WO2015011246A1 - Use of flecainide as an anti-connexin agent and method for potentiating the effects of a psychotropic drug - Google Patents

Use of flecainide as an anti-connexin agent and method for potentiating the effects of a psychotropic drug Download PDF

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Publication number
WO2015011246A1
WO2015011246A1 PCT/EP2014/065975 EP2014065975W WO2015011246A1 WO 2015011246 A1 WO2015011246 A1 WO 2015011246A1 EP 2014065975 W EP2014065975 W EP 2014065975W WO 2015011246 A1 WO2015011246 A1 WO 2015011246A1
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WO
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Prior art keywords
connexin
flecainide
disorders
sleep
psychotropic drug
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PCT/EP2014/065975
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French (fr)
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Franck Mouthon
Mathieu Charveriat
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Commissariat A L'energie Atomique Et Aux Energies Alternatives
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Priority to US14/907,221 priority Critical patent/US9750734B2/en
Priority to KR1020177015674A priority patent/KR20170068629A/en
Application filed by Commissariat A L'energie Atomique Et Aux Energies Alternatives filed Critical Commissariat A L'energie Atomique Et Aux Energies Alternatives
Priority to JP2016528540A priority patent/JP6192830B2/en
Priority to MX2016001049A priority patent/MX365782B/en
Priority to DK14742249.7T priority patent/DK3024458T3/en
Priority to CN201480051866.3A priority patent/CN105579041B/en
Priority to BR112016001446A priority patent/BR112016001446A8/en
Priority to AU2014295030A priority patent/AU2014295030B2/en
Priority to ES14742249.7T priority patent/ES2661647T3/en
Priority to PL14742249T priority patent/PL3024458T3/en
Priority to KR1020167004739A priority patent/KR101754045B1/en
Priority to EP14742249.7A priority patent/EP3024458B1/en
Priority to RU2016105971A priority patent/RU2661026C2/en
Priority to CA2919140A priority patent/CA2919140C/en
Priority to EP17203646.9A priority patent/EP3308785A3/en
Publication of WO2015011246A1 publication Critical patent/WO2015011246A1/en
Priority to IL243746A priority patent/IL243746A/en
Priority to ZA2016/01146A priority patent/ZA201601146B/en
Priority to US15/667,999 priority patent/US20180028519A1/en
Priority to IL254210A priority patent/IL254210B/en
Priority to HRP20180487TT priority patent/HRP20180487T1/en
Priority to US16/138,641 priority patent/US10639301B2/en

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Definitions

  • the present invention relates to the use of flecainide as an anti-connexin agent.
  • This anti- connexin agent is advantageously used to potentiate the therapeutic effect of various psychotropic drugs. More specifically, the invention provides a combination product containing flecainide and modafmil.
  • Gap junctions are involved in intercellular communication, which is important for maintaining tissue and organ homeostasis. Gap junctions connect the cell cytoplasm, enabling the exchange of ions (Ca + and K + ), second messengers (AMPc, GMPc, IP3), several small metabolites (glucose) and ensuring electrical and metabolic coupling between the cells.
  • the gap junctions are junctions with a selective permeability, formed by protein channels contained in the plasma membrane, and formed by connexin hexamers. Connexin hexamers might as well form hemichannel, linked the intracellular space to extracellular one.
  • Connexins are integral proteins of the plasma membrane, which are synthesized by practically every cell type, regardless of the position of a multicellular organism in the phylogenesis of the animal world. In vertebrates, occasional cells not producing connexins are adult striated muscle cells, spermatozoids and circulating blood cells. Unlike numerous membrane proteins, connexins have a short half-life (between 3 and 6 hours), are not glycosylated and do not have an enzymatic activity. At present, at least thirteen distinct connexins have been identified in mammals; corresponding, in humans, to 21 isoforms.
  • connexins can be present in a plurality of tissues, and most of the cells synthesize a plurality of connexins.
  • the connexins assemble in groups of six molecules to form hollow tubular structures called connexons, which join the plasma membrane by means of Golgi vesicles.
  • the connexons of a cell align end-to-end with those of the neighboring cell, establishing a continuous hydrophilic channel around 10 nm long. This junctional channel establishes direct contact between the cytoplasms of the two cells in contact, over the intercellular space.
  • Connexins are involved in a huge number of physiological processes, and several applications of connexin blocking agents (also called hereafter “connexin blocking agents” or “anti-connexin agents”) have been described.
  • anti-connexin agents have been proposed for treating and/or preventing the following conditions:
  • anti-connexin agents are able to potentiate the therapeutic effects of psychotropic drugs (WO 2010/029131).
  • administration of anti-connexin agents such as meclofenamic acid (MFA) increases the therapeutic effects of various psychotropic molecules, enabling to reduce the active doses and thus the undesirable effects of these psychotropic molecules.
  • MFA meclofenamic acid
  • Identifying new anti-connexin agents is therefore of primary importance to highlight new therapeutic tools aiming to treat various diseases and disorders, in particular in combination with psychotropic drugs.
  • flecainide has a broad anti-connexin activity. This is a very surprising result, since flecainide had been described so far to interfere with sodium channels, in particular on heart muscle cells, and these channels are not related with brain gap junctions. Moreover, flecainide had been shown not to influence junctional resistance of cardiac myocyte cell pairs (Daleau et al, 1998).
  • flecainide designates a compound of formula N- (piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy) benzamide.
  • this term designates any form of this compound, such as a salt thereof.
  • said salt is the flecainide acetate.
  • This term may also encompass the flecainide precursors which can be metabolized in the human body and/or its derivatives (for example, chemical derivatives resulting from one or several halogen substitutions and/or from addition of protective groups).
  • FIG. 5A shows the formulas of R-flecainide (Fig. 5A, (i?)-N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2- trifluoroethoxy)benzamide) and S-flecainide (Fig. 5B, (5)-N-(piperidin-2-ylmethyl)-2,5- bis(2,2,2-trifluoroethoxy)benzamide).
  • the term "flecainide” designates the racemate form of N-(piperidin-2- ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy) benzamide, as well as the R and S enantiomers thereof ((i?)-N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide and (S)-N- (piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide, respectively).
  • the R enantiomer of flecainide ((i?)-N-(piperidin-2- ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide) will be used.
  • Flecainide is currently administered as a racemate (Kroemer et al, 1989; Lie et al, 1989).
  • the pharmacokinetic parameters of the two enantiomers of flecainide have been largely described, after administration in human and rodents, as described below:
  • Hanada et al. demonstrated an absence of enantioselective distribution of the two enantiomers of flecainide in several tissue, after intravenous administration of flecainide racemate in rats [Hanada et al, 1998].
  • the renal clearances of the enantiomers of flecainide are not stereoselective in both healthy volunteers and patients.
  • Literature is thus globally coherent on the absence of stereoselective effects of flecainide on pharmacokinetics and metabolism.
  • the physicochemical properties of the two enantiomers of flecainide have been also described.
  • Turgeon et al. described a stereoselective analytical method for the determination of the antiarrhythmic agent flecainide in human plasma.
  • the resolution of the enantiomers is achieved by high-performance liquid chromatography (HPLC) on a normal phase silica column following derivatization with the optically active reagent (-)- methyl chloro formate [Turgeon et al, 1990].
  • Alessi-Severini et al. described a stereospecific high-performance liquid chromatographic method for the determination of (R,S)-flecainide acetate in human plasma and urine.
  • Flecainide diastereomers were separated after i) a single-step extraction of alkalinized samples performed with distilled diethyl ether, ii) the organic layer was evaporated and the drug was derivatized with l-[(4-nitrophenyl)sulfonyl]-L-propyl chloride at 80 degrees C for 2 h and iii) by high-performance liquid chromatography (HPLC) on a CI 8 reversed-phase column with a mobile phase consisting of acetonitrile:water:triethylamine (45:55:0.2) at a flow rate of 1 mL/min [Alessi-Severini et al, 1990].
  • HPLC high-performance liquid chromatography
  • Racemic flecainide acetate is a widely used class lc antiarrhythmic agent, which is indicated for treating various types of arrhythmias. More specifically, it is used to regulate the rate and rhythm of the heart. The heart's pumping action is controlled by electrical signals that pass through the heart muscle. These electrical signals cause the two pairs of heart chambers (left and right arteria and ventricles) to contract in a regular manner to produce regular heartbeats. If the electrical activity in the heart is disturbed for any reason, irregular heartbeats (arrhythmias) of various types can result.
  • Flecainide helps to treat arrhythmias by decreasing the sensitivity of the heart muscle cells to electrical impulses. This regulates the electrical conduction in the heart muscle and reduces disturbances in the heart rhythm. As a class I antiarrhythmic agent, flecainide interferes with the sodium channel. Importantly, several studies have demonstrated that these cardiovascular effects are not mediated by a single enantiomer, both of them contributing to cardiovascular functions:
  • the present invention therefore pertains to the use of flecainide, in vitro and in vivo, as an anti-connexin agent.
  • the present invention relates to flecainide for use as an anti-connexin agent, or, in other words, for blocking gap junctions.
  • connexins 26 (Cx 26), 30 (Cx 30), 30.2 (Cx30.2), 32 (Cx 32), 36 (Cx 36), 37 (Cx 37), 40 (Cx 40), 43 (Cx 43), 45 (Cx 45), 46 (Cx 46), and 47 (Cx 47) are expressed in human on cells of the Central or Peripheral Nervous System (Nakase & Naus, 2004).
  • flecainide is effective for inhibiting gap junctions made of all connexin they tested.
  • flecainide is effective for inhibiting gap junctions made of connexin Cx40, Cx26, Cx30, Cx32, and /or Cx43.
  • this anti-connexin effect is similar to the one observed for well-known anti-connexin agents such as mefloquine and meclofenamic acid (MFA) (Juszczak & Swiergiel, 2009; Cruikshank et al, 2004; Harks et al, 2001). Higher inhibition levels were even reached for glial connexins Cx26, Cx30 and Cx43 (see figure 1).
  • MFA mefloquine and meclofenamic acid
  • the present invention therefore relates to the in vitro use of flecainide as an anti-connexin agent.
  • this agent can be used to inhibit gap junctions made of the connexins selected in the group consisting of: Cx23 (SEQ ID NO: l), Cx25 (SEQ ID NO:2), Cx26 (SEQ ID NO:3), Cx 30 (SEQ ID NO:4), Cx30.2 (SEQ ID NO:5), Cx30.3 (SEQ ID NO:6), Cx31 (SEQ ID NO:7), Cx31.1 (SEQ ID NO:8), Cx31.9 (SEQ ID NO:9), Cx32 (SEQ ID NO: 10), Cx36 (SEQ ID NO: l l), Cx37(SEQ ID NO: 12), Cx40 (SEQ ID NO: 13), Cx40.1 (SEQ ID NO: 14), Cx43 (SEQ ID NO: 15), Cx45 (SEQ ID NO: 16), Cx46 (SEQ ID NO: 17), Cx
  • flecainide is used for blocking one or more of the connexins expressed in human cells of the Central or Peripheral Nervous System, that are selected in the group consisting of: Cx 26 (SEQ ID NO:3), Cx 30 (SEQ ID NO:4), Cx 30.2 (SEQ ID NO:5), Cx 32 (SEQ ID NO: 10), Cx 36 (SEQ ID NO: 11), Cx 37 (SEQ ID NO: 12), Cx 40 (SEQ ID NO: 13), Cx 43 (SEQ ID NO: 15), Cx 45 (SEQ ID NO: 16), Cx 46 (SEQ ID NO: 17) and Cx 47 (SEQ ID NO: 18).
  • Cx 26 SEQ ID NO:3
  • Cx 30 SEQ ID NO:4
  • Cx 30.2 SEQ ID NO:5
  • Cx 32 SEQ ID NO: 10
  • Cx 36 SEQ ID NO: 11
  • Cx 37 SEQ ID NO: 12
  • Cx 40 SEQ ID NO: 13
  • Cx 43 SEQ ID NO
  • flecainide is used for blocking one or more of the connexins selected in the group consisting of: Cx40 (SEQ ID NO: 13), Cx26 (SEQ ID NO:3), Cx30 (SEQ ID NO:4), Cx32 (SEQ ID NO: 10), and Cx43 (SEQ ID NO: 15).
  • flecainide is used for blocking one or more of the connexins selected in the group consisting of: Cx26 (SEQ ID NO:3), Cx30 (SEQ ID NO:4) and Cx43 (SEQ ID NO: 15).
  • flecainide Due to its anti-connexin activity, flecainide can be used for the treatment of a number of disorders and conditions known to benefit from treatment by anti-connexin molecules.
  • disorders and conditions include, but are not limited to: cancers, cardiovascular diseases, wounds, pain, migraines, epilepsy, neurological conditions and neurodegenerative diseases, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, ischemia and inflammatory disorders. More preferably, flecainide can be used for the prevention and/or the treatment of cancers, wounds, migraines, epilepsy, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, ischemia and inflammatory disorders.
  • flecainide can be used for the prevention and/or the treatment of wounds, migraines, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, and ischemia.
  • flecainide can be used for the prevention and/or the treatment of drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, and ischemia.
  • flecainide is used as an agent for potentiating the effects of a psychotropic drug. These potentiating effects are illustrated below by experiments performed with modafmil (see figures 2 to 4). As an anti-connexin agent, flecainide can potentiate the effects of any psychotropic drug (as shown in WO 2010/029131 and US 2011/172188, incorporated by reference).
  • a "psychotropic drug” or “psychotropic agent” refers to any substance that acts primarily on the state of the central nervous system by modifying certain cerebral biochemical and physiological processes.
  • Examples of psychotropic drugs which can be used in the context of the present invention include anesthetics, analgesics such as opioids, antipyretics and antimigraine preparations, anti-epileptics, anti-Parkinson drugs such as anti-cholinergic and dopaminergic anti-Parkinson agents, psycho leptics such as antipsychotics, anxiolytics, hypnotics and sedatives, psychoanaleptics such as antidepressants, psychostimulants and anti-dementia drugs, as well as parasymptomimetics, anti-addiction drugs, antivertigo preparations etc.
