AU5182500A - Anti-TNF antibodies and methotrexate in the treatment of autoimmune disease - Google Patents

Description

S&F Ref: 446978D1

AUSTRALIA

PATENTS ACT 1990 COMPLETE SPECIFICATION FOR A STANDARD PATENT

ORIGINAL

Name and Address of Applicant: Actual Inventor(s): Address for Service: Invention Title: The Kennedy Institute of Rheumatology 1 Aspenlea Road Hammersmith London W6 8LH United Kingdom Marc Feldmann Ravinder Nath Maini Spruson Ferguson St Martins Tower 31 Market Street Sydney NSW 2000 Anti-TNF Antibodies and Methotrexate in the Treatment of Autoimmune Disease The following statement is a full description of this invention, including the best method of performing it known to me/us:- 5845c ANTI-TNF ANTIBODIES AND METHOTREXATE IN THE TREATMENT OF AUTOIMMUNE DISEASE Descriotion Backaround of the Invention Monocytes and macrophages secrete cytokines known as tumor necrosis factor alpha (TNFa) and tumor necrosis factor beta (TNF3) in response to endotoxin or other stimuli. TNFe is a soluble homotrimer of 17 kD protein subunits (Smith et al., J. Biol. Chem. 262:6951- 6954 -(1987)) A membrane-bound 26 kD precursor form of TNF also exists (Kriegler et al., Cell 53:45-53 (1988)). For *reviews of TNF, see Beutler et al., Nature 320:584 (1986); Old, Science 230:630 (1986); and Le et al., Lab. Invest.

56:234 (1987) Cells other than monocytes or macrophages also produce TNFa. For example, human non-monocytic tumor cell lines produce tumor necrosis factor (TNF) (Rubin et al., J. Exp.

Med. 164:1350 (1986); Spriggs et al., Proc. Natl. Acad.

Sci. USA 84:6563 (1987)). CD4+ and CD8+ peripheral blood T lymphocytes and some cultured T and B cell lines (Cuturi et al., J. Exp. Med. 165:1581 (1987); Sung et al., J. Exp.

Med. 168:1539 (1988); Turner et al., Eur. J. Immunol.

17:1807-1814 (1987)) also produce TNFa.

TNF causes pro-inflammatory actions which result in tissue injury, such as degradation of cartilage and bone, induction of adhesion molecules, inducing procoagulant activity on vascular endothelial cells (Pober et al., J.

Immunol. 136:1680 (1986)), increasing the adherence of

S

1 0 neutrophils and lymphocytes (Pober et al., J. Immunol.

138:3319 (1987)), and stimulating the release of platelet activating factor from macrophages, neutrophils and vascular endothelial cells (Camussi et al., J. Exp. Med.

166:1390 (1987)).

Recent evidence associates TNF with infections (Cerami et al., Immunol. Today 9:28 (1988)), immune disorders, neoplastic pathologies (Oliff et al., Cell 50:555 (1987)), autcimmune pathologies and graft-versus-host pathologies (Piguet et al., J. Exp. Med. 166:1280 (1987)). The 20 association of TNF with cancer and infectious pathologies is often related to the host's catabolic state. Cancer patients suffer from weight loss, usually associated with anorexia.

The extensive wasting which is associated with cancer, and other diseases, is known as "cachexia" (Kern et al., J.

Parent. Enter. Nutr. 12:286-298 (1988)). Cachexia includes progressive weight loss, anorexia, and persistent erosion of body mass in response to a malignant growth. The fundamental physiological derangement can relate to a decline in food intake relative to energy expenditure. The cachectic state causes most cancer morbidity and mortality.

TNF can mediate cachexia in cancer, infectious pathology, and other catabolic states.

TNF also plays a central role in gram-negative sepsis and endotoxic shock (Michie et al., Br. J. Surg. 76:670-671 (1989); Debets et al., Second Vienna Shock Forum, p.463-466 (1989); Simpson et al., Crit. Care Clin. 5:27-47 (1989)), including fever, malaise, anorexia, and cachexia.

Endotoxin strongly activates monocyte/macrophage production and secretion of TNF and other cytokines (Kornbluth et al., J. Immunol. 137:2585-2591 (1986)). TNF and other monocyte-derived cytokines mediate the metabolic and neurohormonal responses to endotoxin (Michie et al., New Engl. J. Med. 318:1481-1486 (1988)). Endotoxin 1 0 administration to human volunteers produces acute illness with flu-like symptoms including fever, tachycardia, increased metabolic rate and stress hormone release (Revhaug et al., Arch. Surg. 123:162-170 (1988)).

.*Circulating TNF increases in patients suffering from Gram-negative sepsis (Waage et al., Lancet 1:355-357 (1987); Hammerle et al., Second Vienna Shock Forum p. 715-718 (1989); Debets et al., Crit. Care Med.

17:489-497 (1989); Calandra et al., J. Infect. Dis.

161:982-987 (1990)) 20 Thus, TNFa has been implicated in inflammatory diseases, autoimmune diseases, viral, bacterial and parasitic infections, malignancies, and/or neurogenerative diseases and is a useful target for specific biological therapy in diseases, such as rheumatoid arthritis and Crohn's disease. Beneficial effects in open-label trials with a chimeric monoclonal antibody to TNFa (cA2) have been reported with suppression of inflammation (Elliott et al., Arthritis Rheum. 36:1681-1690 (1993); Elliott et al., Lancet 344:1125-1127 (1994)). See also, Van Dullemen et al., Gastroenterology 109:129-135 (1995). Beneficial results in a randomized, double-blind, placebo-controlled trial with cA2 have also been reported with suppression of inflammation (Elliott et al., Lancet 344:1105-1110 (1994)).

Summary of the Invention The present invention is based on the discovery chat treatment of patients suffering from a TNF-mediated disease with a tumor necrosis factor antagonist, such as an antitumor necrosis factor antibody, as adjunctive and/or concomitant therapy to methotrexate therapy produces a rapid and sustained reduction in the clinical signs and symptoms of the disease. The present invention is also based on the unexpected and dramatic discovery that a S. 10 multiple dose regimen of a tumor necrosis factor antagonist, such as an anti-tumor necrosis factor antibody, when administered adjunctively with methotrexate to an individual suffering from a TNF-mediated disease produces a highly beneficial or synergistic clinical response for a 1 5 significantly longer duration compared to that obtained with a single or multiple dose regimen of the antagonist administered alone or that obtained with methotrexate administered alone. As a result of Applicants' invention, a method is. provided herein for treating and/or preventing 20 a TNF-mediated disease in an individual comprising coadministering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. In a particular embodiment, methotrexate is administered in the form of a series of low doses separated by intervals of days or weeks.

A method is also provided herein for treating and/or preventing recurrence of a TNF-mediated disease in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts. TNF-mediated diseases include rheumatoid arthritis, Crohn's disease, and acute and chronic immune diseases associated with an allogenic transplantation renal, cardiac, bone marrow, liver, pancreatic, small intestine, skin or lung transplantation) Therefore, in one embodiment, the invention relates to a method of treating and/or preventing rheumatoid arthritis in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the Sindividual in therapeutically effective amounts. In a second embodiment, the invention relates to a method of treating and/or preventing Crohn's disease in an individual comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in 10 therapeutically effective amounts. In a third embodiment, the invention relates to a method of treating and/or preventing other autoimmune diseases and/or acute or chronic immune disease associated with a transplantation in an individual, comprising co-administering an anti-TNF antibody or a fragment thereof and methotrexate to the individual in therapeutically effective amounts.

A further embodiment of the invention relates to compositions comprising an anti-TNF antibody or a fragment thereof and methotrexate.

20 In addition to anti-TNF antibodies, TNF antagonists include anti-TNF antibodies and receptor molecules which bind specifically to TNF; compounds which prevent and/or inhibit TNF synthesis, TNF release or its action on target cells, such as thalidomide, tenidap, phosphodiesterase inhibitors pentoxifylline and rolipram), A2b adenosine receptor agonists and A2b adenosine receptor enhancers; and compounds which prevent and/or inhibit TNF receptor signalling.

Brief Description of the Drawings Figures 1A-1C are a set of three graphs showing the results over time for swollen joint count in rheumatoid arthritis (RA) patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for :he placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph.

White circle methotrexate black circle methotrexate square placebo.

Figures 2A-2C are a set of three graphs showing the results over time for tender joint count in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/ko) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The 10 number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle methotrexate; black circle methotrexate; suare placebo.

Figures 3A-3C are a set of three graphs showing the results over time for the Physician's Global Disease Assessment in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at 20 each evaluation visit is shown at the bottom of each graph.

White circle methotrexate; black circle methotrexate; square placebo.

Figures 4A-4C are a set of three graphs showing the results over time for the Patient Disease Assessment in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph.

White circle methotrexate; black circle methotrexate; square placebo.

Figures 5A-5C are a set of three graphs showing the results over time for C-reactive protein (CRP) concentration in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without -7methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph. White circle methotrexate; black circle methotrexate; square placebo.

Figures 6A-6C are a set of three graphs showing the results over time for the Health Assessment Questionnaire (HAQ) in RA patients receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate. Results for the placebo group (methotrexate alone) are shown with the 1 mg/kg group. The number of patients with data at each evaluation visit is shown at the bottom of each graph.

White circle methotrexate; black circle methotrexate; square placebo.

Figures 7A-7F are a set of six graphs showing the serum cA2 concentration in each RA patient receiving cA2 treatment (1 mg/kg, 3 mg/kg or 10 mg/kg) with or without methotrexate, plotted over time. Data plotted are the serum cA2 concentrations obtained just before the 20 administration of cA2 at weeks 2, 6, 10 and 14 and then at weeks 18 and 26. The scales for the serum cA2 concentration are condensed with higher doses of cA2.

.eg Figures 8A and 8B are a set of two graphs showing the median serum cA2. concentration over time in RA patients receiving 3 mg/kg cA2 (top panel) or 10 mg/kg cA2 (bottom panel) with or without methotrexate. Square methotrexate; circle or triangle methotrexate.

Detailed Description of the Invention The present invention relates to the discovery that tumor necrosis factor antagonists can be administered to patients suffering from a TNF-mediated disease as adjunctive and/or concomitant therapy to methotrexate therapy, with good to excellent alleviation of the signs and symptoms of the disease. The present invention also relates to the discovery that tumor necrosis factor antagonists can be administered to patients suffering from a TNF-mediated disease in multiple doses and as adjunctive and/or concomitant therapy to methotrexate therapy, with a significant improvement in duration of clinical response.

As a result of Applicants' invention, a method is provided herein for treating and/or preventing a TNFmediated disease in an individual, comprising coadministering methotrexate and a tumor necrosis factor 1 0 antagonist to the individual in therapeutically effective amounts. The TNF antagonist and methotrexate can be administered simultaneously or sequentially. The TNF antagonist and methotrexate can each be administered in single or multiple doses. Multiple TNF antagonists can be co-administered with methotrexate. Other therapeutic regimens and agents can be used in combination with the therapeutic co-administration of TNF antagonists and methotrexate or other drugs that suppress the immune system.

20 A method is also provided herein for treating and/or preventing recurrence of a TNF-mediated disease in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.

As used herein, a "TNF-mediated disease" refers to a TNF related pathology or disease. TNF related pathologies or diseases include, but are not limited to, the following: acute and chronic immune and autoimmune pathologies, such as, but not limited to, rheumatoid arthritis juvenile chronic arthritis

(JCA),

thyroiditis, graft versus host disease (GVHD), scleroderma, diabetes mellitus, Graves' disease, allergy, acute or chrcnic immune disease associated with an allogenic transplantation, such as, but not limited to, renal transplantation, cardiac transplantation, bone marrow transplantation, liver transplantation, pancreatic transplantation, small intestine transplantation, lung transplantation and skin transplantation; infections, including, but not limited to, sepsis syndrome, cachexia, circulatory collapse and shock resulting from acute or chronic bacterial infection, acute and chronic parasitic and/or infectious diseases, bacterial, viral or fungal, such as a human innunodeficiency virus (HIV), acquired immunodeficiency 1 0 syndrome (AIDS) (including symptoms of cachexia, autoimmune :disorders, AIDS dementia complex and infections); inflammatory diseases, such as chronic inflammatory pathologies, including chronic inflammaccry pathologies such as, but not limited to, sarcoidosis, chronic inflammatory bowel disease, ulcerative colitis, and Crohn's pathology or disease; vascular inflammatory pathologies, such as, but not limited to, disseminated intravascular coagulation, atherosclerosis, Kawasaki's pathology and vasculitis syndromes, such as, but not 20 limited to, polyarteritis nodosa, Wegener's granulomacosis, Henoch-Sch6nlein purpura, giant cell arthritis and microscopic vasculitis of the kidneys; chronic active hepatitis; Sj6gren's syndrome; spondyloarthropathies, such as ankylosing spondylitis, psoriatic arthritis and spondylitis, enteropathic arthritis and spondylitis, reactive arthritis and arthritis associated with inflammatory bowel disease; and uveitis; neurodegenerative diseases, including, but not limited to, demyelinating diseases, such as multiple sclerosis and acute transverse myelitis; myasthenia gravis; extrapyramidal and cerebellar disorders, such as lesions of the corticospinal system; disorders of the basal ganglia or cerebellar disorders; hyperkinetic movement disorders, such as Huntington's chorea and senile chorea; drug-induced movement disorders, such as those induced by drugs which block central nervous system (CNS) dopamine receptors; hypokinetic movement disorders, such as Parkinson's disease; progressive supranucleo palsy; cerebellar and spinocerebellar disorders, such as astructural lesions of the cerebellum; spinocerebellar degenerations (spinal ataxia, Friedreich's ataxia, cerebellar cortical degenerations, multiple systems degenerations (Mencel, Dejerine-Thomas, Shi-Drager, and MachadoJoseph)); and systemic disorders (Refsum's disease, abetalipoprotemia, S* 1 0 ataxia, telangiectasia, and mitochondrial multisystem I disorder); disorders of the motor unit, such as neurogenic muscular atrophies (anterior horn cell degeneration, such as amvotrophic lateral sclerosis, infantile spinal muscular atrophy and juvenile spinal muscular atrophy); Alzheimer's -5 disease; Down's syndrome in middle age; diffuse Lewy body disease; senile dementia of Lewy body type; Wernicke-Korsakoff syndrome; chronic alcoholism; primary biliary cirrhosis; cryptogenic fibrosing alveolitis and other fibrotic lung diseases; hemolytic anemia; 20 Creutzfeldt-Jakob disease; subacute sclerosing panencephalitis, Hallerrorden-Spatz disease; and dementia pugilistica, or any subset thereof; malignant pathologies involving TNF-secreting tumors or other malignancies involving TNF, such as, but not limited to, leukemias (acute, chronic myelocytic, chronic lymphocytic and/or myelodyspastic syndrome); lymphomas (Hodgkin's and non-Hodgkin's lymphomas, such as malignant lymphomas (Burkitt's lymphoma or Mycosis fungoides)); cachectic syndromes and other pathologies and diseases involving excess TNF, such as, but not limited to, cacnexia of cancer, parasitic disease and heart failure; and alcohol-induced heDatitis and other forms of chronic hepatitis.

