WO2022152856A1

WO2022152856A1 - Methods and compositions for treating ischaemia in a subject

Info

Publication number: WO2022152856A1
Application number: PCT/EP2022/050759
Authority: WO
Inventors: Joan Montaner Villalonga; Alba SIMATS ORIOL; Laura RAMIRO PASCUAL; Laura ARTIGAS MATILLA; Raquel VALLS BELL; Teresa Sardón Urtiaga
Original assignee: Fundació Hospital Universitari Vall D'hebron - Institut De Recerca; Anaxomics Biotech, S.L.
Priority date: 2021-01-15
Filing date: 2022-01-14
Publication date: 2022-07-21

Abstract

The present application refers to alpha-1 antitrypsin for use in combined therapy for the treatment of ischaemia, wherein the combined therapy comprises the simultaneous, sequential or separate administration within a therapeutic interval of alpha-1 antitrypsin and a tumor necrosis factor alpha inhibitor.

Description

Methods and compositions for treating ischaemia in a subject

This application claims the benefit of European Patent Application EP21382021.0 filed on 15.01.2021.

Field of the invention

Provided herein are methods and compositions related to treating ischaemia in a subject by administering to the subject a composition comprising alpha-1 antitrypsin (A1AT) and a Tumor Necrosis Factor alpha (TNF-o ) inhibitor.

Background of the invention

Stroke accounts for more than 6 million deaths per year worldwide and is the first cause of chronic and severe disability in industrialized countries. On average, once every 4 minutes someone dies of a stroke and more than 5 million stroke survivors remained permanently disabled. With the actual increase in the life expectancy, it is even estimated that stroke-related disability will become more prevalent in the coming years, which overall supposes devastating effects that range from a decrease in patients' quality of life and increased mortality to large-scale economic consequences in the healthcare systems (World Health Organization).

The only approved therapeutic options for ischemic stroke are the intravenous administration of rt-PA and the mechanical removal of the clot with stent-retriever devices. Due to medical contraindications, these thrombolytic strategies are applied to less than a 15% of stroke patients. Moreover, patients treated with rt-PA fail to re-canalize the occluded brain artery in more than 50% of the cases, and approximately 40% of recanalized patients are still expected to present persistent poor outcome after stroke onset. Stroke-related long-term disabilities comprise numerous physical limitations, which causes social interaction problems and limited participation in economic life and family responsibilities. The growing demand for stroke care and the limited resources available for healthcare are also becoming a major socio-economic concern worldwide.

To overcome this devastating disease, there is an urgent need to seek ways to identify neuroprotective agents as adjunct therapies to actual recanalization strategies. Neuroprotective treatments might ideally reduce the progression of the disease from a very early stage, and consequently reduce stroke-related mortality and improve freedom from disability among stroke survivors. Ideally, these drugs would be safe and effective and might be given at the ambulance while transferring the stroke patient to the hospital.

Summary of the invention

The present invention is confronted with the problem of identifying potential neuroprotective drug combinations to treat stroke and other ischemia-related conditions. In this sense and as shown in the examples included in the present specification, the inventors found that combinations formed by alpha-1 antitrypsin (A1AT) and a Tumor Necrosis Factor alpha (TNF-o) inhibitor have surprisingly good neuroprotective effects. The inventors have validated the neuroprotective effect of the selected drug combination and found a solid synergic effect in front of single drug treatment. For example, the combination of A1 AT with TNF-o inhibitor showed efficacy by protecting mouse brains from cerebral ischaemia, since it showed a reduction of 34.88% in the infarct volume compared to the vehicle (p<0.0001 , Figure 6A). However, none of the drugs when given alone was capable of reducing the infarct volume compared to vehicle group. Moreover, drug combination showed a significant reduction of infarct volume when compared to A1 AT alone (p=0.027) and TNF-o inhibitor alone (p=0.0003) (Figure 6A). Importantly, animals receiving the drug combination also showed a significant improvement in functional status after stroke (Figures 11 , 12 and 16).

Therefore, provided herein are methods and compositions related to treating and/or preventing ischaemia and/or for slowing or reversing ischaemia by administering to a subject in need thereof (e.g., a subject with ischemic stroke) A1 AT in combination with at least one TNF-o inhibitor. Provided herein are also methods and compositions to afford protection of neuronal cells by administering to a subject in need thereof (e.g., a subject with ischemic stroke) A1 AT in combination with at least one TNF-o inhibitor.

Thus, a first aspect of the invention refers to A1 AT for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor. This aspect may be reformulated as use of A1 AT for the manufacture of a neuroprotective agent, wherein said neuroprotective agent is administered simultaneously, sequentially or separately within a therapeutic interval with a TNF-o inhibitor. Also disclosed herein is a method of neuroprotection, said method comprising administering to a subject in need thereof a therapeutically effective amount of A1 AT in combination with a TNF-o inhibitor, wherein the A1AT and the TNF-o inhibitor are administered simultaneously, sequentially or separately within a therapeutic interval.

A second aspect of the invention provides A1 AT for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor. This aspect may also be reformulated as use of A1AT for the manufacture of a medicament for the treatment of ischaemia, wherein said treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor. Also disclosed herein is a method of treatment of ischaemia, said method comprising administering to a subject in need thereof a therapeutically effective amount of A1 AT in combination with a TNF-o inhibitor, wherein the A1 AT and the TNF-o inhibitor are administered simultaneously, sequentially or separately within a therapeutic interval.

A third aspect of the invention refers to a combination of A1 AT and a TNF-o inhibitor for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration of the A1AT and the TNF-o inhibitor. This aspect may be reformulated as use of A1AT and a TNF-o inhibitor in the preparation of a neuroprotective agent for combined therapy, wherein the combined therapy comprises administering A1 AT and a TNF-o inhibitor simultaneously, sequentially or separately within a therapeutic interval. Also disclosed herein is a method of neuroprotection by combined therapy, said method comprising administering to a subject in need thereof a therapeutically effective combination of A1AT and a TNF-o inhibitor, wherein the A1 AT and the TNF-o inhibitor are administered simultaneously, sequentially or separately within a therapeutic interval.

A fourth aspect refers to a combination of A1 AT and a TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration of the A1 AT and the TNF-o inhibitor. This aspect may be reformulated as use of A1 AT and a TNF-o inhibitor in the preparation of a medicament for the treatment of ischaemia, wherein said treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1 AT and a TNF-o inhibitor. Also disclosed herein is a method of treatment of ischaemia, said method comprising administering to a subject in need thereof a therapeutically effective combination of A1AT and a TNF-o inhibitor, wherein the A1AT and the TNF-o inhibitor are administered simultaneously, sequentially or separately within a therapeutic interval.

A fifth aspect refers to a TNF-o inhibitor for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration within a therapeutic interval of TNF-o inhibitor and A1 AT. This aspect may be reformulated as use of a TNF-o inhibitor for the manufacture of a neuroprotective agent, wherein said neuroprotective agent is administered simultaneously, sequentially or separately within a therapeutic interval with A1 AT. Also disclosed herein is a method of neuroprotection, said method comprising administering to a subject in need thereof a therapeutically effective amount of a TNF-o inhibitor in combination with A1 AT, wherein the TNF-o inhibitor and the A1 AT are administered simultaneously, sequentially or separately within a therapeutic interval.

A sixth aspect of the invention provides a TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of TNF-o inhibitor and A1AT. This aspect may also be reformulated as use of a TNF-o inhibitor for the manufacture of a medicament for the treatment of ischaemia, wherein said treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of TNF-o inhibitor and A1 AT. Also disclosed herein is a method of treatment of ischaemia, said method comprising administering to a subject in need thereof a therapeutically effective amount of a TNF-o inhibitor in combination with A1 AT, wherein the TNF-o inhibitor and the A1 AT are administered simultaneously, sequentially or separately within a therapeutic interval.

A seventh aspect of the invention refers to pharmaceutical compositions which comprise a therapeutically- effective amount of A1 AT and a therapeutically-effective amount of at least one TNF-o inhibitor, formulated together with one or more pharmaceutically acceptable excipients, carriers and/or diluents.

In an eight aspect, the present invention refers to a kit of parts wherein said kit comprises pharmaceutically acceptable compositions which comprise a therapeutically-effective amount of A1 AT, formulated together with one or more pharmaceutically acceptable excipients, carriers and/or diluents, and a further pharmaceutically acceptable composition which comprises a therapeutical ly-effective amount of at least one TNF-o inhibitor, formulated together with one or more pharmaceutically acceptable excipients, carriers and/or diluents.

Brief Description of Drawings

Figure 1. Schematic representation of the experimental design. The starting material was a manually curated list of key proteins in stroke from the bibliography, from which a biological map of the disease was constructed. Using TPMS, network static maps were converted into topological maps associated with mathematical equations. Proteomics and transcriptomics data from human brain from ischemic stroke patients were used to enrich the mathematical model and to build a set of restrictions collated into a truth table, which all generated models had to fulfill. Drug repositioning strategy was used to search for combinations of FDA- approved drugs from the DrugBank.

Figure 2. Experimental design to evaluate safety outcome of the drug combination administration.

Figure 3. Experimental design to evaluate neuroprotective potential of A1AT+inhibitor of murine TNF-o combination.

Figure 4. A1 AT+inhibitor of murine TNF-o combination. (A) Body weight of animals in each group is indicated in the panel. (B) Biochemical parameters analyzed in blood samples. Abbreviations: AST: Aspartate transaminase, ALT: Alanine transaminase, CK: creatine kinase.

Figure 5. Efficacy evaluation of the A1 AT+inhibitor of murine TNF-o combination. (A) Infarct volumes (%) of animals treated with vehicle (n=67), drug combination (n=14), TNF-o inhibitor (n=8) and A1AT (n=7) 24 hours after cerebral ischemia. Mean ± SEM is shown. (B) Grip strength test measurements performed before MCAO surgery and 24h after surgery. Histograms represent strength for left and right forepaws, data were assessed in grams and converted in % normalized for each mouse with the corresponding baseline values. Mean ± SEM is shown, p-value is indicated.

Figure 6. Effect of infliximab+A1 AT and etanercept+A1 AT combinations on the rt-PA-related clot lysis. (A) Representation of the clot lysis profile showing administration time-point. (B) Clot lysis rate after A1 AT+Infliximab administration. (C) Clot lysis rate after A1AT+Etanercept administration. (D) Clot area parameters after A1 AT+Infliximab administration. (E) Clot area parameters after A1 AT+Etanercept administration.

Figure 7. Experimental design to evaluate efficacy of the combinations after cerebral ischemia in rats. Figure 8. Body weight loss (% from baseline) measured 72h after combinations administration in ischemic rats; n=8 vehicle; n=7 A1 AT+infliximab; n=8 A1AT+etanercept. Data expressed as Mean ± SD.

Figure 9. Infarct volume expressed as % of ischemic hemisphere and determined in T2W-images at 24h after ischemic stroke in the different experimental groups. n=8 vehicle; n=7 A1 AT+infliximab; n=8 A1AT+etanercept. Data expressed as Mean ± SD.

Figure 10. Motor-neurological score at different time points before (basal) and after cerebral ischemia induction in all experimental groups. n=8 vehicle; n=7 A1 AT+infliximab; n=8 A1AT+etanercept. Data expressed as Mean±SD. Multiple comparison corrected by Bonferroni.

Figure 11. Behavioural score at different time points before (basal) and after cerebral ischemia induction in all experimental groups. n=8 vehicle; n=7 A1 AT+infliximab; n=8 A1AT+etanercept. Data expressed as Mean±SD. Multiple comparison corrected by Bonferroni.