  • Examples of psychotropic drugs which can be used in the context of the present invention include anesthetics, analgesics such as opioids, antipyretics and antimigraine preparations, anti-epileptics, anti-Parkinson drugs such as anti-cholinergic and dopaminergic anti-Parkinson agents, psycho leptics such as antipsychotics, anxiolytics
  • Amides 18. bupivacaine; lidocaine;
  • mepivacaine prilocaine
  • dihydrocodeine diamorphine; papaveretum; morphine; codeine,
  • Phenylpiper 27 ketobemidone; pethidine; idine derivatives
  • Salicylic 38 acetylsalicylic acid; aloxiprin; analgesics and acid and choline salicylate; sodium antipyretics derivatives salicylate; salicylamide;
  • analgesics and floctafenine analgesics and floctafenine; viminol; nefopam; antipyretics ziconotide; methoxyflurane;
  • Hydantoin 58 ethotoin; phenytoin;
  • Anti- 71 Anticho liner 72. Tertiary 73. Trihexyphenidyl; biperiden; Parkinson gic agents amines metixene; procyclidine;
  • Dopamine 84 bromocriptine; pergolide; agonists dihydroergocryptine; esylate;
  • Phenothiazi 95. periciazine; thioridazine; nes with mesoridazine; pipotiazine piperidine
  • oxazepines olanzapine
  • quetiapine asenapine
  • thiazepines clotiapine
  • clobazam ketazolam; prazepam; alprazolam; halazepam;
  • pine related drugs zaleplon; eszopiclone
  • hexapropymate bromides; apronal; valnoctamide; methylpentynol; niaprazine;
  • Antidepress 143 Non144. desipramine; imipramine; leptics ants selective imipramine oxide; clomipramine;
  • inhibitors amitriptyline; nortriptyline; protriptyline; doxepin; iprindole;
  • melitracen butriptyline; dosulepin; amoxapine; dimetacrine;
  • antidepressants mianserin; nomifensine; trazodone;
  • nefazodone nefazodone
  • minaprine bifemelane
  • viloxazine oxaflozane
  • milnacipran milnacipran; reboxetine; gepirone; duloxetine; agomelatine;
  • Neurode 165 Other nervous 165.
  • Antivertigo 180 Antivertigo 181. betahistine; cinnarizine; preparations preparations flunarizine; acetylleucine
  • the said psychotropic drug is selected in the group consisting of: dopaminergic, GABAergic, adrenergic, acetylcholinergic, serotoninergic, opioidergic, adenosinergic, ionotropic, histaminergic, IMAO, Catechol-O-methyl transferase, DOPA decarboxylase, noradrenergic and glutamatergic psychotropic effectors, as well as molecules having an effect on the hypocretin/orexin system (including hypocretin-1 and hypocretin-2).
  • effector refers to any substance activating or inhibiting, directly or indirectly, one or more neuroreceptors, as well as any substance that modifies the concentration of said neurotransmitter; therefore, an effector according to the present invention can be an agonist or an antagonist of said receptors.
  • modafinil acts as a GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors, and it has an effect on the hypocretin/orexin system (including hypocretin-1 and hypo cretin-2).
  • Any compound modulating the same molecular receptors as modafinil can be advantageously associated with flecainide.
  • the psychotropic drug which is associated with flecainide acts on the very same receptors as modafinil does.
  • the psychrotropic drug associated with flecainide is therefore preferably selected in the group consisting of: GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors. Also, it may have an effect on the hypocretin/orexin system (including hypocretin-1 and hypo cretin-2).
  • the said psychotropic drug is a dopaminergic effector selected in the group consisting of: ADX-N05 (formely "YKP10A", having the formula: (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride), amphetamine, loxapine, acepromazine, methylphenidate, pergolide, lisuride, bromocriptine, dopamine, ropinirole, apomorphine, aripiprazole, sulpiride, amisulpride, sultopride, tiapride, pimozide, risperidone, haloperidol, penfluridol, zuclopenthixol or bupropion.
  • ADX-N05 formely "YKP10A"
  • YKP10A having the formula: (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochlor
  • the said psychotropic drug is a GABAergic effector selected in the group consisting of: tiagabine, topiramate, clorazepate, diazepam, clonazepam, oxazepam, lorazepam, bromazepam, lormetazepam, nitrazepam, clotiazepam, aiprozolam, estazolam, triazolam, loprazolam, etifoxin, meprobamate, zopiclone, Zolpidem, pregabaline, gabapentine, phenobarbital, felbamate and vigabatrin.
  • GABAergic effector selected in the group consisting of: tiagabine, topiramate, clorazepate, diazepam, clonazepam, oxazepam, lorazepam, bromazepam, lormetazepam,
  • the said psychotropic drug is a serotoninergic effector selected in the group consisting of: chlorpromazine, trimipramine, clozapine, olanzapine, cyamemazine, flupentixol, nefopam, fluvoxamine, clomipramine, sertraline, fluoxetine, citalopram, escitalopram, paroxetine, amitriptyline, duloxetine, venlafaxine, buspirone, carpipramine, zolmitriptan, sumatriptan, naratriptan, indoramine, ergotamine, ergotamine tartrate, pizotifene, pipamperone, methysergide, pizotyline, milnacipran,, viloxazine, tianeptine, hypericum and lithium.
  • a serotoninergic effector selected in the group consisting of: chlorpromazine, trimipramine, clo
  • the said psychotropic drug is a histaminergic effector selected in the group consisting of: acrivastine, alimemazine, antazoline, astemizole, azatadine, azelastine, brompheniramine, buclizine, carbinoxamine, carebastine, cetirizine, chlorcyclizine, chlorpheniramine, cinnarizine, clemastine, clemizole, clocinizine, clonidine, cyclizine, cyproheptadine, descarboethoxyloratidine, dexchlorpheniramine, dimenhydrinate, dimethindene, dimethothiazine, diphenhydramine, diphenylpyraline, doxylamine, ebastine, efletirizine, epinastine, fexofenadine,hydroxyzine, ketotifen, levocabastine, loratidine, mec
  • the said psychotropic drug is a hypocretin/orexin modulator selected in the group consisting of: EMPA, SB-334867, SB- 674042, SB-408124, GSK1059865, almorexant, suvorexant, MK-6096, DORA-1, DORA- 22, DORA-12, SB-649868, JNJ-1037049 (described in Gotter et al, 2012)).
  • the said psychotropic drug is a norepinephrinergic effector selected in the group consisting of: (R)-3-nitrobiphenyline, 2- fluoronorepinephrine, 4-NEMD, 5-fluoronorepinephrine, 6-fluoronorepinephrine, abediterol, albuterol, amibegron, amidephrine, amitraz, anisodamine, anisodine, apraclonidine, arbutamine, arformoterol, arotinolol, bambuterol, befunolol, bitolterol, brimonidine, bromoacetylalprenololmenthane, broxaterol, buphenine, cannabivarin, carbuterol, cimaterol, cirazoline, clenbuterol, denopamine, deterenol, detomidine, dexmedetomidine, dihydr
  • the said psychotropic drug is a glutamatergic effector selected in the group consisting of: memantine, amantadine, MK-801, ketamine, norketamine, dextromethorphan, levometorphan, dextrorphan, levorphanol, phencyclidine, PCA, CNS-1102, remacemide, pentamidine, and 9-aminoacridine (described in Traynelis et al, 2010).
  • a glutamatergic effector selected in the group consisting of: memantine, amantadine, MK-801, ketamine, norketamine, dextromethorphan, levometorphan, dextrorphan, levorphanol, phencyclidine, PCA, CNS-1102, remacemide, pentamidine, and 9-aminoacridine (described in Traynelis et al, 2010).
  • said psychotropic drug is not flupirtine.
  • the potentiating effects of flecainide can be achieved by administrating same to a patient, either before, at the same time, of after administration of the psychotropic drug to said patient.
  • the present invention describes a method for treating a patient with psychiatric and/or neurodegenerative disorders, including the administration to said patient of a) flecainide and b) at least one psychotropic drug as mentioned above, in which said compounds a) and b) are administered simultaneously, separately or spread out over time.
  • Patients needing this treatment may have psychiatric, neurologic and/or neurodegenerative disorders included in the group consisting of: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine- Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication-induced somnolence (due to benz
  • EDS daytime sleepiness
  • EDS characterizes several conditions or diseases: insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, recurrent hypersomnia (Kleine-Levin syndrome), circadian rhythm disorders (jet lag), disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), neurological conditions commonly associated with sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders), medical conditions commonly associated with sleepiness (respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), mood disorders, anxiety disorders, schizophrenia, or medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, antipsychotics).
  • SAHOS obstructive sleep a
  • Cataplexy is characterized by a sudden drop of muscle tone triggered by emotional factors, most often by positive emotions such as laughter, repartee, pleasant surprise (e.g., seeing friends in the street or scoring a goal), or by anger, but almost never by stress, fear, or physical effort.
  • Many neurophysio logical and pharmaceutical studies indicate that cataplexy shares common neurophysio logical mechanisms with REM sleep atonia (Dauvilliers I. et al, 2007).
  • the two components of the treatment are administered to the patient simultaneously.
  • the two components can be packaged together, in the form of a mixture, or separately, then mixed spontaneously before being administered together to the patient.
  • the two components are administered simultaneously, but separately.
  • the routes of administration of the two components may be different.
  • the administration can also be performed at different sites.
  • the two components are administered sequentially or spaced apart over time, for example in the same day or at an interval ranging from several minutes to several days.
  • flecainide potentiates the effects of psychotropic drugs, it can advantageously be used for reducing the doses of said psychotropic drug, thereby limiting the adverse effects of said psychotropic drug, and/or reducing the risks of failure and withdrawal.
  • the effective equivalent dose of a psychotropic drug i.e., the psychotropic drug dose that, when administered in combination with flecainide, induces a physiological effect or a pharmacological signature similar or identical to that of the psychotropic drug alone administered at the active pharmacological dose, can be determined by the methods disclosed in WO2010/029131 and US 2011/172188.
  • the present invention pertains to a composition, especially a pharmaceutical composition, comprising flecainide and at least one psychotropic drug.
  • This composition is preferably formulated for patients with psychiatric and/or neurodegenerative disorders, as disclosed above.
  • the composition can comprise any pharmaceutical vehicle, stabilizer, adjuvant and the like as frequently used in the art.
  • Examples of pharmaceutically acceptable vehicles include, but are not limited to: water; aqueous vehicles such as, but not limited to, sodium chloride solution, Ringer's solution, dextrose solution, dextrose and sodium chloride solution, and lactated Ringer's solution; water-miscible vehicles such as, but not limited to, ethyl alcohol, polyethylene glycol, and polypropylene glycol; and nonaqueous vehicles such as, but not limited to, corn oil, cottonseed oil, peanut oil, sesame oil, ethyl oleate, isopropyl myristate, and benzyl benzoate.
  • aqueous vehicles such as, but not limited to, sodium chloride solution, Ringer's solution, dextrose solution, dextrose and sodium chloride solution, and lactated Ringer's solution
  • water-miscible vehicles such as, but not limited to, ethyl alcohol, polyethylene glycol, and polypropylene glycol
  • nonaqueous vehicles
  • this composition is formulated for oral administration (including buccal cavity or sublingually).
  • oral administration including buccal cavity or sublingually.
  • Other interesting formulations include formulations for intraperitoneal (i.p.), intravenous (i.v.), subcutaneous (s.c), intramuscular (i.m.), transcutaneous, transdermal, intrathecal and intracranial administrations.
  • Still other formulations include epidural, submucosal, intranasal, ocular cul-de-sac and rectal routes of administration, as well as administration by pulmonary inhalation.
  • a variety of administration means including but not limited to capsules, tablets, syrups, creams and ointments, suppositories, patches or any reservoir capable of containing and dispensing flecainide and the psychotropic drug, can be used for formulating the above- described compositions.
  • the psychotropic drug is as described above.
  • said psychotropic drug is used for treating narcolepsy and is therefore selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride, modafmil and armodafinil.
  • the composition of the invention contains between 1 to 1000 mg, preferably 5 to 800 mg of the psychotropic drug, depending of its nature. A preferred posology would be to administer to the patient between 1 to 1000 mg/day, more preferably between 5 to 800 mg/day of the psychotropic drug.
  • the composition of the invention contains between 1 to 200, preferably 1 to 100 mg of flecainide. A preferred posology would be to administer to the patient between 1 to 200, preferably 1 to 100 mg/day of flecainide.
  • said flecainide is the R enantiomer disclosed on figure 5A.
  • flecainide is associated with the psychotropic drug modafmil.
  • modafmil is herein meant the 2-[(diphenylmethyl) sulfmyl] acetamide (Provigil, see figure 5C), as well as its precursors or prodrugs such as adrafmil (Dubey et al, 2009) which can be metabolized in the human body and its active derivatives. More precisely, the term “Modafmil” herein designates any form of modafmil (racemate, R-modafmil, S- modafmil, etc.), as well as its precursors which can be metabolized in the human body and its derivatives.
  • Figure 5 shows the formulas of R-Modafmil (Fig. 5C) and S-Modafmil (Fig. 5D).
  • Modafmil is an analeptic drug prescribed essentially for the treatment of narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnea. Besides these wake-promoting properties, modafmil also improves working memory and episodic memory, and other processes dependent on prefrontal cortex and cognitive control (Minzenberg MJ et al, 2008).
  • flecainide strongly potentiates in vivo the waking effects of Modafmil, whereas it has no effect on wake duration on its own (example 2).
  • flecainide strongly potentiates in vivo the cognitive activity of Modafmil, whereas it has no promnesiant effect on its own (example 3).
  • This synergistic activity could be explained by the fact that flecainide strongly extends the duration of Modafmil treatment (example 4).
  • the present inventors herein describes that the flecainide / modafmil combination has a synergistic effect on cataplectic-like phenotype in narcoleptic mice (example 5) and is all the more surprising than either flecainide or modafmil has no effect on this phenotype (figure 6B).