-11- See, Berkow et al., Eds., The Merck Manual, 16th edition, chapter 11, pp. 1380-1529, Merck and Co., Rahway, New Jersey, 1992, incorporated herein by reference.

The terms "recurrence", "flare-up" or "relapse" are defined to encompass the reappearance of one or more symptoms of the disease state. For example, in the case of rheumatoid arthritis, a reoccurrence can include the experience of one or more of swollen joints, morning stiffness or joint tenderness.

1 0 In one embodiment, the invention relates to a method of treating and/or preventing rheumatoid arthritis in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.

15 In a second embodiment, the invention relates to a method for treating and/or preventing Crohn's disease in an individual comprising co-administering a methotrexate and a TNF antagonist to the individual in therapeutically effective amounts.

20 In a third embodiment, the invention relates to a method for treating and/or preventing an acute or chronic immune disease associated with an allogenic transplantation in an individual comprising co-administering methotrexate and a TNF antagonist to the individual in therapeutically effective amounts. As used herein, a "transplantation" includes organ, tissue or cell transplantation, such as renal transplantation, cardiac transplantation, bone marrow transplantation, liver transplantation, pancreatic transplantation, small intestine transplantation, skin transplantation and lung transplantation.

The benefits of combination therapy with methotrexate and TNF antagonists include high clinical response rates for significantly longer durations in comparison with that obtained with treatment with each therapeutic modality separately. In addition, methotrexate significantly -12reauces immunogenicity of anti-TNF antibodies, thus permitting administration of multiple dosages of anti-TNF antibodies with enhanced safety. The results described herein suggest that methotrexate can be used to reduce immunogenicity of other antibodies or proteins. Based on the results described herein, methotrexate can be used in other forms of antibody therapy, such as anti-IL-2 antibody therapy. This method is particularly pertinent in therapies other than anti-CD4 antibody therapy.

1 0 In a further embodiment, the invention relates to :compositions comprising methotrexate and a TNF antagonist.

Sg. The compositions of the present invention are useful for treating a subject having a pathology or condition S# associated with abnormal levels of a substance reactive with a TNF antagonist, in particular TNF in excess of, or less than, levels present in a normal healthy subject, oo where such excess or diminished levels occur in a systemic, localized or particular tissue type or location in the body. Such tissue types can include, but are not limited 20 to, blood, lymph, central nervous system (CNS), liver, kidney, spleen, heart muscle or blood vessels, brain or spinal cord white matter or grey matter, cartilage, ligaments, tendons, lung, pancreas, ovary, testes, prostate. Increased or decreased TNF concentrations relative to normal levels can also be localized to specific regions or cells in the body, such as joints, nerve blood vessel junctions, bones, specific tendons or ligaments, or sites of infection, such as bacterial or viral infections.

Tumor Necrosis Factor Antagonists As used herein, a "tumor necrosis factor antagonist" decreases, blocks, inhibits, abrogates or interferes with TNF activity in vivo. For example, a suitable TNF antagonist can bind TNF and includes anti-TNF antibodies and receptor molecules which bind specifically to TNF: A -13suitable TNF antagonist can also prevent or inhibit TNF synthesis and/or TNF release and includes compounds such as thalidomide, tenidap, and phosphodiesterase inhibitors, such as, but not limited to, pentoxifylline and rolipram.

A suitable TNF antagonist that can prevent or inhibit TNF synthesis and/or TNF release also includes A2b adenosine receptor enhancers and A2b adenosine receptor agonists 5'-(N-cyclopropyl)-carboxamidoadenosine, ethylcarboxamidoadenosine, cyclohexyladenosine and R-N 6 phenyl-2-propyladenosine). See, for example, Jacobson (GB 2 289 218 the teachings of which are entirely incorporated herein by reference. A suitable TNF antagonist can also prevent or inhibit TNF receptor signalling.

Anti-TNF Antibodies As used herein, an "anti-tumor necrosis factor antibody" decreases, blocks, inhibits, abrogates or interferes with TNF activity in vivo. Anti-TNF antibodies useful in the methods and compositions of the present invention include monoclonal, chimeric, humanized, resurfaced and recombinant antibodies and fragments thereof which are characterized by high affinity binding to TNF and low toxicity (including human anti-murine antibody (HAMA) and/or human anti-chimeric antibody (HACA) response). In particular, an antibody where the individual components, such as the variable region, constant region and framework, individually and/or collectively possess low immunogenicity is useful in the present invention. The antibodies which can be used in the invention are characterized by their ability to treat patients for extended periods with good to excellent alleviation of symptoms and low toxicity. Low immunogenicity and/or high affinity, as well as other undefined properties, may contribute to the therapeutic results achieved.

-14 An example of a high affinity monoclonal antibody useful in the methods and compositions of the present invention is murine monoclonal antibody (mAb) A2 and antibodies which will competitively inhibit in vivo the binding to human TNFa of anti-TNFc murine mAb A2 or an antibody having substantially the same specific binding characteristics, as well as fracnments and regions thereof.

Murine monoclonal antibody A2 and chimeric derivatives thereof, such as cA2, are described in U.S. Application No. 08/192,093 (filed February 4, 1994), U.S. Application No. 08/192,102 (filed February 4, 1994), U.S. Application No. 08/192,861 (filed February 4, 1994), U.S. Application No. 08/324,799 (filed October 18, 1994), and Le, J. eE al., **"International Publication No. WO 92/16553 (published October i, 1992), which references are entirely incorporated herein by reference. A second example of a high affinity monoclonal antibody useful in the methods and compositions of the present invention is murine mAb 195 and antibodies which will competitively inhibit in vivo the binding to human TNFa of anti-TNFa murine 195 or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof.

Other high affinity monoclonai antibodies useful in the methods and compositions of the present invention include murine mAb 114 and murine mAb 199 and antibodies which will competitively inhibit in vivo the binding to human TNFa of anti-TNFa murine mAb 114 or mAb 199 or an antibody having substantially the same specific binding characteristics of mAb 114 or mAb 199, as well as fragments and regions thereof. Murine monoclonal antibodies 114, 195 and 199 and the method for producing them are described by M611er,

A.

et al. (Cytokine 2(3):162-169 (1990)), the teachings of which are entirely incorporated herein by reference.

Preferred methods for determining mAb specificity and affinicy by ccmpetitive inhibition can be found in Harlow, et al., Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press, Cold Spring Harbor, New York (1988); Colligan et al., eds., Current Protocols in Immunology, Greene Publishing Assoc. and Wiley Interscience, New York (1992, 1993); Kozbor et al., Immunol. Today 4:72-79 (1983); Ausubel et al., eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1992, 1993) and Muller, Meth. Enzymol. 92:589-601 (1983), which references are entirely incorporated herein by reference.

Additional examples of monoclonal anti-TNF antibodies that can be used in the present invention are described in the art (see, U.S. Application No. 07/943,852 (filed September 11, 1992); Rathjen et al., International Publication No. WO 91/02078 (published February 21, 1991); 15 Rubin et al., EPO Patent Publication 0218868 (published April 22, 1987); Yone et al., EPO Patent Publication No. 3288088 (October 26, 1988); Liang, et al., Biochem.

Biopnys. Res. Comm. 137:847-854 (1986); Meager, et al., Hybridoma 6:305-311 (1987); Fendly et al., Hybridoma 6:359-369 (1987); Bringman, et al., Hybridoma 6:489-507 (1987); Hirai, et al., J. Immunol. Meth. 96:57-62 (1987) Moller, et al., Cytokine 2:162-169 (1990), which references are entirely incorporated herein by reference) Chimeric antibodies are immunoglobulin molecules 25 characterized by two or more segments or portions derived from differenc animal species. Generally, the variable region of the chimeric antibody is derived from a non-human mammalian antibody, such as a murine mAb, and the immunoglobulin constant region is derived from a human immunoglobulin molecule. Preferably, a variable region with low immunogenicity is selected and combined with a human constant region which also has low immunogenicity, the combination also preferably having low immunogenicity.

"Low" immunogenicity is defined herein as raising significant HACA or HAMA responses in less than about -16or preferably less than about 50% of the patients treated and/cr raising low titres in the patient treated (less than about 300, preferably less than about 100 measured with a double antigen enzyme immunoassay) (Elliott et al., Lancec 344:1125-1127 (1994), incorporated herein by reference).

As used herein, the term "chimeric antibody" includes monovalent, divalent or polyvalent immunoglobulins

A

monovalent chimeric antibody is a dimer formed by a chimeric H chain associated through disulfide bridges with a chimeric L chain. A divalent chimeric antibody is a tetramer (H2L2) formed by two HL dimers associated through **at least one disulfide bridge. A polyvalent chimeric Santiody can also be produced, for example, by employing a CH region that aggregates from an IgM H chain, or u S• 15 chain) SAntibodies comprise individual heavy and/or light S(L) mmunoglobulin chains. A chimeric H chain comprises an antigen binding region derived from the H chain of a non-human antibody specific for TNF, which is linked to at least a portion of a human H chain C region such as CHl or CH2. A chimeric L chain comprises an antigen binding region derived from the L chain of a non-human antibody specific for TNF, linked to at least a portion of a human L chain C region

(CL).

Chimeric antibodies and methods for their production have been described in the art (Morrison et al., Proc.

Natl. Acad. Sci. USA 81:6851-6855 (1984); Boulianne et al.

Nature 312:643-646 (1984); Neuberger et al., Nature 314:268-270 (1985); Taniguchi et al., European Patent Application No. 171496 (published February 19, 1985); Morrison et al., European Patent Application No. 173494 (published March 5, 1986); Neuberger et al., PCT Application No. WO 86/01533, (published March 13, 1986); Kudo et al., European Patent Application No. 184187 (published June 11, 1986); Morrison et al., European Patent -17- Application No. 173494 (published March 5, 1986); Sahagan et al., J. Inmunol. 137:1066-1074 (1986); Robinson et al., International Publication No. PCT/US86/02269 (published May 7, 1987); Liu et al., Proc. Natl. Acad. Sci. USA 84:3439-3443 (1987); Sun et al., Proc. Natl. Acad. Sci. USA 84:214-218 (1987); Better et al., Science 240:1041-1043 (1988); and Harlow and Lane, Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory, New York, 1988).

These references are entirely incorporated herein by reference.

The anti-TNF chimeric antibody can comprise, for example, two light chains and two heavy chains, each of the chains comprising at least part of a human constant region and at least part of a variable region of non-human 15 origin having specificity to human TNF, said antibody binding with high affinity to an inhibiting and/or neutralizing epitope of human TNF, such as the antibody cA2. The antibody also includes a fragment or a derivative of such an antibody, such as one or more portions of the 20 antibody chain, such as the heavy chain constant or variable regions, or the light chain constant or variable regions.

Humanizing and resurfacing the antibody can further reduce the immunogenicity of the antibody. See, for example, Winter Patent No. 5,225,539 and EP 239,400 Bl), Padlan et al. (EP 519,596 Al) and Pedersen et al. (EP 592,106 Al). These references are incorporated herein by reference.

Preferred antibodies useful in the methods and compositions of the present invention are high affinity human-murine chimeric anti-TNF antibodies, and fragments or regions thereof, that have potent inhibiting and/or neutralizing activity in vivo against human TNFa. Such antibodies and chimeric antibodies can include those generated by immunization using purified recombinant TNFa -18or peptide fragments thereof comprising one or more epitopes.

An example of such a chimeric antibody is cA2 and antibodies which will competitively inhibit in vivo the binding to human TNFa of anti-TNFa murine mAb A2, chimeric mAb cA2, or an antibody having substantially the same specific binding characteristics, as well as fragments and regions thereof. Chimeric mAb cA2 has been described, for example, in U.S. Application No. 08/192,093 (filed February 4, 1994), U.S. Application No. 08/192,102 (filed February 4, 1994), U.S. Application No. 08/192,861 (filed February 4, 1994), and U.S. Application No. 08/324,799 (filed October 18, 1994), and by Le, J. et al.

(International Publication No. WO 92/16553 (published October 1, 1992)); Knight, D.M. et al. (Mol. Immunol 30:1443-1453 (1993)); and Siegel, S.A. et al. (Cytokine 7(1):15-25 (1995)). These references are entirely incorporated herein by reference.

Chimeric A2 anti-TNF consists of the antigen binding 20 variable region of the high-affinity neutralizing mouse anti-human TNF IgGl antibody, designated A2, and the constant regions of a human IgGl, kappa immunoglobulin.

The human IgG 1 Fc region improves allogeneic antibody effector function, increases the circulating serum half-life and decreases the immunogenicity of the antibody.

The avidity and epitope specificity of the chimeric A2 is derived from the variable region of the murine A2.

Chimeric A2 neutralizes the cytotoxic effect of both natural and recombinant human TNF in a dose dependent manner. From binding assays of cA2 and recombinant human TNF, the affinity constant of cA2 was calculated to be 1.8x10'M-. Preferred methods for determining mAb specificity and affinity by competitive inhibition can be found in Harlow, et al., Antibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press, Cold Sprina Harbor, -19- New York, 1988; Colligan et al., eds., Current Protocols in Immunology, Greene Publishing Assoc. and Wiley Interscience, New York, (1992, 1993); Kozbor et al., Immunol. Today 4:72-79 (1983); Ausubel et al., eds. Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1992, 1993); and Muller, Meth. Enzymol.

92:589-601 (1983), which references are entirely incorporated herein by reference.

As used herein, the term "antigen binding region" refers to that portion of an antibody molecule which contains the amino acid residues that interact with an antigen and confer on the antibody its specificity and affinity for the antigen. The antibody region includes the "framework" amino acid residues necessary to maintain the 15 proper conformation of the antigen-binding residues.

Generally, the antigen binding region will be of murine origin. In other embodiments, the antigen binding region can be derived from other animal species, such as sheep, rabbit, rat or hamster. Preferred sources for the DNA encoding such a non-human antibody include cell lines which produce antibody, preferably hybrid cell lines commonly known as hybridomas. In one embodiment, a preferred hybridoma is the A2 hybridoma cell line.

An "antigen" is a molecule or a portion of a molecule capable of being bound by an antibody which is additionally capable of inducing an animal to produce antibody capable of selectively binding to an epitope of that antigen. An antigen can have one or more than one epitope.

The term "epitope" is meant to refer to that portion of the antigen capable of being recognized by and bound by an antibody at one or more of the antibody's antigen binding region. Epitopes usually consist of chemically active surface groupings of molecules such as amino acids or sugar side chains and have specific three dimensional structural characteristics as well as specific charge characteristics. By "inhibiting and/or neutralizing epitope" is intended an epitope, which, when bound by an antibody, results in loss of biological activity of the molecule containing the epitope, in vivo or in vitro, more preferably in vivo, including binding of TNF to a TNF receptor. Epitopes of TNF have been identified within amino acids 1 to about 20, about 56 to about 77, about 108 to about 127 and about 138 to about 149. Preferably, the antibody binds to an epitope comprising at least about amino acids of TNF within TNF residues from about 87 to about 107, about 59 to about 80 or a combination thereof.

