CA2478456A1 - Combination therapy - Google Patents

Abstract

Disclosed are methods for treating multiple sclerosis and other disorders. An exemplary method includes administering a VLA-4 binding antibody and a second agent, such as a recombinant interferon .beta.-1a, to provide an overall therapeutic effect.

Description

COMBINATION THERAPY
BACKGROUND
Multiple sclerosis (MS) is one of the most common diseases of the central nervous system. Today over 2,500,000 people wound the world have MS.
SUMMARY OF THE INVENTION
The invention is based, at least in part, on the finding that anti-VLA-4 therapy (e.g., anti-VLA-4 antibody therapy, e.g., natalizumab) can be used in combination with a second agent (e.g., a biologic agent, e.g., an immunomodulating or anti-inflammatory biologic agent such as interferon beta or glatiramer acetate) to provide a therapeutic effect for an inflammatory disorder, e.g., a central nervous system (CNS) inflammatory disorder, e.g., multiple sclerosis (MS).
In one aspect, this disclosure features a method of treating multiple sclerosis in a subject, e.g., a human subject. The method includes administering to the subject a first agent in combination with a second agent. The first agent binds andlor antagonizes VLA-4, for example, the first agent is a VLA-4 binding protein such as a VLA-4 binding antibody (e.g., natalizuxnab). The second agent includes an agent that is effective for treating multiple sclerosis. The first and second agents can be administered in an amount effective to provide a combinatorial therapeutic effect. A "combinatorial therapeutic effect" is an effect, e.g., an improvement, that is greater than one produced by either agent alone. The difference between the combinatorial therapeutic effect and the effect of each agent alone can be a statistically significant difference. The combinatorial therapeutic effect can be an improvement of at least 10%, 20%, 30%, 40%, SO%, 60%, 70%, $0% or greater relative to the effect of the first agent or second agent alone, e.g., as observed in a parameter referred to herein.
As used herein, "administered in combination" means that two or more agents are administered to a subject at the same time or within an interval, such that there is overlap of an effect of each agent on the patient. Preferably the administrations of the first and second agent are spaced sufficiently close together such that a combinatorial effect is achieved. The interval can be an interval of hours, days or weeks. Generally, the agents _1_ are concurrently bioavailable, e.g., detectable, in the subject. In a preferred embodiment at least one administration of one of the agents, e.g., the first agent, is made while the other agent, e.g., the second agent, is still present at a therapeutic level in the subject.
In a preferred embodiment the second agent is administered between an earlier and a later administration of the first agent. In other embodiments the first agent is administered between an earlier and a later administration of the second agent. In a preferred embodiment at least one administration of one of the agents, e.g., the first agent, is made within 1, 7, 14, 30, or 60 days of the other agent, e.g., the second agent.
In one embodiment, prior to administering the first and second agents, the subject was receiving either the first or second agent, but not the other. The subj ect may have.
had a response that did not meet a predetermined threshold. For example, the subject may have had a failed or incomplete response, e.g., a failed or incomplete clinical and/or MRI response to the agent. For example, the subject is a breakthrough patient, i.e., a patient that has had one or more of: (a) at least one relapse, (b) appearance of new MRI
lesions, and (c) progression of disability (EDSS) while being treated with one of the agents for a specified period of time, e.g., for at least 3 months, 6 months, 9 months, or at least one year. For example, a VLA-4 binding antibody is administered in combination with an interferon beta to a subject who has had one or more relapses while receiving a VLA-4-binding antibody therapy for at least 6 months, preferably at least 9 months, at least one year. In another example, a VLA-4-binding antibody is administered in combination with an interferon beta to a subject who has had one or more relapses while receiving an interferon beta therapy for at least 6 months, preferably at least 9 months, at least one year.
In another embodiment, the subject can be one who has not been previously administered the first nor the second agent for at least 3 months (e.g., at least 6 months, 9 months, or a year prior) prior to being administered the first and second agent in combination. For example, a VLA-4-binding antibody is administered in combination with an interferon beta. to a subject who has received neither a VLA-4-binding antibody nor an interferon therapy for at least one year prior to being administered the antibody and interferon beta in combination. In some embodiments one of the agents has been administered and that administration ceased for at least 3, 6, 9, or 12 months and then the combination is administered.
