Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/045—Hydroxy compounds, e.g. alcohols; Salts thereof, e.g. alcoholates
  • A61K31/047—Hydroxy compounds, e.g. alcohols; Salts thereof, e.g. alcoholates having two or more hydroxy groups, e.g. sorbitol
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
  • A61K31/194—Carboxylic acids, e.g. valproic acid having two or more carboxyl groups, e.g. succinic, maleic or phthalic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
  • A61K31/191—Carboxylic acids, e.g. valproic acid having two or more hydroxy groups, e.g. gluconic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
  • A61K31/195—Carboxylic acids, e.g. valproic acid having an amino group
  • A61K31/197—Carboxylic acids, e.g. valproic acid having an amino group the amino and the carboxyl groups being attached to the same acyclic carbon chain, e.g. gamma-aminobutyric acid [GABA], beta-alanine, epsilon-aminocaproic acid or pantothenic acid
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/185—Acids; Anhydrides, halides or salts thereof, e.g. sulfur acids, imidic, hydrazonic or hydroximic acids
  • A61K31/19—Carboxylic acids, e.g. valproic acid
  • A61K31/195—Carboxylic acids, e.g. valproic acid having an amino group
  • A61K31/197—Carboxylic acids, e.g. valproic acid having an amino group the amino and the carboxyl groups being attached to the same acyclic carbon chain, e.g. gamma-aminobutyric acid [GABA], beta-alanine, epsilon-aminocaproic acid or pantothenic acid
  • A61K31/198—Alpha-amino acids, e.g. alanine or edetic acid [EDTA]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/21—Esters, e.g. nitroglycerine, selenocyanates
  • A61K31/215—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids
  • A61K31/22—Esters, e.g. nitroglycerine, selenocyanates of carboxylic acids of acyclic acids, e.g. pravastatin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/40—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil
  • A61K31/403—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with one nitrogen as the only ring hetero atom, e.g. sulpiride, succinimide, tolmetin, buflomedil condensed with carbocyclic rings, e.g. carbazole
  • A61K31/404—Indoles, e.g. pindolol
  • A61K31/405—Indole-alkanecarboxylic acids; Derivatives thereof, e.g. tryptophan, indomethacin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0053—Mouth and digestive tract, i.e. intraoral and peroral administration
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0087—Galenical forms not covered by A61K9/02 - A61K9/7023
  • A61K9/0095—Drinks; Beverages; Syrups; Compositions for reconstitution thereof, e.g. powders or tablets to be dispersed in a glass of water; Veterinary drenches
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/06—Antimigraine agents

Definitions

• the present invention relates to the use of D beta-hydroxybutyric ( ⁇ ) acid or a metabolic precursor for the prevention or treatment of migraine or symptoms of migraine.
• Migraine is a complex, genetically heterogeneous, common and debilitating neurological disorder that affects approximately 15% of the world population. With a peak incidence during the most productive years of life, migraine not only causes much suffering, but also inflicts substantial costs on society: approximately € 18.5 billion per year in Europe alone. It is characterized by recurrent moderate to severe, typically throbbing and unilateral headache attacks that last between 4 - 72 h, which are aggravated by any kind of physical activity and accompanied by either photo-, phono-, or osmophobia, nausea or a combination of these.
• migraine a very heterogeneous disorder, divided into two major subgroups, based on the presence (migraine with aura (MA)) or absence (migraine without aura (MO)) of an aura, a phase of transient and reversible visual, sensory or motor disturbances that typically occurs up to one hour before the attack itself in one third of migraineurs.
• Migraines are much more than the headache (ictal) phase, as they are typically accompanied by neurological symptoms during a premonitory phase preceding the headache by up to 12 hours and a postdromal phase, which follows the migraine and can last hours or days. To date, the primary migraine pathogenic mechanisms are still largely unknown.
