WO2008010768A1 - Method of treating and diagnosing restless legs syndrome and periodic limb movements during sleep and means for carrying out the method - Google Patents

Method of treating and diagnosing restless legs syndrome and periodic limb movements during sleep and means for carrying out the method Download PDF

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WO2008010768A1
WO2008010768A1 PCT/SE2007/050479 SE2007050479W WO2008010768A1 WO 2008010768 A1 WO2008010768 A1 WO 2008010768A1 SE 2007050479 W SE2007050479 W SE 2007050479W WO 2008010768 A1 WO2008010768 A1 WO 2008010768A1
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dopamine
zonisamide
biologically active
agonist
rls
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PCT/SE2007/050479
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French (fr)
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Ludger Grote
Jan Hedner
Kaj Stenlöf
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Cereuscience Ab
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    • 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
    • A61K31/13—Amines
    • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
    • A61K31/137—Arylalkylamines, e.g. amphetamine, epinephrine, salbutamol, ephedrine or methadone
    • 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
    • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
    • A61K31/19—Carboxylic acids, e.g. valproic acid
    • A61K31/195—Carboxylic acids, e.g. valproic acid having an amino group
    • A61K31/197—Carboxylic acids, e.g. valproic acid having an amino group the amino and the carboxyl groups being attached to the same acyclic carbon chain, e.g. gamma-aminobutyric acid [GABA], beta-alanine, epsilon-aminocaproic acid or pantothenic acid
    • A61K31/198—Alpha-amino acids, e.g. alanine or edetic acid [EDTA]
    • 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
    • A61K31/38—Heterocyclic compounds having sulfur as a ring hetero atom
    • A61K31/381—Heterocyclic compounds having sulfur as a ring hetero atom having five-membered rings
    • 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
    • A61K31/40—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
    • A61K31/403—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil condensed with carbocyclic rings, e.g. carbazole
    • A61K31/404—Indoles, e.g. pindolol
    • A61K31/4045—Indole-alkylamines; Amides thereof, e.g. serotonin, melatonin
    • 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
    • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/42—Oxazoles
    • A61K31/423—Oxazoles condensed with carbocyclic rings
    • 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
    • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/425—Thiazoles
    • A61K31/428—Thiazoles condensed with carbocyclic rings
    • 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
    • A61K31/48—Ergoline derivatives, e.g. lysergic acid, ergotamine
    • 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
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/4965—Non-condensed pyrazines
    • 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
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/4985—Pyrazines or piperazines ortho- or peri-condensed with heterocyclic ring systems
    • 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

Definitions

  • the present invention relates to a method of treating and diagnosing restless legs syndrome and periodic limb movements during sleep, and to a means for carrying out the method.
  • RLS Restless Leg Syndrome
  • Activities that require maintaining motor rest and include limited cognitive stimulation such as transportation (travelling by car, plane, train, etc.) or attending longer meetings, lectures, movies or other performances, becomes difficult or even impossible.
  • the symptoms typically worsen during the evening and early night period a subgroup of RLS patients actually experience great difficulties to sleep and insomnia is frequently a prominent complication.
  • the symptoms have a considerable negative impact on Quality of Life.
  • the symptoms can typically be relieved by movement, such as standing up, moving around, or short walks. However, the symptoms may return with increased intensity shortly after such activities. If an RLS patient is forced to lay still, symptoms will continue and may led to involuntary movements.
  • PLMS periodic limb movements during sleep
  • PLMW periodic limb movements during wakefulness
  • PLMS are best described as rhythmic extensions of the foot, big toe and dorsal flexions of the ankle. Occasionally, this movement is accompanied by flexion of the knee and hip. The movements last for approximately 0.5 to 5 seconds and appear with a frequency of about one every 20 to 40 seconds. PLMS occur in cluster episodes, each of which lasts several minutes or even hours. PLMS/PLMW and RLS may be found independently from each other but epidemiological data suggests that approximately 90% of RLS patients also have considerable periods of PLMS. However, PLMS may occur in patients without RLS symptoms during wakefulness.
  • RLS The clinical diagnosis of RLS is based on four major criteria which should be met ( Walters A S et al.; International Restless Legs Syndrome Study Group (IRLSSG). Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003 Mar;4(2): 121-32): (1) A sensation of an urge to move the limbs (usually the legs, but also arms or the trunk may be involved); (2) motor restlessness to reduce sensations; (3) when at rest, symptoms often return or get worse; and (4) there is a marked circadian variation with a peak occurrence or severity of RLS symptoms during evening and early night.
  • IRLSSG International Restless Legs Syndrome Study Group
  • RLS and PLMS are typically diagnosed by patient history and standardized questionnaires as well as by polysomnographic evaluation.
  • a ten-question evaluation scale developed by the IRLSSG has been found to be useful for assessment of RLS severity for purposes of clinical assessment, research, or therapeutic trials.
  • Standardized tests such as the Suggested Immobilization Test and the Forced Immobilization Test for quantification of RLS or PLM have been proposed.
  • RLS/PLMS a number of studies suggest that the fundamental pathophysiology of RLS/PLMS involves mechanisms of iron and dopamine transport and turn-over. Reduced iron content of the brain and other fluids/compartments of the body as well as reduced dopamine synthesis in the brain have been proposed in RLS.
  • Dopamine is a neurotransmitter synthesized in the brain and with essential features for adequate central nervous system (CNS) function.
  • CNS central nervous system
  • RLS Reduced dopamine availability as a result of reduced tyrosine hydroxylase activity or other mechanisms like a decrease of dopamine receptor content in basal ganglia, strengthen the hypothesis that both iron and dopamine deficits, particularly at the level of the central nervous system, play an essential role in the occurrence of RLS.
