Technical field of the invention

The present invention relates to Rufinamide or derivatives thereof for use in the treatment of myotonia. In particular, the present invention relates to

pharmaceutical compositions comprising Rufinamide or derivatives thereof for use in the treatment of Myotonia congenita, hyperkalaemic paralysis, hypokalaemic paralysis, Paramyotonia Congenita and myotonic dystrophy. Background of the invention

Myotonia congenita and myotonic dystrophy are skeletal muscle disorders associated with loss of CIC-1 ion channel function. The CIC-1 channel dysfunction results in a large reduction in the membrane conductance of muscle fibres and, in turn, results in muscle fibre hyperexcitability. This hyperexcitability introduces spontaneous action potential excitations that triggers spontaneous contractions and delayed relaxation of muscle, which are the clinically hallmarks of myotonia. To alleviate myotonic symptoms, anti-myotonic treatment has generally focussed on dampening the sodium current through the voltage gated sodium channels (NaV1.4) that are responsible for creating the upstroke of the action potential in muscle fibers. Pharmacologically, such Navl.4 blockade has been accomplished with Mexilitine or Tocainide. However, both of these drugs have variable effects on myotonia, and they have been withdrawn from the market in some countries due to their adverse side effects. Therefore, there is currently no FDA-approved treatment for myotonia congenita. From this, it is clear that while Navl.4 is a validated target in anti-myotonic treatment there is a need for new

pharmaceutical approaches for inhibition or modulation of these channels.

EP0199262 (A2) discloses fluorinated benzyl triazole compounds and methods of producing such compounds.

Hence, an improved treatment of myotonia would be advantageous, and in particular a more efficient and/or reliable treatment of symptoms associated with myotonia would be advantageous. Summary of the invention

The present study has used clinically approved anti-convulsant, sodium channel modulating drugs to test whether they can reduce myotonia in rat and human muscle. Specifically, it explores whether myotonia can be reduced by: i) a depolarising shift in the activation curve for Navl.4, ii) a hyperpolarizing shift in the slow-inactivation curve, or facilitated entry into this state, and iii) a

hyperpolarizing shift in the inactivation curve.

The present study shows that Lacosamide (LCM), Rufinamide (RUF) and

Lamotrigine (LTG) were all capable of reducing myotonic contractions in CIC-1 inhibited rat and human muscles. Importantly, these anti-myotonic effects were observed at clinically accepted concentrations. The combination of LTG and RUF furthermore showed a clear synergistic anti-myotonic effect.

Thus, an object of the present invention relates to providing drugs/compositions for use in the treatment of myotonia.

Thus, one aspect of the invention relates to a (pharmaceutical) composition comprising Rufinamide or active derivatives thereof according to formula (I) :

wherein,

- A is an aryl or heteroaryl,

R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, optionally R ¹ and/or R ² are absent,

- X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, - Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide, for use in the

- treatment of myotonia; and/or

- treatment or alleviation of symptoms associated with myotonia; wherein said active derivatives thereof are capable of inhibiting and/or modulating the Navl.4 voltage-gated sodium channel. In a preferred embodiment, the compound of formula (I) is Rufinamide.

A second aspect of the invention relates to a (pharmaceutical) composition comprising Rufinamide for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia.

In an additional aspect, the invention relates to a (pharmaceutical) composition comprising Lacosamide (LCM) or Lamotrigine (LTG) for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia. Preferably, the symptoms are muscle damage and/or muscle wasting.

Another aspect of the present invention relates to a (combinatorial) composition comprising

- Rufinamide or active derivatives thereof according to formula (I) :

wherein,

- A is an aryl or heteroaryl, R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amineoptionally R ¹ and/or R ² are not present,

- X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine,

- Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5

alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide,

Lamotrigine or active derivatives thereof according to formula (II)

wherein,

- Z and Q are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide,

R' and R" are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide, optionally R ^' and/or R ^" are absent, wherein said active derivatives thereof, are capable of inhibiting and/or

modulating the Na _v 1.4 voltage-gated sodium channel. In a preferred embodiment, the compound of formula (I) is Rufinamide, and the compound of formula (II) is Lamotrigine.

Yet another aspect of the present invention is to provide a kit of parts comprising a first composition comprising Rufinamide or active derivatives thereof according to formula (I) :

wherein,

- A is an aryl or heteroaryl,

R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, optionally R ¹ and/or R ² are absent,

- X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine,

- Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5

alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide, and a second composition comprising Lamotrigine or active derivatives thereof;

according to formula (II)

R" (ID wherein,

- Z and Q are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide,

R' and R" are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide, optionally R ¹ and/or R ² are absent, wherein said active derivatives thereof, are capable of inhibiting and/or

modulating the Na _v 1.4 voltage-gated sodium channel, for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia. In a preferred embodiment, the compound of formula (I) is Rufinamide, and the compound of formula (II) is Lamotrigine. An additional aspect relates to a method of treating a subject in need of treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia, the method comprising administrating a composition according to the invention to the subject. Brief description of the figures