  • the present invention thus pertains to flecainide, for use for potentiating the promnesiant and/or awakening effects of modafmil, and/or for improving its safety, and/or for increasing the duration of action of modafmil in patients in need thereof, especially in patients suffering from: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine-Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple
  • the present invention specifically pertains to flecainide, for use for potentiating the awakening effects of modafmil, and/or for improving its safety, and/or for increasing the duration of action of modafmil in patients suffering from: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine-Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain
  • EDS excessive day
  • the present invention specifically pertains to flecainide, for use for potentiating the awakening effects of modafinil, and/or for improving its safety, and/or for increasing the duration of action of modafinil in patients suffering from excessive daytime sleepiness (EDS).
  • EDS daytime sleepiness
  • the present invention relates to flecainide, for use for potentiating the awakening effects of modafinil, and/or for improving its safety, and/or for increasing the duration of action of modafinil in patients suffering from conditions or diseases involving EDS, that are for example: insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, recurrent hypersomnia (Kleine-Levin syndrome), circadian rhythm disorders (jet lag), disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders and sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), neurological conditions commonly associated with sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders), medical conditions commonly associated with sleepiness (respiratory disorders, chronic renal failure, liver failure, rheumatologic
  • the present invention relates to a modafinil/flecainide combination product, for use for treating cataplexy in narcoleptic patients.
  • the potentiation of the effects of modafinil by flecainide enables a reduction of the dose of modafinil, and hence a reduction of its side-effects.
  • some applications of modafinil, for which this drug was not approved because of its side-effects and possible risks associated thereto can now be envisioned, such as its use as a performance-enhancing and/or brain-boosting agent.
  • the present invention thus pertains to a performance-enhancing product comprising flecainide and modafinil.
  • the present invention specifically pertains to the use of flecainide and modafinil for enhancing the memory of healthy subjects and/or to maintain them awake for long-lasting periods of time and/or to treat cataplexy in narcoleptic patients.
  • These subjects can be for example individuals that need to memorize a lot of information and/or to remain awake for long lasting periods.
  • said subjects are humans (e.g., security agents, students, etc.).
  • the present invention also relates to a composition comprising flecainide and modafinil, which can advantageously be used for treating diseases and conditions including but not limited to excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, jet-lag, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia.
  • this composition can be used for treating cataplexy in narcoleptic patients.
  • This composition can also be used for enhancing the memory of healthy subjects and/or for maintaining them awake for long-lasting periods of time.
  • Typical periods of time are for example 6 hours, preferably 12 hours.
  • the present invention moreover relates specifically to the use of flecainide and modafinil in the preparation of a medicament that is intended to be used for treating diseases and conditions such as excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post- myelitis, or to fibromyalgia.
  • the present invention relates to the use of flecainide and modafmil in the preparation of a medicament that is intended to be used for treating cataplexy in narcoleptic patients.
  • composition / medicament of the invention can comprise other agents such as vitamin C, vitamin B6, magnesium, L-arginine, L- glutamine, L-citrulline, taurine, caffeine, etc.
  • this product can be sold over-the-counter. It can be formulated, for example, as an OTC medicine or as a food supplement.
  • the composition of the invention contains between 1 to 1000 mg, preferably between 5 to 800 mg, and more preferably between 5 to 600 mg of the modafmil.
  • the composition of the invention is formulated so that 5 to 800, preferably 5 to 600 mg/day of modafmil are administered to a patient in need thereof, in one, two or more takings.
  • the composition of the invention contains between 1 to 200, preferably 1 to 100 mg of flecainide.
  • the composition of the invention is formulated so that 1 to 200, preferably 1 to 100 mg/day of flecainide are administered to a patient in need thereof, in one, two or more takings.
  • said flecainide is the R enantiomer disclosed on figure 5A.
  • the present invention relates to a combination product comprising flecainide and modafmil, for simultaneous, separated or staggered use for preventing and/or treating excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, jet-lag, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia.
  • This combination product is preferably used for preventing and/or treating cataplexy in narcoleptic patients.
  • Other characteristics of the invention will also become apparent in the course of the description which follows of the biological assays which have been performed in the framework of the invention and which provide it with the required experimental support, without limiting its scope.
  • Figure 1 Inhibition of the human connexins functionality by flecainide.
  • Rin-Cx26 cells, Rin-Cx30 cells, Rin-Cx32 cells, Rin-CX40 cells and Rin-Cx43 cells are cultured in the presence of flecainide (280 ⁇ ), mefloquine (10 ⁇ ) and MFA (100 ⁇ ) for 4 hours.
  • the transfer of fluorochrome by gap junctions (composed of connexins) is evaluated by flow cytometry (1 A and IB). Viability of the cells treated with flecainide is shown on figure IB.
  • FIG 2 Efficiency of flecainide for potentiating the awakening effect of modafinil.
  • the wake duration was measured using polygraphic analyses.
  • FIG. 3 Efficacy of flecainide for potentiating the promnesiant effect of modafinil.
  • the graphic represents the percentage of alternation after 6 trials, 50% corresponding to a random alternation.
  • Figure 5 Molecular structure of A. R-flecainide; B. S-flecainide; C. R-Modafmil, D. S- Modafmil.
  • Figure 6 Number of episodes of OREM/DREM phases in narcoleptic mice (Ox-/-) treated by modafinil/flecainide (A) or flecainide alone (B).
  • A Oral treatment of Ox-/- male mice with modafinil 64 mg/kg with flecainide 1 mg/kg was compared to Modafinil 64 mg/kg and vehicle. **: p ⁇ 0,01 ; ***:p ⁇ 0,005, Two-Way ANOVA.
  • B Oral treatment of Ox-/- male mice with flecainide 1 mg/kg was compared to vehicle.
  • Figure 7 Number of episodes of OREM/DREM phases in narcoleptic mice (Ox-/-) treated by the combination between modafinil and one of the two enantiomers of flecainide (R- flecainide and S- flecainide). Oral treatment with modafinil 64 mg/kg with R-flecainide 1 mg/kg or S-flecainide 1 mg/kg was compared to vehicle.
  • the rat insulinoma RIN cell line deficient in GJIC (del Corsso et al, 2006), was grown in OptiMem medium, supplemented with 10% fetal calf serum.
  • GJB6 Cx30
  • GJB1 Cx32
  • GJB2 Cx26
  • GJA5 Cx40
  • GJAl Cx43
  • open reading frames were amplified from human cDNA.
  • the open reading frames were cloned in pcDNA3.1/V5-His-TOPO (Invitrogen). Cells were transfected using Lipofectamine and further selected using geneticin.
  • Cells were seeded and loaded with two fluorochromes, calcein acetoxymethyl ester, a gap junction permeable dye, and Vybrant Dil, a membrane lipophilic dye. The next day, cells were dissociated and incubated for four hours in presence of previously seeded non-loaded cells and in the presence of flecainide racemate 70, 140 or 280 ⁇ , mefloquine 10 ⁇ or meclofenamic acid (MFA) 100 ⁇ . Flow cytometry was conducted on a FACScan.
  • Inhibition was quantified as the relative number of receiver cells that gained fluorescence to the total number of receiver cells (non GJ-mediated dye transfer was then substracted to these ratio based on connexin non-expressing RIN cells, defined at background dye transfer ratio). This ratio of cellular coupling was then normalized, after each treatment, on the vehicle one.
  • flecainide inhibits all the tested isoforms of cerebral connexin using dye- transfer cell-parachute assay (Cx30, Cx32, Cx26, Cx40, Cx43) (it is estimated that a more than a significant 10% reduction in gap junction cellular is considered as physiologically relevant). In addition, higher inhibition levels are reached for glial connexins Cx26, Cx30 and Cx43.
  • Modafmil is a molecule that promotes wakefulness in humans and mice, increasing in mice their activity in a dose-dependent manner (Simon et al, 1994). The activity of mice treated with modafmil at 32 mg/kg was compared with that of mice treated with the combination modafmil 32 mg/kg + flecainide 1 mg/kg or vehicle.
  • Figure 2A shows that flecainide significantly increases the waking effects of modafmil.
  • Figure 2B shows that this effect is not mediated by flecainide alone.
  • flecainide significantly potentiates modafmil waking activity in wild type mice, while being devoid of own effect on wake duration.
  • Modafmil induces a cognitive enhancing effect (Beracochea et al, 2003), such property can be assessed using the alternating sequential test, a widely used apparatus to assess spatial working memory in mice (Beracochea & Jaffard, 1987).
  • Spontaneous alternation is the innate tendency of rodents to alternate their choices to enter into the compartments of arrival of a T-maze device, over successive trials.
  • the animal To alternate during a given trial N, the animal must remember the choice made selectively in test N-l, and the response in alternating is performance measure.
  • Acute administration of modafinil before entering the maze can improve the performance of mice in this test (Beracochea et al, 2001).
  • the inventors' results showed that flecainide significantly potentiates the promnesiant effect of a subefficient dose of modafmil, while flecainide alone is devoid of any own promnesiant effect.
  • the experiment takes place in a T-maze (50 cm x 10 cm x 25 cm). All the subjects were given 7 successive trials separated by a 120-s intertrial interval.
  • the mouse was placed in the start box for 120 s before the door to the stem was opened.
  • the door to that arm was closed.
  • the chosen arm and the time that elapsed between opening the door and the arrival to the end of the chosen arm (task achievement time) were registered.
  • the animal was removed and placed in the start box for a new trial. Between each test, the unit is cleaned with a cloth soaked in water and alcohol to avoid olfactory detection.
  • the T-maze is a device for assessing working memory in mice. Acute administration of modafinil before entering the maze, can improve the performance of mice in this test (Beracochea et al, 2001). The validity of the test was performed by comparing the responses of mice intraperitoneally treated with an effective dose of modafinil alone (128 mg/kg), a dose of flecainide alone (1 mg/kg) and a sub-effective dose of modafinil (64 mg/kg) with or without flecainide alone (1 mg/kg). The results are shown in Figure 3.
  • Modafinil is a molecule that promotes wakefulness in humans and mice, increasing in mice their activity in a dose-dependent manner (Simon et al, 1994).
  • the inventors' results showed that flecainide significantly potentiates the locomotor effect of a subefficient dose of modafinil, while flecainide alone is devoid of any own locomotor effect in rodents.
  • Locomotor activity is evaluated by video tracking. Videos have been analyzed using Ethovision XT software (Noldus®).*: p ⁇ 0,01 in a Two- Way ANOVA analysis 4.2.Results
  • mice treated with modafinil at 64 mg/kg were compared with that of mice treated with the combination modafinil 64 mg/kg + flecainide 1 mg/kg.
  • Figure 4 shows that flecainide significantly increases the duration of effect of modafinil on the activity of mice.
  • Flecainide significantly inhibits the functionality of gap junctions, without inducing cellular toxicity.
  • this compound potentiates the efficacy and duration of effect of modafmil, notably in its promnesiant and awakening side.
  • Prepro-orexin knockout (KO) mice were offspring of the mouse strain generated by Chemelli et al. [1999] and kept on C57BL/6J genomic background. After backcrossing male orexin-/- mice and female wild-type (WT) mice for nine generations, the obtained orexin+/- mice were crossed to produce heterozygote and ho mo zygote WT and KO littermates. To determine their genotypes with respect to orexin gene, tail biopsies were performed at the age of 4 weeks for DNA detection using PCR.
  • EEG electroencephalogram
  • EMG electromyogram
  • Electrodes were previously soldered to a multi-channel electrical connector and each was separately insulated with a covering of heat-shrinkable polyolefin/polyester tubing.
  • Cortical electrodes were inserted into the dura through 3 pairs of holes made in the skull, located respectively in the frontal (1 mm lateral and anterior to the bregma), parietal (1 mm lateral to the midline at the midpoint between the bregma and lambda), and occipital (2 mm lateral to the midline and 1 mm anterior to the lambda) cortex. Muscle electrodes were inserted into the neck muscles. Finally, the electrode assembly was anchored and fixed to the skull with Super-Bond (Sun Medical Co., Shiga, Japan) and dental cement. This implantation allows stable and long-lasting polygraphic recordings [Parmentier et al, 2002].
  • Direct REM sleep onset (DREMs) episodes also called narcoleptic episodes or sleep onset REM periods by some authors [Chemelli et al, 1999; Mignot et al, 2005; Fujiki et al, 2006], were defined as the occurrence of REM sleep directly from wake, namely a REM episode that follows directly a wake episode lasting more than 60 s without being preceded by any cortical slow activity of more that 5 s during the 60 s.
  • each mouse was subjected to a recording session of two continuous days, beginning at 7 a.m. Administrations were performed at 6:45 p.m. just before lights-off (7:00 p.m.), since orexin-/- mice display narcoleptic attacks only during lights-off phase [Chemelli et al, 1999]. The order of administration was randomized. Polygraphic recordings were made immediately after administration and were maintained during the whole lights-off period (12 h). Two administrations were separated by a period of 7 days (washout).
  • mice were orally treated by either modafmil (64 mg/kg) or modafinil (64mg/kg) and flecainide racemate (lmg/kg) or flecainide racemate alone (lmg/kg) or vehicle. 52. Results
  • Orexins are two hypothalamic neuropetides identified in 1998 [Sakurai et al, 1998; De Lecea L. et al, 1998]. Neurons containing orexins have been identified in the hypothalamic dorsolateral and peri-fornical areas, these neurons play a key role in behavioral arousal. A large body of evidence indicates that an orexin deficiency is responsible for the pathogenesis of human and animal narcolepsy [Lin et al, 1999; Chemelli et al, 1999].
  • flecainide racemate (alone), at 1 mg/kg dose, has no effect on DREM cataplectic-like phenotype in narcoleptic Ox-/- mice.
  • flecainide and modafinil do not have any significant effect on a DREM cataplectic- like phenotype when used alone, whereas their combination importantly decreases the DREM cataplectic-like phenotype.
  • Connexin hemichannel blockade is neuroprotective after, but not during, global cerebral ischemia in near-term fetal sheep.
  • Experimental neurology de Lecea L, Kilduff TS, Peyron C, Gao X, Foye PE, Danielson PE, Fukuhara C, Battenberg EL, Gautvik VT, Bartlett FS, 2nd, Frankel WN, van den Pol AN, Bloom FE, Gautvik KM, Sutcliffe JG (1998)
  • the hypocretins hypothalamus-specific peptides with neuroexcitatory activity.

