device was constructed and investigated to deposit

T
mannitol and nelfinavir at olfactory epithelium for brain targeting. Compared to nasal drops,

IP
POD administered mannitol and nelfinavir olfactory depositio n with POD in rats had shown 3.6-

CR
fold and 13.6-fold higher cortex-to-blood ratio, respectively. It was concluded that deposition of
drug at olfactory region of nasal cavity by the POD resulted in higher drug distribution to brain

US
[292]. POD could be beneficial for transport of both liquid and powder formulations through
nasal epithelium. Impel NeuroPharma utilized POD to deliver aqueous and powder form of
AN
cholinergic reactivator (pralidoxime, 2-PAM) to CNS. POD delivered significantly higher
concentration of 2-PAM in brain and lower concentration in plasma than IV administration.
M

Moreover, powder form showed higher brain concentration than aqueous formulation. POD
deposited the formulations at olfactory epithelium and promoted direct transport to brain [293].
ED
PT
CE
AC
ACCEPTED MANUSCRIPT

T
IP
CR
US
AN
M

Fig.8: Pressurized Olfactory Device with its functional parts. Modified from [290].
ED

5.2.6 Nebulizers and Atomizers


PT

Nebulizers are intended to enable the drug depositition to the upper part of the nose, housing the
neural connection between nose and brain. Nebulizers break up liquid solution or suspension into
CE

small aerosol droplets with the help of compressed gas or ultrasonic power. Compared to
tradational spray pumps, droplets produced from nebulizer, upon nasal inhalation deposited to
AC

the upper posterior region of the nasal cavity, thus promoted nose to brain targetting [294, 295].
Chen et al. explored a novel, hands free nebulizer device for brain tumor targetted delivery.
Initial phase I/II clinical trial was conducted on 37 patients of recurrent glioblastoma. Effect of
perillyl alcohol (POH) delivered intranasally via nebulizer on recurrent glioblastoma was
studied. They used light weight, portable, patients operated and rechargable battery powered
device. This study had shown positive clinical effects and improved patient compliance up to
95% [296]. Further work reported that long- term IN POH chemotherapy was a safer and
effective approach for patients with recurrent glioblastoma. Kurve Technology Inc.,
ACCEPTED MANUSCRIPT

(Lynnwood, WA, USA) introduced ViaNase, a pocket-sized advanced electronic atomizer


incorporated Controlled Particle Dispersion Technology. This technology has the ability to
deliver wide variety of solutions and suspensions with varying surface tension and viscosity.
ViaNase targeted the upper part of nose and sinus and thus its potential could be utilized for
nose to brain drug delivery [297, 298]. IN insulin was administered by ViaNase V atomizer
for treatment of Alzheimer′s disease and po sitive outcomes were reported [299]. Reduction in
pulmonary function was concerning issue, limited the benefits of this technology [300]. Wolfe

T
Tory Medical designed "MAD Nasal™ IN Mucosal Atomization Device". They utilized this

IP
novel atomizer to intranasally deliver neuroprotective agents during cryonics to prevent ischemic

CR
damage to brain. IN Atomization Device delivery was an alternative to intravenous or
intraosseous delivery [301]. Recently, vibrating mesh and jet nebulizers have gained attention to

US
test the olfactory deposition of aerosol medicines. A study was conducted to examine the
olfactory delivery via vibrating mesh and jet nebulizers in a nasal model. Normal and
AN
bidirectional delivery concept and Sar Gel technique to visualize particle deposition was applied.
Mesh nebulizer using bidirectional technique, significantly, enhanced deposition in olfactory
M

region than PARI Sinus nebulizer. Higher speed aerosols generated from PARI Sinus nebulizer
penetrated deeper into dorsal passage. Bidirectional delivery was superior in depositing aerosol
ED

into nasal cavity and olfactory region than normal delivery. It was concluded that mesh-typed
nebulizer with bidirectional concept was better choice for olfactory targeting [302]. In another
PT

study, protein aerosol for IN delivery to brain was investigated using vibrating mesh nebulizer.
Diffusion of different molecular weight sized protein, concentrations and formulations across
CE

human nasal epithelial cells model was studied. Diffusion of FAB was significantly higher than
that of IgG A. Higher concentration of IgG showed more diffusion than lower concentration.
AC

Mesh nebulizer improved the stability of proteins and increased deposition across nose model.
This system was suitable for nose to brain delivery of protein aerosol [303].
ACCEPTED MANUSCRIPT

Table 6: FDA approved products based on nasal drug delivery device.


Name of Pharmaceutical Type of Active Ingredients Disease
product Firm delivery device

Merck's Mometasone furoate Nasal


Apotex Inc. Nasal spray
Nasonex® monohydrate congestion

Multidose Nasal Allergic


Nemera Corticosteroid

T
Advancia® spray pump rhinitis

IP
Naloxone Opoid
Adapt Pharma nasal spray
hydrochloride overdose

CR
Narcan®

Breath Powered Sumatriptan nasal

US
Optinose Inc. Migraine
Onzetra™ Delivery Device powder
Xsail™
AN
Meda Seasonal
Nasal spray Azelastine
Pharmaceuticals allergic rhinitis
Dymista® hydrochloride/
Inc.
M

fluticasone propionate
Meda Seasonal
ED

Pharmaceuticals Nasal spray Azelastine


Astelin® allergic rhinitis
Inc. hydrochloride
AstraZeneca Nasal spray Acute migraine
PT

Zomig® Zolmitriptan
Pharamaceuticals
McNeil Nasal
Nasal spray
CE

Rhinocort® Consumer Budesonide congestion


Healthcare
Triamcinolone Allergic
Metered spray
AC

Triamist® Cipla Medpro rhinitis


acetonide.

5.3 Patents on Nasal Drug Delivery Devices.


Many patent applications on IN administration for CNS drug delivery have been filed and
granted in the past 10 years. A patent was awarded to Impel Neuropharma Inc., with title of
"Nasal drug delivery device" for nose to brain delivery of drug [127]. Similarly, US patent [304]
and Chinese patent [305] have also been awarded for same invention. World Intellectual
Property Organization (WIPO) published a patent of Tongli Biomedical titled "Brain-Targeted
ACCEPTED MANUSCRIPT

Nasal Drug Delivery Device and Body Position Fixator Thereof". Chinese inventors applied a
specially designed body position fixator to keep the body position of a user in such a position so
that nasally delivered drug could reach to olfactory region. Fixator kept the user in the above-
mentioned body position and drug is delivered to target the brain by an applicator having a shape
matching the nasal cavity of user. With the help of fixator and smart controlling element, an
applicator delivered drug is targeted to olfactory region of nasal cavity at required time for direct
nose to brain targeting [306].

T
IP
6. Conclusion
In summary, an analysis of the available literatures has revealed that brain targeting via nasal

CR
drug delivery is an attractive approach. Surface modifications of nanocarriers and the
introduction of specific ligands provided useful information and progress in this field. Surface

US
modifications of carriers with CPP (NPs, micelles and liposomes) opened a new era of drug
delivery systems especially peptides and protein based therapeutic agents to brain. Most research
AN
publications focused on prevention and management of neurological disorders but intranasally
administered TAT modified micelles and chitosan NPs have shown potential for targeting
M

different types of brain tumors hence, more efforts are required to explore brain tumor targeted
novel IN DDSs. Nasal drug delivery systems also have some limitations such as small quantities
ED

of drugs could be administered with increasing drug molecular weight [3].The partial
degradation of some molecules in nasal cavity and nasal mucosa toxicity was also a drawback of
PT

this route. Nasal drug delivery devices could overcome these problems related with DDSs, in
near future, more complex and automatic operating delivery devices for chronic dosing and
CE

treatment of brain tumors would be demanded. Available delivery devices deposited drug at
respiratory epithelium alongwith deep part of the nasal cavity, leading to the systemic
AC

absorption. Novel drug delivery devices are under development to overcome barriers related to
complex geometry of the nasal cavity and strictly deposit drug only at olfactory region without
systemic exposure. Clinical and preclinical trials of nasal DDSs and devices should be conducted
to ensure specificity for brain tissues using novel targeting moieties. Thus, to further explore
potential of novel IN DDSs and devices for an efficient and effective delivery of potential drugs
to brain more efforts are required. Recently, many drugs have been successfully delivered to
brain via nasal administration and products based on novel nasal nanoformulations for brain
ACCEPTED MANUSCRIPT

targeting will be available in market. This route is predicted to be utilized not only for
therapeutic but also diagnostic purposes [307].
Acknowledgements
This work was supported by the China-Australia Centre for Health Sciences Research (CACHSR
no. 2016GJ01).

Reference

T
[1] BrainFacts.org, The Blood Brain Barrier. http://www.brainfacts.org/brain

IP
basics/neuroanatomy/articles/2014/blood-brain-barrier.

CR
[2] W.M. Pardridge, The Blood-Brain Barrier: Bottleneck in Brain Drug Development,
NeuroRX, 2 (2005) 3–14.

[3] A. Mistry, S. Stolnik, L. Illum, Nanoparticles for direct nose-to-brain delivery of drugs, Int

US
J Pharm, 379 (2009) 146-157.
[4] L. Illum, Transport of drug from nasal cavity to the central nervous system, Eur J Pharm Sci,
11 (2000) 1-18.
AN
[5] M.V. Woensel, N. Wauthoz, R. Rosiere, K. Amighi, V. Mathieu, F. Lefranc, S.W. Gool,
S.D. Valeeschouwer, Formulation for intranasal delivery of pharmacological agents to
combat brain disease: A new opportunity to tackle GBM? Cancers, 5 (2013) 1020-48.
M

[6] S.I. Rapoport, P.J. Robinson, Tight-junctional modification as the basis of osmotic opening
of the blood-brain barrier, Ann N Y Acad Sci, 481(1986) 250–267.
ED

[7] S. Joshi, A. Ergin, M. Wang, R R. Reif, J. Zhang, J.N. Bruce, I.J. Bigio, Inconsistent blood
brain barrier disruption by intraarterial mannitol in rabbits: implications for chemotherapy, J
Neurooncol, 104 (2011)11–19.
[8] A. Rodriguez , S.B. Tatter , W. Debinski, Neurosurgical Techniques for Disruption of the
PT

Blood-Brain Barrier for Glioblastoma Treatment, Pharmaceutics, 7(2015) 175–187.