In one embodiment, the subject has a baseline EDSS score greater than a threshold, e.g., greater than l, 2, 3, 4, 5 or 6.
In one implementation, the first and second agents are provided as a co-formulation, and the co-formulation is administered to the subject. It is further possible, e.g., at least 24 hours before or after administering the co-formulation, to administer one of the first and second agents separately from the other. In another implementation, the first and second agents are provided as separate formulations, and the step of administering includes sequentially administering the first and second agents.
The sequential administrations can be provided on the same day (e.g., within one hour of one another or at least 3, 6, or 12 hours apart) or on different days.
Generally, the first and second agents are each administered as a plurality of doses separated in time. The first and second agents are generally each administered according to a regimen. The regimen for one or both may have a regular periodicity. The regimen for the first agent can have a different periodicity from the regimen for the second agent, e.g., one can be administered more frequently than the other. In one implementation, one of the first and second agent is administered once weekly and the other once monthly. In another implementation, one of the first and second agent is administered continuously, e.g., over a period of more than 30 minutes but less than l, 2, 4, or 12 hours, and the other is administered as a bolus. The first and second agents can be administered by any appropriate method, e.g., subcutaneously, intramuscularly, or intravenously.
The subject can be administered doses of the first agent and doses of the second agent for greater than 14 weeks, greater than six or nine months, greater than 1, 1.5, or 2 years.
In some embodiments, each of the first and second agents is administered at about the same dose as is administered for monotherapy. In other embodiments, the first agent is administered at a dosage that is equal to or less than an amount required for efficacy if administered alone. Likewise, the second agent can be administered at a dosage that is equal to or less than an amount required for efficacy if administered alone.
In one embodiment, the frst agent includes a VLA-4 binding antibody, e.g., a full length antibody such as an IgGI, IgG2, IgG3, or IgG4. Typically the antibody is effectively human, human, or humanized. The VLA-4 binding antibody can inhibit VLA-4 interaction with a cognate ligand of VLA-4, e.g., VCAM-1. The VLA-4 binding antibody binds to at least the a chain of VLA-4, e.g., to the extracellular domain of the a4 subunit. For example, the VLA-4 binding antibody recognizes epitope B
(e.g., Bl or B2) on the a chain of VLA-4. The VLA-4 binding antibody may compete with, or have an overlapping epitope with, natalizumab, HP1/2, or another VLA-4 binding antibody described herein for binding to VLA-4. In a preferred embodiment, the VLA-4 binding antibody is natalizumab or includes the heavy chain and light chain variable domains of natalizumab.
The second agent can be a biologic, e.g., a protein of defined sequence such as an interferon. In one embodiment, the second agent includes an interferon beta, e.g., interferon beta-la, e.g., AVONEXC~ (interferon beta-la) or Rebif~ (interferon beta-la), or BETASERON~ (interferon beta-lb). The second agent can also be a protein of undefined sequence, e.g., a random copolymer of selected amino acids, e.g., glatiramer acetate.
In one embodiment, the anti-VLA-4 antibody is administered at a dose sufficient to achieve at least 80% (preferably 90%, 95%, 100%, 110% or greater) of the bioavailability achieved with a monthly (e.g., once every four weeks) dose of between about 50 and 600 mg (e.g., between about 200 and 400 mg, e.g., about 300 mg by intravenous (IV) route). For example, the VLA-4 binding antibody is administered as a monthly IV infusion of between about 50 and 600 mg (e.g., between about 200 and 400 mg, e.g., about 300 mg). In another example, the VLA-4 binding antibody is administered as a subcutaneous (SC) injection of between 25-300 mg (e.g., between 50 and 150 mg, e.g., about 75 mg), e.g., once a week, twice a week or once every 2 weeks.
In one embodiment, a VLA-4 binding antibody (e.g., natalizumab) is administered in combination with interferon beta 1 a , wherein interferon beta 1 a is administered at least once weekly at a unit dose between 10 ~.g and 60 p,g. For example, about 300 mg natalizumab IV is administered once every 4 weeks in combination with AVONEX~
wherein AVONEX~ is administered once weekly at a unit dose of between about 20-~.g (e.g., about 30 ~,g) by intramuscular (IM) route. In another example, about 300 mg natalizumab IV is administered in combination with Rebif~, wherein Rebif~ is administered three times per week at a unit dose between 30 and 60 ~,g (e.g., about 44 pg) by SC route. The combination treatment can last at least 3 months, preferably at least 6 months, 9 months, at least one year or longer.