Generally, epitopes include at least about 5 amino acids and Less than about 22 amino acids embracing or overlapping one or more of these regions.

15 For example, epitopes of TNF which are recognized by, and/or binds with anti-TNF activity, an antibody, and fracrents, and variable regions thereof, include: 59-80: Tyr-Ser-Gln-Val-Leu-Phe-Lys-Gly-Gln-Gly- Cys-Pro-Ser-Thr-His-Val-Leu-Leu-Thr-His- 20 Thr-Ile (SEQ ID NO:1); and/or 87-108: Tyr-Gln-Thr-Lys-Val-Asn-Leu-Leu-Ser-Ala- Ile-Lys-Ser-Pro-Cys-Gln-Arg-Glu-Thr-Pro- Glu-Gly (SEQ ID NO:2) The anti-TNF antibodies, and fragments, and variable regions thereof, that are recognized by, and/or binds with anti-TNF activity, these epitopes block the action of TNFa without binding to the putative receptor binding locus as presented by Eck and Sprang Biol. Chem. 264(29): 17595-17605 (1989) (amino acids 11-13, 37-42, 49-57 and 155-157 of hTNFa). Rathjen et al., International Publication No. WO 91/02078 (published February 21, 1991), -21incorporated herein by reference, discloses TNF ligands which can bind additional epitopes of TNF.

Antibody Production Usina Hybridomas The techniques to raise antibodies to small peptide sequences that recognize and bind to those sequences in the free or conjugated form or when presented as a native sequence in the context of a large protein are well known in the art. Such antibodies can be produced by hybridoma or recombinant techniques known in the art.

1 0 Murine antibodies which can be used in the preparation of the antibodies useful in the methods and compositions of the present invention have also been described in Rubin et al., EP 0218868 (published April 22, 1987); Yone et al., EP 0288088 (published October 26, 1988); Liang, et al.

Biochem. Biophys. Res. Comm. 137:847-854 (1986); Meager, et al., Hybridoma 6:305-311 (1987); Fendly et al., Hybridoma 6:359-369 (1987); Bringman, et al., Hybridoma 6:489-507 (1987); Hirai, et al., J. Immunol. Meth. 96:57-62 (1987); M6ller, et al., Cytokine 2:162-169 (1990).

20 The cell fusions are accomplished by standard procedures well known to those skilled in the field of immunology. Fusion partner cell lines and methods for fusing and selecting hybridomas and screening for mAbs are well known in the art. See, e.g, Ausubel infra, Harlow infra, and Colligan infra, the contents of which references are incorporated entirely herein by reference.

The TNFa-specific murine mAb useful in the methods and compositions of the present invention can be produced in large quantities by injecting hybridoma or transfectoma cells secreting the antibody into the peritoneal cavity of mice and, after appropriate time, harvesting the ascites fluid which contains a high titer of the mAb, and isolating the mAb therefrom. For such in vivo production of the mAb with a hybridoma rat or human), hybridoma cells are preferably grown in irradiated or athymic nude mice.

Alternatively, the antibodies can be produced by culturina hybridoma or transfectoma cells in vitro and isolating secreted mAb from the cell culture medium or recombinantly in eukaryotic or prokaryotic cells.

In one embodiment, the antibody used in the methods and compositions of the present invention is a mAb which binds amino acids of an epitope of TNF recognized by A2, rA2 or cA2, produced by a hybridoma or by a recombinant host. In another embodiment, the antibody is a chimeric antibody which recognizes an epitope recognized by A2. In still another embodiment, the antibody is a chimeric antibody designated as chimeric A2 (cA2) As examples of antibodies useful in the methods and 15 compositions of the present invention, murine mAb A2 is 0produced by a cell line designated c134A. Chimeric antibody cA2 is produced by a cell line designated c168A.

c168A was deposited at the American Type Culture Collection, Rockville, Maryland, as a "Culture Safe Deposit." "Derivatives" of the antibodies including fragments, regi c ns or proteins encoded by truncated or modified aenes to yield molecular species functionally resembling the immuncglobulin fragments are also useful in the methods and 25 compositions of the present invention. The modifications include, but are not limited to, addition of genetic sequences coding for cytotoxic proteins such as plant and bacterial toxins. The fragments and derivatives can be produced from appropriate cells, as is known in the art.

Alternatively, anti-TNF antibodies, fragments and regions can be bound to cytotoxic proteins or compounds in vitro, to provide cytotoxic anti-TNF antibodies which would selectively kill cells having TNF on their surface.

"Fragments" of the antibodies include, for example, Fab, Fab', and Fv. These fragments lack the Fc -23fragment of intact antibody, clear more rapidly from the circulation, and can have less non-specific tissue binding than an intact antibody (Wahl et al., J. Nucl. Med.

24:316-325 (1983)) These fragments are produced from intacz antibodies using methods well known in the art, for example by proteolytic cleavage with enzymes such as papain (to produce Fab fragments) or pepsin (to produce F(ab') fragments).

Recc inant Expression of Anti-TNF Antibodies Recombinant and/or chimeric murine-human or human-human antibodies that inhibit TNF can be produced Susing known techniques based on the teachings provided in SU.S. Application No. 08/192,093 (filed February 4, 1994) U.S. Application No. 08/192,102 (filed February 4, 1994) s U.S. Application No. 08/192,861 (filed February 4, 1994), U.S. Application No. 08/324,799 (filed on October 18, 1994) and Te, J. et al., International Publication No.

WO 92/16553 (published October 1, 1992), which references are entirely incorporated herein by reference. See, e.g., 20 Ausubel et al., eds. Current Protocols in Molecular Bioicgy, Wiley Interscience, New York (1987, 1992, 1993); and Sambrook et al. Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989), the contents of which are entirely incorporated herein by reference. See also, Knight, et al., Mol. lmmunol 30:1443-1453 (1993); and Siegel, et al., Cytokine 7(1) :15-25 (1995), the contents of which are entirely incorporated herein by reference.

The DNA encoding an anti-TNF antibody can be genomic DNA cr cDNA which encodes at least one of the heavy chain constant region the heavy chain variable region (Hc), the light chain variable region (Lv) and the light chain constant regions A convenient alternative to the use of chromosomal gene fragments as the source of DNA encoding -24the murine V region antigen-binding segment is the use of cDNA for the construction of chimeric immunoglobulin genes, as reported by Liu et al. (Proc. Natl. Acad. Sci, USA 84:3439 (1987) and J. Immunology 139:3521 (1987)), which references are entirely incorporated herein by reference. The use of cDNA requires that gene expression elements appropriate for the host cell be combined with the gene in order to achieve synthesis of the desired protein.

The use of cDNA sequences is advantageous over genomic sequences (which contain introns), in that cDNA sequences can be expressed in bacteria or other hosts which lack appropriate RNA splicing systems. An example of such a preparation is set forth below.

Because the genetic code is degenerate, more than one 15 codon can be used to encode a particular amino acid. Usina the genetic code, one or more different oligonucleotides can be identified, each of which would be capable of encoding the amino acid. The probability that a particular oligonucleotide will, in fact, constitute the actual

XXX-

encoding sequence can be estimated by considering abnormal base pairing relationships and the frequency with which a particular codon is actually used (to encode a particular amino acid) in eukaryotic or prokaryotic cells exDressina .an anti-TNF antibody or fragment. Such "codon usage rules" are disclosed by Lathe, et al., J. Mol. Biol. 183:1-12 (1985). Using the "codon usage rules" of Lathe, a single oligonucleotide, or a set of oligonucleotides, that contains a theoretical "most.probable" nucleotide secuence capable of encoding anti-TNF variable or constant reaion sequences is identified.

Although occasionally an amino acid sequence can be encoded by only a single oligonucleotide, frequently the amino acid sequence can be encoded by any of a set of similar oligonucleotides. Importantly, whereas all of the members of this set contain oligonucleotides which are capable of encoding the peptide fragment and, thus, potentially contain the same oligonucleotide sequence as the cene which encodes the peptide fragment, only one member of the set contains the nucleotide sequence that is identical to the nucleotide sequence of the gene. Because this member is present within the set, and is capable of hybridizing to DNA even in the presence of the other members of the set, it is possible to employ the unfractionated set of oligonucleotides in the same manner in which one would employ a single oligonucleotide to clone the gene that encodes the protein.

The oligonucleotide, or set of oligonucleotides, containing the theoretical "most probable" sequence canable o f encoding an anti-TNF antibody or fragment including a 15 variable or constant region is used to identify the sequence of a complementary oligonucleotide or set of oliccnucleotides which is capable of hybridizing to the ^"most probable" sequence, or set of sequences. An oligonucleotide containing such a complementary sequence can be employed as a probe to identify and isolate the variable or constant region anti-TNF gene (Sambrook ec al., infra) A suitable oligonucleotide, or set of oligonucleotides, which is capable of encoding a fragment 25 of the variable or constant anti-TNF region (or which is complementary to such an oligonucleotide, or set of oliccnucleotides) is identified (using the above-described procedure), synthesized, and hybridized by means well known in t-e art, against a DNA or, more preferably, a cDNA preparation derived from cells which are capable of expressing anti-TNF antibodies or variable or constant regions thereof. Single stranded oligonucleotide molecules complementary to the "most probable" variable or constant anti-fNF region peptide coding sequences can be synthesized using procedures which are well known to those of ordinary -26skill in the art (Belagaje, et al., J. Biol. Chem.

254:5765-5780 (1979); Maniatis, et al., In: Molecular Mechanisms in the Control of Gene Expression, Nierlich, ec al., eds., Acad. Press, New York (1976); Wu, et al., Prog.

Nucl. Acid Res. Molec. Biol. 21:101-141 (1978); Khorana, Science 203:614-625 (1979)). Additionally, DNA synthesis can be achieved through the use of automated synthesizers.

Techniques of nucleic acid hybridization are disclosed by Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989); and by Haynes, et al., in: Nucleic Acid Hybridization,

A

Practical Approach, IRL Press, Washington, DC (1985), which references are entirely incorporated herein by reference.

Techniques such as, or similar to, those described above 15 have successfully enabled the cloning of genes for human aldehyde dehydrogenases (Hsu, et al., Proc. Natl. Acad.

Sci. USA 82:3771-3775 (1985)), fibronectin (Suzuki, ec al., Bur. Mol. Biol. Organ. J. 4:2519-2524 (1985)), the human 'estrogen receptor gene (Walter, et al., Proc. Natl. Acad.

Sci. USA 82:7889-7893 (1985)), tissue-type plasminogen activator (Pennica, et al., Nature 301:214-221 (1983)) and human placental alkaline phosphatase complementary

DNA

(Keun, et al., Proc. Natl. Acad. Sci. USA 82:8715-8719 (1985)).

25 In an alternative way of cloning a polynucleotide encoding an anti-TNF variable or constant region, a library of expression vectors is prepared by cloning DNA or, more preferably, cDNA (from a cell capable of expressing an anti-TNF antibody or variable or constant region) into an expression vector. The library is then screened for members capable of expressing a protein which competitively inhibits the binding of an anti-TNF antibody, such as A2 or cA2, and which has a nucleotide sequence that is capable of encoding polypeptides that have the same amino acid sequence as anti-TNF antibodies or fragments thereof. In -27this embodiment, DNA, or more preferably cDNA, is extracted and purified from a cell which is capable of expressing an anti-TNF antibody or fragment. The purified cDNA is fragmentized (by shearing, endonuclease digestion, etc.) to produce a pool of DNA or cDNA fragments. DNA or cDNA fragments from this pool are then cloned into an expression vector in order to produce a genomic library of expression vectors whose members each contain a unique cloned DNA or cDNA fragment such as in a lambda phage library, expression in prokaryotic cell bacteria) or eukaryotic cells, mammalian, yeast, insect or, fungus). See, e.g., Ausubel, infra, Harlow, infra, Colligan, infra; Nyyssonen et al. Bio/Technology 11:591-595 (1993); Marks et al., SBio/Technology 11:1145-1149 (October 1993). Once nucleic acid encoding such variable or constant anti-TNF regions is isolated, the nucleic acid can be appropriately expressed in a host cell, along with other constant or variable heavy or light chain encoding nucleic acid, in order to provide recombinant monoclonal antibodies that bind TNF with inhibitory activity. Such antibodies preferably include a murine or human anti-TNF variable region which contains a framework residue having complementarity determining residues which are responsible for antigen binding.

Human genes which encode the constant regions of 25 the chimeric antibodies, fragments and regions of the present invention can be derived from a human fetal liver library, by known methods. Human C region genes can be derived from any human cell including those which express and produce human immunoglobulins. The human CH region can be derived from any of the known classes or isotypes of human H chains, including gamma, A, a, 6 or e, and subtypes thereof, such as Gl, G2, G3 and G4. Since the H chain isotype is responsible for the various effector functions of an antibody, the choice of CH region will be guided by the desired effector functions, such as complement -28fixation, or activity in antibody-dependent cellular cytocoxicity (ADCC). Preferably, the CH region is derived from gamma 1 (IgGl), gamma 3 (IgG3), gamma 4 (IgG4), or 4 (IgM) The human CL region can be derived from either human L chain isotype, kappa or lambda.

Genes encoding human immunoglobulin C regions are obtained from human cells by standard cloning techniques (Sambrook, et al. (Molecular Cloning: A Laboratory Manual, 2nd Edition, Cold Spring Harbor Press, Cold Spring Harbor, New York (1989) and Ausubel et al., eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987-1993)). Human C region genes are readily available from known clones containing genes representing the two classes of L chains, the five classes of H chains and 15 subclasses thereof. Chimeric antibody fragments, such as F(ab') 2 and Fab, can be prepared by designing a chimeric

H

chain gene which is appropriately truncated. For example, a chimeric gene encoding an H chain portion of an F(ab'), fragment would include DNA sequences encoding the CH1 domain and hinge region of the H chain, followed by a -translational stop codon to yield the truncated molecule.

Generally, the murine, human and chimeric antibodies, fra gm ents and regions are produced by cloning DNA segments encoding the H and L chain antigen-binding regions of a 25 TNF-specific antibody, and joining these DNA segments to DNA segments encoding CH and CL regions, respectively, to produce murine, human or chimeric immunoglobulin-encoding genes. Thus, in a preferred embodiment, a fused chimeric gene is created which comprises a first DNA segment that encodes at least the antigen-binding region of non-human origin, such as a functionally rearranged V region with joining segment, linked to a second DNA seament encoding at least a part of a human C region.