[9] E.A. Neuwelt, P.A. Barnett, C.I. McCormick, L.G. Remsen, R.A. Kroll, G. Sexton,
Differential permeability of a human brain tumor xenograft in the nude rat: impact of tumor
CE

size and method of administration on optimizing delivery of biologically diverse agents,


Clin Cancer Res Off J Am Assoc Cancer Res, 4(1998) 1549–1555.
[10] A. Gregor, M. Lind, H. Newman, C. Osborn, Phase II studies of RMP-7 and carboplatin in
AC

the treatment of recurrent high grade glioma. RMP-7 European Study Group, J Neurooncol,
44(1999) 137–145.
[11] M.D. Prados, S.J.S. Schold, H.A. Fine, K. Jaeckle, F. Hochberg, L. Mechtler, M.R.
Fetell, S. Phuphanich, L. Feun, T.J. Janus, K. Ford, W. Graney, A randomized, double-
blind, placebo controlled, phase 2 study of RMP-7 in combination with carboplatin
administered intravenously for the treatment of recurrent malignant glioma, Neuro-Onco,
5(2003) 96–103.
[12] A. I. Qureshi, M. Fareed, K. Suri, J. Khan, M. Sharma, K. Olson, L. R. Guterman,
L. N. Hopkins, Superselective intra-arterial carboplatin for treatment of intracranial
neoplasms: experience in 100 procedures, J Neuro oncol, 51(2001) 151–158.
[13] L.B. Liu, Y.X. Xue, Y.H. Liu, Bradykinin increases the permeability of the blood-tumor
barrier by the caveolae-mediated transcellular pathway, J Neuro oncol, 99 (2010) 187-194.
ACCEPTED MANUSCRIPT

[14] H. Zhang, Y.T. Gu, Y.X. Xue, Bradykinin- induced blood-brain tumor barrier permeability
increase is mediated by adenosine 5'-triphosphate-sensitive potassium channel, Brain Res,
1144 (2007) 33-41.
[15] K. Matsukado, T. Inamura, S. Nakano, M. Fukui, R.T. Bartus, K.L. Black, Enhanced tumor
uptake of carboplatin and survival in glioma-bearing rats by intracarotid infusion of
bradykinin analog, RMP-7, Neurosurgery, 39(1996) 125-134.
[16] C.V. Borlongan, D.F. Emerich, Facilitation of drug entry into the CNS via transient
permeation of blood brain barrier: laboratory and preliminary clinical evidence from
Bradykinin receptor agonist, Cereport, Brain Res Bull, 60 (2003) 297-306.
[17] E. Sanovich, R.T. Bartus, P.M. Friden, R.L. Dean, H.Q. Le, M.W. Brightman, Pathway

T
across bloodbrain barrier opened by the bradykinin agonist, RMP-7, Brain Res, 705

IP
(1995) 125-135.
[18] M.D. Prados, S.J.S. Schold, H.A. Fine, K. Jaeckle, F. Hochberg, L. Mechtler, M.R. Fetell,

CR
S. Phuphanich, L. Feun, T.J. Janus, K. Ford, W. Graney, A randomized, double-blind,
placebo-controlled, phase 2 study of RMP-7 in combination with carboplatin administered
intravenously for the treatment of recurrent malignant glioma, Neuro Oncol, 5 (2003) 96-
103.

US
[19] Y.C. Kuo, C.L. Lee, Methylmethacrylate-sulfopropylmethacrylate nanoparticles with
surface RMP-7 for targeting delivery of antiretroviral drugs across the blood-brain barrier,
Colloids Surf B Biointerfaces, 90 (2012) 75-82.
AN
[20] N.G. Rainov, K. Ikeda, N.H. Qureshi, S. Grover, U. Herrlinger, P. Pechan, E.A. Chiocca,
X.O. Breakefield, F.H. Barnett, Intraarterial delivery of adenovirus vectors and liposome-
DNA complexes to experimental brain neoplasms, Hum Gene Ther, 10 (1999) 311-318.
M

[21] N. Das, B. Raay, M.K. Basu, Effect of angiotensin II on liposome uptake by the rat brain in
vivo, Indian J Exp Biol, 37 (1999) 871-875.
ED

[22] E.J. Park, Y.Z. Zhang, N. Vykhodtseva, N. McDannold, Ultrasound-mediated blood-


brain/blood-tumor barrier disruption improves outcomes with trastuzumab in a breast
cancer brain metastasis model, J Control Release,163 (2012) 277– 284.
PT

[23] C.Horodyckid,M.Canney, A.Vignot, R. Boisgard, A. Drier, G. Huberfeld, C. François, A.


Prigent, M. D. Santin, C. Adam, J.C. Willer, C. Lafon, J.Y. Chapelon, A. Carpentier, Safe
CE

long-term repeated disruption of the blood-brain barrier using an implantable ultrasound


device : a multiparametric study in primates, J Neurosurg, (2015).
[24] K. Hynynen, N. McDannold, N.A. Sheikov, F.A. Jolesz, N. Vykhodtseva, Local and
AC

reversible blood-brain barrier disruption by noninvasive focused ultrasound at frequencies


suitable for trans-skull sonications, Neuro Image, 24(2005) 12–20.
[25] M.A. O'Reilly, Y. Huang, K. Hynynen, The impact of standing wave effects on transcranial
focused ultrasound disruption of the blood-brain barrier in a rat model, Phys Med Biol, 55
(2010) 5251-5267.
[26] M. Aryal, C.D. Arvanitis, P.M. Alexander, N. McDannold, Ultrasound-mediated blood-
brain barrier disruption for targeted drug delivery in the central nervous system, Adv Drug
Deliv Rev, 0 (2014) 94-109.
[27] T.D. Azad, J. Pan, I.D. Connolly, A. Remington, C.M. Wilson, G.A. Grant, Therapeutic
strategies to improve drug delivery across the blood-brain barrier, Neurosurgical focus, 38
(2015) E9.
ACCEPTED MANUSCRIPT

[28] K.C. Wei, P.C. Chu, H.Y. Wang, C.Y. Huang, P.Y. Chen, H.C. Tsai, Y.J. Lu, P.Y. Lee, I.C.
Tseng, L.Y. Feng, P.W. Hsu, T.C. Yen, H.L. Liu, Focused ultrasound- induced blood-brain
barrier opening to enhance temozolomide delivery for glioblastoma treatment: a preclinical
study, PLoS One, 8 (2013) e58995.
[29] J. Mei, Y. Cheng, Y. Song, Y. Yang, F. Wang, Y. Liu, Z. Wang, Experimental study on
targeted methotrexate delivery to the rabbit brain via magnetic resonance imaging- guided
focused ultrasound, J Ultrasound Med, 28 (2009) 871-880.
[30] A. Burgess, Y. Huang, W. Querbes, D.W. Sah, K. Hynynen, Focused ultrasound for
targeted delivery of siRNA and efficient knockdown of Htt expression, J Control Release,
163 (2012) 125-129.

T
[31] R. Alkins, A. Burgess, M. Ganguly, G. Francia, R. Kerbel, W.S. Wels, K. Hynynen,

IP
Focused ultrasound delivers targeted immune cells to metastatic brain tumors, Cancer Res,
73 (2013) 1892-1899.

CR
[32] E. Nance, K. Timbie, G.W. Miller, J. Song, C. Louttit, A.L. Klibanov, T.Y. Shih, G.
Swaminathan, R.J. Tamargo, G.F. Woodworth, J. Hanes, R.J. Price, Non- invasive delivery
of stealth, brain-enetrating nanoparticles across the blood-brain barrier using MRI- guided
focused ultrasound, J Control Release, 189 (2014) 123-132.

US
[33] M. Aryal, N. Vykhodtseva, Y.Z. Zhang, J. Park, N. McDannold, Multiple treatments with
liposomal doxorubicin and ultrasound- induced disruption of blood-tumor and blood-brain
AN
barriers improve outcomes in a rat glioma model, J Control Release, 169 (2013) 103–111.
[34] R.J. Diaz, P.Z. McVeigh, M.A. O’Reilly, K. Burrell, M. Bebenek, C. Smith, A. Etame, G.
Zadeh, K. Hynynen, B.C. Wilson, J.T. Rutka, Focused ultrasound delivery of Raman
M

nanoparticles across the blood brain barrier: Potential for targeting experimental brain
tumors, Nanomedicine, 10 (2014) 1075-1087.
[35] R. Price, Ultrasound-targeted nanoparticle delivery across the blood-brain barrier, J Ther
ED

Ultrasound, 3 (2015) O20.


[36] W.J. Fry, W.H. Mosberg, Jr., J.W. Barnard, F.J. Fry, Production of focal destructive lesions
in the central nervous system with ultrasound, J Neurosurg, 11 (1954) 471-478.
PT

[37] A. Chapman, G. ter Haar, Thermal ablation of uterine fibroids using MR-guided focused
ultrasound-a truly non-invasive treatment modality, Eur Radiol, 17 (2007) 2505-2511.
[38] R. Catane, A. Beck, Y. Inbar, T. Rabin, N. Shabshin, S. Hengst, R.M. Pfeffer, A. Hanannel,
CE

O. Dogadkin, B. Liberman, D. Kopelman, MR-guided focused ultrasound surgery


(MRgFUS) for the palliation of pain in patients with bone metastases--preliminary clinical
experience, Ann Oncol, 18 (2007) 163-167.
AC

[39] D.J. Begley, L.K. Squires, B.V. Zlokovic, D.M. Mitrovic, C.C.W. Hughes, P.A. Revest, J.
Greenwood, J Neurochem, 55 (1998) 1222- 1230.
[40] U. Jaehde, M.W.E. Langemeije, A.G. de Boer, D.D. Breimer, Cerebrospinal fluid transport
and disposition of the quinolones ciprofloxacin and pefloxacin in rats, J Pharmacol Exp
Ther, 263 (1992)1140-1146.
[41] D.R. Groothuis, H. Benalcazar, C.V. Allen, R.M. Wise, C. Dills, C. Dobrescu, V.
Rothholtz, R.M. Levy, Comparison of cytosine arabinoside delivery to rat brain by i.v,
intrathecal, intraventricular and intraparenchymal routes of administration, Brain Res, 856
(2000) 281-290.
ACCEPTED MANUSCRIPT

[42] J.A. MacKay, D.F. Deen, F.C. Szoka, Distribution in brain liposomes after convection
enhanced delivery; modulation by particle charge, particle diameter and presence of steric
coating, Brain Res, 1035 (2005) 129-135.
[43] M.J. Mahoney, W.M. Saltman, Controlled release of proteins to tissue transplants for
treatments of neurodegenerative disorders, J Pharm Sci, 85 (1996)1276-1281.
[44] C. Nicholson, E. Sykova, Extracellular space structure revealed by diffusion analysis,
Trends Neuro sci, 21 (1998) 207-215.
[45] O. Lewis, M. Woolley, D. Johnson, A. Rosser, N.U. Barua, A.S. Bienemann, S.S. Gill, S.
Evans, Chronic, intermittent convection-enhanced delivery devices, J Neurosci Methods,
259 (2016) 47-56.

T
[46] M.A. Vogelbaum, M.K. Aghi, Convection-enhanced delivery for the treatment of

IP
glioblastoma, Neuro Oncol, 17 (2015) ii3-ii8.
[47] M.F. Lam, M.G. Thomas, C.R. Lind, Neurosurgical convection-enhanced delivery of

CR
treatments for Parkinson's disease, J Clin Neurosci, 18 (2011) 1163-1167.
[48] M.M. Nordling-David , R. Yaffe, D. Guez, H. Meirow, D. Last, E. Grad, S. Salomon, S.
Sharabi, Y. Levi-Kalisman, G. Golomb, Y. Mardo, Liposomal temozolomide drug
delivery using convection enhanced delivery, J Control Release, 10 ( 2017) 261:138-14

US
[49] M.S. Fiandaca, J.R. Forsayeth, P.J. Forsayeth, K.S. Bankiewicz, Image-Guided
Convection-Enhanced Delivery Platform in the Treatment of Neurological Diseases,
Neurotherapeutics, 5(2008) 123-127.
AN
[50] J.K. Saucier-Sawyer, Y.E. Seo, A. Gaudin, E. Quijano, E. Song , A.J. Sawyer, Y.
Deng, A. Huttner , W.M. Saltzman, Distribution of polymer nanoparticles by convection-
enhanced delivery to brain tumors, J Control Release, 23 (2016)103-112.
M

[51] H. Brem, M.S. Mahaley Jr, N.A. Vick, K.L. Black, S.C. Schold Jr, P.C. Burger, A.H.
Friedman, I.S. Ciric, T.W. Eller, J.W. Cozzens, Interstitial chemotherapy with drug
ED

polymer implants for the treatment of recurrent gliomas, J Neurosurg, 74 (1991) 441-446.
[52] G.L. Gallia, S. Brem, H. Brem, Local treatment of malignant brain tumors using
implantable chemotherapeutic polymers, J Natl Compr Canc Netw, 3 (2005) 721–728.
PT

[53] P.P. Wang, J. Frazier, H. Brem, Local drug delivery to the brain, Adv Drug Deliv Rev, 54
(2002) 987–1013.
[54] R. Renato V. La, M.H. Maximilian, Localized BCNU chemotherapy and the multimodal
CE

management of malignant glioma, Curr Med Res Opin, 25 (2009) 149–160.