• migraine treatment options are limited and their mechanisms of action are also not completely understood. While the primary goals of preventative migraine treatment include reducing headache frequency and restoring function, an additional important goal may be the prevention of progression to chronic migraine. None of the prophylactic agents licensed to date (such as beta-blockers, anticonvulsants or antidepressants) are migraine-specific and most are associated with significant - often intolerable - side-effects. Furthermore, their migraine-preventive properties are moderate at most ( ⁇ 25% average reduction in migraine frequency). Hence, there is a huge medical need for developing alternative anti-migraine therapies. The objective of the present invention is to provide novel therapeutic agents for the treatment of migraine, which exhibit improved efficiency and decreased side-effects. Ketogenic diet / Endogenous elevation of KB and reduction in glucose
• KD ketogenic diet
• ketogenic substances such as middle chain triglycerides (MCTs), ketogenic amino acids, ⁇ or AcAc supplements and more recently keto esters ( ⁇ and/or AcAc esterified with one another). Dietary supplementation of KB themselves does not require the limitation of carbohydrate and protein, thus increasing the chance of compliance, particularly since carbohydrate diets are common in most cultures.
• ketogenic acids In comparison to the KD itself, the therapeutic efficacy of KB supplementation is less established to date. Studies in humans using MCTs suggest that those are safe, but in higher therapeutic doses not well tolerated due to strong gastrointestinal upset. Ketone esters have the problem of a very foul taste and while high blood ketone concentrations can be reached, most research has been conducted on gavaged animals. A direct administration of ketogenic acids is potentially dangerous, due to the possibility of acidosis following rapid absorption in the gastrointestinal tract.
• the objective of the present invention is to provide a new treatment option for migraine by exogenously raising blood KB levels in a safe way with improved palatability and reduced gastrointestinal distress, thereby increasing patient compliance.
• KB refers to ketone bodies.
• Ketone bodies are endogenous metabolites, which are produced by the liver from fatty acids released from adipose tissue in times of starvation, fasting, glucose deprivation or caloric restriction. They can be used as an alternative energy substrate to glucose by most tissues of the body, most notably the brain, which cannot metabolise any other energy substrate apart from glucose and KB.
• Endogenous KB include beta-hydroxybutyrate ( ⁇ ; also known as 3 betahydroxybyturate) and acetoacetate (AcAc).
• ⁇ beta-hydroxybutyrate
• AcAc acetoacetate
• MCTs middle chain triglycerides
• MCTs middle chain triglycerides
• other exogenous ketogenic substances have become available, such as ⁇ mineral salts or keto esters.
• ketogenic amino acid refers to an amino acid that can be degraded to Acetyl-CoA, the precursor of ketone bodies.
• Leucine and lysine are ketogenic amino acids that are exclusively ketogenic.
• Isoleucine, phenylalanine, tryptophan and tyrosine are ketogenic amino acids that are also glucogenic.
• ⁇ refers to beta-hydroxybutyric acid or beta- hydroxybutyrate, CAS No. 300-85-6.
• D- ⁇ refers to the D enantiomer of ⁇ .
• AcAc refers to acetoacetate, CAS No. 541-50-4.
• LL refers to L-leucine.
• LY refers to L-lysine
• KD ketogenic diet
• the term "mild to medium nutritional ketosis” refers to a concentration of blood ketone bodies of 0.4-4 mmol/l, which is achieved by a suitable nutrition.
• triglyceride refers to an ester derived from glycerol (CAS No. 56-81 -5) and three fatty acids.
• fatty acid refers to an aliphatic monocarboxylic acid comprising a chain of 4 to 28 carbon atoms.
• the chain can be saturated or unsaturated.
• free fatty acid refers to a fatty acid that is not bound to another molecule, e.g. glycerol.
• MCFA middle chain fatty acid
• MCT middle chain triglyceride
• triacetin refers to 1 ,2,3-triacetoxypropane, CAS No. 102-76-1 .
• the invention provides a compound for use in a method of treatment or prevention of migraine and/or symptoms thereof.
• the compound is selected from
• the metabolic precursor is selected from 1 ,3-butanediol (CAS No. 107 88 0) and triacetin (CAS No. 102-76-1 ).
• Formula (la) specifies 3-hydroxybutyl 3-hydroxybutanoate.
• Formula (lb) specifies (3-hydroxy-1 -methyl-propyl) 3-hydroxybutanoate.
• Formula (lc) specifies 3-(3-hydroxybutanoyloxy)butyl 3-hydroxybutanoate.
• Formula (II) specifies 3-(3-hydroxybutanoyloxy)butanoic acid.
• Formula (Ilia) specifies 3-hydroxybutyl 3-oxobutanoate.
• Formula (1Mb) specifies (3-hydroxy-1-methyl-propyl) 3-oxobutanoate.
