Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/435—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with one nitrogen as the only ring hetero atom
  • A61K31/47—Quinolines; Isoquinolines
  • A61K31/485—Morphinan derivatives, e.g. morphine, codeine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
  • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
  • A61K31/529—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim forming part of bridged ring systems
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/04—Centrally acting analgesics, e.g. opioids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/18—Antipsychotics, i.e. neuroleptics; Drugs for mania or schizophrenia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/22—Anxiolytics
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/30—Drugs for disorders of the nervous system for treating abuse or dependence
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P25/00—Drugs for disorders of the nervous system
  • A61P25/30—Drugs for disorders of the nervous system for treating abuse or dependence
  • A61P25/36—Opioid-abuse

Definitions

• the present invention refers to a new combination of sodium channel blockers, especially Tetrodotoxin, and their derivatives with opioid antagonists, especially naloxone, according medicinal products for human and/or animal therapeutics and their use for the treatment of a variety of diseases, especially pain, preferably neuropathic pain.
• Pain is defined by the International Association for the Study of Pain (IASP) as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 210). Even though pain is always subjective its causes or syndromes can be classified.
• IASP International Association for the Study of Pain
• neuropathic pain i.e. pain caused by lesions of the peripheral or central nervous system
• neuropathic pain is still a challenge for clinicians as no specific drugs actually exist for its alleviation.
• the use of antidepressants and anticonvulsants to reduce neuropathic pain is founded on empirical observations only, and the efficacy of these drugs is most often limited both in amplitude and duration.
• patients often complain of undesirable side effects and develop tolerance to the anti-pain action of these drugs. Therefore, novel therapeutic strategies have to be developed, possibly on a rationale basis. Therefore, it was the underlying problem of this invention to find new ways of treating pain, especially neuropathic pain.
• Figure 1 represents the time-course curves for the Paw Withdrawal Test of a combination according to the invention and a comparison of the overall effects between two groups (saline + TTX and naloxone + TTX). See also Example 1.
• Figure 2 represents the time-course curves for the Vocalization Test of a combination according to the invention and a comparison of the overall effects between two groups (saline + TTX and naloxone + TTX). See also Example 1.
• Figure 3 represents the time-course curves for the Paw Withdrawal Test (left) and the Vocalization Test (right) of a combination of TTX and morphine (an opioid agonist) and a comparison of the overall effects between two groups (saline + TTX and morphine + TTX). See also Example 2.
• Figure 4 represents the AUC values corresponding to time-course changes depicted in figure 3. From left to right the columns signify saline+TTX, morphine+saline and TTX+morphine. See also Example 2.
• Figure 5 represents the DAGO stimulated [ 35 S]GTP ⁇ S specific binding in subcellular fractions of rat brain.
• SPM synaptic plasma membranes
• Ml microsomal membranes
• C physiological saline
• ChroT chronic TTX
• ChroM chronic morphine
• ChroM+T chronic morphine and TTX.
• Data is expressed as [ 35 S]GTP ⁇ S binding activities in fmol x mg protein "1 and is the means ⁇ S. E. M. See also Example 3.
• Figure 6 represents changes in the basal [ 35 S]GTP ⁇ S binding activity due to chronic drug treatments in subcellular fractions of rat brain.
• SPM synaptic plasma membranes
• Ml microsomal membranes
• C physiological saline
• ChroT chronic TTX
• ChroM chronic morphine
• ChroM+T chronic morphine and TTX.
• Data is expressed as [ 35 S]GTP ⁇ S binding activities in fmol x mg protein "1 and are the means ⁇ S.E.M. See also Example 3.
• Figure 7 represents changes in the maximal [ 35 S]GTP ⁇ S binding activity due to chronic drug treatments in subcellular fractions of rat brain.
• SPM synaptic plasma membranes
• Ml microsomal membranes
• C physiological saline
• ChroT chronic TTX
• ChroM chronic morphine
• ChroM+T chronic morphine and TTX.
• Figure 8 represents changes in the EC 50 of [ 35 S]GTP ⁇ S binding activity due to chronic drug treatments in subcellular fractions of rat brain.
• SPM synaptic plasma membranes
• Ml microsomal membranes
• C physiological saline
• ChroT chronic TTX
• ChroM chronic morphine
• ChroM+T chronic morphine and TTX.
• Data is expressed as EC 50 of [ 35 S]GTP ⁇ S binding activities in nM and are the means ⁇ S.E.M. See also Example 3.
