Compounds for preventing sudden death in epilepsy (SUDEP), methods and uses thereof

Abstract

The present disclosure relates to the use of cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for preventing and / or reducing the risk of Sudden Unexpected Death in Epilepsy (SUDEP). The disclosure further provides pharmaceutical compositions and methods for preventing and / or reducing the risk of SUDEP, particularly in Dravet Syndrome patients.

Description

D E S C R I P T I O NCOM POUNDS FOR PREVENTI NG SUDDEN DEATH IN EPI LEPSY (SU DEP), METHODS AN D USES THEREOFTECH NICAL FIELD

[0001] The present disclosure relates to the fields of medical therapeutics, specifically to methods and compositions for prevention of Sudden Unexpected Death in Epilepsy (SUDEP), namely SUDEP in Dravet Syndrome.

[0002] The present disclosure relates to the use cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for use in the prevention of SUDEP and / or in the reduction of the risk of SUDEP.

[0003] The present disclosure also relates to the use a composition comprising cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, DHEA, dexamethasone, betamethasone, ACTH, ganaxolone, tetracosactide or combinations thereof in a therapeutically effective amount and a pharmaceutical acceptable carrier, adjuvant, excipient, or mixtures thereof for SUDEP prevention and / or for the reduction of the risk of SUDEP.

[0004] The present disclosure relates to the fields of medical prevention of Sudden Unexpected Death in Epilepsy or Dravet syndrome.BACKGROUND

[0005] Epilepsy is a heterogeneous clinical condition characterized by recurrent unprovoked seizures, their causes, and complications. There are numerous causes of epilepsy including, but not limited to birth trauma, perinatal infection, anoxia, infectious diseases, ingestion of toxins, tumors of the brain, inherited disorders or degenerative disease, head injury or trauma, metabolic disorders, cerebrovascular accident, and alcohol withdrawal1. Also, a person's epilepsy diagnosis can be further specified by identifying their epilepsy syndrome. An epilepsy syndrome is defined by a unique set of clinical features, signs, and symptoms that accompanythe seizures. Examples of epilepsy syndrome include but are not limited to juvenile myoclonic epilepsy, Lennox-Gastaut Syndrome, Landau-Kleffner syndrome, West syndrome, febrile seizures and Dravet Syndrome2.

[0006] Among deaths directly attributable to epilepsy or seizures, SUDEP is estimated to account for up to 50% of deaths in patients with chronic refractory epilepsy, and up to 17% of deaths in all epileptic patients3, being the leading cause of epilepsy-related death4. Risk population is difficult to define, since there is an apparent lack of agreement regarding features such as age of onset of epilepsy, polytherapy, genetic predispositions, alcohol abuse or intellectual disability5. Still, epidemiological data allows to identify chronic refractory epilepsy, in particular nocturnal generalized tonic-clonic seizures (GTCS) in prone position as the major risk factor for SUDEP6. The risk of SUDEP in Dravet Syndrome is up to 15 times higher than other childhood-onset epilepsies. It is the biggest cause of death in Dravet Syndrome, responsible for nearly half of all Dravet Syndrome deaths. SUDEP tends to occur at a younger age (73% before the age of 11) than in other epilepsies7.

[0007] SUDEP is the sudden, unexpected, witnessed or unwitnessed, non-traumatic, and nondrowning death of patients with epilepsy with or without evidence of a seizure, excluding documented status epilepticus, and in which post-mortem examination does not reveal a structural or toxicological cause of death3. Despite of being well defined, SUDEP cannot be predicted nor prevented, thus being the leading cause of epilepsy-related death.

[0008] SUDEP underlying pathomechanisms, involves the cardiac, respiratory, and autonomic nervous systems. Possible respiratory disabilities contributing to SUDEP include central and obstructive apnea, pulmonary edema, ictal hypoxia, aspiration, and laryngospasm8Simultaneously, seizures can induce cardiac arrhythmias, changes in blood pressure or asystole9. The chronological causality is controversial since apnea is rarely secondary to brain hypoperfusion due to cardiac dysfunction5. Likewise, a change in cardiac rhythm cannot be interpreted as the primary problem unless there is also respiratory monitoring because arrhythmias can be secondary to hypoxia and hypercapnia4. Postictal generalized electroencephalogram suppression is a fatal downstream event of cardiorespiratory arrest in SUDEP. In the MORTEMUS study during SUDEP event, the initial GTCS triggered a short period of normal or increased heart and respiratory rates then severe bradycardia and central apnoea with PGES9. Electrocerebral shutdown, not being the primary cause of death, was fatal in one third of the cases4.

[0009] Given the frequency and severity of seizure-induced respiratory abnormalities, it is surprising that death does not occur more often5. It may be that ictal respiratory dysfunction is only dangerous when associated with impaired arousal. In MORTEMUS study, patients who died of SUDEP were frequently found prone positioned in bed with no observable corrective action to optimize their position, remaining in the same position from seizure until death. Prone position allows the mouth and nose to be wholly or partly occluded, and it may take more muscular effort to expand the chest, increasing the risk of rebreathing or asphyxia if the patient fails to achieve arousal5.

[0010] Diencephalon and upper brainstem constitute ascending arousal system (AAS) and are responsible for arousal and consciousness. Impairment of the AAS leaves a patient with epilepsy at greater risk of SUDEP since in some individuals with postictal depression of consciousness, protective reflexes are suppressed during the postictal coma6. AAS serotonin neurons are triggered by hypoxia and hypercapnia, stimulating breathing, and causing arousal when they are activated. Dysfunction of serotonin neurons leads to reduced ability to respond appropriately to an external stressor during a state of generalized central nervous system depression (sleep vs postictal state)4. In sum, ictal and postictal arousal impairment demonstrated contribution to SUDEP, indicate arousal as a crucial process to endure and evade cardiorespiratory arrest in SUDEP being the SUDEP risk manager.