Figure 1

Figure 1 shows that Lacosamide, Rufinamide and Lamotrigine reduce myotonia in rat soleus. Al, Bl and CI all show the force responses to 15 Hz stimulation for 2 s with 0.2 ms pulses in representative isolated rat soleus muscles. A2, B2 and C2 show force responses to this stimulation after incubation with 9-AC to block CIC-1 channels and this introduces myotonia akin to myotonia congenita and myotonic dystrophy. The dotted line in A2 indicates cessation of stimulation and the force integral above this line was quantified as the myotonic response (Tail AUC). A3 and A4 show the myotonic response after adding 2 and 5 μΜ LCM, respectively. Similarly, B3 and B4 show response to 20 and 100 μΜ RUF, and C3 and C4 show force responses in the presence of 2 and 16 μΜ LTG. D shows AUC from individual muscles plotted as % of maximal AUC (A2, B2, C2) at a range of concentrations of LCM, with the 3-parameter sigmoidal fit for each muscle (n = 20). E and F show similar data for RUF (n = 10) and LTG (n = 10), respectively.

Figure 2

Figure 2 shows that Lacosamide, Rufinamide and Lamotriqine reduce myotonia in isolated human abdominal rectus muscle. Al shows force response from a bundle of human abdominal muscle stimulated for 2 s at 15 Hz by 0.2 ms pulses. As in rat muscles myotonia was induced with 9-AC and quantified from the AUC as determined from the cessation of stimulation to force returned to baseline. A2 shows the force response to block of CIC-1 channels with 9-AC. A3 shows the response to stimulation in the presence of 9AC and 20 μΜ RUF, and A4 shows the response in the presence of 9AC and 80 μΜ RUF. B Shows AUC from individual muscle bundles as % of maximal AUC (A2) at a range of concentrations of LCM, with 3 parameter sigmoidal fit for each muscle bundle (n = 5). C and D show similar data for RUF (n=4) and LTG (n = 6), respectively.

Figure 3

Figure 3 shows the synergistic effect of LTG and RUF. Al shows the force response to 15 Hz stimulation for 2 s with 0.2 ms pulses, in isolated rat soleus muscles. A2 shows force response after incubation with 9-AC to block CIC-1 channels, introducing myotonia. A3 shows the force response in the presence of 9AC and 0.5 μΜ LTG. A4 shows the force response when i LTG was raised to 8 μΜ RUF. A5 and A6 show force response when RUF was further raised to 18 μΜ and 144 μΜ, respectively. B Shows an isobole plot that depicts the concentrations of RUF that was required to abolish 50 % of maximal AUC in the presence of a given concentration of LTG. Two fixed concentrations of LTG were used to determine the synergy effect of RUF and LTG: 0.5 μΜ (n = 6) and 1 μΜ (n = 4). The dashed line shows the best hyperbolic fit to the data, indicating the expected RUF concentration to be used along with a given LTG concentration. The solid line indicates the concentration of RUF at any given LTG concentration that would be expected if the drugs acted purely in an additive manner. Data points below this line reflect that drugs act in a synergistic manner.

Figure 4

Figure 4 shows effects of myotonia and RUF or LTG on release of lactate dehydrogenase (LDH), an indirect measure of damage from rat EDL muscles. In all cases a sample was taken before stimulation (Pre), the muscles were then stimulated to contraction for 2 s at 30 Hz by 0.2 ms pulses every 3 minutes for 60 min (20 stimulations) or left resting. Open symbols are from muscles incubated with 9AC ± LTG or RUF. Solid triangles are from muscles incubated with 9AC without stimulation. Immediately after cessation of stimulation, a new sample was taken from solution incubating the muscles. For the next 180 minutes a sample was taken from the incubating solution every 30 minutes, as designated by the time after stimulation. The period from cessation of stimulation to 180 min after stimulation is termed recovery.

Figure 5

Figure 5 shows schematic drawings of the two compounds, Compound 1 (5- amino-l-benzyl-lH-l,2,3-triazole-4-carboxamide) and Compound 2 (l-benzyl-5- methyl-lH-l,2,3-triazole-4-carboxamide), with UPAC name above each

compound. B shows the relative area under the curve (AUC) from rat soleus muscle stimulated at 60 Hz, 2s with 0.2 ms pulses, incubated with 9AC to induce myotonia by blocking CIC-1 channels. When myotonia had fully developed (100 % AUC) the compounds were added at increasing concentrations, and myotonia was tested at each concentration (60 Hz, 2s). Data from the experiments was fitted to a 3-parameter sigmoid function, and the resulting fit is shown as a solid line for each muscle. Each compound was tested on two muscles.

The present invention will now be described in more detail in the following. Detailed description of the invention

Definitions

Prior to discussing the present invention in further details, the following terms and conventions will first be defined :

Myotonia

Myotonia is a symptom of a small handful of certain neuromuscular disorders characterized by delayed relaxation (prolonged contraction) of the skeletal muscles after voluntary contraction or electrical stimulation.

Myotonia is present in Myotonia congenita, hyperkalaemic paralysis, hypokalaemic paralysis, Paramyotonia Congenita and myotonic dystrophy.