[55] K. Kawano, M. Watanabe, T.Yamamoto, M. Yokoyama, P. Opanasopit, T. Okano, Y.
Maitani, Enhanced antitumor effect of camptothecin loaded in long-circulating polymeric
AC

micelles, J Control Release, 112 (2006) 329–332.


[56] M. Staples, Microchips and controlled-release drug reservoirs, WIREs Nanomed
Nanobiotech, 2 (2010) 400–17.
[57] G.Y. Kim, B.M. Tyler, M.M. Tupper, J.M. Karp, R.S. Langer, H. Brem, M.J. Cima,
Resorbable polymer microchips releasing BCNU inhibit tumor growth in the rat 9L flank
model, J Control Release, 123 (2007) 172-178.
[58] B.C. Masi, B.M. Tyler, H. Bow, R.T. Wicks, Y. Xue, H. Brem, R. Langer, M.J. Cima,
Intracranial MEMS based temozolomide delivery in a 9L rat gliosarcoma model,
Biomaterials, 33 (2012) 5768-5775.
[59] G.Y. Kim, M.J. Chima, M.M. Tupper, J.M. Karp, R.S. Langer, H. Brem, M.
Cima, Resorbable polymer microchips releasing BCNU inhibit tumor growth in the rat 9L
flank model, J Control Release, 123 (2007) 172–178.
ACCEPTED MANUSCRIPT

[60] A.G. De Boer, P.J. Gaillard, Drug targeting to the brain, Annu Rev Pharmacol Toxicol, 47
(2007) 323–55.
[61] M. Minocha, V. Khurana, B. Qin, D. Pal, A.K. Mitra, Enhanced brain accumulation of
pazopanib by modulating P-gp and Bcrp1 mediated efflux with canertinib or erlotinib, Int
J Pharm,436 (2012) 127–34.
[62] R. Callaghan, F. Luk, M. Bebawy, Inhibition of the Multidrug Resistance P-Glycoprotein:
Time for a Change of Strategy?, Drug Metab Dispos, 42 (2014) 623-631.
[63] P. Breedveld, J.H. Beijnen, J.H. Schellens, Use of P-glycoprotein and BCRP inhibitors to
improve oral bioavailability and CNS penetration of anticancer drugs, Trends Pharmacol
Sci, 27 (2006) 17-24.

T
[64] X.R. Song, Z. Cai, Y. Zheng, G. He, F.Y. Cui, D.Q. Gong, S.X. Hou, S.J. Xiong, X.J. Lei,

IP
Y.Q. Wei, Reversion of multidrug resistance by co-encapsulation of vincristine and
verapamil in PLGA nanoparticles, Eur J Pharm Sci, 37 (2009) 300-305.

CR
[65] Y. Patil, T. Sadhukha, L. Ma, J. Panyam, Nanoparticle- mediated simultaneous and
targeted delivery of paclitaxel and tariquidar overcomes tumor drug resistance, J Control
Release, 136 (2009) 21-29.
[66] N.R. Patel, A. Rathi, D. Mongayt, V.P. Torchilin, Reversal of multidrug resistance by co-

US
delivery of tariquidar (XR9576) and paclitaxel using long-circulating liposomes, Int J
Pharm, 416 (2011) 296-299.
[67] C. Sarisozen, I. Vural, T. Levchenko, A.A. Hincal, V.P. Torchilin, Long-circulating PEG-
AN
PE micelles coloaded with paclitaxel and elacridar (GG918) overcome multidrug
resistance, Drug Delivery, 19 (2012) 363-370.
[68] S. Shukla, S. Ohnuma, S.V. Ambudkar, Improving cancer chemotherapy with modulators
M

of ABC drug transporters, Curr Drug Targets, 12 (2011) 621-630.


[69] B. Pavan, A. Dalpiaz, Prodrugs and endogenous transporters: are they suitable tools for
ED

drug targeting into the central nervous system? Curr Pharm Des, 17 (2011) 3560–76.

[70] R.K. Singh. D.N. Prasad, T.R.Bhardwaj, Design, synthesis, chemical and biological
evaluation of brain targeted alkylating agent using reversible redox prodrug approach,
PT

Arab J Chem, 10 (2017) 420-429.

[71] P. Chen, N. Bodor, W.M. Wu, L. Prokai, Strategies to target kyotorphin analogues to the
CE

brain, Journal of medicinal chemistry, 41 (1998) 3773-3781.

[72] M. Gynther, K. Laine, J. Ropponen, J. Leppänen, A. Mannila, T. Nevalainen, J.


AC

Savolainen, T. Järvinen, J. Rautio, Large Neutral Amino Acid Transporter Enables Brain
Drug Delivery via Prodrugs, J Med Chem, 51 (2008) 932-6.
[73] M. Mavroudi, P. Zarogoulidis, K. Porpodis, I. Kioumis, S. Lampaki, L. Yarmus, R.
Malecki, K. Zarogoulidis, M. Malecki, Stem cells' guided gene therapy of cancer: New
frontier in personalized and targeted therapy, J Cancer Res Ther (Manch), 2 (2014) 22-33.
[74] B. Engelhardt, R.M. Ransohoff, Capture, Crawl, Cross: The T Cell Code To Breach the
BloodBrain Barriers, Trends Immunol, 33 (2012) 579–589.
[75] N.S. Ivey, A.G. Maclean, A.A. Lackner, Acquired Immunodeficiency Syndro me and the
BloodBrain Barrier, J NeuroVirol, 15 (2009) 111–122.
[76] S.K. Baek, A.R. Makkouk, T. Krasieva, C.H. Sun, S.J. Madsen, H. Hirschberg,
Photothermal treatment of glioma; an in vitro study of macrophage- mediated delivery of
gold nanoshells, J Neurooncol, 104 (2011) 439-448.
ACCEPTED MANUSCRIPT

[77] K.B. Johnsen, J.M. Gudbergsson, M.N. Skov, L. Pilgaard, T. Moos, M.A. Duroux,
Comprehensive Overview of Exosomes as Drug Delivery Vehicles Endogenous
Nanocarriers for Targeted Cancer Therapy, Biochim Biophys Acta Rev Cancer, 1846
(2014) 75–87.
[78] N.D. Mazarakis, M. Azzouz, J.B. Rohll, F.M. Ellard, F.J. Wilkes, A.L. Olsen, E.E. Carter,
R.D. Barber, D.F. Baban, S.M. Kingsman, A.J. Kingsman, K. O'Malley, K.A.
Mitrophanous, Rabies Virus Glycoprotein Pseudotyping of Lentiviral Vectors Enables
Retrograde Axonal Transport and Access to the Nervous System after Peripheral
Delivery, Hum Mol Genet, 10 (2001) 2109–2121.
[79] J.K. Liu, Q. Teng, M. Garrity-Moses, T. Federici, D. Tanase, M.J. Imperiale, N.M.

T
Boulis, A Novel Peptide Defined through Phage Display for Therapeutic Protein and

IP
Vector Neuronal Targeting, Neurobiol Dis, 19 (2005) 407–418.
[80] M.E. Hegi, P. Rajakannu, M. Weller, Epidermal Growth Factor Receptor: A Re-emerging

CR
Target in Glioblastoma, Curr Opin Neurol, 25 (2012) 774–779.
[81] X. Hong, C. Miller, S. Savant-Bhonsale, S.N. Kalkanis, Antitumor treatment using
interleukin- 12- secreting marrow stromal cells in an invasive glioma model,
Neurosurgery, 64 (2009) 1139-1146;discussion 1146-1137.

US
[82] K. Shah, Mesenchymal Stem Cells engineered for Cancer Therapy, Adv Drug Deliv Rev,
64 (2012) 739-748.
[83] J. Kranzler, M.A. Tyler, A.M. Sonabend, I.V. Ulasov, M.S. Lesniak, Stem cells as
AN
delivery vehicles for oncolytic adenoviral virotherapy, Curr Gene Ther, 9 (2009) 389-395.
[84] M. Duebgen, J. Martinez-Quintanilla, K. Tamura, S. Hingtgen, N. Redjal, H. Wakimoto,
K. Shah, Stem cells loaded with multimechanistic oncolytic herpes simplex virus variants
M

for brain tumor therapy, J Natl Cancer Inst, 106 (2014) dju090.
[85] A. Béduneau, P. Saulnier, J.P. Benoit, Active targeting of brain tumors using nanocarriers.
ED

Biomaterials. 28 (2007) 4947–67.


[86] H.Y. Yoon, S. Son, S.J. Lee, D.G. You, J.Y. Yhee, J.H. Park, M. Swierczewska, S. Lee,
I.C. Kwon, S.H. Kim, K. Kim, M.G. Pomper, Glycol chitosan nanoparticles as specialized
cancer therapeutic vehicles: sequential delivery of doxorubicin and Bcl-2 siRNA, Sci Rep,
PT

4 (2014) 6878.
[87] J. Bruun, T.B. Larsen, R.I. Jølck, R. Eliasen, R. Holm, T. Gjetting, T.L. Andresen,
Investigation of enzyme-sensitive lipid nanoparticles for delivery of siRNA to blood-brain
CE

barrier and glioma cells, Int J Nanomedicine, 10 (2015) 5995-6008.


[88] S. Martins, I. Tho, I. Reimold , E. Souto, D. Ferreira, M. Brandl, Brain delivery of
camptothecin by means of solid lipid nanoparticles: formulation design, in vitro and in
AC

vivo studies, Int J Pharm, 439 (2012) 49–62.


[89] M. Zhao, J. Chang, X. Fu, C. Liang, S. Liang, R. Yan, A. Li, Nano-sized cationic
polymeric magnetic liposomes significantly improve drug delivery to the brain in rats, J
Drug Target, 20 (2012) 416–21.
[90] P.J. Gaillard, C.C.M. Appeldoorn, R. Dorland, J.V. Kregten, F. Manca, D.J. Vugts, B.
Windhorst, G.A.M.S. van Dongen, H.E. de Vries, D. Maussang, O.V. Tellingen,
Pharmacokinetics, brain delivery, and efficacy in brain tumor-bearing mice of glutathione
pegylated liposomal doxorubicin (2B3-101), PloS one, 9 (2014) 82331.
[91] J. Huwyler, D. Wu, W.I. Ardridge, Brain drug delivery of small molecules using
Immunoliposomes, PNAS, 93 (1996) 14164-14169.
ACCEPTED MANUSCRIPT

[92] R.J.L. Ippens, Liposomal daunorubicin (DaunoXome) in children with recurrent or


progressive brain tumors, Pediatr Hematol Oncol, 16 (1999) 131-139.
[93] S. Serres, M.S. Soto, A. Hamilton, M.A. McAteer, W.S. Carbonell, M.D. Robson, O.
Ansorge, A. Khrapitchev, C. Bristow, L. Balathasan, T. Weissensteiner, Molecular MRI
enables early and sensitive detection of brain metastases, PNAS, 109 (2012) 6674-6679.
[94] F. Dilnawaz , A. Singh A, S. Mewar S, U. Sharma, N.R. Jagannathan , S.K. Sahoo , The
transport of non-surfactant based paclitaxel loaded magnetic nanoparticles across the
blood brain barrier in a rat model, Biomaterials, 33(2012) 2936–2951.
[95] S. Roy, Strategic Drug Delivery Targeted to the Brain: A Review. Der Pharmacia Sinica,
3 (2012) 76-92.