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Abstract

The present invention relates to the use of flecainide as an anti-connexin agent. This anti-connexin agent is advantageously used to potentiate the therapeutic effectof various psychotropic drugs. More specifically, the invention provides a combination product containing flecainide and modafinil.

Description

USE OF FLECAINIDE AS AN ANTI-CONNEXIN AGENT AND METHOD FOR POTENTIATING THE EFFECTS OF A PSYCHOTROPIC DRUG
Summary of the invention
The present invention relates to the use of flecainide as an anti-connexin agent. This anti- connexin agent is advantageously used to potentiate the therapeutic effect of various psychotropic drugs. More specifically, the invention provides a combination product containing flecainide and modafmil.
Background of the invention
Gap junctions are involved in intercellular communication, which is important for maintaining tissue and organ homeostasis. Gap junctions connect the cell cytoplasm, enabling the exchange of ions (Ca+ and K+), second messengers (AMPc, GMPc, IP3), several small metabolites (glucose) and ensuring electrical and metabolic coupling between the cells. The gap junctions are junctions with a selective permeability, formed by protein channels contained in the plasma membrane, and formed by connexin hexamers. Connexin hexamers might as well form hemichannel, linked the intracellular space to extracellular one. Connexins are integral proteins of the plasma membrane, which are synthesized by practically every cell type, regardless of the position of a multicellular organism in the phylogenesis of the animal world. In vertebrates, occasional cells not producing connexins are adult striated muscle cells, spermatozoids and circulating blood cells. Unlike numerous membrane proteins, connexins have a short half-life (between 3 and 6 hours), are not glycosylated and do not have an enzymatic activity. At present, at least thirteen distinct connexins have been identified in mammals; corresponding, in humans, to 21 isoforms. In practice, various types of connexins can be present in a plurality of tissues, and most of the cells synthesize a plurality of connexins. Before reaching the cell membrane, the connexins assemble in groups of six molecules to form hollow tubular structures called connexons, which join the plasma membrane by means of Golgi vesicles. When cell contact is established, the connexons of a cell align end-to-end with those of the neighboring cell, establishing a continuous hydrophilic channel around 10 nm long. This junctional channel establishes direct contact between the cytoplasms of the two cells in contact, over the intercellular space.
Connexins are involved in a huge number of physiological processes, and several applications of connexin blocking agents (also called hereafter "connexin blocking agents" or "anti-connexin agents") have been described.
For example, anti-connexin agents have been proposed for treating and/or preventing the following conditions:
- cancers (WO2006/134494 and WO2006/049157),
some cardiovascular diseases (WO2006/134494),
- wounds (WO2006/134494 and WO2009/097077),
- pain (WO2009/148613),
migraines (Durham and Garrett, 2009),
epilepsy (Juszczak and Swiergiel, 2009),
- neurological conditions (WO2006/134494) and neurodegenerative diseases (Takeuchi et al. 2011),
ischemia (Davidson et al, 2013),
drug-induced liver injury (Patel et al, 2012)
- infectious diseases (WO2011/067607),
cytotoxicity induced by chemotherapeutic agents (Tong X. et al,
2013)
and
- inflammatory disorders (WO2006/134494).
Furthermore, the present inventors previously described that anti-connexin agents are able to potentiate the therapeutic effects of psychotropic drugs (WO 2010/029131). In particular, they described that administration of anti-connexin agents such as meclofenamic acid (MFA) increases the therapeutic effects of various psychotropic molecules, enabling to reduce the active doses and thus the undesirable effects of these psychotropic molecules. These synergistic effects have been observed with a wide range of psychotropic molecules (clozapine, paroxetine, modafmil, diazepam, venlafaxine, escitalopram, bupropion and sertraline).
Identifying new anti-connexin agents is therefore of primary importance to highlight new therapeutic tools aiming to treat various diseases and disorders, in particular in combination with psychotropic drugs.
In this context, the inventors have now demonstrated that the well-known antiarrhythmic agent flecainide, has a broad anti-connexin activity. This is a very surprising result, since flecainide had been described so far to interfere with sodium channels, in particular on heart muscle cells, and these channels are not related with brain gap junctions. Moreover, flecainide had been shown not to influence junctional resistance of cardiac myocyte cell pairs (Daleau et al, 1998).
Detailed description of the invention
In the context of the invention, "flecainide" designates a compound of formula N- (piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy) benzamide. As used herein, this term designates any form of this compound, such as a salt thereof. Preferably, said salt is the flecainide acetate. This term may also encompass the flecainide precursors which can be metabolized in the human body and/or its derivatives (for example, chemical derivatives resulting from one or several halogen substitutions and/or from addition of protective groups).
As disclosed on figure 5A and 5B, flecainide possesses a chiral center implying the existence of an R and S enantiomers (S-(+)-flecainide and R-(-)-flecainide). Figure 5 shows the formulas of R-flecainide (Fig. 5A, (i?)-N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2- trifluoroethoxy)benzamide) and S-flecainide (Fig. 5B, (5)-N-(piperidin-2-ylmethyl)-2,5- bis(2,2,2-trifluoroethoxy)benzamide).
As used herein, the term "flecainide" designates the racemate form of N-(piperidin-2- ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy) benzamide, as well as the R and S enantiomers thereof ((i?)-N-(piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide and (S)-N- (piperidin-2-ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide, respectively). In a preferred embodiment of the invention, the R enantiomer of flecainide ((i?)-N-(piperidin-2- ylmethyl)-2,5-bis(2,2,2-trifluoroethoxy)benzamide) will be used.
Flecainide is currently administered as a racemate (Kroemer et al, 1989; Lie et al, 1989). The pharmacokinetic parameters of the two enantiomers of flecainide have been largely described, after administration in human and rodents, as described below:
In 1989, Kroemer et al. published a study in 13 patients receiving long-term oral flecainide therapy. S-flecainide and R-flecainide plasma levels were determined, and plasma concentrations of R-flecainide were significantly higher than those of the S-flecainide enantiomer (R/S ratio = 1.10), suggesting that the flecainide drug undergoes modest enantio selective disposition [Kroemer et al, 1989].
In 1989, Gross et al. compared the disposition of the two enantiomers in two human populations: extensive (EM) and five poor (PM) metabolizers of sparteine/debrisoquine after administration of 50mg of racemic flecainide acetate [Gross et al, 1989]. Gross et al. presented data indicating that the half-life of R-flecainide (12.9h) was longer (P< 0.03) than that of S-flecainide (9.8h). The renal clearance of the two enantiomers was, however, comparable and similar to that observed in the EM subjects. The urinary recovery of R- flecainide (15.6± 3.7mg) was greater (P< 0.03) than that of the S-enantiomer (12.0 ± 3.7 mg). The enantioselective disposition observed in PMs is therefore due to greater impairment in the metabolism of R-flecainide than S-flecainide.
In 1991 , Alessi-Severini et al. summarized key findings on pharmacokinetics and concluded that there was no evidence of enantioselective disposition of flecainide in human [ Alessi-Severini et al, 1991], citing three reports on stereoselective therapeutic monitoring, which found R/S ratio ranges of 0.67-1.39 (mean 1.03 ± 0.16), 0.75-1.44 (mean 1.04), and 0.89-1.32 (mean 1.10 ± 0.13), and that Gross et al. 1989 study was not relevant on the total population.
In 1998, Hanada et al. demonstrated an absence of enantioselective distribution of the two enantiomers of flecainide in several tissue, after intravenous administration of flecainide racemate in rats [Hanada et al, 1998]. As reviewed in [Mehvar et al, 2002], it appears that the renal clearances of the enantiomers of flecainide are not stereoselective in both healthy volunteers and patients.
Literature is thus globally coherent on the absence of stereoselective effects of flecainide on pharmacokinetics and metabolism. The physicochemical properties of the two enantiomers of flecainide have been also described. In particular, Turgeon et al. described a stereoselective analytical method for the determination of the antiarrhythmic agent flecainide in human plasma. The resolution of the enantiomers is achieved by high-performance liquid chromatography (HPLC) on a normal phase silica column following derivatization with the optically active reagent (-)- methyl chloro formate [Turgeon et al, 1990].
Moreover, Alessi-Severini et al. described a stereospecific high-performance liquid chromatographic method for the determination of (R,S)-flecainide acetate in human plasma and urine. Flecainide diastereomers were separated after i) a single-step extraction of alkalinized samples performed with distilled diethyl ether, ii) the organic layer was evaporated and the drug was derivatized with l-[(4-nitrophenyl)sulfonyl]-L-propyl chloride at 80 degrees C for 2 h and iii) by high-performance liquid chromatography (HPLC) on a CI 8 reversed-phase column with a mobile phase consisting of acetonitrile:water:triethylamine (45:55:0.2) at a flow rate of 1 mL/min [Alessi-Severini et al, 1990].
Racemic flecainide acetate is a widely used class lc antiarrhythmic agent, which is indicated for treating various types of arrhythmias. More specifically, it is used to regulate the rate and rhythm of the heart. The heart's pumping action is controlled by electrical signals that pass through the heart muscle. These electrical signals cause the two pairs of heart chambers (left and right arteria and ventricles) to contract in a regular manner to produce regular heartbeats. If the electrical activity in the heart is disturbed for any reason, irregular heartbeats (arrhythmias) of various types can result. Flecainide helps to treat arrhythmias by decreasing the sensitivity of the heart muscle cells to electrical impulses. This regulates the electrical conduction in the heart muscle and reduces disturbances in the heart rhythm. As a class I antiarrhythmic agent, flecainide interferes with the sodium channel. Importantly, several studies have demonstrated that these cardiovascular effects are not mediated by a single enantiomer, both of them contributing to cardiovascular functions:
Antiarrhythmic effects of flecainide and its enantiomers were assessed in two different animal models, chloroform-induced ventricular fibrillation in mice and ouabain-induced ventricular tachycardia in dogs. The two enantiomers were highly effective in suppressing both of these experimental arrhythmias and appeared to be essentially equipotent. No significant differences were found either between the two enantiomers or between the enantiomers and racemic flecainide [Banitt et al, 1986].
The effects of the enantiomers on action potential characteristics in canine cardiac Purkinje fibers were assessed, and they were shown to exert similar electrophysiological effects [Kroemer et al, 1989].
The effects of flecainide acetate racemate and its two enantiomers on voltage-operated sodium and potassium channels and on the sodium pump activity of non-myelinated fibers of the guinea-pig vagus nerve were studied with the sucrose-gap method. There was no significant difference in the effect caused by the enantiomers separately [Lie et al, 1989].
The effects of the enantiomers were evaluated in isolated canine Purkinje fibers using standard microelectrode techniques. The results suggest there is no significant difference between the effects of flecainide enantiomers on basic electro- physiological parameters of canine Purkinje fibers [Smallwood et al, 1989]. To conclude, all those studies have provided no evidence to indicate that administration of a single enantiomer, rather than the racemic drug, would offer any advantage.
According to a first aspect, the present invention therefore pertains to the use of flecainide, in vitro and in vivo, as an anti-connexin agent. In particular, the present invention relates to flecainide for use as an anti-connexin agent, or, in other words, for blocking gap junctions.
There are 21 genes coding for different connexin iso forms in humans, and different combinations of connexin monomers involved in the composition of the gap junctions are described. In particular, the connexins 26 (Cx 26), 30 (Cx 30), 30.2 (Cx30.2), 32 (Cx 32), 36 (Cx 36), 37 (Cx 37), 40 (Cx 40), 43 (Cx 43), 45 (Cx 45), 46 (Cx 46), and 47 (Cx 47) are expressed in human on cells of the Central or Peripheral Nervous System (Nakase & Naus, 2004).
The present inventors observed that flecainide is effective for inhibiting gap junctions made of all connexin they tested. In particular, and as disclosed in the experimental part below, flecainide is effective for inhibiting gap junctions made of connexin Cx40, Cx26, Cx30, Cx32, and /or Cx43. Importantly, this anti-connexin effect is similar to the one observed for well-known anti-connexin agents such as mefloquine and meclofenamic acid (MFA) (Juszczak & Swiergiel, 2009; Cruikshank et al, 2004; Harks et al, 2001). Higher inhibition levels were even reached for glial connexins Cx26, Cx30 and Cx43 (see figure 1).
The present invention therefore relates to the in vitro use of flecainide as an anti-connexin agent. Preferably, this agent can be used to inhibit gap junctions made of the connexins selected in the group consisting of: Cx23 (SEQ ID NO: l), Cx25 (SEQ ID NO:2), Cx26 (SEQ ID NO:3), Cx 30 (SEQ ID NO:4), Cx30.2 (SEQ ID NO:5), Cx30.3 (SEQ ID NO:6), Cx31 (SEQ ID NO:7), Cx31.1 (SEQ ID NO:8), Cx31.9 (SEQ ID NO:9), Cx32 (SEQ ID NO: 10), Cx36 (SEQ ID NO: l l), Cx37(SEQ ID NO: 12), Cx40 (SEQ ID NO: 13), Cx40.1 (SEQ ID NO: 14), Cx43 (SEQ ID NO: 15), Cx45 (SEQ ID NO: 16), Cx46 (SEQ ID NO: 17), Cx47 (SEQ ID NO: 18), Cx50 (SEQ ID NO: 19), Cx59 (SEQ ID NO:20), and Cx62 (SEQ ID NO:21).
In a preferred embodiment of the invention, flecainide is used for blocking one or more of the connexins expressed in human cells of the Central or Peripheral Nervous System, that are selected in the group consisting of: Cx 26 (SEQ ID NO:3), Cx 30 (SEQ ID NO:4), Cx 30.2 (SEQ ID NO:5), Cx 32 (SEQ ID NO: 10), Cx 36 (SEQ ID NO: 11), Cx 37 (SEQ ID NO: 12), Cx 40 (SEQ ID NO: 13), Cx 43 (SEQ ID NO: 15), Cx 45 (SEQ ID NO: 16), Cx 46 (SEQ ID NO: 17) and Cx 47 (SEQ ID NO: 18).
In a more preferred embodiment, flecainide is used for blocking one or more of the connexins selected in the group consisting of: Cx40 (SEQ ID NO: 13), Cx26 (SEQ ID NO:3), Cx30 (SEQ ID NO:4), Cx32 (SEQ ID NO: 10), and Cx43 (SEQ ID NO: 15). In an even more preferred embodiment, flecainide is used for blocking one or more of the connexins selected in the group consisting of: Cx26 (SEQ ID NO:3), Cx30 (SEQ ID NO:4) and Cx43 (SEQ ID NO: 15).