• the main object of this invention is a combination of pharmaceutically active compounds comprising:
• a further object of the invention is a pharmaceutical formulation comprising a combination of compound A and compound B as defined above and optionally at least one auxiliary material and/or additive.
• a further aspect of the invention is the use a combination of compound A and compound B as defined above for the production of a medicament for the treatment and/or prophylaxis of the conditions as described later under the corresponding heading.
• sodium channel blocker mentioned in this application is defined as a compound that specifically binds to and specifically inhibits sodium channels, especially TTX-resistant or TTX-sensitive sodium channels.
• TTX-resistant and TTX- sensitive refers to a difference in the tightness of TTX binding, with the TTX resistant channel having a binding constant as mentioned in Hunter et al., Current Opinion in CPNS Investigational Drugs 1 (1 ), 1999 as well as in Clare et al.
• a preferred sodium channel blocker thus binds to a sodium channel with a Ki of less than 200 ⁇ M, preferably less than 100 ⁇ M or with an IC 50 of 2 ⁇ M. Said inhibition refers to suppression or modification of any downstream effect caused by activation of said sodium channels.
• sodium channel blocker refers to compounds binding to an alpha subunit of sodium channels, especially TTX-resistant or TTX-sensitive sodium channels. More preferably, the term “sodium channel blocker” mentioned in this invention refers to compounds binding to either a SS1 or SS2 region of an alpha subunit of sodium channels, especially TTX-resistant or TTX-sensitive sodium channels.
• Preferred sodium channel blockers for use in this invention are tetrodotoxin and saxitoxin which both specifically inhibit said sodium channels.
• Opioids is the common name for all compounds which have the same mode of action as the constituents of opium, the dried milky liquid of the poppy seed, Papaver somniferum
• opioid receptor The opioid peptide systems plays an important role in pain and is significantly implicated in antinociceptive processes.
• the main groups of opioid peptides are enkephalins, dynorphins and beta-endorphin which derive from proenkephalin, prodynorphin and proopiomelanocortin, respectively.
• the peptide structure of the four different opioid receptors is very similar (Gaveriaux-Ruff and Kieffer, 1999) and this is the reason why most of the opioid receptor ligands show affinity for more than one type of receptor. In most cases, one type is preferred and the action and side-effect profile is dominated by the properties of this receptor. Intensive research was necessary to find out receptor-specific 'selective' ligands, but several selective agonists and antagonists for each type of opioid receptor have now been developed.
• opioid antagonist refers to a molecule or a compound which has affinity to an opioid receptor and inhibits, modifies or reduces the intensity of its downstream signalling. Additionally, the term “opioid antagonist” refers to a compound which shows at least 50 % inhibition at a concentration of 10 ⁇ M in radioactive replacement experiments or has at least a Ki value of 1 ⁇ M towards an opioid receptor.
• Opioid receptors referred to in this invention are ⁇ , K, ⁇ or ORL-1 receptor.
• opioid antagonists include but are not limited to Naloxone, Naltrexone, Etonitazenyl isothiocyanate, Naloxonazine dihydrochloride, Clocinnamox mesylate, b-Funaltrexamine hydrochloride, CTOP or CTAP.
• analogues as used in this application is defined here as meaning a chemical compound structurally related to an acting compound having similar activity.
• derivatives as used in this application is defined here as meaning a chemical compound having undergone a chemical derivation starting from a acting compound e.g. a ⁇ -opioid antagonist, to change (ameliorate for pharmaceutical use) any of its physico- chemical properties, especially a so-called prodrug, e.g. their esters and ethers.
• a prodrug e.g. their esters and ethers.
• Examples of well known methods of producing a prodrug of a given acting compound are known to those skilled in the art and can be found e.g. in Krogsgaard-Larsen et al., Textbook of Drugdesign and Discovery, Taylor & Francis (April 2002).
• neutral form refers to the non-ionic form but also to (at its isoelectric point) neutrally charged forms (that means containing an equal amount of positive and negative charges) especially the Zwitter-lon.
• salt is to be understood as meaning any form of the active compound according to the invention in which this compound assumes an ionic form or is charged and - if applicable - is also coupled with a counter-ion (a cation or anion).
• a counter-ion a cation or anion
• complexes of the active compound with other molecules and ions in particular complexes which are complexed via ionic interactions.