Myotonic dystrophy

Myotonic dystrophy (dystrophia myotonica, myotonia atrophica) is a chronic, slowly progressing, highly variable, inherited multisystemic disease. It is an autosomal-dominant disease. It is characterized by wasting of the muscles (muscular dystrophy), cataracts, heart conduction defects, endocrine changes, and myotonia.

There are two main types of myotonic dystrophy. Myotonic dystrophy type 1 (DM1), also called Steinert disease, has a severe congenital form and an adult- onset form. Myotonic dystrophy type 2 (DM2), also called proximal myotonic myopathy (PROMM) is rarer than DM1 and generally manifests with milder signs and symptoms. Myotonic dystrophy can occur in people of any age. Both forms of the disease display an autosomal-dominant pattern of inheritance. Both DM1 and DM2 have adult-onset forms.

Myotonia congenita

Congenital myotonia (also myotonia congenita), is a genetic, neuromuscular channelopathy that affects skeletal muscles (muscles used for movement). The hallmark of the disease is the failure of initiated contraction to terminate, often referred to as delayed relaxation of the muscles (myotonia) and rigidity. The disorder is caused by mutations in part of a gene (CLCN1) encoding the CIC-1 chloride channel, resulting in muscle fiber membranes to have an unusually exaggerated response to stimulation (hyperexcitability). Symptoms include delayed relaxation of the muscles after voluntary contraction (myotonia), and may include stiffness, hypertrophy (enlargement), transient weakness in some mutations, and cramping.

Paramyotonia Congenita

Paramyotonia Congenita results from mutation in the SCN4A gene encoding the voltage-gated sodium channel in skeletal muscle fiber membrane, Navl.4.

Mutations may alter the kinetics of the channel, such that the channel fails to inactivate properly, thus allowing spontaneous action potentials to occur after voluntary activity has terminated, prolonging relaxation of the muscle, or can result in paralysis if the relaxation is severely prolonged.

Rufinamide

Rufinamide (RUF) has the systematic UPAC name: l-(2,6-Difluorobenzyl)-lH- l,2,3-triazole-4-carboxamide. Trade names of Rufinamide are Banzel (US) and Inovelon (EU). Rufinamide may also be described by its chemical structure by formula (III) :

Rufinamide is an anticonvulsant medication. It is used in combination with other medication and therapy to treat Lennox-Gastaut syndrome and various other seizure disorders.

Thus, in an embodiment Rufinamide is given by the formula (III) :

In another embodiment, Rufinamide is given by the formula (UPAC): l-(2,6-Difluorobenzyl)-lH-l,2,3-triazole-4-carboxamide.

Lamotrigine

Lamotrigine (LTG) has the systematic UPAC name: 6-(2,3-dichlorophenyl)-l,2,4- triazine-3,5-diamine. Lamotrigine may also be described by its chemical structure by formula (IV) :

Lamotrigine is marketed in most of the world as "Lamictal", Lamotrigine is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used off-label as an adjunct in treating clinical depression. For epilepsy, it i used to treat focal seizures, primary and secondary tonic-clonic seizures, and seizures associated with Lennox-Gastaut syndrome.

Thus, in an embodiment, Lamotrigine is given by the formula (IV) :

In yet an embodiment, Lamotrigine is given by the formula (UPAC) :

6-(2,3-dichlorophenyl)-l,2,4-triazine-3,5-diamine. Lacosamide

Lacosamide (LCM) has the systematic UPAC name: V ² -acetyl- V-benzyl-D- homoserinamide. Lacosamide may also be described by its chemical structure by formula V) :

Lacosamide (LCM) (INN, formerly known as eriosamide, harkeroside, SPM 927, ADD 234037) is a medication developed by Union Chimique Beige (UCB) for the adjunctive treatment of partial-onset seizures and diabetic neuropathic pain marketed under the trade name Vimpat.

Thus in an embodiment, Lacosamide (LCM) is given by the formula (V) :

In yet an embodiment, Lacosamide (LCM) is given by the formula (UPAC): V ² -acetyl- V-benzyl-D-homoserinamide.

Therapeutically effective amount

In the present context, the term "therapeutically effective amount" relates to a concentration or (daily) dosage, which is sufficient to treat myotonia, or treat or alleviate symptoms associated with myotonia.

Nayl.4 voltage-gated sodium channel

The Navl.4 voltage-gated sodium channel is encoded by the SCN4A gene.

Mutations in the gene are associated with hypokalemic periodic paralysis, hyperkalemic periodic paralysis, paramyotonia congenita, and potassium- aggravated myotonia.

Active derivatives thereof

In the present context, the term "active derivatives thereof" relates to compounds capable of inhibiting and/modulating the Na _v 1.4 voltage-gated sodium channel.

