Folate for use in methods of reducing severity, incidence or risk in lymphedema or in glymphatic- related neurodevelopmental disorders

Abstract

A composition is described comprising at least one folate which is useful in the treatment of a disorder linked to a deficiency of a micronutrient, in particular a folate, in a lymphatic and / or glymphatic system.

Description

FOLATE FOR USE IN METHODS OF REDUCING SEVERITY, INCIDENCE OR RISK IN LYMPHEDEMA OR IN GLYMPHATIC- RELATED NEURODEVELOPMENTAL DISORDERSBACKGROUND OF THE INVENTION

[0001] Vitamin B-9 (folate) is important for normative function of blood vasculature. Insufficient Vitamin B-9 is known to impair the capillaries of the blood vessels and lymphatic vessels, commonly called microcirculation. Such impairment impacts fluid exchange from the lumen of the blood and lymph capillaries to the interstitial space. This impairment can impede transit of nutrients to the interstitial space and impede removal of waste products from the interstitial space back to the blood and lymph.

[0002] Folate is available in most diets, with the primary source being in a reduced form, in particular carrying mono- or polyglutamate groups and being optionally substituted, such as the L-methylfolate and its derivatives, which is present in many vegetables, and a secondary source being folate in oxidized form, such as folic acid, which is added to cereal grains in the US. The form of folate that is bioactive in the body is the reduced form. The oxidized form is typically converted to the reduced form in the digestion process and in the liver.

[0003] In some people, bioavailable folate levels in the blood may be diminished. This diminished folate can occur when insufficient reduced folate is consumed and also can occur when excess oxidized folate is consumed in the presence of lower reduced folate levels.

[0004] A lower level of reduced folate in the blood can impair transit of fluid and waste across the lymphatic capillary beds.

[0005] Impaired removal of fluids by lymphatic vessels is a sign of lymphedema.Primary lymphedema is believed to be genetic in origin, with the condition often developing following a stress on the lymphatic system.

[0006] When blood levels of reduced folate are low, the concentration of homocysteine in the blood is elevated. Homocysteine provides a useful indicator of available folate levels.

[0007] Additionally, people who have a condition such as cerebral folate deficiency(CFD) cannot absorb sufficient folate into the brain. This condition may reduce the folate necessary for proper function of glymphatic vessels and impede transit of fluid and wastes from brain into glymphatic vessels.

[0008] Impaired removal of wastes by the glymphatic system is implicated in neurological conditions such as Alzheimer’s dementia, Parkinson’s disease, Huntington’s disease, and other neurodegenerative disorders.

[0009] There remains a need for improved methods of early detection and treatment of disorders where drainage across lymphatic and / or glymphatic capillaries is impaired. The problem is solved by compositions as defined in claim 1. Preferred embodiments are subject to the dependent claims. The problem is solved according to methods disclosed.SUMMARY OF THE INVENTION

[0010] The present invention relates to methods for reducing incidence of, or reducing severity, or reduce risk of developing, lymphedema, as well as Alzheimer’s dementia, Parkinson’s disease, Huntington’s disease and other neurodegenerative disorders. Furthermore, the present invention relates to a composition for use and the use of the composition in the method according to the invention and for the treatment of a disorder linked to a deficiency and / or an insufficiency of a micronutrient, in particular deficiency and / or insufficiency of a folate, in a lymphatic and / or glymphatic system the composition comprising at least one folate such as a reduced folate and / or folate salt.

[0011] In one aspect, the invention relates to methods of reducing incidence or severity of lymphedema via use of a drug product or a supplement containing folate, in particular reduced folate, such as L-methylfolate or folinic acid / levofolinic acid. The type of lymphedema may be primary lymphedema or secondary lymphedema. Folate may be augmented along with other vitamins such as vitamin Bl 2, vitamin B3, vitamin B6, vitamin B2, Vitamin D3, N-acetylcysteine or similar sulfur containing compound.

[0012] In another aspect, the invention relates to methods of reducing incidence or reducing risk of developing or reducing severity of a cerebral folate deficiency (CFD) related disorder such as Alzheimer’s Dementia (AD), Parkinson’s Disease (PD), Huntington’s Disease (HD) or other neurodegenerative disorder. In such aspect, theglymphatic microcirculation may be impaired due to insufficient folate due to (a) subject with a family history of a CFD-related disorder, (b) one or more folate receptor alpha (FRoc) autoantibodies detected in a fluid sample from the subject and / or (c) the subject has a mutation in the methylenetetrahydrofolate reductase (MTHFR) gene or (d) dihydrofolate reductase (DHFR) or (e) methionine synthase (MTR) or (f) methionine synthase reductase (MTRR) or (g) various mutations of folate receptors.

[0013] In this other aspect, provided are methods of reducing incidence of cerebral folate deficiency (CFD) or neurodegenerative disorder such as AD, PD or HD, the methods comprising the step of: administering an effective amount of folate, in particular of a reduced folate compound to a subject, wherein: (a) the subject has a family history of a CFD-related disorder, (b) one or more FRoc autoantibodies has been detected in a fluid sample from the subject and / or (c) the subject has a mutation in the methylenetetrahydrofolate reductase (MTHFR) gene or (d) dihydrofolate reductase (DHFR) or (e) methionine synthase (MTR) or (f) methionine synthase reductase (MTRR) or (g) various mutations of folate receptors.

[0014] In some embodiments, provided methods further comprise co-administering an effective amount of one or more additional agents selected from vitamin B3, vitamin B12 (methylcobalamin), vitamin D3, vitamin B6, vitamin B2, N-acetylcysteine or other sulfur containing compound. For example, in some embodiments, an effective amount of vitamin Bl 2 and an effective amount of vitamin D3 are co-administered with the effective amount of the reduced folate compound.