The first and second agents can be administered in amounts that together are effective to provide a decreased rate of relapse (e.g., a 10%, 20%, 25%, 30%, 40%, SO%
or greater reduction in rate of relapse) compared to the VLA-4 binding antibody or second agent (e.g., AVONEX~ or other interferon beta product) alone, when measured between 3-24 months (e.g., between 6-18 months, e.g., 12 months) after a previous relapse or between 3-24 months (e.g., between 6-18 months, e.g., 12 months) after the initiation of combination therapy. Initiation can be taken as the first dose of either the first or the second agent.
In some embodiments, the first and second agents can be administered in amounts that together are effective to result in one or more of the following: a) decreased severity of relapse, b) prevention of an increase in EDSS score, c) decreased EDSS
score (e.g., a decrease of greater than l, 1.5, 2, 2.5, or 3 points, e.g., over at least six months, one year, or longer), d) decreased number of new Gd+ lesions, e) reduced rate of appearance of new Gd+ lesions, and f) decreased increase in Gd+ lesion area. The first and second agents can be administered in multiple doses and in amounts that together are effective to maintain an exacerbation-free or relapse free period for at least three, six, or nine months, or one, two, or three years.
In one embodiment, the subject is an adult, e.g., a subject whose age is greater or equal to 16, 18, 19, 20, 24, or 30 years. Typically, the subject is between 19 and 55 years of age. The subject can be female or male.
In one embodiment, the subject has relapsing remitting multiple sclerosis. In another embodiment, the subject has chronic progressive multiple sclerosis, e.g., primary-progressive (PP), secondary progressive, or progressive relapsing multiple sclerosis.
The subject can be one who has not previously received the second agent, prior to being administered the first and second agent, or one who has previously received the second agent, but received it for less than 11.9, eleven, ten, nine, or six months. For example, the second agent is an interferon beta. In another example, the subject received glatiramer acetate, prior to being administered the first and glatiramer acetate, but received it for less than 2.9, two or one months.
Alternatively, the subject can be one who received a plurality of doses of the second agent, e.g., during the course of at least two, ten, or twelve months, or at least two or three years, prior to receiving the first agent far the first time, or conversely, one who received a plurality of doses of the first agent, e.g., during the course of at least two, ten, or twelve months, or at least two or three years, prior to receiving the second agent for the first time.
In one embodiment, where the subject has previously received the first (or second) agent, the subject is administered the same dose of the first (or second) agent during the combination therapy as during the prior therapy. In some embodiments in which the subject has previously received the second agent, the subject is administered a reduced dose of the second agent after receiving the first agent (relative to the dose of the second agent received before receiving the first agent for the first time). In some embodiments in which the subject has previously received the first agent, the subject is administered a reduced dose of the first agent after receiving the second agent (relative to the dose of the first agent received before receiving the second agent for the first time).
In one embodiment, the subject previously received a corticosteroid prior to receiving the first and second agent, the second agent being other than a corticosteroid.
A subject can be evaluated after receiving the first and second agent, e.g., for indicia of responsiveness. A skilled artisan can use various clinical or other indicia of effectiveness of treatment, e.g., EDSS score; MRI scan; relapse number, rate, or severity;
multiple sclerosis functional composite (MSFC); multiple sclerosis quality of life inventory (MSQLI). The subject can be monitored at various times during a regimen. In one embodiment, the subject is not examined for interferon bioavailability (e.g., before or after the administering).
Prior to administering the first and second agent, a subject can be identified, e.g., by evaluating a subject to determine if the subject has an EDSS score greater than a threshold or a deterioration in symptoms or other index of multiple sclerosis disease.
Treatment with the first and second agent can be initiated, for example, if the EDSS score is greater than 1.5, 2, 3, 3.5, 4, 5, f or greater. A relapse or increase in Gd+ lesions can indicate a subject as being in need of treatment with the first and second agent. In a preferred embodiment the subject is evaluated by a set of criteria that has been developed for or which is used to identify patients for the suitability for combination therapy.
In another aspect, this disclosure features a method that includes providing a therapeutic regimen including dosages of a first agent, but not a second agent, to a subject; evaluating the subject for responsiveness, e.g., to the first agent;
and, if a deficiency in responsiveness is detected (e.g., if the subject has a breakthrough while on the first agent), providing a second agent to the subject, in addition to the first agent.