Discussion

The present study aimed to evaluate the effect of three anticonvulsant drugs on myotonia in isolated muscle from rat and human. We found that Lacosamide (LCM), Lamotrigine (LTG) and Rufinamide (RUF) were all able to reduce myotonia within their clinically relevant concentration ranges. However, LCM was not able to reduce myotonia more than 60 ± 2 %, while RUF and LTG both reduced myotonia by 92 ± 2%, within clinically observed concentration ranges. Clear synergistic effect on myotonia was observed for LTG and RUF. The study also reveals that myotonia can cause pronounced muscle damage and that LTG and RUF can prevent this myotonia-induced damage. This was apparent from myotonia causing marked LDH release from myotonic muscles. LDH is a clinically used indicator of muscle damage and its elevation with myotonia in this study strongly suggests that myotonia contributes to the muscle damage and wasting in myotonic dystrophy. Since, RUF and LTG were both able to abolish myotonia and the myotonia-induced damage it is suggested that RUF and LTG could be used to reduce myotonia and thereby muscle wasting in myotonic dystrophy.

Composition comprising Rufinamide for use in the treatment of myotonia In a first aspect, the invention relates to a (pharmaceutical) composition comprising Rufinamide or active derivatives thereof according to formula (I) :

(I) wherein,

- A is an aryl or heteroaryl,

R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, optionally R ¹ and/or R ² are absent,

- X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine,

- Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5

alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide, for use in the

- treatment of myotonia; and/or

- treatment or alleviation of symptoms associated with myotonia; wherein said active derivatives thereof are capable of inhibiting and/or modulating the Navl.4 voltage-gated sodium channel.

A second aspect of the invention relates to a (pharmaceutical) composition comprising Rufinamide for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia.

As shown in examples 1, 2 and 4, Rufinamide (and Lamotrigine and Lacosamide) are capable of inhibiting myotonia in both rat and human muscles. In an embodiment, A is selected from the group consisting of phenyl, pyridine, pyrimidine, pyridazine, pyrazine, pyrrole, pyrazole, imidazole, furane, and thiophene. In another embodiment, A is phenyl.

In yet another embodiment, R ¹ and R ² are in the 2- and 6- (ortho) positions of said phenyl. In a further embodiment, R ¹ and R ² are selected from the group consisting of halogen, methyl, and amine, preferably halogen. In yet a further embodiment R ¹ and R ² are fluorine. In a specific embodiment, R ¹ and/or R ² are absent (see example 5), thus R ¹ and/or R ² are H. In accordance with this specific embodiment, in yet a further embodiment the compound is 5-amino-l-benzyl-lH- l,2,3-triazole-4-carboxamide or l-benzyl-5-methyl-lH-l,2,3-triazole-4- carboxamide.

In an embodiment, X is selected from the group consisting of hydrogen, halogen, methyl and amine, preferably hydrogen.

In another embodiment, Y is a carboxamide, preferably -C(0)NH2.

In yet another embodiment, the optional further substituents are selected from the group consisting of halogen, methyl and amine.

In a preferred embodiment, the composition for use comprises Rufinamide and/or the compound of formula (I) is Rufinamide.

Different types of myotonia exist. Thus, in an embodiment, the myotonia is selected from the group consisting of myotonia congenita, paramyotonia congenita, myotonic hyperkalemic periodic paralysis (HPP) hyperkalaemic hypokalaemic paralysis, and myotonic dystrophy. In another embodiment, the myotonia is myotonia congenita or myotonic dystrophy. In yet an embodiment the myotonia is selected from the group consisting of myotonia congenita, myotonic dystrophy type 1 and myotonic dystrophy type 2.

Different types of symptoms are associated with myotonia. Thus, in an

embodiment, said symptoms are selected from the group consisting of unwilling muscle contractions, muscle stiffening, arrest of movement, delayed relaxation of the muscles after voluntary contraction (myotonia), hypertrophy (enlargement), transient weakness, muscle damage, muscle atrophy, muscle wasting, and cramping, preferably muscle wasting. As further shown in example 4, Rufinamide and Lamotrigine are capable of inhibiting muscle damage in a rat model, tested by the release of LDH. Damage is a precursor for wasting. The composition may further comprise other drugs. Thus, in yet an embodiment, the composition for use further comprises Lamotrigine or active derivatives thereof according to formula (II)

wherein,

- Z and Q are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide,

R' and R" are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide, optionally R ^' and/or R ^" are absent, wherein said active derivatives thereof, are capable of inhibiting and/or modulating the Na _v 1.4 voltage-gated sodium channel. In an embodiment, Z and Q are both amine.

In another embodiment, R' and R" are amine, methyl, or halogen. In yet another embodiment R' and R" are both halogen. In a further embodiment R' and R" are both chlorine. In a specific embodiment, R ^' and/or R ^" are absent (see example 5).

In yet another embodiment, Z and Q are both amine, and R' and R" are both chlorine. In yet another embodiment, the optional further substituents are selected from the group consisting of halogen, methyl and amine.

In a preferred embodiment, the compound of formula (I) is Rufinamide, and the compound of formula (II) is Lamotrigine.

In yet a preferred embodiment, the combined inhibition and/or modulation of the Navl.4 voltage-gated sodium channel achieved when administering the

combinatorial composition according to the invention is greater than the sum of the inhibition and/or modulation achieved when administering the compound of formula (I) and the compound of formula (II) separately. In short, a synergistic effect is obtained. As shown in example 3, a clear synergistic effect between Rufinamide and Lamotrigine is documented by the use of an isobole plot. In yet an embodiment, the composition further comprises Lacosamide (LCM) or active derivatives thereof, wherein said active derivatives thereof, are capable of inhibiting and/or modulating the Na _v 1.4 voltage-gated sodium channel.

