Assessing the Safety and Efficacy of Lamotrigine as Anti-myotonic Agent in Myotonic Dystrophy Type 1 (DM1): A Longitudinal, Open-Label, Pilot Study

Abstract

Introduction

Myotonia, defined as impaired relaxation of skeletal muscles after voluntary contraction or electrical stimulation, is a core feature of myotonic dystrophy type 1 (DM1) and can be highly disabling. The most used anti-myotonic drug, mexiletine, has limited availability and is associated with several side effects. Lamotrigine (LTG), an anti-epileptic drug that reduces voltage-sensitive sodium channel activity, has shown efficacy in treating myotonia in both in vitro models and patients with non-dystrophic myotonias. We aimed to investigate in a cohort of patients with DM1 the use of LTG as an anti-myotonic treatment in a real-world setting.

Methods

We enrolled 14 consecutive adult patients with genetically confirmed DM1 and clinically significant myotonia impacting daily living (Myotonia Behaviour Scale, MBS > 1). LTG was administered in escalating doses, starting from 50 mg/day up to 200 mg/day. Efficacy was assessed using a linear mixed-effects model. Two functional timed tests [the 9-Hole Peg Test (9HPT) and the preparation of a coffee pot, devised by us and called the “Coffee Task” test] were performed at baseline (pre-treatment) and at each dose level. Safety data was also collected.

Results

The mean age at enrollment was 40 years, and the mean disease duration was 12 years. LTG dosage had a significant positive effect on 9HPT performance at the maximum dose compared to baseline. Age and disease duration significantly influenced 9HPT results. No significant changes were observed in the other functional timed test. No serious adverse events were reported.

Conclusion

This pilot, open-label study provides preliminary evidence for the efficacy and safety of LTG as an anti-myotonic treatment in patients with DM1. These findings support the need for larger, placebo-controlled trials to confirm its clinical utility.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-025-00804-z.

Key Summary Points

Why carry out this study?

Myotonia is a hallmark of myotonic dystrophy type 1 (DM1), which is characterized by delayed relaxation of the skeletal muscles following voluntary contraction or electrical stimulation. This disabling symptom impacts daily activities, mobility, and social interaction. The only approved drug targeting this condition, mexiletine, is poorly available and has numerous side effects. New disease-modifying drugs under development can also act on the myotonic phenomenon, but they probably will not be available to all patients worldwide.

Considering the effectiveness of lamotrigine in reducing myotonia in patients with non-dystrophic myotonias as emerged in recent clinical trials, this pilot study aimed to evaluate for the first time the effect and safety of this drug in a cohort of patients with DM1.

What was learned from this study?

Patients treated with lamotrigine performed the 9-Hole Peg Test, which is used as a measure of manual dexterity, more quickly than at baseline when they were treatment-naïve. The change was significant at the maximum dosage of lamotrigine. The safety profile was satisfactory.

These results demonstrate the potential value of lamotrigine as a treatment for myotonia. This drug is already on the market, inexpensive, and well tolerated. The results should pave the way for future placebo-controlled trials.

Introduction

Myotonic dystrophy type 1 (DM1) is the most common form of muscular dystrophy in adults [1]. It is an autosomal dominant disorder caused by the expansion (ranging from 50 to 4000 repeats) of an unstable CTG trinucleotide repeat in the DMPK gene on chromosome 19, which encodes a myosin kinase expressed in skeletal muscle [2–4].

A hallmark of DM1 is myotonia, defined as delayed relaxation of skeletal muscle following voluntary contraction or electrical stimulation. This phenomenon typically improves with repeated contractions, known as the warm-up phenomenon [5]. Myotonia can affect nearly any muscle, but it is particularly disabling when it involves the hand muscles (leading to handgrip myotonia) or the bulbar, tongue, or facial muscles, resulting in difficulties with speaking, chewing, and swallowing [6]. These features significantly impair patients’ quality of life.

The etiopathogenesis of myotonia in DM1 has been extensively studied. One early hypothesis suggested that DMPK dysfunction might impair the fast inactivation of sodium channels—a time-dependent mechanism that physiologically halts sodium influx and cell depolarization [7]. Delayed closing of inactivation gates results in increased muscle fiber excitability and susceptibility to sustained, repetitive discharges, causing myotonia [8, 9]. However, studies in both DMPK loss-of-function (knockout mice) and gain-of-function (kinase overexpression) models failed to show muscle hyperexcitability, arguing against this as the primary mechanism [10, 11].