One of the first and second agents is a VLA-4 binding antibody. Evaluating responsiveness of a subject can include detecting a relapse for multiple sclerosis or evaluating an index of multiple sclerosis disease, e.g., Gd+ lesions or EDSS
score. In one embodiment, the first agent is a VLA-4 binding antibody and the second agent is an interferon. In another embodiment, the second agent is a VLA-4 binding antibody and the first agent is an interferon.
As further described herein, the disclosure also features kits, pharmaceutical compositions and medical devices that include a first and second agent. The first and second agents can be included at a ratio effective for ameliorating the inflammatory condition.
Any feature described herein can also be applied to a method in which a VLA-4 binding antibody is administered, irrespective of whether any second agent or a particular second agent (e.g., interferon) is also administered. For example, a VLA-4 binding antibody can be administered to a subject having a disease state described herein, e.g., as mono-biologic therapy. A mono-biologic therapy is one in which no other biologic is administered to treat the relevant disorder. In one implementation, the subject has relapsed remitting multiple sclerosis. Alternatively, the subject has chronic progressive multiple sclerosis, e.g., primary-progressive (PP), secondary progressive, or progressive relapsing multiple sclerosis. The subject may have a baseline EDSS score greater than a threshold, e.g., greater than l, 1.5, 2.5, 3, 4, or 5.
The subject can be administered doses of a VLA-4 binding antibody (e.g., natalizumab), for example, as a mono-biologic therapy or as a combination described _7_ herein, for greater than 14 weeks, greater than six or nine months, greater than 1, 1.5, or 2 years.
It is also possible to select subjects that have a high-baseline with respect to MS
symptoms. For example, subjects that have a baseline EDSS score greater than a threshold, e.g., greater than 2.5, 3, 4, or 5, can be selected and administered a VLA-4 binding antibody, e.g., as a mono-biologic therapy or as a combination described herein.
Definitions The term "treating" refers to administering a therapy in an amount, manner, and/or mode effective to improve a condition, symptom, or parameter associated with a disorder or to prevent progression of a disorder, to either a statistically significant degree or to a degree detectable to one skilled in the art. An effective amount, manner, or mode can vary depending on the subject and may be tailored to the subject.
The term "biologic" refers t~ a protein-based therapeutic agent. In a preferred embodiment the biologic is at least 10, 20, 30, 40, 50 or 100 amino acid residues in length.
A "VLA-4 binding agent" refers to any compound that binds to VLA-4 integrin with a Ka of less than 10-6 M. An example of a VLA-4 binding agent is a VLA-4 binding protein, e.g., an antibody such as nataluzimab.
A "VLA-4 antagonist" refers to any compound that at least partially inhibits an activity of a VLA-4 integrin, particularly a binding activity of a VLA-4 integrin or a signaling activity, e.g., ability to transduce a VLA-4 mediated signal. For example, a VLA-4 antagonist may inhibit binding of VLA-4 to a cognate Iigand of VLA-4, e.g., a cell surface protein such as VCAM-1, or to an extracellular matrix component, such as fibronectin or osteopontin. A typical VLA-4 antagonist can bind to VLA-4 or to a VLA-4 ligand, e.g., VCAM-1 or an extracellular matrix component, such as fibronectin or osteopontin. A VLA-4 antagonist that binds to VLA-4 may bind to either the a4 subunit or the (31 subunit, or to both. A VLA-4 antagonist may also interact with other a4 subunit containing integrins (e.g., a4(37) or with other X31 containing integrins. A
VLA-4 antagonist may bind to VLA-4 or to a VLA-4 ligand with a Kd of less than 106, 10'', 10-8, 10-9, or 101° M.
_g_ As used herein, the term "antibody" refers to a protein that includes at least one immunoglobulin variable region, e.g., an amino acid sequence that provides an immunoglobulin variable domain or immunoglobulin variable domain sequence. For example, an antibody can include a heavy (H) chain variable region (abbreviated herein as VH), and a light (L) chain variable region (abbreviated herein as VL). In another example, an antibody includes two heavy (H) chain variable regions and two light (L) chain variable regions. The term "antibody" encompasses antigen-binding fragments of antibodies (e.g., single chain antibodies, Fab fragments, F(ab')2 fragments, Fd fragments, Fv fragments, and dAb fragments) as well as complete antibodies, e.g., intact immunoglobulins of types IgA, IgG, IgE, IgD, IgM (as well as subtypes thereof). The light chains of the immunoglobulin may be of types kappa or lambda. In one embodiment, the antibody is glycosylated. An antibody can be functional for antibody-dependent cytotoxicity and/or complement-mediated cytotoxicity, or may be non-functional for one or both of these activities.