[0011] The major challenge to SUDEP prediction and prevention is the multiplicity of potential underlying pathomechanisms and the phenotypical heterogeneity among epileptic subjects affected by SUDEP.

[0012] Seizure-detection technologies such as mattress, watch, camera, and motion devices that alert the caregivers upon an epileptic seizure are being studied fortheir potential to avoid SUDEP. These devices are currently limited by the immediate availability and education of the caregiver on resuscitation maneuvers and by the unknown critical window for resuscitation. One case of SUDEP was reported in a patient wearing a wrist -worn seizure detection system and respiratory cessation happened within 5 minutes suggesting a very limited time to react3. Finally, none of the above-mentioned technologies can distinguish a life-threatening seizure nor provide data on the evolution of SUDEP risk in order to allow the patients to adapt their medication to preventSUDEP.

[0013] Glucocorticoids, cortisol in humans and corticosterone in rodents, are a major subclass of steroid hormones that regulate metabolic, cardiovascular, immune, and behavioral processes12. Cortisol is the primary endogenous adrenal steroid in most mammals, including humans, whereas corticosterone is the primary adrenal corticosteroid in laboratory rodents (2-6). Rats and mice do not produce appreciable cortisol, because they lack the adrenocortical zona fasciculata enzyme 17-a hydroxylase (CYP17)13. CORT is the rodent stress hormone analog of cortisol in humans and is the major output of the HPA axis. Chronic corticosterone administration induces negative valence and impairs positive valence behaviors in mice, often used as a functional equivalent to cortisol in humans in preclinical research and experimental models14.

[0014] Cortisol exerts its effects via hypothalamic-pituitary-adrenal (HPA) axis15. In a presence of a stimulus, the secreted corticotropin-releasing hormone (CRH) by the hypothalamus triggers cells in the neighboring anterior pituitary to secrete ACTH into the vascular system which in turn stimulates cortisol release in the adrenal cortex16.

[0015] Cortisol is associated with sudden death. Sudden death has been attributed to adrenal crisis18-20(a life-threatening condition in which adrenal glands do not produce enough cortisol), which is now identified as the principal death cause in 15% of Addison patients21. Furthermore, a near sudden infant death, similar condition to SUDEP, was identified as a consequence of adrenal crisis22. Moreover, serum cortisol levels are significantly higher in surviving victims of cardiopulmonary arrest than non-survived patients, suggesting that serum cortisol levels may serve as a predictor of survival23.

[0016] Cortisol is associated with epilepsy, both by its circadian fluctuation24and through its role in stress response25. A systematic review performed by Campen and colleagues in 2015, revealed that circadian seizure distribution varied with localization of the epileptic focus in patients with focal seizures and between seizure types. Furthermore, in the particular case of GTCS there was an increase in the early morning. Similarity to the cortisol rhythm was however less striking because their occurrence was already high during the night and showed a downward trend during the day24.

[0017] People with epilepsy often report seizures precipitated by stress. This is believed to be due to effects of stress hormones, such as cortisol on neuronal excitability26. In this duality of stress, it is proposed that acute stress is protective against seizure events whereas chronic stress may be deleterious25. The major sources of chronic stress for the person with epilepsy are thefrequency of seizures, their unpredictability, the risk of injury and their bizarre behavior during seizures. Hence, in a devastating positive feedback loop, the chronic stress may lead to increased seizure frequency, which may exacerbate the state of chronic stress27. This is demonstrated by the increased basal levels of cortisol commonly found in epileptic patients28. However, mainly due to the seizure's heterogeneity and stress adaptive capacities, reports on hormone levels in patients with epilepsy at resting conditions have been contradictory15.

[0018] In opposition to the contradictory reports on cortisol hormone levels in patients with epilepsy at resting conditions, this consistency was surprisingly found in the postictal cortisol and ACTH values. Directly after an epileptic seizure, which is often considered an acute stressor itself, a consistent and sharp increase in cortisol and ACTH was shown. This is a specific physiological adaptation in response to seizure, named hereinafter in the present application as Cortisol Acute Epileptic Seizure Adaptive Response CAESAR is a consistent fast-sharp cortisol rise found specifically in the postictal phase of epileptic seizures29-34'36. Although changes in cortisol and ACTH concentrations are not specific of a particular stressful event, this particular dynamic increase is a distinctive pattern of epileptic seizures.

