US20210015813A1 - Treatment of demyelinating diseases - Google Patents

Treatment of demyelinating diseases Download PDF

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US20210015813A1
US20210015813A1 US16/978,542 US201916978542A US2021015813A1 US 20210015813 A1 US20210015813 A1 US 20210015813A1 US 201916978542 A US201916978542 A US 201916978542A US 2021015813 A1 US2021015813 A1 US 2021015813A1
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nalfurafine
subject
disease
mice
decrease
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Bronwyn Maree Kivell
Anne Camille La Flamme
Thomas Edward Prisinzano
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Victoria Link Ltd
University of Kansas
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Victoria Link Ltd
University of Kansas
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/28—Drugs for disorders of the nervous system for treating neurodegenerative disorders of the central nervous system, e.g. nootropic agents, cognition enhancers, drugs for treating Alzheimer's disease or other forms of dementia
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
    • A61K31/47—Quinolines; Isoquinolines
    • A61K31/485—Morphinan derivatives, e.g. morphine, codeine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P25/00—Drugs for disorders of the nervous system
    • A61P25/02—Drugs for disorders of the nervous system for peripheral neuropathies

Definitions

  • the disclosure relates generally to the use of nalfurafine (NaIF) in the prevention and treatment of demyelinating diseases, in particular, multiple sclerosis.
  • NaIF nalfurafine
  • the myelin sheath covers important nerve fibres in the central and peripheral nervous system of mammals, helping to facilitate transmission of neural impulses. Diseases that affect myelin interrupt these nerve transmissions.
  • the developing myelin sheath can be affected by congenital metabolic disorders such as phenylketonuria, Tay-Sachs disease, Niemann-Pick disease, Hurler's syndrome, and Krabbe's disease. Demyelination can also occur in adults as a result of injury, metabolic disorders, immune attack, ischemia and toxic agents.
  • Demyelination impairs conduction of signals to the affected nerves, causing deficiency of sensation, movement, cognition and other functions.
  • Demyelination of the central nervous system is associated with multiple sclerosis (MS), Devic's disease, acute disseminated encephalomyelitis, adrenoleukodystrophy, leukoencephalopathy and Leber's optiv atrophy.
  • MS multiple sclerosis
  • Devic's disease acute disseminated encephalomyelitis, adrenoleukodystrophy, leukoencephalopathy and Leber's optiv atrophy.
  • Demyelination of the peripheral nervous symptom gives rise to diseases such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, Charcot Marie Tooth (CMT) disease and progressing inflammatory neuropathy.
  • CMT Charcot Marie Tooth
  • MS Multiple sclerosis
  • MS is the most well-known demyelination disease, affecting about 2.5 million people worldwide. Sufferers endure a range of symptoms including fatigue, vision problems, numbness, cognitive impairment, incontinence, poor balance and muscle weakness, ultimately leading to paralysis. MS can follow four major disease courses, each of which can be mild, moderate or severe:
  • MS While there is no cure for MS, many FDA approved drugs such as beta-interferon and glatiramer acetate are used to reduce relapse rates and the formation of new lesions.
  • FDA approved drugs such as beta-interferon and glatiramer acetate are used to reduce relapse rates and the formation of new lesions.
  • current treatments are not very successful in preventing the disability associated with MS and are more successful in treating RRMS than other types. For example, current drugs are unable to stop or reverse disease progression and disability.
  • alternative treatments for MS are needed.
  • the invention provides a pharmaceutical composition comprising nalfurafine and pharmaceutically acceptable excipients for treating a demyelinating disease in a subject in need thereof.
  • the invention provides a pharmaceutical composition comprising nalfurafine and at least one pharmaceutically acceptable excipient for use for treating a demyelinating disease in a subject in need thereof.
  • the invention provides unit dosage forms comprising about 0.01 to about 5 mg of nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the unit dosage form comprises 0.05 to about 2.0 mg of nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the unit dosage form comprises about 0.15 to about 0.6 mg nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the invention provides a method of treating a demyelinating disease in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of treating a demyelinating disease in a subject comprising identifying a subject who would benefit from a decreased level of demyelination and administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of treating a demyelinating disease in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of increasing remyelination in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of increasing remyelination in a subject comprising identifying a subject who would benefit from an increased level of remyelination and administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of increasing remyelination in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for treating a demyelinating disease in a subject in need thereof.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for increasing remyelination in a subject in need thereof.
  • the invention also provides nalfurafine for use for treating a demyelinating disease.
  • the invention also provides nalfurafine for use for increasing remyelination.
  • the disease is a demyelinating myelinoclastic disease.
  • the disease is a demyelinating leukodystrophic disease.
  • the demyelinating disease is a central nervous system demyelinating disease.
  • the central nervous system demyelinating disease is selected from the group comprising MS (including clinically isolated syndrome; CIS), optic neuritis, Devic's disease, inflammatory demyelinating diseases, central nervous system neuropathies, myelopathies like Tabes dorsalis , leukoencephalopathies, leukodystrophies, or a combination thereof.
  • the demyelinating disease is MS.
  • the demyelinating disease is a peripheral nervous system demyelinating disease.
  • the peripheral nervous system demyelinating disease is elected from the group comprising Guillain-Barre syndrome and its chronic counterpart, chronic inflammatory demyelinating polyneuropathy, anti-myelin associated glycoprotein (MAG) peripheral neuropathy, Charcot Marie Tooth (CMT) disease, copper deficiency and progressive inflammatory neuropathy.
  • MAG anti-myelin associated glycoprotein
  • CMT Charcot Marie Tooth
  • the invention provides a method of attenuating demyelination in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject and thereby attenuating a level of demyelination in the subject relative to the level of demyelination when nalfurafine is not administered.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for attenuating demyelination in a subject in need thereof.
  • the subject is a human with MS.
  • the invention also provides nalfurafine for use for attenuating demyelination in a subject in need thereof.
  • the invention provides a method of treating MS in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of treating MS in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that decreases a level of demyelination in the subject relative to the level before administering the agent and/or that increases a level of remyelination in the subject in the subject relative to the level before administering the agent, wherein the agent comprises nalfurafine.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for treating MS in a subject in need thereof.
  • the invention also provides nalfurafine for use for treating MS in a subject in need thereof.
  • the subject has RRMS. In one embodiment the subject has PPMS. In one embodiment the subject has, or is diagnosed as having, SPMS. In one embodiment the subject has, or is diagnosed as having, PRMS. In one embodiment the subject has, or is diagnosed as having, Clinically Isolated Syndrome (CIS).
  • RRMS In one embodiment the subject has PPMS. In one embodiment the subject has, or is diagnosed as having, SPMS. In one embodiment the subject has, or is diagnosed as having, PRMS. In one embodiment the subject has, or is diagnosed as having, Clinically Isolated Syndrome (CIS).
  • CIS Clinically Isolated Syndrome
  • the treatment of MS results in a reduction of one or more clinical symptoms of MS including, but not limited to loss of sensitivity or changes in sensation such as tingling, pins and needles or numbness, muscle weakness or paralysis of variable severity, very pronounced reflexes, muscle spasms, or difficulty in moving; difficulties with coordination and balance (ataxia); spasticity; problems with speech or swallowing, visual problems (nystagmus, optic neuritis or double vision), fatigue, acute or chronic pain, neuropathic pain, facial pain (trigeminal neuralgia), bladder and bowel difficulties, incontinence, reduced cognitive ability, depression, anxiety and other emotional abnormalities, sexual dysfunction, Uhthoff's phenomenon (a worsening of symptoms due to exposure to higher than usual temperatures), and Lhermitte's sign (an electrical sensation that runs down the back when bending the neck).
  • loss of sensitivity or changes in sensation such as tingling, pins and needles or numbness, muscle weakness or paralysis of variable severity, very pronounced reflexes
  • the invention provides a method of accelerating remission from MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of accelerating remission from MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of accelerating remission from MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for accelerating remission from MS in a subject in need thereof.
  • the invention also provides nalfurafine for use for accelerating remission from MS in a subject in need thereof.
  • the invention provides a method of treating a demyelinating disease in a subject comprising identifying a subject who would benefit from a decreased level of demyelination and administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of increasing remyelination in a subject comprising identifying a subject who would benefit from an increased level of remyelination and administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the therapeutically effective amount for a subject is equivalent to a dose of about 0.003 to about 0.3 mg/kg/day in mice.
  • the subject is human.
  • the method comprises administering about 0.01 to about 5 ⁇ g nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine, preferably less than 1 ug nalfurafine daily.
  • the method comprises a long duration therapy.
  • the long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least 5 days, at least 6 days, or at least 7 days.
  • a long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least a week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 6 weeks, or at least 8 weeks.
  • the long duration therapy comprises administration for at least 5 days, at least 6 days, at least 7 days, at least 14 days, at least 21 days, at least 28 days, at least 35 days, at least 42 days, at least 45 days, at least 60 days, at least 120 days, at least 240 days, or at least 360 days.
  • the long duration therapy comprises a dosing gap of at least 1 day.
  • FIG. 1 is a graph showing the progression of disease in mice which have experimental autoimmune encephalomyelitis (EAE) over 45 days, wherein the mice in Example 1 were treated with 0.01, 0.03, 0.1 or 0.3 mg/kg nalfurafine daily from onset (day 17).
  • EAE experimental autoimmune encephalomyelitis
  • FIG. 2 is two graphs showing the total disability of EAE mice over (A) 45 days and (B) 18 days wherein the mice in Example 2 were treated with 0.03, 0.1 or 0.3 mg/kg nalfurafine daily from onset (day 17).