Figure 12. Experimental design to evaluate deleterious effects of the combinations after intracerebral hemorrhage in rats.

Figure 13. Body weight loss (% from baseline) in all the experimental groups at 72h after collagenase injection. Data are expressed as percentage from baseline weight (Mean±SD). n=8 for each group.

Figure 14. Hemorrhage volume expressed as % of hemorrhagic hemisphere determined in T2W-MRI images at 24h after collagenase injection in the different experimental Hemorrhagic Stroke groups; n=8 for each group.

Figure 15. Motor-neurological scores at different time points before (basal) and after collagenase injection in all experimental groups. Data expressed as Mean±SD. Multiple comparison corrected by Bonferroni; All results at all times are different to their respective Baseline.

Figure 16: Disposition of samples in the assay plates in the assay for determination of the Relative Potency of an Anti-TNF Monoclonal Antibody (mAb) by Neutralizing TNF.

Figure 17: Dose-response curve in the assay for determination of the Relative Potency of an Anti-TNF Monoclonal Antibody (mAb) by Neutralizing TNF. Anti-TNFo mAb concentration versus luminescence (cell viability) is depicted. A fourth parameter equation describing the anti-TNFo protection of mAbs was used as a model. EC50 is the concentration of mAb that can neutralize the amount of TNFo that cause 50% cell death in each assay, exemplified in the graph as the change in slope. Bars describe the standard deviation of luminescence for each mAb concentration, / represents anti-TNFo Ab concentration and is depicted as a logarithmic function in ng/mL, while y represents the luminescence response in arbitrary luminescence units. Figure 18: Mathematical equation used for calculating the EC50s and their values in the assay for determination of the Relative Potency of an Anti-TNF Monoclonal Antibody (mAb) by Neutralizing TNF. EC50 values, or C parameters, have their uncertainty depicted as standard error. A comparison of EC50s between the sample and reference results of relative potency is also depicted. The confidence interval is calculated with an o = 0.05.

Detailed description of the invention

Before describing the present invention in detail, it is to be understood that this invention is not limited to particular administration modes, patient populations, and the like, as such may vary, as will be apparent from the accompanying description and figures.

Definitions

All terms as used herein in this application, unless otherwise stated, shall be understood in their ordinary meaning as known in the art. Other more specific definitions for certain terms as used in the present application are as set forth below and are intended to apply uniformly through-out the specification and claims unless an otherwise expressly set out definition provides a broader definition.

It must be noted that, as used in this specification and the intended claims, the singular forms "a,” "an,” and "the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a drug” includes a single drug as well as two or more of the same or different drugs, reference to "an optional excipient” refers to a single optional excipient as well as two or more of the same or different optional excipients, and the like.

"Pharmaceutically acceptable excipient or carrier” refers to an excipient that may optionally be included in the compositions of the invention and that causes no significant adverse toxicological effects to the patient.

"Pharmaceutically acceptable salt” includes, but is not limited to, amino acid salts, salts prepared with inorganic acids, such as chloride, sulfate, phosphate, diphosphate, bromide, and nitrate salts, or salts prepared from the corresponding inorganic acid form of any of the preceding, e.g., hydrochloride, etc., or salts prepared with an organic acid, such as malate, maleate, fumarate, tartrate, succinate, ethylsuccinate, citrate, acetate, lactate, methanesulfonate, benzoate, ascorbate, para-toluenesulfonate, palmoate, salicylate and stearate, as well as estolate, gluceptate and lactobionate salts. Similarly salts containing pharmaceutically acceptable cations include, but are not limited to, sodium, potassium, calcium, aluminum, lithium, and ammonium (including substituted ammonium).

"Active molecules” or "active agents” as described herein include A1 AT and a TNF-o inhibitor. "Substantially” or "essentially” means nearly totally or completely, for instance, 95% or greater of some given quantity.

"Optional” or "optionally” means that the subsequently described circumstance may or may not occur, so that the description includes instances where the circumstance occurs and instances where it does not.

The terms "subject”, "individual” or "patient” are used interchangeably herein and refer to a vertebrate, preferably a mammal. Mammals include, but are not limited to, murines, rodents, simians, humans, farm animals, sport animals and pets. The terms "pharmacologically effective amount” or "therapeutically effective amount” of a composition or agent, as provided herein, refer to a nontoxic but sufficient amount of the composition or agent to provide the desired response, such as a reduction or reversal of ischaemia. The exact amount required will vary from subject to subject, depending on the species, age, and general condition of the subject, the severity of the condition being treated, the particular drug or drugs employed, mode of administration, and the like. An appropriate "effective” amount in any individual case may be determined by one of ordinary skill in the art using routine experimentation, based upon the information provided herein.

The term "about”, particularly in reference to a given quantity, is meant to encompass deviations of plus or minus five percent.

The term "neuroprotection” is understood as protecting neurons or neural cells from damage or cell death. In particular, neuroprotection may be understood as protecting neurons or neural cells from damage or cell death, for example, after ischemia. An agent that effects neuroprotection is a "neuroprotective agent”. As will be evident to the skilled person in the field of the invention, neuroprotection may be achieved by administering the neuroprotective agent before or after the ischemic event (Ayuso and Montaner, "Advanced neuroprotection for brain ischemia: an alternative approach to minimize stroke damage”, Expert Opinion on Investigational Drugs Volume 24, 2015 - Issue 9, pages 1137-1142. DOI: 10.1517/13543784.2015.1065040). Other non-limitative examples of conditions that would benefit from neuroprotection in the sense of the present invention are neurodegenerative diseases such as such as Alzheimer's disease.

"Treatment” or "treating” ischaemia or ischemia related disorders includes a prophylactic treatment before the clinical onset of the disease or a therapeutic treatment after the clinical onset of the disease and may be achieved by arresting the development or reversing the symptom of any of these diseases.

The present invention is for protecting neurons or neuronal cells from damage or cell death, in particular, as a result of an ischemic event. Thus the invention is for the treatment of ischaemia or ischemic-related disorders, are based upon administration of the following molecules: A1AT and a TNF-o inhibitor.

Alpha-1 -antitrypsin or a 1 -antitrypsin (A1 AT, A1 A, or AAT) is a protein belonging to the serpin superfamily. It is encoded in humans by the SERPINA1 gene. A protease inhibitor, it is also known as alphal-proteinase inhibitor (A1 PI) or alphal-antiproteinase (A1AP) because it inhibits various proteases (not just trypsin). A1AT is a protein that was initially named "antitrypsin" because of its ability to bind and irreversibly inactivate the enzyme trypsin in vitro covalently. Trypsin, a type of peptidase, is a digestive enzyme active in the duodenum and elsewhere. The term alpha-1 refers to the protein's behavior on protein electrophoresis. On electrophoresis, the protein component of the blood is separated by electric current. There are several clusters, the first being albumin, the second being the alpha, the third beta and the fourth gamma (immunoglobulins). The non-albumin proteins are referred to as globulins. The alpha region can be further divided into two sub-regions, termed "1" and "2". A1AT is the main protein of the alpha-globulin 1 region. Another name used is alpha-1 proteinase P01009 inhibitor (o1 -PI). Its sequence is available in Uniprot database with the reference code (sequence version 3). It is primarily expressed as a precursor protein of 418 amino acids which contains a 24 amino acid signal peptide. The mature protein is a single polypeptide chain of 394 amino acids and three carbohydrate side chains linked to asparagine residues (Proteomics 6:3369- 3380(2006)). In most embodiments, the therapeutic combinations according to the present invention contain the mature protein. A1 AT in the sense of the present invention encompasses plasma-derived A1AT, as well as recombinant A1 AT. A1 AT is commercially available from several sources, for example, under the tradenames Prolastin®, Prolastin®-C, Prolastin®-C Liquid and Lynspad™ from Grifols, Aralast™ and Glassia® from Takeda, or Respreeza® and Zemaira® from CSL. In particular embodiments, the A1AT is selected from Prolastin®, Prolastin®-C, and Prolastin®-C Liquid. In more particular embodiments, the A1 AT is Prolastin®-C. The CAS registry number for human A1 AT is 9041-92-3.

Tumor necrosis factor alpha (TNF-a, TNFa, TNFa, cachexin, or cachectin, or simply TNF - tumor necrosis factor -) is a cell signaling protein (cytokine) involved in systemic inflammation and is one of the cytokines that make up the acute phase reaction.

A TNF-a inhibitor is a pharmaceutical drug that suppresses the physiologic response to TNF-a. TNF-a inhibitors are well-known in the state of the art. Illustrative non-limitative examples of these inhibitors are antibodies such as Remicade® ("Infliximab”, CAS number: 170277-31-3), Humira® ("Adalimumab”, CAS number: 331731-18-1), Simponi® ("Golimumab”, CAS number: 476181-74-5), Cimzia® ("Certolizumab pegol”, CAS number: 428863-50-7), and also fusion proteins such as Enbrel® ("Etanercept CAS number: 185243-69- 0”). Small drugs that have been disclosed as having TNF-a inhibitor activity are also contemplated herein as TNF-a inhibitors. Illustrative non-limitative examples of said other small drugs are Pletal® (“cilostazol", CAS number 73963-72-1), Trental® ("pentoxifylline”, CAS number 6493-05-6), Zyntabac® ("bupropion”, CAS number 34911-55-2), Thalomid® ("Thalidomide ", CAS number: 50-35-1), and thalidomide derivatives such as Revlimid® ("lenalidomide”, CAS number: 191732-72-6) and Pomalyst® ("pomalidomide”, CAS number: 19171-19-8). All the above inhibitors have been authorized by the European Medicines Agency (EMA). All the technical information about doses and routes of administration can be obtained from EMA's authorizations.

Other illustrative, non-limitative TNF-a inhibitors contemplated herein are further antibodies such as Afelimomab (CAS number: 156227-98-4), CDP 571 (Humicade, CAS number: 336128-48-4), CytoFab (CAS number: 736982-58-4), as well as further proteins or fusion proteins such as Pegsunercept (CAS number: 330988-75-5), lenercept (CAS number: 156679-34-4), Onercept (CAS number: 199685-57-9), cTfRMAb- TNFR, XPro1595 (CAS number: 2489785-77-3), DPH-067517 (TNF-o converting enzyme inhibitor).

Methods to determine whether a compound is a TNF-o inhibitor are well known in the art. In the sense of the present invention, the TNF-o inhibitory activity may be determined as disclosed by Tierrablanca-Sanchez et al (J. Vis. Exp. (127), e55376, doi: 10.3791/55376 (2017)).

A reference to any one or more of the herein-described drugs, in particular alpha-1 -antitrypsin and TNF-o inhibitors is meant to encompass, where applicable, any and all enantiomers, mixtures of enantiomers including racemic mixtures, prodrugs, precursors, pharmaceutically acceptable salt forms, hydrates (e.g., monohydrates, dihydrates, etc.), solvates, irrelevant mutations, glycosylation variants, and different physical forms. Also, a reference to the herein described biologicals, for example, infliximab or etanercept, is meant to encompass, where applicable, any and all of the corresponding biosimilars. For example, a reference to infliximab encompasses its biosimilars, such as, Avsola®, Inflectra®, Remsima®. A reference to adalimumab encompasses biosimilars such as Amgevita®, Imraldi®, Hyrimoz®, Hulio® and PF-06410293. A reference to etanercept encompasses biosimilars such as Erelzi® and Eticovo®.

In some embodiments, the TNF-o inhibitor is a monoclonal or polyclonal antibody such as those disclosed above. In other embodiments, the TNF-o inhibitor is a protein or a fusion protein such as those disclosed above. In other embodiments, the TNF-o inhibitor is a small molecule such as those disclosed above.