Subsequent research highlighted the role of reduced chloride channel conductance. Under normal conditions, chloride conductance stabilizes the resting membrane potential and counteracts depolarization induced by extracellular potassium (K⁺) accumulation in the T tubules—events that can trigger myotonic discharges [12]. When chloride conductance is impaired, K⁺ builds up in these invaginations, as demonstrated in both animal and human studies [13–15].

In DM1, impaired chloride conductance results from dysregulation of alternative splicing [16]. RNA transcripts from the expanded allele form nuclear foci containing long (CUG)_n repeats, which sequester double-stranded CUG-binding proteins such as muscleblind-like 1 (MBNL1), a key regulator of pre-mRNA splicing, including that of the CLCN1 gene encoding the chloride channel [17, 18]. Loss of MBNL1 function leads to mis-splicing of CLCN1, reducing functional chloride channels and increasing muscle excitability. The presence of normal SCN4A protein levels in patients with DM1, along with evidence of late sodium channel openings in CLCN1-deficient models, suggests that sodium current abnormalities are secondary to impaired chloride conductance [19–21].

Currently, there is no approved disease-modifying therapy for DM1. However, for symptomatic treatment, drugs targeting the Na_v1.4 sodium channel subunit have shown efficacy in managing myotonia. Among these, mexiletine, a class 1B antiarrhythmic agent structurally similar to lidocaine, is widely used as a first-line treatment for DM1-related myotonia and is approved for use in non-dystrophic myotonias (NDM) [22–26]. Mexiletine blocks the inward sodium current [27, 28], producing an action potential-dependent inhibition of inactivated sodium channels in cardiac and skeletal muscle, thereby reducing repetitive motor unit discharges [25].

Despite its effectiveness, mexiletine has notable side effects, which complicate its use in DM1. It may prolong QRS duration (especially at higher heart rates), shorten the QT interval, impair hemodynamic function in patients with heart failure, and increase the pacing threshold and defibrillation energy requirement [29]. While some safety data exist for mexiletine use in small DM1 cohorts, the high prevalence of conduction system disease in these patients necessitates regular cardiac monitoring [30–32]. In controlled trials, common adverse effects included upper gastrointestinal symptoms (41%), dizziness (10.5%), tremor (12.6%), and coordination issues (10.2%), leading to treatment discontinuation in 40% of patients [25, 26, 33–36]. Other studies report intolerance rates between 20% and 30% [37, 38].

Alternative treatments for myotonia have been less thoroughly investigated and are supported by low-quality evidence [39]. Lamotrigine (LTG), an antiepileptic drug, reduces voltage-sensitive sodium channel activity and modulates GABAergic transmission [40]. Specifically, it promotes hyperpolarization by shifting the steady-state inactivation of Na_v1.4 channels [41]. LTG’s adverse events are typically mild (e.g., blurred vision, unsteadiness, double vision, coordination issues, and rash) [42, 43]. Though severe skin rashes are rare (0.3% in adults), a recent review estimated a fatal outcome in 0.01% of rash cases per 1000 patient-years [44]. Significant cardiac side effects are infrequent [45].

In vitro studies demonstrated LTG’s effectiveness in reducing myotonia in both rat and human muscle tissues [40]. LTG markedly reduced abnormal force generation during and after electrical stimulation in myotonic muscles, without affecting normal muscle response. Notably, these effects were observed at clinically relevant concentrations, which are equivalent to those found in the serum of patients with epilepsy [40].

A recent double-blind, placebo-controlled trial showed that LTG significantly reduced myotonia in patients with NDM, leading to corresponding improvements in physical function and quality of life [46]. The study was halted early after enrolling 26 participants because of clear efficacy. No serious or unexpected adverse events occurred. More recently, a head-to-head, double-blind trial comparing LTG and mexiletine in NDM failed to demonstrate non-inferiority of LTG; however, both treatments led to substantial symptom improvement [47].

These findings support the hypothesis that LTG may also be effective for treating myotonia in DM1. The present study aims to evaluate the safety and efficacy of lamotrigine in managing myotonia in patients with DM1.

Methods

Patients

This longitudinal, monocentric brief report was conducted in accordance with the principles of the Declaration of Helsinki. Approval was granted by the local Ethics Committee (22 November 2024, No. 0063419/24).