  • FIG. 3 is a graph showing the % weight change of EAE mice in Example 3 over 45 days wherein the mice were treated with 0.03, 0.1 or 0.3 mg/kg nalfurafine daily from onset (day 17).
  • FIG. 4 is three graphs showing immune cell infiltration into the brain of EAE mice in Example 4 after 45 days, wherein the mice were treated with 0.03, 0.1 or 0.3 mg/kg nalfurafine daily from onset (day 17).
  • FIG. 5 is a graph showing the progression of disease in EAE mice in Example 5 over 45 days, wherein the mice, which had not yet developed EAE, were treated with 0.03, 0.1 or 0.3 mg/kg nalfurafine daily from onset (day 17).
  • FIG. 6 is a series of Transmission Electron Microscope (TEM) images of spinal cord sections from EAE mice in Example 6 after 45 days, wherein the mice were treated with 0.03 mg/kg nalfurafine daily from onset (day 17).
  • TEM Transmission Electron Microscope
  • FIG. 7 is a graph showing weight gain over 65 days of mice in Example 7 treated with 0.3% cuprizone for 5 weeks, wherein the mice were treated with 0.1 mg/kg nalfurafine daily from week 4.
  • FIG. 8 is a graph showing the rotarod performance score of mice in Example 8 at 9 weeks treated with cuprizone for 5 weeks, wherein the mice were treated with 0.1 mg/kg nalfurafine daily from week 4.
  • FIG. 9 is a series of TEM imagines of the corpus callosum of mice in Example 9 at 9 weeks treated with cuprizone for 5 weeks, wherein the mice were treated with 0.1 mg/kg nalfurafine daily from week 4.
  • FIG. 10 shows that nalfurafine promotes functional recovery from paralysis when administered therapeutically (at disease onset) in the experimental autoimmune encephalomyelitis (EAE) model of MS.
  • EAE experimental autoimmune encephalomyelitis
  • FIG. 11 shows that nalfurafine is not effective when administered therapeutically as a short 4-day course starting at disease onset in EAE model of MS.
  • FIG. 12 shows that nalfurafine does not alter peak disease when administered therapeutically in the EAE model of MS.
  • FIG. 13 shows that nalfurafine promotes full recovery from EAE-induced paralysis when administered therapeutically.
  • FIG. 14 shows that nalfurafine promotes full recovery from EAE-induced paralysis when administered therapeutically with an EC50 for % recovery of ⁇ 0.001 mg/kg.
  • FIG. 15 shows that nalfurafine promotes sustained recovery from EAE-induced paralysis when administered therapeutically.
  • FIG. 16 shows that nalfurafine also promotes functional recovery from paralysis in male mice when administered therapeutically in EAE model of MS.
  • FIG. 17 shows that nalfurafine also promotes full recovery in male mice when administered therapeutically in EAE model of MS.
  • FIG. 18 shows that nalfurafine promotes sustained recovery in male mice from EAE-induced paralysis when administered therapeutically.
  • FIG. 19 shows that nalfurafine reduces the immune cell infiltration into the brain when administered therapeutically in the EAE model of MS (A) whereas U 50488 does not (B).
  • FIG. 20 shows that myelination is improved in mice treated with nalfurafine after the onset of paralysis in the EAE model of MS.
  • FIG. 21 shows that nalfurafine does not alter the proportion of major lymphocyte populations in the spleen during the chronic phase of EAE.
  • FIG. 22 shows that nalfurafine does not alter the overall number of CD4 T helper cells in the spleen but shifts the CD4 T cells from an effector to memory phenotype being suggestive of immune resolution during the chronic phase of EAE.
  • FIG. 23 shows that nalfurafine reduces disease but does not enable full recovery when the kappa opioid receptor (KOR) is blocked.
  • KOR kappa opioid receptor
  • FIG. 24 shows that activation of the KOR is required for full recovery from paralysis mediated by nalfurafine.
  • FIG. 25 shows that myelination is improved in mice treated with nalfurafine after the onset of paralysis in the EAE model of MS.
  • FIG. 26 shows that nalfurafine treatment decreases cellular infiltration into the spinal cord when administered therapeutically in the EAE model of MS.
  • FIG. 27 shows that nalfurafine treatment reduces the level of activated astrocytes in the spinal cord when administered therapeutically in the EAE model of MS.
  • FIG. 28 shows nalfurafine treatment enhances recovery from weight loss when administered therapeutically in the cuprizone model of MS.
  • FIG. 29 shows that nalfurafine treatment enhances remyelination in the brain when administered after demyelination in the cuprizone demyelination disease model of MS.
  • FIG. 30 shows nalfurafine is more effective at promoting functional recovery than clemastine fumarate, a known remyelinating drug.
  • FIG. 31 shows that nalfurafine promotes a greater and more sustained recovery than clemastine fumarate, a known remyelinating drug.
  • FIG. 32 shows that nalfurafine promotes recovery in pain threshold when administered after demyelination in the cuprizone demyelination disease model of MS.
  • Nalfurafine is a drug commonly prescribed for treatment of uremic pruritus in people with chronic kidney disease. It is a non-narcotic opioid with selective K-opioid receptor (KOR) agonist activity.
  • KOR K-opioid receptor
  • the IUPAC name for nalfurafine is (E)-N-[(4R,4aS,7R,7aR,12bS)-3-(cyclopropylmethyl)-4a,9-dihydroxy-1,2,4,5,6,7,7a,13-octahydro-4,12-methanobenzofuro[3,2-e]isoquinoline-7-yl]-3-(furan-3-yl)-N-methylprop-2-enamide. Its CAS number is 152657-84-6.
  • Nalfurafine HCl may also be referred to as 17-cyclopropylmethyl-3,14-beta-dihydroxy-4,5-alpha-epoxy-6beta-(N-methyl-trans-3-(3-furyl)acrylamido)morphinan hydrochloride, TRK 820, AC-820 and MT-9938.
  • nanofurafine refers to the compound identified above as well as to its pharmaceutically acceptable salts and solvates.
  • salts refers to salts prepared from pharmaceutically acceptable non-toxic bases or acids including inorganic or organic bases and inorganic or organic acids.
  • Salts derived from inorganic bases include aluminum, ammonium, calcium, copper, ferric, ferrous, lithium, magnesium, manganic salts, manganous, potassium, sodium, zinc, and the like. Particularly preferred are the ammonium, calcium, magnesium, potassium, and sodium salts. Salts in the solid form may exist in more than one crystal structure and may also be in the form of hydrates.
  • Salts derived from pharmaceutically acceptable organic non-toxic bases include salts of primary, secondary, and tertiary amines, substituted amines including naturally occurring substituted amines, cyclic amines, and basic ion exchange resins, such as arginine, betaine, caffeine, choline, N,N′-dibenzylethylene-diamine, diethylamine, 2-diethylaminoethanol, 2-dimethylamino-ethanol, ethanolamine, ethylenediamine, N-ethyl-morpholine, N-ethylpiperidine, glucamine, glucosamine, histidine, hydrabamine, isopropylamine, lysine, methylglucamine, morpholine, piperazine, piperidine, polyamine resins, procaine, purines, theobromine, triethylamine, trimethylamine, tripropylamine, tromethamine, and the like.
  • basic ion exchange resins
  • salts can be prepared from pharmaceutically acceptable non-toxic acids, including inorganic and organic acids.
  • acids include acetic, benzenesulfonic, benzoic, camphorsulfonic, citric, ethanesulfonic, fumaric, gluconic, glutamic, hydrobromic, hydrochloric, isethionic, lactic, maleic, malic, mandelic, ethanesulfonic, mucic, nitric, pamoic, pantothenic, phosphoric, succinic, sulfuric, tartaric, p-toluenesulfonic acid, and the like.
  • Particularly preferred are citric, hydrobromic, hydrochloric, maleic, phosphoric, sulfuric, fumaric, and tartaric acids.
  • solvate refers to an aggregate that consists of a solute ion or molecule with one or more solvent molecules.
  • Solvates include hydrates, that is, aggregates of a compound of interest with water.
  • Nalfurafine can be purchased from small molecule suppliers such as Med Chem Express, Monmouth Junction and New Jersey, USA; AdooQ BioScience, Irvine Calif., USA.
  • demyelinating diseases including MS
  • demyelinating diseases including MS
  • pharmaceutical compositions containing nalfurafine can be used to treat demyelination diseases including but not limited to MS by acting to increase remyelination and/or to decrease demyelination.
  • the invention provides a pharmaceutical composition comprising nalfurafine and pharmaceutically acceptable excipients for treating a demyelinating disease in a subject in need thereof.
  • the invention provides a pharmaceutical composition comprising nalfurafine and at least one pharmaceutically acceptable excipient for use for treating a demyelinating disease in a subject in need thereof.
  • composition encompasses a product comprising one or more active agents, and pharmaceutically acceptable excipients comprising inert ingredients, as well as any product which results, directly or indirectly, from combination, complexation or aggregation of any two or more of the ingredients, or from dissociation of one or more of the ingredients, or from other types of reactions or interactions of one or more of the ingredients.
  • pharmaceutical compositions are prepared by bringing the active agent into association with a liquid carrier, a finely divided solid carrier or both, and then, if necessary, shaping the product into the desired formulation.
  • Said compositions are prepared according to conventional mixing, granulating, or coating methods, respectively, and contain a percentage (%) of the active ingredient and can be determined by a skilled worker in view of the art.
  • pharmaceutically acceptable excipient or “pharmaceutically acceptable carrier” it is meant that the excipient or carrier must be compatible with the other ingredients of the formulation and not harmful to the subject to whom the composition is administered.