[0015] In some embodiments, a fluid sample comprises a blood sample, for example, a plasma or serum sample, a whole blood sample, or a cellular fraction of a whole blood sample. In some embodiments, the fluid sample comprises cerebrospinal fluid, lymph, sweat, urine, tears, saliva, pleural fluid, pericardial fluid, cavity rinse, or organ rinse sample.

[0016] In some embodiments, the reduced folate compound is selected from the group consisting of folinic acid (leucovorin), methyltetrahydrofolate (MTHF), levofolinic acid (levoleucovorin), L-methyltetrahydrofolate (L-MTHF), a mixture of dextroleucovorinand levoleucovorin, and combinations thereof.

[0017] In some embodiments, the step of administering comprises oral administration. For example, the reduced folate compound may be administered as an oral drug product or food supplement. In some embodiments, the tablet comprises the reduced folate compound in solid form.

[0018] In some embodiments, the step of administering comprises administering the reduced folate compound intranasally.

[0019] In one aspect, provided are kits comprising one or more pharmaceutically acceptable dosage forms, wherein at least one pharmaceutically acceptable dosage form comprises a reduced folate compound, and instructions for use according to methods provided herein. In some embodiments, the one or more pharmaceutical dosage forms collectively comprise one or more additional agents selected from the group consisting of vitamin B12 (methylcobalamin), vitamin B6, vitamin B2, vitamin D3, and N- acetylcysteine or other sulfur containing compound. In some embodiments, the one or more pharmaceutically dosage forms collectively comprise vitamin B 12 and vitamin D3.DETAILED DESCRIPTION OF THE INVENTION

[0020] The present invention encompasses the recognition that lymphatic and / or glymphatic microvasculature are impaired by a reduced level of folate due to a genetic disorder or a cerebral folate deficiency (CFD)-related disorder, or another cause of folate deficiency / insufficiency.

[0021] Additionally, existing interventions for folate deficiencies are inadequate to address problems specific to cerebral folate deficiencies and metabolic disorders. For example, pregnant women are recommended to take folic acid supplements. However, folic acid is not the active form of vitamin B9 and must be converted to L-methylfolate (L-MTHF) by DHFR and MTHFR to be bioactive. While DHFR and MTHFR are hence involved in the conversion of folic acid to L-MTHF, MTR regenerates methionine from homocysteine in most individuals, and MTRR is responsible for regulation of MTR by reductive methylation. Defects in MTR and MTRR can result in reduced catalytic activity of enzymes leading to high homocysteine concentration in blood and increased risk fornumerous diseases.

[0022] In some embodiments, methods disclosed herein overcome these and other problems by administering chemically reduced folate compounds (which, in contrast to folic acid, are the form used by microvasculature of the lymphatic and glymphatic vessels and which can overcame the transport problems across the choroid plexus of the bloodbrain barrier) to various subjects, in order to reduce the incidence or risk of folate deficiency-related disorders such as lymphedema or neurodegenerative disorders such as AD, or PD, or HD. Methods disclosed herein may, in some embodiments, circumvent effects of folate receptor alpha antibodies (FRAA) that interfere with folate transport into the brain in neurodegenerative disorders implicated by the impaired glymphatic system function.

[0023] Definitions

[0024] As used herein, the term lymphedema generally refers to a condition characterized by insufficient drainage of extracellular fluid from extremities presumably due to impaired function of the lymphatic vasculature in the region of, or proximal to, the lymphedema swelling.

[0025] As used herein, the terms lymphatic and glymphatic vasculature refer to the lymphatic capillaries and veins and the glymphatic capillaries and veins, each of which provide for removal by drainage of excess fluid and waste products from the interstitial spaces to which they attend.

[0026] As used herein, the term "cerebral folate deficiency" (CFD) generally refers to a condition characterized by low concentrations of L-methylfolate (L-MTHF) in the cerebrospinal fluid in the presence of normal or undefined blood folate concentrations in the blood. CFD may result from, e.g., lack of ability of folate in the blood to cross the blood-brain barrier (BBB), such as occurs with certain variants and / or deficiencies of gene products involved in folate transport and / or folate metabolism (e.g. reduction of folic acid by DHFR). For example, deficiencies and / or variants of folate receptor alpha (FRoc), dihydrofolate reductase (DHFR), methylenetetrahydrofolate reductase (MTHFR), and / or methenyltetrahydrofolate synthetase (MTHFS) are known as causes of CFD.Additional conditions that are known to cause CFD include folate receptor alpha antibodies (FRAAs) in the blood, mitochondrial disorders, serine deficiency, dihydropteridine reductase (DHPR) deficiency, and aromatic L-amino acid decarboxylate (AADC) deficiency.

[0027] As used herein, the terms "cerebral folate deficiency-related disorder" or "CFD- related disorder" are used interchangeably and refer to any of a variety of conditions that are associated with CFD. In some embodiments, the CFD-related disorder is characterized by one or more symptoms selected from Multiple Sclerosis (MS). Examples of disorders that may be associated with CFD include, but are not limited to, multiple sclerosis (MS), depression, and spina bifida.

[0028] As used herein, the term "effective amount" refers to an amount sufficient, at dosages and for periods of time necessary, to achieve a desired result, e.g., reduced incidence, severity, and / or risk of developing a CFD-related disorder such as MS. An "effective amount" may depend on the context in which it is being applied and the specific disorder whose incidence or risk is being lowered. An "effective amount" may be administered in a single dose or in multiple (e.g., at least two, at least three, at least four, at least five) doses. In some embodiments, an "effective amount" is administered via regular doses (e.g., thrice daily, twice daily, daily, every two days, every three days, twice a week, once a week, once every two weeks, etc.).