Fourteen consecutive adult patients with a genetically confirmed diagnosis of DM1 were recruited at our center. Inclusion criteria included clinically evident myotonia affecting the hands and/or leg muscles, with a negative impact on daily living, and a Myotonic Behaviour Scale (MBS) score ≥ 1 [48].

Exclusion criteria were as follows:

• (i)Known hypersensitivity to lamotrigine (LTG)
• (ii)Concurrent use of other antiepileptic drugs, mexiletine, or medications inhibiting hepatic metabolism
• (iii)History of cardiac insufficiency (New York Heart Association [NYHA] class III/IV), uncontrolled arrhythmias, unstable ischemic heart disease, or uncontrolled hypertension
• (iv)History of hepatic insufficiency
• (v)Breastfeeding or women of childbearing potential without effective contraception

All patients provided both oral and written informed consent for the off-label use of prescription medications.

Procedures and Outcomes

Patients were assessed at baseline (T0), prior to starting treatment, and at each LTG dose escalation. The planned escalating daily doses were 50 mg (T50), 100 mg (T100), 150 mg (T150), and 200 mg (T200), administered in two divided doses per day. Each assessment was performed at least 2 weeks after the patient had reached a given dose, typically during the third or fourth week after the dose was changed. If there were no adverse events, patients were required to proceed to the next dose after the assessment. The scheme and maximum dose were based on the protocol used by Andersen et al., which included a maximum daily dose of 300 mg. The decision to stop at 200 mg was influenced by the lack of safety data on the use of lamotrigine in patients with DM1. The decision to administer the drug twice daily was made in accordance with the regimen typically used for patients with epilepsy, as it is well tolerated and ensures adequate persistence of drug plasma concentrations. At baseline, patients underwent a comprehensive evaluation including medical history, structured interview regarding myotonic symptoms, electrocardiogram (ECG), and neurological examination.

At baseline and at each subsequent LTG dose level, patients performed two timed functional tests to assess clinical hand closure myotonia: the validated 9-Hole Peg Test (9HPT) and a second test developed at our center, which we have named the “Coffee Task” [49, 50].

The 9HPT involves placing nine pegs into holes on a board as quickly as possible, after the patient keeps their hand clenched in a fist for 30 s to provoke myotonia. The test was conducted separately for the right hand (“9HPT-R”) and the left hand (“9HPT-L”). The 9HPT was chosen to overcome the inter-rater variability of the more widespread video Hand Opening Time (vHOT) test [26]. Moreover, the 9HPT is similar to the Jebsen–Taylor Hand Function Test (JTHFT) subtest, which involves picking up and placing small, common objects in a container. The JTHFT is a standardized, objective measure of fine and gross motor hand function using simulated activities of daily living (ADLs) and it was used in Heatwole et al.’s trial on mexiletine in DM1 [26].

The Coffee Task simulates bilateral daily activity and involves dismantling and reassembling a coffee pot placed in front of the patient (including unscrewing/screwing the top part of the coffee pot onto the base and removing/positioning the filter in the middle), again following 30 s of bilateral hand clenching.

Laboratory evaluations (including blood count, creatinine, aspartate transaminase, alanine transaminase, gamma-glutamyl transaminase, bilirubin, sodium, and potassium) were performed immediately after each dose increase.

Adverse events were recorded on the basis of patient self-reporting or identified during clinical evaluation.

Statistical Analysis

Statistical analyses were performed using IBM SPSS software version 26.0, with a significance threshold set at p ≤ 0.05. As a result of the presence of some missing data, since not all patients reached the maximum daily dose of 200 mg, a linear mixed-effects model was used to compare primary outcomes (9HPT, Coffee Task) across different LTG doses.

Separate models were constructed for each functional timed test as the dependent variable. Models were adjusted for age and disease duration. The independent variables included “subject” (random effect) and “sex” and “time” (fixed effects). Post hoc analyses were performed using independent t tests with Bonferroni correction. All timed test data were log₁₀-transformed prior to analysis.

To further test the validity of the results, a sensitivity analysis was performed using repeated measures analysis of covariance (ANCOVA) (with “sex” as the between-subjects factor and “age” and “disease duration” as the covariates), imputing missing data using the last observation carried forward method. As this was a pilot study, no a priori sample size calculation was performed.