  • RLS pathophysiology may be extended to conditions in PLMS/PLMW and they are in principle analogous to those in RLS. Impairment of sleep by frequent awakenings and associated consequences for daytime function and quality of life are important features in this condition. For this reason, the conditions of RLS and PLMS/PLMW will be jointly referred to as RLS in this patent description.
  • RLS treatment modalities
  • these include the administration of dopamine receptor agonists, other dopaminergic agents, benzodiazepines, opiates and anti-convulsants.
  • dopamine receptor agonists include the administration of dopamine receptor agonists, other dopaminergic agents, benzodiazepines, opiates and anti-convulsants.
  • the use of several of these agents is hampered by undesirable side effects that, depending on the substance, include nausea, vomiting, insomnia, daytime sedation, cognitive side effects, allergic reactions, anaphylactic shock etc.
  • Certain forms of RLS so called secondary RLS a condition that is related to e.g. pregnancy or end-stage renal disease, may be specifically resolved be treatment or elimination of the underlying condition/disease. In these cases there may a profound reduction or even complete remission of RLS following treatment.
  • a further object of the present invention is its application as a diagnostic tool for the detection of the presence of RLS/PLMW and PLMS in a given patient.
  • the present invention is based on the hypothesis that the beneficial effect of zonisamide in patients with RLS may comprise a stabilising effect on the electrical membrane potential of neural cells which is derived from its anti-epileptic activity. Possibly certain RLS/PLM preventing mechanisms, like e.g. dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area, are enhanced by this effect on electrical membrane stability. This may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements.
  • a method of treating the Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient.
  • Administration is suitably in form of a composition comprising a pharmaceutically acceptable carrier. It is preferred for the
  • dopaminergic agent to be selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids.
  • the dopaminergic agent is a dopamine agonist or a dopamine turnover promoting agent is a dopamine uptake inhibitor.
  • the combination of dopaminergic agent and biologically active zonisamide combination is administered in a form of a composition for controlled release or in form of a device for controlled release.
  • the biologically active zonisamide is administered in a form of a composition for controlled release or in form of a device for controlled release.
  • one of dopaminergic agent and biologically active zonisamide is administered via the skin or the oral mucosa, and the other is administered per os or intravenously.
  • the biologically active zonisamide prefferably administered in a total daily dose ranging from 10 to 600 mg divided into two or more portions administered in intervals over a selected period of time.
  • a fourth preferred aspect of the invention comprises the additional administration of a sleep promoting agent selected from benzodiazepines, zaleplon, Zolpidem, zopiclon, agents interacting with the benzodiazepine receptor complex, melatonin receptor agonist, GABA receptor agonists, opioids, and antihistamines.
  • a sleep promoting agent selected from benzodiazepines, zaleplon, Zolpidem, zopiclon, agents interacting with the benzodiazepine receptor complex, melatonin receptor agonist, GABA receptor agonists, opioids, and antihistamines.
  • RLS as their concentration can be kept at a lower level than if administered separately.
  • the combination targeting two different biological mechanisms provides a higher degree of RLS symptom control. It is likely better suited for long-term treatment.
  • the combination of zonisamide and DAG of the invention can be administered by different routes, each providing specific advantages and disadvantages.
  • the selection of given weight proportions for zonisamide and DAG in the combination as well as of a specific galenic formulation will depend on factors such as the specific patient group targeted, the desired kinetics of the medication and differences in tolerability.
  • a method of treating RLS/PLMS in a patient comprising the administration of first agent that exhibits an excitatory effect on the dopaminergic receptor or increases dopamine turnover (DAG), and of a second agent that is zonisamide or comprises a releaseable form of zonisamide.
  • DAG dopamine turnover
  • a second agent that is zonisamide or comprises a releaseable form of zonisamide.
  • Releaseable form of zonisamide comprises prodrugs of zonisamide.
  • pharmaceutically acceptable salts of zonisamide are comprised by "zonisamide”.
  • Movements during Sleep comprises the administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient, and a therapeutically effective dose of an agent selected from carbamazepin, carbamazepin like agents, baclofen and other GABA receptor agonists, melatonin receptor agonists, clonidine and other central alpha receptor or opioid receptor agonist.
  • a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor
  • an agent selected from carbamazepin, carbamazepin like agents, baclofen and other GABA receptor agonists, melatonin receptor agonists, clonidine and other central alpha receptor or opioid receptor agonist.
  • a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating Restless Legs Syndrome or Periodic Limb Movements during Sleep and (b) the use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a diagnostic device, kit or composition for the diagnosis of the restless legs syndrome or periodic limb movements during sleep.
  • RLS diseases PL, PLMW and PLMS
  • DAG has been used for decades to treat a number of conditions including RLS.
  • Other recognized and documented indications for DA include Morbus Parkinson (cerebral D2 and D3 receptors), heart failure and cardiogenic shock (vascular Dl receptors).
  • Morbus Parkinson Cerebral D2 and D3 receptors
  • heart failure vascular Dl receptors
  • cardiogenic shock vascular Dl receptors
  • the beneficial effect of DAG in patients with RLS appears to include an enhancement of dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area. This effect may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements. In addition, increased central nervous system dopaminergic activity may balance the sensory stimuli which cause restless legs symptoms. While this hypothesis provides a scientifically attractive explanation for the observed effect of said DAG in the conditions which the present invention seeks to treat, it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
  • a "pharmacologically effective amount of DAG” is one of a DAG or a combination of two or more DAG that eliminates or substantially reduces the manifestations of RLS over a period of time, such as the afternoon, evening, and even sleep periods from 10 minutes to 10 hours.