[0029] As used herein, the term "folate receptor alpha," abbreviated 'FRoc, " refers to the alpha isoform of the folate receptor, a glycosylphosphatidylinositol (GPI- anchored membrane protein with high affinity for binding and transport of folic acid and the active form of folate, L-methylfolate (L-MTHF). FRoc is also known as FOLR1 or folate binding protein. As used herein, the term "folate receptor alpha antibody," abbreviated FRAA and also known as "folate receptor alpha autoantibody," refers to an antibody that is capable of binding to FRoc. In some embodiments, a FRAA impairs folate transport into the brain. For example, a "blocking FRAA" directly interferes with the binding or blocking of folate to FRoc. For example, a "binding FRAA" triggers an antibody-mediated immune reaction upon binding to FRoc.

[0030] As used herein, the term "folate-binding fragment" refers to a fragment of a folate-binding molecule (e.g., a folate receptor, such as FRoc), which fragment is capable of binding to folate. Such fragments are also known as soluble folate receptors.

[0031] Methods of reducing incidence or risk in neurodegenerative disorders impacted by impairment of the glymphatic system.

[0032] Provided methods generally comprise a step of administering an effective amount of a reduced folate compound to a subject when one or more situations (as elaborated further herein) apply.

[0033] For example, provided are methods of reducing incidence of CFD or a CFD- related disorder such as AD or PD or HD or other neurodegenerative disorder by administering an effective amount of a reduced folate compound to a subject.

[0034] In various methods disclosed herein, one or more of the following situations may indicate that a subject should be administered a reduced folate compound in accordance with methods disclosed herein: (1) detection of FRoc autoantibodies in a fluid sample; and / or (2) presence of a genetic marker associated with increased risk of developing a CFD-related disorder and / or (3) a mutation of DHFR, MTR, MTRR or MTHFR.

[0035] Detection of FRoc autoantibodies

[0036] In accordance with some methods of the present disclosure, a subject may be administered reduced folate compounds to reduce incidence of a CFD-related disorder such as MS. The fluid sample may comprise a blood, cerebrospinal fluid, lymph, sweat, urine, tears, saliva, pleural fluid, pericardial fluid, cavity rinse, or organ rinse samples, or a mixture of any of the foregoing. Examples of suitable blood samples include, but are not limited to, plasma samples, serum samples, whole blood samples, cellular fractions of whole blood samples, and mixtures of any of the foregoing.

[0037] Methods of detecting FRoc autoantibodies (FRAAs) include methods known in the art and methods described herein. In some embodiments, the method is a quantitative or semiquantitative method.

[0038] In some embodiments, an enzyme-linked immunosorbent assay (ELISA) (e.g., a direct ELISA, an indirect ELISA, or a sandwich ELISA) is used to detect FRoc autoantibodies (which can also be used to detect mutations and / or genetic markers). For example, in one version of a suitable indirect ELISA format, 1) FRoc (or a folate- binding fragment thereof) is immobilized on the surface of vessels (e.g., wells), 2) samples are added to the vessels and incubated (FRoc in the sample may bind to the immobilized FRoc (or a folate-binding fragment thereof), 3) labeled antibodies against FRoc are added and incubated with the samples, and 4) label is measured. More measured label indicates more FRoc in the sample.

[0039] In a competitive version of the above-described indirect ELISA, labeled folic acid is used instead of labeled antibodies against FRoc in step 3) and more measured label indicates less FRoc in the sample. In one version of a suitable sandwich ELISA format, 1) antibodies against FRoc is immobilized on the surfaces of vessels (e.g., wells), 2) samples are added to the vessels and incubated (FRoc in the sample may bind to the immobilized antibodies against FRoc), 3) labeled antibodies against FRoc are added and incubated with the samples (thereby possibly forming a sandwich of immobilized antibodies against FRoc, FRoc from the sample, and labeled antibodies against FRoc) and 4) the label is measured. More measured label indicates more FRoc in the sample. A competitive version of such a sandwich ELISA assay, in which less measured label indicates more FRoc in the sample, may also be used.

[0040] In some embodiments, a competitive radioimmunoassay (RIA) may be used to detect FRoc autoantibodies. For example, in one version of a competitive RIA to detect FRocs, fluid samples are added to a vessel (e.g., a well) having a surface coated with FRoc (or a folate binding fragment thereof). Radiolabeled folate receptor antibodies (FRocs) are then added and then incubated, then the vessel is washed. The radiolabeled FRoc competes with any FRoc in the sample for binding to FRoc (or a folate-binding fragment thereof) coated on the vessel's surface. Radioactivity is measured, and decreased radioactivity indicates more FRoc in the sample. A similar competitive RIA may be used in which antibodies against FRocs are used in place of the FRoc (or a folate-bindingfragment thereof) to coat the surface of the vessel. In some embodiments, a lateral flow immunoassay is used to detect FRoc autoantibodies. For example, in one version of such an assay, an absorbent strip contains, in the following order (1) a conjugate pad comprising gold-tagged FRoc (or a folate-binding fragment thereof) and gold-tagged control antigen; (2) a first strip on which antibodies against FRocs are immobilized; and (3) a second strip on which control antibodies are immobilized. During the assay, the sample is flowed past the conjugate pad, and any FRocs in the sample may bind to the gold-tagged FRoc (or a folate-binding fragment thereof), thereby forming complexes of FRoc in the sample and gold-tagged FRoc (or a folate-binding fragment thereof), while control antigens form the conjugate pad are caught up the flow. The sample is flowed past the first strip, where any complexes that form are caught by the immobilized antibodies against FRoc. The first strip becomes colored if there is enough FRoc in the sample. This sample is then flowed past the second strip, where gold-tagged control antigens originally from the conjugate pad may bind to the immobilized control antibodies. The second strip becomes colored if the assay worked.