  • compositions as described herein can be administered topically, orally or parenterally.
  • the pharmaceutical compositions can be administered orally, including sublingually, in the form of capsules, tablets, elixirs, solutions, suspensions, or boluses formulated to dissolve in, for example, the colon or duodenum.
  • the formulations can comprise excipients such as starch or lactose or flavouring, preserving or colouring agents.
  • compositions can be injected parenterally, for example, intravenously, intramuscularly or subcutaneously.
  • parenteral administration the compositions can be formulated in a sterile aqueous solution or suspension that optionally comprises other substances, such as salt or glucose.
  • compositions can be administered topically, in the form of sterile creams, gels, pour-on or spot-on formulations, suspensions, lotions, ointments, dusting powders, drug-incorporated dressings, shampoos, collars or transdermal patches.
  • compositions as described herein can be incorporated into a cream comprising an aqueous or oily emulsion of polyethylene glycols or liquid paraffin; an ointment comprising a white wax soft paraffin base; a hydrogel with cellulose or polyacrylate derivatives or other suitable viscosity modifiers; a dry powder; aerosol with butane, propane, HFA, or CFC propellants; a dressing, such as, a tulle dressing, with white soft paraffin or polyethylene glycol impregnated gauze dressings or with hydrogel, hydrocolloid, or alginate film dressings.
  • the compositions can also be administered intra-ocularly as an eye drop with appropriate buffers, viscosity modifiers (for example, cellulose derivatives), and preservatives (for example, benzalkonium chloride).
  • compositions as described herein can also be incorporated into a transdermal patch comprising nalfurafine. Details of such patches can be found in, for example, WO2015/025766, WO2015/025767, WO2016/208729, WO2017/094337 and WO2017/170933, the details of which are incorporated by reference herein.
  • capsules, boluses, or tablets can be prepared by mixing the pharmaceutical compositions as described herein with a suitable finely divided diluent or carrier, additionally containing a disintegrating agent and/or binder such as starch, lactose, talc, or magnesium stearate.
  • a suitable finely divided diluent or carrier additionally containing a disintegrating agent and/or binder such as starch, lactose, talc, or magnesium stearate.
  • injectable formulations can be prepared in the form of a sterile solution or emulsion.
  • compositions described herein can be presented in unit dosage form and can be prepared by any of the methods well known in the art of pharmacy.
  • unit dosage form means a single dose wherein all active and inactive ingredients are combined in a suitable system, such that the patient or person administering the drug can open a single container or package with the entire dose contained therein and does not have to mix any components together from two or more containers or packages.
  • Typical examples of unit dosage forms are tablets or capsules for oral administration or transdermal patches comprising the unit dosage.
  • the invention provides unit dosage forms comprising about 0.01 to about 5 mg of nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the unit dosage form comprises 0.05 to about 2.0 mg of nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the unit dosage form comprises about 0.15 to about 0.6 mg nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the invention provides a unit dosage form comprising about 0.1 to about 10 ⁇ g of nalfurafine and at least one pharmaceutically acceptable carrier or excipient.
  • the unit dosage form comprises about 0.5 to about 7.5 ⁇ g nalfurafine, about 0.75 to about 5 ⁇ g nalfurafine, about 1 to 4 ⁇ g nalfurafine, about 2-3 ⁇ g nalfurafine, about 2 ⁇ g nalfurafine, about 3 ⁇ g nalfurafine, about 4 ⁇ g nalfurafine or about 5 ⁇ g nalfurafine.
  • the unit dosage form comprises less than about 2 ⁇ g, 1.5 ⁇ g, 1.0 ⁇ g, 0.5 ⁇ g, 0.25 ⁇ g or 0.1 ⁇ g, preferably less than 2 ⁇ g, 1.5 ⁇ g, 1.0 ⁇ g, 0.5 ⁇ g, 0.25 ⁇ g or 0.1 ⁇ g.
  • the unit dosage form is for treating a demyelinating disease in a subject in need thereof, preferably wherein the subject has MS.
  • the unit dosage is formulated for treating a demyelinating disease in a subject in need thereof.
  • the demyelinating disease is MS.
  • the unit dose is formulated for increasing remyelination in a subject in need thereof, preferably wherein the subject has MS.
  • the unit dosage form is for oral administration, preferably the unit dosage form is formulated for oral administration. In another embodiment, the unit dosage form is a transdermal patch.
  • compositions of nalfurafine can be used in combination with other therapies for treating demyelination diseases.
  • nalfurafine gives rise to many positive effects in demyelination in MS mouse models.
  • the inventors have found that nalfurafine is effective at treating demyelination in mouse models of EAE and cuprizone-induced demyelination, results that are translatable to treating demyelinating diseases such as MS in humans.
  • the inventors have also found that nalfurafine is unexpectedly effective at increasing remyelination in subjects in need thereof. Accordingly, this drug, which has a proven safety record, could be highly beneficial in the treatment of demyelination diseases and/or for increasing remyelination.
  • nalfurafine promotes functional (including full and sustained) recovery from EAE-induced paralysis in male and female mice.
  • Nalfurafine also reduces EAE-induced total disability (see Example 2) and promotes recovery from EAE-induced weight loss (see Example 3).
  • the disease score is reduced completely in the examples described herein to ⁇ 0.5, which is considered to represent a “full recovery” from paralysis in the art, with one exception.
  • a short 4-day time course starting at disease outset was not effective at promoting recovery (Example 11), demonstrating the efficacy of a long duration therapy as described herein.
  • Nalfurafine reduces immune cell infiltration into the brain in the EAE model of MS (see Example 4) and is more effective than the comparator U-50488, which does not (Example 19.
  • nalfurafine promotes functional recovery from paralysis, in the EAE model of MS (see Example 5). Myelination is also improved in mice treated with nalfurafine after the onset of paralysis in the EAE model of MS (Examples 6, 20 and 25).
  • Example 6 TEM images of the spinal cords of EAE mice treated with nalfurafine resemble those of the healthy control.
  • Example 15 the demonstration of sustained recovery is noteworthy and shows the quite unexpected ability of nalfurafine to reverse, in a sustained manner, the symptoms of demyelination. This surprising result indicates that nalfurafine can mediate sustained recovery of demyelinating diseases including MS.
  • nalfurafine does not deplete the major immune cell populations in the periphery despite reducing immune cell infiltration into the brain.
  • nalfurafine promotes a switch in T helper cells from effector to memory cells suggestive of immune response resolution.
  • mice were particularly surprising at dosages of 0.003 mg/kg to 0.3 mg/kg, which can be converted to an equivalent human dose using the Regan-Shaw equation (Reagan-Shaw S; Nihal M; Ahmad N: Dose translation from animal to human studies revisited , FASEB J. 2007, Oct. 17).
  • dosages of 0.003 to 0.3 mg/kg can be converted to an equivalent human dose using the method of interspecies comparison described herein.
  • a skilled worker employs the ratio of the efficacy dose for itch vs the efficacy dose for MS in the same species. This ratio can be applied to the human dose to convert dosage for itch to the dosage for MS. In this case, there is dose data for treating itch in both mouse and human models, and this enables the calculations described below.
  • itch response is a biomarker (surrogate) for EAE.
  • EAE mouse dose/(3 ⁇ g/kg/day mouse itch ⁇ 2.5 ⁇ g/body/day human itch) Human MS dose.
  • nalfurafine is an effective treatment for demyelinating diseases, and in particular MS.
  • the inventors believe that treatment with nalfurafine will be effective for alleviating the debilitating symptoms related to Clinically Isolated Syndrome (CIS).
  • CIS Clinically Isolated Syndrome
  • One of the MS disease courses, CIS generally refers to a first episode of neurologic symptoms associated with MS. Typically, this initial episode is caused by inflammation or demyelination in the central nervous system (CNS), and will last 24 hours or more.
  • the invention provides a method of treating a demyelinating disease in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of treating a demyelinating disease in a subject comprising identifying a subject who would benefit from a decreased level of demyelination and administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of treating a demyelinating disease in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • treating refers to the following: (a) ameliorating the disease or condition such as by eliminating or causing regression of or decreasing the severity of the disease or medical condition of the subject being treated relative to an untreated subject according to art-accepted criteria for monitoring the disease or condition (Wattjes et al. (2015). Evidence-based guidelines: MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients. Nat. Rev. Neurol. 11, 597-606; Traboulsee et al. (2016). Revised Recommendations of the Consortium of MS Centers Task Force for a Standardized MRI Protocol and Clinical Guidelines for the Diagnosis and follow-Up of Multiple Sclerosis.
  • Imaging outcome measures of neuroprotection and repair in MS A consensus statement from NAIMS. Neurology; Sormani et al. (2017). Assessing Repair in Multiple Sclerosis: Outcomes for Phase II Clinical Trials. Neurother. J. Am. Soc. Exp. Neurother. 14, 924-933; Zhang et al. (2016). Clinical trials in multiple sclerosis: milestones. Ther. Adv. Neurol. Disord. 11; Bjartmar et al. (2003). Axonal loss in the pathology of MS: consequences for understanding the progressive phase of the disease. J. Neurol. Sci. 206, 165-171; Toosy et al. (2014). Optic neuritis. Lancet Neurol.
  • treating refers to ameliorating as in (a), suppressing as in (b) and/or alleviating as in (c) in a statistically significant manner relative to an appropriate untreated control subject according to art-accepted criteria for monitoring the disease or condition.