The symptoms associated to myotonia may arise from different cellular defects. Thus, in a further embodiment the symptoms associated with myotonia is associated to mutations in the gene (CLCN1) encoding the CIC-1 chloride channel and/or lowered protein expression and/or failure to express the CIC-1 due to CIC- 1 mRNA aggregation. The composition may be administered to a subject by different routes. Thus, in an embodiment the composition is administered orally, topically, subcutaneously or intravenously. Preferably, the composition is orally administered such as in the form of a tablet. It is to be understood that the subject preferably is a mammal, and most preferably is a human.

The daily dosage of Rufinamide may vary. Thus, yet a further embodiment, the composition for use comprises Rufinamide or active derivatives thereof at a therapeutically effective amount, such as in a daily dosage in the range 10 - 7200 mg/day, such as 400-3600 mg/day, such as 100-2100 mg/day or such as 1600- 7200 mg/day. The composition may be further optimized. Thus, in an embodiment the composition for use further comprises a pharmaceutically acceptable adjuvant, diluent, and/or carrier.

Composition comprising Rufinamide and Lamotrigine

As shown in example 3, a surprising synergistic effect between Rufinamide and Lamotrigine in the treatment of myotonia is disclosed. Thus, further aspect of the invention relates to a (combinatorial) composition comprising

Rufinamide or active derivatives thereof according to formula (I) :

wherein,

- A is an aryl or heteroaryl,

- R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, optionally R ¹ and/or R ² are absent,

- X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine,

- Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5

alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide, and

Lamotrigine or active derivatives thereof according to formula (II)

wherein,

- Z and Q are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide,

R' and R" are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide, optionally R ^' and/or R ^" are absent , wherein said active derivatives thereof, are capable of inhibiting and/or modulating the Na _v 1.4 voltage-gated sodium channel.

It is of course to be understood that A, X, Y, Z, N, Q, R' and R" may be selected as previously defined for the previous aspects of the invention.

A further aspect relates to this combinatorial composition for use as a

medicament. In yet a further aspect relates to this combinatorial composition for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia.

Yet a further aspect relates to this combinatorial composition further comprising a pharmaceutically acceptable adjuvant, diluent, and/or carrier.

An embodiment also relates to the combinatorial composition according to the invention comprising Rufinamide or active derivatives thereof according to formula (I), at a therapeutically effective amount; and

Lamotrigine or active derivatives thereof according to formula (II), at a therapeutically effective amount.

In yet another embodiment the therapeutically effective amount is sufficient to treat myotonia, or treat or alleviate symptoms associated with myotonia. The symptoms are as previously described. A more specific embodiment of the invention, relates to the combinatorial composition according to the invention comprising

5 - 7200 mg Rufinamide or active derivatives thereof according to formula

(I) ; and

- 5 - 800 mg Lamotrigine or active derivatives thereof according to formula

(II) .

Kit of parts

The combinatorial treatment may be administered simultaneously or in any order to achieve the desired treatment as outlined above.

Thus yet an aspect of the invention relates to a kit of parts comprising a first composition comprising Rufinamide or active derivatives thereof according to formula (I) :

wherein,

- A is an aryl or heteroaryl, R ¹ and R ² are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, optionally R ¹ and/or R ² are absent,

X is selected from the group consisting of hydrogen, halogen, C1-C5 alkyl,

C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine,

Y is selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and

carboxamide, and a second composition comprising Lamotrigine or active derivatives thereof;

according to formula (II)

wherein,

- Z and Q are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide,

- R' and R" are independently selected from the group consisting of halogen, C1-C5 alkyl, C2-C5 alkenyl, C2-C5 alkynyl, optionally substituted ketone, optionally substituted aldehyde, and optionally substituted amine, carboxylic acid and carboxamide, optionally R ^' and/or R ^" are absent, wherein said active derivatives thereof, are capable of inhibiting and/or

modulating the Na _v 1.4 voltage-gated sodium channel, for use in the treatment of myotonia; and/or treatment or alleviation of symptoms associated with myotonia.

It is of course to be understood that A, X, Y, Z, N, Q, R' and R" may be selected as previously defined for the previous aspects of the invention. In a preferred embodiment, the compound of formula (I) is Rufinamide, and the compound of formula (II) is Lamotrigine.

It should be noted that embodiments and features described in the context of one of the aspects of the present invention also apply to the other aspects of the invention. This in particular, relates to the described formulas, and possible substituents.

All patent and non-patent references cited in the present application, are hereby incorporated by reference in their entirety.

The invention will now be described in further details in the following non-limiting examples.