Due to its anti-connexin activity, flecainide can be used for the treatment of a number of disorders and conditions known to benefit from treatment by anti-connexin molecules.
These disorders and conditions include, but are not limited to: cancers, cardiovascular diseases, wounds, pain, migraines, epilepsy, neurological conditions and neurodegenerative diseases, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, ischemia and inflammatory disorders. More preferably, flecainide can be used for the prevention and/or the treatment of cancers, wounds, migraines, epilepsy, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, ischemia and inflammatory disorders.
Even more preferably, flecainide can be used for the prevention and/or the treatment of wounds, migraines, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, and ischemia.
Even more preferably, flecainide can be used for the prevention and/or the treatment of drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, and ischemia.
According to a particular aspect of the present invention, flecainide is used as an agent for potentiating the effects of a psychotropic drug. These potentiating effects are illustrated below by experiments performed with modafmil (see figures 2 to 4). As an anti-connexin agent, flecainide can potentiate the effects of any psychotropic drug (as shown in WO 2010/029131 and US 2011/172188, incorporated by reference).
The term "potentiate" in this case means that flecainide significantly increases the therapeutic effects of the psychotropic drug administered to the same patient. Thus, the combination of the psychotropic drug with flecainide makes it possible to reduce the doses of said psychotropic drug and therefore to limit the adverse effects of said psychotropic drug, and/or to obtain a stronger therapeutic effect without increasing the dose of said psychotropic drug. In the present text, a "psychotropic drug" or "psychotropic agent" refers to any substance that acts primarily on the state of the central nervous system by modifying certain cerebral biochemical and physiological processes. Examples of psychotropic drugs which can be used in the context of the present invention include anesthetics, analgesics such as opioids, antipyretics and antimigraine preparations, anti-epileptics, anti-Parkinson drugs such as anti-cholinergic and dopaminergic anti-Parkinson agents, psycho leptics such as antipsychotics, anxiolytics, hypnotics and sedatives, psychoanaleptics such as antidepressants, psychostimulants and anti-dementia drugs, as well as parasymptomimetics, anti-addiction drugs, antivertigo preparations etc. Non-limitative examples of specific molecules which can be advantageously used as psychotropic drugs according to the invention are listed in Table 1 below.
Therapeutic Pharmacological Chemical sub-class Active agent
category sub-class
Anesthetics 1. General 2. Ethers 3. diethyl ether; vinyl ether anesthetics 4. Halogenate 5. halothane; chloroform;
d hydrocarbons enflurane; trichloroethylene;
isoflurane; desflurane; sevoflurane
6. Barbiturates 7. methohexital; hexobarbital;
, plain
8. Barbiturates 9. narcobarbital
in combination
with other drugs
10. Opioid 11. fentanyl; alfentanil;
anesthetics sufentanil; phenoperidine;
anileridine; remifentanil;
12. Other 13. droperidol; ketamine;
general propanidid; alfaxalone; etomidate; anesthetics propofol; sodium oxybate; nitrous oxide; esketamine; xenon;
14. Local 15. Esters of 16. metabutethamine; procaine; anesthetics aminobenzoic tetracaine; chloroprocaine;
acid benzocaine;
17. Amides 18. bupivacaine; lidocaine;
mepivacaine; prilocaine;
butanilicaine; cinchocaine;
etidocaine; articaine;ropivacaine; levobupivacaine ; bupivacaine ;
19. Esters of 20. cocaine
benzoic acid
21. Other local 22. ethyl chloride; dyclonine; anesthetics phenol; capsaicin Analgesics 23. Opioids 24. Natural 25. opium; hydromorphone;
opium alkaloids nicomorphine; oxycodone;
dihydrocodeine; diamorphine; papaveretum; morphine; codeine,
26. Phenylpiper 27. ketobemidone; pethidine; idine derivatives
28. Diphenylpr 29. dextromoramide; piritramide; opylamine dextropropoxyphene;
derivatives bezitramide; methadone,
30. Benzomorp 31. pentazocine; phenazocine han derivatives
32. Morphinan 33. butorphanol; nalbuphine derivatives
34. Other 35. tilidine; tramadol; dezocine; opioids meptazinol; tapentadol;
36. Other 37. Salicylic 38. acetylsalicylic acid; aloxiprin; analgesics and acid and choline salicylate; sodium antipyretics derivatives salicylate; salicylamide;
salsalate; ethenzamide;
morpholine salicylate;
dipyrocetyl; benorilate;
diflunisal; potassium salicylate; guacetisal;
carbasalate calcium; imidazole salicylate
39. Pyrazolones 40. phenazone; metamizole
sodium; aminophenazone ; propyphenazone; nifenazone;
41. Anilides 42. paracetamol; phenacetin;
bucetin; propacetamol ;
43. Other 44. rimazolium; glafenine;
analgesics and floctafenine; viminol; nefopam; antipyretics ziconotide; methoxyflurane;
nabiximols
45. Antimigrai 46. Ergot 47. Dihydroergotamine;
ne Preparations alkaloids ergotamine; methysergide; lisuride;
48. Corticosteroi 49. flumedroxone
d derivatives
50. Selective 51. sumatriptan; naratriptan; serotonin (5HT1) zolmitriptan; rizatriptan;
agonists almotriptan; eletriptan; frovatriptan
52. Other 53. pizotifen; clonidine;
antimigraine iprazochrome; dimetotiazine ; preparations oxetorone
Anti-epileptics 54. Antiepilepti 55. Barbiturates 56. methylphenobarbital;
cs and derivatives Phenobarbital; primidone;
barbexaclone; metharbital
57. Hydantoin 58. ethotoin; phenytoin;
derivatives amino(diphenylhydantoin) valeric acid; mephenytoin; fosphenytoin;
59. Oxazolidine 60. paramethadione;
derivatives trimethadione; ethadione
61. Succinimide 62. Ethosuximide; phensuximide; derivatives mesuximide;
63. Benzodiaze 64. clonazepam
pine derivatives
65. Carboxamid 66. carbamazepine;
e derivatives oxcarbazepine; rufinamide;
eslicarbazepine
67. Fatty acid 68. valproic acid; valpromide; derivatives aminobutyric acid; vigabatrin;
progabide; tiagabine
69. Other 70. sultiame; phenacemide;
antiepileptics lamotrigine; felbamate;
topiramate; gabapentin;
pheneturide; levetiracetam;
zonisamide; pregabalin;
stiripentol; lacosamide;
carisbamate; retigabine;beclamide
Anti- 71. Anticho liner 72. Tertiary 73. Trihexyphenidyl; biperiden; Parkinson gic agents amines metixene; procyclidine;
drugs profenamine; dexetimide;
phenglutarimide; mazaticol; bornaprine; tropatepine
74. Ethers 75. etanautine; orphenadrine chemically close
to antihistamines
76. Ethers of 77. benzatropine; etybenzatropine tropine or tropine
derivatives
78. Dopaminerg 79. Dopa and 80. levodopa; decarboxylase ic agents dopa derivatives inhibitor; COMT inhibitor;
melevodopa ; etilevodopa
81. Adamantan 82. amantadine
e derivatives
83. Dopamine 84. bromocriptine; pergolide; agonists dihydroergocryptine; esylate;
ropinirole; pramipexole;
cabergoline; apomorphine;
piribedil; rotigotine
85. Monoamine 86. selegiline; rasagiline oxidase B
inhibitors
87. Other 88. olcapone; entacapone;
dopaminergic budipine
agents
Psycho-leptics 89. Antipschoti 90. Phenothiazi 91. chlorpromazine;
cs nes with levomepromazine; promazine; aliphatic side- acepromazine; triflupromazine; chain cyamemazine; chlorproethazine
92. Phenothiazi 93. dixyrazine; fiuphenazine; nes with perphenazine; prochlorperazine; piperazine thiopropazate; trifluoperazine; structure acetophenazine; thioproperazine;
butaperazine; perazine
94. Phenothiazi 95. periciazine; thioridazine; nes with mesoridazine; pipotiazine piperidine
structure
96. Butyrophen 97. Haloperidol; trifluperidol; one derivatives melperone; moperone;
pipamperone; bromperidol;
benperidol; droperidol; fluanisone
98. Indole 99. oxypertine; molindone;
derivatives sertindole; ziprasidone
100. Thioxanthe /0/. fiupentixol; clopenthixol; ne derivatives chlorprothixene; tiotixene;
zuclopenthixol
102. Diphenylbut /03. fluspirilene; pimozide;
ylpiperidine penfluridol derivatives
104. Diazepines, /05.1oxapine; clozapine;
oxazepines, olanzapine; quetiapine; asenapine; thiazepines and clotiapine
oxepines
106. Benzamides 107. sulpiride; sultopride; tiapride;
remoxipride; amisulpride;
veralipride; levosulpiride
108. Lithium 109. lithium
110. Other 111. prothipendyl; risperidone; antipsychotics mosapramine; zotepine;
aripiprazole; paliperidone
112. Anxiolytics 113. Benzodiaze 114. chlordiazepoxide;
pine derivatives medazepam; oxazepam;
potassium clorazepate; lorazepam; adinazolam; bromazepam;
clobazam; ketazolam; prazepam; alprazolam; halazepam;
pinazepam camazepam;
nordazepam; fludiazepam; ethyl loflazepate; etizolam;
clotiazepam; cloxazolam;
tofisopam ;
115. Diphenylme 116. hydroxyzine; captodiame; thane derivatives
117. Carbamates 118.meprobamate; emylcamate;
mebutamate; 119. Dibenzo- 120. benzoctamine
bicyclo-octadiene
derivatives
121. Azaspirodec 122. buspirone
anedione
derivatives
123. Other 124. Mephenoxalone; gedocarnil; anxiolytics etifoxine
125. Hypnotics 126. Barbiturates 127. Pentobarbital; amobarbital; and , plain butobarbital; barbital; aprobarbital; sedatives secobarbital; talbutal; vinylbital;
vinbarbital; cyclobarbital;
heptabarbital; reposal;
methohexital; thiopental;
etallobarbital; allobarbital;
proxibarbal
128. Aldehydes 129. chloral hydrate; chloralodol; and derivatives acetylglycinamide;
dichloralphenazone; paraldehyde
130. Benzodiaze 131. flurazepam; nitrazepam; pine derivatives flunitrazepam; estazolam;
triazolam; lormetazepam;
temazepam; midazolam;
brotizolam; quazepam; loprazolam; doxefazepam; cino tazepam
132. Piperidinedi 133. glutethimide; methyprylon; one derivatives pyrithyldione
134. Benzodiaze 135. zopiclone; Zolpidem;
pine related drugs zaleplon; eszopiclone
136. Melatonin 137. melatonin; ramelteon receptor agonists
138. Other 139. methaqualone; clomethiazole; hypnotics and bromisoval; carbromal;
sedatives scopolamine; propiomazine;
triclofos
ethchlorvynol; valerian;
hexapropymate; bromides; apronal; valnoctamide; methylpentynol; niaprazine;
dexmedetomidine
140. Hypnotics 141. emepronium;
and sedatives in dipiperonylamino ethano 1 combination, excl.
barbiturates
142. Antidepress 143. Non144. desipramine; imipramine; leptics ants selective imipramine oxide; clomipramine;
monoamine opipramol; trimipramine;
reuptake lofepramine; dibenzepin;
inhibitors amitriptyline; nortriptyline; protriptyline; doxepin; iprindole;
melitracen; butriptyline; dosulepin; amoxapine; dimetacrine;
amineptine ; maprotiline;
quinupramine
145. Selective 146. zimeldine; fluoxetine;
serotonin reuptake citalopram; paroxetine; sertraline; inhibitors alaproclate; fluvoxamine;
etoperidone; escitalopram
147. Monoamine 148. isocarboxazid; nialamide; oxidase inhibitors, phenelzine; tranylcypromine;
non-selective iproniazide; iproclozide
149. Monoamine 150. moclobemide; toloxatone oxidase A
inhibitors
151. Other 152. oxitriptan; tryptophan;
antidepressants mianserin; nomifensine; trazodone;
nefazodone; minaprine; bifemelane; viloxazine; oxaflozane;
mirtazapine; bupropion;
medifoxamine; tianeptine;
pivagabine; venlafaxine;
milnacipran; reboxetine; gepirone; duloxetine; agomelatine;
desvenlafaxine
153. Psychostim 154. Centrally 155. amphetamine;
ulants, acting dexamfetamine; metamfetamine; agents used sympathomimetic methylphenidate; pemoline;
for ADHD s fencamfamin; modafmil;
and armodafinil; fenozolone;
nootropics atomoxetine; fenetylline ;
exmethylphenidate;
lisdexamfetamine
156. Xanthine 157. caffeine; propentofylline derivatives
158. Other 159. meclofenoxate; pyritinol; psychostimulants piracetam; deanol; fipexide;
and nootropics citicoline; oxiracetam; pirisudanol;
linopirdine; nizofenone;
aniracetam; acetylcarnitine;
idebenone; prolintane; pipradrol; pramiracetam; adrafmil;
vinpocetine ; pitolisant ;
Anti- 161. Anticho lines 162. tacrine; donepezil;
dementia terases rivastigmine; galantamine drugs 163. Other anti- 164. memantine; ginkgo biloba dementia
drugs
Other nervous 165. Parasympat 166. Anticho lines 167. neostigmine; pyridostigmine; system drugs homimetics terases distigmine; ambenonium;
168. Choline 169. carbachol; bethanechol esters
170. Other 171. pilocarpine; choline
parasympath alfoscerate; cevimeline omimetics
172. Drugs used 173. Drugs used 174. nicotine; varenicline
in addictive in nicotine
disorders dependence
175. Drugs used 176. disulfiram; calcium
in alcohol carbimide; acamprosate;
dependence naltrexone; baclofene
177. Drugs used 178. buprenorphine;
in opioid levacetylmethadol ; lofexidine; dependence
179. Antivertigo 180. Antivertigo 181. betahistine; cinnarizine; preparations preparations flunarizine; acetylleucine
182. Other 183. Other 184. tirilazad; riluzole; xaliproden nervous nervous ; amifampridine; tetrabenazine; system system drugs fampridine; mazindol
drugs
Table 1 : Psychotropic molecu es
Preferably, the said psychotropic drug is selected in the group consisting of: dopaminergic, GABAergic, adrenergic, acetylcholinergic, serotoninergic, opioidergic, adenosinergic, ionotropic, histaminergic, IMAO, Catechol-O-methyl transferase, DOPA decarboxylase, noradrenergic and glutamatergic psychotropic effectors, as well as molecules having an effect on the hypocretin/orexin system (including hypocretin-1 and hypocretin-2).