• this includes the acetate, mono-trifluoracetate, acetate ester salt, citrate, formate, picrate, hydrobromide, monohydrobromide, monohydrochloride or hydrochloride.
• physiologically acceptable salt in the context of this invention is understood as meaning a “salt” (as defined above) of at least one of the compounds according to the invention which are physiologically tolerated - especially if used in humans and/or mammals.
• solvate is to be understood as meaning any form of the active compound according to the invention in which this compound has attached to it via non-covalent binding another molecule (most likely a polar solvent) especially including hydrates and alcoholates, e.g. methanolate.
• a polar solvent especially including hydrates and alcoholates, e.g. methanolate.
• the main object of the present invention is a combination of pharmaceutically active compounds comprising at least one Compound A) and at least one Compound B).
• Another preferred aspect of the invention is a combination of pharmaceutically active compounds consisting of: at least one Compound A) selected from a Sodium channel blocker, and/or of one of its derivatives, optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate; and
• Another preferred aspect of the invention is a combination according to the invention wherein at least one compound A is a sodium channel blocker specific for a TTX-sensitive Sodium channel.
• the term "specific" means, in the case of TTX, binding to one subtype (TTX-sensitive or TTX-resistant) of a sodium channel with an IC 50 lower than for the other subtype and, in the case of an opioid antagonist, binding with a lower Ki value for any of opioid receptor subtypes ( ⁇ , K, ⁇ or ORL-1 ) than for the other opioid receptor subtypes.
• TTX-sensitive sodium channel refers to a type of voltage-gated sodium channel with IC 50 values of TTX being in the range of 1 to 12 nM, as published in the IUPHAR Compendium of Voltage-gated Ion Channels (2002).
• TTX-sensitive sodium channels include the Na v 1.1 , Nav1 -2, Na v 1.3, Na v 1.6, and Na v 1.7.
• Another preferred aspect of the invention is a combination according to the invention wherein at least one compound A is a sodium channel blocker specific for a TTX-resistant Sodium channel.
• TTX-resistant sodium channel refers to a type of voltage-gated sodium channel with IC 50 values of TTX being above 1 ⁇ M, as published in the IUPHAR Compendium of Voltage-gated Ion Channels (2002).
• TTX-resistant sodium channels include the Na v 1.4, Na v 1.5, Na v 1.8 and Na v 1.9.
• Another preferred aspect of the invention is a combination according to the invention wherein at least one compound A is selected from Tetrodotoxin and/or at least one of its analogues or derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate; and/or from Saxitoxin and/or at least one of its analogues or derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially
• Tetrodotoxin also known as Ti Qu Duo Xin
• Ti Qu Duo Xin is an alkaloid found in puffer fish (Tetradontiae).
• the chemical name is Octahydro-12-(Hydroxymethyl)-2-imino-5, 9, 7, 10a-dimethano-1 OaH-[1 , 3]dioxocino[6,5- d]pyrimidine-4,7, 10,11 ,12-pentol with a molecular formula C 1 I H 17 N 3 O 8 and a Molecular weight of 319.27. It is a potent non-protein neurotoxin and an indispensable tool for the study of neurobiology and physiology.
• Tetrodotoxin is a marine organic toxin which is mainly found in testicles, ovaries, eggs, livers, spleens, eyeballs, and blood of puffer fish as well as in diverse animal species, including goby fish, newt, frogs and the blue ringed octopus and even in marine alga.
• TTX is a marine organic toxin which is mainly found in testicles, ovaries, eggs, livers, spleens, eyeballs, and blood of puffer fish as well as in diverse animal species, including goby fish, newt, frogs and the blue ringed octopus and even in marine alga.
• Several processes for producing TTX are known.
• TTX is extracted from marine organisms (e.g.
• Tetrodotoxin is a well known compound described for example in WO02/22129 as systemically acting as analgesic.
• WO02/22129 describes TTX as systemically acting as an analgesic, including acting on neuropathic pain. This general mentioning of neuropathic pain as an example of pain to be treated with TTX is not going into any details regarding neuropathic pain especially no mentioning of any subtype.
• derivatives and analogues of tetrodotoxin are including but are not limited to anhydro- tetrodotoxin, tetrodaminotoxin, methoxytetrodotoxin, ethoxytetrodotoxin, deoxytetrodotoxin and tetrodonic acid, 6 epi-tetrodotoxin, 11-deoxytetrodotoxin as well as the hemilactal type TTX analogues (e.g.