Examples

Example 1

Aim

To test whether Rufinamide (RUF), Lamotrigine (LTG) and Lacosamide (LCM) can abolish myotonia induced by CIC-1 inhibition in rat soleus muscles. Methods

Animal handling

No experiments were performed on live animals, and all handling and killing of animals complied with Danish animal welfare regulations and the local guidelines for animal handling at Aarhus University. Contractile force was measured in soleus muscles after dissection from young 4-week-old male/female Wistar rats (65-

75 g) that were obtained from Janvier laboratories. All animals were fed ad libitum and kept at constant temperature (21 °C) and day length (12 h). Solutions and compounds

The standard Krebs-Ringer solution used for incubation during experiments contained (mM): 122 NaCI, 25 NaHCOs, 2.8 KCI, 1.2 KH ₂ P0 ₄ , 0.6 MgS0 ₄ , 1.27 CaCI ₂ and 5 D-glucose. In all experiments, solutions were maintained at 30 °C and equilibrated with a mixture of 95% 0 ₂ and 5% C0 ₂ (pH~7.4). To induce experimental myotonia, 100 μΜ of the CIC-1 channel inhibitor 9-anthracene- carboxylic acid (9AC) (Sigma Aldrich, DK) dissolved in DMSO (Sigma Aldrich, DK) was added to the incubation solution. The final DMSO concentration never exceeded 0.35%. Measurement of contractile force

The force produced during isometric contractions of the muscles was recorded using an experimental setup that has previously been described in detail (Skov M, Riisager A, Fraser JA, Nielsen OB, Pedersen TH. Extracellular magnesium and calcium reduce myotonia in CIC-1 inhibited rat muscle. Neuromuscular Disorders 2013 06;23(6) :489-502). Briefly, field stimulation across the central part of the muscle (0.2 ms pulses, 24-30 V/cm) was used to trigger contractile activity. At the beginning of incubation in the experimental chambers, the muscles were stretched to the length that resulted in maximum active twitch force (2 Hz). In all experiments, muscles were stimulated every 10 min at 15 Hz for 2 s. To quantify myotonic behaviour of the muscles, including increased force and prolonged relaxation, the force-time integral of the active force responses (area under curve, AUC) was determined for each contraction, with the active force being calculated as the difference between the total and the resting force after cessation of electrical stimulation. To assess the effect of LCM, RUF and LTG on myotonia the tail AUC of the force response was used. This corresponds to the AUC from cessation of stimulation-induced contraction until full relaxation (see Figure 1 in example 1). To determine the dose-response relationship of between myotonia and drug, muscles were incubated with 9AC and stimulated until a stable myotonic phenotype had developed (usually 5-7 stimulations). Muscles were then incubated at progressively increasing concentration of drug with each drug concentration being tested for at least 30 min (three stimulations), before further increase in concentration. In experiments where combinations of drugs were tested, muscles were incubated for 30 min at every combination of drugs before evaluating the effect of the drugs. After this the drug concentrations were further increased.

Statistical analysis

All average data is presented as means with SEM. Statistically significant difference between two data groups was ascertained using Student's two-tailed t test for paired or un-paired observations as appropriate. One way analysis of variance (ANOVA) was used for comparison of more than two data groups with Holm-Sidak post hoc test to detect significant differences between individual groups. P-values of less than 0.05 were considered to indicate significant difference between tested groups. Data from dose-response experiments were fitted to a 3 parameter sigmoidal function to get the concentration were half the myotonia had been suppressed (EC50, Table 1).

Results

Isolated rat soleus

To first test for effects of the three drugs (RUF, LCM and LTG) on force in non- myotonic rat soleus muscles, muscles were exposed to 2 s stimulations at both 5 Hz and 60 Hz every 10 mins during three hrs of drug incubation. The drug concentrations were the highest free concentrations that are tolerated clinically: For both 5 and 60 Hz stimulation, incubation with 5 μΜ LCM reduced force by -6-8 % in two muscles. With 25 μΜ LTG force was reduced by ~ 6 % in three muscles, and with 100 μΜ RUF force was reduced by 4 % in three muscles. In all cases, these reductions in force during the three hours were similar to reductions observed in time-matched control muscles.

In the first series of experiments assessing for effects of RUF, LCM and LTG on myotonia, the myotonic phenotype was induced by incubating the muscles with either 100 μΜ of the CIC-1 channel blocker 9AC, or by reducing CI ^" concentration in the bathing solution to 30 (n = 8) or 10 (n = 8) mM (rat soleus, LCM treated). These approaches for reducing CIC-1 function were taken to resemble the CIC-1 dysfunction in myotonia congenita and myotonic dystrophy. Accordingly, incubation with 9AC or reduction in CI ^" concentration resulted in marked prolongation of relaxation, and increased maximal force when stimulated at 15 Hz for 2 s, as exemplified by Figure 1 (Al, Bl and CI vs. A2, B2 and C2). The addition of 2 μΜ LCM to the incubation solution reduced AUC by -40 %, Fig. 1 (A2 vs. A3). Increasing the LCM concentration to 5 μΜ reduced AUC by another -20 % (Fig. 1 A4). Likewise addition of 20 μΜ RUF to 9AC treated muscles reduced AUC by more than 50 % (Fig. 1 B2 vs. B3), and when RUF concentration was increased to 100 μΜ the AUC was reduced by -98% (Fig. 1 B4). Finally, addition of 2 μΜ LTG reduced AUC by -46% at (Fig .1 C3) and when LTG concentration was increased to 16 μΜ the AUC was reduced by -98% (Fig. 1 C4). All three anti- convulsants (drugs) were able to completely abolishing myotonia if their concentrations were increased sufficiently. To quantify the dose dependency of the drugs on myotonia, the AUCs at different drug concentrations were plotted against drug concentration and the resulting plots of drug concentration versus degree of myotonia are shown for each drug in Fig. 1 D, E and F for LCM, RUF and LTG, respectively. Curves resulting from fitting data to a 3-parameter sigmoid equation are shown for individual muscles in each treatment group in Fig 1D-F. Drugs were tested at concentrations that cover the whole clinical range (in μΜ); LCM from 0.5 to 80, LTG from 0.5 to 32 and RUF from 0.5 to 120. In every single muscle tested did AUC decline with increasing concentrations of drug. The concentration required to reduce AUC to 50 % of maximal value (ECso) are listed in Table 1 for each drug.