  • Criteria for measuring disability may include the expanded disability scale, multiple sclerosis functional composite Z-score and multiple sclerosis Impact Scale and Medical Outcomes Study Short Form, imaging of the brain, spinal cord or optic nerve, Multiple Sclerosis Functional Composite, and novel composite measures of disability, in addition to tests evaluating manual dexterity, ambulation, vision (including measures of axial diffusivity, visual acuity, contrast sensitivity, visual evoked potentials (VEPs), and thickness of the retinal nerve fiber layer (RNFL) and cognition.
  • vision including measures of axial diffusivity, visual acuity, contrast sensitivity, visual evoked potentials (VEPs), and thickness of the retinal nerve fiber layer (RNFL) and cognition.
  • the subject may show an observable or measurable decrease in one or more of the symptoms associated with or related to the disease or condition as known to those skilled in the art, as indicating improvement.
  • the disease or condition is a demyelinating disease, preferably MS, and the subject shows an observable and measurable decrease in one or more of the symptoms associated with or related to MS, preferably a decrease in demyelination as known to those skilled in the art, as indicating improvement.
  • the improvement is a statistically significant improvement relative to an appropriate untreated control subject according to art-accepted criteria for monitoring the disease or condition.
  • decrease and “reduced” as used herein with reference to demyelination mean any measurable or observable reduction in an amount or level of demyelination or of any symptom of a demyelinating disease that is attributable to demyelination in a treated subject relative to the level of demyelination in an appropriate control (e.g., untreated) subject.
  • the measurable or detectable decrease or reduction is a statistically significant decrease or reduction, relative to an appropriate control.
  • the term “increase” means any measurable or observable increase in an amount or level of remyelination or an improvement of any symptom of a demyelinating disease that is attributable to remyelination in a treated subject relative to the level of remyelination in an appropriate control (e.g., untreated) subject; e.g., placebo or non-active agent.
  • an appropriate control e.g., untreated
  • placebo or non-active agent e.g., placebo or non-active agent.
  • the measurable or detectable reduction is a statistically significant reduction, relative to an appropriate control.
  • administering should be understood to mean providing nalfurafine or a pharmaceutical composition comprising, consisting essentially of, or consisting of, nalfurafine to the subject in need of treatment in a therapeutically useful form for the mode of administration.
  • Nalfurafine can be administered via any suitable route.
  • Potential routes of administration include without limitation oral, parenteral (including intramuscular, subcutaneous, intradermal, intravenous, intraarterial, intramedullary and intrathecal), intraperitoneal, and topical (including dernnal/epicutaneous, transdermal, mucosal, transmucosal, intranasal (e.g., by nasal spray or drop), intraocular (e.g., by eye drop), pulmonary (e.g., by inhalation), buccal, sublingual, rectal and vaginal.
  • nalfurafine is administered via oral dosage forms such as tablets, capsules, syrups, suspensions, and the like. In another embodiment, nalfurafine is administered via a transdermal patch.
  • terapéuticaally effective amount refers to a sufficient quantity of the active agent, in a suitable composition, and in a suitable dosage form to treat the noted disease conditions or to obtain a measurable or observable result such as a decrease in demyelination or an increase in remyelination.
  • the “therapeutically effective amount” will vary depending on the compound, the severity of the demyelination disease, and the species, age, weight, etc., of the subject to be treated.
  • the therapeutically effective amount of nalfurafine is the amount equivalent to about 0.003-about 0.3 mg/kg in a mouse which can be converted according to accepted practice into an animal or human subject dosage.
  • a therapeutically effective amount of nalfurafine for a dog would be about 0.67-about 2 mg/kg.
  • the therapeutically effective amount of nalfurafine is the amount equivalent to about 0.003-about 0.3 mg/kg in a mouse, converted according the method of interspecies comparison described herein.
  • a therapeutically effective amount of nalfurafine for a human is about 0.01 to about 5 ⁇ g nalfurafine daily, preferably about 0.01 to about 2.5 ⁇ g nalfurafine daily.
  • the subject is human.
  • the method comprises administering about 0.01 to about 5 ⁇ g nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily.
  • the method comprises administering about 0.01 to about 2.5 ⁇ g nalfurafine daily, about 0.025 to about 2 ⁇ g, about 0.05 to about 1 ⁇ g, about 0.075 to about 0.75 ⁇ g, about 0.1 to about 0.5 ⁇ g, or about 0.225 to about 0.325 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine daily, preferably less than 1 ⁇ g nalfurafine daily.
  • the method comprises administering about 0.01 to about 0.1 ⁇ g nalfurafine daily, about 0.025 to about 0.075 ⁇ g, about 0.06 to about 0.04 ⁇ g, or about 0.05 ⁇ g nalfurafine daily.
  • the method comprises a long duration therapy.
  • the long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least 5 days, at least 6 days, or at least 7 days.
  • the long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least 5, preferably at least 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, preferably at least 90 days.
  • a long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least a week, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 6 weeks, or at least 8 weeks.
  • the long duration therapy comprises administration for at least 5 days, at least 6 days, at least 7 days, at least 14 days, for at least 21 days, for at least 28 days, for at least 35 days, for at least 42 days, for at least 45 days, for at least 60 days, for at least 120 days, for at least 240 days, or for at least 360 days.
  • a long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least 1 week, at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, or at least 52 weeks.
  • a long duration therapy comprises administration of a therapeutically effective dose of nalfurafine to a subject in need thereof for at least 1 month, at least 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, or at least 36 months.
  • the long duration therapy comprises a dosing gap, preferably wherein the dosing gap is at least 1 day.
  • dosing gap comprises at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, or 14 days.
  • the dosing gap comprises at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 weeks.
  • the dosing gap comprises at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 months.
  • Demyelinating disease refers to a disease of the nervous system in which the myelin sheath of neurons is damaged.
  • Demyelinating diseases include demyelinating myelinoclastic diseases and demyelinating leukodystrophic diseases.
  • Treatment of a demyelinating disease can comprise treatment with an agent that decreases demyelination and/or an agent that increases remyelination.
  • Demyelinating diseases may affect the central nervous system and peripheral nervous system.
  • the central nervous system demyelinating diseases include multiple sclerosis including clinically isolated syndrome (CIS) optic neuritis, Devic's disease, inflammatory demyelinating diseases, central nervous system neuropathies like those produced by Vitamin B12 deficiency, myelopathies like Tabes dorsalis , leukoencephalopathies like progressive multifocal leukoencephalopathy, leukodystrophies, or a combination thereof.
  • CIS clinically isolated syndrome
  • Devic's disease inflammatory demyelinating diseases
  • central nervous system neuropathies like those produced by Vitamin B12 deficiency
  • myelopathies like Tabes dorsalis
  • leukoencephalopathies like progressive multifocal leukoencephalopathy, leukodystrophies, or a combination thereof.
  • the peripheral nervous system demyelinating diseases include Guillain-Barre syndrome and its chronic counterpart, chronic inflammatory demyelinating polyneuropathy, anti-MAG peripheral neuropathy, Charcot Marie Tooth (CMT) disease, copper deficiency, progressive inflammatory neuropathy, or a combination thereof.
  • subject refers to a mammal, more preferably a human, or companion animal.
  • Preferred companion animals include cats, dogs and horses.
  • Other mammalian subjects include agricultural animals, including horses, pigs, sheep, goats, cows, deer, or fowl: and laboratory animal, including monkeys, rats, mice, rabbits and guinea pig.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for treating a demyelinating disease in a subject in need thereof.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for increasing remyelination in a subject in need thereof.
  • the invention also provides nalfurafine for use for treating a demyelinating disease.
  • the invention also provides nalfurafine for use for increasing remyelination.
  • the disease is a demyelinating myelinoclastic disease.
  • the disease is a demyelinating leukodystrophic disease.
  • the demyelinating disease is a central nervous system demyelinating disease.
  • the central nervous system demyelinating disease is selected from the group comprising MS (including clinically isolated syndrome; CIS), optic neuritis,
  • Devic's disease inflammatory demyelinating diseases, central nervous system neuropathies, myelopathies like Tabes dorsalis , leukoencephalopathies, leukodystrophies, or a combination thereof.
  • the demyelinating disease is MS.
  • the demyelinating disease is a peripheral nervous system demyelinating disease.
  • the peripheral nervous system demyelinating disease is elected from the group comprising Guillain-Barre syndrome and its chronic counterpart, chronic inflammatory demyelinating polyneuropathy, anti-myelin associated glycoprotein (MAG) peripheral neuropathy, Charcot Marie Tooth (CMT) disease, copper deficiency and progressive inflammatory neuropathy.
  • MAG anti-myelin associated glycoprotein
  • CMT Charcot Marie Tooth
  • the invention provides a method of increasing remyelination in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of increasing remyelination in a subject comprising identifying a subject who would benefit from an increased level of remyelination and administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of increasing remyelination in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • embodiments of the invention described herein relating to a method of increasing remyelination in a subject are all of the embodiments of the invention set forth herein relating to the aspects of the invention that are methods of decreasing demyelination, methods of treating MS, methods of attenuating demyelination, methods of accelerating remission of MS, and methods of treating a demyelinating disease.
  • the invention provides a method of attenuating demyelination in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject and thereby attenuating a level of demyelination in the subject relative to the level of demyelination when nalfurafine is not administered.
  • the invention provides a method of attenuating demyelination in a subject in need thereof, comprising administering a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent and/or that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent wherein the agent comprises nalfurafine.
  • the subject is human.
  • the method comprises administering about 0.01 to about 5 ⁇ g nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily.
  • the method comprises administering about 0.01 to about 2.5 ⁇ g nalfurafine daily, about 0.025 to about 2 ⁇ g, about 0.05 to about 1 ⁇ g, about 0.075 to about 0.75 ⁇ g, about 0.1 to about 0.5 ⁇ g, or about 0.225 to about 0.325 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine daily, preferably less than 1 ⁇ g nalfurafine daily.