  • agents with an excitatory effect on dopamine receptors are known in the art. Their chemical structure may vary considerably. DAG and central nervous dopaminergic effects promoting agents particularly useful in the invention include karbidopa and levodopa, dopamine, dobutamine, dopamine agonists like ropinerol, cabergoline, pramipexol, pergolide, rotigotine, lisurid and bromocriptine, as well as dopamine promoting MAO-B inhibitors like e.g. selegiline, rasagiline and safinamide, and dopamine reuptake inhibitors like e.g.
  • vanoxerine GRR 12909
  • radafaxine and SEP 226 330
  • pharmaceutically acceptable salts including pharmaceutically acceptable salts, enantiomers of those in the aforementioned compounds which are able to form salt with organic or inorganic acids.
  • the aforementioned compounds are extensively described in the literature; see, for instance: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 10th Ed., Pergamon Press, New York, 2001 and Martindale, The Complete Drug Reference 34 Ed., Pharmaceutical Press, New York, 2005 and the references cited therein.
  • pharmaceutical compositions useful in the invention are described for a number of DAG. All different chemical structures and specifically salts being only slightly soluble in aqueous solutions are included in the invention. This is true, in particular, for those chemical entities that may be of particular interest in the manufacture of controlled release DAG/Z-preparations.
  • a potential DAG/Z mixture is advantageously formulated in a way appropriate to the chosen administration route.
  • the beneficial effect of Z in patients with RLS may include a stabilising effect on the electrical membrane potential of sensory and motor neurons which is known from its anti-epileptic activity. It is possible, that certain RLS/PLM preventing mechanisms, like e.g. dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area, will be enhanced by this effect on electrical membrane stability. Again, this effect may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements. In addition, reduced central nervous cell excitability as well as increased central nervous system dopaminergic activity may balance the sensory stimuli which cause restless legs symptoms. While this hypothesis provides a scientifically attractive explanation for the observed effect of Z in the conditions which the present invention seeks to treat, it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
  • the DAG/Z combination may be administered by various routes.
  • the most preferred route is by per oral administration.
  • the compound of the invention is incorporated in tablets, lozenges, capsules or similar, in particular solid pharmaceutical preparations designed for preferred uptake of the compound through the oral mucosa. Most preferred is a gastro intestinal absorption.
  • formulations using absorption within the oral cavity and administered via the sublingual route or other pharmaceutical compositions adapted to such absorption are of particular interest.
  • Knowledge about clinical pharmacokinetics of DAG and Z is useful in designing DAG/Z preparations for administration to a patient. It is also an object of the present invention, to describe the administration of DAG and Z separately, by means of different preparations and potentially also at different time points.
  • a combination package (DAG and Z) that contains medication with a different distinct numbers of scheduled intakes per time unit (e.g. one to several times per day, week or over one to several weeks) and a peroral DAG formulation to be taken on a daily (one to several times per day), weekly, or even monthly basis.
  • the exact dosages applied in such combination packages will be based on efficacy data from clinical studies (e.g. 50mg zonisamide together with a once daily intake of 0.35 mg pramipexol).
  • Another combination package with formulations for oral use may contain the combination of daily use of Z (e.g.
  • a further object of this invention is to describe a means whereby these latter combinations for oral use may be administered as a single pharmaceutical formulation containing the two components of DAG and Z.
  • a DA/Z compound with a short pharmacological half-life it is desirable to design an oral, buccal or sublingual pharmaceutical formulation for sustained release of the DAG/Z combination in order to avoid the need for frequent administration which would be particularly difficult during sleep.
  • a suitable solution for this problem would be a fixation, at least for a certain period of time, of one or both components of the formulation containing the DAG/Z combination in or near the sublingual region. This could be done by a device for fixation or a holding the tablet, lozenge, or similar attached to one or several teeth of the lower jaw, or by implantation of a holding means, of titanium, for instance, in the lower jaw.
  • Such holding means could also be used for holding a small plastic container enclosing a liquid or solid pharmaceutical composition of the DAG/Z of the invention, from which container the solution would leak through a minute opening or through a system of micropores driven by, for example, osmotic pressure. It is also possible to incorporate the compound of the invention in polymer matrix, biodegradable or not, from which it could leak slowly into the oral cavity.
  • Appropriate technology for producing biodegradable polyester matrices of the polylactide/ ployglycolide type for incorporation and sustained release of pharmacologically active compounds is described in, for instance, L A Sanders et al., J Pharmaceutical Sci. 75 (1986) 356-360, and in the U.S. Patent No. 3,773,919 (Boswell).
  • Non-degradable polymers of appropriate physical properties can also be used as matrices.
  • the amount of DAG and Z to be administered for treatment of RLS will vary depending on factors such as the particular chemical nature of the DAG/Z formulation used, the route of administration, the release profile of the formulation into which it is incorporated, the severity of the disease, individual pharmacokinetic and pharmacodynamic properties as well as the status of the patient.
  • the dose range for per oral administration of pramipexol will be in the interval from 0.009 to lmg per 24 hours. Normally, an amount of from 0.18 to 0.5 mg of pramipexol is envisaged as the normal range used for a per oral administration.
  • the dosage range for a Z preparation may vary between 10 and 400mg.
  • the appropriate dose range for a particular compound or the combination of DAG and Z compounds can be determined by titration in routine experiments.
  • parenteral, intranasal, and rectal administration is useful, as well as administration by inhalation or transdermal administration.
  • the DAG/Z can be effectively administered also by inhalation, such as inhalation via the mouth or via the nose.
  • the nasal mucosa is easily accessible by use of extra- or intranasal devices, the later ones appropriately shaped and designed similarly to what has been described above for intraoral and sublingual administration.
  • the transdermal formulation for DAG is specifically advantageous in regard of simplicity and from a patient comfort standpoint.
  • the agent is applied to the skin in form of a viscous ointment or similar.