[0041] Other versions of lateral flow assays may also be suitable. For example, (i) in the conjugate pad, gold-tagged antibodies against FRoc may be used in place of the gold- tagged FRoc (or a folate-binding fragment thereof), and (ii) in the first strip, FRoc (or a folate-binding fragment thereof) may be used in place of antibodies against FRoc.

[0042] Genetic markers

[0043] In accordance with some methods of the present disclosure, a subject may be administered reduced folate compounds to reduce incidence of a glymphatic-related neurodevelopmental disorder such as AD or PD or HD when the subject (i) has a genetic marker associated with increased risk of developing a CFD related disorder or (ii) has a proximate family member who has a genetic marker associated with an increased risk of developing a CFD-related disorder or other disorder that impairs folate availability in the central nervous system.

[0044] In some embodiments, the genetic marker is associated with a mutation or variant that affects the function of a gene product involved in folate reduction, folate transport,and / or folate metabolism, for example, folate receptor alpha (FRoc), dihydrofolate reductase (DHFR), methylenetetrahydrofolate reductase (MTHFR), methenyltetrahydrofolate synthetase (MTHFS), dihydropteridine reductase (DHPR), and aromatic L-amino acid decarboxylate (AADC). In some embodiments, the genetic marker is associated with a mutation in the methylenetetrahydrofolate reductase (MTHFR) gene. In some embodiments, the genetic marker is associated with mitochondrial DNA deletions and affects genotoxicity in peripheral tissue and / or low folate levels.

[0045] Reduced folate compounds

[0046] As used herein, the term "reduced folate compound" generally refers to a folate compound (di- or tetrahydrofolic acid) that is reduced folic acid (the oxidized form of folate). Such reduced forms of folate are generally more metabolically active than folic acid. For example, folinic acid (5-formyl-(6R / S)-THF) is more metabolically active than folic acid. The pure levofolinic acid (5-formyl-(6S)-THF) is 100% active and is an immediate precursor to 5,10-methylene-(6R)-tetrahydrofolate, which in turn is rapidly metabolized to produce active L-methylfolate (5-methyl-(6S)-tetrahydrofolate (L- MTHF)). L-MTHF is able to cross the blood-brain barrier.

[0047] Suitable reduced folate compounds include, but are not limited to folinic acid (e.g., levofolinic acid), L-MTHF, and analogs, derivatives, mixtures, or combinations thereof. For example, leucovorin (a racemic mixture of the diastereoisomers of the 5- formyl derivative of tetrahydrofolic acid), levoleucovorin (the pure (6S) diastereoisomer of folinic acid), and / or mixtures of dextroleucovorin and levoleucovorin, may be used as reduced folate compounds. Derivatives, metabolites, prodrugs, stereoisomers, polymorphs, analogues, and / or pharmaceutically acceptable salts (e.g. calcium, sodium, arginine, choline) of any of the foregoing may also be suitable. For example, leucovorin calcium, and levoleucovorin calcium may be used.

[0048] In some embodiments, administering folinic acid or an analog or derivative thereof bypasses the need for dihydrofolate reductase (DHFR) full activity (ins / ins). In some embodiments, administering L-MTHF or an analog or derivative thereof bypasses the need for methylenetetrahydrofolate reductase (MTHFR).

[0049] Additional agents

[0050] Additional agents may also be co-administered with reduced folate compounds, supporting e.g. the activity of various enzymatic steps. By "co-administered" (a term that may be used interchangeable with "in combination with"), it is meant that the reduced folate compound and the additional agent may be administered in the same composition or in separate compositions (e.g., simultaneously, sequentially, or in overlapping dosing regimens) in such a manner that the subject is exposed simultaneously to both the reduced folate compound and the additional agent.

[0051] In some embodiments, the additional agent is a cofactor or coenzyme of folate or metabolite thereof. In some embodiments, the additional agent is capable of improving the absorption and / or transport of folate or a reduced folate compound. In some embodiments, the additional agent acts in a pathway unrelated to folate metabolism but can supplement a deficiency in the subject and / or otherwise provide a benefit to the subject. For example, the additional agent can be an agent that is typically found in lower levels than optimal in the subject being administered the reduced folate compound. In some embodiments, the additional agent is an agent whose deficiency may be masked in the presence of higher levels of folates. For example, vitamin B12 deficiencies may limit the activity of methionine synthase (MS), one of the reasons for elevated homocysteine- levels.

[0052] In some embodiments, the additional agent is a vitamin. For example, the additional agent may be vitamin B3, vitamin Bl 2 (methylcobalamin), vitamin C, vitamin D3, or a combination thereof.

[0053] Combinations of two or more additional agents may also be administered in accordance with methods of the present disclosure. For example, the two or more additional agents may comprise vitamin B 12 and vitamin D3. In some embodiments, the two or more additional agents comprise vitamin Bl 2, vitamin C, and vitamin D3.

[0054] Compositions

[0055] As indicated above, the present invention also relates to compositions and / or preparations of folates, in particular reduced folates and / or folate salts (especially salts ofreduced folates) for treatment, or reducing incidence of, or reducing severity, or reduce risk of developing, lymphedema, as well as Alzheimer’s dementia, Parkinson’s disease, Huntington’s disease and other neurodegenerative disorders. In particular, the indicated disorders are linked to a deficiency of a micronutrient, in a lymphatic and / or glymphatic system, wherein treatment can include increasing the drainage of intercellular fluid from extremities and / or increasing the drainage of excess fluid and waste products from the interstitial spaces and / or increasing drainage across lymphatic and / or glymphatic capillaries by administration of the composition. In the following the composition and / or preparation for use in the treatment of averting lymphedema-related swelling (which can e.g. be detected by measuring the diameter of the limbs), or reducing risk of developing a neurodevelopmental disorder such as AD or PD or HD is further described.