In some embodiments, the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept. In one particular embodiment the TNF-o inhibitor is infliximab. In another particular embodiment the TNF-o inhibitor is etanercept. In another particular embodiment the TNF-o inhibitor is adalimumab. In another particular embodiment the TNF-o inhibitor is certolizumab pegol. In another particular embodiment the TNF-o inhibitor is golimumab.

The invention refers to combination therapies for use in the treatment of ischaemia. Said treatment may be a prophylactic treatment before the clinical onset of the disease or a therapeutic treatment after the clinical onset of the disease.

The combination therapy may include sequential, simultaneous, separate, or co-administration of the above compounds of the invention, wherein the therapeutic effects of the first administered has not entirely disappeared when the subsequent compounds are administered. In some embodiments of the first to sixth aspects of the invention the combination is the simultaneous or sequential administration of A1 AT and at least one TNF-o inhibitor to the subject. In other embodiments, the combination is the separate administration of the compounds within a therapeutic interval, i.e., wherein the therapeutic effects of the first administered has not entirely disappeared when the subsequent compounds are administered. In one embodiment of the first to sixth aspects of the invention the combination is A1 AT with infliximab. In another embodiment the combination is A1 AT with etanercept. In another embodiment the combination is A1AT with adalimumab. In another embodiment the combination is A1AT with certolizumab pegol. In another embodiment the combination is A1 AT with golimumab.

Prophylactic treatment may be desired in particular situations, for example, before a surgical intervention or in patients that are at high risk of suffering from stroke. Thus, in one embodiment the combinations are for prophylactic treatment. In other embodiments the combinations are for therapeutic treatment after the clinical onset of the disease or after the ischemic event.

Compositions

In some embodiments the agents described herein, particularly, A1 AT and TNF-o inhibitor, for example, infliximab, can be administered as such, or administered in mixtures with pharmaceutically acceptable carriers and can also be administered in conjunction with other agents. Conjunctive therapy thus includes sequential, simultaneous and separate, or co-administration of the above mentioned compounds of the invention, wherein the therapeutic effects of the first administered has not entirely disappeared when the subsequent compounds are administered.

Provided herein is also a composition comprising A1 AT and TNF-o inhibitor. In one embodiment it is provided a composition comprising A1 AT and infliximab. In another embodiment the composition comprises A1 AT and etanercept. In another embodiment the composition comprises A1 AT and adalimumab. In another embodiment the composition comprises A1 AT and certolizumab pegol. In another embodiment the composition comprises A1 AT and golimumab. In particular, said compositions are pharmaceutical compositions further comprising a pharmaceutically acceptable excipients, carriers, and/or diluents.

As described in detail below, the pharmaceutical compositions described herein may be specially formulated for administration in solid or liquid form, including those adapted for the following: (1) oral administration, for example, drenches (aqueous or non-aqueous solutions or suspensions), tablets, e.g., those targeted for buccal, sublingual, and systemic absorption, boluses, powders, granules, pastes for application to the tongue; (2) parenteral administration, for example, by subcutaneous, intramuscular, intravenous or epidural injection as, for example, a sterile solution or suspension, or sustained-release formulation; or (3) sublingually.

In some embodiments, the composition/s comprises additional agents. For example, the composition/s may comprise a nutritional agent, such as an antioxidant. Examples of pharmaceutically-acceptable antioxidants include: (1) water soluble antioxidants, such as ascorbic acid, cysteine hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal chelating agents, such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like.

The formulations of the compounds described herein may be presented in unit dosage form and may be prepared by any methods well known in the art of pharmacy. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will vary depending upon the host being treated and the particular mode of administration. The amount of active ingredient which can be combined with a carrier material to produce a single dosage form will generally be that amount of the agent which produces a therapeutic effect.

In certain embodiments, a formulation described herein comprises an excipient, including, but not limited to, cyclodextrins, liposomes, micelle forming agents, e.g., bile acids, and polymeric carriers, e.g., polyesters and polyanhydrides; and an agent of the invention. In some embodiments, an aforementioned formulation renders orally bioavail able an agent of the invention. Methods of preparing these formulations or compositions may include the step of bringing into association a compound of the invention with the carrier and, optionally, one or more accessory ingredients.

Liquid dosage forms for oral administration of the formulations or compositions provided herein include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active ingredient, the liquid dosage forms may contain inert diluents commonly used in the art, such as, for example, water or other solvents, solubilizing agents and emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3- butylene glycol, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof.

Besides inert diluents, the oral compositions can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, coloring, perfuming and preservative agents.

Suspensions, in addition to the active compounds, may contain suspending agents as, for example, ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and sorbitan esters, microcrystalline cellulose, aluminum metahydroxide, bentonite, agar-agar and tragacanth, and mixtures thereof.

Formulations provided herein suitable for oral administration may be in the form of capsules, cachets, pills, tablets, lozenges (using a flavored basis, usually sucrose and acacia or tragacanth), powders, granules, or as a solution or a suspension in an aqueous or non-aqueous liquid, or as an oil-in-water or water-in-oil liquid emulsion, or as an elixir or syrup, or as pastilles (using an inert base, such as gelatin and glycerin, or sucrose and acacia) and/or as mouth washes and the like, each containing a predetermined amount of a compound of the invention as an active ingredient. A compound of the invention may also be administered as a bolus, electuary, or paste. In solid dosage forms of the invention for oral administration (e.g., capsules, tablets, pills, dragees, powders, granules and the like), the active ingredient is mixed with one or more pharmaceutically-acceptable carriers, such as sodium citrate or dicalcium phosphate, and/or any of the following: (1) fillers or extenders, such as starches, lactose, sucrose, glucose, mannitol, and/or silicic acid; (2) binders, such as, for example, carboxymethylcellulose, alginates, gelatin, polyvinyl pyrrolidone, sucrose and/or acacia; (3) humectants, such as glycerol; (4) disintegrating agents, such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; (5) solution retarding agents, such as paraffin; (6) absorption accelerators, such as quaternary ammonium compounds; (7) wetting agents, such as, for example, cetyl alcohol, glycerol monostearate, and non-ionic surfactants; (8) absorbents, such as kaolin and bentonite clay; (9) lubricants, such a talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and mixtures thereof; and (10) coloring agents. In the case of capsules, tablets and pills, the pharmaceutical compositions may also comprise buffering agents. Solid compositions of a similar type may also be employed as fillers in soft and hard-shelled gelatin capsules using such excipients as lactose or milk sugars, as well as high molecular weight polyethylene glycols and the like.

A tablet may be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets may be prepared using binder (for example, gelatin or hydroxypropylmethyl cellulose), lubricant, inert diluent, preservative, disintegrant (for example, sodium starch glycolate or cross-linked sodium carboxymethyl cellulose), surface-active or dispersing agent. Molded tablets may be made by molding in a suitable machine a mixture of the powdered compound moistened with an inert liquid diluent.

The tablets, and other solid dosage forms of the pharmaceutical compositions described herein, such as dragees, capsules, pills and granules, may optionally be scored or prepared with coatings and shells, such as enteric coatings and other coatings well known in the pharmaceutical-formulating art. They may also be formulated so as to provide slow or controlled release of the active ingredient therein using, for example, hydroxypropylmethyl cellulose in varying proportions to provide the desired release profile, other polymer matrices, liposomes and/or microspheres. Compositions described herein may also be formulated for rapid release, e.g., freeze-dried. They may be sterilized by, for example, filtration through a bacteria-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved in sterile water, or some other sterile injectable medium immediately before use. These compositions may also optionally contain opacifying agents and may be of a composition that they release the active ingredient(s) only, or preferentially, in a certain portion of the gastrointestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes. The active ingredient can also be in micro-encapsulated form, if appropriate, with one or more of the abovedescribed excipients.

Pharmaceutical composition/s provided herein suitable for parenteral administration comprise one or more compounds of the invention in combination with one or more pharmaceutically-acceptable sterile isotonic aqueous or nonaqueous solutions, dispersions, suspensions or emulsions, or sterile powders which may be reconstituted into sterile injectable solutions or dispersions just prior to use, which may contain sugars, alcohols, antioxidants, buffers, bacteriostats, solutes which render the formulation isotonic with the blood of the intended recipient or suspending or thickening agents.

Examples of suitable aqueous and nonaqueous carriers which may be employed in the pharmaceutical compositions of the invention include water, ethanol, polyols (such as glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, coconut oils, vegetable oils, such as olive oil, and injectable organic esters, such as ethyl oleate. Proper fluidity can be maintained, for example, by the use of coating materials, such as lecithin, by the maintenance of the required particle size in the case of dispersions, and by the use of surfactants.

In an eight aspect, provided herein is a kit of parts, wherein said kit comprises pharmaceutically acceptable compositions which comprise a therapeutical ly-effective amount of A1 AT, formulated together with one or more pharmaceutically acceptable excipients, carriers and/or diluents, and a further pharmaceutically acceptable composition which comprises a therapeutically-effective amount of at least one TNF-o inhibitor, formulated together with one or more pharmaceutically acceptable excipients, carriers and/or diluents. In particular embodiments, the kit of parts comprises at least two recipients wherein one of the recipients comprises a composition comprising A1 AT, and the other recipient a composition comprising a TNF-o inhibitor. In some embodiments, the kit of parts also comprises instructions for use in the treatment of a disease involving the simultaneous, sequential or separate administration of both active ingredients, wherein the therapeutic effects of the first administered has not entirely disappeared when the subsequent compounds are administered. In particular embodiments, the kit of parts of the eight aspect of the invention or the composition of the seventh aspect of the invention is for use in neuroprotection, in particular for the treatment of ischaemia, as defined in any one of the first to sixth aspects. Said treatment is further defined in more detail in the next section.

Treatments

Disclosed herein is the treatment of ischaemia, such as cerebral ischaemia, vascular ischaemia, cardiac ischaemia. Also disclosed is treating an ischaemia related disorder, such as traumatic brain injury. Also disclosed is treating stroke. In particular embodiments the treatment of the first to sixth aspects of the invention is the treatment of a disorder selected from the group consisting of cerebral ischaemia, vascular ischaemia, cardiac ischaemia, and/or traumatic brain injury. In particular embodiments the treatment of the first to sixth aspects of the invention is the treatment of stroke. The treatment comprises administering to the subject (e.g., a subject in need thereof) a therapeutically-effective amount of A1AT and a therapeutically- effective amount of a TNF-o inhibitor. The combination of compounds protects the neurons or neuronal cells from damage or death, such that prevention or treatment of the above disorders is achieved. A skilled person in the art will understand that prevention or treatment of the above disorders may not be absolute. Indeed, partial neuroprotection may provide relevant advantages to the patients suffering from ischaemia, for example, in terms of functional performance.

In some embodiments the treatment comprises preventing that the neuronal cells are damaged by oxygen deprivation, or reducing the damage caused by oxygen deprivation in neuronal cells.

In some embodiments, the treatment comprises slowing or reversing the progression of ischaemia or an ischaemia related disorder; in particular for slowing or reversing the progression of cerebral ischaemia, vascular ischaemia, cardiac ischaemia, and/or traumatic brain injury. In some embodiments, the treatment comprises slowing or reversing the progression of stroke. The stroke may be ischemic stroke. In particular embodiments the stroke is ischemic stroke. In particular embodiments the stroke is acute ischemic stroke. In other embodiments the stroke is focal acute ischemic stroke.