• Formula (I lie) specifies 3-(3-oxobutanoyloxy)butyl 3-oxobutanoate.
• Formula (IV) specifies 3-(3-oxobutanoyloxy)butanoic acid.
• Formula (Va) specifies 2, 3-d i hydroxy propyl 3-oxobutanoate.
• Formula (Vb) specifies [2-hydroxy-1 -(hydroxymethyl)ethyl] 3-oxobutanoate.
• Formula (Vc) specifies [2-hydroxy-3-(3-oxobutanoyloxy)propyl] 3-oxobutanoate.
• Formula (Vd) specifies [3-hydroxy-2-(3-oxobutanoyloxy)propyl] 3-oxobutanoate.
• Formula (Ve) specifies 2,3-bis(3-oxobutanoyloxy)propyl 3-oxobutanoate.
• ⁇ , AcAc, the metabolic precursor of ⁇ or AcAc and the compound comprising an acetoacetyl- or 3-hydroxybutyrate moiety can be in the form of a pharmaceutically acceptable salt.
• the compound is a pharmaceutically acceptable ester of ⁇ .
• the compound is a pharmaceutically acceptable ester of AcAc.
• the metabolic precursor of D- ⁇ is an esterified molecule synthesised using D- ⁇ .
• the compound is an ester of ⁇ or AcAc with a monohydric, dihydric or trihydric alcohol.
• the compound is a pharmaceutically acceptable amid of ⁇ .
• the compound is a pharmaceutically acceptable amid of AcAc.
• the compound is selected from ⁇ , AcAc, or pharmaceutically acceptable salt thereof.
• the compound is selected from ⁇ , a metabolic precursor of ⁇ and a compound comprising a 3-hydroxybutyrate moiety and a pharmaceutically acceptable salt of said compounds.
• the compound is ⁇ or a pharmaceutically acceptable salt thereof. In certain embodiments, the compound is D- ⁇ or a pharmaceutically acceptable salt thereof.
• the D- ⁇ is administered in a form which also supplies AcAc.
• the D- ⁇ is administered as a metabolic precursor, which when administered to a human or animal body is metabolised, e.g. by liver, to produce D- ⁇ and AcAc, preferably in a physiological ratio.
• a physiologically acceptable salt of the compound according to the invention offers a way to improve palatability of the compound.
• the pharmaceutically acceptable salt is selected from a potassium salt, a sodium salt, a calcium salt, a magnesium salt, an arginine salt, a lysine salt, a histidine salt, an ornithine salt, a creatine salt, an agmatine salt, a citrulline salt, a methyl glucamine salt and a carnitine salt, possibly in conjunction with other ketogenic substances.
• the salt may also be a more complex pharmaceutically acceptable salt.
• the pharmaceutically acceptable salt is a combination of several of the aforementioned salts.
• the combination of salts comprises a mixture of a lysine salt and a calcium, potassium, magnesium and sodium salt. In certain embodiments, the combination of salts comprises a mixture of a lysine salt and a calcium, potassium, magnesium or sodium salt. In certain embodiments, the combination of salts comprises a lysine salt, a calcium salt, a potassium salt and/or a magnesium salt and/or a sodium salt.
• the combination of salts is a combination of a lysine salt and a mineral salt. In certain embodiments, the combination of salts is a combination of a lysine, a calcium and a sodium salt.
• the combination of salts is a combination of a calcium and a sodium salt.
• the salts may contain the isomer D- ⁇ or the racemic DL- ⁇ .
• the compound may be provided alone or in combination with other ketogenic substances. In certain embodiments, the compound is provided for
• the treatment or prevention has the effect of decreasing migraine attack frequency; decreasing migraine attack severity; decreasing the severity of migraine symptoms; preventing disease progression and/or preventing disease chronification.
• the symptoms of migraine include at least two of the following symptoms: medium to strong predominantly unilateral headache, light, noise and/or smell sensitivity, nausea or sickness, facial pain, sore eyes, balance disturbance, word finding difficulties, other neurological symptoms, such as sensory or motor disturbances, allodynia or any other of the features known to accompany, precede or follow a migraine attack, such as fatigue, nausea, cognitive difficulties, tiredness, ravenous hunger or thirst, reduced libido, depression, mania, mood swings, as well as changes in brain structure and function, such as white matter lesions or disturbances in functional connectivity.