[0056] The composition can comprise a folate such as levofolinic acid or L-MTHF. In preferable embodiments the folate is a folate salt comprising a tetrahydrofolic acid anion and a cation. The anion can be selected from the group consisting of 5-formyl-(6RS)- tetrahydrofolic acid, 5-formyl-(6S)-tetrahydrofolic acid, 10-formyl-(6R)-tetrahydrofolic acid, 5-methyl-(6RS)-tetrahydrofolic acid, 5-methyl-(6S)-tetrahydrofolic acid, (6S)- tetrahydrofolic acid, 5,10-methylene-(6R)-tetrahydrofolic acid, 5-methyl-10-formyl-(6R)- tetrahydrofolic acid, and 5,10-diformyl-(6R)-tetrahydrofolic acid. The cation can be selected from the group consisting of arginine, choline, acetylcholine, N- methylaminoethanol, 2-amino-2-methyl-propanol, 1 , 1 -dimethyl-biguanidin, phenylethyl- biguanidin, glucosamine, calcium, sodium, and zinc. In particular, the cation is an organic compound selected from the group consisting of di-arginine, di-choline, di-acetylcholine, di-N-methylaminoethanol, di-2-amino-2-methyl-pr opanol, di-( 1,1 -dimethyl-biguanidin), di-(phenylethyl-biguanidin) and di-glucosamine or selected from the group consisting of mono-arginine, mono-choline, mono-acetylcholine, mono-N-methylaminoethanol, mono- 2-amino-2-methyl-pr opanol mono-( 1,1 -dimethyl-biguanidin), and mono-(phenylethyl- biguanidin). In preferable embodiments the folate salt is crystalline but could also be amorph. Preferable embodiments include the (optionally di-) salts of arginine and choline for organic salts and calcium or sodium for inorganic salts, in particular with 5-formyl- (6S)-tetrahydrofolic acid or 5-methyl-(6S)-tetrahydrofolic acid as anion.

[0057] In further preferable embodiments the folate is the reduced folate compound in particular selected from the group consisting of 5-formyl-(6RS)-tetrahydrofolic acid, 5- formyl-(6S)-tetrahydrofolic acid, 10-formyl-(6R)-tetrahydrofolic acid, 5-methyl-(6RS)- tetrahydrofolic acid, 5-methyl-(6S)-tetrahydrofolic acid, (6S)-tetrahydrofolic acid, 5,10- methylene-(6R)-tetrahydrofolic acid, 5-methyl-10-formyl-(6R)-tetrahydrofolic acid, and 5,10-diformyl-(6R)-tetrahydrofolic acid, and combinations thereof, in particular a reduced folate compound selected from the group consisting of folinic acid (leucovorin), methyltetrahydrofolate (MTHF), levofolinic acid (levoleucovorin), L- methyltetrahydrofolate (L-MTHF), a mixture of dextroleucovorin and levoleucovorin, and combinations thereof.

[0058] In a preferred embodiment, the composition further comprises at least one compound selected from the group consisting of vitamin B12, B6, B5, B2, Bl, vitamin C, D, E, carotenoids, natural orange oil, and minerals. Minerals are for instance copper or zinc. Natural orange oil can be used as flavor compound masking other compounds such as sulfur compounds having disagreeable flavors. In addition, natural orange oil possesses antioxidant properties. In particular the composition can additionally comprise at least one compound selected from the group consisting of selenium, cholecalciferol, pantothenic acid, vitamin Bl 2, vitamin B6, vitamin B2, vitamin Bl, zeaxanthine, lutein, vitamin E, vitamin C, copper salt, zinc salt, natural orange oil and a sulfur compound. Optionally, the composition may also comprise meso-zeaxanthine, omega-3 fatty acids or a polyphenol such as resveratrol. The latter belongs to the class of polyphenols and has antioxidative properties. A suitable selenium compound is L-selenomethionine. The selenium compound may also be sodium selenite, sodium hydrogen selenite, or sodium selenate, Cholecalciferol is also known as vitamin D, in particular vitamin D3.Pantothenic acid may be present as dexpanthenol, calcium-D -pantothenate, or sodium-D- pantothenate. Vitamin Bl 2 can be comprised in the composition in one of its different forms, such as methylcobalamin, cyanocobalamin, hydroxycobalamin, adenosylcobalamin. Vitamin B6 may be included as pyridoxine hydrochloride or pyridoxal-5’ -phosphate. Vitamin B2 is for instance sodium-riboflavin-5’-phophate or riboflavin. Vitamin Bl may be thiamine hydrochloride or thiamine mononitrate. Vitamin E is included in one of its different forms, e.g. D-a-tocopherol, DL-a-tocopherol, D-a-tocopherol. Also, vitamin C may be present either as sodium-ascorbate, potassiumascorbate, calcium-ascorbate, L-ascorbic acid, or L-ascorbyl-6-palmitate. The copper salt is either copper gluconate, copper citrate, copper oxide, or copper lysine complex. A suitable form of the zinc salt is zinc oxide, zinc gluconate, zinc lactate or zinc citrate. The natural orange oil is for instance natural orange extract, limonene, or myrcene. And the sulfur compound may be comprised as N-acetylcysteine, N-acetylcysteine amide, cysteine, lipoic acid, or methionine.