The VH and VL regions can be further subdivided into regions of hypervariability, termed "complementarity determining regions" ("CDR"), interspersed with regions that are more conserved, termed "framework regions" (FR). The extent of the FR's and CDR's has been precisely defined (see, Kabat, E.A., et al. (1991) Sequences of Proteins of Immunological Interest, Fifth Edition, US Department of Health and Human Services, NIH Publication No. 91-3242; and Chothia, C. et al. (1987) J.
Mol.
Biol. 196:901-917). Kabat definitions are used herein. Each VH and VL is typically composed of three CDR's and four FR's, arranged from amino-terminus to carboxyl-terminus in the following order: FRI, CDR1, FR2, CDR2, FR3, CDR3, FR4.
An "immunoglobulin domain" refers to a domain from the variable or constant domain of immunoglobulin molecules. Immunoglobulin domains typically contain two (3-sheets formed of about seven (3-strands, and a conserved disulphide bond (see, e.g., A.
F. Williams and A. N. Barclay 1988 Ann. Rev Immunol. 6:381-405).
As used herein, an "immunoglobulin variable domain sequence" refers to an amino acid sequence that can form the structure of an immunoglobulin variable domain.
For example, the sequence may include all or part of the amino acid sequence of a naturally-occurring variable domain. For example, the sequence may omit one, two or more N- or C-terminal amino acids, internal amino acids, may include one or more insertions or additional terminal amino acids, or may include other alterations. In one embodiment, a polypeptide that includes an immunoglobulin variable domain sequence can associate with another immunoglobulin variable domain sequence to form a target binding structure (or "antigen binding site"), e.g., a structure that interacts with VLA-4.
The VH or VL chain of the antibody can further include all or part of a heavy or light chain constant region, to thereby form a heavy or light irnmunoglobulin chain, respectively. In one embodiment, the antibody is a tetramer of two heavy immunoglobulin chains and two light immunoglobulin chains. The heavy and light immunoglobulin chains can be connected by disulfide bonds. The heavy chain constant region typically includes three constant domains, CHI, CH2 and CH3. The light chain constant region typically includes a CL domain. The variable region of the heavy and light chains contains a binding domain that interacts with an antigen. The constant regions of the antibodies typically mediate the binding of the antibody to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component (Clq) of the classical complement system.
One or more regions of an antibody can be human, effectively human, or humanized. For example, one or more of the variable regions can be human or effectively human. For example, one or more of the CDRs, e.g., HC CDRI, HC
CDR2, HC CDR3, LC CDRI, LC CDR2, and LC CDR3, can be human. Each of the light chain CDRs can be human. HC CDR3 can be human. One or more of the framework regions can be human, e.g., FR1, FR2, FR3, and FR4 of the HC or LC. In one embodiment, all the framework regions are human, e.g., derived from a human somatic cell, e.g., a hematopoietic cell that produces immunoglobulins or a non-hematopoietic cell.
In one embodiment, the human sequences are germline sequences, e.g., encoded by a germline nucleic acid. One or more of the constant regions can be human, effectively human, or humanized. In another embodiment, at least 70, 75, 80, 85, 90, 92, 95, or 98%
of the framework regions (e.g., FRl, FR2, and FR3, collectively, or FRl, FR2, FR3, and FR4, collectively) or the entire antibody can be human,. effectively human, or humanized. For example, FRI, FR2, and FR3 collectively can be at least 70, 75, 80, 85, 90, 92, 95, 98, or 99% identical to a human sequence encoded by a human germline segment.

An "effectively human" immunoglobulin variable region is an immunoglobulin variable region that includes a sufficient number of human framework amino acid positions such that the immunoglobulin variable region does not elicit an immunogenic response in a normal human. An "effectively human" antibody is an antibody that includes a sufficient number of human amino acid positions such that the antibody does not elicit an immunogenic response in a normal human.