  • Transdermal systems (patches provided with a liquid or semi-liquid pharmaceutical composition) for controlled drug delivery through the skin are well known in the art, for instance formulations used for administration of nicotine and drugs used for diseases of the circulatory system.
  • DAG/Z compound according to the invention will depend on the particular compound, its rate of absorption through the mucosa or the skin, the release profile of the respective sustained release formulation and/or device, if used, and similar. Typically, administration of the DAG/Z will, in the majority of cases, have to start well in advance of the RLS symptoms period to achieve optimal effect, for instance 10 minutes to 6 hours prior to the onset of sleep.
  • DAG/Z combination of the invention may also be combined, in one and the same pharmaceutical preparation, with other pharmacologically active compounds useful in the treatment of RLS/PLMS.
  • the DAG/Z compound of the invention may also be used for diagnosing RLS and thereby to dissociate this condition from other types of sleep disorders.
  • the diagnostic method according to the invention comprises administration to the patient a DAG/Z combination given in increasing amounts prior to or during a series of day/ evening/sleep periods; administration can be in single or multiple doses. The observation of a reduction of the severity and/or RLS events or episodes or reduced daytime sleepiness/increased alertness is indicative of the presence of RLS.
  • a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating the Restless Legs Syndrome and/or Periodic Limb Movements during Sleep.
  • the dopaminergic agent is selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids. It is also preferred for the dopaminergic agent to be a dopamine agonist or a dopamine turnover promoting agent or a dopamine uptake inhibitor. According to an advantageous aspect of the invention the medicament is in form of a composition for sustained release or in form of a device for sustained release.
  • a method of manufacture of a medicament for oral administration intended for treating Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising mixing a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor with a pharmaceutically acceptable carrier, and pressing the mixture into a tablet or filing it into a capsule.
  • a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor
  • the carrier is preferably one suitable for forming a tablet for sustained release.
  • FIG. 1 a preferred but not limiting embodiment illustrated by a figure (Fig. 1) showing the combined DAG and Z effect on clinical symptoms of RLS assessed by the International Restless Legs Syndrome Scale (IRLSS) in each of the patients.
  • Fig. 1 a figure showing the combined DAG and Z effect on clinical symptoms of RLS assessed by the International Restless Legs Syndrome Scale (IRLSS) in each of the patients.
  • EXAMPLE Open, uncontrolled treatment study with zonisamide and a dopaminergic agent in one patient with restless legs

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Abstract

A method of treating Restless Legs Syndrome and/or Periodic Limb Movements during Sleep (RLS) comprises administration of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient. Also disclosed is a corresponding method of treatment, the use of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating RLS, and a corresponding method of manufacture.

Description

Description
METHOD OF TREATING AND DIAGNOSING RESTLESS LEGS SYNDROME AND PERIODIC LIMB MOVEMENTS DURING SLEEP AND MEANS FOR CARRYING OUT THE METHOD Field of the Invention
[0001] The present invention relates to a method of treating and diagnosing restless legs syndrome and periodic limb movements during sleep, and to a means for carrying out the method.
Background of the Invention
[0002] Patients with Restless Leg Syndrome (RLS), have difficulties to remain seated or even to stand still. Activities that require maintaining motor rest and include limited cognitive stimulation, such as transportation (travelling by car, plane, train, etc.) or attending longer meetings, lectures, movies or other performances, becomes difficult or even impossible. The symptoms typically worsen during the evening and early night period, a subgroup of RLS patients actually experience great difficulties to sleep and insomnia is frequently a prominent complication. The symptoms have a considerable negative impact on Quality of Life. The symptoms can typically be relieved by movement, such as standing up, moving around, or short walks. However, the symptoms may return with increased intensity shortly after such activities. If an RLS patient is forced to lay still, symptoms will continue and may led to involuntary movements.
[0003] The majority of RLS patients exhibit periodic limb movements during sleep (PLMS) or periodic limb movements during wakefulness (PLMW). PLMS are best described as rhythmic extensions of the foot, big toe and dorsal flexions of the ankle. Occasionally, this movement is accompanied by flexion of the knee and hip. The movements last for approximately 0.5 to 5 seconds and appear with a frequency of about one every 20 to 40 seconds. PLMS occur in cluster episodes, each of which lasts several minutes or even hours. PLMS/PLMW and RLS may be found independently from each other but epidemiological data suggests that approximately 90% of RLS patients also have considerable periods of PLMS. However, PLMS may occur in patients without RLS symptoms during wakefulness.
[0004] The clinical diagnosis of RLS is based on four major criteria which should be met ( Walters A S et al.; International Restless Legs Syndrome Study Group (IRLSSG). Validation of the International Restless Legs Syndrome Study Group rating scale for restless legs syndrome. Sleep Med. 2003 Mar;4(2): 121-32): (1) A sensation of an urge to move the limbs (usually the legs, but also arms or the trunk may be involved); (2) motor restlessness to reduce sensations; (3) when at rest, symptoms often return or get worse; and (4) there is a marked circadian variation with a peak occurrence or severity of RLS symptoms during evening and early night.
[0005] RLS and PLMS are typically diagnosed by patient history and standardized questionnaires as well as by polysomnographic evaluation. A ten-question evaluation scale developed by the IRLSSG has been found to be useful for assessment of RLS severity for purposes of clinical assessment, research, or therapeutic trials. Standardized tests such as the Suggested Immobilization Test and the Forced Immobilization Test for quantification of RLS or PLM have been proposed.
[0006] A number of studies suggest that the fundamental pathophysiology of RLS/PLMS involves mechanisms of iron and dopamine transport and turn-over. Reduced iron content of the brain and other fluids/compartments of the body as well as reduced dopamine synthesis in the brain have been proposed in RLS. Dopamine is a neurotransmitter synthesized in the brain and with essential features for adequate central nervous system (CNS) function. Experimental data points to iron as an essential component for adequate transmembraneous transport of dopamine and dopamine receptor function in CNS regions responsible for motor and sensory function.