-29- Therefore, cDNA encoding the antibody V and C reaions and the method of producing a chimeric antibody can involve several steps, outlined below: 1. isolation of messenger RNA (mRNA) from the cell line producing an anti-TNF antibody and from optional additional antibodies supplying heavy and light constant regions; cloning and cDNA production therefrom; 2. preparation of a full length cDNA library from 10 purified mRNA from which the appropriate V and/or C region gene segments of the L and H chain cenes can be: identified with appropriate probes, (ii) sequenced, and (iii) made compatible with a C or V gene segment from another antibody for a chimeric antibody; 3. Construction of complete H or L chain coding sequences by linkage of the cloned specific

V

region gene segments to cloned C region gene, as described above; 20 4. Expression and production of L and H chains in selected hosts, including prokaryotic and eukaryotic cells to provide murine-murine, human-murine, human-human or human-murine antibodies.

One common feature of all immunoglobulin H and L chain genes and their encoded mRNAs is the J region. H and L chain J regions have different sequences, but a high degree of sequence homology exists (greater than 80%) amono each group, especially near the C region. This homology is exploited in this method and consensus sequences of H and L chain J regions can be used to design oligonucleotides for use as primers for introducing useful restriction sites into the J region for subsequent linkage of V region segments to human C region segments.

C region cDNA vectors prepared from human cells can be modified by site-directed mutagenesis to place a restriction site at the analogous position in the human sequence. For example, one can clone the complete human kappa chain C (Ck) region and the complete human gamma-1 C region (C gamma-1). In this case, the alternative method based upon genomic C region clones as the source for C regicn vectors would not allow these genes to be expressed in bacterial systems where enzymes needed to remove intervening sequences are absent. Cloned V region segments 15 are excised and ligated to L or H chain C region vectors.

Alternatively, the human C gamma-i region can be modified by introducing a termination codon thereby generating a gene sequence which encodes the H chain portion of an Fab molecule. The coding sequences with linked V and C regions are :hen transferred into appropriate expression vehicles Sfor expression in appropriate hosts, prokaryotic or *e eukarvotic.

Two coding DNA sequences are said to be "operably linked" if the linkage results in a continuously 25 translatable sequence without alteration or interruption of the triplet reading frame. A DNA coding sequence is operably linked to a gene expression element if the linkage results in the proper function of that gene expression element to result in expression of the coding sequence.

Expression vehicles include plasmids or other vectors.

Preferred among these are vehicles carrying a functionally complete human CH or CL chain sequence having appropriate restriction sites engineered so that any VH or VL chain sequence with appropriate cohesive ends can be easily inser:ed therein. Human CH or CL chain sequence-containing -31vehicles thus serve as intermediates for the expression of any desired complete H or L chain in any appropriate host.

A chimeric antibody, such as a mouse-human or human-human, will typically be synthesized from genes driven by the chromosomal gene promoters native to the mouse H and L chain V regions used in the constructs; splicing usually occurs between the splice donor site in the mouse J region and the splice acceptor site preceding the human C region and also at the splice regions that occur within the human C, region; polyadenylation and transcription termination occur at native chromosomal sites downstream of the human coding regions.

"A nucleic acid sequence encoding at least one anti-TNF antibody fragment may be recombined with vector DNA in 15 accordance with conventional techniques, including blunt-ended or staggered-ended termini for ligation, restriction enzyme digestion to provide appropriate termini, filling in of cohesive ends as appropriate, alkaline phosphatase treatment to avoid undesirable joining, and ligation with. appropriate ligases. Techniques for such manipulations are disclosed, by Ausubel, supra, Sambrook, supra, entirely incorporated herein by reference, and are well known in the art.

A nucleic acid molecule, such as DNA, is "capable of 25 expressing" a polypeptide if it contains nucleotide sequences which contain transcriptional and translational regulatory information and such sequences are "operably linked" to nucleotide sequences which encode the polypeptide. An operable linkage is a linkage in which the regulatory DNA sequences and the DNA sequence sought to be expressed are connected in such a way as to permit gene expression as anti-TNF peptides or antibody fragments in recoverable amounts. The precise nature of the regulatory regions needed for gene expression may vary from organism 33 to organism and is well known in the analogous art. See, -32- Sambrook et al., Molecular Cloning: A Laboratory Manual, Cold Spring Harbor Laboratory Press, New York (1989); and Ausubel, eds., Current Protocols in Molecular Biology, Wiley Interscience, New York (1987, 1993).

Many vector systems are available for the expression of cloned anti-TNF peptide H and L chain genes in mammalian cells (see Glover, ed., DNA Cloning, Vol. II, pp. 143-238, IRL Press, Washington, DC, 1985). Different approaches can be followed to obtain complete H2L2 antibodies. It is possible to co-express H and L chains in the same cells to achieve intracellular association and linkage of H and L chains into complete tetrameric H2L2 antibodies. The S.o. co-expression can occur by using either the same or different plasmids in the same host. Genes for both H and S* 15 L chains can be placed into the same plasmid, which is then transfected into cells, thereby selecting directly for cells that express both chains. Alternatively, cells can be transfected first with a plasmid encoding one chain, for example the L chain, followed by transfection of the resulting cell line with an H chain plasmid containing a second selectable marker. Cell lines producing H2L2 molecules via either route could be transfected with plasmids encoding additional copies of peptides, H, L, or H plus L chains in conjunction with additional selectable 25 markers to generate cell lines with enhanced properties, such as higher production of assembled H2L2 antibody molecules or enhanced stability of the transfected cell lines.

Receotor Molecules Receptor molecules (also referred to herein as soluble TNF receptors) useful in the methods and compositions of the present invention are those that bind TNF with high affinity (see, Feldmann et al., International Publication No. WO 92/07076 (published April 30, 1992), -33incorporated herein by reference) and possess low immuncgenicity. In particular, the 55 kDa (p55 TNF-R) and the 75 kDa (p75 TNF-R) TNF cell surface receptors are useful in the present invention. Truncated forms of these receptors, comprising the extracellular domains (ECD) of the receptors or functional portions thereof, are also useful in the present invention. Truncated *forms of the TNF receptors, comprising the ECD, have been detected in urine and serum as 30 kDa and 40 kDa TNF inhibitory binding proteins (Engelmann, H. et al., J. Biol. Chem. 265:1531- 1536 (1990)). TNF receptor multimeric molecules and TNF immuncreceptor fusion molecules, and derivatives and fragments or portions thereof, are additional examoles of receptor molecules which are useful in the methods and 15 compositions of the present invention. The receptor molecules which can be used in the invention are characterized by their ability to treat patients for extended periods with good to excellent alleviation of *n symptoms and low toxicity. Low immunogenicity and/or hiah affinity, as well as other undefined properties, may contribute to the therapeutic results achieved.

TNF receptor multimeric molecules useful in the present invention comprise all or a functional portion of the ECD of two or more TNF receptors linked via one or more polypeptide linkers. The multimeric molecules can further comprise a signal peptide of a secreted protein to direct expression of the multimeric molecule. These multimeric molecules and methods for their production have been described in U.S. Application No. 08/437,533 (filed May 9, 1995), the content of which is entirely incorporated herein by reference.

TNF immunoreceptor fusion molecules useful in the methods and compositions of the present invention comorise at least one portion of one or more immunoglobulin molecules and all or a functional portion of one or more -34- TNF receptors. These immunoreceptor fusion molecules can be assembled as monomers, or hetero- or homo-multimers.

The immunoreceptor fusion molecules can also be monovalent or multivalent. An example of such a TNF immunoreceptor fusion molecule is TNF receptor/IgG fusion protein.

TNF immunoreceptor fusion molecules and methods for their production have been described in the art (Lesslauer et al., Eur. j. Immunol. 21:2883-2886 (1991); Ashkenazi et al., Proc. Natl. Acad. Sci. USA 88:10535-10539 (1991); Peppel et al., J. Exp. Med. 174:1483-1489 (1991); Kolls et al., Proc. Natl. Acad. Sci. USA 91:215-219 (1994); Butler et ai., Cytokine 6(6):616-623 (1994); Baker et al., Eur. J.

Immunol. 24:2040-2048 (1994); Beutler et al., U.S. Patent No. 5,447,851; and U.S. Application No. 08/442,133 (filed 15 May 16, 1995)). These references are entirely incorporated S. herein by reference. Methods for producing immunoreceptor fusion molecules can also be found in Capon et al., U.S.

Patent No. 5,116,964; Capon et al., U.S. Patent No. 5,225,538; and Capon et al., Nature 337:525-531 (1989) which references are entirely incorporated herein by reference.

Derivatives, fraaments, regions and functional portions of the receptor molecules functionally resemble the receptor molecules that can be used in the present invention they bind TNF with high affinity and possess low immunogenicity). A functional equivalent or derivative of the receptor molecule refers to the portion of the receptor molecule, or the portion of the receptor molecule sequence which encodes the receptor molecule, that is of sufficient size and sequences to functionally resemble the receptor molecules that can be used in the present invention bind TNF with high affinity and possess low immunogenicity). A functional equivalent of the receptor molecule also includes modified receptor Smolecules that functionally resemble the receptor molecules that can be used in the present invention bind TNF with high affinity and possess low immunogenicity) For example, a functional equivalent of the receptor molecule can contain a "SILENT" codon or one or more amino acid substitutions, deletions or additions substitution of one acidic amino acid for another acidic amino acid; or substitution of one codon encoding the same or different hydrophobic amino acid for another codon encoding a hydrophobic amino acid). See Ausubel et al., Current Protocols in Molecular Biology, Greene Publishing Assoc.

and Wiley-Interscience, New York (1989).

'l *e Methotrexate Presently available oral and intravenous formulations of mechotrexate include Rheumatrex® methotrexate dose oack (Lederle Laboratories, Wayne, NJ); methotrexate tablets (Mylan Pharmaceuticals Inc., Morgantown, WV; Roxane Laboratories, Inc., Columbus, OH); and methotrexate sodium tablets, for injection and injection (Immunex Corporation, Seattle, WA) and methotrexate LPF® sodium (methotrexate 20 sodium injection) (Immunex Corporation, Seattle,

WA)

Methotrexate is also available from Pharmacochemie (Net.erlands) Methotrexate prodrugs, homoloas and/or analcas folate antagonists) can also be used in the methods and compositions of the present invention.

Alternatively, other immunosuppressive agents (or druas that suppress the immune system) can be used in the methods and compositions of the present invention.

Administration TNF antagonists, methotrexate and the compositions of the present invention can be administered to an individual in a variety of ways. The routes of administration include intradermal, transdermal in slow release polymers) intramuscular, intraperitoneal, intravenous, subcutaneous, -36oral, topical, epidural, buccal, rectal, vaginal and intranasal routes. Any other therapeutically efficacious route of administration can be used, for example, infusion or bolus injection, absorption through epithelial or mucocutaneous linings, or by gene therapy wherein a DNA molecule encoding the therapeutic protein or peptide is administered to the patient, via a vector, which causes the protein or peptide to be expressed and secreted at therapeutic levels in vivo. In addition, the TNF 10 antagonists, methotrexate and compositions of the present invention can be administered together with other components of biologically active agents, such as pharm.aceutically acceptable surfactants glycerides), excipients lactose), carriers, diluents and vehicles. If desired, certain sweetening, flavoring and/or coloring agents can also be added.

The TNF antagonists and methotrexate can be administered prophylactically or therapeutically to an individual. TNF antagonists can be administered prior to, 20 simultaneously with (in the same or different compositions) or sequentially with the administration of methotrexate.

For example, TNF antagonists can be administered as adjunctive and/or concomitant therapy to methotrexate therapy.

For parenteral intravenous, subcutaneous, intramuscular) administration, TNF antagonists, methotrexate and the compositions of the present invention can be formulated as a solution, suspension, emulsion or lyophilized powder in association with a pharmaceutically acceptable parenteral vehicle. Examples of such vehicles are water, saline, Ringer's solution, dextrose solution, and 5% human serum albumin. Liposomes and nonaqueous vehicles such as fixed oils can also be used. The vehicle or lyophilized powder can contain additives that maintain isotonicity sodium chloride, mannitol) and chemical -37stability buffers and preservatives) The formulation is sterilized by commonly used techniques Suitable pharmaceutical carriers are described in Remington's Pharmaceutical Sciences, A. Osol, a standard reference text in this field of art.

For example, a parenteral composition suitable for administration by injection is prepared by dissolving by weight of active ingredient in 0.9% sodium chloride solution.

TNF antagonists and methotrexate are administered in therapeutically effective amounts; the compositions of the present invention are administered in a therapeutically effective amount. As used herein, a "therapeutically effective amount" is such that administration of TNF antagonist and methotrexate, or administration of a composition of the present invention, results in inhibition of the biological activity of TNF relative to the biological activity of TNF when therapeutically effective *amounts of antagonist and methotrexate are not 20 administered, or relative to the biological activity of TNF when a therapeutically effective amount of the composition is not administered. A therapeutically effective amount is preferably an amount of TNF antagonist and methotrexate necessary to significantly reduce or eliminate signs and symptoms associated with a particular TNF-mediated disease.

As used herein, a therapeutically effective amount is not necessarily an amount such that administration of the TNF antagonist alone, or administration of methotrexate alone, must necessarily result in inhibition of the biological activity of TNF.

Once a therapeutically effective amount has been administered, a maintenance amount of TNF antagonist alone, of methotrexate alone, or of a combination of TNF antagonist and methotrexate can be administered to the individual. A maintenance amount is the amount of TNF -38antagonist, methotrexate, or combination of TNF antagonist and methotrexate necessary to maintain the reduction or elimination of the signs and symptoms associated with a particular TINF-mediated disease achieved by the S ther-apeutial effective dose. The maintenance amount can be administered in the form of a single dose, or a series or doses separated by intervals of days or weeks.

The dosage administered to an individual will vary depending upon a variety of factors, including the pharmacodynamic characteristics of the particular antaaonj 5 sad t md and route of administration.size, age, sex, health, body weight and diet of the reciient, nature and extent of symptoms of the disease being treated, kind of concurrent treatment, frequency of :15 treatment, and the effect desired. In vitro and in vivo methods of determining the inhibition of TNF in an individual are well known to those of skill in the art. Such i"Ln vitro assays can include a TUF cytotoxicity assay the WEHI assay or a radioimmunoassay, ELISA) .In 20 vivo methods can include rodent lethality assays and/or primate pathology model systems (Mathison et al. LT. Clin.

Invest., 81:1925..1937 (1988); Beutler et al., Science 229:-c69-87 1 (1985); Tracey et al., Nature 330:662-664 (1987); Shimamoto et al. Immjunol Lett. 17:311-318 (1988); Silva et al., LT. Infect. Dis. .162:421-427 (1990); Opal et al J. Inf ect. Dis. 161: 1148 1152 (19 90) Hinshaw e t al., Circ. Shock 20:279-292 (1990)).