• 6-ep/-TTX lactone
• 11 -deoxy-TTX lactone
• 11- ⁇ or-TTX-6(S)-ol lactone
• 11-nor-TTX-6(R)-ol lactone
• 11- ⁇ or-TTX-6,6-diol lactone
• 5-cteoxy-TTX 5, 11 -dideoxy-TTX
• 4-ep/-5, 11 -didroxy-TTX 1 -hydroxy-5, 11 -dideoxy-TTX, 5,6,11 -t ⁇ deoxy- TTX and 4-ep/-5,6,11-fr7c/eoxy-TTX
• 4,9-anhydro type TTX analogs e.g.
• TTX analogues examples include novel TTX analogs isolated from various organisms, as well as those that are partially or totally chemically synthesized (see e.g., Yotsu, M. et al. Agric. Biol. Chem., 53(3):893-895 (1989)). "Analogues" of TTX bind to the same site on the alpha subunit of sodium channels as does TTX.
• Saxitoxin is - according to the Merck Index on CD Version 12:1 - a mussel poison; clam poison; paralytic shellfish poison; gonyaulax toxin.
• This powerful neurotoxin is produced by the dinoflagellates Gonyaulax catenella, or G. tamarensis, the consumption of which causes the California sea mussel Mytilus californianus, the Alaskan butterclam Saxidomus giganteus and the scallop to become poisonous: Sommer et al., Arch. Pathol. 24, 537, 560 (1937); Schantz et al., Can. J. Chem. 39, 2117 (1961 ); Ghazarossian et al., Biochem. Biophys. Res.
• the combination according to the invention is defined in that Compound A is selected from tetrodotoxin, optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio;in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• Compound A is selected from tetrodotoxin, optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio;in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• the combination according to the invention is defined in that Compound A is selected from tetrodotoxin in neutral form or as a salt, especially a physiologically acceptable salt.
• the combination according to the invention is defined in that in that Compound A is selected from tetrodotoxin, its derivative or its analogue which is isolated from a biological source, preferably from fish, especially puffer fish.
• the combination according to the invention is defined in that Compound A is selected from tetrodotoxin, its derivative or its analogue which is synthesized.
• the combination according to the invention is defined in that at least one Compound B is an unspecific opioid antagonist, a specific ⁇ - opioid antagonist, a specific ORL1 -antagonist, a specific ⁇ -opioid antagonist, or a specific ⁇ -opioid antagonist, including their derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• the combination according to the invention is defined in that at least one Compound B is a specific ⁇ -opioid antagonist, including the derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• a specific ⁇ -opioid antagonist including the derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a
• the combination according to the invention is defined in that at least one Compound B is a specific ⁇ -opioid antagonist, including their derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• a specific ⁇ -opioid antagonist including their derivatives optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a
• the combination according to the invention is defined in that at least one Compound B is naloxone, Naltrexone, Etonitazenyl isothiocyanate, Naloxonazine dihydrochloride, Clocinnamox mesylate, b-Funaltrexamine hydrochloride, CTOP or CTAP.
• the combination according to the invention is defined in that Compound A is Tetrodotoxin and Compound B is a ⁇ -opioid antagonist.
• the combination according to the invention is defined in that Compound A is Tetrodotoxin and Compound B is a ⁇ -opioid antagonist.
• the combination according to the invention is defined in that Compound A is Tetrodotoxin and Compound B is Naloxone, Naltrexone, Etonitazenyl isothiocyanate, Naloxonazine dihydrochloride, Clocinnamox mesylate, b-Funaltrexamine hydrochloride, CTOP or CTAP.
• Another aspect of this invention is a Pharmaceutical formulation containing a combination according to the invention and optionally at least one auxiliary material and/or additive.
• the Compound A especially tetrodotoxin, is present in the amount of between 10 ⁇ g and 4 mg, especially between 5 and 2000 ⁇ g, preferably between 250 and 1000 ⁇ g or between 25 and 50 ⁇ g.
• the Compound B is present in the amount of between 10 and 4000 mg/day, preferably between 20 to 2000 mg/day, most preferably between 40 and 500 mg/day.
• the ratio between Compound A, especially tetrodotoxin, and Compound B, especially naloxone, in the Pharmaceutical formulation is between 1 : 2000 up to 1 : 10, preferably between 1 : 500 up to 1 : 50, most preferably between 1 : 300 up to 1 : 80.