T
[96] R.T. Jackson, J. Tigges, W. Arnold, Arch Otolaryngol, 105 (1979) 180-184.

IP
[97] D.Sanjay, B. Mahantil, B. Majumder, Der pharmacia Sinicia, 2 (2011) 94-106.
[98] P.O. Freskgård, J. Niewoehner, E. Urich, Time to open the blood–brain barrier gate for

CR
biologics? Future Neurology, 9 (2015) 243-245.
[99] E. A. Neuwelt, B. Bauer, C. Fahlke, G. Fricker, C. Iadecola, D. Janigro, L. Leybaert , Z.
Molnár , M.E. O'Donnell, J.T. Povlishock, N.R. Saunders, F. Sharp , D. Stanimirovic,
R.J. Watts, L.R. Drewes, Engaging neuroscience to advance translational research in

US
brain barrier biology, Nat Rev Neurosci, 12 (2011) 169-182.
[100] Alz forum. AD monoclonals.
http://www.alzforum.org/news/conferencecoverage/aducanumab-solanezumab-
AN
gantenerumab-data-lift-crenezumab-well August 10 (2015).
[101] R.S. Doody, M. Farlow, P.S. Aisen, Alzheimer's Disease Cooperative Study Data, A. &
Publication, C. Phase 3 trials of solanezumab and bapineuzumab for Alzheimer's disease,
M

N Engl J Med, 370 (2014) 1460.


[102] P.O. Freskgård, E. Urich, Antibody therapies in CNS diseases, Neuropharmacol, 120
ED

(2016) 38-55.
[103] A. Chaudhuri, P.O. Behan, Natalizumab for relapsing multiple sclerosis, N Engl J Med,
348 (2003) 1598-1599.
[104] P.S. Sorensen, S. Lisby, R. Grove, F. Derosier, S. Shackelford, E. Havrdova, J.
PT

Drulovic, M. Filippi, Safety and efficacy of ofatumumab in relapsing-remitting multiple


sclerosis: a phase 2 study, Neurology, 82 (2014) 573-581.
[105] Roche. Roche’s ocrelizumab significantly reduced both relapses and disability
CE

progression versus interferon beta-1a (Rebif®) in two Phase III studies in multiple
sclerosis. http://www.roche.com/media/store/releases/med-cor-2015-06-30.htm (2015).
[106] Roche. Ocrelizumab first investigational medicine to show efficacy in people with
AC

primary progressive multiple sclerosis in large Phase III study. http://www.


roche.com/investors/updates/inv-update-2015-09-28.htm (2015).
[107] R.B. Pepinsky, Z. Shao, B. Ji, Q. Wang, G. Meng, L. Walus, X. Lee, Y. Hu, C. Graff , E.
Garber, W. Meier, S. Mi, Exposure levels of anti- LINGO-1 Li81 antibody in the central
nervous system and dose-efficacy relationships in rat spinal cord remyelination models
after systemic administration, J Pharmacol Exp Ther, 339 (2011) 519-529.
[108] S. Mi, B. Hu, K. Hahm, Y. Luo, E.S.K. Hui, Q. Yuan, W.M. Wong, L. Wang, H. Su,
T.H. Chu, J. Guo, W. Zhang, K.F. So, B. Pepinsky, Z. Shao, C. Graff, E. Garber, V. Jung,
E.X. Wu, W. Wu, LINGO-1 antagonist promotes spinal cord remyelination and axonal
integrity in MOG- induced experimental autoimmune encephalomyelitis, Nat Med, 13
(2007) 1228-1233.
ACCEPTED MANUSCRIPT

[109] D. Wickramasinghe, Tumor and T cell engagement by BiTE, Discov Med, 16 (2013)
149–152.
[110] Y.J. Yu, Y. Zhang, M. Kenrick, K. Hoyte, W. Luk, Y. Lu, J. Atwal, J.M. Elliott,
S. Prabhu, R.J. Watts, M.S. Dennis, Boosting brain uptake of a therapeutic antibody by
reducing its affinity for a transcytosis target, Sci Transl Med, 3 (2011) 84ra44.
[111] L. Tengfei, M. Vandesquill , F. Koukouli , C. Dudeffant, I. Youssef, P. Lenormand, C.
Ganneau , U. Maskos, C. Czech, F. Grueninger, C. Duyckaerts, M. Dhenain, S. Bay, B.
Delatour, P. Lafaye, Camelid single-domain antibodies: A versatile tool for in vivo
imaging of extracellular and intracellular brain targets, J Control Release, 243 (2016) 1–
10.

T
[112] S. Kyoungho, Lipocalin-2 as a therapeutic target for brain injury: An astrocentric

IP
perspective, Prog Neurobiol, 144 (2016) 158-172.
[113] E. Venereau, F. D. Leo, R. Mezzapelle, G. Careccia, G. Musco, M.E. Bianchi, HMGB1

CR
as biomarker and drug target, Pharmacol Res, 111 (2016) 534-44.
[114] A. Ben-Zvi, B. Lacoste, E. Kur, B.J. Andreone, Y. Mayshar, H. Yan, C. Gu, Mfsd2a is
critical for the formation and function of the blood–brain barrier, Nature, 509 (2014)
507–511.

US
[115] L.N. Nguyen, D. Ma, G. Shui, P. Wong, A. Cazenave-Gassiot, X. Zhang, M.R.Wenk,
E.L. Goh, D.L. Silver, Mfsd2a is a transporter for the essential omega-3 fatty
aciddocosahexaenoic acid, Nature, 509 (2014) 503–506.
AN
[116] C. Gu, A. Ben-Zvi, Modulating or treating permeability of blood–brain barrierby
administering inhibitor of gene, or agonist of gene, or gene expressionproduct e.g. major
facilitator superfamily domain-containing protein 2(Mfsd2A) to human, Harvard College
M

(Hard-C), p. 131. Internationalapplication number: PCT/US2014/043395, International


publicationnumber: WO 2014/205338 A2.
ED

[117] C. Betsholtz, Lipid transport and human brain development, Nat Genet, 47 (2015) 699–
701.
[118] W.M. Pardridge, Blood–brain barrier endogenous transporters astherapeutic targets: a
new model for small molecule CNS drug discovery, Expert Opin Ther Targets, 19 (2015)
PT

1059–1072.
[119] L. Peura, K. Malmioja, K. Huttunen, J. Leppanen, M. Ha malainen, M.M. Forsberg,
J. Rautio, K. Laine, Design, synthesis and brain uptake of LAT1-targeted aminoacid
CE

prodrugs of dopamine, Pharm Res, 30 (2013) 2523–2537.


[120] A. Vyas, A. Jain, P. Hurkat, A. Jain, S.K. Jain, Targeting of AIDS relatedencephalopathy
using phenylalanine anchored lipidic nanocarrier, Colloids and Surfaces B:
AC

Biointerfaces , 131 (2015) 155–161.


[121] X.C. Yu , J.J. Yang, B.H. Jin, H.L. Xu, H.Y. Zhang, J. Xiao, C.T. Lu, Y.Z. Zhao, W.
Yang. A strategy for bypassing the blood-brain barrier: Facial intradermal braintargeted
delivery via the trigeminal nerve, J Control Release, 258 (2017) 22–33.
[122] T. Fernandez, F. Pozo, Induction of cell death in a glioblastoma line by hyperthermic
therapy based on gold nanorods, Int J Nanomedicine, 7 (2012) 1511–1523.
[123] M. Choi, T. Ku, K. Chong, J. Yoon, C. Choi, minimally invasive molecular delivery into
the brain using optical modulation of vascular permeability, Proc Natl Acad Sci U S A,
108 (2011) 9256–9261.
[124] R.G. Thorne, C.R. Emory, T.A. Ala, W.H. Frey 2 nd, Quantitative analysis of the olfactory
path-way for drug delivery to the brain, Brain Res, 692 (1995) 278-82.
ACCEPTED MANUSCRIPT

[125] M.T. Shipley, Transport of molecules from nose to brain: Transneuronal anterograde and
retrograde labeling in the rat olfactory system by wheat germ agglutinin- horseradish
peroxidase applied to the nasal epithelium, Brain Res Bull, 15 (1985) 129–142.

[126] J.J. Lochhead, R.G. Thorne, Intranasal delivery of biologics to central nervous system,
Adv Drug Deliv Rev, 64 (2012) 614-628.

[127] C.D. Chapman, W.H. Frey 2nd, S. Craft, L. Danielyan, M. Hallschmid, H.B. Schiöth, C.
Benedict, Intranasal treatment of central nervous system dysfunction in human, Pharm
Res, 30 (2012) 2475-2484.

T
IP
[128] D.A. Leopold, The relationship between nasal anatomy and human olfaction,
Laryngoscope, 98 (1988) 1232–1238.

CR
[129] M. Caggiano, J.S. Kauer, D.D. Hunter, Globose basal cells are neuronal progenitors in the
olfactory epithelium: A lineage analysis using a replication- incompetent retrovirus,
Neuron, 13(1994) 339–352.

US
[130] G. Brand, Olfactory/trigeminal interactions in nasal chemoreception, Neurosci Biobehav
Rev, 30 (2006) 908–917.
[131] A. Brodbelt, M. Stoodley, CSF pathways: a review, Br J Neurosurg, 21 (2007) 510–520.
AN
[132] A.D. Lorenzo, Electron microscopy of the olfactory and gustatory pathways, Ann Otol
Rhinolaryngol, 68 (1960) 410–420.
M

[133] N.J. Johnson, L.R. Hanson, W.H Frey, Trigeminal pathways deliver a low molecular
weight drug from the nose to the brain and orofacial structures, Mol Pharm , 7 (2010)
ED

884–893.

[134] R.G. Thorne, G.J. Pronk, V. Padmanabhan, W.H. Frey, Delivery of insulin- like growth
factor- i to the rat brain and spinal cord along olfactory and trigeminal pathways following
PT

intranasal administration, Neuroscience, 127 ( 2004) 481–496.


CE

[135] C.V. Pardeshi, V.S. Belgamwar, Direct nose to brain drug delivery via integrated nerve
pathways bypassing the blood-brain barrier: an excellent platform for brain targeting,
Expert Opin Drug Deliv, 10 (2013) 957-72.
AC

[136] M.A. Edeling, C. Smith, D. Owen, Life of a clathrin coated: insight from clathrin and AP
structures, Nat Rev Mol Cell Biol, 7 (2006) 32-44.
[137] J. Rejman, V. Oberle, I.S. Zuhorn, D. Hoekstra, Size dependent internalization of
particles via the pathway of clathrin and caveolae mediated endocytosis, Bioche m J, 377
(2004) 159-69.

[138] A.T. Jones, Gateways and tools for drug delivery: endocytic pathway and the cellular
dynamics of cell penetrating peptides, Int J Pharm, 354 (2008) 34-38.