In particular embodiments the combination therapy described herein is an adjuvant therapy with respect to a first-line therapy for the treatment of ischaemia. Thus, in particular embodiments of the first to sixth aspects of the invention, the treatment of ischaemia (or an ischaemia-related disorder) further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a first-line therapy suitable for the treatment of ischaemia. The first-line therapy for the treatment of ichaemia or ischaemia-related disorder as defined above may be selected from a reperfusion therapy such as a thrombolytic agent, mechanical thrombectomy and combinations thereof. In particular embodiments, said thrombolytic agent is tissue plasminogen activator (rt-PA), for example, Tenecteplase.

In some examples, provided herein is the use of A1 AT in combination with a TNF-o inhibitor, as an adjuvant therapy administered simultaneously, sequentially or separately within a therapeutic interval with respect to a first-line therapy suitable for the treatment of ischaemia. The combination is herein understood as the simultaneous, sequential or separate administration of A1AT and a TNF-o inhibitor to a subject. In particular embodiments, said combination therapy is for treating a condition selected from the group consisting of cerebral ischaemia, vascular ischaemia, cardiac ischaemia, and traumatic brain injury. In particular embodiments, said combination therapy is for treating stroke. In special examples, said A1 AT is used in combination with infliximab or etanercept.

In still some further embodiments, provided herein is the use of A1AT in combination with a TNF-o inhibitor, as an adjuvant therapy administered simultaneously, sequentially or successively with respect to a reperfusion therapy such as a thrombolytic agent suitable for the treatment of cerebral ischaemia or stroke and/or mechanical thrombectomy. In a particular embodiment, said thrombolytic agent is tissue plasminogen activator (rt-PA) or recombinant tissue plasminogen activator (rt-PA) or Tenecteplase.

In some embodiments of the invention, the A1 AT and the TNF-o inhibitor are administered in a sole pharmaceutical composition or in separate pharmaceutical compositions. In particular embodiments, the administration of A1AT and TNF-o inhibitor is carried out simultaneously, for example in a single dose via intravascular bolus injection and/or via the intravenous route of administration that can be used for injections (with a syringe at higher pressures) or infusions (typically using only the pressure supplied by gravity).

In some embodiments, the treatment is administered within the first twenty, or within the first twenty four hours, or within the first twelve hours, of symptom onset. In particular embodiment, the treatment is administered within the first six hours, for example within the first three hours. In a particular embodiment, the disorder is stroke. In more particular embodiments, the stroke is ischemic stroke. In yet a more particular embodiment the stroke is acute ischemic stroke, for example focal acute ischemic stroke.

The therapeutic window for the treatment of stroke is quite narrow. Thus, it is desirable to administer the treatment as soon as possible after the stroke. However, state of the art treatments must wait until the etiology of the stroke is elucidated, since the treatments indicated for ischemic stroke are generally contraindicated for hemorrhagic stroke. Elucidation of the etiology of stroke must be made in the hospital using sophisticated imaging techniques. It follows that often precious time is lost while getting the patient to the hospital and elucidating the etiology of the stroke. In this sense, it is noteworthy that the treatment of the invention is safe when administered after an hemorrhagic stroke. As shown in the examples below, no deleterious effects were observed in hemorrhage volume and motor-neurological status in intracerebral haemorrhage mouse models. This means that the treatment of the invention might be given in the ambulance before knowing the type of stroke, saving time and improving the chances of recovery for the patient.

Sometimes it may be desirable to administer the treatment of the invention before the ischemic event, for example, before a stroke, takes place. Thus, in some other embodiments the treatment is administered before an ischemic event (prophylactic treatment). In particular embodiments, the prophylactic treatment is administered to subjects in risk of suffering from stroke, for example, ischemic stroke.

In some embodiments of the first, third and fifth aspects of the invention, the treatment comprises treatment of a neurodegenerative disease, such as Alzheimer's disease.

Actual dosage levels and administration regimen of the compositions disclosed herein may be varied so as to obtain an amount of A1 AT and TNF-o inhibitor that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient. In some embodiments of any one of the first to eight aspects of the invention, the TNF-o inhibitor is present in a therapeutically effective amount which is lower than the therapeutically effective amount needed when the inhibitor is administered alone. In this embodiment, the "therapeutically effective amount needed when the inhibitor is administered alone” refers to the dose authorized by the Medicament Agency.

Table 1 summarizes the dose authorized for TNF-o inhibitors accepted by the European Medicines Agency (EMA): Table 1

In one embodiment of any one of the first to eighth aspects of the invention, the pharmaceutical composition comprises Infliximab as TNF-o inhibitor and it is present in a dose lower than 3 mg/kg (which is the dose authorized by the EMA when it is administered alone). In another embodiment of any one of the first to eighth aspects of the invention, the pharmaceutical composition comprises Infliximab as TNF-o inhibitor and it is in any dose equal to or lower than 2.99, equal to or lower than 2.9 mg/kg, equal to or lower than 2.8 mg/kg, equal to or lower than 2.7 mg/kg, equal to or lower than 2.6 mg/kg, equal to or lower than 2.5 mg/kg, equal to or lower than 2.4 mg/kg, equal to or lower than 2.3 mg/kg, equal to or lower than 2.2 mg/kg, equal to or lower than 2.1 mg/kg, equal to or lower than 2.0 mg/kg, equal to or lower than 1.9 mg/kg, equal to or lower than 1.8 mg/kg, equal to or lower than 1 .7 mg/kg, equal to or lower than 1 .6 mg/kg, equal to or lower than 1 .5 mg/kg, equal to or lower than 1 .4 mg/kg, equal to or lower than 1 .3 mg/kg, equal to or lower than, equal to or 1 .2 mg/kg, equal to or lower than 1.1 mg/kg, equal to or lower than 1.0 mg/kg, equal to or lower than 0.9 mg/kg, equal to or lower than 0.8 mg/kg, equal to or lower than 0.7 mg/kg, equal to or lower than 0.6 mg/kg, equal to or lower than 0.5 mg/kg, equal to or lower than 0.4 mg/kg, equal to or lower than 0.3 mg/kg, equal to or lower than 0.2 mg/kg or equal to or lower than 0.1 mg/kg.

In one embodiment of any one of the first to eighth aspects of the invention, the pharmaceutical composition comprises A1 AT in a dose equal or lower than 700 mg/kg. In another embodiment, the dose of A1 AT is lower than 600 mg/kg, or equal or lower than 500 mg/kg, or equal or lower than 400 mg/kg, or equal or lower than 300 mg/kg, or equal or lower than 200 mg/kg, or equal or lower than 100 mg/kg, or equal or lower than 50 mg/kg, or equal or lower than 25 mg/kg, or equal or lower than 10 mg/kg, or equal or lower than 5 mg/kg. In other embodiments the amount of A1 AT is equal or higher than 0.5 mg/kg, or equal or higher than 1 mg/kg, or equal or higher than 2 mg/kg, or equal or higher than 5 mg/kg.

In some embodiments, the treatment comprises administration of the composition in one or more dose(s). In some embodiments, administration of the composition comprises administration of the composition in one or more, five or more, ten or more, twenty or more, thirty or more, forty or more, fifty or more, one hundred or more, or one thousand or more dose(s).

The compositions disclosed herein may be administered over any period of time effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, without being toxic to the patient. The period of time may be at least 1 day, at least 10 days, at least 20 days, at least 30, days, at least 60 days, at least three months, at least six months, at least a year, at least three years, at least five years, or at least ten years. The dose may be administered when needed, sporadically, or at regular intervals. For example, the dose may be administered monthly, weekly, biweekly, triweekly, once a day, or twice a day.

In some embodiments, the subject is given a test to measure the general progression or symptomatic progression of an ischemic disease.

In all above embodiments, the treatments comprise using a TNF-o inhibitor that may be selected from infliximab, etanercept, adalimumab, certolizumab pegol and golimumab.ln some embodiments the treatments comprise using infliximab. In other embodiments the treatments comprise using etanercept.

For completeness, the present description also disclosed the following numbered embodiments.

1 . A1 AT for use in therapy, wherein the therapy comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor.

2. A1 AT for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1 AT and a TNF-o inhibitor.

3. The A1 AT for use according to embodiment 2, wherein said treatment is for cerebral ischaemia, vascular ischaemia, cardiac ischaemia, traumatic brain injury or neurodegenerative diseases such as Alzheimer's disease.

4. The A1 AT for use according to any of the embodiments 2-3, wherein the treatment is for stroke.

5. The A1 AT for use according to the preceding embodiment, wherein the stroke is ischemic stroke.

6. The A1AT for use according to the preceding embodiment, wherein the stroke is acute ischemic stroke.

7. The A1 AT for use according to embodiment 6, wherein the stroke is focal acute ischemic stroke.

8. The A1 AT for use according to any of the embodiments 2-6, wherein treatment is administered within the first twenty, for example within the first twelve hours, of symptom onset.

9. The A1 AT for use according to the preceding embodiment, wherein the treatment is administered within the first six hours of symptom onset, for example within the first three hours, of symptom onset. 10. The alpha-1 -antitrypsin for use according to any one of embodiments 2-9, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a first-line therapy suitable for the treatment of ischaemia.

11 . The A1 AT for use according to embodiment 10, wherein the first line therapy is a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

12. The alpha-1-antitrypsin for use according to any one of embodiments 1-11, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab and etanercept.

13. The alpha-1-antitrypsin for use according to embodiment 12, wherein the TNF-o inhibitor is infliximab.

14. The alpha-1-antitrypsin for use according to embodiment 12, wherein the TNF-o inhibitor is adalimumab.

15. The alpha-1-antitrypsin for use according to embodiment 12, wherein the TNF-o inhibitor is certolizumab pegol.

16. The alpha-1-antitrypsin for use according to embodiment 12, wherein the TNF-o inhibitor is golimumab.

17. The alpha-1-antitrypsin for use according to embodiment 12, wherein the TNF-o inhibitor is etanercept.

18. A combination of A1 AT and a TNF-o inhibitor for use in therapy, wherein the therapy comprises the simultaneous, sequential or separate administration of the A1 AT and the TNF-o inhibitor.

19. A combination of an A1 AT and a TNF-o inhibitor for use in the treatment of ischaemia wherein the treatment comprises the simultaneous, sequential or separate administration the A1 AT and the TNF-o inhibitor.

20. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 19, wherein the treatment is for cerebral ischaemia, vascular ischaemia, cardiac ischaemia, or traumatic brain injury.

21. The combination of an A1 AT and a TNF-o inhibitor for use according to any of the embodiments 19- 20, wherein the treatment is for stroke.

22. The combination of an A1 AT and a TNF-o inhibitor for use according to the preceding embodiment, wherein the stroke is ischemic stroke.

23. The combination of an A1 AT and a TNF-o inhibitor for use according to the preceding embodiment, wherein the stroke is acute ischemic stroke.

24. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 23, wherein the stroke is focal acute ischemic stroke.

25. The combination of an A1 AT and a TNF-o inhibitor for use according to any of the embodiments 19- 24, wherein the treatment is administered within the first twenty, for example within the first twelve hours, of symptom onset.

26. The combination of an A1 AT and a TNF-o inhibitor for use according to the preceding embodiment, wherein the treatment is administered within the first six hours of symptom onset, for example within the first three hours, of symptom onset.

27. The combination of an A1 AT and a TNF-o inhibitor for use according to any one of embodiments 19- 26, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a first-line therapy suitable for the treatment of ischaemia.

28. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 27, wherein the first line therapy is a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

29. The combination of an A1 AT and a TNF-o inhibitor for use according to any one of embodiments 18- 28, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab and etanercept.

30. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 29, wherein the TNF-o inhibitor is infliximab.

31 . The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 29, wherein the TNF-o inhibitor is adalimumab.

32. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 29, wherein the TNF-o inhibitor is certolizumab pegol. 33. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 29, wherein the TNF-o inhibitor is golimumab.