Results

Patients

Fourteen patients with DM1 were enrolled, including eight men (57.1%). The mean age was 40 years (range 34.7–51), and the mean disease duration, defined as the time from symptom onset or, if unavailable, from the year of diagnosis, was 12 years (range 5.7–19). All patients had CTG repeat expansions in the E2 range (150–1000 repeats). Five patients were on nocturnal non-invasive ventilation (NIV) for type 2 respiratory failure and/or sleep apnea syndrome, while four others had received a recommendation for NIV but declined to initiate it. According to the Muscular Impairment Rating Scale (MIRS) [51], nine patients were graded as score 3, four as score 4, and one as score 5.

Efficacy Data

Of the 14 patients, 5 reached a maximum daily dose of 50 mg (T50), 3 reached 150 mg (T150), and 6 reached 200 mg (T200).

Increasing doses of LTG (“time”) significantly predicted performance in the following timed tests: (a) 9HPT-R: F(4, 23.162) = 6.216, p = 0.002; (b) 9HPT-L: F(4, 19.947) = 9.023, p < 0.001.

The estimates (along with standard errors and 95% confidence intervals) of fixed effects are shown in Tables S1 and S2.

The effect of increasing doses of LTG was partially confirmed in the sensitivity analysis performed, with p values obtained through Greenhouse–Geisser correction since the Mauchly sphericity test was significant [9HPT-R: F(1.164, 11.637) = 4.018, p = 0.064; 9HPT-L; F(1.418, 14.184) = 5.732, p = 0.022].

No significant effect was observed for the Coffee Task.

In addition, disease duration significantly predicted performance in 9HPT-R (F(1, 10.104) = 8.965, p = 0.013); an interaction effect between “time” and “age” was also significant for 9HPT-R (F(4, 23.183) = 8.730, p < 0.001) (Fig. S1); for 9HPT-L, significant predictors included the interaction between “time” and “age” (F(4, 19.956) = 8.468, p < 0.001) (Fig. S1) and between “time” and “disease duration” (F(4, 19.939) = 4.927, p = 0.006) (Fig. S2).

Post hoc comparisons revealed that 9HPT-R times were significantly reduced at T200 compared to T0 (p = 0.018); 9HPT-L times were significantly reduced both at T200 (p = 0.016) and at T150 (p = 0.015) compared to T0 (Fig. 1).

Fig. 1.

9HPT-R and 9HPT-L values at baseline and at each LTG dose increase. The timepoints representing the increasing daily dose of LTG (mg) are shown on the x-axis. On the y-axis, the values of 9HPT-R (a) and 9HPT-L (b) are shown as the time taken to perform the test in seconds. 9HPT-R and 9HPT-L are reported as mean ± SEM and have been log₁₀-transformed prior to analysis. The number of patients at each timepoint is illustrated at the bottom of the graph. 9HPT-R was significantly lower at T200 compared to BSL (p = 0.018) (a). 9HPT-L was significantly lower at T150 compared to BSL (p = 0.015) and at T200 compared to BSL (p = 0.016) (b). BSL baseline, LTG lamotrigine, sec seconds, T50 50 mg daily dose, T100 100 mg daily dose, T150 150 mg daily dose, T200 200 mg daily dose, 9HPT-L Nine-Hole Peg Test on left side, 9HPT-R Nine-Hole Peg Test on right side

Although no overall effect was observed for the Coffee Task, a significant reduction in task time was noted at T150 compared to T0 (p = 0.004).

The MBS mean score, which was available for 11 patients at the end of treatment (three patients were unable to provide this information as a result of non-compliance), decreased from 2.73 ± 0.3 to 1.81 ± 0.3.

The overall efficacy data are shown in Table 1.

Table 1.

Outcome measures before and after treatment with LTG

Outcome measure	Pre-LTG	Post-LTG	p value
9HPT-R (s)	78.2 ± 42.6 (n = 14)	36.7 ± 9.3 (n = 6)	0.002a*
9HPT-L (s)	95.3 ± 42.4 (n = 14)	40.3 ± 9.4 (n = 6)	< 0.001a*
Coffee Task (s)	22.9 ± 5.5 (n = 14)	13 ± 1.1 (n = 6)	0.327a
MBS (score)	2.73 ± 0.3 (n = 11)	1.81 ± 0.3 (n = 11)	0.013b*

The values for each outcome measure before and after treatment with LTG are shown. For the first three timed tests, the post-treatment values shown are those obtained for six patients at the T200 dose. The post-treatment MBS score was obtained for each patient at the maximum tolerated dose and was globally available for 11 patients. Values are shown as mean ± SEM

LTG lamotrigine, MBS Myotonia Behaviour Scale, s seconds, 9HPT-L Nine-Hole Peg Test on left side, 9HPT-R Nine-Hole Peg Test on right side

*Significant p values

^aAnalysis performed by linear mixed-effects model

^bAnalysis performed by Wilcoxon test

Safety Data

Reasons for discontinuation at lower doses included subjective lack of efficacy (n = 3, at T150), unwillingness to continue treatment (n = 1, at T50), transaminase elevation up to four times the upper normal limit (UNL) (n = 1, at T50), which normalized after LTG discontinuation (Table 2).