[139] C.M. Van Itallie, J.M. Anderson, Claudins and epithelial paracellular transport, Annu
Rev Physiol, 68 ( 2006) 403–429.
ACCEPTED MANUSCRIPT

[140] M. Miyamoto, H. Natsume, I. Satoh, K. Ohtake, M. Yamaguchi, D. Kobayashi, K.


Sugibayashi, Y. Morimoto, Effect of poly–L-arginine on the nasal absorption of FTIR-
dextran of different molecular weights and recombinant human granulocyte colony
stimulating factor (RHG-SF) in rats, Int J Pharm, 226 ( 2001) 127-38.
[141] A. Yamamoto, T. Iseki, M. Ochi-Sugiyama, N. Okada, T. Fujita, S. Muranishi, J Control
Release, 76 (2001) 363–74.
[142] M. Hinchcliffe, L. Illum, Intranasal insulin delivery and therapy, Adv Drug Deliv Rev, 35
(1999) 199–234.

T
[143] S. Dey, B. Mahanti, B. Mazumder, A. Malgope, S. Dasgupta, Nasal drug delivery: An
approach of drug delivery through nasal route, Der Pharmacia Sinica, 2 (2011) 94-106.

IP
[144] X.A. Si, J. Xi, J. Kim, Y. Zhou, H. Zhong, Modeling of release position and ventilation
effects on olfactory aerosol drug delivery, Respir Physio Neurobiol, 186 (2013) 22–32.

CR
[145] A.J. Guastella, I.B. Hickie, M.M. Mcguinness, M. Otis, E.A. Woods, H.M. Disinger,
H.K. Chan, T.F. Chen, R.B. Banati, Recommendations for the standardisation of oxytocin
nasal administration and guidelines for its reporting in human, research,

US
Psychoneuroendocrinology, 38 (2013) 612–625.

[146] R. J. Soane, M. Frier, A.C. Perkins, N. S. Jones, S.S. Davis, L. Illum, Evaluation of the
clearance characteristics of bioadhesive systems in humans, Int J Pharm, 178 (1999) 55–
AN
65.
[147] F.W. Merkus, J.C. Verhoef, N.G. Schipper, E. Marttin, Nasal mucociliary clearance as a
factor in nasal drug delivery, Adv Drug Deliv Rev, 29 (1998) 13–38.
M

[148] E.L. Smith, R.L. Hill, A. Borman, Activity of insulin degraded by leucine
aminopeptidase, Biochem Biophys Acta, 29 (1958) 207–14.
ED

[149] V.H. Lee, A. Yamamoto, Penetration and enzymatic barriers to peptide and protein
absorption, Adv Drug Deliv Rev, 4 (1990) 171-207.
PT

[150] P. Cole, The four components of the nasal valve, Am J Rhinol, 17 (2003) 107–110.
[151] L.L. Wearly, Recent progress in protein and peptide delivery by non- invasive routes, Crit
Rev Ther Drug Carrier Syst, 8 (1991) 331-94.
CE

[152] R. Smolnik, M. Molle, H.L. Fehm, J. Born, Brain potential and attention after acute
subchronic intranasal administration of ACTH4-10 desacetyl-a-MSH in human,
Neuroendocrinol, 70 (1999) 63-72.
AC

[153] X.F. Liu, J.R. Fawcett, R.G. Thorn, T.A. Defor, W.H. Frey, Intranasal administration of
insulin like growth factor-I bypass the blood brain barrier and protects against focal
cerebral ischemic damage, J Neuro Sci, 187 (2001) 91-7.

[154] L.Danielyan, R. Schafer, A. von Ameln-Mayerhofer, M. Buadze, J.


Geisler, T.Klopfer, U. Burkhardt, B. Proksch, S. Verleysdonk, M. Ayturan, G.H.
Buniatian, C.H. Gleiter, W.H. Frey 2nd, Intranasal delivery of cells to brain, Eur J Cell
Bio, 88 (2009) 315-24.
[155] M. Reitz, M. Demestre, J. Sedlacik, H. Meissner, J. Fiehler, S.U. Kim, M. Westphal,
N.O. Schmidt, Intranasal delivery of neural stem/progenitor cells: a non- invasive passage
to target intracerebral gioma, Stem Cell Transl Med, 1 (2012) 866-873.
ACCEPTED MANUSCRIPT

[156] I.V. Balyasnikova, M.S. Prasol, S.D. Ferguson, Y. Han, A.U. Ahmed, M. Gutova, A.L.
Tobias, D. Mustafi, E. Rincón, L. Zhang, K.S. Aboody, M.S. Lesniak, Intranasal
delivery of mesenchymal stem cells significantly extends survival of irradiated mice with
experimental brain tumors, Mol Ther, 22 (2014) 140-8.

[157] C.A. Fonseca1, R.M. Teixeira , R. Ramina , G. Kovaleski , J.T. Silva, J. Nagel, T. Quirico-
Santos, Case of advanced recurrent glioblastoma successfully treated with monoterpene
perillyl alcohol by intranasal administration, J Cancer Ther, 2 (2011) 16-21.

[158] K. Ozduman, G. Wollmann, J.M. Piepmeier, A. van den Pol, Systemic vesicular

T
stomatitis virus selectively destroys multifocal glioma and metastatic carcinoma in brain, J

IP
Neurosci, 28 (2008) 1882–93.
[159] T. Shingaki, D. Inoue, T. Furubayashi, T. Sakane, H. Katsumi, A. Yamamoto, S.

CR
Yamashita, Intranasal delivery of methotrexate to brain tumors in rat: new strategy for
brain tumor chemotherapy, Mol Pharm, 7 (2010) 1561-68.

US
[160] R. Hashizume, T. Ozawa, S.M. Gryaznov, A.W. Bollen, K.R. Lamborn, W.H. Frey 2nd,
D.F. Deen, New therapeutic approach for brain tumors: intranasal delivery of telomerase
inhibitor GRN163, Neuro Oncol, 10 (2008) 112-120.
AN
[161] T.C. Chen, H.Y. Cho, W. Wang, M. Barath, N. Sharma, F.M. Hofman, A.H. Schontha, A
novel temozolomide-perillyl alcohol conjugate exhibits superior activity against breast
cancer cells in vitro and intracranial triple-negative tumor growth in vivo, Mol Cancer
M

Ther, 13 (2014) 1181–93.


[162] T.C. Chen, H.Y. Cho, W. Wang, M. Barath, N. Sharma, F.M. Hofman, A.H.
ED

Schönthal, A novel temozolomide-perillyl alcohol conjugate exhibits superior activity


against breast cancer cells in vitro and intracranial triple-negative tumor growth in vivo,
Mol Cancer Ther, 13(2014) 1181-93.
PT

[163] M.A. Reger, G.S. Watson, W.H. Frey 2nd, L.D. Baker, B. Cholerton, M.L. Keeling, D.A.
Belongia, M.A. Fishel, S.R. Plymate, G.D. Schellenberg, M.M. Cherrier, S. Craft, Effects
of intranasal insulin on cognition in memory-impaired older adults: modulation by APOE
CE

genotype, Neurobiol Aging, 27 (2006) 451-8.


[164] M.A. Reger, G.S. Watson, P.S. Green, L.D. Baker, B. Cholerton, M.A. Fishel, S.R.
Plymate, M.M. Cherrier, G.D. Schellenberg, W.H. Frey 2 nd, S. Craft, Intranasal insulin
AC

administration dose-dependently modulates verbal memory and plasma amyloid-beta in


memory-impaired older adults, J Alzheimer′s Dis, 13 (2008) 323-31.
[165] A.J. Guastella, S.L. Einfeld, K.M. Gray, N.J. Rinehart, B.J. Tonge, T.J. Lambert, I.B.
Hickie, Intranasal oxytocin improves emotion recognition for youth with autism
spectrum disorders, Biol Psychiatry, 67 (2010) 692-4.
[166] P.C. Baier, S.L. Weinhold, V. Huth, B. Gottwald, R. Ferstl, D. Hinze-Selch, Olfactory
dysfunction in patients with narcolepsy with cataplexy is restored by intranasal Orexin A
(Hypocretin-1), Brain, 131 (2008) 2734-41.
[167] C. Schulz, K. Paulus, O. Jöhren, H. Lehnert, Intranasal leptin reduces appetite and
induces weight loss in rats with diet- induced obesity (DIO), Endocrinology, 153 (2012)
143-53.
ACCEPTED MANUSCRIPT

[168] S. Fliedner, C. Schulz, H. Lehnert, Brain uptake of intranasally applied radioiodinated


leptin in Wistar rats, Endocrinology, 47 (2006) 2088-94.
[169] T. Fişgin, Y. Gurer, T. Tezic, N. Senbil, P. Zorlu, C. Okuyaz, D. Akgün, Effects of
intranasal midazolam and rectal diazepam on acute convulsions in children: prospective
randomized study, J Child Neurol, 17 ( 2002)123-6.
[170] G.J. Haan, P. van der Geest, G. Doelman, E. Bertram, P. Edelbroek, A comparison of
midazolam nasal spray and diazepam rectal solution for the residential treatment of
seizure exacerbations, Epilepsia, 51 (2010) 478-82.
[171] H. Ashton, Z. Hassan, Best evidence topic report. Intranasal naloxone in suspected opioid
overdose, Emerg Med, 23 (2006) 221-3.

T
[172] H.Y. Cho, W. Wang, N. Jhaveri, S. Torres, J. Tseng, M.N. Leong, D.J. Lee, A.

IP
Goldkorn, T. Xu, N.A. Petasis, S.G. Louie, A.H. Schönthal, F.M. Hofman, T.C. Chen,
Perillyl alcohol for the treatment of temozolomide-resistant gliomas, Mol Cancer Ther,

CR
11 (2012) 2462–2472.

[173] L. Illum, Nasal drug delivery--possibilities, problems and solutions, J Control Release, 87
(2003) 187-198.

US
[174] R.M. Mainardes, M.C. Urban, P.O. Cinto, M.P. Gremiao, Liposomes and
Micro/Nanoparticles as Colloidal Carriers for Nasal Drug Delivery, Curr Drug Deliv, 3
AN
(2006) 275-85.
[175] L. Illum, Nanoparticle systems for nasal delivery of drugs: a real improvement over
simple systems? J Pharm Sci, 96 (2006) 473–48.
M

[176] F. Chen, Z.R. Zhang, F. Yuan, X. Qin, M. Wang, Y. Huang, In vitro and in vivo study of
N-trimethyl chitosan nanoparticles for oral protein delivery, Int J Pharm, 349 (2008)
ED

226–233.

[177] A. Dalpiaz, E. Gavini, G. Colombo, P. Russo, F. Bortolotti, L. Ferraro, S. Tanganelli, A.


PT

Scatturin, E. Menegatti, P. Giunchedi, Brain uptake of an anti- ischemic agent by nasal


administration of microparticles, J Pharm Sci, 97 (2008) 4889–4903.
[178] A. Des Rieux, E.G. Ragnarsson, E. Gullberg, V. Preat, Y.J. Schneider, P. Artursson,
CE

nanoparticles across an in vitro model of the human follicle associated epithelium, Eur J
Pharm Sci, 25 (2005) 455–465.
[179] Y. Huang, M.D. Donovan, Microsphere transport pathways in the rabbit nasal mucosa,
AC

Int J Pharm Adv, 1(1996) 298–309.


[180] A. Bernkop-Schnurch, S. Dunnhaupt, Chitosan-based drug delivery systems, Eur J
Pharm Biopharm, 81( 2012) 463–469.
[181] M. Garcia-Fuentes, M.J. Alonso, Chitosan-based drug nanocarriers: Where do we stand?
J Control Release, 161 (2012) 496–504.