Table 1 :

Conclusion

Overall, these results show that the three anti-convulsants (Lacosamide,

Lamotrigine and Rufinamide) are able to completely abolish myotonia in a dose depending manner in a rat model.

Example 2

Aim To investigate if the three anti-convulsant drugs (Rufinamide (RUF), Lamotrigine (LTG) and Lacosamide (LCM)) are capable of reducing myotonia in human muscles. Methods

Human tissue

The use of human muscles was approved by the Danish Ethics Committee, Region Midtjylland, Comite I (reference number 1-10-72-20-13) and was performed in accordance with the Helsinki Declaration. Informed consent was obtained from all subjects before inclusion. Muscles were obtained from 4 male subjects admitted in relation to planned aortic aneurysm surgery at Skejby hospital. Isolation of tissue from subjects was performed as described earlier (Skov M, De Paoli FV, Lausten J, Nielsen OB, Pedersen TH. Extracellular magnesium and calcium reduce myotonia in isolated CIC-1 chloride channel-inhibited human muscle. Muscle Nerve. 2015 Jan;51(l) : 65-71). After isolation the tissue was transported to the laboratory at the University (<30 min) in a HEPES based solution (pH 7.4) at ~5 °C. Upon arrival to the laboratory, the tissue was incubated in often-replaced fresh Krebs- Ringer bicarbonate solution equilibrated with 5% CO2 in oxygen at 30 °C for 10 to 20 min, before further dissection into smaller bundles of approx. 4 cm length weighing 515 ± 61 mg. For contraction experiments, bundles were tied at both ends with polyester string, to enable mounting of the preparations in the setups for measurement of contractile force.

Solutions, contraction setup, data analysis and statistics

As in Example 1.

Results

The experiments in Fig. 1 were repeated for small muscle bundles of human abdominal muscle. 9AC was used to induce myotonia and, subsequently, LCM, RUF or LTG were added at increasing concentrations. In all cases, myotonia was reduced with increased concentration of drug. Figure 2A shows traces from a single bundle of isolated human muscle stimulated at 15 Hz for 2 s before and after exposure to RUF. Myotonia was induced by incubation with 100 μΜ 9AC, and subsequent additions of RUF reduced myotonia gradually with almost full abolishment of myotonia at 80 μΜ. Similar traces were obtained with LCM- and LTG-treated bundles of human muscle. Figure 2B-D show data and sigmoidal fits from individual bundles with additions of LCM (n=5), RUF (n=5) and LTG (n=6), respectively. The concentrations required to reduce AUC to 50 % of maximal value (EC50) are listed in Table 2 for each drug. Table 2:

Conclusion

Overall, these results show that the three anticonvulsants (Lacosamide,

Lamotrigine and Rufinamide) are able to completely abolish myotonia in a dose dependent manner in isolated human muscles.

Example 3

Aim

To determine if the drugs had additive or synergistic effects on myotonia.

Methods

As described in Example 1. Results

Effect of combining drugs

Rufinamide, Lamotrigine and Lacosamide all reduced myotonia at concentrations that are within the observed free serum concentrations in patients. However, while Lacosamide had to be raised above clinically accepted concentrations to abolish myotonia, the concentrations of Lamotrigine and Rufinamide that were required to abolish myotonia were well within the clinically accepted ranges.

To determine if additive or synergistic effects could be observed when drugs were combined, experiments with the following combinations of drugs were next performed : LCM-RUF, LCM-LTG, LTG- RUF and all three together. In all these experiments, rat soleus muscles were used. As with either drug alone, a marked reduction in AUC was observed with any combination of drugs. Hence, combining 2 μΜ LCM with 9 μΜ RUF, which roughly corresponded to half the EC50 values for these drugs (Table 1), the AUC of the isolated myotonic muscle was reduced by 58 ± 9 %. When concentrations were raised to 4 μΜ LCM and 18 μΜ RUF, the AUC was reduced by 88 ± 1.3 % and when concentration were finally raised to 150 % of their EC50 values, the AUC was reduced by 95 ± 0.45 %. Likewise, incubation with 4 μΜ LCM and 1.5 μΜ LTG resulted in a reduction in AUC by 79 ± 3.6 % and with 1.5 μΜ LTG and 18 μΜ RUF the AUC was reduced by 74 ± 6.9 %. When muscles were incubated with all three drugs at EC50 values of each drug, the AUC was reduced by 87 ± 2.1 %.