• the dose administered is normally between 10 and 4000 ⁇ g/day of the sodium channel blocker, especially tetrodotoxin, its derivatives or its analogues, especially the dose of tetrodotoxin administered is normally between 10 and 4000 ⁇ g/day or - given the likely twice per day treatment - between 5 to 2000 ⁇ g each given dose, sometimes preferably between 250 and 1000 ⁇ g each given dose, sometimes preferably between 25 and 50 ⁇ g each given dose depending on the route of administration.
• the dose administered of the opiod antagonist is normally between 10 and 4000 mg/day, preferably between 20 to 2000 mg/day, most preferably between 40 and 500 mg/day or - given the likely twice per day treatment - between 5 to 2000 mg each given dose, sometimes preferably between 10 and 1000 mg each given dose, sometimes preferably between 20 and 250 mg each given dose depending on the route of administration.
• the proper dose is well known in the art.
• any amount defined refers to each compound individually not to any combination and refers to the compound having a purity of > 97%.
• This on the other hand will exclude any impurity contained within the >3% to be mentioned, defined or referred to as active compound in the sense of this invention.
• active compound in the sense of this invention.
• the auxiliary material and/or additive can be specifically selected from conserving agents, emulsifiers and/or carriers for parenteral application.
• the selection of these auxiliary materials and/or additives and of the amounts to be used depends upon how the pharmaceutical composition is to be applied. Examples include here especially parenteral like intravenous subcutaneous or intramuscular application formulations but which could also be used for other administration routes.
• Routes of administration of tetrodotoxin its derivatives and its analogues can include intramuscular injection, intraveneous injection, subcutaneous injection, sublingual, bucal, patch through skin, oral ingestion, implantable osmotic pump, collagen implants, aerosols or suppository.
• Another aspect of this invention refers to a process for the production of a combination according to the invention in which Compounds A and B are mixed.
• Another aspect of this invention refers to a process for the production of a pharmaceutical formulation according to the invention in which the Compounds A and B are combined during the process of formulating the pharmaceutical formulation.
• Another aspect of this invention refers to the use of a combination according to the invention for the production of a medicament for the treatment of pain, especially moderate to severe pain, cancer pain (resulting from cancer), and neuropathic pain.
• this use for pain according to the invention is for neuropathic pain.
• Neuronal pain is defined by the IASP as “pain initiated or caused by a primary lesion or dysfunction in the nervous system” (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 210).
• IASP Pain initiated or caused by a primary lesion or dysfunction in the nervous system
• Neuroogenic Pain is defined by the IASP as "pain initiated or caused by a primary lesion, dysfunction or transitory perturbation in the peripheral or central nervous system”.
• the neuropathic pain is central pain.
• central pain is defined as "a pain initiated or caused by a primary lesion or dysfunction in the central nervous system” (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 211 ).
• the neuropathic pain is peripheral neuropathic pain or peripheral neurogenic pain.
• Peripheral neuropathic pain is defined by the IASP as “pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system” and “Peripheral neurogenic pain” as “pain initiated or caused by a primary lesion, dysfunction or transitory perturbation in the peripheral nervous system” (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 213). 5
• the neuropathic pain is allodynia.
• IASP allodynia
• the neuropathic pain is causalgia.
• IASP cerebral spastic syndrome
• IASP a syndrome of sustained burning pain, allodynia and hyperpathia after a traumatic nerve lesion, often combined with vasomotor and sudomotor dysfunction and later trophic changes
• the neuropathic pain is hyperalgesia.
• hypoalgesia is defined as "an increased response to a stimulus which is normally painful(IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 211 ).
• the neuropathic pain is hyperesthesia.
• IASP hyperesthesia
• the neuropathic pain is hyperpathia.
• hypopathia is defined as "a painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold” (IASP 1 Classification of chronic pain, 2 nd Edition, IASP Press (2002), 212).
• the IASP draws the following difference between "allodynia”, “hyperalgesia” and “hyperpathia” (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 212):
• the neuropathic pain is neuralgia.
• nervegia is defined as "Pain in the distribution of a nerve or nerves” (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 212).
• the neuropathic pain is neuritis.
• IASP Inflammation of a nerve or nerves
• the neuropathic pain is neuropathy.