[182] D. Mittal, S. Md, Q. Hasan, M. Fazil, A. Ali, S. Baboota, J. Ali, Brain targeted
nanoparticulate drug delivery system of rasagiline via intranasal route, Drug Deliv,
1(2016) 130-9.

[183] S. Md, R.A. Khan, G. Mustafa, K. Chuttani, S. Baboota, J.K. Sahni, J. Ali,
Bromocriptine loaded chitosan nanoparticles intended for direct nose to brain delivery:
ACCEPTED MANUSCRIPT

Pharmacodynamic, pharmacokinetic and scintigraphy study in mice model, Eur J Pharm


Sci,48 (2012) 393–405.

[184] M. Tafaghodi, S. Abolghasem Sajadi Tabassi, M.R. Jaafari, S.R. Zakavi, M. Momen-
Nejad, Evaluation of the clearance characteristics of various microspheres in the human
nose by gamma-scintigraphy, Int J Pharm, 280 (2004) 125–135.

[185] H.K. Makadia, S.J. Siegel, Poly lactic-co-glycolic acid (PLGA) as biodegradable
controlled drug delivery carrier, Polymers, 3 (2011)1377–1397.

T
[186] T. Musumeci, R. Pellitteri, M. Spatuzza, G. Puglisi, Nose-to-brain delivery: evaluation of

IP
polymeric nanoparticles on olfactory ensheathing cells uptake, J Pharm Sci, 103 (2014)
628-35.

CR
[187] Z. Wen, Z. Yan, K. Hu, Z. Pang, X. Cheng, L. Guo, Q. Zhang, X. Jiang , L. Fang, R.
Lai, Odorranalectin-conjugated nanoparticles: Preparation, brain delivery and
pharmacodynamic study on Parkinson's disease following intranasal administration, J

US
Control release, 151 (2011) 131-138.

[188] M. Elfinger, C. Maucksch, C. Rudolph, Characterization of lactoferrin as a targeting


AN
ligand for nonviral gene delivery to airway epithelial cells, Biomaterials, 28 (2007) 3448–
3455.
M

[189] C. Bi, A. Wang, Y. Chu, S. Liu, H. Mu, W. Liu, Z. Wu, K. Sun, Y. Li, Intranasal
delivery of rotigotine to the brain with lactoferrin- modified PEG-PLGA nanoparticles for
Parkinson’s disease treatment, Int J Nanomedicine, 11 (2016) 6547–6559.
ED

[190] Y.K. Katare, R.P. Daya, G.C. Sookram, R.E. Luckham, J. Bhandari, A.S. Chauhan, R.K.
Mishra, Brain targeting of a water insoluble antipsychotic drug haloperidol via the
intranasal route using PAMAM dendrimers, Mol Pharm, 12 (2015) 3380–3388.
PT

[191] I.D. Kim, J.H. Shin, S.W. Kim, S. Choi, J. Ahn, P.L. Han, J.S. Park, J.K. Lee, Intranasal
delivery of HMGB1 siRNA confers target gene knockdown and robust neuroprotection in
CE

the postischemic brain, Mol Ther, 20 (2012) 829–839.


[192] T.T. Win-Shwe, H. Sone, Y. Kurokawa, Y. Zeng, Q. Zeng, H. Nitta, S. Hirano, Effects
of PAMAM dendrimers in the mouse brain after a single intranasal
AC

instillation,Toxicology Letters, 228 (2014) 207-215.


[193] T. Lin, E. Liu, H. He, M.C. Shin, C. Moon, V.C. Yang, Y. Huang, Nose-to-brain delivery
of macromolecules mediated by cell-penetrating peptides, Acta Pharm Sin B, 6 (2016)
352-58.
[194] H. Xia, X. Gao, G. Gu, Z. Liu, N. Zeng, Q. Hu, Q. Song, L. Yao, Z. Pang, X.
Jiang, J. Chen, H. Chen, Low molecular weight protamine functionalized nanoparticles
for drug delivery to the brain after intranasal administration, Biomaterials, 32 (2011)
9888-98.
[195] N. Kamei, M. Takeda-Morishita, Brain delivery of insulin boosted by intranasal
coadministration with cell-penetrating peptides, J Control Release, 197 (2015) 105-110.
ACCEPTED MANUSCRIPT

[196] E. Mattiuz, R. Franklin, T. Gillespie, A. Murphy, J. Bernstein, A. Chiu, T. Hotten, K.


Kassahun, Disposition and metabolism of olanzapine in mice, dogs, and rhesus monkeys,
Drug Metab Dispos, 25 (1997) 573–583.
[197] S. Md, M. Ali, S. Baboota, J.K. Sahni, A. Bhatnagar, J. Ali , Preparation,
characterization, in vivo biodistribution and pharmacokinetic studies of donepezil- loaded
PLGA nanoparticles for brain targeting,Drug Dev Ind Pharm ,40(2014) 278-87.
[198] C. Zhang, J. Chen, C. Feng, X. Shao, Q. Liu, Q. Zhang , Z. Pang, X. Jiang, Intranasal
nanoparticles of basic fibroblast growth factor for brain delivery to treat Alzheimer's
disease, Int J Pharm,1-2 (2014) 192-202.

T
[199] Q. Liu, Y. Shen, J. Chen, X. Gao, C. Feng, L. Wang, Q. Zhang, X. Jiang, Nose to brain

IP
transport pathway of wheat germ agglutinin conjugated PEG-PLA nanoparticles, Pharm
Res, 29 (2012) 546-58.

CR
[200] L. Yan, W. Huiyuan, Y. Jiang, Y. Huang, Cell-penetrating peptide- modified PLGA
nanoparticles for enhanced nose-to-brain macromolecular delivery. Macromol Res, 21
(2013) 435-441.

US
[201] B. Shah, D. Khunt, H. Bhatt, M. Misra, H. Padh, Application of quality by design
approach for intranasal delivery of rivastigmine loaded solid lipid nanoparticles: effect on
AN
formulation and characterization parameters, Eur J Pharm Sci, 78 (2015) 54–66.

[202] Y.Z. Zhao, X. Li, C.T. Lu, M. Lin, L.J. Chen, Q. Xiang, M. Zhang, P.R. Jin, X.
M

Jiang, X.T. Shen , X.K. Li, J. Cai, Gelatin nanostructured lipid carriers- mediated
intranasal delivery of basic fibroblast growth factor enhances functional recovery in
ED

hemiparkinsonian rats, Nanomedicine: Nanotechnology, Biology and medicine, 10(2014)


755-764.
[203] R.H. Müller, M. Radtke, S.A. Wissing, Nanostructured lipid matrices for improved
PT

microencapsulation of drugs, Int J Pharm, 242 (2002) 121–128.


[204] T.B. Devkar, A.R. Tekade, K.R. Khandelwal, Surface engineered nanostructured lipid
CE

carriers for efficient nose to brain delivery of ondansetron HCl using Delonix regia gum
as a natural mucoadhesive polymer, Colloids and Surfaces B: Biointerfaces, 122 (2014)
143-150.
AC

[205] O. Gartziandia, E. Herran, J.L. Pedraz, E. Carro, M. Igartua, R.M. Hernandez, Chitosan
coated nanostructured lipid carriers for brain delivery of proteins by intranasal
administration, Colloids and Surfaces B: Biointerfaces, 134 ( 2015) 304-313.
[206] S. Yadav, F. Gattacceca, R. Panicucci, M.M. Amiji, Comparative Biodistribution and
Pharmacokinetic Analysis of Cyclosporine-A in the Brain upon Intranasal or Intravenous
Administration in an Oil- in-Water Nanoemulsion Formulation, Mol Pharmaceutics, 2
(2015) 1523–1533.
[207] Z. Ding, Y. Zhang, N. Wen, Z. Sun, C. Li, B. Zhang, W/O nanoemulsion-based
intranasal drug delivery system of Panax notoginseng saponins for brain targeting, J
Control Release, 213 (2015) e8–e152.
ACCEPTED MANUSCRIPT

[208] S. Sood, K. Jain, K. Gowthamarajan, Optimization of curcumin nanoemulsion for


intranasal delivery using design of experiment and its toxicity assessment, Colloids Surf
B, 113 (2014) 330–337.
[209] S.Yadav, S.K. Gandham, R. Panicucci, M.M. Amiji, Intranasal brain delivery of cationic
nanoemulsion-encapsulated TNFα siRNA in prevention of experimental
neuroinflammation, Nanomed-Nanotechnol, 12 (2016) 987-1002.
[210] R.H. Parikh, R.J. Patel, Nanoemulsions for Intranasal Delivery of Riluzole to Improve
Brain Bioavailability: Formulation Development and Pharmacokinetic Studies, Curr
Drug Deliv, 13(2016) 1130-1143.

T
[211] R. Jain, S. Nabekar, P. Dandekar, V. Patravale, Micellar Nanocarriers: Potential Nose-to-

IP
Brain Delivery of Zolmitriptan as Novel Migraine Therapy, Pharm Res, 27 (2010) 655-
664.

CR
[212] T. Kanazawa, H. Taki, K. Tanaka, Y. Takashima, H. Okada, Cell penetrating peptide-
modified block copolymer micelles promote direct brain delivery via intranasal
administration, Pharma Res, 28 (2011) 2130-2139.

US
[213] T. Kanazawa, F. Akiyama, S. Kakizaki, S. Takashima, Y. Seta, Delivery of siRNA to
the brain using a combination of nose-to-brain delivery and cell-penetrating peptide-
AN
modified nano-micelles, Biomaterials, 34 (2013) 9220-9226.
[214] H. Taki, T. Kanazawa, F. Akiyama, Y. Takashima, H. Okada, Intranasal delivery of –
loaded Tat-modified nanomicells for treatment of intracranial brain tumors,
M

Pharmaceutics, 5 ( 2012) 1092–1102.


ED

[215] S. Shelke , S. Shahi, S. Jalalpure, D. Dhamecha, S. Shengule, Formulation and


evaluation of thermoreversible mucoadhesive in-situ gel for intranasal delivery of
naratriptan hydrochloride, J Drug Deliv Sci Technol, 29 (2015) 238-244.
PT

[216] A.P. Perez, C. Mundina-Weilenmann, E.L. Romero, M.J. Morilla, Increased brain
radioactivity by intranasal P- labeled siRNA dendriplexes within in situ-forming
CE

mucoadhesive gels, Int J Nanomedicine, 7 (2012) 1373–1385.


[217] J. Hao, J. Zhao, S. Zhang, T. Tong, Q. Zhuang, K. Jin, W. Chen, H. Tang, Fabrication of
an ionic-sensitive in situ gel loaded with resveratrol nanosuspensions intended for direct
AC

nose-to-brain delivery, Colloids and Surfaces B: Biointerfaces, 147 (2016) 376-86 .

[218] S. Khan, K. Patil, N. Bobade, P. Yeole, R. Gaikwad, Formulation of intranasal


mucoadhesive temperature-mediated in situ gel containing ropinirole and evaluation of
brain targeting efficiency in rats, J Drug Target, 18 (2010) 223–234.