34. The combination of an A1 AT and a TNF-o inhibitor for use according to embodiment 29, wherein the TNF-o inhibitor is etanercept.

35. A pharmaceutical composition comprising A1 AT and a TNF-o inhibitor, together with pharmaceutically acceptable excipients and/or carriers.

36. A kit of parts comprising a pharmaceutical composition comprising A1 AT together with pharmaceutically excipients and/or carriers, and a pharmaceutical composition comprising a TNF-o inhibitor together with pharmaceutically excipients and/or carriers.

37. The kit of parts according to embodiment 36, further comprising instructions for use in the treatment of a disease involving the simultaneous or sequential administration of both active ingredients.

38. The pharmaceutical composition according to embodiment 35, or the kit of parts according to any of the embodiments 36-37, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

39. The pharmaceutical composition or the kit of parts according to embodiment 38, wherein the TNF-o inhibitor is infliximab.

40. The pharmaceutical composition or kit of parts according to embodiment 38, wherein the TNF-o inhibitor is adalimumab.

41 . The pharmaceutical composition or kit of parts according to embodiment 38, wherein the TNF-o inhibitor is certolizumab pegol.

42. The pharmaceutical composition or kit of parts according to embodiment 38, wherein the TNF-o inhibitor is golimumab.

43. The pharmaceutical composition or kit of parts according to embodiment 38, wherein the TNF-o inhibitor is etanercept.

44. The pharmaceutical composition according to any of the embodiments 35, 38-43, or the kit of parts according to any of the embodiments 36-43, for use in the treatment of ischaemia. 45. The pharmaceutical composition or kit of parts for use according to embodiment 44, wherein the treatment is for cerebral ischaemia, vascular ischaemia, cardiac ischaemia, or traumatic brain injury.

46. The pharmaceutical composition or kit of parts for use according to any of the embodiments 44-45, wherein the treatment is for stroke.

47. The pharmaceutical composition or kit of parts for use according to the preceding embodiment, wherein the stroke is ischemic stroke.

48. The pharmaceutical composition or kit of parts for use according to the preceding embodiment, wherein the stroke is acute ischemic stroke.

49. The pharmaceutical composition or kit of parts for use according to embodiment 44, wherein the stroke is focal acute ischemic stroke.

Clauses

1 . Alpha-1 antitrypsin (A1 AT) for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a Tumor Necrosis Factor alpha (TNF) inhibitor.

2. The A1AT for use according to claim 1, wherein said treatment of ischaemia is treating a disorder selected from the group consisting of cerebral ischaemia, vascular ischaemia, cardiac ischaemia, and traumatic brain injury.

3. The A1 AT for use according to claim 2, wherein said disorder is ischemic stroke.

4. The A1 AT for use according to any one of claims 1-3, wherein the A1 AT and the TNF-o inhibitor are administered within the first twenty, for example within the first twelve hours, of symptom onset, in particular within the first six hours, for example within the first three hours.

5. The alpha-1 -antitrypsin for use according to any one of claims 3-4, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

6. The A1 AT for use according to any one of claims 1-3, wherein the A1 AT and the TNF-o inhibitor are administered before the ischemic event. 7. The A1 AT for use according to claim 6, wherein the A1 AT and the TNF-o inhibitor are administered to subjects in risk of suffering from ischemic stroke.

8. The A1 AT for use according to any one of claims 1-7, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

8. A combination of an A1 AT and a TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration of the A1 AT and the TNF-o inhibitor.

9. The combination for use according to claim 8, wherein said treatment of ischaemia is treating ischemic stroke.

10. The combination for use according to claim any one of claims 8-9, wherein the combination is administered within the first twenty hours, for example, within the first twelve hours, of symptom onset, in particular within the first six hours of symptom onset, for example within the first three hours of symptom onset.

11 . The combination for use according to any one of claims 9-10, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

12. The combination for use according to any one of claims 8-9, wherein the A1 AT and the TNF-o inhibitor are administered before the ischemic event.

13. The combination for use according to any one of claims 8-12, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

14. A kit of parts comprising at least two recipients wherein one of the recipients comprises a pharmaceutical composition comprising A1 AT together with pharmaceutically excipients and/or carriers, and the other recipient a pharmaceutical composition comprising a TNF-o inhibitor together with pharmaceutically excipients and/or carriers, together with instructions for use in the treatment of ischemia involving the simultaneous or sequential administration of both active ingredients.

15. The kit of parts according to claim 14, wherein the instructions are for use in the treatment of ischemic stroke.

16. The kit of parts according to any one of claims 14-15, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

17. A TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of a TNF-o inhibitor and A1AT.

18. The TNF-o inhibitor for use according to claim 17, wherein said treatment of ischaemia is treating ischemic stroke.

19. The TNF-o inhibitor for use according to any one of claims 17-18, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

20. A1 AT for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor.

21 . A combination of an A1 AT and a TNF-o inhibitor for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration of the A1AT and the TNF- o inhibitor.

22. A kit of parts comprising at least two recipients wherein one of the recipients comprises a pharmaceutical composition comprising A1 AT together with pharmaceutically excipients and/or carriers, and the other recipient a pharmaceutical composition comprising a TNF-o inhibitor together with pharmaceutically excipients and/or carriers, together with instructions for use in neuroprotection involving the simultaneous, sequential or separate administration within a therapeutic interval of both active ingredients.

23. The TNF-o inhibitor for use according to claim 20, the combination for use according to claim 21 , or the kit of parts according to claim 22, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

Throughout the description and claims the word "comprise" and variations of the word, are not intended to exclude other technical features, additives, components, or steps. Furthermore, the word "comprise” encompasses the case of "consisting of'. Additional objects, advantages and features of the invention will become apparent to those skilled in the art upon examination of the description or may be learned by practice of the invention. The following examples and drawings are provided by way of illustration, and they are not intended to be limiting of the present invention. Furthermore, the present invention covers all possible combinations of particular and preferred embodiments described herein.

Examples

Example 1. In silico stroke modelling

1.1. Materials and methods

1.1.1. Therapeutic Performance Mapping System (TMPS) technology

We have used the TPMS technology, a top-down systems biology approach (Anaxomics S.L., Spain), for drug repositioning [Mas JM, Pujol A, Aloy P, et al. Methods and systems for identifying molecules or processes of biological interest by using knowledge discovery in biological data. US 2011/0098993 A1, 2010], In brief, TMPS approach included the following steps (Figure 1):

(1) Generation of molecular maps for ischemic stroke disease. A manually-curated list of known molecular mediators that characterize the pathology of ischemic stroke was created by carefully reviewing full- length published articles (287 proteins; data not shown). The generation and extension of the subsequent network map was conducted by incorporating all known relationships of the molecular mediators from this list, based on the following sources: KEGG [Kanehisa M, Goto S, Hattori M, et al. From genomics to chemical genomics: new developments in KEGG. Nucleic Acids Res 2006; 34: D354-7], REACTOME [Croft D, Mundo AF, Haw R, et al. The Reactome pathway knowledgebase. Nucleic Acids Res 2014; 42: D472-7], BIOGRID [Salwinski L, Licata L, Winter A, et al. Recurated protein interaction datasets. Nat Methods 2009; 6: 860-1], INTACT [Kerrien S, Aranda B, Breuza L, et al. The IntAct molecular interaction database in 2012. Nucleic Acids Res 2012; 40: 841-846], HDPR [Keshava Prasad TS, Goel R, Kandasamy K, et al. Human Protein Reference Database-2009 update. Nucleic Acids Res 2009; 37: D767-72], MATRIXDB [Chautard E, Fatoux- Ardore M, Ballut L, et al. MatrixDB, the extracellular matrix interaction database. Nucleic Acids Res 2011; 39: D235-40], MIPS [Mewes HW, Ruepp A, Theis F, et al. MIPS: Curated databases and comprehensive secondary data resources in 2010. Nucleic Acids Res 2011; 39: 220-224], DIP [Xenarios I, Fernandez E, Salwinski L, et al. DIP: The Database of Interacting Proteins: 2001 update. Nucleic Acids Res 2001; 29: 239— 41] and MINT [Chatr-Aryamontri A, Zanzoni A, Ceol A, et al. Searching the protein interaction space through the MINT database. Methods Mol Biol 2008; 484: 305-17], The final network included 6640 proteins (data not shown 1).

(2) Generation of the mathematical models. Static network maps were transformed into mathematical models (topological maps) through the use of Artificial Neuronal Networks (ANN) and pattern recognition techniques based on the optimization of generic algorithms, as previously published elsewhere [Romeo- Guitart D, Sci Rep. 2018;8(1): 1879], The multilayer perceptron (MLP) neural network classifier was the algorithm used for ANN [Gybenko G. Approximation by Superpositions of a Sigmoidal Function. Math Control , Signals , Syst 1989; 303-314],

(3) Feeding of the mathematical models with experimental data from our lab. The machine learning methodology consisted of a model constructed by stratified clusters of neural networks, which was trained with a gradient of algorithms to approximate the values of a given truth table. The truth table incorporated a set of functional values and restrictions based on the available biological knowledge about the molecular mediators of the constructed network. Proteomics and transcriptomics data from human brain samples from patients who died due to stroke were also used to further characterize the truth table. In brief, own data from 4 different studies were included into the mathematical models: 2 different strategies of mass spectrometry (MS)-based proteomics with brain homogenates ([Cuadrado E, Resell A, Colome N, et al. The Proteome of Human Brain After Ischemic Stroke. J Neuropathol Exp Neurol 2010; 69: 1105-1115], MS analysis of microdissected neurons and brain blood vessels [Garcia-Berrocoso T, Llombart V, Colas-Campas L, et al. Single Cell Immuno-Laser Microdissection Coupled to Label-Free Proteomics to Reveal the Proteotypes of Human Brain Cells After Ischaemia. Mol Cell Proteomics 2018; 17: 175-189] and microarray-based transcriptomics with brain homogenates (unpublished data). Repeats and contradictions among MS-based studies were disregarded and gene information was transformed to protein data before inclusion into the model. In all cases, infarct, peri-infarcted and healthy contralateral regions were compared and 1876 differentially expressed proteins were finally included in the model (data not shown). Through this strategy, 4 different mathematical models were finally generated by selectively integrating into them all high-throughput information. These models simulate (I) healthy and (II) disease conditions (ischaemia), and (III) infarct and (IV) peri-infarct brain regions.

(4) Solving the mathematical models: drug repositioning strategy. Once the mathematical models were generated, drug repositioning solutions were acquired by perturbing them with multiple sets of stimuli, which corresponded to two-by-two combinations of drugs from the DrugBank Database (v4.3) [Wishart DS, Feunang YD, Guo AC, et al. DrugBank 5.0: A major update to the DrugBank database for 2018. Nucleic Acids Res 2018; 46: D 1074— D 1082]. Approximations to the best treatment solution for ischemic stroke were obtained based on three complementary approaches, which identified the best drug combinations for (1) treating ischemic stroke in general (disease model), (2) recovering the peri-infarct area and (3) promoting the conversion of the peri-infarct zone model to a healthy brain model and avoiding the conversion of the periinfarct zone model to the infarct zone model. All identified drug combinations had to fulfill a minimum threshold of ANN predictive value of 80%. This cut-off point corresponded to the maximum ANN predictive value obtained from screening in our mathematical models a set of previous unsuccessful treatments studied in clinical trials for ischemic stroke [19] (Table 1). To further restrict the discovery of potential drug combinations, the following specific filters were applied: (1) an approved-administration for all individual drugs; (2) a theoretical synergic effect of drugs when combined (higher than 20%); (3) no association to hypotension or hemorrhages according to public databases; (4) no incompatibilities for intravenous administration; (5) identified in the two proposed ANN strategies (disease and peri-infart area models) or in model reversion strategies. The following associated DrugBank categories have not been considered in the study: affinity labels, artificial tears, buffers, dietary supplements, food additives, food preservatives, imaging agents, pesticides, photoaffinity labels, pigmenting agents and ultrasound contrast agents.