The term "effector" herein refers to any substance activating or inhibiting, directly or indirectly, one or more neuroreceptors, as well as any substance that modifies the concentration of said neurotransmitter; therefore, an effector according to the present invention can be an agonist or an antagonist of said receptors.
It is shown in the examples below that said psychotropic drug is advantageously modafmil.
As a matter of fact, the present inventors have shown that flecainide potentiates the promnesiant and/or awakening effects of modafmil (see figures 2 and 3), and that the modafinil/flecainide combination shows promising effects by reducing cataplectic-like events in mice. The precise mechanism of modafmil action has not been completely elucidated yet. In fact, it is known that modafinil acts on several molecular receptors, in particular on the dopamine, norepinephrine, serotonine, glutamate, GABA, orexine and histamine receptors (Ishizuka et al, 2012; Minzenberg et al, 2008). Therefore, modafinil acts as a GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors, and it has an effect on the hypocretin/orexin system (including hypocretin-1 and hypo cretin-2).
Any compound modulating the same molecular receptors as modafinil can be advantageously associated with flecainide.
Thus, in a preferred embodiment, the psychotropic drug which is associated with flecainide acts on the very same receptors as modafinil does. The psychrotropic drug associated with flecainide is therefore preferably selected in the group consisting of: GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors. Also, it may have an effect on the hypocretin/orexin system (including hypocretin-1 and hypo cretin-2). According to a specific embodiment, the said psychotropic drug is a dopaminergic effector selected in the group consisting of: ADX-N05 (formely "YKP10A", having the formula: (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride), amphetamine, loxapine, acepromazine, methylphenidate, pergolide, lisuride, bromocriptine, dopamine, ropinirole, apomorphine, aripiprazole, sulpiride, amisulpride, sultopride, tiapride, pimozide, risperidone, haloperidol, penfluridol, zuclopenthixol or bupropion.
According to another specific embodiment, the said psychotropic drug is a GABAergic effector selected in the group consisting of: tiagabine, topiramate, clorazepate, diazepam, clonazepam, oxazepam, lorazepam, bromazepam, lormetazepam, nitrazepam, clotiazepam, aiprozolam, estazolam, triazolam, loprazolam, etifoxin, meprobamate, zopiclone, Zolpidem, pregabaline, gabapentine, phenobarbital, felbamate and vigabatrin.
According to another specific embodiment, the said psychotropic drug is a serotoninergic effector selected in the group consisting of: chlorpromazine, trimipramine, clozapine, olanzapine, cyamemazine, flupentixol, nefopam, fluvoxamine, clomipramine, sertraline, fluoxetine, citalopram, escitalopram, paroxetine, amitriptyline, duloxetine, venlafaxine, buspirone, carpipramine, zolmitriptan, sumatriptan, naratriptan, indoramine, ergotamine, ergotamine tartrate, pizotifene, pipamperone, methysergide, pizotyline, milnacipran,, viloxazine, tianeptine, hypericum and lithium.
According to another specific embodiment, the said psychotropic drug is a histaminergic effector selected in the group consisting of: acrivastine, alimemazine, antazoline, astemizole, azatadine, azelastine, brompheniramine, buclizine, carbinoxamine, carebastine, cetirizine, chlorcyclizine, chlorpheniramine, cinnarizine, clemastine, clemizole, clocinizine, clonidine, cyclizine, cyproheptadine, descarboethoxyloratidine, dexchlorpheniramine, dimenhydrinate, dimethindene, dimethothiazine, diphenhydramine, diphenylpyraline, doxylamine, ebastine, efletirizine, epinastine, fexofenadine,hydroxyzine, ketotifen, levocabastine, loratidine, meclizine, mequitazine, methdilazine, mianserin, mizolastine, niaprazine, noberastine, norastemizole, oxatomide, oxomemazine, phenbenzamine, pheniramine, picumast, promethazine, pyrilamine, temelastine, terfenadine, trimeprazine, tripelennamine, triprolidine, ranitidine, cimetidine, famotidine, nizatidine, tiotidine, zolantidine, ciproxifan, pitolisant and ritanserine. According to another specific embodiment, the said psychotropic drug is a hypocretin/orexin modulator selected in the group consisting of: EMPA, SB-334867, SB- 674042, SB-408124, GSK1059865, almorexant, suvorexant, MK-6096, DORA-1, DORA- 22, DORA-12, SB-649868, JNJ-1037049 (described in Gotter et al, 2012)).
According to another specific embodiment, the said psychotropic drug is a norepinephrinergic effector selected in the group consisting of: (R)-3-nitrobiphenyline, 2- fluoronorepinephrine, 4-NEMD, 5-fluoronorepinephrine, 6-fluoronorepinephrine, abediterol, albuterol, amibegron, amidephrine, amitraz, anisodamine, anisodine, apraclonidine, arbutamine, arformoterol, arotinolol, bambuterol, befunolol, bitolterol, brimonidine, bromoacetylalprenololmenthane, broxaterol, buphenine, cannabivarin, carbuterol, cimaterol, cirazoline, clenbuterol, denopamine, deterenol, detomidine, dexmedetomidine, dihydroergotamine, dipivefrine, dobutamine, dopexamine, ephedrine, epinephrine , esproquin, etafedrine, ethylnorepinephrine, etilefrine, fenoterol, formoterol, guanabenz, guanfacine, guanoxabenz, hexoprenaline, higenamine, indacaterol, indanidine, isoetarine, isoprenaline, isoproterenol, isoxsuprine, labetalol, levonordefrin, levosalbutamol, lofexidine, mabuterol, medetomidine, metaraminol, methoxamine, methoxyphenamine, methyldopa, midodrine, mivazerol, n-isopropyloctopamine, naphazoline, norepinephrine, octopamine, orciprenaline, oxyfedrine, oxymetazoline, phenylephrine, phenylpropanolamine, piperoxan, pirbuterol, prenalterol, procaterol, pseudoephedrine, ractopamine, reproterol, rilmenidine, rimiterol, ritodrine, romifidine, salbutamol, salmeterol, solabegron, synephrine, talipexole, terbutaline, tetrahydrozoline, tizanidine, tolonidine, tretoquinol, tulobuterol, urapidil, xamoterol, xylazine, xylometazoline, zilpaterol, and zinterol.
According to another specific embodiment, the said psychotropic drug is a glutamatergic effector selected in the group consisting of: memantine, amantadine, MK-801, ketamine, norketamine, dextromethorphan, levometorphan, dextrorphan, levorphanol, phencyclidine, PCA, CNS-1102, remacemide, pentamidine, and 9-aminoacridine (described in Traynelis et al, 2010).
Preferably, said psychotropic drug is not flupirtine.
The potentiating effects of flecainide can be achieved by administrating same to a patient, either before, at the same time, of after administration of the psychotropic drug to said patient.
Consequently, the present invention describes a method for treating a patient with psychiatric and/or neurodegenerative disorders, including the administration to said patient of a) flecainide and b) at least one psychotropic drug as mentioned above, in which said compounds a) and b) are administered simultaneously, separately or spread out over time. Patients needing this treatment may have psychiatric, neurologic and/or neurodegenerative disorders included in the group consisting of: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine- Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, anti-psychotics...), mood disorders, anxiety disorders, schizophrenia, tinnitus, depression, malaise, dementia, bipolar disorder, obesity, hyperphagia, manic episode, obsessive-compulsive disorder, senility, dependence or addiction (to games, drugs, alcohol, tobacco, etc.), fecal or urinary incontinence, premature ejaculation, breathing difficulty and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia.
Excessive daytime sleepiness (EDS) occurs daily, recurring typically every 2 h, although this can vary widely. Sleepiness is exacerbated when the patient is physically inactive. The sleep episodes have several characteristics (Dauvilliers I. et al, 2007 and Boulos et al, 2010):
• They are often irresistible, despite the individual making desperate efforts to fight the urge to sleep;
• They are usually short, although their length can vary with environmental factors (eg, the duration can increase with passive activities such as watching television);
• They are frequently associated with dreaming;
• They typically restore normal wakefulness for up to several hours.
EDS characterizes several conditions or diseases: insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, recurrent hypersomnia (Kleine-Levin syndrome), circadian rhythm disorders (jet lag), disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), neurological conditions commonly associated with sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders), medical conditions commonly associated with sleepiness (respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), mood disorders, anxiety disorders, schizophrenia, or medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, antipsychotics...). Cataplexy is characterized by a sudden drop of muscle tone triggered by emotional factors, most often by positive emotions such as laughter, repartee, pleasant surprise (e.g., seeing friends in the street or scoring a goal), or by anger, but almost never by stress, fear, or physical effort. Many neurophysio logical and pharmaceutical studies indicate that cataplexy shares common neurophysio logical mechanisms with REM sleep atonia (Dauvilliers I. et al, 2007).
In the case of simultaneous use, the two components of the treatment are administered to the patient simultaneously. According to this embodiment of the present invention, the two components can be packaged together, in the form of a mixture, or separately, then mixed spontaneously before being administered together to the patient. Alternatively, the two components are administered simultaneously, but separately. In particular, the routes of administration of the two components may be different. The administration can also be performed at different sites. In another embodiment, the two components are administered sequentially or spaced apart over time, for example in the same day or at an interval ranging from several minutes to several days.
Since flecainide potentiates the effects of psychotropic drugs, it can advantageously be used for reducing the doses of said psychotropic drug, thereby limiting the adverse effects of said psychotropic drug, and/or reducing the risks of failure and withdrawal.
The effective equivalent dose of a psychotropic drug, i.e., the psychotropic drug dose that, when administered in combination with flecainide, induces a physiological effect or a pharmacological signature similar or identical to that of the psychotropic drug alone administered at the active pharmacological dose, can be determined by the methods disclosed in WO2010/029131 and US 2011/172188.
According to another aspect, the present invention pertains to a composition, especially a pharmaceutical composition, comprising flecainide and at least one psychotropic drug. This composition is preferably formulated for patients with psychiatric and/or neurodegenerative disorders, as disclosed above. In addition to flecainide and to said psychotropic drug, the composition can comprise any pharmaceutical vehicle, stabilizer, adjuvant and the like as frequently used in the art. Examples of pharmaceutically acceptable vehicles include, but are not limited to: water; aqueous vehicles such as, but not limited to, sodium chloride solution, Ringer's solution, dextrose solution, dextrose and sodium chloride solution, and lactated Ringer's solution; water-miscible vehicles such as, but not limited to, ethyl alcohol, polyethylene glycol, and polypropylene glycol; and nonaqueous vehicles such as, but not limited to, corn oil, cottonseed oil, peanut oil, sesame oil, ethyl oleate, isopropyl myristate, and benzyl benzoate.
According to a preferred embodiment, this composition is formulated for oral administration (including buccal cavity or sublingually). Other interesting formulations include formulations for intraperitoneal (i.p.), intravenous (i.v.), subcutaneous (s.c), intramuscular (i.m.), transcutaneous, transdermal, intrathecal and intracranial administrations. Still other formulations include epidural, submucosal, intranasal, ocular cul-de-sac and rectal routes of administration, as well as administration by pulmonary inhalation. A variety of administration means, including but not limited to capsules, tablets, syrups, creams and ointments, suppositories, patches or any reservoir capable of containing and dispensing flecainide and the psychotropic drug, can be used for formulating the above- described compositions.
In the compositions according to the invention, the psychotropic drug is as described above.
In a preferred embodiment, said psychotropic drug is used for treating narcolepsy and is therefore selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride, modafmil and armodafinil. In a preferred embodiment, the composition of the invention contains between 1 to 1000 mg, preferably 5 to 800 mg of the psychotropic drug, depending of its nature. A preferred posology would be to administer to the patient between 1 to 1000 mg/day, more preferably between 5 to 800 mg/day of the psychotropic drug. According to another preferred embodiment, the composition of the invention contains between 1 to 200, preferably 1 to 100 mg of flecainide. A preferred posology would be to administer to the patient between 1 to 200, preferably 1 to 100 mg/day of flecainide.
More preferably, said flecainide is the R enantiomer disclosed on figure 5A. In a more preferred embodiment, flecainide is associated with the psychotropic drug modafmil.
By "modafmil" is herein meant the 2-[(diphenylmethyl) sulfmyl] acetamide (Provigil, see figure 5C), as well as its precursors or prodrugs such as adrafmil (Dubey et al, 2009) which can be metabolized in the human body and its active derivatives. More precisely, the term "Modafmil" herein designates any form of modafmil (racemate, R-modafmil, S- modafmil, etc.), as well as its precursors which can be metabolized in the human body and its derivatives. Figure 5 shows the formulas of R-Modafmil (Fig. 5C) and S-Modafmil (Fig. 5D).
Modafmil is an analeptic drug prescribed essentially for the treatment of narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnea. Besides these wake-promoting properties, modafmil also improves working memory and episodic memory, and other processes dependent on prefrontal cortex and cognitive control (Minzenberg MJ et al, 2008).