• migraine attack such as fatigue, nausea, cognitive difficulties, tiredness, ravenous hunger or thirst, reduced libido, depression, mania, mood swings, as well as changes in brain structure and function, such as white matter lesions or disturbances in functional connectivity.
• the compound is to be administered before symptoms of a migraine attack, in particular those recited in the previous paragraph, occur.
• the daily dose to be administered is 3.5 g to 70 g. In certain embodiments, the daily dose to be administered is 5 g to 50 g. In certain embodiments, the daily dose to be administered is 10 g to 40 g. In certain embodiments, the daily dose to be administered is 10 g to 40 g. In certain embodiments, the daily dose to be administered is 10 g. In certain embodiments, the daily dose to be administered is 20 g.
• the inventors have examined the effect of various ketogenic substances, such as LL, LY, racemic and D- ⁇ on blood KB levels (pharmokokinetic), tolerability and migraine attack frequency. MCTs were not used due to known problems with tolerability and palatability.
• the D- ⁇ isomer led to a more than threefold elevation in blood ⁇ levels (up to 1.94 mmol/l) as compared to the racemic version. Levels remained elevated for over 4 hours. In addition, there was no concomitant drop in blood glucose, as observed with the racemic mix. Participants reported the taste was improved (less foul) and fewer gastrointestinal side-effects were observed, even with 2 months consumption. Efficacy data suggest that surprisingly as little as 10 g of D- ⁇ daily might match the efficacy of 40 g of the racemic mix, with an average of 68.5% reduction in migraine days with 10 g of D- ⁇ compared to 72% reduction with 40 g racemic ⁇ .
• the daily dose is divided into one to six doses. In certain embodiments, the daily dose is divided into two doses. In certain embodiments, the daily dose is divided into three doses.
• the daily dose is to be administered over a time period of at least one month. In certain embodiments, the daily dose is to be administered over a time period of at least 6 months. In certain embodiments, the daily dose is to be administered over a time period of at least one year. In certain embodiments, the daily dose is to be administered over a time period of 2 years.
• the administration of said compound to a subject causes elevation of blood ketone body (KB) levels to 0.3 mM to 6 mM. In certain embodiments, the administration of said compound to a subject causes elevation of blood ketone body (KB) levels to 0.4 mM to 4 mM. In certain embodiments, the administration of said compound to a subject causes elevation of blood ketone body (KB) levels to 1 mM to 4 mM.
• a pharmaceutical composition for use in the treatment or prevention of migraine and/or symptoms thereof comprising the compound according to the first aspect of the invention.
• the pharmaceutical composition can be a medicament or a nutritional aid.
• the pharmaceutical composition is a formulation or dosage form.
• the dosage form is a powder, tablet, gas or a solution.
• the pharmaceutical composition may comprise stevia and/or other artificial sweeteners (saccharin, acesulfame, suclarose), menthol, citrus, berry or other flavours.
• artificial sweeteners sacharin, acesulfame, suclarose
• menthol menthol
• citrus berry or other flavours.
• the pharmaceutical composition is a combination medicament further comprising an amino acid selected from the group comprising leucine, lysine, isoleucine, tryptophan, tyrosine and phenylalanine.
• the components of the combination medicament can be administered simultaneously or one after another.
• the content of the compound according to the first aspect of the invention in the pharmaceutical composition is at least 25% (w/w). In certain embodiments of this aspect of the invention, the content of the compound according to the first aspect of the invention in the pharmaceutical composition is at least 35% (w/w). In certain embodiments of this aspect of the invention, the content of the compound according to the first aspect of the invention in the pharmaceutical composition is 50% to 100% (w/w).
• the pharmaceutical composition is to be administered to a subject diagnosed with migraine suffering from 1 to 31 migraine days per months.
• the pharmaceutical composition is to be administered before symptoms of a migraine attack occur.
• the daily dose to be administered of said compound comprised in the pharmaceutical composition is 0.05 g/kg to 1 g/kg body weight, preferably 0.1 g/kg to 0.7 g/kg body weight, more preferably 0.2 g/kg to 0.4 g/kg body weight (depending on disease severity).
• the daily dose is divided into one to six doses, particularly into two or three doses.
• the daily dose is to be administered over a time period of at least one month, preferably at least 6 months, most preferably over 2 years.