1.2. Results

1.2.1. Identification of neuroprotective drug combinations

To identify potential neuroprotective drug combinations to treat ischemic stroke, we applied machine-learning tools. To generate our systems biology-based artificial maps for stroke modeling 13 main pathological pathways were covered, which encompassed a total of 6640 proteins.

In brief, these maps were created and computationally converted into mathematical stroke models incorporating all biological knowledge available. It is important to remark that these models also incorporate datasets from 4 different proteomics and transcriptomics studies previously conducted in our lab on human brain samples from patients who died due to stroke.

Disease-orientated drug repositioning neuroprotective solutions were then acquired by perturbing these virtual stroke models with multiple two-by-two combinations of drugs. From all drug combinations that fulfilled the established criteria, the first 25 were pre-selected.

The combinations of A1 AT with any one of the following TNF-o inhibitors: infliximab, adalimumab, golimumab or certolizumab pegol showed the most promising results as neuroprotective drug combinations. These combinations showed higher ANN predictive value of neuroprotection against ischemic stroke injury, higher value of the predicted synergic effect and with experimental evidences reported in the scientific literature supporting the neuroprotective potential of the individual drugs. Said drug combinations showed an ANN predicted value of neuroprotection against ischemic stroke injury of 92%.

Thereupon, the potential role of A1AT and TNF-o inhibitors has been studied as an acute neuroprotective therapy after ischemic stroke.

Remicade® (Infliximab, Janssen Biologies) and Enbrel® (Etanercept, Pfizer) were used as TNF-o inhibitors in in-vitro experiments, while a neutralizing antibody for murine TNF-o (BioXCell, BE0058) was used in in-vivo experiments. Prolastin®-C (Grifols) was used for both in-vitro and in-vivo studies.

Example 2. In vivo safety and therapeutic effect of the combination of TNF-o inhibitor and A1 AT

2.1. Materials and methods

2.1.1. In vivo safety evaluation of the drug combination administration In a first step, the safety of the drug combination administration was evaluated in order to discard any toxic effect derived from the pre-selected drug doses and the co-administration of the two drugs at the same time. The dose of each drug was chosen according to an extensive literature-based research on published studies. The final dose was 20 mg/kg for TNF-o inhibitor (neutralizing antibody for murine TNF-o (BioXCell, BE0058)) and 60mg/kg for A1 AT (Prolastin®-C (Grifols)). We initially evaluated safety outcomes on naive animals receiving one dose of the drug combination (n=5), or the respective drug vehicles (n=4) (Figure 2). Drug administration was performed via de retro-orbital sinus. 24h after the first administration, animals were sacrificed and blood was drawn through cardiac puncture, collected in EDTA tubes and centrifuged for 10 min at 3000g at 4°C. Routine clinical biochemistry parameters (including urea, alkaline phosphatase, creatinine, aspartate transaminase (AST), Alanine transaminase (ALT) and Creatine kinase (CK)) were analyzed in plasma samples in the Clinical laboratories from Hospital Vail d'Hebron (Barcelona, Spain).

2.1.2. In vivo determination of the synergic neuroprotective effect of drug combination

Thereupon, the neuroprotective potential of the drug combination was studied in a mouse ischemic stroke model. Transient ischaemia in the territory of the middle cerebral artery (MCA) was induced by introducing an intraluminal filament through the external carotid artery, as described elsewhere [Clark W, Lessov N, Dixon M, et al. Monofilament intraluminal middle cerebral artery occlusion in the mouse. Neurol Res 1997; 19: 641— 648],

In summary, animals were anesthetized and body temperature was maintained at 37°C using a heating pad. The regional cerebral blood flow (CBF) was monitored close to the region irrigated by the MCA by affixing a laser Doppler probe (Moor Instruments, UK) to the skull. Then, animals were placed in the supine position and after surgical exposure of the right bifurcation of the external carotid artery and internal carotid artery, a silicone-coated nylon monofilament (Doccol Corporation, USA; reference number: 602256PK10Re) was introduced to occlude the MCA. MCA occlusion (MCAO) was confirmed by a reduction in the cortical CBF recorded by the laser Doppler probe and the incision was closed with a silk suture. Within the first 10 minutes of occlusion, animals were treated with individual drugs, drug combination or vehicles according to their experimental group, and were allowed to recover from anesthesia. Ninety minutes later, mice were reanesthetized and the filament was removed to induce reperfusion of the MCA. Only animals that exhibited a reduction of 80% of CBF after filament introduction and a recovery of 75% after filament removal were included in the study.

An investigator blinded to the treatments evaluated the infarct volumes and the strength loss (trough a grip strength test) (Figure 3). After 24h, all animals were euthanatized. Blood was drawn and brain was removed and cut into 6 serial 1mm coronal sections. Infarct volume was assessed on these coronal sections using 2,3,5-triphenyltetrazolium chloride (TTC) staining. Infarct volumes were calculated by integration of the lesion areas, corrected for edema and expressed in cubic millimeters (mm3). 2.2. Results

2.2.1. In vivo safety evaluation of the drug combination administration

Animals receiving either drugs in combination or vehicles did not report any body weight loss (Figure 4A). Moreover, 24h after the last treatment administration, clinical biochemical parameters were analyzed in blood. All biochemical parameters showed similar levels between vehicle- and drug-treated animals (Figure 4B). Blood levels of urea showed a decrease in treated animals compared to their respective controls, but only increased levels of urea are cause of concern.

2.2.2. In vivo determination of the synergic neuroprotective effect of drug combination

We validated the theoretical neuroprotective effect of the selected drug combination (TNF-a inhibitor and A1 AT) and the synergic effect in front of single drug treatment. Drug combination showed efficacy by protecting mouse brains from cerebral ischaemia, since it showed a reduction of 34.88% in the infarct volume compared to the vehicle (p<0.0001, Figure 5A). However, none of the drugs when given alone was capable of reducing the infarct volume compared to vehicle group. Moreover, drug combination showed a significant reduction of infarct volume when compared to A1 AT alone (p=0.027) and TNF-a inhibitor alone (p=0.0003) (Figure 5A).

Also, animals treated with drug combination also showed an improvement in the grip strength at 24h after stroke when compared to vehicles, A1AT alone and TNF-a alone (Figure 5B).

Example 3. Compatibility of rt-PA with TNF-a inhibidor + A1 AT combination

3.1. Materials and methods. In vitro clot formation and lysis assay

A pool of plasma was obtained from 10 healthy volunteers (5 men and 5 women, age 78 [75.25-82.25] (median [interguartile range]), with no recorded history of coagulation disturbances. Blood samples were collected in citrate tubes and centrifuged at 4°C, 1500g for 15 minutes. All 10 plasma samples were mixed together for 2h at 4°C and then kept at -80°C until further use.

The assay was conducted in a microtiter 96-well plate. Twenty-five microliters of citrate plasma were added to 75 ul of assay buffer containing 0.05M Tris-HCI (Sigma-Aldrich, USA), 1 M NaCI (Sigma-Aldrich) and 1.245ng of rt-PA (Actylise®, Boheringer) at a pH=7.4 (rt-PA final concentration of 83ng/mL). A final volume of 50ul of activation mix containing 7.5mM CaCI2 and 0.03U/mL thrombin was then added to start the clot reaction. Internal controls without rt-PA were also run in each independent experiment. Optical densities (OD) were immediately read at 405nm and every 40 sec for 40 min at 37°C using a BIO-TEK Elx-808 microplate reader and Gen5 software. Three independent experiments were performed for each experimental condition. Within each experiment, samples were run per triplicate, and those with a coefficient of variation (CV) higher than 20% were excluded for the analysis.

A1 AT and Infliximab or Etanercept were loaded at two different doses: low dose, with a final concentration of 500ng/mL for A1 AT, 306ng/mL for Infliximab and 8,3ng/mL for Etanercept; and high dose, corresponding to a final concentration of 5000ng/mL for A1 AT, 3060ng/ml for Infliximab and 83ng/mL for Etanercept. To extrapolate drug doses from the in vivo experiment, a ratio between the in vivo and the in vitro rt-PA dose was calculated based to the in vivo commonly used 10mg/kg rt-PA dose. This balanced ratio was then used to extrapolate the low drug doses. High doses corresponded to a 10-times increase in the extrapolated low doses. To study the clot lysis, plate readings were interrupted for 1 min when all reactions reached their maximum OD to add drugs' volumes to the reaction. Note that in this case, the volume of activation mix added in the reaction during the formation of the clot is less than 50ul (50ul - volume of drugs added).

To analyze clot formation and lysis parameters, the elapsed time gap between the addition of the activation mix to each well and the start of the reading was always recorded in order to adjust the clot initiation time point. Analyzed parameters include the slope of the curve during the clot lysis phase (clot lysis rate) and the area under the clotting and lysis curve (clot area). Clot formation rate was also calculated to ensure equal clot formation rates among conditions before adding the treatments.

3.2. Results. In vitro characterization of the drug combination effect on rt-PA protease activity

Since the neuroprotective drug combination might be given to ischemic stroke patients together with or within a narrow time window before or after rt-PA administration, we further studied whether our drugs could produce any deleterious effect on the protease activity of rt-PA. To that end, an in vitro simulation of the formation of a blood clot and its lysis due to rt-PA protease activity was created.

To evaluate the effect of such drugs on the rt-PA-related clot lysis, drugs were added to the reaction after the clot was formed (Figure 6A). After adding the drugs to the formed clot no differences were observed in the clot lysis rate nor with A1 AT+Infliximab (Figure 6B) neither with A1AT+Etanercept combinations (Figure 6D). In addition, no differences were observed in the total area under the clot formation and lysis curve nor with A1 AT+Infliximab (Figure 6C) neither with A1AT+Etanercept combinations (Figure 6E). Thus, these results demonstrate no deleterious effects of our drug combination on the rt-PA protease activity in vitro.

Example 4. Neuroprotecting efficacy upon ischemic and hemorrhagic stroke of the combination formed by A1AT and a TNF-a inhibitor

Considering the promising results obtained in previous experiments, and following STAIR recommendations ("Recommendations for standards regarding preclinical neuroprotective and restorative drug development" doi: 10.1161/01 ,str.30.12.2752) we aimed to confirm the efficacy of the combination formed by A1 AT and a TNF-o inhibitor in neuroprotecting the brain in rats. To do so, two different TNF-o inhibitors were selected: Infliximab and Etanercept. Etanercept is a fusion protein that mimics natural TNF-soluble receptor and bind to TNF- o and TNF-p, while Infliximab is a chimeric murine/human monoclonal antibody that bins to TNF- a. Both anti-TNFs bind TNF- a but Etanercept binds soluble TNF with more affinity than Infliximab.

First, we have tested the efficacy of these two combinations in reducing the infarct volume and improving the state of the animals in a rat model of cerebral ischemia. Moreover, considering that these combinations might be given in the ambulance before determining the type of stroke (ischemic stroke or hemorrhagic stroke), we have tested whether the administration of the drug combinations produced any deleterious effect in an intracerebral hemorrhage (ICH) model in rats.