The present inventors have shown that, surprisingly, flecainide strongly potentiates in vivo the waking effects of Modafmil, whereas it has no effect on wake duration on its own (example 2). Moreover, flecainide strongly potentiates in vivo the cognitive activity of Modafmil, whereas it has no promnesiant effect on its own (example 3). This synergistic activity could be explained by the fact that flecainide strongly extends the duration of Modafmil treatment (example 4). On the other hand, the present inventors herein describes that the flecainide / modafmil combination has a synergistic effect on cataplectic-like phenotype in narcoleptic mice (example 5) and is all the more surprising than either flecainide or modafmil has no effect on this phenotype (figure 6B). In a preferred embodiment, the present invention thus pertains to flecainide, for use for potentiating the promnesiant and/or awakening effects of modafmil, and/or for improving its safety, and/or for increasing the duration of action of modafmil in patients in need thereof, especially in patients suffering from: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine-Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication- induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, antipsychotics...), mood disorders, anxiety disorders, schizophrenia, tinnitus, depression, malaise, dementia, bipolar disorder, obesity, hyperphagia, manic episode, obsessive- compulsive disorder, senility, dependence or addiction (to games, drugs, alcohol, tobacco, etc.), fecal or urinary incontinence, premature ejaculation, breathing difficulty and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia, which have been proposed to be treated by modafmil.
In a more preferred embodiment, the present invention specifically pertains to flecainide, for use for potentiating the awakening effects of modafmil, and/or for improving its safety, and/or for increasing the duration of action of modafmil in patients suffering from: excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine-Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, anti- psychotics...), mood disorders, anxiety disorders, schizophrenia, tinnitus, depression, malaise, dementia, bipolar disorder, obesity, hyperphagia, manic episode, obsessive- compulsive disorder, senility, dependence or addiction (to games, drugs, alcohol, tobacco, etc.), fecal or urinary incontinence, premature ejaculation, breathing difficulty and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia, for which modafinil has been proposed or authorized.
In a preferred embodiment, the present invention specifically pertains to flecainide, for use for potentiating the awakening effects of modafinil, and/or for improving its safety, and/or for increasing the duration of action of modafinil in patients suffering from excessive daytime sleepiness (EDS).
In another preferred embodiment, the present invention relates to flecainide, for use for potentiating the awakening effects of modafinil, and/or for improving its safety, and/or for increasing the duration of action of modafinil in patients suffering from conditions or diseases involving EDS, that are for example: insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, recurrent hypersomnia (Kleine-Levin syndrome), circadian rhythm disorders (jet lag), disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders and sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), neurological conditions commonly associated with sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders), medical conditions commonly associated with sleepiness (respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), mood disorders, anxiety disorders, schizophrenia, or medication- induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, anti-psychotics...).
In another preferred embodiment, the present invention relates to a modafinil/flecainide combination product, for use for treating cataplexy in narcoleptic patients.
It is to be noted that the potentiation of the effects of modafinil by flecainide enables a reduction of the dose of modafinil, and hence a reduction of its side-effects. As a consequence, some applications of modafinil, for which this drug was not approved because of its side-effects and possible risks associated thereto, can now be envisioned, such as its use as a performance-enhancing and/or brain-boosting agent. According to a particular embodiment, the present invention thus pertains to a performance-enhancing product comprising flecainide and modafinil.
In another preferred embodiment, the present invention specifically pertains to the use of flecainide and modafinil for enhancing the memory of healthy subjects and/or to maintain them awake for long-lasting periods of time and/or to treat cataplexy in narcoleptic patients. These subjects can be for example individuals that need to memorize a lot of information and/or to remain awake for long lasting periods. In a preferred embodiment, said subjects are humans (e.g., security agents, students, etc.). In a particular embodiment, the present invention also relates to a composition comprising flecainide and modafinil, which can advantageously be used for treating diseases and conditions including but not limited to excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, jet-lag, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia. In particular, this composition can be used for treating cataplexy in narcoleptic patients.
This composition can also be used for enhancing the memory of healthy subjects and/or for maintaining them awake for long-lasting periods of time. Typical periods of time are for example 6 hours, preferably 12 hours.
The present invention moreover relates specifically to the use of flecainide and modafinil in the preparation of a medicament that is intended to be used for treating diseases and conditions such as excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post- myelitis, or to fibromyalgia. In a preferred embodiment, the present invention relates to the use of flecainide and modafmil in the preparation of a medicament that is intended to be used for treating cataplexy in narcoleptic patients.
In addition to modafmil and flecainide, the composition / medicament of the invention can comprise other agents such as vitamin C, vitamin B6, magnesium, L-arginine, L- glutamine, L-citrulline, taurine, caffeine, etc. According to a particular embodiment, this product can be sold over-the-counter. It can be formulated, for example, as an OTC medicine or as a food supplement.
In a preferred embodiment, the composition of the invention contains between 1 to 1000 mg, preferably between 5 to 800 mg, and more preferably between 5 to 600 mg of the modafmil. According to another preferred embodiment, the composition of the invention is formulated so that 5 to 800, preferably 5 to 600 mg/day of modafmil are administered to a patient in need thereof, in one, two or more takings.
According to another preferred embodiment, the composition of the invention contains between 1 to 200, preferably 1 to 100 mg of flecainide. According to another preferred embodiment, the composition of the invention is formulated so that 1 to 200, preferably 1 to 100 mg/day of flecainide are administered to a patient in need thereof, in one, two or more takings. In a more preferred embodiment, said flecainide is the R enantiomer disclosed on figure 5A. In a final aspect, the present invention relates to a combination product comprising flecainide and modafmil, for simultaneous, separated or staggered use for preventing and/or treating excessive daytime sleepiness (EDS), narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), shift work sleep disorder, restless leg syndrome, hypersomnia, idiopathic hypersomnia and fatigue, notably due to cancer, jet-lag, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia. This combination product is preferably used for preventing and/or treating cataplexy in narcoleptic patients. Other characteristics of the invention will also become apparent in the course of the description which follows of the biological assays which have been performed in the framework of the invention and which provide it with the required experimental support, without limiting its scope.
Legends to the figures
Figure 1: Inhibition of the human connexins functionality by flecainide. Rin-Cx26 cells, Rin-Cx30 cells, Rin-Cx32 cells, Rin-CX40 cells and Rin-Cx43 cells are cultured in the presence of flecainide (280μΜ), mefloquine (10 μΜ) and MFA (100 μΜ) for 4 hours. The transfer of fluorochrome by gap junctions (composed of connexins) is evaluated by flow cytometry (1 A and IB). Viability of the cells treated with flecainide is shown on figure IB.
Figure 2: Efficiency of flecainide for potentiating the awakening effect of modafinil. Mice (n = 8 per batch) were orally treated by either modafinil (32 mg/kg) or modafinil (32mg/kg) and flecainide (1 mg/kg) (figure 2 A) or flecainide alone (1 mg/kg) (figure 2B) and replaced in their home cage. The wake duration was measured using polygraphic analyses.
Figure 3: Efficacy of flecainide for potentiating the promnesiant effect of modafinil. Mice (n = 6 to 23 per batch) are tested in the T-maze. They were intraperitoneally treated by either modafinil (64 mg/kg or 128mg/kg) or modafinil (64mg/kg) and flecainide (lmg/kg) or flecainide alone (lmg/kg). The graphic represents the percentage of alternation after 6 trials, 50% corresponding to a random alternation.
Figure 4 : Efficacy of flecainide for potentiating the locomotor effect of modafinil. Mice (n=8 per batch) were orally treated by either modafinil (64 mg/kg) or modafinil (64mg/kg) and flecainide (lmg/kg) or flecainide alone (lmg/kg) and replaced in their home cage. The locomotor activity was measured using videotracking device.
Figure 5: Molecular structure of A. R-flecainide; B. S-flecainide; C. R-Modafmil, D. S- Modafmil. Figure 6: Number of episodes of OREM/DREM phases in narcoleptic mice (Ox-/-) treated by modafinil/flecainide (A) or flecainide alone (B). (A). Oral treatment of Ox-/- male mice with modafinil 64 mg/kg with flecainide 1 mg/kg was compared to Modafinil 64 mg/kg and vehicle. **: p<0,01 ; ***:p<0,005, Two-Way ANOVA. (B) Oral treatment of Ox-/- male mice with flecainide 1 mg/kg was compared to vehicle.
Figure 7: Number of episodes of OREM/DREM phases in narcoleptic mice (Ox-/-) treated by the combination between modafinil and one of the two enantiomers of flecainide (R- flecainide and S- flecainide). Oral treatment with modafinil 64 mg/kg with R-flecainide 1 mg/kg or S-flecainide 1 mg/kg was compared to vehicle.
EXAMPLES
Example 1: Effect of Flecainide on gap junctions
1.1. Materials and methods Cell culture
The rat insulinoma RIN cell line, deficient in GJIC (del Corsso et al, 2006), was grown in OptiMem medium, supplemented with 10% fetal calf serum. GJB6 (Cx30), GJB1 (Cx32), GJB2 (Cx26), GJA5 (Cx40) and GJAl (Cx43) open reading frames were amplified from human cDNA. The open reading frames were cloned in pcDNA3.1/V5-His-TOPO (Invitrogen). Cells were transfected using Lipofectamine and further selected using geneticin.
Dye transfer experiments
Cells were seeded and loaded with two fluorochromes, calcein acetoxymethyl ester, a gap junction permeable dye, and Vybrant Dil, a membrane lipophilic dye. The next day, cells were dissociated and incubated for four hours in presence of previously seeded non-loaded cells and in the presence of flecainide racemate 70, 140 or 280 μΜ, mefloquine 10 μΜ or meclofenamic acid (MFA) 100 μΜ. Flow cytometry was conducted on a FACScan. Inhibition was quantified as the relative number of receiver cells that gained fluorescence to the total number of receiver cells (non GJ-mediated dye transfer was then substracted to these ratio based on connexin non-expressing RIN cells, defined at background dye transfer ratio). This ratio of cellular coupling was then normalized, after each treatment, on the vehicle one.
Toxicity analysis
Twenty thousand RIN were seeded in 100 μΐ of culture medium in 96-wells plates. After 48h culture, cells were treated for 4 hours with previously identified chemical compounds at several concentrations. Cells were rinsed in PBS and grown 24h in fresh medium. Cell viability was measured by using WST- 1 (Roche).
1.2. Experimental results
Cellular models were validated by using two classical inhibitors described in litterature, meclofenamic acid (MFA) (Dhein, 2004) (100 μΜ) and mefloquine (Cruikshank et al, 2004) (10 μΜ). Results are shown on figure 1A. Flecainide is as efficient in blocking connexin as the other anti-connexin agents.
Cell viability tests (using WST-1, dotted curve on Figure IB) after one day of treatment, indicate that flecainide has no cell toxicity at the dose inhibiting cerebral connexins.
In addition, flecainide inhibits all the tested isoforms of cerebral connexin using dye- transfer cell-parachute assay (Cx30, Cx32, Cx26, Cx40, Cx43) (it is estimated that a more than a significant 10% reduction in gap junction cellular is considered as physiologically relevant). In addition, higher inhibition levels are reached for glial connexins Cx26, Cx30 and Cx43.
Example 2: Flecainide potentiates the waking effects of Modafinil
Preclinical and clinical data indicated that modafinil modifies sleep-cycle rhythm and promotes wake phases (Lin et al, 2008). Here we tested in rodents whether such activity was potentiated by flecainide after oral challenge with modafinil, using polysomnographic analysis on implanted mice. Using a sub-efficient dosage of modafinil (32 mg/kg), the inventors demonstrated a new feature of the combination of modafinil and flecainide since it significantly increases the total duration of wake episodes.
2.1. Materials and Methods Wild-type C57bl/6 male mice (n=9/groups) were implanted with EEG/EMG/EOG electrodes for polysomnographic analyses. After a two-week recovery period, mice were orally treated with vehicle, Modafmil 32 mg/kg and Modafmil 32 mg/kg + flecainide racemate 1 mg/kg and wake periods were quantified using Spike2 scripts. Here the inventors represented the duration of wake during the first three hours (after a one-hour period post-administration). **: p<0,01 in a One- Way ANOVA analysis.
2.2. Results
Modafmil is a molecule that promotes wakefulness in humans and mice, increasing in mice their activity in a dose-dependent manner (Simon et al, 1994). The activity of mice treated with modafmil at 32 mg/kg was compared with that of mice treated with the combination modafmil 32 mg/kg + flecainide 1 mg/kg or vehicle.
Figure 2A shows that flecainide significantly increases the waking effects of modafmil. Figure 2B shows that this effect is not mediated by flecainide alone.
Thus, flecainide significantly potentiates modafmil waking activity in wild type mice, while being devoid of own effect on wake duration.
Exemple 3: Flecainide significantly enhances modafinil cognitive activity
Modafmil induces a cognitive enhancing effect (Beracochea et al, 2003), such property can be assessed using the alternating sequential test, a widely used apparatus to assess spatial working memory in mice (Beracochea & Jaffard, 1987). Spontaneous alternation is the innate tendency of rodents to alternate their choices to enter into the compartments of arrival of a T-maze device, over successive trials. To alternate during a given trial N, the animal must remember the choice made selectively in test N-l, and the response in alternating is performance measure. Acute administration of modafinil before entering the maze, can improve the performance of mice in this test (Beracochea et al, 2001). The inventors' results showed that flecainide significantly potentiates the promnesiant effect of a subefficient dose of modafmil, while flecainide alone is devoid of any own promnesiant effect.
3.1. Materials and methods
The alternating sequential test is widely used to assess spatial working memory in mice (Beracochea & Jaffard, 1987). Spontaneous alternation is the innate tendency of rodents to alternate their choices to entry into the compartments of arrival of a T-maze device, over successive trials. To alternate during a given trial N, the animal must remember the choice made selectively in test N-l, so the decline in alternating will reflect the phenomenon of oblivion. The response in alternating is performance measure. Sequential alternating assesses more specifically the sensitivity to interference, a major factor in oblivion.
The experiment takes place in a T-maze (50 cm x 10 cm x 25 cm). All the subjects were given 7 successive trials separated by a 120-s intertrial interval. To begin a trial, the mouse was placed in the start box for 120 s before the door to the stem was opened. When the subject entered one of the goal arms, the door to that arm was closed. The chosen arm and the time that elapsed between opening the door and the arrival to the end of the chosen arm (task achievement time) were registered. Following a 30-s confinement period (fixed and invariant) in the chosen arm, the animal was removed and placed in the start box for a new trial. Between each test, the unit is cleaned with a cloth soaked in water and alcohol to avoid olfactory detection. The index memory is represented by the average of alternating percentage (number of alternation choices / total number of tests X 100). (n=6 to 23 for each group). Mice were intraperitoneally treated by either modafmil (64 mg/kg or 128mg/kg) or modafmil (64mg/kg) and flecainide racemate (lmg/kg) or flecainide racemate alone (lmg/kg) or vehicle.