• the pharmaceutical composition is formulated for oral administration. In certain embodiments of this aspect of the invention, the pharmaceutical composition is formulated for parenteral administration. In certain embodiments of this aspect of the invention, the pharmaceutical composition is formulated for any other form of conventional administration.
• the pharmaceutical composition is formulated as a powder for oral administration.
• the powder is dissolved in water prior to comsumption.
• the pharmaceutical composition is a drink.
• the administration of said pharmaceutical composition to a subject causes elevation of blood ketone body (KB) levels to 0.3 mM to 6 mM, particularly to 0.4 mM to 4 mM, more particularly to 1 mM to 4 mM.
• KB blood ketone body
• the inventors' results suggest that between 5 g to 70 g of KB, particularly 5 g to 40 g of ⁇ , more particularly 10 g to 20 g of ⁇ per patient per day are required to achieve this.
• the necessary elevation for migraine freedom will depend on disease severity (i.e. number of migraine days per months).
• a method of treatment or prevention of migraine and/or symptoms thereof comprising administration of the compound according to the first aspect of the invention or the pharmaceutical composition according to the second aspect of the invention to a subject in need thereof.
• the subject in need is suffering from 1 to 31 migraine days per month.
• the subject in need shows manifestation of at least two of the following symptoms of migraine: medium to strong predominantly unilateral headache, light, noise and/or smell sensitivity, nausea or sickness, facial pain, sore eyes, balance disturbance, word finding difficulties, other neurological symptoms, such as sensory or motor disturbances, allodynia or any other of the features known to accompany, precede or follow a migraine attack, such as fatigue, nausea, cognitive difficulties, tiredness, ravenous hunger or thirst, reduced libido, depression, mania, mood swings, as well as changes in brain structure and function, such as white matter lesions or disturbances in functional connectivity.
• migraine medium to strong predominantly unilateral headache, light, noise and/or smell sensitivity, nausea or sickness, facial pain, sore eyes, balance disturbance, word finding difficulties, other neurological symptoms, such as sensory or motor disturbances, allodynia or any other of the features known to accompany, precede or follow a migraine attack, such as fatigue, nausea, cognitive difficulties, tiredness, ravenous hunger or thirst, reduced libido, depression, mania, mood swings, as well as
• SEM standard error of the means
• Fig. 2 shows the pharmacokinetics of 10 g racemic beta-hydroxybutyrate ( ⁇ ) ante cibum on 5 migraine patients and its effect on glucose levels.
• ⁇ racemic beta-hydroxybutyrate
• ⁇ ante cibum
• ⁇ glucose levels
• ⁇ was given in powdered sodium-calcium-salt form dissolved in water on an empty stomach.
• Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• Fig. 3 shows the effect of 20 g ⁇ daily on days with migraine.
• Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• Fig. 4 A shows the dose dependent effect of 20 g ⁇ or 40 g ⁇ on days with migraine. Average number of migraine days (y-axis) at baseline (black) in 2 chronic migraineurs (20 or 22 migraine days/month) and the reduction in migraine days after 4 weeks of intervention with 20 g ⁇ (grey) and 40 g ⁇ (white dotted). Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• Fig. 4 B shows the dose response curve to 0, 20 and 40 g ⁇ daily (percent reduction in migraine days from baseline). Percent in reduction in migraine days from baseline (y-axis) after 4 weeks of 0 g ⁇ daily (0 g), after 4 weeks of 20 g ⁇ daily (20 g) and after 4 weeks of 40 g ⁇ daily (40 g) in 2 chronic migraineurs (20 or 22 migraine days/month). Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• Fig. 5 shows the pharmacokinetics of 10 g D-beta-hydroxybutyrate ( ⁇ ) ante cibum on 5 participants and its effect on glucose levels.
• D- ⁇ was given in powdered mixed mineral and lysine-salt form dissolved in water on an empty stomach.
• Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• the rise in blood glucose from 1 h onwards in the case of the racemic ⁇ corresponds to the intake of a mixed food breakfast (food intake indicated by the arrow) one hour after consumption of ⁇ , which was given to prevent potential hypoglycemia.
• Racemic ⁇ was given in powdered sodium-calcium-salt form, D- ⁇ was given in powdered mixed mineral and lysine-salt form, both dissolved in water on an empty stomach.
• Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Error bars depict the standard error of the means (SEM).