[0059] In particular, the composition can be in the form of a capsule or tablet, or a plurality of capsules or tablets, which capsule(s) or tablet(s)can comprise the components, a folate, e.g. the calcium salt of L- methylate, in an amount of 0.2 mg to 1.5 mg, and optionally one or more of the following components, N-acetylcysteine or its salt in an amount of 40 mg to 250 mg, L- selenomethionine in an amount of 0. 005 mg to 0.04 mg, cholecalciferol in an amount of 0.009 mg to 0.06 mg, calcium D-panthothenate in an amount of 1 mg to 8 mg, methylcobalamin in an amount of 0.003 mg to 0. 8 mg, pyridoxal-5'-phosphate in an amount of 1 mg to 4 mg, riboflavin in an amount of2 mg to 14 mg, thiamine mononitrate in an amount of 0. 2 mg to 2 mg, zeaxanthin in an amount of 1 mg to 3 mg, lutein in an amount of 4 mg to 15 mg, D-alpha-tocopherol in an amount of 1 mg to 8 mg, calcium ascorbate in an amount of 20 mg to 65 mg, copper gluconate in an amount of 0.1 to 1 mg and zinc oxide in an amount of 2 mg to 33 mg.

[0060] In a preferred embodiment, the components are present in the following amounts, folate, e.g. calcium salt of L-methylfolate, in an amount of 0.5 mg to 1.1 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 90 mg to 190 mg, L-selenomethionine in an amount of 0. 01 mg to 0.03 mg, cholecalciferol in an amount of 0.015 mg to 0.045 mg, calcium D-panthothenate in an amount of 2 mg to 6 mg, methylcobalamin in an amount of 0.005 mg to 0.6 mg, pyridoxal-5'-phosphate in an amount of 1.6 mg to 3.5 mg, riboflavin in an amount of 3.7 mg to 10.5 mg, thiamine mononitrate in an amount of 0.45 mg to 1.6 mg, zeaxanthin in an amount of 1.9 mg to 2.1 mg, lutein in an amount of 9 mg to 11 mg, D-a-tocopherol in an amount of 2 mg to 6 mg, calcium ascorbate in an amount of 35 mg to 50 mg, copper gluconate in an amount of 0.2 mg to 0.8 mg and zinc oxide in an amount of 4 mg to 26 mg.

[0061] In another embodiment, the composition comprises the components in the following amount, folate, e.g. calcium salt of L-methylfolateinanamount of 0.9 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 180 mg, L-selenomethionine in an amount of 0.02 mg, cholecalciferol in an amount of 0.0375 mg, calcium D-panthothenate in an amount of 5 mg, methylcobalamin 0.5 mg, pyridoxal 5'-phosphate in an amount of 3 mg, riboflavin in an amount of 10 mg, thiamine mononitrate in an amount of 1.5 mg, zeaxanthin in an amount of 2 mg, lutein in an amount of 10 mg, D-a-tocopherol in an amount of 5 mg, calcium ascorbate in an amount of 45 mg, copper gluconate in an amount of 0.667 mg and zinc oxide in an amount of 25 mg.

[0062] In another preferred embodiment, a capsule or tablet comprises the components in the following amounts, folate, e.g. calcium salt of L-methylfolate in an amount of 0.6 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 100 mg, L-selenomethionine in an amount of 0.02 mg, cholecalciferol in an amount of 0.02 mg, calcium D-panthothenate in an amount of 3 mg, methylcobalamin 0.009 mg, pyridoxal 5'-phosphate in an amount of 2. Img, riboflavin in an amount of 4.2 mg, thiamine mononitrate in an amount of 0.55 mg, zeaxanthin in an amount of 2 mg, lutein in an amount of 10 mg, D-a-tocopherol in an amount of 3 mg, calcium ascorbate in an amount of 40 mg, copper gluconate in an amount of 0.1 mg and zinc oxide in an amount of 5 mg. However, in all embodiments the amount of folate, in particular L-methylfolate can be in an amount of 0.1 mg to 10 mg, preferably 0.2 mg to 5 mg, more preferably 0.5 mg to 3 mg.

[0063] The compositions may further comprise a pharmaceutically acceptable carrier.

[0064] Further, other folate salts may be used as components of the described compositions. Such other salts are for instance a magnesium salt of folate, a sodium salt of folate, and a zinc salt of folate. Mixtures of these salts are also conceivable, so that a composition comprises two or more different folate salts, e.g., the calcium folate salt and the magnesium folate salt.

[0065] Administration

[0066] Reduced folate compounds and / or additional agents as described herein may be formulated into any of a variety of dosage forms suitable for administration to the intended subject. In many embodiments, reduced folate compounds and / or additional agents are administered by a systemic route, e.g., orally, topically or intranasally. For example, reduced folate compounds and / or additional agents may be formulated as a food additive or as a tablet for oral consumption. In some embodiments, tablets comprise reduced folate compounds and / or additional agents in solid form. As another example, reduced folate compounds and / or additional agents may be formulated as an aerosol (e.g., as aerosolized particles), which may be inhaled by a subject to achieve intranasal delivery.

[0067] For the use and treatment according to the invention, the amount of the reduced folate in the composition required to be administered will vary depending upon factors such as the risk and severity of the disease, any underlying medical condition or disease, age, the form of the preparation, and other medications being administered. Further the amount may vary depending upon whether the reduced folate is being used to reduce / increase (when the dose may be higher) or whether the reduced folate is being used during maintenance (when the dose may be lower). However, the required amount can be readily set by a medical practitioner and would generally be in the range from about 700 pg to about 50 mg per day, in certain embodiments from about 800 pg to about 15 mg per day, for example from about 900 pg to about 3 mg per day. An appropriate dose can be determined based on several factors, including, for example, body weight and / or condition, the severity of the disease being treated or prevented, other ailments and / or diseases, the incidence and / or severity of side effects and the manner of administration. Appropriate dose ranges may be determined by methods known to those skilled in the art. During an initial phase, the dosing can be higher (for example 0. Img to lOOmg per day, preferably 0.2mg to 50mg per day). During a maintenance phase, the dosing can be reduced (for example, 0.05mg to 50mg per day, preferably 0.075mg to 15mg per day, more preferably 0.8mg to 3 mg).