[0019] Abbott and colleagues found elevated postictal cortisol levels in three patients in the first hour (between 21.5 pg / dl and 46.0 pg / dl), with a decline tendency afterwards. In one patient, cortisol was not assessed and interestingly the last patient whose cortisol values remained stably low within the first hour (10.6 pg / dl and 11.8 pg / dl), had an unusual, prolonged seizure lasting for 30 minutes and received diazepam. In the stimulated seizure group, they found a consistent rise of cortisol levels posticta I ly from tOmin (~11 pg / dl) to tl5min (~17 pg / dl) with a decline to the basal levels at t45min. Additionally, in a third group of postictal patients, cortisol levels were found increased (30.5 pg / dl) when compared with control group (17.7 pg / dl). They concluded that the change in cortisol level may reflect a non-specific stress response and these findings may have a clinical value in the diagnosis of epilepsy29. Four years later, 24 single GTCS were studied in 20 patients. The results obtained in 30 minutes intervals showed a significant consistent postictal elevation in plasma cortisol preceded by a marked increase in plasma ACTH30. In line with these results, this seizure cortisol response was compared between 6 epileptic and 6 pseudoepileptic seizures. In all epileptic seizures they found a consistent rise of cortisol levels within the first 15 minutes with a further increase until the 30 minutes posticta I ly and a decay in the 45 and 60 minutes after seizure. In the particular case of the only tonic-clonic seizure analyzed, the cortisol levels duplicated within the first 30 minutes after seizure (tOmin 21.6 pg / dl;tl5min 32.4 pg / dl; t30min 40.6 pg / dl). Conversely, the values obtained for pseudo epileptic seizures followed a tendency of decay for all time points within the first hour33. Reinforcing homogeneity of previous results, Rao demonstrated in 1989 that cortisol is increased posticta lly, followed by a decrease after grand mal or complex partial seizure but not after psychogenic seizure in comparison to baseline levels obtained during the same time on a seizure-free day31. The most recent study dedicated to cortisol seizure response is of particular interest for SUDEP research since it was studied on nocturnal GTCS. The change of serum ACTH and cortisol (Table 1) showed a course declining from wake status (33.8 pg / dl, 10.5 pg / dl) to sleep status (16.1 pg / dl, 4.7 pg / dl), slightly falling just before a seizure (11.5 pg / dl, 4.6 pg / dl). During the seizure, there is a sharp raise of both ACTH and cortisol levels (39.3 pg / dl, 11.3 pg / dl), even more pronounced posticta lly (97.2 pg / dl, 15.3 pg / dl)32.

[0020] Table 1. Cortisol variation during seizures: Case epileptic seizures vs control psychogenic seizures; Spontaneous vs Induced seizure (Adapted from32).

[0021] Corticosteroids have been used for the treatment of patients with epilepsy for over 60 years. In 1958, Sorel and Dusaucy-Bauloye first reported a marked improvement in 21 patients with epileptic spasms treated with ACTH. Since then, corticosteroids have evolved into an essential component of the standard therapy of epileptic spasms backed up by evidence of randomized controlled trials35.

[0022] At present, although some retrospective studies show good response rates of various steroid treatment regimens in various epilepsy syndromes, there is a lack of results fromrandomized controlled trials providing clear evidence for the use of specific steroid regimens in epilepsies other than epileptic spasms35.

[0023] There is accordingly a need to provide a therapeutic and diagnostic method for predicting and preventing SUDEP, as well as an improved method for treating Dravet Syndrome and / or for treating, preventing and / or ameliorating seizures experienced by sufferers of Dravet Syndrome.

[0024] These facts are disclosed in order to illustrate the technical problem addressed by the present disclosure.GENERAL DESCRIPTION

[0025] The present disclosure provides novel uses of cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide , or combinations thereof in the prevention of SUDEP and / or in the reduction of the risk of SUDEP, including reduction in seizure severity outcome, namely SUDEP in infants or young children, more in particular in patients with Dravet syndrome.

[0026] The present disclosure also relates to the use of a pharmaceutical composition comprising cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide, or combinations thereof in a therapeutically effective amount and a pharmaceutically acceptable carrier, adjuvant, excipient, or mixtures thereof for preventing or reducing the risk of SUDEP, in particular SUDEP related to an epileptic seizure syndrome. In an embodiment, the pharmaceutical composition comprises cortisol in a therapeutically effective amount and a pharmaceutically acceptable carrier, adjuvant, excipient, or mixtures thereof.

[0027] In an embodiment, cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide, or combinations thereof is administered prophylactically to prevent and / or decrease the risk of SUDEP namely to prevent and / or decrease the risk of SUDEP, including thereduction of seizure severity outcome, in infants or young children, more in particular in patients with Dravet syndrome.

[0028] Additionally, the present disclosure relates to cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for use in the prevention and / or in the reduction of the risk of SUDEP experienced by sufferers of epileptic syndromes; namely for preventing seizures experienced by sufferers of Dravet Syndrome.

[0029] In another aspect, the present disclosure provides for the use of cortisol, cortisone, cortisone acetate hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide, or combinations thereof for preventing, and / or reducing the risk of SUDEP, particularly in patients suffering from Dravet Syndrome.

[0030] According to the present disclosure, cortisol, cortisone, cortisone acetate hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide , or combinations thereof can be administered to patients suffering from epilepsy syndromes such as Dravet Syndrome to prevent and / or reduce the risk of SUDEP.

[0031] In an embodiment, the Dravet Syndrome is associated with a mutation in one, some or all of the genes selected from the group consisting of SCN1A, SCN1B, SCN2A, SCN3A, SCN9A, GABRG2, GABRD and PCDH19.

[0032] The present disclosed subject matter relates to a composition comprising cortisol, cortisone, cortisone acetate hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide , or combinations thereof and also to a composition that includes these substances in a therapeutically effective amount along with a pharmaceutically acceptable carrier, adjuvant, excipient, or mixtures thereof for use in the prevention and / or reduction of the risk of SUDEP. It is demonstrated that these compounds, when administered acutely or chronically, significantly improve survival and seizure outcomes in preclinical epilepsy models (see fig 3 and 4).

[0033] In an embodiment, the composition is administered as a single dose.

[0034] In an embodiment for better results, the composition is in a solid form or liquid form.

[0035] In an embodiment for better results, the composition is suitable for administration orally, nasally, transdermally, rectally, vaginally, subcutaneously, by inhalation or by intravenous injection or intramuscular injection.