A "humanized" immunoglobulin variable region is an immunoglobulin variable region that is modified such that the modified form elicits less of an immune response in a human than does the non-modified form, e.g., is modified to include a sufficient number of human framework amino acid positions such that the immunoglobulin variable region does not elicit an immunogenic response in a normal human. Descriptions of "humanized" immunoglobulins include, for example, US Pat. No. 6,407,213 and US
Pat.
No. 5,693,762. In some cases, humanized immunoglobulins can include a non-human amino acid at one or more framework amino acid positions.
All or part of an antibody can be encoded by an immunoglobulin gene or a segment thereof. Exemplary human immunoglobulin genes include the kappa, lambda, alpha (IgAl and IgA2), gamma (IgGI, IgG2, IgG3, IgG4), delta, epsilon and mu constant region genes, as well as the myriad immunoglobulin variable region genes. Full-length immunoglobulin "light chains" (about 25 Kd or 214 amino acids) are encoded by a variable region gene at the NH2-terminus (about 110 amino acids) and a kappa or lambda constant region gene at the COOH--terminus. Full-length immunoglobulin "heavy chains" (about 50 Kd or 446 amino acids), are similarly encoded by a variable region gene (about 116 amino acids) and one of the other aforementioned constant region genes, e.g., gamma (encoding about 330 amino acids).
The term "antigen-binding fragment" of a full length antibody refers to one or more fragments of a full-length antibody that retain the ability to specifically bind to a target of interest, e.g., VLA-4. Examples of binding fragments encompassed within the term "antigen-binding fragment" of a full length antibody include (i) a Fab fragment, a monovalent fragment consisting of the VL, VH, CL and CH1 domains; (ii) a F(ab'~
fragment, a bivalent fragment including two Fab fragments linked by a disulfide bridge at the hinge region; (iii) a Fd fragment consisting of the VH and CH1 domains;
(iv) a Fv fragment consisting of the VL and VH domains of a single arm of an antibody, (v) a dAb fragment (Ward et al., (1989) Nature 341:544-546), which consists of a VH
domain; and (vi) an isolated complementarity determining region (CDR) that retains functionality.
Furthermore, although the two domains of the Fv fragment, VL and VH, are coded for by separate genes, they can be joined, using recombinant methods, by a synthetic linker that enables them to be made as a single protein chain in which the VL and VH
regions pair to form monovalent molecules known as single chain Fv (scFv). See e.g., Bird et ad. (1988) Science 242:423-426; and Huston et al. (1988) Proc. Natl. Acad Sci. USA
85:5879-5883.
DETAILED DESCRIPTION
Previous studies have shown that VLA-4 expression on peripheral blood lymphocytes is downregulated after treatment of multiple sclerosis with interferon beta, suggesting that a VLA-4 binding antibody and interferon beta may act on the same pathway (Calabresi et al., 1997, Neurology 49:1111-1116). In addition, multiple sclerosis patients being treated with interferon beta show increased levels of soluble VLA-4 that could interact with a VLA-4 binding antibody.
Described herein are methods wherein a subject is administered (i) an anti-VLA-therapy, e.g., a first agent comprising a VLA-4 binding protein or VLA-4 antagonist, and (ii) a second agent, e.g., another agent for treating an immune or inflammatory disorder, such as MS, or a symptom thereof. The administration of the two agents can achieve results that surpass the results of using either agent alone.
A VLA-4 antagonist can be a compound that includes a protein moiety or a compound that does not include a protein moiety. Examples of VLA-4 protein antagonists include antagonizing antibodies, such as nataluzimab, and peptide antagonists. Examples of non-protein antagonists include small molecule antagonists. A
"small molecule" is an organic molecule that has a molecular weight of less than 1000 Daltons.

Nataluzimab and Other VLA-4 Binding Antibodies Natalizumab, an a4 integrin binding antibody, inhibits the migration of leukocytes from the blood to the central nervous system. Natalizumab binds to on the surface of activated T-cells and other mononuclear leukocytes. It can disrupt adhesion between the T-cell and endothelial cells, and thus prevent migration of mononuclear leukocytes across the endothelium and into the parenchyma. As a result, the levels of proinflammatory cytokines can also be reduced.