Table 2.

Safety data: reasons for withdrawal (W) or dose decrease (D) and timepoint of occurrence

AE	N (%)	T50	T100	T150	T200
Transaminase increase	1 (7.1)	W
Subjective lack of efficacy	3 (21.4)			WWW
Unwillingness to continue treatment	1 (7.1)	W
Diarrhea	1 (7.1)		D
Lower limbs pain	1 (7.1)		D
Abdominal rush	1 (7.1)		W

Most adverse events occurred at lower doses (T50 and T100). In two cases, a reduction to the previous dose (from T100 to T50) was sufficient to solve the adverse event. No serious adverse event was registered

AE adverse event, D decrease, N number of subjects, T50 50 mg daily dose, T100 100 mg daily dose, T150 150 mg daily dose, T200 200 mg daily dose, W withdrawal

Other reported adverse events included diarrhea (n = 1) and diffuse lower limb pain (n = 1) at T100; both patients reverted to 50 mg/day with resolution of symptoms and continued treatment. No functional assessments were available for these timepoints. One patient developed an abdominal rash at T100 and discontinued treatment.

The flow of patients at each timepoint is shown in Fig. S3.

Anecdotally, one patient independently escalated to 400 mg/day without reporting adverse events; however, this patient was excluded from the efficacy analysis.

No serious adverse events were reported.

Discussion

In this open-label, pilot study, we evaluated the safety and efficacy of LTG as an anti-myotonic agent in a cohort of 14 patients with DM1. The treatment was generally well tolerated, with only mild adverse events reported. These included elevated transaminase levels, diarrhea, and rash, adverse effects already known to be potentially related to LTG. In all such cases, the treatment was either discontinued or the dose was reduced, with subsequent resolution of symptoms.

Efficacy data showed a positive response to treatment, particularly evidenced by a reduction in the mean times to complete the bilateral 9HPT. This test, widely validated in various neurological disorders to assess fine dexterity, was modified in our study to include a preceding period of sustained hand contraction, thus serving as a proxy for the myotonic phenomenon [49, 50]. Our primary findings demonstrated a statistically significant reduction in 9HPT duration at LTG doses of 150 mg and 200 mg daily, compared to baseline (i.e., pre-treatment values). One patient independently escalated to 400 mg daily without adverse events; however, the test results did not differ significantly from those observed at 200 mg, suggesting a possible ceiling effect at higher doses. A similar plateau was observed in the performance curve between the 100 mg and 200 mg dose levels (Fig. 1).

Interestingly, adverse events appeared to occur more frequently at the lower dose of 50 mg and were absent at the higher doses. This paradoxical observation underscores the importance of careful monitoring, particularly in the early phases of treatment, including regular liver function testing and vigilance for dermatologic and gastrointestinal symptoms.

Supporting the objective findings, the post-treatment MBS scores, available for a subgroup of 11 patients, showed a mean reduction from 2.73 to 1.81, suggesting an overall improvement in the functional impact of myotonia in daily life.

In contrast, the Coffee Task, another outcome measure, did not reveal significant changes across timepoints. This may be attributed to the complexity of the task, which, beyond motor performance, engages additional cognitive processes such as working memory and visuospatial skills—areas known to be impaired in DM1. Therefore, we cannot exclude the possibility that cognitive dysfunction influenced the results of this test.

More broadly, the incomplete clinical response may reflect limitations in LTG’s mechanism of action relative to the multifactorial pathogenesis of myotonia in DM1. While myotonia in NDM often results from sodium or chloride channel mutations, in DM1 it is predominantly due to alternative splicing defects affecting the chloride channel CLCN1 [20, 21]. Thus, a multimodal approach targeting additional channels, such as chloride channels, might yield more robust clinical benefits [52].