• neuroneuropathy is defined as "a disturbance of function or pathological change in a nerve: in one nerve mononeuropathy, in several nerves mononeuropthy multiplex, if diffuse and bilateral, polyneuropathy" (IASP, Classification of chronic pain, 2 nd Edition, IASP Press (2002), 212).
• IASP Classification of chronic pain, 2 nd Edition, IASP Press (2002), 2112.
• the combination according to the invention is the use of the combination according to the invention for the production of a medicament for the prophylaxis and/or treatment of drug abuse and/or drug addiction, medicament abuse and/or medicament addiction, preferably drug abuse and/or drug addiction.
• Medicaments/drugs which are frequently the subject of misuse (leading often to addiction) include opioids, especially morphine, barbiturates, cannabis, cocaine, amphetamines, phencyclidine, hallucinogens and benzodiazepines.
• treatment means administration of a compound or formulation according to the invention to prevent, ameliorate or eliminate one or more symptoms associated with de-addiction from the drug/medicament. Such symptoms can arise from withdrawal, or can be associated with relapse behavior, such as a craving of a subject for the drug/medicament.
• Treatment also encompasses preventing, ameliorating or eliminating the physiological sequelae of removal of the drug/medicament from an addicted subject that may cause the exhibited symptoms perceived by the subject.
• Treatment also encompasses a reduction in the amount of the drug/medicament that is consumed by a subject.
• effects of a de-addiction treatment in the context of this invention is understood as including any side effect coming with any de-addiction treatment, especially any kind of withdrawal syndrome.
• meltiorate in the context of this invention is understood as meaning any improvement on the situation of the patient treated - either subjectively (feeling of or on the patient) or objectively (measured parameters).
• the Compound A is used at 10 and 4000 ⁇ g/day, preferably between 5 to 2000 ⁇ g/day.
• the Compound B is used at 10 and 4000 mg/day, preferably between 20 to 2000 mg/day.
• the ratio between Compound A and Compound B is between 1 : 2000 up to 1 : 10, preferably between 1 : 500 up to 1 : 50, most preferably between 1 : 300 up to 1 : 80.
• ком ⁇ онент includes but does not exclusively mean the concomitant administration of compounds, but also the sequential administration of each of the compounds, as well as administration of one compound, followed by administration of the other compound, whereas the time interval between the two administrations can be between 1 min and 1 week. Additionally and most preferably though, in this context of methods of treatment "combination" refers to a formulation containing all compounds in its respective carrier such as a tablet, capsule, a pill or a gum.
• “combination” means a fixed combination of compounds in a single dosage form such as a tablet, a pill, a capsule or a gum. It is also preferred if the method of treatment is restricted to tetrodotoxin as Compound A and a ⁇ -opioid receptor antagonist as Compound B, whereas tetrodotoxin, its derivative and/or one of its analogues is used in an amount between 10 ⁇ g/day and 4 mg/day and is isolated from a biological source, preferably from fish, especially puffer fish, or is synthesized and the compound B is used in an amount between 10 mg/day and 4000 mg/day.
• kits comprising a drug comprising a substance A selected from the group of sodium channel blockers, and/or one of its derivatives, optionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate,
• substance B selected from an opioid antagonist optionally in the form of its racemate, and/or one of its derivativesoptionally in the form of its racemate, pure stereoisomers, especially enantiomers or diastereomers or in the form of mixtures of stereoisomers, especially enantiomers or diastereomers, in any suitable ratio; in neutral form, in the form of an acid or base or in form of a salt, especially a physiologically acceptable salt, or in form of a solvate, especially a hydrate.
• Rats were anaesthetized and the sciatic nerve was exposed through blunt dissection and gently freed from adhering tissues.
• Four ligatures (5-0 chromic catgut, applied 1-2 mm apart) were then placed around the nerve (Bennett and Xie, 1988). To obtain the desired degree of constriction, the criterion formulated by Bennett and Xie (1988) was applied.
• TTX was injected s.c. after 15 min prior administration of naloxone or saline at a dose of 3 ⁇ g/kg.
• concentration of naloxone used in the experiments was 0.5 mg/kg
• control animals received the vehicle (0.09% NaCI) under the very same time and environmental conditions.
• each rat received only one treatment (at only one dose of a given compound), and was used once only.
• Morphine or saline was injected 15 min prior to TTX, and pressure thresholds were determined thereafter at 30 min intervals up to 2h 30 min post TTX injection. Each point is the mean + S. E. M. of the number of determinations (one determination per rat) indicated in parentheses.