[0007] Reduced dopamine availability as a result of reduced tyrosine hydroxylase activity or other mechanisms like a decrease of dopamine receptor content in basal ganglia, strengthen the hypothesis that both iron and dopamine deficits, particularly at the level of the central nervous system, play an essential role in the occurrence of RLS. Although less extensively investigated, there is a consensus that the principles of RLS pathophysiology may be extended to conditions in PLMS/PLMW and they are in principle analogous to those in RLS. Impairment of sleep by frequent awakenings and associated consequences for daytime function and quality of life are important features in this condition. For this reason, the conditions of RLS and PLMS/PLMW will be jointly referred to as RLS in this patent description.
A number of different treatment modalities are currently available in RLS. These include the administration of dopamine receptor agonists, other dopaminergic agents, benzodiazepines, opiates and anti-convulsants. However, the use of several of these agents is hampered by undesirable side effects that, depending on the substance, include nausea, vomiting, insomnia, daytime sedation, cognitive side effects, allergic reactions, anaphylactic shock etc. Certain forms of RLS, so called secondary RLS a condition that is related to e.g. pregnancy or end-stage renal disease, may be specifically resolved be treatment or elimination of the underlying condition/disease. In these cases there may a profound reduction or even complete remission of RLS following treatment. [0008] Intake of oral levodopa generally treats RLS effectively during the first weeks or months of treatment. However, continued use frequently leads to tolerance development, augmentation of symptoms or even a general worsening of RLS. Similar effects are frequently seen during long-term treatment with dopamine receptor agonists. Other frequently used remedies like benzodiazepines, opiates and anticonvulsants are uniformly less effective than the dopamine agents and side effects are prevalent in a manner that clearly limits their clinical applicability.
[0009] A novel treatment principle has been introduced recently by showing that the anti- epileptic drug zonisamide caused a remarkable decrease in RLS. RLS symptoms have been resolved in the majority of cases after initiation of both short and long term treatment with zonisamide between 1 to 29 months (Restless legs syndrome treated with zonisamide, WA Tosches, Neurology, Proceedings of the AAN Meeting 2004, P06.131, A507).
[0010] As evident from the preceding description of the state of the art, there is a need for an improved method for treating RLS/PLMS. In particular, a new pharmacological treatment in these disorders would offer a definite advantage in front of the methods used at present, many of which provide insufficient relief and some of which are associated with potentially severe side effects and limitations.
Objects of Invention
[0011] One object of the present invention is thus to provide a method for the treatment of RLS/PLMS which reduces and/or eliminates some or all of the drawbacks of the methods known in art. Another object of the present invention is to provide a means for carrying out said method according to the invention. A further object of the present invention is its application as a diagnostic tool for the detection of the presence of RLS/PLMW and PLMS in a given patient.
Summary of the Invention
[0012] The present invention is based on the hypothesis that the beneficial effect of zonisamide in patients with RLS may comprise a stabilising effect on the electrical membrane potential of neural cells which is derived from its anti-epileptic activity. Possibly certain RLS/PLM preventing mechanisms, like e.g. dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area, are enhanced by this effect on electrical membrane stability. This may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements. This hypothesis provides a scientifically attractive explanation of the effect observed in patients described below but should not detract from the practical working of the invention, which is not bound in any way by this hypothesis. [0013] According to the present invention administration of zonisamide in combination with a dopamine agonist (DA) and/or a dopamine turnover promoting agent, which term includes dopamine reuptake inhibitor, (DATPA) provides a resolution of RLS that is superior to either of these agents alone. In this specification, dopamine agonist (DA) and dopamine turnover promoting agent (DATPA) are jointly designated "dopamine agent" (DAG).
[0014] To obtain the effect on a patient the combined amounts of zonisamide and dopamine agent (DAG) have to be pharmacologically effective.
[0015] According to the present invention is disclosed a method of treating the Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient. Administration is suitably in form of a composition comprising a pharmaceutically acceptable carrier. It is preferred for the
[0016] dopaminergic agent to be selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids. Preferably the dopaminergic agent is a dopamine agonist or a dopamine turnover promoting agent is a dopamine uptake inhibitor.
[0017] According to a preferred aspect of the invention the combination of dopaminergic agent and biologically active zonisamide combination is administered in a form of a composition for controlled release or in form of a device for controlled release.
[0018] According to another preferred aspect of the invention the biologically active zonisamide is administered in a form of a composition for controlled release or in form of a device for controlled release.
[0019] According to a third preferred aspect of the invention one of dopaminergic agent and biologically active zonisamide is administered via the skin or the oral mucosa, and the other is administered per os or intravenously.
[0020] It is preferred for the biologically active zonisamide to be administered in a total daily dose ranging from 10 to 600 mg divided into two or more portions administered in intervals over a selected period of time.
[0021] A fourth preferred aspect of the invention comprises the additional administration of a sleep promoting agent selected from benzodiazepines, zaleplon, Zolpidem, zopiclon, agents interacting with the benzodiazepine receptor complex, melatonin receptor agonist, GABA receptor agonists, opioids, and antihistamines.
[0022] The combination of zonisamide and DAG is simple, provides a safer treatment for
RLS as their concentration can be kept at a lower level than if administered separately. The combination targeting two different biological mechanisms provides a higher degree of RLS symptom control. It is likely better suited for long-term treatment.
[0023] The combination of zonisamide and DAG of the invention can be administered by different routes, each providing specific advantages and disadvantages. The selection of given weight proportions for zonisamide and DAG in the combination as well as of a specific galenic formulation will depend on factors such as the specific patient group targeted, the desired kinetics of the medication and differences in tolerability.