4.1. Material and methods

4.1.1. Drug doses

For this set of experiments two combinations were tested: A1 AT + Etanercept and A1 AT + Infliximab. The tested doses were:

A1AT (Prolastin®-C): 60 mg/kg (administration volume: 300 ul) Infliximab: 5 mg/kg (administration volume: 200 ul) Etanercept: 1 mg/kg (administration volume: 200 ul) Vehicle: Saline (administration volume: 500 ul)

4.1.2. Ischemic stroke model:

_Male Wistar rats (Envigo) 8 weeks old (200-225 g) were used for the ischemic stroke model. Animals were randomized for all experiments and assessments were performed in a blinded manner. Focal cerebral ischemia was induced by 70 min transient occlusion of the left middle cerebral artery and left common carotid artery (CCA), as previously described (Pradillo, 2017). Isoflurane (2% for induction and 1.5% during surgery) was used in a mixture of 70% N2O and 30% 02. Core body temperature was maintained at 37.0 C ± 0.5 C throughout the surgery by a heating blanket (Homeothermic Blanket Control Unit; Harvard Apparatus, Kent, UK). Ischemia was induced by a transient ligature of the left MCA trunk and CCA with a 10-0 suture (Prolene, Ethicon, Somerville, NJ, USA). Occlusion and reperfusion were confirmed visually under the surgical microscope. Right after MCA occlusion (MCAO), vehicle or drug combinations were administered intravenously via the tail vein. Animals were allowed to recovery during the MCA occlusion period. Seventy minutes later, animals were re-anesthetized to induce reperfusion by removal of the filament.

After surgery, animals were returned to home cages and allowed free access to water and food. Animals were excluded from statistical analysis based on an a priori exclusion criterion, namely if animals experienced brain hemorrhage, lack of reperfusion or if the surgery took longer than 45 min and there was excessive bleeding Animals were kept alive for 72 h. Infarct volume was measured by MRI (T2W-images) at 24h, and behavioural and motor-neurological characterization was performed at 24h, 48h and 72h as well as body weight monitoring.

Behavioural characterization: Animals were tested according to the procedures detailed, modified from Hunter et al. (2000) at 24h, 48h and 72h (prior to euthanasia) after MCAO induction. First, assessment of each animal began with observation of undisturbed behaviour in a clear plastic cage: body position (completely flat, 0 to upright position, 4) and spontaneous activity (none, 0 to repeated vigorous movement, 3). Then, animals were transferred to an arena for observation of the following behaviours: transfer arousal (coma, 0 to extremely excited, 5), gait (absolute incapacity, 0 to normal, 3), touch escape (none, 0 to extremely vigorous, 3) and positional passivity (no struggle when held with a hand, 0, maximal struggle, 4).

Motor-Neurological characterization after MCAO: A neurological test was made by two unaware independent observers as previously described (Hunter et al., 2000) at 24h, 48h and 72h (prior to euthanasia) after MCAO induction. According to the test, animals were scored as: 0 points, No deficit; 1 point, failure to extend right forepaw fully; 2 points, decreased grip of right forelimb while tail pulled; 3 points, spontaneous circling or walking to contralateral side; 4 points, walks only when stimulated with depressed level of consciousness; 5 points, unresponsive to stimulation.

4.1.3. Hemorrhagic stroke model:

Male Wistar rats (Envigo) 10 weeks old (250-300 g) were used for the hemorrhagic stroke model. Animals were randomized for all experiments and assessments were performed in a blinded manner. Animals were subjected to an experimental model of intracerebral hemorrhage (ICH) as previously described (Rosenberg, 1990; Otero-Ortega, 2018). In brief, anesthesia was induced using an anesthetic chamber with 8% isoflurane in a 5-L/min oxygen flow and the animals were maintained using a face mask with 4% isoflurane in a 2-L/min oxygen flow. After intraperitoneal injection of meloxicam (2 mg/kg), the animals were placed in a stereotactic frame. Craniotomy was performed adjacent to the bregma, and intrastriatal white matter injury was induced by injection of 1 mL saline containing 0.25 U collagenase type IV (Sigma-Aldrich). Stereotaxic coordinates of the injection site with respect to the bregma were as follows: 0.04 mm posterior, 0.35 mm lateral, 0.6 mm ventral. Right after ICH induction, vehicle or drug combinations were administered intravenously via the tail vein. Animals were kept alive for 72 h. Homerrhage volume was measured by MRI (T2W-images) at 24h, and motor-neurological characterization was performed at 24h, 48h and 72h, as well as body weight monitoring.

Motor-Neurological characterization after MCAO: A neurological test was made by two unaware independent observers as previously described (Hunter et al., 2000) at 24h, 48h and 72h (prior to euthanasia) after MCAO induction. According to the test, animals were scored as: 0 points, No deficit; 1 point, failure to extend right forepaw fully; 2 points, decreased grip of right forelimb while tail pulled; 3 points, spontaneous circling or walking to contralateral side; 4 points, walks only when stimulated with depressed level of consciousness; 5 points, unresponsive to stimulation (coma).

4.2. Results

We first aimed to confirm the neuroprotective effects of the combinations in a model of cerebral ischemia in rats, following STAIR recommendations ("Recommendations for Standards Regarding Preclinical Neuroprotective and Restorative Drug Development”, supra). Figure 7 summarizes the experimental design. In brief, rats were subjected to 70 minutes of MCAO. Animals were kept alive for 72 h. Infarct volume was measured by MRI (T2W-images) at 24h, and behavioural and motor-neurological characterization was performed at 24h, 48h and 72h, as well as body weight monitoring. Animals receiving either drugs in combination or vehicles showed a body weight loss, but no differences were observed between groups (Figure 8). In addition, both drug combinations showed efficacy by protecting rat brains from cerebral ischemia. Reduction in infarct volume for rats receiving A1 AT+infliximab was 11.21 % greater than rats receiving vehicle (p=0.0416), while the reduction in infarct volume for rats receiving A1AT+etanercept was 15.87% greater rats receiving vehicle (p=0.0103) (Figure 9). Moreover, both combinations produced an improved motor-neurological status of the animals at 24h when compared to vehicle, and this improved motor- neurological status was maintained at 48h and 72h in A1 AT+etanercept treated group when compared to vehicle (Figure 10). Finally, the behavioural status of the animals was determined at 24h, 48h and 72h, revealing that A1 AT+infliximab treated group showed improved behavioural status at 24h and 48h, and A1 AT+etanercept treated group at 48h and 72h when compared to vehicle (Figure 11).

Overall, our results revealed that the administration of A1AT combined with a TNF-o inhibitor, either Infliximab or Etanercept showed efficacy in neuroprotecting the brain after cerebral ischemia in rats.

Once we confirmed the efficacy of the drug combination in a model of cerebral ischemia, we aimed to discard any possible deleterious effect of the combinations in intracerebral hemorrhage (ICH), since the combination might be given in the ambulance before knowing the type of stroke (ischemic or hemorrhagic). Figure 12 summarizes the experimental design. In brief, rats underwent a procedure to induce intracerebral hemorrhage. Animals were kept alive for 72 h. Hemorrhage volume was measured by MRI (T2W-images) at 24h, and motor-neurological characterization was performed at 24h, 48h and 72h, as well as body weight monitoring. Animals receiving either drugs in combination or vehicles showed a body weight loss. Interestingly, animals treated with A1 AT+infliximab showed a reduced body weight loss when compared to the other two groups, and no differences were observed between vehicles and A1 AT+etanercept groups (Figure 13). Both drug combinations showed no deleterious effect when administered after ICH, since the volume of the hemorrhage was not different between groups (Figure 14). Interestingly, animals receiving

A1 AT+infliximab showed improved motor-neurological status at 24h, 48h and 72h when compared to vehicle, while no differences were observed between vehicle and A1 AT+etanercept treated group (Figure 15). Overall, these results revealed that both combinations are safe when administered after ICH, since no deleterious effects were observed in hemorrhage volume and motor-neurological status in treated groups when compared to vehicles.

Example 5. Protocol for determination of the Relative Potency of an Anti-TNF Monoclonal Antibody (mAb) by Neutralizing TNF Using an In Vitro Bioanalytical Method (extracted from Tierrablanca- Sanchez et al, supra).

1. Preparation of the Media and Solutions

1. Prepare the culture medium: RPMI-1640 with 10% PBS, pH 7.4.

2. Prepare assay culture medium: RPMI-1640 without phenol red but with 1% PBS, pH 7.4.

3. Prepare cell wash solution: DPBS Mg- and Ca-free solution with 0.02% EDTA, pH 7.4.

4. Prepare cell detachment solution: 0.125% trypsin with 1 mM EDTA.

1 . Thaw 100 mL of a 0.25% solution of trypsin-EDTA and transfer to a sterile 500-mL flask.

2. Mix with 100 mL of cell wash solution and dispense 15 mL aliquots into 15 mL sterile tubes. Store at -70 to -80 °C until use.

3. Filter these solutions through a 0.22-pim membrane and warm up to 37 °C for at least 30 min prior to use.

5. Prepare apoptosis-induction stock solution TNFo solution at 3.3 pig/mL.

1 . Dissolve 20 pig of TNFo with 500 piL of filter-sterilized water in its primary container and mix until complete dissolution.

2. Transfer into a 15 mL sterile tube and add 5.5 mL of DPBS Mg- and Ca-free solution to this tube. Mix gently using a vortex mixer.

3. Aliquot the solution into 70 piL portions. Dispense each aliquot into 0.5 mL microtubes and store at -80 °C.

6. Prepare apoptosis induction solution : TNFo solution at 40 ng/mL.

1 . Thaw an aliquot of the apoptosis induction stock solution, incubating it in a water bath at 25 °C for 10 min.

2. Dilute the apoptosis induction stock solution to 40 ng/mL by adding 61 piL of 3.3 pig/mL TNFo solution to 4.939 mL of assay culture medium in a 15 mL sterile tube.

3. Mix by vortex mixer for 10 s; this solution must be prepared freshly before use.

4. Warm up the solution to 37 °C for at least 30 min prior to use in th eneutralization assay.

7. Prepare the substrate solution: caspase 3/7 Gio solution (Karvinen J, et al. Homogeneous time- resolved fluorescence quenching assay (LANCE) for caspase-3. J Biomol Screen. 2002;7(3):223— 231).

1 . Thaw the caspase buffer solution (caspase 3/7 Gio buffer) 12 h before use.

2. Let the caspase buffer solution and the substrate (caspase 3/7 Gio substrate) sit separately at 25 ± 5 °C for 30 min prior to mixing.

3. Transfer 10 mL of the caspase buffer solution to the substrate vial and mix by inversion. 4. Keep at 25 ± 5 °C, light-protected until use. NOTE: The solution is stable for 6 h at room temperature. ll Culturing and Counting

1 . Cell thawing and the first subculture.

1. Remove one vial with WEH1 164 cells9 from a freezer at -80 °C and transfer them to an icebath.

2. Pipette up and down with 1 mL of pre-warmed culture medium until the frozen cells completely thaw.

3. Dispense 9 mL of pre-warmed culture medium onto a 15 mL sterile tube.

4. Transfer the cell suspension into the 15-mL sterile tube and mix gently five times by inversion.

5. Centrifuge the cell suspension at 125 x g for 3 min. Discard the supernatant and disaggregate the cell pellet.

6. Add 5 mL of culture medium to the tube . Mix until the cells are completely resuspended.

7. For cell counting, transfer 50 piL of the cell suspension to a 500 piL microtube and mix with 50 piL of 0.4% trypan blue. Count the cells and adjust to 0.5 x 10⁶ cells/mL. See step 2.2, below.

8. Add 13 mL of pre-warmed culture medium to a 75 mL cell culture flask.

9. Dispense enough cell suspension volume from step 2.1.6 to achieve 0.5 x 10⁶ cells/mL in the cell culture flask and incubate at 37 °C and 5% CO2 overnight.