• Fig. 8 shows the effect of 10 g racemic ⁇ versus 10 g D- ⁇ daily on migraine frequency. Average number of migraine days (y-axis) at baseline (white) in 2 high-frequency migraineurs (17 and 10 migraine days/month) and the reduction in average monthly migraine days after 8 weeks of intervention with 10 g racemic ⁇ (grey) versus 10 g D- ⁇ (black). Blood ⁇ concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes. Examples
• L-leucine (LL) and L-lysine (LY) are the two completely ketogenic amino acids.
• unused ketogenic amino acids i.e. leucine or lysine
• KB unused ketogenic amino acids
• Precision Xtra® Precision Xtra®
• the patients were given 10 g racemic beta- hydro xybuty rate ( ⁇ ) orally dissolved in water in 3 different conditions: (1 ) post cibum (after meal) (2) ante cibum (before meal) (3) 1 hour before meal.
• Blood ⁇ and glucose concentrations were measured using a portable point-of-care blood ketone meter (Precision Xtra®) and matching test stripes at 5 points in time: 1 ) Baseline (directly before consumption), 2) 0.5 h after consumption, 3) 1 h after consumption, 4) 2 h after consumption, 5) 3 h after consumption and 6) 4 h after consumption.
• Glucose levels were measured at the same time as ⁇ , in order to examine the effect of ⁇ on glucose levels.
• Figure 2 B shows that the increase of ⁇ blood levels after 0.5 and 1 h is accompanied by a concomitant substantial drop in blood glucose levels.
• a mixed meal was provided and measurements continued.
• Those two chronic migraineurs (20 or 22 migraine days/month) where instructed to take 20 g racemic ⁇ daily for 4 weeks and after a 1 week washout period double the dose to 40 g ⁇ for the following 4 weeks.
• Migraine days were recorded for the duration of the intervention and patients were instructed to refrain from any other life-style or medication changes.
• Glucose levels were measured at the same time as ⁇ , in order to examine the effect of D- ⁇ on glucose levels.
• the high average elevation of ⁇ blood levels to almost 2 mmol/l is not accompanied by a concomitant change in blood glucose levels, which seem to stay completely stable throughout the 4 hours (see Figure 5B). This is in contrast to the drop in blood glucose patients experienced with racemic ⁇ (see Figure 6); it did not seem to occur when consuming the same amount of D- ⁇ .
• Endpoint(s) Primary endpoint Change from baseline in days with migraine during last 4 weeks of intervention
• Exploratory endpoint(s) Change in markers of markers of oxidative stress, gene expression changes, genetic profile, peak KB and blood glucose level change from baseline
• the inventors propose the use of D- ⁇ , or a metabolic precursor thereof, alone or in combination with other ketogenic substances, in the manufacture of a medicament or nutritional aid for the treatment of prevention or migraine or symptoms thereof.
• verum For feasibility reasons and mineral load, patients in the phase 2 trial described below are dosed with 18 g ⁇ in mineral salt form. In the following the study medicament will be referred to as verum.
• the study is a double-blind, randomised, placebo-controlled, safety, tolerability and efficacy trial with one active intervention ( ⁇ ) and one placebo group.
• 45 medium- to high-frequency migraineurs (5-14 migraine days/months) aged between 18 and 65 years are included. Participants are required to keep a detailed headache diary (www.myheadache.ch), for the entire duration of the study.
• the study period will begin with a 4 week run-in period, during which there is no investigational treatment (see figure 1 ).
• the purpose of the run-in period will be observation for baseline comparison.
• the run-in period will be followed by a 12 week intervention period, when the subjects will receive the study medicament or matched placebo (three times a day).
• the first intervention period will be followed by an 4 week wash-out period and a second 4 week run-in period during which there will be no further intervention. This will be followed by the second intervention period, when the participants will "cross-over", i.e. received the alternative treatment of the first intervention (if they received verum the first 12 weeks, they will receive placebo the second 12 weeks or the other way round).
• Migraine Disability Questionnaire and Headache Impact Test German versions, standard questionnaires for assessing the extent of migraine related disability
• Routine laboratory renal and liver function tests, electrolytes, full blood count, C reactive protein, serum cholesterol, triglycerides, serum proteins, albumin, glucose, Hbal c, insulin, Cortisol, lactate, TSH, FT4 and FT3)
• Blood draw (1 x EDTA, 1 x PAXgene) at each time point for genetic profiling and gene expression analysis using microarrays.