[0036] In an embodiment for better results, the composition may further comprise a sodium salt, preferably sodium chloride. Such a combination improves the results by further reducing the risk of SUDEP. The inclusion of sodium chloride enhances the therapeutic efficacy of the composition, providing additional benefits in managing these severe epilepsy-related conditions.

[0037] In an embodiment for better results, the composition may further comprise a pharmaceutically acceptable salt thereof; and a nonaqueous liquid carrier, wherein the nonaqueous carrier comprises propylene glycol, glycerin, polyethylene glycol (PEG), alcohol, or a combination thereof; wherein the liquid pharmaceutical composition is an oral solution, and wherein the liquid pharmaceutical composition contains less than 5% weight by weight (% wt) of water.

[0038] In some embodiments, hydrocortisone or a pharmaceutically acceptable salt thereof may be present in the liquid pharmaceutical composition in an amount of about 1 mg / mL.

[0039] In an embodiment for better results, the compound / composition of the present disclosure may be administered as a daily dosage to the patient in at least 0.5 mg / Kg per day; preferably at least 1 mg / Kg per day; more preferably at least 20 mg / Kg per day, even more preferably from 20 to 240 mg / Kg per day.

[0040] In an embodiment for better results, the dosage can be formulated for once-a-day administration, or for multiple daily administrations (e.g. 2, 3 or 4 times a day administration).

[0041] In an embodiment for better results, the compound / composition of the present disclosure may be formulated in any pharmaceutically acceptable dosage form including oral dosage forms such as tablets including orally disintegrating tablets, capsules, lozenges, oral solutions or syrups, oral emulsions, oral gels, oral films, buccal liquids, powder e.g. for suspension, and the like; injectable dosage forms; transdermal dosage forms such as transdermal patches, ointments, creams; inhaled dosage forms; and / or nasally, rectally, vaginallyadministered dosage forms. Liquid dosage forms, such as solutions, emulsions and syrups, e.g. for oral administration.

[0042] In an embodiment for better results, the compound / composition of the present disclosure may be prepared by combining the compound / composition of the present disclosure with one or more pharmaceutically acceptable diluents, carriers, adjuvants, and the like in a manner known to those skilled in the art of pharmaceutical formulation.

[0043] In an embodiment for better results, the compound / composition of the present disclosure may be employed as a monotherapy, i.e. it is employed as the sole therapeutic agent in those treatments.

[0044] Alternatively, the compound / composition of the present disclosure may be coadministered simultaneously, sequentially, or separately with one or more co-therapeutic agents, such as anticonvulsants. Preferred co-therapeutic agents can be selected from the group consisting of carbamazepine, ethosuximide, fosphenytoin, lamotrigine, levetiracetam, phenobarbitol, progabide, topiramate, stiripentol, valproic acid, valproate, verapamil, and benzodiazepines such as clobazam, clonazepam, diazepam, ethyl loflazepate, lorazepam, midazolam. Use of a pharmaceutically acceptable salt of a co-therapeutic agent is also disclosed.

[0045] In an embodiment for better results, the daily form consists of a tablet, suppository, ampoule, or other device, comprising a definitive amount of the composition disclosed in the present disclosure, the whole of which is intended to be administered as a single dose.

[0046] The compounds and compositions of the present disclosure can be used in high doses during the acute phase to prevent SUDEP, or in lower doses as a prophylactic measure to prevent and / or reducing the risk of SUDEP.

[0047] In an embodiment, it was observed a fast sharp rise in cortisol levels, similar to cortisol awakening response (doubling of cortisol levels within 30 to 45 minutes), as a postictal effect of epileptic seizures and is named in the present disclosure as Cortisol Acute Epileptic Seizure Adaptive Response - CAESAR b) (Figure 1). As for cortisol awakening response, CAESAR was surprisingly found, by the inventors of the present disclosure, to enable epilepsy patients to achieve arousal after a seizure (Figure l.A). In contrast, CAESAR was observed to be impaired (Figure l.B) in life-threatening seizures since this cortisol burst is absent in both near SUDEP and impaired arousal.

[0048] Another aspect of the present disclosure relates to a method for determining whether a patient with epilepsy has, or is at risk of SUDEP, comprising the steps of: i) providing a test sample from said patient, wherein the test sample is a biological sample collected from a patient, in particular interstitial fluid (ISF), saliva, blood, plasma, urine, or serum, preferably ISF. ii) assaying the basal level or amount at least one of the following biomarkers selected from a list consisting of: cortisol, cortisone, aldosterone, corticosterone, ACTH or mixtures thereof; iii) comparing the level or amount determined in step ii) to a reference historical value reflecting the basal level or amount of biomarker in a healthy person, wherein a higher level or amount relative to the reference value is indicative for risk of SUDEP; iv) Administering the compounds or pharmaceutical composition of the present disclosure to prevent SUDEP and / or reducing the risk of SUDEP.

[0049] Another aspect of the present disclosure relates to a method of determining whether a patient with epilepsy has, or is at risk of SUDEP, comprising the steps of: i) measuring a content of a biomarker in a (ex vivo) biological sample collected from the patient during an epileptic seizure, wherein said biomarker is selected from a list consisting of: cortisol, corticosterone, cortisone, aldosterone, ACTH, or mixtures thereof; ii) comparing the level of the biomarker in the biological sample with a threshold value indicative of a lower limit of the historical data of the level of the biomarker in the same patient during epileptic seizures; iii) wherein if the level of at least one of the said biomarkers in the biological sample is below the threshold value then the patient is diagnosed with having SUDEP; iv) Administering the compounds or pharmaceutical composition of the present disclosure to prevent SUDEP and / or reducing the risk of SUDEP.