Natalizumab can decrease the number of brain Lesions and clinical relapses in patients with relapse remitting multiple sclerosis and relapsing secondary-progressive multiple sclerosis. Natalizumab can be safely administered to patients with multiple sclerosis when combined with interferon beta-la (IFN-beta-la) therapy.
Natalizumab and related VLA-4 binding antibodies are described, e.g., in US
Pat.
No. 5,840,299. Monoclonal antibodies 2I.6 and HPI/2 are exemplary marine monoclonal antibodies that bind VLA-4. Natalizumab is a humanized version of marine monoclonal antibody 21.6 (see, e.g., US Pat No. 5,840,299). A humanized version of HP1/2 has also been described (see, e.g., US Pat. No. 6,602,503). Several additional VLA-4 binding monoclonal antibodies, such as HP2/1, HP2/4, LZS and P4C2, are described, e.g., in US Pat. No. 6,602,503; Sanchez-Madrid et al., 1986 Eur. J.
Immunol., 16:1343-1349; Hemler et al., 1987 J. Biol. Chem. 2:11478-11485; Issekutz and Wykretowicz, 1991, J. Imrnunol., 147: 109 (TA-2 mab); Pulido et al., 1991 J.
Biol.
Chem., 266(16):10241-10245; and US Pat. No. 5,888,507).
Some VLA-4 binding antibodies recognize epitopes of the a4 subunit that are involved in binding to a cognate ligand, e.g., VCAM-1 or fibronectin. Many such antibodies inhibit binding of VLA-4 to cagnate ligands (e.g., VCAM-1 and fibronectin).
Some useful VLA-4 binding antibodies can interact with VLA-4 on cells, e.g., lymphocytes, but do not cause cell aggregation. However, other VLA-4 binding antibodies have been observed to cause such aggregation. HP1/2 does not cause cell aggregation. The HP1/2 monoclonal antibody (Sanchez-Madrid et al., 1986) has an extremely high potency, blocks VLA-4 interaction with both VCAM1 and fibronectin, and has the specificity for epitope B on VLA-4. This antibody and other B
epitope-specific antibodies (such as BI or B2 epitope binding antibodies; Pulido et al., 1991, supra) represent one class of VLA-4 binding antibodies that can be used in the methods described herein.
An exemplary VLA-4 binding antibody has one or more CDRs, e.g., all three HC
CDRs and/or all three LC CDRs of a particular antibody disclosed herein, or CDRs that are, in sum, at least 80, 85, 90, 92, 94, 95, 96, 97, 98, 99% identical to such an antibody, e.g., natalizumab. In one embodiment; the HI and H2 hypervariable Loops have the same canonical structure as those of an antibody described herein. In one embodiment, the Ll and L2 hypervariable loops have the same canonical structure as those of an antibody described herein.
In one embodiment, the amino acid sequence of the HC and/or LC variable domain sequence is at least 70, 80, 85, 90, 92, 95, 97, 98, 99, or 100%
identical to the amino acid sequence of the HC and/or LC variable domain of an antibody described herein, e.g., natalizumab. The amino acid sequence of the HC and/or LC
variable domain sequence can differ by at least one amino acid, but no more than ten, eight, six, five, four, three, or two amino acids from the corresponding sequence of an antibody described herein, e.g., natalizumab. For example, the differences may be primarily or entirely in the framework regions.
The amino acid sequences of the HC and LC variable domain sequences can be encoded by a nucleic acid sequence that hybridizes under high stringency conditions to a nucleic acid sequence described herein or one that encodes a variable domain or an amino acid sequence described herein. In one embodiment, the amino acid sequences of one or more framework regions (e.g., FR1, FR2, FR3, and/or FR4) of the HC and/or LC
variable domain are at Least 70, 80, 85, 90, 92, 95, 97, 98, 99, or 100% identical to corresponding framework regions of the HC and LC variable domains of an antibody described herein.
In one embodiment, one or more heavy or light chain framework regions (e.g., HC FR1, FR2, and FR3) are at least 70, 80, 85, 90, 95, 96, 97, 98, or 100% identical to the sequence of corresponding framework regions from a human germline antibody.