2. Cell counting.

1 . Using the solution from step 2.1 .6, transfer 0.05 mL to a hemocytometer and determine the cell density under a microscope using trypan blue exclusion.

2. Quantify the total number of cells and viable cells.

3. Adjust the cell suspensions to 0.5 x 10⁶ cells/mL. Equation 1 V_CUituremedium(mL) =

suspension NVC = Number of viable WEH1 164 cells/mL V_CUituremedium(mL) = Assay culture medium volume added to the cell suspension to achieve 0.5 x 10⁶ cells/mL 0.5 x 10⁶ = Target cell density

3. Cell detachment and the second and third subculture. NOTE: A vacuum system can be used to remove the solutions from the flasks. Disposable or glass sterile pipettes can be used. If the pipette has a cotton clog at the top, it must be removed before use. 1 . Remove the culture medium from the cell culture T-flask using a 1 mL sterile pipette and a vacuum.

2. Dispense 5 mL of cell wash solution into the culture T-flask, mix gently, and discard the solution. Repeat this step twice. NOTE: The complete removal of the culture medium is critical for efficient cell detachment.

3. Add 15 mL of cell detachment solution to the T-flask and let stand for 3 min in an incubator at 37 °C and 5% CO₂.

4. Verify the absence of attached cells in the flask inner wall under the microscope. Remove the cells from the culture T-flask using a 20 mL sterile pipette and dispense them into a 50- mL sterile tube.

5. Centrifuge the cell suspension at 125 x g for 3 min. Discard the supernatant and resuspend the pellet with another 5 mL of culture medium.

6. Count the cells and add enough culture medium to reach the desired cell concentration according to Equation 1.

7. Add this suspension to a 72 cm² T-flask and incubate overnight at 37 °C and 5% CO₂.

8. Subculture the cells at least two times before using them in the neutralization assay. Repeat steps 2.3.1-2.3.8 for the next two days.

4. Assay cell suspension.

1. Select a WEH1 164 subculture that has at least three passes. See step 2.1.

2. Detach and count the cells according to steps 2.2 and 2.3 of this protocol.

3. Dilute the cell suspension according to Equation 1 to 0.5 x 10⁶ cells/mL.

4. Use this cellular suspension for the neutralization assay. Mix all cell suspensions by vortex mixer prior to use.

3. Antibody Preparation and Dilutions

1 . Quantitation of the mAbs.

1 . Determine the concentration of reference substance, control sample, and analytical sample through UV absorption at 280 nm using their mass extinction coefficient (1 .39)1 . NOTE: Original concentrations could be taken from drug product labels. However, this must be verified by UV absorption.

2. mAb dilutions.

1 . Dilute all samples independently in triplicate, with DPBS Mg- and Ca-free solution in 2 mL microtubes, down to 2 mg/mL. Confirm this concentration by UV absorption in triplicate, using DPBS Mg- and Ca-free solution as the blank.

2. Mix the stock protein solutions for 5 s using a vortex mixer.

3. Dilute 100 piL of each 2 mg/mL mAb solution with 0.9 mL of the assay culture medium.

4. Mix for 5 s by vortex mixer. NOTE: These solutions have a concentration of 200 pig/mL Dilutions must be done for each triplicate. Dilute 10 piL of each 200 pig/mL mAb solution with 0.99 mL of the assay culture medium. Mix for 5 s using a vortex mixer. These solutions have a concentration of 2 pg/mL. Perform serial dilutions for each triplicate before using them in the neutralization assay. Make anti-TNFo mAb dilutions in three independent microplates. Make a duplicate from each independent triplicate and dispense them in one microplate, as indicated in Table 2. Reference Substance

Table 2: Microplate sample arrays. A complete neutralization assay must be run in three microplates within coordinates B2 to G11. Random dispensing of reference, analytical, and control samples allow researchers to verify any bias in the assay. Perform mAb dilutions of each reference, sample, or control, as shown in Table 3. NOTE:

The anti-TNFo mAb concentrations described in this table are not the final concentrations in the neutralization assay.

Volume of Assay Volume of Reference Substance,

Plate Concentration in the culture medium Analytical Sample or Control

Column Assay Plate (ng/mL)

(ML) Sample (uL)

2 0 230 2000

3 150 150 from line 2 1000

4 75 75 from line 3 500

5 100 50 from line 3 333

6 75 75 from line 4 250

7 75 75 from line 5 166

8 75 75 from line 6 125

9 75 75 from line 7 83

10 75 75 from line 9 41 11 150 75 from line 10 13

Table 3: Anti-TNFa mAb dilutions. Serial dilutions of anti-TNFo mAbs are demonstrated in this table. Final concentrations described in this table are not the concentrations in the assay, where anti-TNFo mAbs were diluted by a factor of 3 (mAb dilution + culture medium + cells suspension). Lines in bold represent dilutions coming from lines 3, 5, 7, 9, and 10; non-bolded lines represent dilution from lines 3, 4, and 6. These serial dilutions are done just before performing the neutralization assay. Care must be taken to mix by pipetting up and down three times before dispensing the dilutions.

8. Keep the plates at 25 ± 5 °C until use. utralization Assay with WEH1 164 Cells

1 . Mix by vortexing all cell suspensions (0.5 x 10⁶ cells/mL) prior to dispensing at any step of this protocol. NOTE: In this section, warm each solution to 37 °C for 30 min prior to use.

2. Transfer 50 piL of the cell suspension to each of the 60 wells of the microplates, moving from column 2 to 11 and line B to G.

3. Transfer 50 piL of mAb reference, sample, and control dilutions into microplates. Follow the pattern depicted in Figure 16.

4. Add 50 piL of the apoptosis induction solution to each well.

5. Use cellular controls of 50 piL of WEH1 164 cells, dispensed in three wells. Bring each well to a final volume of 150 piL with assay culture medium.

6. Use a cytotoxicity control of a mixture of 50 piL of WEH1 164 cells plus 50 piL of apoptosis induction solution. Bring each well to a final volume of 150 piL with assay culture medium.

7. For the TNFo control, use 50 piL of the apoptosis induction solution and bring it to 150 piL with the assay culture medium.

8. For the blank, use 150 piL of the assay culture medium alone.

9. Fill the remaining wells with 150 piL of culture medium to avoid plate evaporation effects.

10. Repeat steps 4.1.1-4.1.9 twice in two other microplates. NOTE: The mAb final concentrations in the microplate are:0.666, 0.333, 0.167, 0.111, 0.083, 0.056, 0.042, 0.028, 0.014, and 0.004 pig/mL

11. Load the samples in microplates, as indicated in Figure 16. B1 to G11 are well coordinates in the microplates and describe the positions where the sample dilutions are placed. Missing coordinates are wells filled with controls and assay culture medium (A1-A12 and H1-H12). This random distribution of samples (forward and reverse dilutions in the microplates) helps to eliminate bias in the results due to the evaporation of medium or other variables. It is best that each microplate is done by one analyst at a time. R: Reference, S: sample, CS: control sample, Dll: dilution.

12. Incubate the three plates at 37 °C and 5% CO2for 16 ± 2 h.

13. Let the caspase 3/7 Gio reagent stand at 25 ± 5 °C for 30 min before use.

14. Add 100 piL of this reagent to all wells, including the samples and controls. Shake the plates using a microplate vortex mixer for 3 min at 25 ± 5 °C immediately after dispensing into the wells. Incubate the plates for 2.5 ± 0.5 h at 25 ± 5 °C, protected from light. Insert the microplates into the luminometer and complete the next section. is of Results Using a software for luminescence detection, select the luminescence mode and endpoint function. Select a 96-well clear-bottom plate and its 80 internal wells, excluding columns 1 and 12. Select an integration time of 1,250 ms and 10 s for mixing the microplate before reading. Select the wells where reference substance, analytical substance, and control sample will be placed and identify with their corresponding concentrations. Read the samples placed in the microplates with the luminometer. Use a fourth parameter equation for the analyses of results. Graph a dose-response curve, as depicted in Figure 17. NOTE: In the fourth parameter equation, C is the effective concentration 50 (EC50). This value will be used to compare the reference substance, analytical sample, and control sample by means of the effector function. For calculating the relative potencies, fix the reference substance to 100% and calculate the potencies of the sample and control accordingly. NOTE: Those values are depicted in Figure 18.

Claims

39 Claims

5. The alpha-1-antitrypsin for use according to any one of claims 3-4, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

6. The A1 AT for use according to any one of claims 1-3, wherein the A1 AT and the TNF-o inhibitor are administered before the ischemic event.

7. The A1AT for use according to claim 6, wherein the A1AT and the TNF-o inhibitor are administered to subjects in risk of suffering from ischemic stroke.

9. A combination of an A1 AT and a TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration of the A1 AT and the TNF-o inhibitor.

10. The combination for use according to claim 9, wherein said treatment of ischaemia is treating ischemic stroke.

11. The combination for use according to claim any one of claims 9-10, wherein the combination is

RECTIFIED SHEET (RULE 91) ISA/EP 40 administered within the first twenty hours, for example, within the first twelve hours, of symptom onset, in particular within the first six hours of symptom onset, for example within the first three hours of symptom onset.

12. The combination for use according to any one of claims 10-11, wherein the treatment further comprises the simultaneous, sequential or separate administration within a therapeutic interval of a reperfusion therapy selected from the group consisting of a thrombolytic agent, mechanical thrombectomy and combinations thereof.

13. The combination for use according to any one of claims 9-10, wherein the A1AT and the TNF-o inhibitor are administered before the ischemic event.

14. The combination for use according to any one of claims 9-13, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

15. A kit of parts comprising at least two recipients wherein one of the recipients comprises a pharmaceutical composition comprising A1 AT together with pharmaceutically excipients and/or carriers, and the other recipient a pharmaceutical composition comprising a TNF-o inhibitor together with pharmaceutically excipients and/or carriers, together with instructions for use in the treatment of ischemia involving the simultaneous or sequential administration of both active ingredients.

16. The kit of parts according to claim 15, wherein the instructions are for use in the treatment of ischemic stroke.

17. The kit of parts according to any one of claims 15-16, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

18. A TNF-o inhibitor for use in the treatment of ischaemia, wherein the treatment comprises the simultaneous, sequential or separate administration within a therapeutic interval of a TNF-o inhibitor and A1AT.

19. The TNF-o inhibitor for use according to claim 18, wherein said treatment of ischaemia is treating ischemic stroke.

20. The TNF-o inhibitor for use according to any one of claims 18-19, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

RECTIFIED SHEET (RULE 91) ISA/EP 41

21 . A1 AT for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration within a therapeutic interval of A1AT and a TNF-o inhibitor.

22. A combination of an A1 AT and a TNF-o inhibitor for use in neuroprotection, wherein the neuroprotection comprises the simultaneous, sequential or separate administration of the A1AT and the TNF- o inhibitor.

23. A kit of parts comprising at least two recipients wherein one of the recipients comprises a pharmaceutical composition comprising A1 AT together with pharmaceutically excipients and/or carriers, and the other recipient a pharmaceutical composition comprising a TNF-o inhibitor together with pharmaceutically excipients and/or carriers, together with instructions for use in neuroprotection involving the simultaneous, sequential or separate administration within a therapeutic interval of both active ingredients.

24. The A1AT for use according to claim 21, the combination for use according to claim 22, or the kit of parts according to claim 23, wherein the TNF-o inhibitor is selected from the group consisting of infliximab, adalimumab, certolizumab pegol, golimumab, etanercept, in particular, the TNF-o inhibitor is infliximab or etanercept.

RECTIFIED SHEET (RULE 91) ISA/EP