[0024] Thus, according to the present invention is provided a method of treating RLS/PLMS in a patient, comprising the administration of first agent that exhibits an excitatory effect on the dopaminergic receptor or increases dopamine turnover (DAG), and of a second agent that is zonisamide or comprises a releaseable form of zonisamide. "Releaseable form of zonisamide" comprises prodrugs of zonisamide. n this application pharmaceutically acceptable salts of zonisamide are comprised by "zonisamide".
[0025] The method of treating the Restless Legs Syndrome and/or Periodic Limb
Movements during Sleep comprises the administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient, and a therapeutically effective dose of an agent selected from carbamazepin, carbamazepin like agents, baclofen and other GABA receptor agonists, melatonin receptor agonists, clonidine and other central alpha receptor or opioid receptor agonist.
[0026] According to a further preferred aspect of the invention is disclosed (a) use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating Restless Legs Syndrome or Periodic Limb Movements during Sleep and (b) the use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a diagnostic device, kit or composition for the diagnosis of the restless legs syndrome or periodic limb movements during sleep.
[0027] In this specification the diseases RLS, PLMW and PLMS will be jointly referred to as RLS. [0028] DAG has been used for decades to treat a number of conditions including RLS. Other recognized and documented indications for DA include Morbus Parkinson (cerebral D2 and D3 receptors), heart failure and cardiogenic shock (vascular Dl receptors). For a recent survey in respect of known therapeutic uses of DA, see: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 10th Ed., Pergamon Press, New York etc., 2001.
[0029] The beneficial effect of DAG in patients with RLS appears to include an enhancement of dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area. This effect may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements. In addition, increased central nervous system dopaminergic activity may balance the sensory stimuli which cause restless legs symptoms. While this hypothesis provides a scientifically attractive explanation for the observed effect of said DAG in the conditions which the present invention seeks to treat, it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
[0030] A "pharmacologically effective amount of DAG" is one of a DAG or a combination of two or more DAG that eliminates or substantially reduces the manifestations of RLS over a period of time, such as the afternoon, evening, and even sleep periods from 10 minutes to 10 hours.
[0031] Many agents with an excitatory effect on dopamine receptors are known in the art. Their chemical structure may vary considerably. DAG and central nervous dopaminergic effects promoting agents particularly useful in the invention include karbidopa and levodopa, dopamine, dobutamine, dopamine agonists like ropinerol, cabergoline, pramipexol, pergolide, rotigotine, lisurid and bromocriptine, as well as dopamine promoting MAO-B inhibitors like e.g. selegiline, rasagiline and safinamide, and dopamine reuptake inhibitors like e.g. vanoxerine (GBR 12909), radafaxine and SEP 226 330, including pharmaceutically acceptable salts, enantiomers of those in the aforementioned compounds which are able to form salt with organic or inorganic acids. The aforementioned compounds are extensively described in the literature; see, for instance: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 10th Ed., Pergamon Press, New York, 2001 and Martindale, The Complete Drug Reference 34 Ed., Pharmaceutical Press, New York, 2005 and the references cited therein. In this publication, which is hereby incorporated by reference, pharmaceutical compositions useful in the invention are described for a number of DAG. All different chemical structures and specifically salts being only slightly soluble in aqueous solutions are included in the invention. This is true, in particular, for those chemical entities that may be of particular interest in the manufacture of controlled release DAG/Z-preparations. A potential DAG/Z mixture is advantageously formulated in a way appropriate to the chosen administration route.
[0032] The beneficial effect of Z in patients with RLS may include a stabilising effect on the electrical membrane potential of sensory and motor neurons which is known from its anti-epileptic activity. It is possible, that certain RLS/PLM preventing mechanisms, like e.g. dopaminergic activity in the central nervous system, in particular in the midbrain and the striatal area, will be enhanced by this effect on electrical membrane stability. Again, this effect may cause an increased threshold for periodic stimuli impinging in the cerebral cortex, the medulla, and the spinal cord thereby reducing the amount of bursts of motoric alpha neuron activity and leg movements. In addition, reduced central nervous cell excitability as well as increased central nervous system dopaminergic activity may balance the sensory stimuli which cause restless legs symptoms. While this hypothesis provides a scientifically attractive explanation for the observed effect of Z in the conditions which the present invention seeks to treat, it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
[0033] The positive effect of Z in the treatment of RLS may be due to an enhancement of dopaminergic activity in the central nervous system mimicking the effects described for DAG above. Again, while this hypothesis may provide a scientifically attractive explanation for the observed effect of zonisamide in the conditions which the present invention seeks to treat, it must be emphasized that it must not be considered to be binding in any way on the concept and the working of the present invention.
[0034] The DAG/Z combination may be administered by various routes. The most preferred route is by per oral administration. In this context the compound of the invention is incorporated in tablets, lozenges, capsules or similar, in particular solid pharmaceutical preparations designed for preferred uptake of the compound through the oral mucosa. Most preferred is a gastro intestinal absorption. However, formulations using absorption within the oral cavity and administered via the sublingual route or other pharmaceutical compositions adapted to such absorption are of particular interest. Knowledge about clinical pharmacokinetics of DAG and Z (see, for instance: Goodman and Gilman's The Pharmacological Basis of Therapeutics, 10th Ed., Pergamon Press, New York etc., 2001) is useful in designing DAG/Z preparations for administration to a patient. It is also an object of the present invention, to describe the administration of DAG and Z separately, by means of different preparations and potentially also at different time points.