[0050] Another aspect of the present disclosure relates to a method for determining whether a patient with epilepsy is at risk of SUDEP, comprising the steps of: i) providing a test sample from said subject, wherein said test sample is collected during an epileptic seizure; ii) assaying the level or amount of at least one of said biomarkers, wherein said biomarker is selected from a list consisting of: cortisol, cortisone, corticosterone, ACTH, aldosterone or mixtures thereof;iii) comparing the level or amount determined in step ii) to a reference value reflecting the historical data of the level or amount of at least one of said biomarkers in the same subject during an epileptic seizure, iv) wherein a decrease in the level or amount relative to the reference value is indicative for risk of SUDEP; v) Administering the compounds or pharmaceutical composition of the present disclosure to prevent SUDEP and / or reducing the risk of SUDEP.

[0051] In an embodiment, concentration of at least one of said biomarkers is inputted into a statistical methodology to produce an output value that indicates whether the patient has or is at risk of SUDEP.

[0052] In an embodiment, the statistical methodology used is selected from the list consisting of: logistic regression, decision trees, support vector machines, neural networks, random forest or another machine learning algorithm.BRI EF DESCRI PTION OF THE DRAWI NGS

[0053] The following figures provide preferred embodiments for illustrating the disclosure and should not be seen as limiting the scope of invention.

[0054] Figure 1: Cortisol variation during seizures: A: GTCS; B: Complex Partial Seizures; C: Minor seizures (Adapted from Takeshita, Kawahara, Nagabuchi34).

[0055] Figure 2: Change in free corticosterone concentration (nanograms per milliliter) overtime in the interstitial fluid using dual-probe microdialysis in the same freely behaving Scnla+ / - mouse, beginning with the baseline, following by seizure induction, and ending after seizure. (A -first seizure; B- last seizure followed by SUDEP). Free corticosterone levels show a clear increase after the non-life-threatening epileptic seizure (Figure 2A) and a reduction after SUDEP (Figure 2B). Free corticosterone basal levels are higher before the first seizure in comparison with the values before the terminal seizure (5 / 5).

[0056] Figure 3: Survival analysis of Heterozygous Senia knockout mice (Scnla+ / ~, a model of Dravet Syndrome). Heterozygous knock-out mice carrying the NaVl.l (Senia) mutation (Scnla+ / _) were used. Animals were genotyped at postnatal day 7 (P7). All mice were adrenalectomized before the seizure induction and divided in two groups accordingly with treatment regimen:Vehicle (placebo pellets were implanted subcutaneously before first seizure induction) and Corticosterone (corticosterone pellets (5mg) were implanted before first seizure induction). Seizures were induced with Flurothyl once a day for 10 days, starting at P21. Liquid flurothyl (Bis 2,2,2-trifluoroethyl ether) was delivered using a syringe pump injector at a rate of 10 pl / min and allowed to volatilize within the chamber. The animal was removed from the chamber at the onset of a generalized tonic clonic seizure. Scnla+ / _mice in the vehicle group have a significantly reduced lifespan (33.3% survival), while corticosterone completely prevented lethality (100% survival). In conclusion, the administration of corticosterone significantly enhances survival in heterozygous Senia knockout mice (Scnla+ / -), a model of Dravet Syndrome. The vehicle group exhibited a significantly reduced lifespan, while the administration of corticosterone completely prevented lethality. These findings underscore the therapeutic effect of corticosterone in preventing SUDEP in this genetic model of epilepsy.

[0057] Figure 4: Survival analysis of Generalized epilepsy with febrile seizures plus (GEFS+) mice model after repeated seizures. Heterozygous knock-in mice carrying the R1648H NaVl.l (Senia) mutation (ScnlaRH / +), were used. Animals were genotyped at postnatal day 7 (P7). The animals divided in four groups: Vehicle (placebo pellets were implanted subcutaneously before first seizure induction), Corticosterone (corticosterone pellets (5mg) were implanted before first seizure induction), Adrenalectomy + Vehicle (adrenalectomization and implantation of placebo pellets subcutaneously before first seizure induction) and Adrenalectomy + Corticosterone (adrenalectomization and implantation of corticosterone pellets (5 mg) subcutaneously before first seizure induction). ScnlaRH / +mice in the vehicle group have a reduced lifespan (85.7% survival), which is further decreased in the adrenalectomy + Vehicle group (14.3%). The increased lethality seen in adrenalectomy + Vehicle group is partially reduced in the Adrenalectomy + Corticosterone group (50%), while corticosterone completely prevented lethality in the corticosterone group (non-adrenalectomized mice, 100% survival). In conclusion, the administration of corticosterone significantly enhances survival in ScnlaRH / +mice. The vehicle group exhibited a reduced lifespan, which was further decreased in the adrenalectomy + vehicle group. Notably, the administration of corticosterone completely prevented lethality in non- adrenalectomized mice and partially improved survival in adrenalectomized mice. These findings demonstrate the therapeutic effect of corticosterone in preventing SUDEP in this genetic model of epilepsy.DETAILED DESCRI PTION

[0058] The present disclosure relates to the use of cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for preventing and / or reducing the risk of Sudden Unexpected Death in Epilepsy (SUDEP). The disclosure further provides pharmaceutical compositions and methods for preventing and / or reducing the risk of SUDEP, particularly in Dravet Syndrome patients.

[0059] The present disclosure relates to the prevention of SUDEP, demonstrating the therapeutic efficacy of corticosteroids and related compounds in preclinical models. The present disclosure relates to the use of cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for preventing or ameliorating Dravet Syndrome or Sudden Unexpected Death in Epilepsy (SUDEP). The disclosure further provides pharmaceutical compositions and methods for treating SUDEP particularly in Dravet Syndrome patients.