[0068] While the invention has been described with reference to specific implementations, it will be understood by those skilled in the art that various changes may be made, and equivalents may be substituted for elements thereof without departing from the true spirit and scope of the invention. In addition, modifications may be made without departing from the essential teachings of the invention as defined in the claims.Example

[0069] A 62-year-old male patient suffering from primary lymphedema (since age of 53) resulting in a swelling of the limbs was treated with Ocufolin® the composition of which is indicated below, and leg diameter was measured to examine the condition of the primary lymphedema (based on the swelling), which is shown in Table 1 below. The patient was treated for 28 months and took three capsules of Ocufolin® per day. The leg (i.e. thigh and calf) diameter was checked during treatment after 6, 12 and 28 months showing a decrease in diameter and hence a reduction of the swelling caused by the primary lymphedema.

[0070] Table 1 : Calf diameter and thigh diameter of the patient before and during the treatment

[0071] The decrease of thigh diameter from 58-60 cm to 52-55 cm and of the calf diameter from 45-48 cm to 40-42 cm in the period of approximately 12 months of daily intake of Ocufolin® is a significant decrease. The measurement after 28 months shows that the swelling has not returned with continued use and the condition has stabilized into a steady state of reduced / no swelling. Ocufolin® is a preparation comprising L-methylfolate, respectively its calcium salt. Since, the L-methylfolate reduces intraluminal pressure thereby increasing lymphatic drainage resulting in a de-accumulation of lymphatic fluid, the swelling-reducing effect of the composition is entirely or to a significant extent due to the folate. The composition, respectivelythe amount of its ingredients is as indicated below. The compounds forming the capsule (315 mg Hypromellose & Gellan Gum) are not indicated.

Claims

Claims1. A composition for use in the treatment of a disorder linked to a deficiency and / or an insufficiency of a micronutrient, in particular a folate, in a lymphatic and / or glymphatic system, the composition comprising at least one folate.

2. The composition according to claim 1, wherein the at least one folate is a folate salt comprising a tetrahydrofolic acid anion and a cation.

3. The composition according to claim 2, wherein the anion is selected from the group consisting of 5-formyl-(6RS)-tetrahydrofolic acid, 5-formyl-(6S)-tetrahydrofolic acid, 10-formyl-(6R)-tetrahydrofolic acid, 5-methyl-(6RS)-tetrahydrofolic acid, 5-methyl- (6S)-tetrahydrofolic acid, (6S)-tetrahydrofolic acid, 5,10-methylene-(6R)- tetrahydrofolic acid, 5-methyl-10-formyl-(6R)-tetrahydrofolic acid, and 5,10- diformyl-(6R)-tetrahydrofolic acid.

4. The composition according to any of claims 2 or 3, wherein the cation is an organic cation selected from the group consisting of arginine, choline, acetylcholine, N- methylaminoethanol, 2-amino-2-methyl-propanol, 1 , 1 -dimethyl-biguanidin, phenylethyl-biguanidin and glucosamine or an inorganic cation selected from the group consisting of calcium, sodium, and zinc.

5. The composition according to claim 4, wherein the organic cation is selected from the group consisting of di-arginine, di-choline, di-acetylcholine, di-N- methylaminoethanol, di-2-amino-2-methyl-pr opanol, di-( 1 , 1 -dimethyl-biguanidin), di-(phenylethyl-biguanidin) and di-glucosamine.

6. The composition according to claim 4, wherein the organic cation is selected from the group consisting of mono-arginine, mono-choline, mono-acetylcholine, mono-N- methylaminoethanol, mono-2-amino-2-methyl-pr opanol mono-( 1 , 1 -dimethyl- biguanidin), and mono-(phenylethyl-biguanidin).

7. The composition according to any of claims 2 to 6, wherein the folate salt is a crystalline folate salt.

8. The composition according to claim 7, wherein the folate salt is a crystalline folate salt consisting of a tetrahydrofolic acid anion and organic cation wherein the anion is5-methyl-(6S)-tetrahydrofolic acid, and the cation is the organic compound di-choline or consisting of a tetrahydrofolic acid anion and organic cation wherein the anion is 5-formyl-(6S)-tetrahydrofolic acid and the cation is the organic compound di-arginine or consisting of a tetrahydrofolic acid anion and organic cation wherein the anion is selected from the group consisting of 5-formyl-(6S)-tetrahydrofolic acid and 5- methyl-(6S)-tetrahydrofolic acid, and the cation is selected from the group consisting of calcium, glucosamine, and sodium.

9. The composition according to any of claims 1 to 8, wherein the folate is a reduced folate compound in particular selected from the group consisting of 5-formyl-(6RS)- tetrahydrofolic acid, 5-formyl-(6S)-tetrahydrofolic acid, 10-formyl-(6R)- tetrahydrofolic acid, 5-methyl-(6RS)-tetrahydrofolic acid, 5-methyl-(6S)- tetrahydrofolic acid, (6S)-tetrahydrofolic acid, 5,10-methylene-(6R)-tetrahydrofolic acid, 5-methyl-10-formyl-(6R)-tetrahydrofolic acid, and 5,10-diformyl-(6R)- tetrahydrofolic acid, and combinations thereof, in particular a reduced folate compound selected from the group consisting of folinic acid (leucovorin), methyltetrahydrofolate (MTHF), levofolinic acid (levoleucovorin), L- methyltetrahydrofolate (L-MTHF), a mixture of dextroleucovorin and levoleucovorin, and combinations thereof.

10. The composition according to any of claim 1 to 9, wherein the disorder linked to a deficiency of a micronutrient, in a lymphatic and / or glymphatic system is a lymphedema, in particular a primary or secondary lymphedema, and / or a glymphatic- related neurodevelopmental disorder, wherein treatment in particular includes increasing the drainage of extracellular fluid from extremities and / or increasing the drainage of excess fluid and waste products from the interstitial spaces and / or increasing drainage across lymphatic and / or glymphatic capillaries by administration of the composition.