[0035] For this purpose formulation techniques known in the art may be used; in this context reference is made to Pharmaceutical Dosage Forms: Tablets. Vol. 1-3, H A Lieberman et al., Eds. Marcel Dekker, New York and Basel, 1998, which hereby incorporated is into this application by reference. Specific reference is made to chapter 7 (Special Tablets, by J W Conine and M J Pikal), chapter 8 (Chewable Tablets, by R W Mendes, O A Anaebonam and J B Daruwala), and chapter 9 (Medicated Lozenges; by D Peters).
[0036] It is also an object of the present invention that a combination package (DAG and Z) that contains medication with a different distinct numbers of scheduled intakes per time unit (e.g. one to several times per day, week or over one to several weeks) and a peroral DAG formulation to be taken on a daily (one to several times per day), weekly, or even monthly basis. The exact dosages applied in such combination packages will be based on efficacy data from clinical studies (e.g. 50mg zonisamide together with a once daily intake of 0.35 mg pramipexol). Another combination package with formulations for oral use may contain the combination of daily use of Z (e.g. 100 mg zonisamide) together with 0.35 mg cabergoline each second day or L-Dopa only at demand. Any other combination of DAG/Z formulations given in different dosage combinations, that have been found to be effective for the treatment of RLS, is included into this invention. A further object of this invention is to describe a means whereby these latter combinations for oral use may be administered as a single pharmaceutical formulation containing the two components of DAG and Z.
[0037] In the event that a DA/Z compound with a short pharmacological half-life is used according to this invention, it is desirable to design an oral, buccal or sublingual pharmaceutical formulation for sustained release of the DAG/Z combination in order to avoid the need for frequent administration which would be particularly difficult during sleep. A suitable solution for this problem would be a fixation, at least for a certain period of time, of one or both components of the formulation containing the DAG/Z combination in or near the sublingual region. This could be done by a device for fixation or a holding the tablet, lozenge, or similar attached to one or several teeth of the lower jaw, or by implantation of a holding means, of titanium, for instance, in the lower jaw. Such holding means could also be used for holding a small plastic container enclosing a liquid or solid pharmaceutical composition of the DAG/Z of the invention, from which container the solution would leak through a minute opening or through a system of micropores driven by, for example, osmotic pressure. It is also possible to incorporate the compound of the invention in polymer matrix, biodegradable or not, from which it could leak slowly into the oral cavity. Appropriate technology for producing biodegradable polyester matrices of the polylactide/ ployglycolide type for incorporation and sustained release of pharmacologically active compounds is described in, for instance, L A Sanders et al., J Pharmaceutical Sci. 75 (1986) 356-360, and in the U.S. Patent No. 3,773,919 (Boswell). Non-degradable polymers of appropriate physical properties can also be used as matrices.
[0038] The amount of DAG and Z to be administered for treatment of RLS will vary depending on factors such as the particular chemical nature of the DAG/Z formulation used, the route of administration, the release profile of the formulation into which it is incorporated, the severity of the disease, individual pharmacokinetic and pharmacodynamic properties as well as the status of the patient. For instance, the dose range for per oral administration of pramipexol will be in the interval from 0.009 to lmg per 24 hours. Normally, an amount of from 0.18 to 0.5 mg of pramipexol is envisaged as the normal range used for a per oral administration. The dosage range for a Z preparation may vary between 10 and 400mg. The appropriate dose range for a particular compound or the combination of DAG and Z compounds can be determined by titration in routine experiments. In addition to the method of administration of the compounds of the invention mentioned above also parenteral, intranasal, and rectal administration is useful, as well as administration by inhalation or transdermal administration.
[0039] According to the invention the DAG/Z can be effectively administered also by inhalation, such as inhalation via the mouth or via the nose. The nasal mucosa is easily accessible by use of extra- or intranasal devices, the later ones appropriately shaped and designed similarly to what has been described above for intraoral and sublingual administration. The transdermal formulation for DAG is specifically advantageous in regard of simplicity and from a patient comfort standpoint. In this case, the agent is applied to the skin in form of a viscous ointment or similar. Transdermal systems (patches provided with a liquid or semi-liquid pharmaceutical composition) for controlled drug delivery through the skin are well known in the art, for instance formulations used for administration of nicotine and drugs used for diseases of the circulatory system.
[0040] The timing of the administration of the composition and/or device comprising the
DAG/Z compound according to the invention will depend on the particular compound, its rate of absorption through the mucosa or the skin, the release profile of the respective sustained release formulation and/or device, if used, and similar. Typically, administration of the DAG/Z will, in the majority of cases, have to start well in advance of the RLS symptoms period to achieve optimal effect, for instance 10 minutes to 6 hours prior to the onset of sleep.
[0041] The DAG/Z combination of the invention may also be combined, in one and the same pharmaceutical preparation, with other pharmacologically active compounds useful in the treatment of RLS/PLMS.
[0042] The DAG/Z compound of the invention may also be used for diagnosing RLS and thereby to dissociate this condition from other types of sleep disorders. The diagnostic method according to the invention comprises administration to the patient a DAG/Z combination given in increasing amounts prior to or during a series of day/ evening/sleep periods; administration can be in single or multiple doses. The observation of a reduction of the severity and/or RLS events or episodes or reduced daytime sleepiness/increased alertness is indicative of the presence of RLS.
[0043] According to the invention is also disclosed the use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating the Restless Legs Syndrome and/or Periodic Limb Movements during Sleep. Preferably the dopaminergic agent is selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids. It is also preferred for the dopaminergic agent to be a dopamine agonist or a dopamine turnover promoting agent or a dopamine uptake inhibitor. According to an advantageous aspect of the invention the medicament is in form of a composition for sustained release or in form of a device for sustained release.
[0044] According to an additional aspect of the invention is disclosed a method of manufacture of a medicament for oral administration intended for treating Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising mixing a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor with a pharmaceutically acceptable carrier, and pressing the mixture into a tablet or filing it into a capsule.