To test for synergistic effects of RUF and LTG a series of experiments were conducted that enabled a drug isobole to be determined. In these experiments rat soleus muscles were first exposed to 9AC to induce the myotonic phenotype (Fig. 3 Al vs A2). Then 0.5 μΜ LTG was added and this resulted in a slight reduction in AUC to 90 % of the full myotonic state (Fig. 3 A2 vs A3). Muscles were next subjected to increasing concentrations of RUF to determine the EC50 value under these conditions of a low concentration of LTG (0.5 μΜ LTG). Fig. 3A4 shows that at 0.5 μΜ LTG, the RUF concentration only had to be raised to 7 μΜ RUF for AUC to be reduced by 50 %. Such experiments were also conducted with preincubation with 1 μΜ LTG and under these conditions 3.1 μΜ RUF was enough to reduce AUC by 50 %. To determine if the combined actions of LTG and RUF could be considered synergistic, these observations were used to construct an isobole plot (Tallarida RJ. Revisiting the isobole and related quantitative methods for assessing drug synergism. J. Pharmacol. Exp. Ther (US, 2012) Jul;342(l) 2-8.) In such plots the abscissa and ordinate show drug concentrations of the two explored drugs. The EC50 for the drugs when administered alone are connected with a simple line. This line is then considered to reflect the concentrations of drugs that will have half effect if the drugs are simply additive in action. The area below the line reflects drug combinations for synergistic drug effects while the area above the line reflect antagonistic drug interaction. As can be seen from Fig. 3B, the 7 μΜ RUF at 0.5 μΜ LTG was in fact 5 μΜ less than what was expected if RUF and LTG acted purely additively, and 3.1 μΜ RUF at 1 μΜ LTG was 3 μΜ less than predicted by the assumption of additivity. Thus in both cases the RUF concentration needed to be added to reach half effect was around 50 % of the concentration that would be expected if the drugs had additive modes of action. This clearly demonstrates that LTG and RUF act synergistically on dampening myotonia.

Conclusion

The presented data shows that Lamotrigine and Rufinamide act synergistically on dampening myotonia. Example 4

Aim

To determine the effect of Rufinamide and Lamotrigine on muscle damage that can induce wasting in vivo. Methods

LDH release measurement

EDL muscles from rats were isolated and placed in small chambers with

oxygenated as previously described in detail (Gissel HI, Clausen T. Excitation- induced Ca(2+) influx in rat soleus and EDL muscle: mechanisms and effects on cellular integrity. Am J Physiol Regul Integr Comp Physiol. 2000 279(3) : R917-24).

Results

To explore for an effect of myotonia on muscle fibre integrity and the effect of the drugs hereupon, the release of the intracellular protein from the muscle, lactate dehydrogenase (LDH), to the incubation solution was determined in contracting EDL muscles. Muscles were stimulated at 15 Hz for 2 s by 0.2 ms pulses every 5 min for 60 min (12 stimulations) and the released LDH was determined before contractions and during 3 hrs after the contraction. As clearly illustrated in Fig. 4, LDH release was only increased after stimulation from muscles if they had been rendered myotonic with 9AC and this myotonia- induced LDH release could be completely blocked with RUF. Very similar effects were observed with LTG. Conclusion The presented data show that Rufinamide and Lamotrigine are capable of inhibiting LDH release, thereby clearly indicating that these drugs may prevent muscle damage, the precursor for muscle wasting in vivo. Example 5

Aim

To determine if analouges of Rufinamide had anti-myotonic effects:

UPAC formula names of compounds:

(1) : 5-amino-l-benzyl-lH-l,2,3-triazole-4-carboxamide

(2) : l-benzyl-5-methyl-lH-l,2,3-triazole-4-carboxamide

Compounds are shown in Fig. 5

Methods

As described in Example 1.

Results

In isolated rat soleus muscle, the myotonic phenotype was induced by incubating the muscles with 100 μΜ of the CIC-1 channel blocker 9AC, and stimulating them at 15 Hz for 2 s by 0.2 ms pulses every 10 min. After myotonia had developed muscles were incubated at increasing concentrations of the two compounds 1 and 2. The resulting reduction in AUC is shown in Fig. 5 B. Both compunds were able to completely abolish myotonia. The ECso values for the compounds were 24.7 μΜ for 1 and 19.1 μΜ for 2. Conclusion

The presented data shows that the two analouges of Rufinamide are able to reduce myotonia in a dose dependent manner similar to that of Rufinamide.

Abbreviations 9AC, 9-anthracenecarboxylic acid; AUC, area under the curve;

LCM, Lacosamide, [(2R)-2-acetamido-N-benzyl-3-methoxy-propanamide]; LTG, Lamotrigine, [6-(2,3-Dichlorophenyl)-l,2,4-triazine-3,5-diamine]; RUF, Rufinamide, [l-(2,6-Difluorobenzyl)-l -l,2,3-triazole-4-carboxamide];