  • the method comprises administering about 0.01 to about 0.1 ⁇ g nalfurafine daily, about 0.025 to about 0.075 ⁇ g, about 0.06 to about 0.04 ⁇ g, or about 0.05 ⁇ g nalfurafine daily.
  • the term “attenuation of demyelination” means in certain embodiments that the amount or level of demyelination in the subject as a result of the disease or as a symptom of the disease is reduced when compared to otherwise identical conditions in an appropriate control subject or at an appropriate control reference timepoint and/or in certain embodiments that the amount or level of remyelination in the subject is increased when compared to an otherwise identical conditions in an appropriate control subject or at an appropriate control reference timepoint.
  • the reduction or increase as compared to the appropriate control is a statistically significant reduction or increase.
  • the term “attenuation of demyelination” thus means that the amount of or level demyelination in the subject as a result of the disease or as a symptom of the disease is reduced or decreased in a statistically significant manner when compared to a suitable control as would be understood by a person of skill in the art in view of the present disclosure and/or the amount or level of remyelination in the subject is increased in a statistically significant manner when compared to a suitable control as would be understood by a person of skill in the art in view of the present disclosure.
  • the term “improvement in nerve function” refers to a quantifiable improvement in function having a statistically different change in a measurable parameter relative to an appropriate control as recognized by a person of skill in the art.
  • the improvement in function has a statistically significant change in the measurable parameter.
  • the measurable parameter is the disease score as described in Example 1.
  • Symptoms attributable to demyelination will vary depending on the disease but may include, for example but not limited to, neurological deficits, such as chronic pain, cognitive impairment (including memory, attention, conceptualization and problem-solving skills) and information processing; paresthesia in one or more extremities, in the trunk, or on one side of the face; weakness or clumsiness of a leg or hand; or visual disturbances, e.g. partial blindness and pain in one eye (retrobulbar optic neuritis), dimness of vision, or scotomas.
  • neurological deficits such as chronic pain, cognitive impairment (including memory, attention, conceptualization and problem-solving skills) and information processing
  • paresthesia in one or more extremities, in the trunk, or on one side of the face weakness or clumsiness of a leg or hand
  • visual disturbances e.g. partial blindness and pain in one eye (retrobulbar optic neuritis), dimness of vision, or scotomas.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for attenuating demyelination in a subject in need thereof.
  • the invention also provides nalfurafine for use for attenuating demyelination in a subject in need thereof.
  • the invention provides a method of treating MS in a subject in need thereof, comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the subject can suffer from any type of MS including CIS, RRMS, PRMS, SPMS, PRMS or MS that follows a different and/or undefined disease course.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for treating MS in a subject in need thereof.
  • the invention also provides nalfurafine for use for treating MS in a subject in need thereof.
  • the subject has RRMS. In one embodiment the subject has PPMS. In one embodiment the subject has, or is diagnosed as having, SPMS. In one embodiment the subject has, or is diagnosed as having, PRMS. In one embodiment the subject has, or is diagnosed as having, Clinically Isolated Syndrome (CIS).
  • RRMS In one embodiment the subject has PPMS. In one embodiment the subject has, or is diagnosed as having, SPMS. In one embodiment the subject has, or is diagnosed as having, PRMS. In one embodiment the subject has, or is diagnosed as having, Clinically Isolated Syndrome (CIS).
  • CIS Clinically Isolated Syndrome
  • the invention provides a method of treating MS in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of an agent that decreases a level of demyelination in the subject relative to the level before administering the agent and/or that increases a level of remyelination in the subject in the subject relative to the level before administering the agent, wherein the agent comprises nalfurafine.
  • the methods of treating MS set forth herein can comprise one or more of the following steps selected from the group consisting of diagnosing MS in the subject, testing for demyelination in the subject, testing for a reduction or reversal in demyelination in the subject, testing for remyelination in the subject, testing for a level of paralysis or a reduction or reversal of a level of paralysis in the subject, and testing for a decrease or increase of coordination and/or balance in the subject.
  • a method of treating MS and/or of treating a demyelinating disease and/or of attenuating demyelination and/or of increasing remyelination comprises identifying a subject who would benefit from a level of decreased demyelination.
  • a subject who would benefit from a level of decreased demyelination and/or a level of increased remyelination is identified on the basis of exhibiting one or more clinical symptoms of MS including, but not limited to: loss of sensitivity or changes in sensation such as tingling, pins and needles or numbness, muscle weakness of variable severity, very pronounced reflexes, muscle spasms, or difficulty in moving; difficulties with coordination and balance (ataxia); spasticity; problems with speech or swallowing, visual problems (nystagmus, optic neuritis or double vision), fatigue, acute or chronic pain, facial pain (trigeminal neuralgia), bladder and bowel difficulties, incontinence, reduced cognitive ability, depression, anxiety and other emotional abnormalities, sexual dysfunction, Uhthoff's phenomenon (a worsening of symptoms due to exposure to higher than usual temperatures), and Lhermitte's sign (an electrical sensation that runs down the back when bending the neck).
  • loss of sensitivity or changes in sensation such as tingling, pins and
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 5 mg nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 2.5 ⁇ g nalfurafine daily, about 0.025 to about 2 ⁇ g, about 0.05 to about 1 ⁇ g, about 0.075 to about 0.75 ⁇ g, about 0.1 to about 0.5 ⁇ g, or about 0.225 to about 0.325 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine daily, preferably less than 1 ⁇ g nalfurafine daily.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 0.1 ⁇ g nalfurafine daily, about 0.025 to about 0.075 ⁇ g, about 0.06 to about 0.04 ⁇ g, or about 0.05 ⁇ g nalfurafine daily.
  • the treatment results in one or more clinical outcomes as compared to subjects not treated with nalfurafine, selected from the group consisting of:
  • the treatment results in a reduction of one or more clinical symptoms of MS including, but not limited to loss of sensitivity or changes in sensation such as tingling, pins and needles or numbness, muscle weakness of variable severity, very pronounced reflexes, muscle spasms, or difficulty in moving; difficulties with coordination and balance (ataxia); spasticity; problems with speech or swallowing, visual problems (nystagmus, optic neuritis or double vision), fatigue, acute or chronic pain, facial pain (trigeminal neuralgia), bladder and bowel difficulties, incontinence, reduced cognitive ability, depression, anxiety and other emotional abnormalities, sexual dysfunction, Uhthoff's phenomenon (a worsening of symptoms due to exposure to higher than usual temperatures), and Lhermitte's sign (an electrical sensation that runs down the back when bending the neck).
  • loss of sensitivity or changes in sensation such as tingling, pins and needles or numbness, muscle weakness of variable severity, very pronounced reflexes, muscle spasms, or difficulty in moving
  • the invention provides a method of accelerating remission of MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of nalfurafine to the subject.
  • the invention provides a method of accelerating remission from MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of an agent that decreases the level of demyelination in the subject relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of accelerating remission from MS in a subject in need thereof, the method comprising administering a therapeutically effective amount of an agent that increases the level of remyelination in the subject relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention also provides a use of nalfurafine in the manufacture of a medicament for accelerating remission from MS in a subject in need thereof.
  • the invention also provides nalfurafine for use in accelerating remission from MS in a subject in need thereof.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 5 ⁇ g nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 2.5 ⁇ g nalfurafine daily, about 0.025 to about 2 ⁇ g, about 0.05 to about 1 ⁇ g, about 0.075 to about 0.75 ⁇ g, about 0.1 to about 0.5 ⁇ g, or about 0.225 to about 0.325 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine daily, preferably less than 1 ⁇ g nalfurafine daily.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 0.1 ⁇ g nalfurafine daily, about 0.025 to about 0.075 ⁇ g, about 0.06 to about 0.04 ⁇ g, or about 0.05 ⁇ g nalfurafine daily.
  • enhanced remission of MS means that the start of the remission process is reached faster and/or the rate at which remission is achieved is faster (as compared to subjects not treated with nalfurafine).
  • Remission of MS can be measured using any technique known in the art including but not limited to physical disability status, biological markers and brain scans using MRI.
  • the invention provides a method of treating MS in a human subject in need thereof, the method comprising administering to the subject about 0.01 to about 5 mg nalfurafine daily, about 0.05 to about 2.0 mg, about 0.15 to 0.6 mg nalfurafine daily, wherein the treatment results in one or more clinical outcomes as compared to subjects not treated with nalfurafine selected from the group consisting of:
  • the invention provides a method of treating MS in a human subject in need thereof, the method comprising administering to the subject about 0.01 to about 5 ⁇ g nalfurafine daily, about 0.01 to about 4 ⁇ g, about 0.01 to about 3 ⁇ g, about 0.01 to about 2.5 ⁇ g, about 0.01 to about 2 ⁇ g, about 0.01 to about 1.5 ⁇ g, about 0.01 to about 1 ⁇ g, about 0.01 to about 0.75 ⁇ g, about 0.01 to about 0.5 ⁇ g, or about 0.25 ⁇ g nalfurafine daily, wherein the treatment results in one or more clinical outcomes as compared to subjects not treated with nalfurafine selected from the group consisting of:
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 2.5 ⁇ g nalfurafine daily, about 0.025 to about 2 ⁇ g, about 0.05 to about 1 ⁇ g, about 0.075 to about 0.75 ⁇ g, about 0.1 to about 0.5 ⁇ g, or about 0.225 to about 0.325 ⁇ g nalfurafine daily.