• oxidative and nitrosative stress markers malondialdehyde (MDA), carbonylated proteins, nitrite, nitrotyrosine
• serum cytokine measurements including, but not limited to: IFNy, IL-1 ⁇ , IL-2, IL-4, IL-5, IL-6, IL-10, MCP-1 , TNFa& ⁇ , TGF- ⁇ 1 ).
• the primary objective is to show in moderate- to high-frequency episodic migraineurs the superiority of the verum to placebo with regard to the reduction in migraine days per 4 weeks from baseline to the last 4 weeks of intervention.
• a detailed pen and paper headache diary (similar to www.myheadache.ch) is used to assess the reduction in monthly migraine frequency (i.e. the primary outcome). Reduction of days with migraine (assessed with headache diaries) is the standard primary efficacy outcome measure in RCTs on migraine prevention.
• the headache diary is available as IOS and android app and is easy to use. Migraine related features such as attack begin, length of attack (in hours), severity of attack (0-10), medication taken (amount and dose), associated symptoms and potential trigger factors are recorded.
• Rate of treatment responders defined as >50% reduction in migraine days.
• the secondary outcomes will be measured using the headache diary (myheadache.ch) and the questionnaires, which will be provided as paper copy during the baseline visit, the visit after the 12 weeks interventions and after the wash-out period respectively.
• MDA malondialdehyde
• carbonylated proteins nitrate, nitrite, nitrotyrosine
• SNPs Genetic profile
• Routine laboratory renal and liver function tests, electrolytes, full blood count, C reactive protein, serum cholesterol, triglycerides, serum proteins, albumin, glucose, Hbal c
• the vital parameters blood pressure, heart rate, weight, height
• flyers publicly displayed in the waiting room of the neurology and general medicine department, as well as the University Library. An announcement similar to the flyer is posted on the webpages of the University of Basel "Marktplatz" dedicated to research studies (https:// notice.unibas.ch/nc/inserate/kategorie/job- in-studien/) as well as the USB Website respectively (https://www.unispital-basel.ch/lehre- utz/studieninserate/).
• Migraine is a prevalent disorder and the inventors already have a contingent of 300 patients willing to take part in research on new forms of migraine inventions. Additionally, the co-applicant has access to a big patient pool through his Headache Clinic and together with the neurology department of the USB approximately 100 patients meet inclusion criteria. The inventors are not anticipating any problems with the recruitment of 50 eligible patients.
• NSAIDs non-steroidal anti-inflammatory drugs
• the primary objective is to show in moderate- to high-frequency episodic migraineurs the superiority of the ketogenic supplement to placebo with regard to the reduction in migraine days per 4 weeks from baseline to the last 4 weeks of intervention.
• the primary endpoint, number of migraine days in the last four weeks of treatment, will be measured twice for each patient, once after the placebo treatment period and once after the verum treatment period.
• the primary analysis will be performed using a linear, mixed effects regression model.
• the primary model will include the primary endpoint - number of migraine days in the last four weeks of treatment - as response variable, the respective baseline value as covariate, treatment (verum vs placebo) and period (first vs. second) as main effects, the two interaction terms "treatment x period” and "treatment x baseline value", and patient as random effect. A significant interaction term between treatment and period would indicate a carry-over effect. Since it is not known how strong the primary end- point correlates with the baseline value, it is not known whether including the base- lines as covariates in the model is sensible. Therefore, the above described primary model will be compared to models without interaction term "treatment x baseline value” and without both interaction term "treatment x baseline value” and baseline value as covariate by means of Akaike's Information Criterion (AIC).
• AIC Akaike's Information Criterion
• sex male/female
• migraine with aura yes/no
• high 10-14 days/4 weeks
• Sensitivity analysis The main analysis, without subgroup analyses, will be repeated on the PP set. Potential deviations from the results of the ITT analysis will be described in detail. Secondary endpoints will be analysed as described for the primary endpoint with the corresponding baseline measure as covariate, if available. A further exploratory objective is to examine the correlation of BK levels with the number of migraine days per 4 weeks from baseline to the last 4 weeks of the follow-up period. The time courses of both variables will be graphically displayed and inspected. Further, the cross-correlation will be calculated. Statistical considerations for the other exploratory objectives (gene expression changes, changes in markers of oxidative stress and potential genetic basis underlying treatment response) are outlined below.

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