TNF antagronist and methotrexate can each be admin.istered in single or multiple doses depending upon faczzrs such as nature and extent of symptoms, kind of concurrent treatment and the effect desired., Thus, other therapeutic regimens or agents multiple drug regimens) can be used in combination with the theraipeutic co-administraticn of TNF antagonists and methotrexate. In io -:icular e2mbodiment, a TNF antagonist is administered -39in multiple doses. In another embodiment- methot-rexate is adin ter edl in dahe form Of a series of low dioses separated by nte-~,ls f d ysor weeks. Adjustment and manipulation of established dosage ranges are well within the ability of those skilled in the art.

Usually a daily dosage of active ingredient can be abouc 0.01 to 1ioo milligrams per kilogram of body weight.

Ordinarily 1 to 40 milligrams per kilogram per day given in divided doses 1 to G times a day or in susta ined release form is effective to obtain desired results. Second or subsequent administrations can be administered at a dosage .which isthe same, less than or greater than the initial or previous dose adiisee to teindividual Asecond orsubsequent administration is preferably during orimmediately prior to relapse or a flare-up of the disease or symptoms of the disease. For examplscn adsubsequent administrations can be given between about one day to 30 weeks from the previous administration. Two, three, four or more total administrations can be delivered to the individual, as needed.

Dosage forms (composition) suitable for internal administration generally contain from about 0.1 milligram to about 500 milligrams of active ingredient per unit. In teepharmaceutical compositions the active ingredient will ordinarily be present in an amount of about 0.5-9S~i by weight based on the total weight of the composition.

The present invention will now be illustrated by the following example, which is not intended to be limiting in any way.

EXAZ{PLES

E X A M D L P ~n f u 1-ln c lCra m n o f R h e u m a t o i d A r t h r i t i s q y Multiole i sons of an Anti-Tjp Altibodv with and Without Methotrexate A randomized, double-blind, placeiho controlled study was conducted to evaluate the safety and efficacy of a chimeric monoclonal anti-TNF antibody (cA2) followina multiple inlfusions of 1, 1 or Jo mg/kg cA2, alone or in combination with methotrexate, compared to multiple 1 0 nf u i o s o p a c e o n c mb n at on w i t h me t h o tr e x a t e in the treatment of rheumatoid arthritis(R)ipaens One hundred one (101) patients at six European centers who had been using methotrexate for at least 6 months, had been~ on a tbedose of 7_5 mg/wk for atleast 4 weeks, andhadactvedisease (cording to the criteria of the AmercanCollege of Rheumatology) with erosive 'changes on X-rays ofhands and fewere enrolled in the trial.

Active disease was defined by the presence of six or more SWolIlen joints plus at least three of four secondary criar±a (duraition of morning stiffness zt45 minutes; z6 tender or painful joints; erythrocyte sedimentation rate (ESR) a2 8 mm/hour; C-reactive protein (CRP) z20 mg/i. In patients using corticosteroids 7.5 mg/day) or non-steroidal anti -inflammatory drugs (NSAIDs) ,the doses had heen stable for 4 weeks prior to screening. The dose of ccrti4costeroids remained stable throughout trial partic~ipation The dose of NSAID typically also remained stable throughout trial participation.

-41- Study Infusions The chimeric monoclonal anti-TNF antibody (cA2) was supplied as a sterile solution containing 5 ma cA2 per ml of 0.01 M phosphate-buffered saline in 0.15 M sodium chloride with o.0i%- polysorbate 80, pH 7.2. The placebo vials contained 0.1s human serum albumin in the same buffer Before use, the appropriate amount of cA2 or placebo was diluted to 300 ml in sterile saline by the pharmacist, and administered intravenously via a 0.2 Am in- line filter over 2 hours. The characteristics of the placebo and cA2 infusion bags were identical, and the investigators and patients did not know which infusicn was :beina administered.

Assessments Patients were randomized to one of seven treatment groups. The number of patients in each dose (or treatment) group is indicated in Table i. Each of the 101 patients received multiple infusions of either 0, 1, 3 or 10 mg/kg cA2. Infusions were to be administered at weeks 0, 2, 6, 10 and 14. Starting at week O, the patients were receiving mg/wk of methotrexate (Pharmacochemie, Netherlands) or 3 placebo tablets/week (Pharmacochemie, Netherlands) Patients were monitored for adverse events during infusions and regularly thereafter, by interviews, physical examination, and laboratory testing.

The six primary disease-activity assessments were chosen to allow analysis of the response in individual patients according to the Paulus index (Paulus, et al., Arthritis Rheumatism 33:477-484 (1990) the teachings of which are incorporated herein by reference) The assessments contributing to this index were the tender joint and swollen joint scores (60 and 58 joints, respectively, hips not assessed for swelling; graded 0-3), the duration of morning stiffness (minutes), the patient's -42and physician's assessment of disease severity (on a scale, ranging from 1 (symptom-free) to 5 (very severe) and erythrocyte sedimentation rate

(ESR).

Patients were considered to have responded if at least four of the six variables improved, defined as at least 209improvement in the continuous variables, and at least two grades of improvement or improvement from grade 2 to 1 in the two disease- severity assessments (Paulus 2096 response) Improvements of.- at least 50% in the continuous variables were also used (Paulus 50%; response).

Other disease-activity assessments included the pain score (0-10 cm on a visual analogue scale an assessment of fatigue (0-10 cm VAS) and grip strength (0-300 mm Hg, mean of three measurements per hand by sphygmomanometer cuff).

The ESR was measured at each study site with a standard method (Westergen) C-reactive protein (CRP) was measured by rate nephelometry (Abbott f luorescent polarizing immunoassay). See also, Elliott et Lancet 344:1105- 1 11 0 (1994); Elliott et al. Lancet 344:1125-1127 (1994) and Elliott et: al., Arthritis Rheum. 36(12) :1681- 1690 (1993), which references are entirely incorporated herein by reference.

Evaluations were performed at weeks 1, 2, 4, 6, 8, 12, 14, 16, 18, 20, 22 and 26.

Results The 101 patients were randomized to one of seven treatment (or dose) groups. The patients enrolled in each dose group were well matched for baseline demographics.

Disease duration and swollen and tender joint counts at baseline were also well-balanced across the groups (Table 1) Table 1 also shows the maximum methotrexate dose administered within 6 months prior to randomization.

Median maximum doses "or each group ranged between 10 and -43ma/week; there were no significant differences amongst the treatment groups (p=0.404).

TABLE 1 Baseline Disease Characteristics Joint Counts MTX Methotrexate -44- TABLE 1 Continued Treatment 3 mg Disease dur. (yrs) Pts evaluated is Me ns 12 j9 Median 16.0 I0 range (13, 22.0) Range (10.0, 29.0) Number of Swonde jintfls, Paulus joint set (0-60) Pts evaluated is MeanSD 14.7+514. 9 Median 216.0 IQ range (12. 0, 322.0) Range (10.0, 29.O0) Nube o. tede *ons auldos jot se M'rx= Methotrexate -4S- TABlLE 1 Continued Treament Groups mg/kg cA.2 Treat- All ment MT+ TX-Patients effect p -value Disease dur. (y-rs) Pts evaluated 14 151s Mean±SD 11.1±7.4 9 -7±7 .4 10018 .3 Mein10.7 7.6 7.6 IQ Range 15.5) 14.9) 14.4) Range 24.1) 37.3) Number of swollen joints, Paulus joint set (0-58) a Mean±SD Median IQ Range Range Number of tender joints, Paulus joint set (0-60) 21.1±8 .2 19. 5 (15.0, 31.0) (10.0, 34.0) 15 17 8±e 7 17.0 (11. 0, 2 1.0) 41.0) 101 18 7 18.0 (12.0, 25.0) 4.1.0) 0.643 Pts evla-1 15 101 Mean±SD 26.5±12.0 26.2±11. 7 2701. Mein25.5 23.0 25.0 IQ Range (21.0, 38.0) (17.0, 3-5.0) (15.0, 38.0) Range 44.0) (11.0, 48.0 (20580 Max dose MTX(2058o prey. 6 mc (mg/kg) Pts evaluated .14 15 99 Mean±SD 12.7±5.0 12.5±3.0 12. 4±4.2- 0.404 Median 10.0 12.5 1.

10Rne (10.0, 15.0) (10. 0, 15. 0) 15.0) Range 2.0) 20.0) 30.0) A Metotrexate -46- The pre-s-pec ified Primary analysis in this trial was the comparison of the total time of clinical response during the 2 6-week follow-up period. The results for the primary analysis are shown in Table 2. The duration of Sresponse of all cA 2 -treated groups, with the exception of the 3. mg/kg group not receiving methotrexate, was snifficantly improved (p<0.001) compared to the placebo group receiving methotrexate alone.

.1 0 TABLE 2 Total Time of Response' Based on Paulus 20%- Criteria Placebo Treatment Gop 0 16.6 c2 16. 17.g 2 2.10 ':0.001Traten p-vaXvs MTX+ aln M0.00 0.119 M0.00 M0.00 <0.00 <0.001 nM=en1wre f l ow d4ro e k (ol w n the in t atnu i n o -48- The response rates at Paulus 20% are shown in Table 3.

Drop-outs were considered as non-responders subsequent to their dropping out from the study. With the exception of the mg/kg group not receiving methotrexate, all of the

A

2 -treated groups demonstrated clinical benefit through 14 weeks when the last dose of cA2 was received. Sustained clinical benefit was observed through 26 weeks (the last follow-up visit) in patients who received 3 or 10 mg/kg cA2 with methotrexate. Approximately one-half of the patients 10 who received 3 mg/kg cA2 with methotrexate demonstrated continued clinical benefit at 26 weeks.

*s

S

-49- Criteria At Each Evaluation Visit Treatmnt Group~s Placebo I mg/kg cA2 MTX+ (NM+4

T

(n14) (n=ls) Pts with any response 21V Got0 (3/4)13/14 12/15 P-value vs; MTX lon <0.0010.0 Time post -infusion 1 Week 0% 31V13 (0/14) (4/13) (8/15) .2 Weeks 7 7 (1/14) (8/14) 4 Weeks' 0% 9%33% (0/14) 11/14 (5/15) 6Weeks 0% 71% 27t (0/14) 10/14 (4/15) 8 Weeks' 14t 64t (2/14) (9/14) (3/15) 1Weeks 7% 71t%0 (1/14) 10/14 (3/15) 12 Weeks' 7t17 13V (1/14) (8/14) (2/15) 14 Weeks 0% 71t%7 (0 /1 4 f I d- Evalatln vsjts pre-specifiled for analysis.

-so- Table 3 Continued Treatment Groups 3 mg/ka-, cA2 10 mg/kg cA2 MTrX MX MTX- Treatment (n=14) 13) (n=15) effect __Evalue Pts with any 80% 79t 85% 80% <0.001 response 12/15 11/14 11/13 12/15 p-value vs MTX alone 0.002 0.002 0.001 0.004 Time O0st-iffusjon 1 Week 27%6 43% 31V (4/13) *2 Weeks 27% 43V 6296 53%- (4/15) (9/14) (8/13) (8/15) 6 Weeks 479 o 4; 4% (71).714.7/3 (7/15) (9/15) (0/14) (9/13) Weeks 67% 64509% 3 1Weeksa 60%1 64t 62V 40% <0.003 /15) 10/14) (B /13) 6/13) Weeks 67 04 6917; 7 53% (8/14) 19/13) (8/15) 12 Weeks' 67% 64O 62O 60V <0.001 1015 (9/14) (7/13) (8/13) 14 Weeks 70% 69% 77V 53V (0/1s) (9/14) 10/13) (8/15) 20We7s5% 43V 54t 67%3000 1/15) (6/14) (8/15) 10145 (5/13) (8/13) (5/14) Evaluation visits pre-specified for analysis.

-51- The response rates at Paulus 50!k are shown in Table 4.

The magnitude of the clinical benefit of cA2 treatmenu was substantial. The majority of patients were responding to cA2 treatment according to the 5O Paulus criteria.

-52- TABLE 4 Number of Patients Responding According To Paulus SOi Criteria At Each Evaluation Visit Treatment Grouns Placebo I mg/kiq cA2 MTX+ MTX+

MTX-

PtS with any respon-se 14.3 1 85. 7V 40.0* I W e e *7 7 12 1 Weeks' 7.1% 53.% 0.3V (0/14) (2/15) 22 Weeks 0.0% 57.1V 0.0* (0/14) (0/15) 28 weeks' 7.1t 21.4% 6.7% (1/14) (7/14) (0/15) Evaiat 10 Wejtpesecfe for 57.alysi0.

-53- TABLE 4 Continued Treatment Grouus 3 mg/kg cA MTX+ MTX- MTX4 Pts with a-ny 73.3t 64.3* 76.91 response (11/15) (9/14) (10/1.: P-value vs MTX 0.001 0.008 O.00 alone Time nost -infusion 1 Week 0.0%l 35.7t .7 (0/15) (5/14) (1/3.3) 2 Weeks 6.7% 28.6t 15.4% (4/14) (2/13) 4 Weeks' 13.3% 28.6% 46.2t (4/14) (6/13) 6 Weeks 26.71 42.9t 38.5k (4/15) (6/14) (5/13) Weeks' 0O 50.0% 69.2t (6/15) (7/14) (9/13) Weeks 40.0% 50.0% 69.2% (6/15) (7/14) (9/13) *12 Weeks' 60.0% 35.7% 61.5% '0 1-.

'Evaluation visits are-specified for analysis.

-54- Commensurate with the clinical response rates shown in Tables 2-4, most of the patients in the treatment grouos demonstrating effectiveness of cA2 treatment received all infusions of cA2 (Table The principle reason for Spatients not receiving the complete dose regimen was because of lack of efficacy in the placebo group (methotrexate alone) and in the 1 mg/kg group not receiving methcurexate. All 15 patients in the 3 mg/kg group that received methotrexate completed the 5-infusion dose regimen.

S

S

S

555 5 5 5 555 S* S S S S S S. S S *S S S S S

S

S S S S

S

55 *55 5 555 5.

TABLE 5 Number of Infusions Completed 'Patients are counted only once for the firs .t group for which they qualify 5ifso,4irui0- etc.. PatintswereOnl coutedif they had completed the entire infusion.

-56- Results for measures of swollen and tender joint counts and the physician and patient global assessments are shown in Figures 1-4. The median results in Figures 1-4 were reported for each evaluation visit based only on the patients with data collected. That is, a last observation carried forward approach was not used for patients who dropped out. Instead, the number of patients with data that comprise each point on the graph was reported at the bottom of the figures.

Despite the number of drop-outs in the placebo group and the 1 mg/kg group not receiving methotrexate, the results in Figures 1-4 demonstrate that cA2 treatment in combination with methotrexate profoundly reduces disease activity for all of the traditional measurements of disease 15 activity, approaching near remission in many patients.

Results for a commonly used serum marker of inflammatory activity, C-reactive protein (CRP) are shown in Figure 5. Treatment with cA2 produced a rapid decrease i. n CRP concentration which was sustained through 26 weeks in the patients who received 3 or 10 mg/kg cA2.