  • the method comprises administering less than about 1 ⁇ g nalfurafine daily, preferably less than 1 ⁇ g nalfurafine daily.
  • the therapeutically effective amount of nalfurafine to be administered to a human subject is about 0.01 to about 0.1 ⁇ g nalfurafine daily, about 0.025 to about 0.075 ⁇ g, about 0.06 to about 0.04 ⁇ g, or about 0.05 ⁇ g nalfurafine daily.
  • the invention provides a method of treating a demyelinating disease in a subject comprising identifying a subject who would benefit from a decreased level of demyelination and administering to the subject a therapeutically effective amount of an agent that decreases the level of demyelination relative to the level of demyelination before administering the agent, wherein the agent comprises nalfurafine.
  • the invention provides a method of increasing remyelination in a subject comprising identifying a subject who would benefit from an increased level of remyelination and administering to the subject a therapeutically effective amount of an agent that increases the level of remyelination relative to the level of remyelination before administering the agent, wherein the agent comprises nalfurafine.
  • nalfurafine for use in decreasing demyelination, attenuating demyelination, accelerating remission of MS, treating MS, treating a demyelinating disease and increasing remyelination are all of the embodiments of the invention set forth herein relating to the aspects of the invention that are methods of decreasing demyelination, attenuating demyelination, accelerating remission of MS, treating MS, treating a demyelinating disease and increasing remyelination.
  • Example 1 Nalfurafine Promotes Functional Recovery from Paralysis when Administered Therapeutically in the Experimental Autoimmune Encephalomyelitis (EAE) Model of MS
  • mice Female, C57BL/6 mice were immunized subcutaneously (s.c.) in the hind flanks to induce EAE using myelin oligodendrocyte glycoprotein (MOG) peptide 35-55 (50 mg/mouse) in complete Freund's adjuvant containing heat-killed Mycobacterium tuberculosis (500 ⁇ g/mouse).
  • MOG myelin oligodendrocyte glycoprotein
  • MAG myelin oligodendrocyte glycoprotein
  • complete Freund's adjuvant containing heat-killed Mycobacterium tuberculosis 500 ⁇ g/mouse.
  • pertussis toxin 200 ng/mouse was administered intraperitoneally (i.p.) on days 0 and 2. Mice were weighed and scored daily. On day 17 (vertical dotted line in FIG.
  • mice were started on daily treatment with vehicle only (Veh; 10% tween and 10% DMSO in saline) or nalfurafine at 0.3, 0.1, 0.03, or 0.01 mg/kg by i.p. injection.
  • Nalfurafine was obtained from the University of Kansas, Synthetic Chemical Biology Core Laboratory (97.6% pure by HPLC). Treatment allocation was blinded. The disease was scored from 0-5 with 0 (normal), 1 (partial tail paralysis), 2 (full tail paralysis), 3 (one hind limb paralysed or severe disability in both hind limbs), 4 (complete paralysis of both hind limbs) and 5 (moribund).
  • This model is a standard disease model for multiple sclerosis and is described in White et al. 2018 . Scientific Reports. 8:259 which is incorporated herein by reference in its entirety. Shown in FIG. 1 are results combined from 2 independent experiments. **** p ⁇ 0.0001 &* p ⁇ 0.05 by one-way ANOVA with Dunnett's multiple comparison test.
  • nalfurafine is able to treat on-going disease.
  • the reduction of disease in all nalfurafine-treated groups indicates recovery from paralysis, which is complete at some doses (0.1 and 0.03 mg/kg) and unusual in this model.
  • the dose at which nalfurafine shows the most rapid recovery in this example is 0.1 mg/kg with doses above and below this level appearing less effective.
  • EAE was induced in female C57BL/6 mice as described in Example 1.
  • mice were started on daily treatment with vehicle only (Veh) or nalfurafine at 0.3, 0.1, or 0.03 mg/kg by i.p. injection.
  • the area under the curve (AUC) was calculated for each mouse based upon the daily disease score and represents the total disability experienced. Shown in FIG. 2 are results from 1 representative experiment. * p ⁇ 0.05 by one-way ANOVA with Dunnett's multiple comparison test.
  • mice treated daily with nalfurafine had significantly lower total disability by day 45 after immunization to induce EAE (upper graph).
  • Doses of 0.03 and 0.1 mg/kg nalfurafine had the greatest effect at reducing disability.
  • the 0.1 mg/kg nalfurafine dose results in a 60% reduction in disease.
  • administration comprises administration for at least 7 days, at least 14 days, at least 30 days, at least 45 days, at least 60 days, at least 120 days, at least 240 days, or at least 360 days.
  • Example 3 Nalfurafine Promotes Recovery from EAE-Induced Weight Loss when Administered Therapeutically
  • EAE was induced in female C57BL/6 mice as described in Example 1. Mice were weighed daily and the % change in body weight calculated. On day 17 (vertical dotted line in FIG. 3 ), mice were started on daily treatment with vehicle only (Veh) or nalfurafine at 0.3, 0.1, or 0.03 mg/kg by i.p. injection.
  • mice rapidly lose weight. Once treatment with nalfurafine is initiated (vertical dotted line), mice recover from EAE-induced weight loss.
  • Example 4 Nalfurafine Reduces the Immune Cell Infiltration into the Brain when Administered at Low Doses Therapeutically in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1.
  • mice were started on daily treatment with vehicle only (Veh) or nalfurafine at 0.3, 0.1, or 0.03 mg/kg by i.p. injection.
  • mice were culled, and immune cells isolated from the brains. Isolation was by Percoll gradient as described in White et al. 2018 . Scientific Reports. 8:259. Once isolated, cells were stained with fluorescently labelled antibodies to identify specific immune cell types and analysed by flow cytometry.
  • CD45 high expression All infiltrating immune cells were identified by CD45 high expression; CD4 T cells were identified as CD45 high CD4 + , and macrophages as CD45 high CD11b + Gr-1 ⁇ .
  • the relative number of cells is expressed as a ratio to microglia (MG), a brain resident immune cell identified as CD45 medium CD11b + . * p ⁇ 0.05 by one-way ANOVA with Dunnett's multiple comparison test.
  • mice treated with 0.03 mg/kg nalfurafine significantly reduced the number of infiltrating immune cells suggesting that at this dose, nalfurafine can have immunomodulatory properties.
  • mice treated with 0.1 nalfurafine had similar levels of infiltrating cells as vehicle-treated animals, these mice had no overt signs of disease and had recovered fully from paralysis ( FIG. 1 ).
  • Example 5 Nalfurafine Promotes Functional Recovery from Paralysis when Administered Before the Onset of Paralysis in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1.
  • mice were started on daily treatment with vehicle only (Veh) or nalfurafine at 0.3, 0.1, or 0.03 mg/kg by i.p. injection. Shown in FIG. 5 are results in mice that were not sick at the time of treatment but developed disease later. * p ⁇ 0.05 by two-way ANOVA with Holm-Sidak's multiple comparison test.
  • Treating with nalfurafine prior to disease onset did not alter the onset of disease. However, treatment with nalfurafine led to a rapid recovery from paralysis compared to vehicle-treated mice. These data suggest that treating with nalfurafine will also be effective at reducing total disability if administered before disease but may not prevent onset.
  • Example 6 Myelination is Improved in Mice Treated with Nalfurafine after the Onset of Paralysis in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1. On day 17, mice were started on daily treatment with vehicle only or nalfurafine at 0.03 mg/kg by i.p. injection. On day 45 after immunization to induce EAE, mice were culled, and spinal cords were processed for transmission electron microscopy (TEM). Shown in FIG. 6 are representative TEM images of spinal cord sections from a healthy (A), vehicle-treated EAE (B), or nalfurafine-treated EAE mouse (C) stained to show that dark myelin rings around the nerve axons.
  • A healthy
  • B vehicle-treated EAE
  • C nalfurafine-treated EAE mouse
  • Example 7 Nalfurafine Improved Weight Gain when Administered after Demyelination in the Cuprizone Model of Demyelination
  • mice Female, C57BL/6 mice were fed 0.3% cuprizone in the diet for 5 weeks to induce demyelination.
  • mice were started on daily treatment with vehicle only or nalfurafine 0.1 mg/kg by i.p. injection.
  • cuprizone was removed from the diet to enable spontaneous remyelination. Mice were weighed daily and the % weight change calculated.
  • Example 8 Nalfurafine Enhances the Functional Recovery of Coordination and Balance when Administered after Demyelination in the Cuprizone Model of Demyelination
  • mice Female, C57BL/6 mice were fed 0.3% cuprizone in the diet for 5 weeks to induce demyelination and treated with nalfurafine as described in Example 7.
  • nalfurafine is effective at reducing disability in a model of non-immune mediated demyelination such as that found in some progressive MS patients.
  • Example 9 Nalfurafine Enhances Myelination when Administered after Demyelination in the Cuprizone Model of Demyelination
  • mice Female, C57BL/6 mice were fed 0.3% cuprizone in the diet for 5 weeks to induce demyelination as described in Example 7. On day 65, mice were culled, and brains were processed for transmission electron microscopy (TEM). Shown are representative TEM images of sections from the corpus callosum of a healthy (no cuprizone), vehicle-treated & cuprizone-treated, or nalfurafine-treated & cuprizone-treated mouse stained to show the dark myelin rings around the nerve axons. Myelin was quantified by g-ratio, which is the inner axonal diameter divided by the total outer diameter.
  • g-ratio is the inner axonal diameter divided by the total outer diameter.