[0060] Cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide disclosed herein demonstrate a technical effect in preventing or reducing the risk of SUDEP, particularly in infants diagnosed with Dravet Syndrome. As shown in figures 3 and 4, administration of the compound led to drastic reduction in SUDEP in validated animal models of Dravet Syndrome.

[0061] Accordingly, the present disclosure provides a therapeutic strategy addressing the unmet clinical need for reducing SUDEP risk and preventing SUDEP, which is particularly acute in early- life stages of Dravet patients. This effect is achieved by the administration of the compound or composition of the present disclosure.

[0062] The present disclosure relates to medical diagnostics and therapeutics, specifically methods and compositions for predicting and preventing SUDEP ; in particularly SUDEP associated with Dravet Syndrome. Additionally, it describes compositions containing cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone,adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide, or combinations thereof, in a therapeutically effective amount with a pharmaceutically acceptable carrier, adjuvant, or excipient for SUDEP prevention and reduction the risk of SUDEP.

[0063] It involves the use of drugs, selected from cortisol, corticosterone, cortisone, aldosterone, adrenocorticotropic hormone (ACTH), or combinations thereof, to assess SUDEP risk. Additionally, it describes compositions containing cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide, in a therapeutically effective amount with a pharmaceutically acceptable carrier, adjuvant, or excipient for SUDEP prevention.

[0064] In an embodiment, the content of cortisol, corticosterone, cortisone, aldosterone, ACTH, or mixture thereof; is determined in a biological sample collected from a subject to be tested. In an embodiment, near-to-baseline cortisol levels are found in SUDEP victims during all epileptic seizure stages, being translated in a flat cortisol curve. This impairment blunts the optimal sharp cortisol burst needed to achieve the threshold for the postictal arousal (Figure 1). This CAESAR impairment is a reflex of the incapacity to raise postictal cortisol levels in SUDEP victims. Cortisol Acute Epileptic Seizure Adaptive Response (CAESAR) b) is a consistent fast-sharp cortisol rise found specifically in the postictal phase of epileptic seizures 20, 21, 22, 23, 24, 25. |mpaj rec| CAESAR, translated in a postictal blunted cortisol rise, is observed only in life-threatening seizures, since this cortisol burst is absent in both near SUDEP and impaired arousal (upstream event of SUDEP). The main novelty of CAESAR concept of the present disclosure is therefore the ability to differentiate for the first time ever life-threatening seizures.

[0065] As shown in Figure 2, corticosterone levels increase after a seizure, as illustrated in CAESAR, and this response is blunted after SUDEP. Thus, increasing the level of corticosterone / cortisol during a seizure improves the CAESAR thus improving post-ictal arousal and consecutively preventing SUDEP.

[0086] It was also demonstrated that corticosterone baseline values are higher before the first seizure and decrease before a life-threatening seizure. Thus, increasing the baseline level of corticosterone / cortisol improves the CAESAR thus improving post-ictal arousal and consecutively preventing SUDEP.Study for seizure-synchronous ISF collection in SUDEP animal model

[0066] All the experiments were performed with a Senia mutant mouse model (leading to a decrease level of Navl.l voltage-dependent sodium channel), or control littermate. This model is a relevant model of a developmental and epileptic encephalopathy in which patients are at high risk of SUDEP. A setup enabling interstitial fluid (ISF) collection on freely moving mice using the microdialysis technique (CMA probes and equipment, Kista, Sweden) was developed. The procedure enables collecting ISF with a minimum of stress to the animal. The samples were kept at -80°C and then corticosterone, murine equivalent of cortisol, was quantified using LC / MS-MS (Liquid chromatography / Mass spectrometry) with adequate sensitivity and specificity. It was induced acute seizure (using the inhalation of the convulsant fluorethyl in homemade recording boxes) during microdialysis collection, repeating the procedure once a day for 2 weeks. Surprisingly it was not observed acute variations of corticosterone during each seizure but rather a progressive diminution of baseline corticosterone levels seizure after seizure in mutant mice. This progressive loss of corticosterone leads to an increase susceptibility to SUDEP. To study this susceptibility, osmotic pumps that deliver corticosterone continuously were implanted, to keep it in a normal physiological range or delivered an inhibitor of the HPA (Hypothalamic-pituitary- adrenal) axis to lower down corticosterone level. It was observed that a diminution of SUDEP in the first group and an increase in the second. These results showed the importance of cortisol / corticosterone as a biomarker and the interest of a device able to measure and infuse cortisol / corticosterone to avoid a low level.

[0067] Figure 3 demonstrates the survival analysis of heterozygous Senia knockout mice (Scnla+ / -, a model of Dravet Syndrome). Heterozygous Scnla+ / - mice were adrenalectomized and divided into two treatment groups: Vehicle (placebo pellets) and Corticosterone (corticosterone pellets). Seizures were induced using Flurothyl daily for 10 days starting at postnatal day 21 (P21). Results indicate a significant reduction in lifespan for the vehicle group (33.3% survival), whereas corticosterone completely prevented lethality (100% survival). This highlights the therapeutic effect of corticosterone in preventing SUDEP.

[0068] Figure 4 presents the survival analysis of Generalized Epilepsy with Febrile Seizures Plus (GEFS+) mouse model. Heterozygous ScnlaRH / + mice were divided into four groups: Vehicle, Corticosterone, Adrenalectomy + Vehicle, and Adrenalectomy + Corticosterone. Survival rates were significantly reduced in the adrenalectomy + Vehicle group (14.3%) compared to the Vehicle group (85.7%). Notably, corticosterone improved survival in the adrenalectomy + Corticosteronegroup (50%) and completely prevented lethality in the corticosterone group (100%). These findings further validate corticosterone's role in SUDEP prevention.