Results for the Health Assessment Questionnaire

(HAQ)

are shown in Figure 6. This measurement of quality of life/disability demonstrated improvement over time corresponding with the clinical improvement observed in 25 patients treated with cA2. In the patients treated with 3 mg/kg cA2 and methotrexate, the HAQ decreased from 2.0 at baseline to 1.1 at 22 weeks.

Pharmacokinetics of cA2 Serum concentrations of cA2 were obtained in all patients in this study. The serum concentration in each patient plotted over time according to the cA2 dose group is shown in Figure 7. Data plotted are the serum cA2 concentrations obtained just before the administration of cA2 ac weeks 2, 6, 10 and 14 and then at weeks 18 and 26.

-57- These sampling times were selected to best demonstrate the stability of the cA2 concentration during the multiple dose regimen and the decline in serum cA2 concentration after the last dose was administered For purposes of data presentation, the scales for cA2 concentration for each graph are condensed as the A2 dose was increased.

Substantial differences were observed for the cA2 serum concentration over time in the 1 mg/kg dose groups according to whether patients received methotrexate Most of the patients receiving 1 mg/kg cA2 with methotrexate demonstrated measurable cA2 concentrations through 18 weeks although it appeared that there was a tendency for the concentration to decline over time In sharp contrast, the majority of patients who received 1 mg/kg cA2 without methotrexate were not able to maintain measurable serum concentrations of cA2 over time. As discussed herein, the inability to maintain serum cA2 in these patients was associated with a high rate of neutralizing antibody formation.

In contrast to the 1 mg/kg groups, patients who received either 3 mg/kg cA2 or 10 mg/kg cA2 were able to S* maintain serum cA2 concentrations through the multiple dose regimen However, even in those dose groups, there was evidence that concomitant treatment with methotrexate was associated with high cA2 serum concentrations. As shown in Figure 8, the median serum cA2 concentration in both the 3 and mg/kg dose groups receiving methotrexate was higher than in the corresponding groups not receiving methotrexate.

Immune Resonses to cA2 Serum samples were collected through 26 weeks from all patients and analyzed for human anti-chimeric antibodies (ACA) to cA2. The results for HACA responses for each cA2 treatment group are shown in Table 6. It should be noted -58that in several patients in the 3 mg/kg group and in most patients in the 10 mg/kg group, cA2 was still present in the 26-week sample and could potentially interfere with the detection of HACA in the assay. However, it could also be reasoned that if neutralizing antibodies were present at 26 weeks, then cA2 should not be present. Therefore, in presenting the data in Table 6, results for the immune response rate are shown not including patients with serum cA2 at 26 weeks and including patients with serum cA2 at 26 weeks, assuming that if cA2 was present at 26 weeks, the patient did not have a positive HACA response.

t e e oe o S S S S 555 5 5 555 55 5S S S S SS S *S S S S S S S S S. S *SS TABLE 6 HACA Responses Patients with a measurable 26-week serum cA2 concentration were considered negative for a M4ACA response for this analysis.

The results in Table 6 demonstrate that concomitant methotrexate treatment suppresses the immune response to cA2, enabling stable pharmacokinetics to be achieved in a multiple dose regimen of cA2. This effect was also found after combined anti-CD4/anti-TNF antibody treatment in mice with collagen-induced arthritis and described in U.S.

Application No. 08/607,419, filed February 28, 1996, the teachings of which are entirely incorporated herein by reference.

Clinical Safety Two out of 86 patients (with most patients receiving treatments) experienced multisystem infusion-related 1 reactions with retreatment. Multisystem, infusion-related reaczions include headache, fever, facial flushing pruritus, myalgia, nausea, chest tightness, dyspnea, vomiting, erythema, abdominal discomfort, diaphoresis, shivers, hypertension, lightheadedness, hypotension, Palpitations and somnolence.

Hypersensitivity reactions, as described herein, may 20 occur whenever protein-containing materials, such as cA2, too. are administered. Thus, it is unclear whether these symptoms represent an immunologic event or physical factors such as infusion rate and immunoglobulin aggregation.

Investigators have reported that symptoms resolve in some patients by decreasing the rate of the infusion. Previous literature reports indicate that vasomotor symptoms have been observed in patients receiving intravenous immunoglobulin therapy (Berkman et al., Ann. Intern Med.

112:278-292 (1990); Ochs et al., Lancet 2:1158-1159 (1980)) One patient developed hypotension during all three infusions of 10 mg/kg cA2. The patient did not display clinical signs of hypotension and did not require medical -61treatment, but, in keeping with predefined safety criteria the treatment schedule of this patient was discontinued.

One patient treated with 3 infusions of 10 mg/kg of cA2 and with 7.5 mg/week methotrexate developed symptoms of sepsis as a result of staphylococcal pneumonia 2 weeks after her last study visit and 14 weeks after her last infusion with cA2. Six days after developing symptoms she was admitted to the hospital and treated. She died one day later. (This patient had not proceeded with the fourth infusion for reasons unrelated to the sepsis.) Patients with RA who develop infections have a worse than expected 3* outcome. Wolfe and coworkers have reported an observed:expected ratio for death due to pneumonia of 5.307 and an observed:expected ratio for death due to infections 15 (excluding pneumonia) of 6.213 in RA patients from the ARAMIS database (Wolfe et al., Arthritis Rheumatism 4:481-494 (1994)).

One patient experienced a serious postoperative infection following cataract surgery 9 weeks after the 20 fifth and last infusion of 3 mg/kg of cA2 (with 7.5 mg/week methotrexate), leading to removal of the eye. This patient was receiving prednisolone (7 mg/day). The incidence of endcpr.halmitis after cataract extraction has been reported to be between 0.072 and 0.093% (Kattan et al., 25 Ophthalmology 98(9) :1147-1148 (1991)) and may be heiahtened in patients receiving corticosteroid therapy.

Eight of 87 patients developed double stranded (ds)-DNA antibodies following multiple infusions of cA2.

Measurements were performed at baseline, week 8, 16 and 26 (12 weeks following the last infusion). In these patients with antibodies against ds-DNA, there was a trend toward a lower level in antibodies at the last evaluation, with two patients being negative.

One patient developed dyspnea, pleuritic chest pain and a rebound of arthritis activity at study week 14 (four -62weeks after the fourth infusion of 3 mg/kg of cA2) Symptoms resolved and she received her fifth dose of cA2.

Symptoms recurred 3 weeks later. Examination of the serial blood samples revealed that the test for antinuclear antibodies and anti ds-DNA antibodies were negative prior to treatment, but became positive at week 6 of the study.

The patient's symptoms responded to oral prednisolone 20-30 mg daily. The working diagnosis was systemic lupus erythematosus (SLE). The patient currently does not have symptoms of SLE but has active RA.

S. To date, although antibodies to ds-DNA have been detected in patients treated with cA2, they generally represent transient increases and only one patient has been symptomatic. In patients who have had sufficient 15 follow-up, anti-ds-DNA antibodies have resolved with discontinuation of treatment.

In summary, treatment with cA2 is well tolerated. The reductions in disease activity produced by cA2 are significant as supported by the findings of a low placebo response rate. High clinical response rates are obtained with a multiple dose regimen of 3 mg/kg cA2 in combination with 7.5 mg/wk methotrexate and can be sustained through 26 weeks. This dose regimen is considered preferable to the 1 mg/kg plus methotrexate regimen because better 25 pharmacokinetics are obtained, virtually no immune response was detected and the clinical response is better sustained following the last treatment with cA2. The clinical benefit obtained by increasing the dose regimen to 10 mg/kg cA2 plus methotrexate is similar to that observed with the 3 mg/kg cA2 plus methotrexate regimen.

Thus, the results of this study indicate that treatment with a multiple dose regimen of cA2 as adjunctive and/or concomitant therapy to methotrexate therapy, in RA patients whose disease is incompletely controlled by methocrexate, produces a highly beneficial or synergistic -63clinical response that can be sustained through 26 weeks.

The benefit produced by cA2 generally exceeds reductions in the traditional measurements of rheumatoid arthritis (swollen and tender joints, patient and physician global disease assessments) and achieves near clinical remission in many patients. Accordingly, the results of this study indicate that treatment with multiple infusions of cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

EXAMPLE 2 Clinical Treatment of Rheumatoid Arthritis

B

Sinale Infusion of an Anti-TNF Antibody In Patients Receivina Methotrexate A randomized, double-blind, placebo controlled study S: 15 was conducted to evaluate the effects of a single infusion of placebo, 5, 10 or 20 mg/kg cA2 in combination with Smethotrexate, administered at a dose of 10 mg/week, in the treatment of rheumatoid arthritis (RA) in patients.

Patients 20 Twenty-eight (28) RA patients at three centers in the United States who, despite receiving three months therapy with methotrexate administered at a stable dose of 10 mg/wk for at least 4 weeks prior to screening, still had active disease according to the criteria of the American College of Rheumatology, were enrolled in the study. Active disease was defined by the presence of six or more swollen joints plus at least three of four secondary criteria (duration of morning stiffness 45 minutes; a6 tender or painful joints; erythrocyte sedimentation rate (ESR) ;28 mm/hour; C-reactive protein (CRP) a20 mg/l.

Patients taking NSAIDs and corticosteroids (prednisone) at screening were allowed to continue at stable doses (7.5 mg/day) -64- Study Tnfusions The chimeric monoclonal anti-TNF antibody (cA2) was supplied as a sterile solution containing 5 mg cA2 per ml of 0.01 M phosphate-buffered saline in 0.15 M sodium chloride with 0.01% polysorbate 80, pH 7.2. The placebo vials contained 0.1% human serum albumin in the same buffer. Before use, the appropriate amount of cA2 or placebo was diluted to 300 ml in sterile saline by the pharmacist, and administered intravenously via a 0.2 pm in-line filter over 2 hours. The characteristics of the Splacebo and cA2 infusion bags were identical, and the investigators and patients did not know which infusion was being administered.

o:oo A sse ssm en t s S: 15 Patients were randomized to one of four treatment groups (7 patients per group). Each of the 28 patients received a single dose of either 0, 5, 10 or 20 mg/kg cA2 and were followed for 12 weeks. Patients continued treatment with methotrexate (Pharmacochemie, Netherlands) 20 administered at 10 mg/week throughout the study. Patients were monitored for adverse events during infusions and regularly thereafter, by interviews, physical examination, and laboratory testing.

The primary measurement of clinical response was defined by the ACR preliminary definition of response (Felson et al., Arthritis Rheumatism 38(6):727-735 (1995)) Patients were considered to have a response if they had a reduction in swollen and tender joint count, and had experienced a 20% reduction in 3 of the 5 following assessments: patient's assessment of pain (VAS), patient's global assessment of disease activity (VAS), physician's global assessment of disease activity (VAS), patient's assessment of physical function (HAQ), and an acute phase reactant (ESR) The ESR was measured at each study site with a standard method (Westergen).

Evaluations were performed at day 3, and at weeks 1, 2, 4, 6, 8, 10, and 12.

Results The 28 patients were randomized to one of four treatment (or dose) groups.

The clinical response rates over time by ACR criteria in each of the treatment groups is shown in 10 Table 7.

TABLE 7 Clinical Response Rates (By ACR 2001 Criteria) In Patients Receiving 10 mg/kg Methotrexate Pts evaluated Pts with any response 1 Week 2 Weeks 4 Weeks 6 Weeks 8 Weeks Weeks 12 Weeks Placebo 7 1 (14.3k) 0 ot) 0 0%) 1(14.3%) 0 (0.0%t) 1(14. 3t) 1 (14.3t) 1(14 Doee of CA2 5 mg/kg 10 mg/kg 120 mgkg 717 17 6 (85.7t) [4(57. 1k) 4 (57.1%t) 3 (42 9W) 3 (42 .9t) 3 (42. 9t) 1(14 .31) 2 (28.6t) 5 (71. 4t) 2 (282. 6%) 5(71.4%) 6 (85.7li) 5(71.4%) 5(71.4%) cA2 Treated Patients 21 17(81.0t) 11(52.4t) 14(66.7t) 5(71.4%) 5(71.4%) 13(61.91) 5(71. 41 4(57. 1%) 4(57. 1%) 4(57.1%) 4 (57.11) 12 (57.11t) 11 (52 .4%t) 8 (3 8.It) 9(42.9%) 4(57 .11) 3(42.91) I -66- Clinical benefit of cA2 treatment was evident at the first evaluation visit at one week. Although each of the 3 doses of cA2 produced clinical responses in the majority of patients treated, the duration of clinical response appeared to be better sustained through 12 weeks in the groups receiving 10 or 20 mg/kg cA2. Clinical response was achieved much more frequently among patients receiving cA2 as ccmpared to placebo. That is, 17/21 patients in the 3 cA2 groups achieved a response, compared with only 1/7 placebo treated patients. The magnitude of clinical response was notable. The mean tender joint count among cA2 treated patients decreased from 30.1 at baseline to 13.3 at week 12, and mean CRP decreased from 3.0 at baseline to 1.1 at week 12.

The duration of clinical response appeared to be dose dependent. 2/6 of the responding patients treated with 5 mg/kg cA2 sustained a response through 12 weeks of followup, compared to 7/11 of the responding patients who received 10 or 20 mg/kg. Treatment in all groups was generally well tolerated.

In summary, the results of this study indicate that treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is effective in the reduction of the sins and symptoms of rheumatoid arthritis in patients 25 whose disease is incompletely controlled by methotrexate Moreover, the clinical response achieved by this approach can be sustained for more than 12 weeks after a single treatment. Accordingly, the results of this study indicate that treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

-67- EXAMPLE 3 Clinical Treatment of Rheumatoid Arthritis Bg Reneated Dose Administration of an Anti-TNF Antibod In Patients Followin A Single Dose Double-Blind, Placebo-Controlled Trial An open label study was conducted to evaluate the effects of repeated infusions of 10 mg/kg cA2 in combination with methotrexate, administered at a dose of mg/week, in the treatment of rheumatoid arthritis in patients.

Patients As described in Example 2, a randomized, double-blind, placebo controlled, 12 week study of cA2 was conducted in RA patients who had active disease despite receiving three months therapy with methotrexate administered at a stable 15 dose of 10 mg/wk for at least 4 weeks prior to screening.

At week 12, patients who had completed the 12 week aevaluation period and had not experienced adverse events prohibiting further infusions of cA2, were offered 3 subsequent open label infusions of cA2, administered at a 20 dose of 10 mg/kg, at eight week intervals (weeks 12, 28). Twenty-three (23) patients from the 12 week study were enrolled in this study.