An important finding of this study was the influence of age and disease duration, in combination with LTG dose, on 9HPT outcomes. This raises the hypothesis that persistent myotonic discharges and associated ionic imbalance may not merely be a secondary feature of DM1 but could act as modifiers of muscle function and structure over time [53]. Recent data from DM1 mouse models have shown that chronic myotonia can drive a shift from glycolytic to oxidative muscle fiber types, a change reversible with CLCN1-targeted antisense oligonucleotides (ASOs), along with a reduction in muscle injury [53]. These findings highlight two clinically relevant considerations: longer disease duration is associated with more advanced muscular degeneration, potentially limiting the effectiveness of symptomatic treatments in older patients with long-standing disease; early treatment of myotonia, even when the symptom burden is relatively mild, might exert protective or disease-modifying effects on muscle function over time.

Despite the promising findings, several limitations must be acknowledged. The small sample size and attrition during follow-up limit the robustness of the results. It is challenging to achieve an adequate sample size in the field of rare diseases such as DM1, and future trial designs should consider dropout rates when calculating sample size to guarantee statistical power. The open-label, uncontrolled design, though partially mitigated by within-subject comparisons, limits the generalizability of the results. In the absence of a control group, it was not possible to rule out the possibility of a placebo or learning effect related to repeated functional tests. These effects may have influenced the improvements observed with increased doses. Furthermore, no pre-specified outcomes were designed as a result of the novelty of the outcome measures used—one of which, the Coffee Task, has not yet been validated—and the lack of a reference for clinically significant changes. Additionally, the absence of consistent patient-reported outcome measures (PROMs) limits our understanding of the subjective impact of treatment. Finally, further mechanistic insights, such as intracellular recordings, would be valuable in elucidating LTG’s precise role in reducing myotonia.

Conclusion

This is the first pilot study evaluating LTG for symptomatic treatment of myotonia in patients with DM1 in a real-world clinical setting. Our findings align with recent studies investigating LTG in NDM due to CLCN1 or SCN4A mutations [46, 47]. Although LTG did not meet non-inferiority to mexiletine in a recent head-to-head trial, it demonstrated clear efficacy and a favorable safety profile [1]. The authors of that study also proposed a clinical decision algorithm prioritizing LTG in patients with cardiac disease, metabolic syndrome, gastrointestinal intolerance, or in women of childbearing age, criteria that are frequently applicable to patients with DM1.

Our findings suggest further investigating the potential role of LTG as an anti-myotonic agent, particularly given the costs, limited availability in several countries, and association with more frequent and serious side effects of the currently approved drug for this purpose, mexiletine [37, 38]. These results warrant larger, placebo-controlled, crossover trials to validate the efficacy and safety of LTG in DM1, which would pave the way for subsequent head-to-head studies comparing LTG and mexiletine. Its current market availability, good tolerability profile, and evidence of benefit make it a promising candidate for the management of myotonia in this population.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contributions

Barbara Risi: Conceptualization; Data acquisition, analysis, and interpretation; Writing—Original Draft; Writing—Review & Editing. Nesaiba Ait Allali: Conceptualization; Data acquisition, analysis, and interpretation. Stefano Cotti Piccinelli: Conceptualization; Data acquisition, analysis, and interpretation; Writing—Original Draft. Filomena Caria, Simona Damioli, Beatrice Labella, Enrica Bertella, Giorgia Giovanelli, Francesca Garofali, Giuseppina Margollicci, Roberto Carugati, Lucia Ferullo, Emanuele Olivieri, Loris Poli: Data acquisition, analysis, and interpretation. Alessandro Padovani: Conceptualization; Writing—Review & Editing. Massimiliano Filosto: Supervision; Conceptualization; Writing—Review & Editing.

Funding

No funding or sponsorship was received for this study or publication of this article. The Rapid Service Fee was funded by the authors.

Data Availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

Barbara Risi, Nesaiba Ait Allali, Stefano Cotti Piccinelli, Filomena Caria, Simona Damioli, Beatrice Labella, Enrica Bertella, Giorgia Giovanelli, Francesca Garofali, Giuseppina Margollicci, Roberto Carugati, Lucia Ferullo, Emanuele Olivieri, Loris Poli, Alessandro Padovani, Massimiliano Filosto have nothing to disclose.

Ethical Approval

This study was conducted in accordance with the principles of the Declaration of Helsinki of 1964, and its later amendments. Approval was granted by the local Ethics Committee Comitato Etico Territoriale Lombardia 6 (22 November 2024, No. 0063419/24). All subjects provided informed consent to participate in the study.