[219] R.j. Babu, P.P. Dayal, K. Pawar, M. Singh, Nose-to-brain transport of melatonin from
polymer gel suspensions: A microdialysis study in rats, J Drug Target, 19 (2011) 731–
740.
[220] V.P. Torchilin, Liposomes as targetable drug carriers, Crit Rev Ther Drug Carrier Syst, 2
(1985) 65-115.
ACCEPTED MANUSCRIPT

[221] V.P. Torchilin, Recent advances with liposomes as pharmaceutical carriers, Nat Rev Drug
Discov, 4 (2005) 145-60.
[222] X. Zheng, X. Shao, C. Zhang, Y. Tan, Q. Liu, X. Wan, Q. Zhang, S. XU, X. Jiang,
Intranasal H102 Peptide loaded liposomes for brain delivery to treat Alzheimer′s disease,
Pharm Res, 32 (2015) 3837-49.
[223] R. Narayan, M. Singh, O. Ranjan, Y. Nayak, S. Garg, G.V. Shavi, U.Y. Nayak,
Development of risperidone liposomes for brain targeting through intranasal route, Life
Science, 163 (2016) 38-45.

T
[224] S. Samudre, A. Tekade, K. Thorve, Xanthan Gum Coated Mucoadhesive Liposomes for

IP
Efficient Nose to Brain Delivery of Curcumin, Drug Deliv Lett, 5 (2016) 201-207.
[225] Z. Yang, Y.Q. Zhang, Z.Z. Wang, K. Wu, J.N. Lou, X.R. Qi, Enhanced brain
distribution and pharmacodynamics of rivastigmine by liposomes following intranasal

CR
administration, Int J Pharm, 452 ( 2013) 344-354.
[226] A. Pal, S. Gupta, A. Jaiswal, A. Dube, S.P. Vyas, Development and evaluation of
tripalmitin emulsomes for the treatment of experimental visceral leishmaniasis, J

US
Liposome Res, 22 (2012) 62–71.
[227] R. Paliwal, S.R. Paliwal, N. Mishra, A. Mehta, S.P. Vyas, Engineered chylomicron
mimicking carrier emulsome for lymph targeted oral delivery of methotrexate, Int J Pharm,
AN
380 (2009) 181–188.
[228] N. Aswathy, M. Vidhya, R. Saranya, R. Sreelakshmy, N. Sreeja, Emulsomes: a novel
liposoomal formulation for sustained drug delivery, Int Res J Pharm, 3 (2013) 192–196.
M

[229] G.M. El-Zaafarany, M.E. Soliman, S. Mansour, G.A. Awad, Identifying lipidic
emulsomes for improved oxcarbazepine brain targeting: In vitro and rat in vivo studies, Int
J Pharm, 503 (2016) 127-140.
ED

[230] E. Gavini, G. Rassu, L. Ferraro, S. Beggiato, A. Alhalaweh, S. Velaga, N. Marchett, P.


Bandiera, P. Giunchedi, A. Dalpiaz, Influence of polymeric microcarriers On the in
PT

vivo intranasal uptake of an anti- migraine drug for brain targeting, Eur J Pharm
Biopharm, 0 (2013) 174–183.
[231] Y.S. Choi, D.Y. Cho, H.K. Lee, J.K. Cho, D.H. Lee, Y.H. Bae, J.K. Lee, H.C. Kang,
CE

Enhanced cell survival of pH-sensitive bioenergetic nucleotide nanoparticles in


energy/oxygen-depleted cells and their intranasal delivery for reduced brain infarction,
Acta Biomater , 41 (2016) 147-160.
AC

[232] H.D. Rosas, Y.I. Chen, G. Doros, D.H. Salat, N.K. Chen, K.K. Kwong, A. Bush, J. Fox,
S.M. Hersch, Alterations in brain transition metals in Huntington disease: an evolving
and intricate story, Arch Neurol, 69 (2012) 887–893.
[233] J. Chen, E. Marks, B. Lai, Z. Zhang, J.A. Duce, L.Q. Lam, I. Volitakis, A.I. Bush, S.
Hersch, J.H. Fox, Iron accumulates in Huntington's disease neurons: protection by
deferoxamine, PLoS One, 8 (2013) e77023.
[234] R.M. Rival, D.S. Page, T.J. Chandraratna, E. Sendall, B. Ryder, H. Liu, T. Lewis,
R.Rosahl, L.M. Hider, M.S. Camargo, D.C. Shearman, D.A. Crowther, D.A. Lomas.
Fenton, chemistry and oxidative stress mediate the toxicity of the beta-amyloid peptide in
a Drosophila model of Alzheimer's disease, Eur J Neurosci, 29 (2009) 1335–1347.
ACCEPTED MANUSCRIPT

[235] J.M. Fine, A.C. Forsberg, D.B. Renner, K.A. Faltesek, K.G. Mohan, J.C. Wong, L.C.
Arneson, J.W. Crow, W.H. Frey II, L.R. Hanson, Intranasally- administered deferoxamine
mitigates toxicity of 6-OHDA in a rat model of Parkinson‫׳‬s disease, Brain Res, 1574
(2014) 96–104.

[236] G. Rassu, E. Soddu, M. Cossu, A. Brundu, G. Cerri, N.


Marchetti, L.Ferraro, R.F.Regan, P. Giunchedi, E. Gavini, A. Dalpiaz, Solid
microparticles based on chitosan or methyl-β- cycl-odextrin: A first formulative
approach to increase the nose-to-brain transport of deferoxamine mesylate, J Control
Release, 201 (2015) 68–77.

T
[237] S. Desai, G. Vidyasagar, A. Bhandhari, Evaluation of brain targeting for the nasal

IP
delivery of midazolam, Int J Pharm Sci Rev Res, 12 (2012) 109-113.

CR
[238] S. Jose, C.R. Ansa, T.A. Cinu, A.J. Chacko, N.A. Aleykutty, S.V. Ferreira, E.B. Souto,
Thermo-sensitive gels containing lorazepam microspheres for intranasal brain targeting,
Int J Pharm, 441 (2013) 516–526.

US
[239] S. Lungare, K. Hallam, R.K. Badhan, Phytochemical- loaded mesoporous silica
nanoparticles for nose-to-brain olfactory drug delivery, Int J Pharm, 513 (2016) 280-293.
AN
[240] G.A. Abdelbary, M.I. Tadros, Brain targeting of olanzapine via intranasal delivery of
core–shell difunctional block copolymer mixed nanomicellar carriers: In vitro
characterization, ex vivo estimation of nasal toxicity and in vivo biodistribution studies,
Pharm Nanotech , 452 (2013) 300–310.
M

[241] M. Kumar, K. Pathak, A. Mishra, Formulation and characterization of nanoemulsion


based drug delivery system of risperidone, Drug Dev Ind Pharm , 35 (2009) 387-95.
ED

[242] S. Haque, S. Md, M. Fazil, M. Kumar, J.K. Sahni, J. Ali, S. Baboota, Venlafaxine
loaded chitosan NPs for brain targeting: Pharmacokinetic and pharmacodynamic
PT

evaluation, Carbohydr Polym, 89 (2012) 72-79.


[243] L.R. Hanson, J.M. Fine, J.D. Hoekman, T.M. Nguyen, R.B. Burns, P.M. Martinez, J.
Pohl, W.H. Frey 2nd, Delivery of growth differentiation factor 5 to the central nervous
CE

system, Drug Deliv, 19 ( 2012) 149-54.


[244] A. Shahiwala, D. Dash, Preparation and evaluation of microemulsion based formulation
for rapid onset intranasal delivery of zonisamide, Adv Sci Lett, 3 (2010) 442-46.
AC

[245] D. Sharma, R.K. Sharma, A. Bhatnagar, D.K. Nishad, T. Singh, R. Gabrani, S.K. Sharma,
J. Ali, S. Dang, Nose to Brain Delivery of Midazolam Loaded PLGA Nanoparticles: In
Vitro and In Vivo Investigations, Curr Drug Deliv, 13 (2016) 557-64.
[246] M. Kumar, A. Misra, A.K. Babbar, A.K. Mishra, P. Mishra, K. Pathak, Intranasal
nanoemulsion based brain targeting drug delivery system of risperidone, Int J Pharm,
358 (2008) 285–291.
[247] S. Eskandari, J. Varshosaz, M. Minaiyan, M. Tabbakhian, Brain delivery of valproic
acid via intranasal administration of nanostructured lipid carriers: in vivo
pharmacodynamic studies using rat electroshock model, Int J Nanomedicine, 6 (2011)
363–371.
ACCEPTED MANUSCRIPT

[248] X. Wang, N. Chi, X. Tang, Preparation of estradiol chitosan nanoparticles for improving
nasal absorption and brain targeting, Eur J Pharm Biopharm, 70 (2008) 735–740.

[249] C. Benedict, M. Hallschmid, A. Hatke, B. Schultes, H.L. Fehm, J. Born, W. Kern,


Intranasal insulin improves memory in humans, Psychoneuroendocrinology, 29
(2004)1326-34.

[250] A.N. Laza, S. Mourtas, I. Youssef, C. Parizot, A. Dauphin, B. Delatour, S.G.


Antimisiaris, C. Duyckaerts, Curcumin-conjugated nanoliposomes with high affinity for
Aβ deposits: possible applications to Alzheimer disease, Nanomed Nanotechnol, 9 (2013)

T
712-721.

IP
[251] A. Bonaccorso, T. Musumeci, M.F. Serapide, R. Pellitteri, I. F. Uchegbu, G. Puglisi,

CR
Nose to brain delivery in rats: effect of surface charge of rhodamine B labeled
nanocarriers on brain subregion localization, Colloids Surf B Biointerfaces, 1 (2017) 297-
306.

US
[252] B. Jansson, E. Björk, Visualization of In Vivo Olfactory Uptake and Transfer Using
Fluorescein Dextran, J Drug Target, 10 (2002) 379–386.
[253] T. Kanazawa, H. Taki, K. Tanaka, Y. Takashima, H. Okada, Cell-penetrating peptide-
AN
modified block copolymer micelles promote direct brain delivery via intranasal
administration, Pharm Res, 28 (2011) 2130-9.
[254] N.G. Schipper, K.M. Varum, P. Artursson, Chitosans as absorption enhancers for poorly
M

absorbable drugs. 1: influence of molecular weight and degree of acetylation on drug


transport across human intestinal epithelial (Caco-2) cells, Pharm Res, 13 (1996)
ED

1686e1692.
[255] T. Aspden, L. Illum, O. Skaugrud, The effect of chronic nasal application of chitosan
solutions on cilia beat frequency in guinea pigs, Int J Pharm, 153 (1997) 137e146.
PT

[256] N. Haffejee, J. Du Plessis, D.G. Muller, C. Schultz, A.F. Kotze, C. Goosen, Intranasal
toxicity of selected absorption enhancers, Pharmazie, 56 (2001) 882e888.
CE

[257] S.R.K. Vaka, S.N. Murthy, M.A. Repka, T. Nagy, Upregulation of endogenous
neurotrophin levels in the brain by intranasal administration of carnosic acid, J Pharm
Sci, 100 (2011) 3139e3145.
AC

[258] H. Bshara, R. Osman, S. Mansour, Ael-H. El-Shamy, Chitosan and cyclodextrin in


intranasal microemulsion for improved brain buspirone hydrochloride pharmacokinetics
in rats, Carbohydr Polym, 99 (2014) 297e305.
[259] D. Vllasaliu, R. Exposito-Harris, A. Heras, L. Casettari, M. Garnett, L. Illum, S. Stolnik,
Tight junction modulation by chitosan nanoparticles: comparison with chitosan solution,
Int J Pharm, 400 (2010) 183e193.