Assessments 11/23 patients entering this open label study were evaluated at 1 of 3 centers in the United States and followed up to 40 weeks after initial entry. Patients continued treatment with methotrexate administered at mg/week throughout the study. Repeated treatments with cA2 were generally well tolerated. Three patients had transient infusion related symptoms (urticaria, somnolence) The primary measurement of clinical response was defined by the ACR preliminary definition of response -68- (Felson et al., Arthritis Rheumatism 38(6) :727-735 (1995)) Patients were considered to have a response if they had a reduction in swollen and tender joint count, and had experienced a 20% reduction in 3 of the 5 following assessments: patient's assessment of pain (VAS), patient's global assessment of disease activity (VAS), physician's global assessment of disease activity (VAS), patient's assessment of physical function (HAQ), and an acute phase reactant (ESR). The ESR was measured at each study site with a standard method (Westergen).

Results S* Of six patients who had all received cA2 during the double-blinded study described in Example 2 and responded S•through the 12 weeks of that study, four patients sustained 15 a response throughout the 40 week followup. Of the remaining two patients, one patient is still responding through week 28, and one patient recently entered this open label trial. For all 4 patients completing 40 weeks of followup and the patient at week 28, final tender joint 20 counts were 2 and swollen joint counts 1, compared to a mean of 23 and 29, respectively, at entry into the doubleblinded study described in Example 2. For 4 of these patients, ESR were 18 mm/hr and CRP 0.7, compared to a mean of 27 and 3.9, respectively, at entry into the double-blind study described in Example 2.

Of two patients who had both received cA2 during the double-blinded study described in Example 2 and responded only through week 10 of that study, one patient responded through 36 weeks and one patient is still responding through week Of three patients who did not respond during the double-blinded study described in Example 2 (2 received placebos, 1 received 5 mg/kg cA2), two of these patients -69experienced a transient clinical response, and one patient is still responding through week In summary, the preliminary results of this study suggest that repeated adjunctive and/or concomitant therapy with cA2, in RA patients whose disease is incompletely controlled by methotrexate, can result in substantial clinical improvement for a majority of the patients.

Moreover, the clinical response achieved by this approach can be sustained for up to 40 weeks of followup.

Accordingly, the results of this study indicate that repeated treatment with cA2 as adjunctive and/or concomitant therapy to methotrexate therapy is an important and efficacious therapeutic approach for treating RA in patients.

15 Equivalents Those skilled in the art will know, or be able to ascertain, using no more than routine experimentation, many equivalents to the specific embodiments of the invention Sdescribed herein. These and all other equivalents are 20 intended to be encompassed by the following claims.

Claims (4)

1111.1 t ilieric mIolcuLle. A comipositioni of claimi 1 \\herein the Soluble TINV:( receptor is a TNV,( 1111111 U liorcepItor- fusion mI lCCIic. I 5. A composi tion of ci aim 4, wheireini the I IIIII LIIIorCCptorI- fuiioni i1iO CCi C is selected Froni the group11 consisting of p)75 T'NF-CL rcccitoi-/IgG Fusion Molecule and *TNFCL rcceptor/lgG fusion molecule. A pharniaccut ical conipos ition, substaitiall Lias hetrciibefore described withI SreiCicc: to anly one of' the examples. T..I A method for treati or Ireven ng a tumiour necrosis fIctor-med jated disease in an 11idividl in need theri-o f coimprisi ng co-adm in seri ii methotrexat and a soluble TN [CL receptor or fniit iona h-fag lent. thlero for a Conmposit ion Ofranly one of claimns I to 6 to the individual, in therapeutically e ffccti ye amounts. S. Methotr-exate and a soluble TNI [CL receptor or functional fragment therco for a 2'conmposi tion of any one of c aims I to 6 Whlen Used inl treat ing or p~reven tin g a tumIourI necrosis factor-niediated disease. 9. Ile use of methotrexate and a soluble TNFCL recep~tor or functional lfragmciit thci-eof or a composition of any onc ofclai ns I to 6 forj the manUfactUre Of a miedicamn t for trcatinrg or preven gi a tumnour necrosis facor-ledliated disease. A iiehod. neotrexae and a sol ubl rIC tNL receptor or. fLiict iona I fragi1n lierco f or use of aniiy one of cla imis 7 to 9, \'hieieiii thle Soluble TN Li. recepitor aiid Het hot i-exdI ate i adnIiI iiistered Si inIII.ltaiicouIly 1 1. A methlodl, met hot exiIe and aI solutble [INl H, receptor or f1iict ioial C raginieri thereof or use of any oneo of' caiiiis 7 to 'vhcreiii tlic soluble *INl:u. receptLor and inlilotrex.ate areC adiiiistl-eo seqlitintial'y. I2. An11CieL iliCtli01tleat- and1 a soluble TNI-I receptor mi Funictional fraciii thereoofor use of any one of chainis 7 to 9, Mwlicri thc tlinoi naois facor-mceliated scase is selcted frou !hle groupr consisting o: iiniiIilieI dfisease, acute or- Chron ic Iiiu ne dIisease, in flainma toiy Ldi sease aniid lieu rodegtonera ti e disease. I I 1 0, 1 1141 11 'th 1 117N 1 3. A niethod, miethiofrexate and a soluble TNIQ, reccpor or fNrctional fragmenit thrcl-of or usc of clao 12~ whcrcii tAe soluble lNli rcccptor is aRlilliulistcrcd inl muiltiple doses. 14I. A: mlethiod, ictiotrcxatc and~ a soluble INQr, rmcjior or functional fiigiicit theireof* or usc of cI ai n 1 3 whercin Wite soluble TNIFi. receptor is selected fromi tile (r[ti p conlsist inlg of- p55 TNFc. rceptor and p75 TNI~c. receptor. 1 5. A method, niethot rexat e and a sol i bl TNLu re~or or funcional IPacuent hereo f Or usc Of' Claiin) 14 \vheC -ii lil lle TNI-F.t receptor is a I irecepitor liii tlin]cr-ic HItOlecuIc 1 6. A miethod, niethot rexat e and a sol ublec TN Eu receptor or funcional Wgiaiin thereof or use of clim 14 xvhcreil the soluble TNI-ci. receptor is a 1-04%. inimiunorecefptor T: fuAniilcme methot roexate and a SoluLblec TNFc. receptor or WSWuc onagament ther-co for usc OAK c 1a nI6 \vhemein ditie TN0F1% ininiunoreceptor fusion nIOlecCUiIc is seCACed fomi the 1-roup11 corisisti g of: p5 TN E ieeeptOr/gG fusion prowk i and p75 TNIAu. rcecptor/IgG fusionl protein. 1 8. A- method for trecating or preventing rIltilo art Iiri tis ill anl i udi Vid na inl need thereof cornrisi ii co-a(I n iStcrini t niethotrexate ainc]d asolc f Ii IcT xrceptor0or 1hii ctona I fraeent thieo for a coiiiposition of any one of clai nis I to 6 to tile id i VidnalI in MClIcr)etI tical ly effective amio itts. 19. Metliotrexate anid a soluble TNFc. receptor or functional f-ragnint thereof or a composition of any onie of clainis I to 6 wvhetn used in treatite or preventing rheumatoid a rthi t is. 2RJ Ile use of meiconrexate and a soluble TNI-c. receptor or fuLnctional fragnicit thereof Or a compositon of an\' one of c lai s I to 6 fbr [le nan n fuci iicofa mied icameni for- treatiini OrelVentli mg rlic1,niatoid arthrfitis.

2 I1. A method, iiiethotrcx ate and1( a solubl TN I-u. receptor or fuinet ional IFragvmnemn iecwo f or use of any oinc of chaimns I 8 to 20R wlherii the soluiib Ic NFlu. recep~tor and inCtltomcxatC are adiniiiliStCreCl Sim"Hltllcotisly. 22. A'\niethol netliotrecxate and a soluible TI'lu rcccpior or functional fr-agmnit [lhereof or nse of anly onc of claliiiis IS to 20, Wheremin Ie Soluble [NFl,, receptor aind itici Itol rcxatC am-c admliniStereCd seq cI ~lial ly. 23. A method, mutotr-ex at anmd a soluble lNFu. receptor or functdional I fragneil thereof or use of army one of W~ iins I18 to 20, whercini the soluble 'INEU. receptor is adlillisteredl ill itiultiple closes. 11 W 1 1I41 it 1,11 7, I 24. A method, miethotrexate anl(l a Soluble TNFcf receptor or functional fragmient hco-21'1 fIS orus f Ci i 23 wherein [lhe soluble TNFu. receptor is se lected froml the gr-oupl coni s wg of:- p55 TINl:t receptor and( p 7 5h TNIFu. receptor. A mcethod, met lotrxate and ani so luic"leIN lit receptor or fI'inct ional I fragmlent thereof' or- use of' claii 24 wherein the solIubl)e TI Lx receptor is it receptor mu1Lltimlcr-iC mole1cule. 26. A method, methotrexate and a so! tib I TNFLx receptor or functional fragn mi thecolfor use of la in 24 Twljrini the Sc) Inhie ['-NlFu rceptor is at TN Lx i in mu nllo-ceptor fusion molecule. 027. A method, met hotr-exate and a so!luibIc TN Fo; receptor or flunctinal fragment thereof or uise of claim 26 whereint the TNFaf imnoi111receptor fusion molecule is selected f~Rom the group consisting of: p55 TNFc. receptor/IgG fusion protein and p 7 5 TNFcf. ccep~tor-/lgG Fusion pirotemin. A method for tOmating or pientilg (i'ohn 's disease iil an indcliv\idl inl need I~1 thereof comprising coadinii tri ig inciliotrei and a So!lubl I N -'Fe receptor, or finct ional I fagmnrt thereof for a coinposi tion of any one of clai ins I to 6 to the ind i Vidna I. n therapeutically effective aino ii n1ts. 29. Methotrexate and a soluble TNO Fcla receptor or Functional firagment thereof or at ,.0.0comnpositlion of any one of cla ins I to 6 when used in treating or preventing Crohn l's W:2 disease. The use of mnotexate and a Soluble TFNFc. receptor or functional fragment J0thereof or a composition of any one of claims I to 6 for the nmnnfcire of a medicament for treating or lpre\'enting Crohns disease. 3I.Amethod, metiotrexate and a soluibIc TNI Fe'. receptor or fitnet ional fragmentc 23 hemreo or use of' ainy one of claims 28 to 30. "Tli Wite solule TAN receptor and meithotrexate at-c adnilin sered siri ilianeon sly. 32. A method net hot-ex ate and a So!b( ThI NF Lx receptor or f'inet iolilht IaL emenl [hereo f or use oft any one of clhiis 28 to 30), whlerei n the sol ublc TNI:F receptor and me~thotrCxate ate adnliliStecl-d sequen2tially'. 33. A ilioi. iulilotixate amnd at soluble tceptoi oir functional lhagmnit thereof or use of any ovic IFi claimrs 28 to 30, \vlcriil the solule INPii. receptor is administered inl multiplecdoses. 34. A method, inethoti-ex ate al( mid asol tfiIc INF I receptor or ['iin l Frtagiment thereof or use of claim 33 wherein the Solu ble INFLx receptor is selected fromvm1 the group Sconsisting o f' p55 TNF Lx receptor aild 1) 75 'F'NF receptor. 11 1 )a Y 1 1 h1 I I I I It lit I 19 741 11 KC A Method, met ot rcxtc and a soIL ubl TN~u. receptor or- Functional Aratimen ecno f or use of cla iii 34 "'hereinl tie soiibLIN [uF rceptor is a TN17Hi. rcepltor inu til i mric Irnoicco Ic. 36. A miethiod, jet hot rexat e and a solutible INFH, receptor or In neit lol I ragnien I therco f or use of c lai ns 34. W&VhcjIi thc sol uble TN Hi reccptor is af TNFPu III I n nIorcptor Fnsion m10]cc nIC. 37. A mehod, met hotrxate and a solunble IN Pu. receptor or Fn ctmm ion 1I.1gren Itecrco I or nsc of ciai 34 \wrein thle soi ub hie NFh receptor is a TI( H'M i11mu Jiorceeptor fusion iiioleCUIe selected Froni the gr-oup consisting of'. p)55 TIH. receptor/loG Fusioni II protein and p 7 5 TNFor reccptoi-/igG I uiri protein. 38. Use of mecthoirexate and a Soluble TNFc. receptor or- functional frag,1mcit thereoFfo tm-ue miaunfacure of coadnijuiistrabie or' SeCILuentially administr-able ied icarmnts, for treatig or preventing aI t urno o1r necrosis Factor-mediated diisease fn anl individual. The use of e Inibn 38, lb the nreatni cot Of t1. onto11 irncrosis faIctor_-mediated diseases selected fromi auto!101iniurc dlisease, acute or cliRon ic innmiine disease. ni lam mnatory disea-se and itewiodegeermat disease. Use of niethotrexate and a soluble TNFcu receptor Obr the mnn ifacture of' coadniin ist rab)ic: Or sequen1t iaily admiinistrable niedicamients For treating or preveniting rletnitatoitl arthritis in an inciik'dual. 41 Use of niethoti-exate and a soluble TPci. receptor For the mnufacture of' coadm illistrable Or sequelntial I admnistrable rredicamients For- treating or- preventinli Crohn's disease i an individual. 42. The use ofclaini 38. 40 or 41, w~hereiti the Soluble TNFci. rceptor. 43. The use (IFclai 38, 4(0 or 41 .T A Thrc itteSoluble TINl-u. receptor is seleccd Froni11 thle group11 conlsist iil- Oi~f: p55 rceptor andl p75 TNFPu. recep)tor. 44. The use ofelaiit 38, 401 or 4L. wvii the soluble TNF(. recptor is a receptor HIIi lt i meric niolcen Ic. The use of claim 38, 04) or 41. "'iierii the soluble receiptor is a TNl:uf lItIItIuoreceptor Fusioni lcleLI. A\ inithod Ior treat i ii or pIeCVeiitiIt a, tuitionI- inecrosis ~aCtor_-niediateCl (liSCaIS ill all i Itdi \idliaI ill iiecd tlier-col com I i~ifiig CO-adI1if iiiSteiI i 0 filte individual Ii)0tcotrX;1tc andl a tiLIltOir_ ntecrosis AwIw~r aiitagon ist. wherein the tHuntour1 ncrIosis factoi itagona is lre\'ens or inibits TI j syntliesis, TNIP release or TN I receptor signallin rg. I II I 11 1 n11 11(1 10i'7uf. 47. Mecthotrexate and a tUrnour necrosis factor antagonist when used in treatirn or Py"re ent i n1 a n nour necrosis factor-med latcd dIiscase, wihcri-c iite Muno- ricoSis factor aniaronist preVents Or inIi hits TNJ[ syn t hes, INF release or TIF receptor signIal Ii Jig. 48. W ie of met~hlitrx atc and J tumour0 necrosi bocor antagonis for tile 1luau iifaoyct of a med (icanuen~lt for treatinig or, preventC lrg a tuinour nccrosis fcor- nediated disease, \\'hcreini the tumour ne i-osis fatratgnstpeet rul isT Svntli1csis, TNF release or TNF receptor sial ig. 49. A MOW ci101.nielo eatce and~ a turn our Jiecrosis facor antagonist or use of an One of c lai Jis 46 to 48, wherein tile unownrJicrosis facor antagonist is a I PhOSpliod iestcrase inJllhiitor. A method, niethotrexate ani a tui mour necJrosis facoor anitagonist or use of' clailli 49, Wherein the phshdees inhibito is selected fronll the gru C~~~il Of: penltox i fy Iinc and rolyiparn. oiitJ~ 51I. A met od. nietiotrexae and a t nnoui necrosis boicor aitagonis or Lse of any I one of chlimis 46 to 48, 'vheri nMte Lt1 uniir iiecrJosis Factor antagoiiis is selectcel froin tie 0 groups Conlsisting of' A2b zadenosine receptor enhancer andi ASb adiiosine recep~tor o.. 0000 ,agonist. 52. A method, niethotrexate and a ttiiii1our necrosis flocor anwtaon st or use of- cla in 51 wh'lerei n the lunonr necrosis Factor ailtagonit is selected fRomn t grouip 1 c o n n s n vig Co R -c y c o p ro p y l) -ca r o x a n id o ac l e o s iu i c too. ~~~etlly~carboxanidoacbeiosiie, cyciohiexylacdeiosiine and -"Iieyl2I-o),aiosi. o:0 53. Use of iriethoti'exate aid a tumour necrosis factor aiLtagonist for the manu Fa-ctuire of miedicaiments for treating or lpre\'ening a Wtmour necrosis factor-miediated disease ini an i ud i vdtiI in Jneed thereof F \hlerek inte i ti on r necisis boicor antagonlist 74prev'ents or inmiihits TNF synthles is. TlN I release or E'INl r eceptor sigenalling,~ 54. Usc of clami 53. vliercii thle WM[lin- necrosis factor antgist Is a Iphi051hic sterase ii hi tor. 51 Use of' clai n54, We IuioSqfodfi sterasc i nhtihi tr is selected froni thle gron p Consisting oif: peiltox i fylline and rolipraii. I Isc of' claimn 53. wliecicin tile tumlouir inecrosis factor antagonist is selectedf fRon11 tile grnuLp 2 OVIlSitimig of: A21) adciutosime Jcemior eiihmicci- mnd A21) aidnosinc recepitor agonlist. 57. IkJe of clairn 56, whleeiin tie tumnour necrosis factor amia~mitiss~o frorn thle group conlsstng of': 5 N-cyclolpropyl )-cairhoxinidloadeIiiosiiie, 5 et Chylca rhox a In idoadeiios Iie, eye lex y adeilosini and l k-N -pltityl -opyladejiosi ne. 58. A conipos t ion comprising iithtrexae al an anti-Lurnour necrosis factor alltibody orFfragnment t hereofI. 59) A \comlpositioni of claini 5S, \\'lerin ilhc ailti-iniio1ir nlecrosis JfaCtor aniliodj\ is a cilinric aillibo(Iv. 00. Ac omposi tion of' c Iairil 58, whelrei n the eb i lierc anilbody hinds ICo 011 Or mlore arino11 acids of- hiN [u selectedl Prnithe group consisting Of' about 87- I 0 and 01. A' conilJosiiioi of' claiiiii 58. \\'I1cF(n tie cimric antibody hindCs to the qu .itope ofIc!2. 1)62. A\ coinposit ion WOfaiiN 6 1 wlirin the cimieric antibhod)' is cA2. 63. A pharivaceutical composition, sobstaidal ly as hereinhefore described ith '09 1 A hdO reference or pvein a tuiour necrosis factor-mediated disease il all i udiVidUal illneed22( theco f coinprising co-admi n iserin ii ethotrexate and an anlti tn nonr rincrosis factor anti body or fragmient thlerco or a comlpositIion of ally one( 01' claits 58 to 63 to the individtlai in terpeultically 1e fCtiV 1e amounts. NMethotrexat andl aln ant-tuoL necriosis Factor antibody or fraginen thereof' ~~or a composition of any one( of claims 58 to 63 Wvenl used in treat i i or preventing 0 o Unotr necrosis factor-mied iateci disease. W' 66. The use of niethotrexate and an anlti-tunlour nlecrosi s fhctor ailtibod)' or fragment thereof or a composition of any on1( of claimis 58 to 63 for the mnannfactUre Of at mledicament Obr treating or preventing a tnIMour necrosis factor-mlediated disease. 000 67. A nilehod, miethotrexate and aln anti-tunonr icansis facor antibod)' or fraglent tierco f or use of any one of cWhyis 64 to 66. \\'ieii tihe anti -tnnior lice rsi fa hctor antibdy and mlll2totreilte are adnistered silllilalleousl\' OS. A meithlod, inethotrexate zind] anl anLi -tuinon r11 necrosis Cactor anlti hod)' or. tragneii thiereof tr LaF of' anmy one of ch ins 64 to 66. '\lemin WItie anLi -tu111101 iiccFow I Actor aiitibody and~ lletlhotrexate amc aditisteed sequnitially. 69). A mlethiod, niethotrexatc a~nd1 il allti-WInlOUr leCrlOSiS 1 iCtOr anltibody' Or tr-aulnieii tilercof or use otl)' one OWlai 64 to W6 wherein tile tuniour nlecrosis f'actor- imediated disease is Selected fromn the group1 COllSiStiillg Of: al1toalllllltiilC diseae, alcute Or chiron ic ii ini tie disease, infl]ammluatory dI sease and icn rodcgCliera i ye di scase. A methI~od, meitllotrexate and l aliti-illrnolir necrosis f'actor antibody or I ragilemt IherefC~ or ulse (f clIaini 69 wvhceini the ant -tuloun Iecrosis ('actor aniti body is S admnlistered ill miultiple doses. 11 hA 110 11 11111100 1, 71. A method, 'nethotrcxat and an anti-umour necrosis FBcor antibody or- hurgntciiI Iheco For use ofc Lairni 70 wicin ie anti-tmour ilCersis Bacor anti bdy is a chimecric antibody. 72 A10( nilodethot rexal c and~ an an(lt I uin iICCmSiS f'actor antibody or s Fagnowi thereof- or- usc of clai ii 7 1 wherei the chiimeric antibody binuds to one or nmorc amino acids of IiTNFcx selecd Amon tMe grOL11 consisting or about 87- 108 and about 59- 7