[0069] These data highlight the unexpected and significant effect of corticosterone in preventing SUDEP and improving survival outcomes.

[0070] The compounds and composition used in the present disclosure modulation of glucocorticoid receptors, to prevent and / or reduce the fatal outcomes associated with SUDEP, in particular SUDEP associated with Dravet Syndrome.

[0071] The term "comprising" whenever used in this document is intended to indicate the presence of stated features, integers, steps, components, but not to preclude the presence or addition of one or more other features, integers, steps, components or groups thereof.

[0072] The disclosure should not be seen in any way restricted to the embodiments described and a person with ordinary skill in the art will foresee many possibilities to modifications thereof. The above-described embodiments are combinable.

[0073] Where ranges are provided, the range limits are included. Furthermore, it should be understood that unless otherwise indicated or otherwise evident from the context and / or understanding of a technical expert, the values which are expressed as ranges may assume any specific value within the ranges indicated in different achievements of the invention, at one tenth of the lower limit of the interval, unless the context clearly indicates the contrary. It should also be understood that, unless otherwise indicated or otherwise evident from the context and / or understanding of a technical expert, values expressed as range may assume any sub-range within the given range, where the limits of the sub-range are expressed with the same degree of precision as the tenth of the unit of the lower limit of the range.

[0074] In an embodiment, the epilepsy syndrome may be the Dravet Syndrome, preferably a Dravet Syndrome associated with a mutation in one, some or all of the genes selected from the group consisting of SCN1A, SCN1B, SCN2A, SCN3A, SCN9A, GABRG2, GABRD and PCDH19. In the following table the mutations are defined

[0075] The following dependent claims further set out particular embodiments of the disclosure.

[0076] This research is part of the NEUROSENSE project: NEUROendocrine SENSor for Sudden Unexpected Death in Epilepsy (SUDEP) prediction and prevention" - ref. - 101047131, financed by Horizon Europe. This project was funded by the European Union.

[0077] The following references should be considered herewith incorporated in their entirety:1. Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Eiger CE, et al. ILAE official report: a practical clinical definition of epilepsy Epilepsia. 2014 Apr;55:475-482.2. Ono T, Galanopoulou AS. Epilepsy and epileptic syndrome Adv Exp Med Biol. 2012;724:99-113.3. Nashef L. Sudden unexpected death in epilepsy: terminology and definitions Epilepsia. 1997 Nov;38:S6-8.4. Richerson GB, Buchanan GF. The serotonin axis: Shared mechanisms in seizures, depression, and SUDEP Epilepsia. 2011 Jan;52 Suppl 1:28-38.5. Dlouhy BJ, Gehlbach BK, Richerson GB. Sudden unexpected death in epilepsy: basic mechanisms and clinical implications for prevention J Neurol Neurosurg Psychiatry. 2016 Apr;87:402-413.6. Massey CA, Sowers LP, Dlouhy BJ, Richerson GB. Mechanisms of sudden unexpected death in epilepsy: the pathway to prevention Nat Rev Neurol. 2014 May;10:271-282.7. Kearney J. 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Nandam LS, Brazel M, Zhou M, Jhaveri DJ. Cortisol and Major Depressive Disorder-Translating Findings From Humans to Animal Models and Back Frontiers in psychiatry. 2019;10:974.15. van Campen JS, Jansen FE, de Graan PN, Braun KP, Joels M. Early life stress in epilepsy: a seizure precipitant and risk factor for epileptogenesis Epilepsy Behav. 2014 Sep;38:160-171.16. Lanfumey L, Mongeau R, Cohen-Salmon C, Hamon M. Corticosteroid-serotonin interactions in the neurobiological mechanisms of stress-related disorders Neurosci Biobehav Rev. 2008 Aug;32:1174-1184.17. Elder GJ, Wetherell MA, Barclay NL, Ellis JG. The cortisol awakening response-applications and implications for sleep medicine Sleep Med Rev. 2014 Jun;18:215-224.18. Gitto L, Stoppacher R, Serinelli S. Death Due to Adrenal Crisis: Case Report and a Review of the Forensic Literature Am J Forensic Med Pathol. 2021 Dec l;42:392-396.19. Palmiere C. Sudden death due to acute adrenal crisis Forensic Sci Med Pathol. 2015 Dec;ll:629.20. Govi A, Fersini F, Tsokos M. Sudden death due to acute adrenal crisis Forensic Sci Med Pathol. 2015 Sep; 11:445-447.21. Erichsen MM, Lpvas K, Fougner KJ, Svartberg J, Hauge ER, Bollerslev J, et al. Normal overall mortality rate in Addison's disease, but young patients are at risk of premature death Eur J Endocrinol. 2009 Feb;160:233-237.22. Gassner HL, Toppari J, Quinteiro Gonzalez S, Miller WL. Near-miss apparent SIDS from adrenal crisis J Pediatr. 2004 Aug;145:178-183.23. Tavakoli N, Bidari A, Shams Vahdati S. Serum Cortisol Levels as a Predictor of Neurologic Survival inSuccessfully Resuscitated Victims of Cardiopulmonary Arrest Journal of cardiovascular and thoracic research. 2012;4:107-111.24. van Campen JS, Valentijn FA, Jansen FE, Joels M, Braun KP. Seizure occurrence and the circadian rhythm of cortisol: a systematic review Epilepsy Behav. 2015 Jun;47:132-137.25. Maguire J, Salpekar JA. Stress, seizures, and hypothalamic-pituitary-adrenal axis targets for the treatment of epilepsy Epilepsy Behav. 2013 Mar;26:352-362.26. van Campen JS, Hompe EL, Jansen FE, Velis DN, Otte WM, van de Berg F, et al. Cortisol fluctuations relate to interictal epileptiform discharges in stress sensitive epilepsy Brain. 2016 Jun;139:1673-1679.27. Yuen AW, Thompson PJ, Flugel D, Bell GS, Sander JW. Mortality and morbidity rates are increased in people with epilepsy: is stress part of the equation? Epilepsy Behav. 2007 Feb;10:l-7.28. Galimberti CA, Magri F, Copello F, Arbasino C, Cravello L, Casu M, et al. Seizure frequency and cortisol and dehydroepiandrosterone sulfate (DHEAS) levels in women with epilepsy receiving antiepileptic drug treatment Epilepsia. 2005 Apr;46:517-523.29. Abbott RJ, Browning MC, Davidson DL. Serum prolactin and cortisol concentrations after grand mal seizures J Neurol Neurosurg Psychiatry. 1980 Feb;43:163-167.30. Aminoff MJ, Simon RP, Wiedemann E. The hormonal responses to generalized tonic-clonic seizures Brain. 1984 Jun;107 ( Pt 2):569-578.31. Rao ML, Stefan H, Bauer J. Epileptic but not psychogenic seizures are accompanied by simultaneous elevation of serum pituitary hormones and cortisol levels Neuroendocrinology. 1989 Jan;49:33-39.32. Zhang SW, Liu YX. Changes of serum adrenocorticotropic hormone and cortisol levels during sleep seizures Neurosci Bull. 2008 Apr;24:84-88.33. Pritchard PB, 3rd, Wannamaker BB, Sagel J, Daniel CM. Serum prolactin and cortisol levels in evaluation of pseudoepileptic seizures Ann Neurol. 1985 Jul;18:87-89.34. Takeshita H, Kawahara R, Nagabuchi T, Mizukawa R, Hazama H. Serum prolactin, cortisol and growth hormone concentrations after various epileptic seizures Jpn J Psychiatry Neurol. 1986 Dec;40:617-623.35. Becker LL, Kaindl AM. Corticosteroids in childhood epilepsies: A systematic review Front Neurol. 2023;14:1142253.36. Clow A, Hucklebridge F, Stalder T, Evans P, Thorn L. 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Claims