• the concentration of morphine used in the experiments was 3 mg/kg, TTX was used at a dose of 3 ⁇ g/kg, control animals received the vehicle (0.09% NaCI) under the very same time and environmental conditions. In all cases, each rat received only one treatment (at only one dose of a given compound), and was used once only.
• Example 3 Effect of TTX on the mu-opioid receptor, especially the effect of chronic in vivo TTX treatments on the signaling of mu-opioid receptors
• TTX TTX on opioid receptor regulatory changes which accompany opioid tolerance/dependence was tested.
• the model system used was based on subcellular fractionation of rat brains followed by ligand binding and functional measurements (Sz ⁇ cs and Coscia, 1992; Fabian et al. 2002). A detailed characterization of the effect of the drugs on the intracellular mu-opioid sites was done.
• Morphine-HCI, (M) was dissolved in sterile physiological saline, and given subcutaneously (s.c) in a volume of 0.2 ml/100 g body weight twice daily for 5 days according to a published paradigm (Fabian et al. 2002) as shown below.
• Subcellular fractions of rat brains were purified as published (Sz ⁇ cs and Coscia, 1992, Fabian et al. 2002). Briefly, fresh forebrains were gently homogenized, and the homogenate centrifuged at 1 ,000 x g for 10 min. This centrifugation step was repeated with the resulting pellets. The combined supematants were spun at 12,000 x g for 20 min. The pellets were suspended in 10% sucrose and subjected to consecutive centrifugations at 20,000 x g for 25 min and 14,000 x g for 20 min twice resulting in crude synaptic plasma membranes (SPM).
• SPM crude synaptic plasma membranes
• 35 suspensions were freshly used in the ligand-stimulated [ S]GTPyS functional assay, but were aliquoted and kept frozen at -80 0 C until used in ligand binding assays.
• Homologous displacement assays were performed with a constant concentration ( ⁇ 1 nM) of [ 3 H]DAGO (spec, activity 36 Ci/mmol), 1 1 concentrations (10 "10 -10 "5 M) of unlabelled DAGO (Tyr-D-Ala-Gly-(NMe)Phe-Gly-ol) and the membrane suspensions (200-300 ⁇ g protein) in 50 mM Tris-HCI pH 7.4 buffer in a final volume of 1 ml. Saturation binding experiments were performed by incubating the membranes with increasing concentrations (0- 8 nM) of [ 3 H]DAGO in 50 mM Tris-HCI pH 7.4 buffer in a final volume of 1 ml.
• Nonspecific binding was defined as the bound radioactivity in the presence of 10 ⁇ M unlabelled DAGO, and subtracted from the total binding to get specific binding.
• the tubes were incubated at 25 0 C for 1 h. The reaction was stopped by vacuum filtration through glass fiber filters using a Cell Harvester. Filters were rapidly washed with 3 x 5 ml ice-cold 50 mM Tris-HCI (pH 7.4) buffer, air-dried and counted in a toluene-based scintillation cocktail in a scintillation counter. All assays were performed in duplicate and repeated at least three times. Curves were constructed and analyzed to obtain K D
• Freshly purified rat brain membrane fractions (»10 ⁇ g of protein/tube) were incubated with 0.05 nM [ 35 S]GTPyS (35-37 TBq/mmol) and increasing concentrations (10 ⁇ 9 - 1 ⁇ "4 M) of DAGO or morphine in the presence of 100 ⁇ M GDP in a total volume of 1 ml in 50 mM Tris-HCI, 1 mM EGTA and 3 mM MgCI 2 pH 7.4 buffer for 60 min at 30 0 C as published
• ChroM+T chronic morphine and TTX.
• rat brains were subjected to subcellular fractionation to obtain SPM and Ml fractions.
• the ability of the highly potent mu-opioid receptor specific agonist DAGO (10 "9 -10 "5 M) to stimulate [ 35 S] GTPYS binding was assessed.
• Figure 5 shows the pooled curves of the individual experiments. In all 4 fractions, albeit to different extents, chronic TTX shifted the dose-response curve of DAGO to the right and lowered the binding activities.
• Chronic TTX treatment decreased the potency (increased the EC 50 ) of the opioid agonist DAGO to elicit signaling, in this case G-protein activation in the morphine- dependent subcellular fractions.

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