  • Example 10 Nalfurafine Promotes Functional Recovery from Paralysis when Administered Therapeutically in the Experimental Autoimmune Encephalomyelitis (EAE) Model of MS
  • nalfurafine By treating after the onset of disease (paralysis), we show that nalfurafine is able to treat on-going disease.
  • the reduction of disease in all nalfurafine-treated groups indicates recovery from paralysis, which is complete at some doses (0.01 and 0.03 mg/kg); full recovery from disease is unusual in this model and the efficacy of the nalfurafine treatment is surprising.
  • the dose at which nalfurafine shows the most rapid recovery in this example is 0.01 mg/kg, and this finding has been replicated in 6 independent experiments.
  • Treatment with nalfurafine does not enhance recovery when administered for only four days starting from disease onset, whereas treatment with a longer duration does enhance recovery effectively.
  • Example 12 Nalfurafine does not Alter Peak Disease when Administered Therapeutically in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1. Results are shown in FIG. 12 .
  • mice were started on daily treatment with vehicle only or nalfurafine at 0.3, 0.1, 0.03, 0.01, or 0.003 mg/kg by i.p. injection.
  • nalfurafine did not appear to alter the initial immune-mediated neuroinflammatory event that leads to demyelination and paralysis. This finding suggests that the functional improvement observed (i.e. the recovery from paralysis) occurs because the initial insult has been repaired and perhaps not because the initial insult itself was stopped.
  • Example 13 Nalfurafine Promotes Full Recovery from EAE-Induced Paralysis when Administered Therapeutically
  • Treatment with nalfurafine enables full functional recovery (i.e. no paralysis) when administered therapeutically and at a wide range of doses (0.003-0.1 mg/kg all show a significant effect). Full recovery in this model of disease is unusual. The efficacy achieved with the treatment of nalfurafine is extraordinary.
  • Example 14 Nalfurafine Promotes Full Recovery from EAE-Induced Paralysis when Administered Therapeutically with an EC 50 of ⁇ 0.001 Ma/Kg
  • a dose-response curve has been fitted from a dose of 0.1 mg/kg, in which 100% recovered, to the vehicle alone, in which 12.1% recovered. This curve calculates an EC 50 of ⁇ 0.001 mg/kg.
  • Treatment with Nalfurafine enables full functional recovery (i.e. no paralysis) when administered therapeutically and at a wide range of doses (0.003-0.1 mg/kg all show a significant effect). Full recovery in this model of disease is unusual.
  • the efficacy achieved with the treatment of nalfurafine is extraordinary. To achieve 50% of this effect (i.e. EC 50 ) an estimated dose of ⁇ 0.001 mg/kg is required.
  • Example 15 Nalfurafine Promotes Sustained Functional Recovery from EAE-Induced Paralysis when Administered Therapeutically
  • EAE was induced in female C57BL/6 mice as described in Example 1,
  • Treatment with nalfurafine enables a sustained functional recovery (i.e. no paralysis) when administered therapeutically and at a wide range of doses (0.003-0.1 mg/kg all show a significant effect).
  • Example 16 Nalfurafine Promotes Functional Recovery from Paralysis in Male Mice when Administered Therapeutically in EAE Model of MS
  • EAE was induced in male C57BL/6 mice as described in Example 1. Results are shown in FIG. 16 . On the day of disease onset (score ⁇ 1, line), mice were started on daily treatment with vehicle only or nalfurafine at 0.01 mg/kg by i.p. injection.
  • Nalfurafine is effective at enabling functional recovery from paralysis in both females and males.
  • Example 17 Nalfurafine Promotes Full Recovery in Male Mice when Administered Therapeutically in EAE Model of MS
  • EAE was induced in male C57BL/6 mice as described in Example 1. Results are shown in FIG. 17 .
  • nalfurafine Treatment with nalfurafine promotes full recovery (i.e. no paralysis) in both female and male when administered therapeutically.
  • Example 18 Nalfurafine Promotes Sustained Recovery in Male Mice from EAE-Induced Paralysis when Administered Therapeutically
  • EAE was induced in male C57BL/6 mice as described in Example 1. Results are shown in FIG. 18 .
  • Treatment with nalfurafine enables a sustained functional recovery (i.e. no paralysis) in both females and males when administered therapeutically.
  • Example 19 Nalfurafine Treatment Reduces the Immune Cell Infiltration into the Brain when Administered Therapeutically in the EAE Model of MS (A) Whereas U-50488 does not (B)
  • mice were started on daily treatment with vehicle only or nalfurafine at 0.3, 0.1, 0.03, 0.01, or 0.003 mg/kg by i.p. injection (A).
  • mice were similarly treated with vehicle alone or U-50488, a KOR agonist at 1.6 and 5 mg/kg (B).
  • mice were culled, and immune cells isolated from the brains. Isolation was by Percoll gradient as described in White et al. 2018. Scientific Reports. 8:259.
  • nalfurafine In the chronic stage of EAE, there was a significant elevation in immune cells in the brains of vehicle-treated EAE mice compared to healthy animals (A). Treatment with 0.03 and 0.01 mg/kg nalfurafine significantly reduced the number of infiltrating immune cells suggesting that at these doses, nalfurafine can have immunomodulatory properties. Interestingly, while mice treated with 0.1 and 0.003 nalfurafine had similar levels of infiltrating cells as vehicle-treated animals, these mice had no overt signs of disease and had recovered fully from paralysis ( FIG. 13 ). Additionally, nalfurafine but not U-50488 reduced neuroinflammation in this model indicating that not all KOR agonists have this activity (B).
  • Example 20 Myelination is Improved in Mice Treated with Nalfurafine after the Onset of Paralysis in the EAE Model of MS
  • mice were started on daily treatment with vehicle only or nalfurafine at 0.03 or 0.01 mg/kg by i.p. injection.
  • mice were culled, perfused with 4% paraformaldehyde and spinal cords were processed for histology. Sections were stained with luxol fast blue to assess the % area of the spinal cord that is demyelinated (i.e. does not stain with luxol fast blue). % demyelination was assessed using ImageJ.
  • Example 21 Nalfurafine does not Alter the Proportion of Major Lymphocyte Populations in the Spleen During the Chronic Phase of EAE
  • mice were started on daily treatment with vehicle only or nalfurafine at 0.01 mg/kg by i.p. injection.
  • Nalfurafine do not alter the proportion of the major lymphocyte populations in the spleen despite reducing the number of infiltrating immune cells into the central nervous system.
  • the maintenance of normal lymphocyte numbers in the spleen in the nalfurafine treated mice indicates that nalfurafine does not reduce immune cell infiltration into the brain by killing immune cells.
  • EAE was induced in female C57BL/6 mice as described in Example 1. Results are shown in FIG. 22 .
  • mice were started on daily treatment with vehicle only or nalfurafine at 0.01 mg/kg by i.p. injection.
  • mice were culled and their splenocytes assessed by flow cytometry.
  • Na ⁇ ve CD4 T cells CD4 + CD44 ⁇ CD62L high
  • effector CD4 T cells CD4 + CD44 + CD62L ⁇
  • central memory CD4 T cells CD4 + CD44 + CD62L high
  • the increased effector to central memory ratio in the vehicle-treated mice with EAE compared to healthy mice indicates an on-going and active immune response mediated by CD4 T cells.
  • the overall number of CD4 T cells was the same between nalfurafine and vehicle treated mice.
  • the reduced ratio in the nalfurafine-treated compared to the vehicle-treated mice indicates a shift toward a memory phenotype which occurs during the resolution phase of the immune response.
  • the shift to a memory state indicates that immune resolution is occurring in nalfurafine-treated mice in a model of MS where disease is driven by an active immune response.
  • EAE was induced in female C57BL/6 mice as described in Example 1. Results are shown in FIG. 24 .
  • mice were treated with vehicle only (daily), nalfurafine (0.01 mg/kg by i.p. injection daily), the KOR antagonist norBNI (10 mg/kg by i.p. injection weekly), or both nalfurafine and norBNI.
  • Example 25 Myelination is Improved in Mice Treated with Nalfurafine after the Onset of Paralysis in the EAE Model of MS
  • mice were started on daily treatment with vehicle only or nalfurafine 0.01 mg/kg by i.p. injection.
  • mice were culled, perfused with 4% paraformaldehyde and spinal cords were processed for histology. Sections were stained with luxol fast blue to assess demyelination. The region of interest taken for analysis is shown in 25A.
  • EAE disease induces extensive lesions in the spinal cord (see vehicle only (25B), characterised by a loss of myelin and neurodegeneration, demonstrating that EAE is a destructive disease in the CNS.
  • Treatment of this disease state with nalfurafine reduces this lesion load and demyelination, suggesting that treatment restores the spinal cord tissue to a near normal state by remyelination.
  • Example 26 Nalfurafine Treatment Decreases Cellular Infiltration into the Spinal Cord when Administered Therapeutically in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1. Results are shown in FIG. 26 .
  • mice were started on daily treatment with vehicle only or nalfurafine 0.01 mg/kg by i.p. injection.
  • mice were culled, perfused with 4% paraformaldehyde and spinal cords were paraffin embedded for histology.
  • 10 ⁇ M coronal sections were stained with Hematoxylin and Eosin (H&E) to assess of leucocyte infiltration, a marker of inflammation within lesions induced in EAE disease.
  • H&E Hematoxylin and Eosin
  • EAE disease induces substantial histopathology in the spinal cord.
  • H&E staining of leucocytes is an indicator of lesion severity, with the higher number of infiltrating cells, the more severe the lesion, including demyelination, as shown in the vehicle only panel and by quantification.
  • Treatment with nalfurafine shows a surprising reduction of infiltrating leucocytes, with a near absence of lesions and demyelination indicating that treatment may resolve lesions and/or cause remyelination.