3. A miethod, methotr-cxatc and ali allti-tuiliour.1 necro0sis Factor antibody or- tragitent thtereof or use ofclai 71 "Arhcii the chierc antibod\ binds to the epitope of i(~cA2. Amtometbotr-exate and all ailti-tuilbour11 necrosis F'actor antibody or- Fi-agment thereoFor use of claim 73 whierein the chimeric antibody is cA2. A mlethlod for treati ig or pieveiltin g rileurnatoid arthritis iln all inivi\iduial in tic~n ed tilereo f comlpri sing coa di i l seinig ilethotrexate afid a11l ani-hi four necrosis~ I Actor anti body or Fugmel I thercofI or a composi tici of any one of c iaiis I to 6 to tie *.*ind(1ivid~ual, ill thla)~ial effct i 'C alllOU il1tS. 76. N'Ithiotrexate and an alt i-t uilo ur inecruosis Factor ani body Vor Fragment theco F or a comiposition of anyN one of cia inms 5S to 63 Whienl used ill trati nu or prevent iii rileunatoi atl-i t is. 2) 77. Thie use of ietibotrexate and an anti-tumour neccrosis facor alt ibody or- Frawnieri thereof or a coilliostion of any one of clainis 58 to 63 for tile manufacture OfN medicanment For treating or prevefiting rheuimatoid arthlritis. 78. A mehod, iethotrexate anid all anti-tunIOiir necrosis factor antibody or- fraglilci I Ihemrc or use of any n'Oe of claims 75 to 77, whrci Wltie at ti-tmnour ne~crosis f'actor anti bodiy andc in hot reXate arFc adhi i StCr-Cd Si 111(11tanOilo IN. A\ methiodi, iietiiotrcx ale anld anl an ti-I nilour Ilecrosis Factor anti ody or- 1Irarlncml tiicrcof or use of any onle of claims 75 to 77, \hviem the anlttI110ur1 inecrosis factor ailt body and nillthotreCxale arc admnlistered se(Jeltiaify. Stf A letd met iotrex atc aild alli anti -tumour0.11 ncrIOSis Cactor alt ibodV Or IratunIcut t11fccoF or usc of any one of claiiis 75 to 77, wvlercin the ;lli-tumllOlii- niecrosis f"act,) anibody N is adin )istered ill muliit i pic (i()Cs. X 1. A' iictfio, uiclioticxaic aild anl ant i-tunoir0.1 IIlcrSiS F'actor antibody or' fragiini thereof or usc of cim 80 %\iicr-Cin the aiiti-tlIllioul1- ncrIosis factor aiitibody is af cii nric anib iody. 11 1 11, 1 [ill 11 11ol 970 [Vitt' 82. A mecthod, micthotrexate and an ant i-tumonr ncrosis factor antibody or" 6agment Mhioor or use oF ci i 8 1 \\'Iicrc &C Mhc ChAie antibody hA~ 10~i one or mre dlii 1 acids of bIN Ic selected fromn Ihc gro tip etilisist l c0 of bout 87- I08 anit ab~out )9- 83. At method. mcthot rexate and an an ti-tuiiou r necrosis factor anfti bomi or fragment thmreo for use of cin 81I wherei&th chieriric antihody UKia i to [lie efi tje of c i\2. 84. A method. inc hot rexate and an ai Ii-tnnr ncrosis factor anti body or 11-agmnent thlroofor use of cii 83 wheiri the cii mer amnt dy is cA 2. I 85. A method for treati ng or preveni ing Croiiii's disease ini an i iivid nal in need thereof comrising co-adhniin isteri ng iethotrexat e andannt-i111.- ICOiSfco antibody or fragment thereof or- a conposition of any one of claimis I to 6 to tue i ndi viduali, in therapen t ica ly effcti\'e amouns.11] 6. Mhlrxt adn ti-tunorncoshw ildoragetM r or a comnposition of any- one oF chinrs 58to p3WC s( i -ai revn Crohn's disease. 87. The use of inethloxate and an anti -t uliotir necrosis factor ant hOml or- Fraoment therco for a composi tion of any one of claimis 58 to 63 F-or thle manuiifacture of a iii~ediicament for treating or preventing Crohn s diese. 11 ~88. A met hod, inethotrexate and an anti 1-111- t nlrncrIosis I'actor anti body or- fragmenit ther or use of any one of claimis 85 to 87, wherein the anti-tunmour ncrIosis factor antibody and mnethotrexaite are adinristem-ed siminnltaneously. 89. A method, iethotrexate and an anl-tuniour necrosis factor antibody or Fragment thereof or use of any onie of ca i ins 85 to 87, wvleiein di[ie anil-turnonr necrosis fa ctor alit ibody and nelt orxate ale adl i i stered seq tIli ll V. A method, iethot ruxate and an dlii i- urnonr niecrosis factor antibod0y1 or ~Iiieii I herF or use of an v onIC of ci i11 85 to 87, \V iere iW[le ani-lu 111011 r liecrosi f'actor antibody is ad i iiStereCd in 111111 ip Ic doseS. 1 1. A iitiiod, mietliotrexate aiid an ant-tuMioIi ncrosis taCtor aiitibody or- l ainient tereoof Or use of clamll 90f \vilreill the adli-tciiocii niecrosis factor antibody is a 92. A methiod, licetlotrxtc and ill aiit1i-IuIIIIOurICIOi aCO nioyO iragne waverF or usc or claiii 91I whiereini the cliiIlcrc anti body binids to oiic or iore diiio 110 eds or wiN Fu selected lion the group conlsbig of about 87-.108 aind about 59- II .1. 78 91. A method, iiethotrcxatc and an antiuour necrosis factor antibody or ragavint thl-co or useof ciaimi 91I. wherein thclie cl-i r ani ody hinldS to Itheepi lope of 9.A miethod, miethotre.\ ate and anl anti-I1union r necrosis factor anti body Or- fraMent there-of or use of Ci ai in 91 IWherei n the clii cric anti body is cA2. A method fir tret ug or prevcenmg a tuo ur necrosis factor-medliated d iscase ill an 11(1 Vid na in neced thereof compr-ising co-ad n~ insteril ii g niethotrXate aiid a tunion r11 necrosis factor antagonist to tihe i ividuakI in thlirapeutIica ly effctive amountLIs. 96. NI thlotrecxate and( a tumnour necrosis factor antagonlist \\'lIi uIsed inl treating Or I reenting a tumour011 necrosis factor-mnediated disease. 97. The use of metliotr-exate and a tumour necrosis factor antagonis for the manufactur of a medicament for treating or preventing a tumnour necrosis factor- med iated diisease. a 98. Use ofr met hotr-exate and an ant i-tu mon r neciosis fbctr anti bdy or fragment thfereo f fir lie mannufactuiire of eoad iiistrab le or seqtuentially adm in istrablIc iii~edl canenits for treatinug or preventing a tumnour necerosis factor-nied iated (disease in ali individual. The use of clain 98, for the treatment Of 11-n11o.ur neerosis factor-miediated (Idiseases selected From autoi mm une disease acwie or chronic immune disease. 2 inn flanitoy disease and neulroclegenerati ye disease. 100. Use of niethotrexate and ant-tumour necrosis factor antibody for the nianu facture of coadmvinistrable or sequenItially' admi nistirable nmedicaments for treating or preventing rheum~ratoid arthritis in an individual. 1 01I. Use of iietiiotrcx ate and an anti -tu ~nonr iiecrosi s factor anti body for the mni ifatu re of coad iiin istrab Ic or sequten til I adni nistrabe Imied icaminits, for treat in Or p~reventinlg ('1ro1in'S disease ini anl individual. 101. Thc use of elaim 98. M t or 1 01, whlerein the anti-tumnour iiecross factor antibody is a Cfiineric antibody. 103. Ihe use of claiii 98, I or 10 1, wherein tihe liieri auitiwody RiIM to one or imore ariio acids of hTNl(/ selected 1troiii1Ilk' groupI COI]SiStin., of ablot S7- 108 and Amiii 59-80. 104 Ile use of claim 98, 10(A or I10)1, wvliciii the ciiinieriei aiitibody inds to the Cqiitope of cA2. 1 05 Ile use ofd iai an 98, IH00 or 101 wlierein ii le ciimieric antibiody is cA2. I I .Vl 111\1 Ili Ill 110 19711 d 106. Usc or methotrexate and a tumour necrosis falctor antagonlisl (or th c Manu facture oF mcdicanients (or t reat ing or prc\'cn I g a Itiniotirl 1lecrosis Factor-Iii ated di scase inl anl ild \idtia ill need Iliei-Co f Dated

4 August, 2000 The Kennedy Institute of Rheumatology Pl'~ ent A I(oriteys for t he A pplican0 /Now iiiat PCIIersoni SPRUSON FERGUSON 11 1 AM~ A~ I "H uso I d 17(