# p<0,05 in one sample t-test vs random 50% alternance ; * p<0,05 One way ANOVA followed by Tukey's multiple comparison vs modafmil group. 3.2.Results
The T-maze is a device for assessing working memory in mice. Acute administration of modafinil before entering the maze, can improve the performance of mice in this test (Beracochea et al, 2001). The validity of the test was performed by comparing the responses of mice intraperitoneally treated with an effective dose of modafinil alone (128 mg/kg), a dose of flecainide alone (1 mg/kg) and a sub-effective dose of modafinil (64 mg/kg) with or without flecainide alone (1 mg/kg). The results are shown in Figure 3.
These results show that flecainide significantly potentiates modafinil promnesiant activity, while flecainide alone shows no own cognitive effect.
Exemple 4: Flecainide significantly prolongs modafinil activity
Modafinil is a molecule that promotes wakefulness in humans and mice, increasing in mice their activity in a dose-dependent manner (Simon et al, 1994). The inventors' results showed that flecainide significantly potentiates the locomotor effect of a subefficient dose of modafinil, while flecainide alone is devoid of any own locomotor effect in rodents.
4.1. Materials and methods
Mice (n=8 per batch) were orally treated by either modafinil (64 mg/kg) or modafinil (64mg/kg) and flecainide racemate (1 mg/kg) or flecainide racemate alone (1 mg/kg) or vehicle and replaced in their home cage. Locomotor activity is evaluated by video tracking. Videos have been analyzed using Ethovision XT software (Noldus®).*: p<0,01 in a Two- Way ANOVA analysis 4.2.Results
The activity of mice treated with modafinil at 64 mg/kg was compared with that of mice treated with the combination modafinil 64 mg/kg + flecainide 1 mg/kg. Figure 4 shows that flecainide significantly increases the duration of effect of modafinil on the activity of mice. To conclude, the above results show that Flecainide significantly inhibits the functionality of gap junctions, without inducing cellular toxicity. In addition, this compound potentiates the efficacy and duration of effect of modafmil, notably in its promnesiant and awakening side.
Exemple 5: Modafinil/Flecainide combination has a surprising efficient profile on DREM cataplectic-like phenotype in narcoleptic mice.
5.1. Material and methods Animals
Prepro-orexin knockout (KO) mice were offspring of the mouse strain generated by Chemelli et al. [1999] and kept on C57BL/6J genomic background. After backcrossing male orexin-/- mice and female wild-type (WT) mice for nine generations, the obtained orexin+/- mice were crossed to produce heterozygote and ho mo zygote WT and KO littermates. To determine their genotypes with respect to orexin gene, tail biopsies were performed at the age of 4 weeks for DNA detection using PCR.
Surgery
At the age of 12 weeks and with a body weight of 30±2 g, mice used for EEG and sleep- wake studies were chronically implanted, under deep gas anesthesia using isoflurane (2%, 200 ml/min) and a TEM anesthesia system (Bordeaux, France), with six cortical electrodes (gold-plated tinned copper wire, 0 = 0.4 mm, Filotex, Draveil, France) and three muscle electrodes (fluorocarbon-coated gold-plated stainless steel wire, 0 = 0.03 mm, Cooner Wire Chatworth, CA, U.S.A.) to record the electroencephalogram (EEG) and electromyogram (EMG) and to monitor the sleep-wake cycle. All electrodes were previously soldered to a multi-channel electrical connector and each was separately insulated with a covering of heat-shrinkable polyolefin/polyester tubing. Cortical electrodes were inserted into the dura through 3 pairs of holes made in the skull, located respectively in the frontal (1 mm lateral and anterior to the bregma), parietal (1 mm lateral to the midline at the midpoint between the bregma and lambda), and occipital (2 mm lateral to the midline and 1 mm anterior to the lambda) cortex. Muscle electrodes were inserted into the neck muscles. Finally, the electrode assembly was anchored and fixed to the skull with Super-Bond (Sun Medical Co., Shiga, Japan) and dental cement. This implantation allows stable and long-lasting polygraphic recordings [Parmentier et al, 2002].
Polygraphic recording in the mouse and data acquisition and analysis After surgery, the animals were housed individually, placed in an insulated sound-proof recording room maintained at an ambient temperature of 23±1 °C and on a 12 h light/dark cycle (lights-on at 7 a.m.). After a 7-day recovery period, mice were habituated to the recording cable for 7 days before polygraphic recordings were started. Direct REM sleep onset (DREMs) episodes, also called narcoleptic episodes or sleep onset REM periods by some authors [Chemelli et al, 1999; Mignot et al, 2005; Fujiki et al, 2006], were defined as the occurrence of REM sleep directly from wake, namely a REM episode that follows directly a wake episode lasting more than 60 s without being preceded by any cortical slow activity of more that 5 s during the 60 s.
Drug administration and experimental procedures in the mouse
After recovery from the surgery and habituation to the recording cables, each mouse was subjected to a recording session of two continuous days, beginning at 7 a.m. Administrations were performed at 6:45 p.m. just before lights-off (7:00 p.m.), since orexin-/- mice display narcoleptic attacks only during lights-off phase [Chemelli et al, 1999]. The order of administration was randomized. Polygraphic recordings were made immediately after administration and were maintained during the whole lights-off period (12 h). Two administrations were separated by a period of 7 days (washout). Mice (n=8 per batch) were orally treated by either modafmil (64 mg/kg) or modafinil (64mg/kg) and flecainide racemate (lmg/kg) or flecainide racemate alone (lmg/kg) or vehicle. 52. Results
Orexins (also known as hypocretins) are two hypothalamic neuropetides identified in 1998 [Sakurai et al, 1998; De Lecea L. et al, 1998]. Neurons containing orexins have been identified in the hypothalamic dorsolateral and peri-fornical areas, these neurons play a key role in behavioral arousal. A large body of evidence indicates that an orexin deficiency is responsible for the pathogenesis of human and animal narcolepsy [Lin et al, 1999; Chemelli et al, 1999]. It has been recently shown that the most major phenotypes of orexin KO mice are a behavior/motor deficit during waking and the occurrence, during the dark phase, of episodes of sleep onset REM (DREM, as known as SOREM) - defined on EEG, EMG and video recordings as sudden onset of paradoxical sleep directly from wakefulness [Anaclet et al, 2009]. Thus SOREM/DREM constitutes a main phenotype of murine narcolepsy which is frequently seen in narcoleptic patients [Lin et al, 20011]. Using this model, it was shown that modafinil allows DREM episodes to persist [Lin et al, 2008], a situation similar to that in the clinic in which modafinil improves excessive daytime sleepiness without clear effect in cataplexy.
Moreover, as disclosed on figure 6B, flecainide racemate (alone), at 1 mg/kg dose, has no effect on DREM cataplectic-like phenotype in narcoleptic Ox-/- mice.
However, and importantly, the results disclosed on figure 6A show that modafinil/flecainide combination decreases the occurrence of DREM episode.
Hence, flecainide and modafinil do not have any significant effect on a DREM cataplectic- like phenotype when used alone, whereas their combination importantly decreases the DREM cataplectic-like phenotype.
These results highlight the synergy existing between flecainide and modafinil, said synergy being due to the potentiation of the modafinil efficiency by flecainide, since no effect is seen with either modafinil or flecainide alone in narcoleptic mice. Exemple 6: Modafinil/R-flecainide is surprisingly more efficient than Modafinil/S- flecainide on DREM cataplectic-like phenotype in narcoleptic mice
The same materials and methods than in example 5 were used, except that the flecainide racemate has been replaced by the R- flecainide enantiomer. As disclosed on figure 7, R-flecainide enantiomer combined with modafinil is more efficient on DREM cataplectic-like phenotype in narcoleptic Ox-/- mice than the S- fiecainide enantiomer combined with modafinil.
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Claims

1. A therapeutic composition comprising flecainide and at least one psychotropic drug, wherein said psychotropic drug is modafmil.
2. The therapeutic composition according to claim 1, for use for treating excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine-Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, anti-psychotics...), mood disorders, anxiety disorders, schizophrenia, tinnitus, depression, malaise, dementia, bipolar disorder, obesity, hyperphagia, manic episode, obsessive-compulsive disorder, senility, dependence or addiction (to games, drugs, alcohol, tobacco, etc.), fecal or urinary incontinence, premature ejaculation, breathing difficulty and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post- myelitis, or to fibromyalgia.
3. The therapeutic composition of claims 1 or 2, for use for enhancing the memory of healthy subjects and/or for maintaining them awake for long-lasting periods of time.
4. The therapeutic composition of claims 1 or 2, for use for treating cataplexy in narcoleptic patients.
5. The therapeutic composition of any one of claims 1 to 4, wherein said flecainide is the R enantiomer of formula:
Figure imgf000043_0001
6. A combination product comprising flecainide and modafmil, for simultaneous, separated or staggered use for preventing and/or treating excessive daytime sleepiness (EDS), sleep disorders, insufficient sleep time, central sleep apnea, narcolepsy (with or without cataplexy), obstructive sleep apnea/hypopnea (SAHOS), idiopathic hypersomnia, Kleine- Levin syndrome, circadian rhythm disorders, shift work sleep disorder, jet-lag, disorders after sleep restriction or sleep deprivation (attention disorders, alertness disorders, sleepiness), restless legs syndrome (RLS) and Periodic Lim Movement Disorders (PLMD), insomnia, parasomnia, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), disorders commonly associated with somnolence or sleepiness (such as Parkinson disease, multiple sclerosis, stroke, neuromuscular disorders or structural brain disorders, respiratory disorders, chronic renal failure, liver failure, rheumatologic disorders), medication-induced somnolence (due to benzodiazepines, barbiturates, sleeping pills, antidepressants, anti-psychotics...), mood disorders, anxiety disorders, schizophrenia, tinnitus, depression, malaise, dementia, bipolar disorder, obesity, hyperphagia, manic episode, obsessive-compulsive disorder, senility, dependence or addiction (to games, drugs, alcohol, tobacco, etc.), fecal or urinary incontinence, premature ejaculation, breathing difficulty and fatigue, notably due to cancer, neurodegenerative disorders, menopause, traumatic brain injuries, viral infection or post-myelitis, or to fibromyalgia.
7. The combination product of claim 6, for use for enhancing the memory of healthy subjects and/or for maintaining them awake for long-lasting periods of time.
8. The combination product of claim 6, for use for treating cataplexy in narcoleptic patients.
9. The combination product of any one of claims 6 to 8, wherein said flecainide is the R enantiomer of formula:
Figure imgf000044_0001
In vitro use of flecainide as an anti-connexin agent.
In vitro use of claim 10, wherein said flecainide is the R enantiomer of formula:
Figure imgf000044_0002
12. In vitro use according to claim 10 or 11, for blocking one or more connexin molecule selected from the group consisting of: Connexin 23, Connexin 25, Connexin 26, Connexin 30, Connexin 30.2, Connexin 30.3, Connexin 31, Connexin 31.1, Connexin 31.9, Connexin 32, Connexin 36, Connexin 37, Connexin 40, Connexin 40.1, Connexin 43, Connexin 45, Connexin 46, Connexin 47, Connexin 50, Connexin 59, and Connexin 62.
13. In vitro use according to claim 10 or 11, for blocking one or more connexin molecule selected from the group consisting of: connexin 26, connexin 30, connexin 30.2, connexin 32, connexin 36, connexin 37, connexin 40, connexin 43, connexin 45, connexin 46 and connexin 47.
14. In vitro use according to claim 10 or 1 1, for blocking one or more connexin molecule selected from the group consisting of: connexin Cx40, connexin Cx26, connexin 30, connexin 32, and connexin 43.
15. Flecainide for use as an anti-connexin agent, for potentiating the effects of a psychotropic drug, preferably for increasing the efficacy and/or safety and/or the duration of action of a psychotropic drug.
16. Flecainide for use according to claim 15, wherein said psychotropic drug is selected from the group consisting of: GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors, and those having an effect on the hypocretin/orexin system.
17. Flecainide for use according to claim 15 or 16, wherein said psychotropic drug is selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride, modafmil and armodafmil.
18. Flecainide for use according to any of claims 15 to 17, for potentiating the effects, preferably the promnesiant effect and/or the awakening effect, of a psychotropic drug selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta-amino-benzenepropyl) carbamate mono- hydrochloride, modafmil and armodafmil.
19. Flecainide for use according to any of claims 15 to 18, for increasing the efficacy and/or the duration of action of a psychotropic drug selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta- amino-benzenepropyl) carbamate mono- hydrochloride, modafmil and armodafmil.
20. Flecainide for use according to any of claims 15 to 19, wherein said psychotropic drug is modafmil.
21. Flecainide for use according to any of claims 15 to 20, wherein said flecainide is the R enantiomer of formula:
Figure imgf000046_0001
22. A therapeutic composition comprising flecainide and at least one psychotropic drug, wherein said psychotropic drug is not flupirtine.
23. The therapeutic composition according to claim 22, wherein said psychotropic drug is selected from the group consisting of: GABAergic, dopaminergic, norepinephrinergic, serotoninergic, histaminergic, and glutamatergic effectors, and those having an effect on the hypocretin/orexin system.
24. The therapeutic composition according to any of claims 22 or 23, wherein said psychotropic drug is a psychotropic drug selected in the group consisting of: caffeine, mazindol, sodium oxybate, pitolisant, amphetamine, methylphenidate, (R)- (beta-amino- benzenepropyl) carbamate mono- hydrochloride, modafinil and armodafmil, preferably modafmil.
25. The therapeutic composition according to any of claims 22 or 23, wherein said flecainide is the R enantiomer of formula:
Figure imgf000046_0002
26. Flecainide for use as an anti-connexin agent, for treating a disorder selected from the group consisting of: wounds, migraines, infectious diseases, drug-induced liver injury, cytotoxicity induced by chemotherapeutic agents, and ischemia.
27. Flecainide for use according to claim 26, wherein said flecainide is the R enantiomer of formula:
Figure imgf000047_0001
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