  • Example 27 Nalfurafine Treatment Reduces the Level of Activated Astrocytes in the Spinal Cord when Administered Therapeutically in the EAE Model of MS
  • EAE was induced in female C57BL/6 mice as described in Example 1. Results are shown in FIG. 27A-B . On day 17, mice were started on daily treatment with vehicle only or nalfurafine at 0.01 mg/kg by i.p. injection. On day 45 after immunization to induce EAE, mice were culled, and spinal cords were processed for immunohistochemistry (IHC). Shown in FIG. 27A are representative glial fibiliary acid protein (GFAP) immunolabeled cells (black staining) from coronal sections of the ventral horn of the spinal cord taken from EAE mice.
  • GFAP glial fibiliary acid protein
  • FIG. 27A As shown and quantified in FIG. 27A , at day 45, there was significant elevation in the activated GFAP + astrocytes in the spinal cord of vehicle treated EAE mice.
  • Astrocytes are recognized to be early and highly active players during lesion formation and key for providing peripheral immune cells access to the central nervous system (Ponath et al. The Role of Astrocytes in Multiple Sclerosis. Front Immunol. 2018; 9: 217).
  • Treatment with 0.01 mg/kg i.p. nalfurafine significantly reduces the number of activated astrocytes suggesting that nalfurafine treatment can have a neuroprotective and anti-inflammatory effect on the spinal cord tissue in the disease state ( FIG. 27B ).
  • Example 28 Nalfurafine Treatment Enhances Recovery from Weight Loss when Administered Therapeutically in the Cuprizone Demyelination Disease Model of MS
  • FIG. 28A shows a time course of cuprizone induced demyelination and treatment regime.
  • mice were fed cuprizone-containing chow (0.3% (w/w) cuprizone) or chow only (normal controls) for 35 days, at which point they were switched back to standard chow.
  • mice were started on daily treatment with vehicle only (DMSO: Tween 80: Saline) or nalfurafine at 0.1 mg/kg by i.p. injection or U-50488 at 1.6 mg/kg by i.p. injection.
  • DMSO Tween 80: Saline
  • nalfurafine at 0.1 mg/kg by i.p. injection or U-50488 at 1.6 mg/kg by i.p. injection.
  • mice were culled and brain tissue were processed for transmission electron microscopy (TEM). Mice were weighed daily and the % weight change calculated.
  • TEM transmission electron microscopy
  • This model is well established as a tool for the study of non-immune system induced demyelination.
  • This model enables the assessment of putative remyelination-promoting therapeutics (Matsushima and Morell, 2001.
  • the neurotoxicant, cuprizone as a model to study demyelination and remyelination in the central nervous system. Brain Pathol. 11, 107-116).
  • FIG. 28B shows cuprizone induced weight change over the time course of study.
  • a demyelinating disease state was induced in female C57BL/6 mice as described in Example 28 and illustrated in FIG. 28 .
  • mice treated with 0.3% cuprizone lose weight as the disease is induced, compared to mice with normal diet, corresponding to disease induction and severity.
  • FIG. 28C shows that nalfurafine treatment enhances weight gain in the recovery phase of the cuprizone demyelination disease model of MS, whereas U-50488 does not.
  • a demyelinating disease state was induced in female C57BL/6 mice as described in FIG. 28C .
  • Diseased animals were treated with Vehicle only, nalfurafine (0.1 mg/kg), U-50488 (1.6 mg/kg) as described in FIG. 28A .
  • mice treated with 0.3% cuprizone lose weight as the disease is induced. Mice recover when returned to normal chow (removal of cuprizone) ( FIG. 28C ). Treatment with nalfurafine enhances recovery of the lost weight faster compared to mice with vehicle only or treatment with U-50488.
  • FIG. 29 Nalfurafine Treatment Enhances Remyelination when Administered after Demyelination in the Cuprizone Demyelination Disease Model of MS
  • FIG. 29A-G Panels A-D of FIG. 29 show representative Transmission Electron Microscopy (TEM) images of the corpus callosum of mice (A) fed normal diet and (B-D) fed 0.3% cuprizone to induce demyelination. Following the time course shown in FIG. 28A , cuprizone fed mice were administered (B) vehicle only treatment, (C) U-50488 (1.6 mg/kg/i.p.) and (D) nalfurafine (0.1 mg/kg/i.p.) and then sacrificed on experimental day 70. Scale bars represent 2000 nm.
  • TEM Transmission Electron Microscopy
  • Mice fed a normal diet have a mean g-ratio of 0.78 ⁇ 0.09 in contrast to mice fed 0.3% cuprizone that have a significant increase in g-ratio of 0.84 ⁇ 0.1 corresponding to the decreased myelin thickness (####p ⁇ 0.0001).
  • Mice fed a diet with cuprizone treated with nalfurafine (0.1 mg/kg/i.p.) (0.75 ⁇ 0.15) show a significant reduction in g-ratio compared to Vehicle treated controls (****p ⁇ 0.0001), corresponding to an increased myelin thickness.
  • mice fed a diet with cuprizone treated with U-50488 show a somewhat increased myelin thickness compared to vehicle-treated controls with a mean g-ratio of (0.80) (**p ⁇ 0.01), but, surprisingly, nalfurafine treatment showed a significant increase in myelin thickness (decrease in g-ratio) compared to mice treated with U-50488 (1.6 mg/kg/i.p.) ( ⁇ circumflex over ( ) ⁇ circumflex over ( ) ⁇ circumflex over ( ) ⁇ p ⁇ 0.001), indicating that nalfurafine is significantly more effective at increasing myelin thickness than U-50488.
  • demyelination was very apparent in the corpus collosum of the brain of cuprizone-induced, vehicle only treated animals (Panel B).
  • the ratio between axonal circumference and myelin circumference (g-ratio) decreases with normal myelination.
  • the cuprizone induced animals treated with nalfurafine show a more normal axonal-myelin structure, the myelinated axons are densely packed within white matter and the myelin sheaths of neighboring fibers often directly touch.
  • the staining of the myelin sheaths black is more prominent indicating increased remyelination.
  • this nalfurafine tissue is surprisingly similar to that of the na ⁇ ve (normal) tissue.
  • the nalfurafine tissue has a significantly lower g-ratio compared to vehicle only treated indicative of enhanced remyelination, with a g-ratio closer to that of na ⁇ ve (normal) tissue.
  • This is further supported by analysis of the percentage increase in the number of myelinated axons and percentage increase in area of myelination in the nalfurafine treated animals.
  • treatment with the compound U-50488 did not show repair or restoration to a near normal state.
  • nalfurafine treatment enhances remyelination that is indicative of a near-full recovery following a demyelination insult of cuprizone.
  • Clemastine fumarate an anti-histamine which also antagonizes the muscarinic receptor
  • ReBUILD remyelinating therapy for multiple sclerosis
  • Example 31 Nalfurafine Promotes a Greater and More Sustained Recovery than Clemastine Fumarate, a Known Remyelinating Drug
  • Mice were considered recovered if they received a score ⁇ 0.5 by day 23 post treatment initiation. Shown are the percentage of mice in each group that recovered (A) and the number of days in recovery (B). ****p ⁇ 0.0001 by Fisher's exact test (% recovered; A) or one-way ANOVA with Holm-Sidak's multiple comparison test (# days in recovery; B).
  • Clemastine fumarate an anti-histamine which also antagonizes the muscarinic receptor
  • Clemastine fumarate has been shown to reduce chronic disability in the EAE model when used at 10 mg/kg starting at the time of immunization. Additionally, it has been shown to enhance remyelination in mice and humans.
  • clemastine fumarate treatment promotes recovery in just over 50% of the mice but the recovery is not sustained. In contrast, all of the mice recover when treated with nalfurafine and have a sustained recovery. This finding indicates that nalfurafine is superior to clemastine fumarate in this model and provides a more sustained improvement in every animal treated.
  • Example 32 Nalfurafine Promotes Recovery in Pain Threshold when Administered after Demyelination in the Cuprizone Demyelination Disease Model of MS
  • mice A demyelinating disease state was induced in female C57BL/6 mice (8-14 weeks older and between 17-23 grams in weight).
  • the mice were fed cuprizone-containing chow (0.3% (w/w) cuprizone) or chow only (normal controls) for 35 days, at which point they were switched back to standard chow.
  • mice were started on daily treatment with vehicle only (DMSO: Tween 80: Saline) or nalfurafine at 0.1 mg/kg by i.p. injection.
  • mice were fed cuprizone-containing chow (0.3% (w/w) cuprizone) or chow only (normal controls) for 42 days, at which point they were switched back to standard chow.
  • mice were started on daily treatment with vehicle only (DMSO: Tween 80: Saline) or nalfurafine at 0.1 mg/kg by i.p. injection. In both studies, on day 70, mice were culled. See FIG. 32 A for an outline of the disease induction and treatment time course.
  • Cuprizone causes increased mechanical sensitivity compared to mice on a normal diet ( ⁇ circumflex over ( ) ⁇ p ⁇ 0.05) ( FIG. 32B ), and this increase in mechanical withdrawal threshold is reduced to baseline levels following treatment with nalfurafine (0.1 mg/kg/i.p.).
  • Allodynia is an increase in pain sensation to a normally non-painful stimulus.
  • von Frey filaments are used to measure the paw withdrawal threshold following application of a defined mechanical force.
  • the pain threshold is a functional biomarker for recovery, indicative of remyelination of the nerve fibres.
  • the diseased animals treated with nalfurafine showed a pain sensitivity that was similar to baseline, indicating that treatment enhances functional recovery.

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