[0045] The carrier is preferably one suitable for forming a tablet for sustained release.
[0046] The invention will now be explained in more detail by reference to a preferred but not limiting embodiment illustrated by a figure (Fig. 1) showing the combined DAG and Z effect on clinical symptoms of RLS assessed by the International Restless Legs Syndrome Scale (IRLSS) in each of the patients.
Description of a Preferred Embodiment
[0047] EXAMPLE. Open, uncontrolled treatment study with zonisamide and a dopaminergic agent in one patient with restless legs
[0048] One patient with moderate RLS/PMLS (PLM index (PLMI) 4, IRLSS Score 27 at baseline) was studied (figure 1). This particular patient had experienced augmentation of RLS symptoms during previous single drug treatment with dopaminergic agents like L-dopa and pramipexol. Zonisamide, given 50 mg once daily (o.d.) for one week and than increased to 100 mg o.d. per oral (p.o.) for an additional period of 14 days, resulted in a symptom improvement with a mean reduction of PLMI from 3 to 0 and a reduction of the IRLSS score from 27 at baseline to 16 at day 21. No side effects were reported during the observational period. Due to remaining RLS complaints the DAG Pramipexol was introduced using the dosage of 0.18 mg once daily. All RLS complaints were resolved (IRLSS score 0) when assessments were performed 3 weeks after the last infusion of iron sucrose. Subsequently, the patient discontinued zonisamide treatment for additional two weeks. The RLS/PLM symptoms reoccurred assessed by the IRLSS scale score of 15 after one week of ongoing Pramipexol treatment but cessation of zonisamide intake. In addition, reoccurrence of PLM were reported by the bedpartner. However, the baseline value of 27 in the IRLSS scale was not reached. Following reintroduction of zonisamide 100 mg once daily per os, RLS symptoms were fully controlled by treatment as visible in an IRLSS score of 2 after 8 weeks. No reoccurrence of augmentation of RLS symptoms was observed after long term treatment in this combination. This case report clearly demonstrates a potent reduction of PLMI and RLS complaints by a combination therapy of DAG and zonisamide. There was a clear additive effect of the two treatments with regard to control of RLS and PLM complaints emphasizing that the combination of zonisamide and DAG results in an effect superior to that obtained by either drug used alone. In addition, DAG/Z combination therapy did not induce augmentation of RLS symptoms in augmentation prone RLS patients.

Claims

Claims
[0001] A method of treating Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient.
[0002] The method of claim 1, wherein the dopaminergic agent is selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids.
[0003] The method of claim 1, wherein the dopaminergic agent is a dopamine agonist.
[0004] The method of claim 1, wherein the dopaminergic agent is a dopamine turnover promoting agent or a dopamine uptake inhibitor.
[0005] The method of any of claims 1 to 4, wherein the combination of dopaminergic agent and biologically active zonisamide is administered in a form of a composition for controlled release or in form of a device for controlled release.
[0006] The method of claims 1 to 4, wherein the biologically active zonisamide is administered in a form of a composition for controlled release or in form of a device for controlled release.
[0007] The method of any of claims 1 to 4, wherein one of dopaminergic agent and biologically active zonisamide is administered via the skin or the oral mucosa, and the other is administered per os or intravenously.
[0008] The method of any of claims 1 to 7, wherein biologically active zonisamide is administered in a total daily dose ranging from 10 to 600 mg divided into two or more portions administered in intervals over a selected period of time.
[0009] The method of any of claims 1 to 8, comprising the administration of a sleep promoting agent selected from benzodiazepine, zaleplon, Zolpidem, zopiclon, agents interacting with the benzodiazepine receptor complex, melatonin receptor agonist, GABA receptor agonist, opioid, and antihistamine.
[0010] A method of treating Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising the administration to a patient of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor over an appropriate period of time, such as a period substantially coinciding with the period of sleep of said patient, and a therapeutically effective dose of an agent selected from carbamazepin, car- bamazepin like agents, baclofen and other GABA receptor agonists, melatonin receptor agonists, clonidine and other central alpha receptor or opioid receptor agonist.
[0011] Use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating Restless Legs Syndrome or Periodic Limb Movements during Sleep.
[0012] Use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a diagnostic device, kit or composition for the diagnosis of the restless legs syndrome or periodic limb movements during sleep.
[0013] Use of a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor for the manufacture of a medicament for treating the Restless Legs Syndrome and/or Periodic Limb Movements during Sleep.
[0014] The use of claim 13, wherein the dopaminergic agent is selected from levodopa, karbidopa, dopamine, dobutamine, ropinerol, cabergoline, pramipexol, pergolide, bromocriptine, rotigotine, lisurid, selegiline, rasagiline, safinamide, vanoxerine (GBR 12909), radafaxine, and SEP 226 330, including pharmaceutically acceptable salts of those in the aforementioned compounds which are able to form salt with organic or inorganic acids.
[0015] The use of claim 13, wherein the dopaminergic agent is a dopamine agonist or a dopamine turnover promoting agent or a dopamine uptake inhibitor.
[0016] The use of any of claims 13 to 15, wherein the medicament is in form of a composition for sustained release or in form of a device for sustained release.
[0017] A method of manufacture of a medicament for oral administration for treating
Restless Legs Syndrome and/or Periodic Limb Movements during Sleep comprising mixing a therapeutically effective dose of biologically active zonisamide and a dopaminergic agent selected from dopamine agonist and dopamine turnover promoting agent including dopamine uptake inhibitor with a pharmaceutically acceptable carrier, and pressing the mixture into a tablet or filing it into a capsule.
[0018] The method of claim 18, wherein the carrier is one suitable for forming a tablet for sustained release.
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