[260] S. Md, S. Haque, M. Fazil, M. Kumar, S. Baboota, J.K. Sahni, J. Ali, Optimised
nanoformulation of bromocriptine for direct nose-to-brain delivery: biodistribution,
pharmacokinetic and dopamine estimation by ultra-HPLC/mass spectrometry method,
Expert Opin Drug Deliv, 11 (2014) 827e842.
ACCEPTED MANUSCRIPT

[261] X. Gao , W. Tao , W. Lu , Q. Zhang , Y. Zhang , X. Jiang, S. Fu, Lectin-conjugated


PEG–PLA nanoparticles: Preparation and brain delivery after intranasal administration,
Biomaterials, 27 (2006) 3482–3490.

[262] K. Kilk, R. Mahlapuu, U. Soomets, U. Langel, Analysis of in vitro toxicity of five cell-
penetrating peptides by metabolic profiling, Toxicology, 265 (2009) 87e95
[263] E. Koren, V.P. Torchilin, Cell-penetrating peptides: breaking through to the other side,
Trends Mol Med, 18 (2012) 385e93.

[264] R. Jain, S. Nabar, P. Dandekar, V. Patravale, Micellar Nanocarriers: Potential Nose-to-

T
Brain 19 Delivery of Zolmitriptan as Novel Migraine Therapy, Pharm Res, 27 (2010)

IP
655–664.
[265] G. A. Abdelbary, M.I. Tadros, Brain targeting of olanzapine via intranasal delivery of
core-shell difunctional block copolymer mixed nanomicellar carriers: in- vitro

CR
characterization, ex-vivo estimation of nasal toxicity and in- vivo biodistribution studies,
Int J Pharm, 16 (2013) 452.
[266] P. Upadhyay, J. Trivedi, K. Pundarikakshudu, N. Sheth, Direct and enhanced delivery of

US
nanoliposomes of anti schizophrenic agent to the brain through nasal rout, Saudi Pharm J,
25 (2017) 346-358.
[267] S. Jose, C.R. Ansa, T.A. Cinu, A.J. Chacko, N.A. Aleykutty, S.V. Ferreira, E.B. Souto,
AN
Thermo-sensitive gels containing lorazepam microspheres for intranasal brain targeting,
Int J Pharm, 441 (2013) 516e526.
[268] J.D. Suman , B.L. Laube, R. Dalby, Comparison of nasal deposition and clearance of
M

aerosol generated by nebulizer and an aqueous spray pump, Pharm Res, 16 (1999) 1648.
[269] P.G. Djupesland, A. Skretting, M. Winderen, T. Holand, Bi-directional nasal delivery of
aerosols can prevent lung deposition, J Aerosol Med, 17 (2004) 249.
ED

[270] P.G. Djupesland, Nasal drug delivery devices: characteristics and performance in a
clinical perspective—a review, Drug Deliv Transl Res, 3 (2013) 42–62.
PT

[271] P.G. Djupesland, J.C. Messina, R.A. Mahmoud, Nasal approach to delivering treatment
for brain disease: An anatomic, physiologic and delivery technology overview, Ther
CE

Deliv, 5 (2014) 709-733.

[272] Optinose, OptiNose to Present at the 34th Annual J.P. Morgan Healthcare Conference.
AC

http://www.optinose.com/press-releases/optinose-to-present-at-the-34th-annual-j-p-
organ-healthcare-conference.

[273] D.S. Quintana, L.T. Westlye, Q.G. Rustan, N. Tesli, C.L. Poppy, H. Smevik, M.
Tesli, M. Røine, R.A. Mahmoud, K.T. Smerud , P.G. Djupesland, O.A. Andreassen,
Low-dose oxytocin delivered intranasally with Breath Powered device affects social-
cognitive behavior: a randomized four-way crossover trial with nasal cavity dimension
assessment, Transl Psychiatry, 5 (2015) e602.

[274] Optinose, OptiNose® Announces Pipeline Project to Evaluate Nose- to-Brain


Application of Bi-Directional™ Breath Powered® Technology Selected for Norwegian
Government Funding 2016. http://www.optinose.com/press-releases/optinose-announces-
ACCEPTED MANUSCRIPT

pipeline-project-to-evaluate-nose-to-brain-application-of-bi-directional-breath-powered-
technology-selected- for-norwegian-government-funding.
[275] M. Pozzoli, P. Rogueda, B. Zhu, T. Smith, P.M. Young, D. Traini, F. Sonvico, Dry
Powder Nasal Drug Delivery: Challenges, Opportunities and a study of the commercial
Teijin Puvlizer Rhinocort® device and formulation, Drug Dev Ind Pharm, 42 (2016)
1660-68.
[276] Platform technology. http://www. SNBL.com

[277] S. Haruta, T. Tsutsui, Meeting the needs for nasal delivery devices for powder

T
formulations, Drug Dev Deliv, 12 (2012) 22–27.
[278] R.S. Kaye, T.S. Purewal, O.H. Alpar, Development and testing of particulate

IP
formulations for the nasal delivery of antibodies, J Control Rel, 135 (2009)127–135.
[279] J. Huanga, R.J. Garmise, T.M. Crowder, K. Mara, C.R. Hwanga, A.J. Hickey, J.A.

CR
Mikszta, V.J. Sullivana, A novel dry powder influenza vaccine and intranasal delivery
technology: induction of systemic and mucosal immune responses in rats, Vaccine, 23
(2004) 794–801.

US
[280] W.E. Berger, J.W. Godfrey, A.L. Slater, Intranasal corticosteroids: the development of a
drug delivery device for fluticasone furoate as a potential step toward improved
compliance, Expert Opin Drug Deliv, 4 (2007) 689–701.
AN
[281] M. Penttilä, P. Poulsen, K. Hollingworth, M. Holmström, Dose-related efficacy and
tolerability of fluticasone propionate nasal drops 400 μg once daily and twice daily in the
treatment of bilateral nasal polyposis: a placebo-controlled randomized study in adult
M

patients, Clin Exp Allergy, 30 (2000) 94–102.


[282] P. Merkus, F.A. Ebbens, B. Muller, W.J. Fokkens, Influence of anatomy and head
position on intranasal drug deposition, Eur Arch Otorhinolaryngol, 263 (2006) 827-32.
ED

[283] M.T. Vidgren, H. Kublik, Nasal delivery systems and their effect on deposition and
absorption, Adv Drug Deliv Rev, 29 (1998)157-177.
PT

[284] B. Marple, P. Roland, M. Benninger, Safety review of benzalkonium chloride used as a


preservative in intranasal solutions: an overview of conflicting data and opinions,
Otolaryngol Head Neck Surg, 130 (2004) 131-41.
CE

[285] A. Rapoport, P. Winner, Nasal delivery of antimigraine drugs: clinical rationale and
evidence base, Headache, 46 (2006) S192-201.
AC

[286] C.S. Hankin , L. Cox, D. Lang, A. Bronstone, Z. Wang, M.S. Lepore , P.O. Buck,
Medical costs and adherence in patients receiving aqueous versus pressurized aerosol
formulations of intranasal corticosteroids, Allergy Asthma Proc, 33 (2012) 258-64.
[287] K. Heslop, How to use pressurised metered dose inhalers, Nurs Times, 104 (2008) 47,
78–80.

[288] E.A. Gross, J.A. Swenberg, S. Fields, J.A. Popp, Comparative morphometry of the nasal
cavity in rats and mice, J Anat,135 (1982) 83–8.

[289] E.E. Morrison, R.M. Costanzo, Morphology of the human olfactory epithelium, J Comp
Neurol, 297 (1990) 1–13.
ACCEPTED MANUSCRIPT

[290] J.D. Hoekman, R.J. HO, Enhanced analgesic responses after preferential delivery of
morphine and fentanyl to the olfactory epithelium in rats, Anesth Analg, 113(2011) 641–
651.

[291] V. Brown, F. Liu, Intranasal Delivery of a Peptide with Antidepressant-Like Effect,


Neuropsychopharmacology, 39 (2014) 2131–2141.

[292] J.D. Hoekman, R.J. HO, Effects of Localized hydrophilic mannitol and hydrophobic
nelfinavir administration targeted to olfactory epithelium on brain distribution, AAPS
Pharm Sci Tech, 12 (2011) 534–543.

T
IP
[293] J.D. Hoekman, M. Hite, A. Brunelle, J. Relethford, R.J. HO, Nasal drug delivery device,
WOO2012119153 A2, 2012.

CR
[294] J.D. Suman, B.L. Laube, R. Dalby, Comparison of nasal deposition and clearance of
aerosol generated by nebulizer and an aqueous spray pump, Pharm Res, 16 (1999) 1648–
1652.

US
[295] W. Moller, G.K. Saba, K. Haussinger, S. Becker, M. Keller, U. Schuschnig, nasally
inhaled pulsating aerosols: lung, sinus and nose deposition, Rhinology, 49 (2011) 286–
AN
291
[296] T.C. Chen, C.D. Fonseca, A.H. Schönthal, Perillyl Alcohol and its drug-conjugated
derivatives as potential novel methods of treating brain metastases, Int J Mol Sci,
M

17 (2016)1463.

[297] B. Laul, Devices for aerosol delivery to treat sinusitis, J Aerosol Med, 20 (2007) S5-
ED

S-17.
[298] M. Giroux, Controlled Particle Dispersion. Effective Nasal Delivery from a Versatile,
Flexible delivery Platform. On Drug Delivery Ltd, East Sussex, UK, (2005) 13-15.
PT

[299] S. Craft, L.D. Baker, T.J. Montine, S. Minoshima, G.S. Watson, A. Claxton, M.
Arbuckle, M. Callaghan, E. Tsai, S.R. Plymate, P.S. Green, J. Leverenz, D. Cross, B.
CE

Gerton, Intranasal insulin therapy for Alzheimer disease and amnestic mild cognitive
impairment: a pilot clinical trial, Arch Neurol, 69 (2012) 29–38.
[300] P.G. Djupesland, Intranasal insulin improves cognition and modulates beta-amyloid in
early AD, Neurology,70 (2008) 440-448.
AC

[301] C.C. Wolf, Nosy Neuroprotection: Intranasal administration of neuroprotective agents


to the brain, Cryonics Magazine, 28 18-20.
[302] X. Jinxiang X, W. Zhaoxuan, N. Danielle, W. Thomas, Z. Yue, Nasal and Olfactory
deposition with Normal and Bidirectional Intranasal Delivery Techniques: In Vitro Tests
and Numerical Simulations, J Aerosol Med Pulm Drug Deliv, 2016.
[303] M. Stützle, S. Carle, L. Engelhardt, U. Simon, A. Schafmeister, C. Mavoungou, K.
Schindowski, Protein aerosol for intranasal nose to brain (N2B) delivery, BMC Proc, 9
(2015) O11.
ACCEPTED MANUSCRIPT

[304] J.D. Hoekman, M. Hite, A. Brunelle, J. Relethford, R.J. HO, Nasal drug delivery device,
US 20140014104, 2014.

[305] J.D. Hoekman, M. Hite, A. Brunelle, J. Relethford, R.J. HO, Nasal drug delivery device,
CN103917265 A, 2014.
[306] Q. Mingxin, H.E. Renyang, S.H.I. Junwei, Brain-Targeted Nasal Drug Delivery Device
and Body Position Fixator Thereof", WIPO Patent WO/2015/127857.

[307] D. Mittal, A. Ali, S. Md, S. Baboota, J.K. Sahni, J. Ali, Insights into

T
direct nose to brain delivery: current status and future perspective, Drug Deliv, 21(2014)

IP
75-86.

CR
US
AN
M
ED
PT
CE
AC
ACCEPTED MANUSCRIPT

T
IP
CR
US
AN
M
ED

Graphical abstract
PT
CE
AC