11. The composition according to any of claims 1 to 10, further comprising one or more additional agents selected from vitamin B3, vitamin B12 (methylcobalamin), vitamin B6, vitamin B2, vitamin D3, N-acetylcysteine or other sulfur containing compounds.

12. The composition according to any of claims 1 to 10 comprising a capsule or tabletcomprising the calcium salt of L- methylfolate, in an amount of 0.2 mg to 1.5 mg, and optionally one or more of the following components, N-acetylcysteine or its salt in an amount of 40 mg to 250 mg, L- selenomethionine in an amount of 0. 005 mg to 0.04 mg, cholecalciferol in an amount of 0.009 mg to 0.06 mg, calcium D-pantothenate in an amount of 1 mg to 8 mg, methylcobalamin in an amount of 0.003 mg to 0. 8 mg, pyridoxal-5'-phosphate in an amount of 1 mg to 4 mg, riboflavin in an amount of 2 mg to 14 mg, thiamine mononitrate in an amount of 0. 2 mg to 2 mg, zeaxanthin in an amount of 1 mg to 3 mg, lutein in an amount of 4 mg to 15 mg, D-alpha-tocopherol in an amount of 1 mg to 8 mg, calcium ascorbate in an amount of 20 mg to 65 mg, copper gluconate in an amount of 0.1 to 1 mg and zinc oxide in an amount of 2 mg to 33 mg.

13. The composition according to any of claims 1 to 10 in the form of a capsule or tablet comprising the calcium salt of L-methylfolate, in an amount of 0.5 mg to 1.1 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 90 mg to 190 mg, L-selenomethionine in an amount of 0.01 mg to 0.03 mg, cholecalciferol in an amount of 0.015 mg to 0.045 mg, calcium D-pantothenate in an amount of 2 mg to 6 mg, methylcobalamin in an amount of 0.005 mg to 0.6 mg, pyridoxal-5'-phosphate in an amount of 1.6 mg to 3.5 mg, riboflavin in an amount of 3.7 mg to 10.5 mg, thiamine mononitrate in an amount of 0.45 mg to 1.6 mg, zeaxanthin in an amount of 1.9 mg to 2.1 mg, lutein in an amount of 9 mg to 11 mg, D-a-tocopherol in an amount of 2 mg to 6 mg, calcium ascorbate in an amount of 35 mg to 50 mg, copper gluconate in an amount of 0.2 mg to 0.8 mg and zinc oxide in an amount of 4 mg to 26 mg.

14. The composition according to any of claims 1 to 10 in the form of a capsule or tablet comprising the calcium salt of L-methylfolate in an amount of 0.9 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 180 mg, L-selenomethionine in an amount of 0.02 mg, cholecalciferol in an amount of 0.0375 mg, calcium D-pantothenate in an amount of 5 mg, methylcobalamin 0.5 mg, pyridoxal 5'-phosphate in an amount of 3 mg, riboflavin in an amount of 10 mg, thiamine mononitrate in an amount of 1.5 mg, zeaxanthin in an amount of 2 mg,lutein in an amount of 10 mg, D-a-tocopherol in an amount of 5 mg, calcium ascorbate in an amount of 45 mg, copper gluconate in an amount of 0.667 mg and zinc oxide in an amount of 25 mg.

15. The composition according to any of claims 1 to 10 in the form of capsule or tablet comprising the calcium salt of L-methylfolate in an amount of 0.6 mg, and optionally one or more of the following components, N-acetylcysteine in an amount of 100 mg, L-selenomethionine in an amount of 0.02 mg, cholecalciferol in an amount of 0.02 mg, calcium D-pantothenate in an amount of 3 mg, methylcobalamin 0.009 mg, pyridoxal 5'-phosphate in an amount of 2. Img, riboflavin in an amount of 4.2 mg, thiamine mononitrate in an amount of 0.55 mg, zeaxanthin in an amount of 2 mg, lutein in an amount of 10 mg, D-a-tocopherol in an amount of 3 mg, calcium ascorbate in an amount of 40 mg, copper gluconate in an amount of 0.1 mg and zinc oxide in an amount of 5 mg.

16. A method for reducing severity, incidence or risk in lymphedema, in particular primary or secondary lymphedema or in glymphatic-related neuro- developmental disorders, the method comprising the steps of: detecting in a patient subject one or more of lymphedema related swelling in extremities of the arms or legs or an elevated level of homocysteine in the blood,FRoc autoantibodies in a fluid sample; and / or presence of a genetic marker associated with increased risk of developing a CFD- related disorder and / or a mutation of DHFR, MTR, MTRR or MTHFR; administering a folate, in particular a composition according to any of the claims 1 to 15 to the patient.

17. The method according to claim 16, wherein the method further comprises the step of:coadministering one or more additional agents selected from vitamin B3, vitamin B12 (methylcobalamin), vitamin B6, vitamin B2, vitamin D3, N-acetyl cysteine or other sulfur containing compounds.

18. The method according to any of the claims 16 or 17, wherein the glymphatic-related disorder is a neurodevelopmental disorder such as Alzheimer’s Dementia (AD), Parkinson’s Disease (PD), or Huntington’s Disease (HD).

19. Use of the composition according to any of the claims 1 to 15, for the preparation of a medicament, a food additive or a nutritional supplement, for the prevention and / or treatment of either deficiencies or disorders that are positively affected by the administration.

20. A kit, comprising a composition for use in the treatment of a disorder linked to a deficiency of a micronutrient, in particular a folate, in a lymphatic and / or glymphatic system comprising one or more pharmaceutically acceptable dosage forms, wherein at least one pharmaceutically acceptable dosage form comprises the composition according to any one of claims 1-15, and / or instructions for use according to any one of claims 16-18.

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