C L A I M S1. Cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for use in the prevention and / or in the reduction of the risk of Sudden Unexpected Death in Epilepsy.

2. The compounds for use according to the previous claim wherein for Sudden Unexpected Death in Epilepsy is related to Dravet Syndrome.

3. The compounds for use according to the previous claim wherein the Dravet Syndrome is associated with a mutation in one, some or all of the genes selected from the group consisting of SCN1A, SCN1B, SCN2A, SCN3A, SCN9A, GABRG2, GABRD and PCDH19.

4. The compounds for use according to any of the previous claims wherein the compound is cortisol.

5. Pharmaceutical composition comprising cortisol, cortisone, cortisone acetate, hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof in a therapeutically effective amount and a pharmaceutical acceptable carrier, adjuvant, excipient, or mixtures thereof for use in the prevention and / or reduction of the risk of SUDEP related to an epileptic seizure syndrome.

6. Pharmaceutical composition for use according to the previous claim wherein the composition is administered as a single dose.

7. Pharmaceutical composition for use according to the previous claims 5-6 wherein the epilepsy syndrome is Dravet Syndrome, preferably a Dravet Syndrome associated with a mutation in one, some or all of the genes selected from the group consisting of SCN1A, SCN1B, SCN2A, SCN3A, SCN9A, GABRG2, GABRD and PCDH19.

8. Pharmaceutical composition for use according to any of the previous claims 5-7 wherein the composition is in a solid form or liquid form.

9. Pharmaceutical composition for use according to any of the previous claims 5-8, wherein the composition is suitable for administration orally, nasally, rectally, vaginally, transdermally, subcutaneously, by inhalation, by intravenous injection or intramuscular injection.

10. Pharmaceutical composition for use according to any of the previous claims 5-9 wherein the daily dose of the composition active substance is at least 0.5 / kg mg per day, preferably at least 1 mg / kg per day.

11. Pharmaceutical composition for use according to any of the previous claims 5-10 wherein the daily dose of the composition active substance is at least 20 mg / kg.

12. Pharmaceutical composition for use according to any of the previous claims 5-11, wherein the daily dose of the composition active substance is at least 20 to 240 mg / kg.

13. Pharmaceutical composition for use according to any of the previous claims 5-12 further comprising a sodium salt, preferably sodium chloride.

14. Pharmaceutical composition for use according to any of the previous claims 5-13 further comprising a co-therapeutic agent, in particular an anticonvulsant.

15. Use of a composition comprising Cortisol, cortisone, cortisone acetate hydrocortisone, fludrocortisone, prednisolone, prednisone, methylprednisolone, Dehydroepiandrosterone (DHEA), dexamethasone, betamethasone, adrenocorticotropic hormone (ACTH), ganaxolone, tetracosactide or combinations thereof for the manufacture of a medicament for the prevention and / or reduction of the risk of SUDEP related to an epileptic syndrome, in particular Dravet syndrome.

16. A method for preventing and / or reducing the risk of SUDEP related to an epileptic syndrome in a subject, the method comprising administering a composition comprising cortisone, hydrocortisone, ganaxolone, tetracosactide, adrenocorticotropic hormone or combinations thereof to the subject.

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