Calculations of "homology" or "sequence identity" between two sequences (the terms are used interchangeably herein) are performed as follows. The sequences are aligned for optimal comparison purposes (e.g., gaps can be introduced in one or both of a first and a second amino acid ar nucleic acid sequence for optimal alignment and non-homologous sequences can be disregarded for comparison purposes). The optimal alignment is determined as the best score using the GAP program in the GCG
softwaxe package with a Blossom 62 scoring matrix with a gap penalty of 12, a gap extend penalty of 4, and a frameshift gap penalty of 5. The amino acid residues or nucleotides at corresponding amino acid positions or nucleotide positions are then compared.
When a position in the first sequence is occupied by the same amino acid residue or nucleotide as the corresponding position in the second sequence, then the molecules are identical at that position (as used herein amino acid or nucleic acid "identity" is equivalent to amino acid or nucleic acid "homology"). The percent identity between the two sequences is a function of the number of identical positions shared by the sequences.
As used herein, the term "hybridizes under high stringency conditions"
describes conditions for hybridization and washing. Guidance for performing hybridization reactions can be found in Current Protocols in Molecular Bi~logy, John Wiley &
Sons, N.Y. (1989), 6.3.1-6.3.6, which is incorporated by reference. Aqueous and nonaqueous methods are described in that reference and either can be used. High stringency hybridization conditions include hybridization in 6X SSC at about 45°C, followed by one or more washes in 0.2X SSC, 0.1% SDS at 65°C, or substantially similar conditions.
Exemplary Second Agents Non-limiting examples of agents for treating or preventing multiple sclerosis that can be administered with a first agent (e.g., a VLA-4 binding antibody) include the following examples:
~ interferons, e.g., human interferon beta-la (e.g., AVONEX~ or Rebif~)) and interferon beta-lb (BETASERONTM; human interferon beta substituted at position 17; Berlex/Chiron);
~ glatiramer acetate (also termed Copolymer l, Cop-1; COPAXONETM; Teva Pharmaceutical Industries, Inc.);
~ fumarates, e.g., dimethyl fumarate (e.g., Fumaderm~);
~ Rituxan~ (rituximab) or another anti-CD20 antibody, e.g., one that competes with or binds an overlapping epitope with rituximab;
~ mixtoxantrone (NOVANTRONE~, Lederle);

~ a chemotherapeutic, e.g., clabribine (LEUSTATIN~), azathioprine (IMURAN~), cyclophosphamide (CYTOXAN~), cyclosporine-A, methotrexate, 4-aminopyridine, and tizanidine;
~ a corticosteroid, e.g., methylprednisolone (MEDRONE~, Pfizer), prednisone;
~ an immunoglobulin, e.g., Rituxan~ (rituximab); CTLA4 Ig; alemtuzumab (MabCAMPATH~) or daclizumab (an antibody that binds CD25);
~ statins;
~ immunoglobulin G i.v. (IgGIV) ~ azathioprine;
~ TNF antagonists.
Glatiramer acetate is protein formed of a random chain of amino acids -glutamic acid, lysine, alanine and tyrosine (hence GLATiramer). It can be synthesized in solution from these amino acids a ratio of approximately 5 parts alanine to 3 of lysine, 1.5 of glutamic acid and 1 of tyrosine using N-carboxyamino acid anhydrides.
Additional second agents include antibodies or antagonists of other human cytokines or growth factors, for example, TNF, LT, IL- l, IL-2, IL-6, IL-7, IL-8, IL-12 IL- 15, IL- 16, IL- 18, EMAP-I 1, GM- CSF, FGF, and PDGF. Still other exemplary second agents include antibodies to cell surface molecules such as CD2, CD3, CD4, CDB, CD25, CD28, CD30, CD40, CD45, CD69, CD80, CD86, CD90 or their ligands.
For example, daclizubmab is an anti-CD25 antibody that may ameliorate multiple sclerosis.
Still other exemplary antibodies include antibodies that provide an activity of an agent described herein, e.g., an antibody that engages an interferon receptor, e.g., an interferon beta receptor. Typically, in implementations in which the second agent includes an antibody, it binds to a target protein other than VLA-4 or other than a4 integrin, or at Ieast an epitope on VLA-4 other than one recognized by the first agent.
Still other additional exemplary second agents include: FK506, rapamycin, mycophenolate mofetil, leflunomide, non-steroidal anti-inflammatory drugs (NSAIDs), for example, phosphodiesterase inhibitors, adenosine agonists, antithrombotic agents, complement inhibitors, adrenergic agents, agents that interfere with signaling by proinflammatory cytokines as described herein, IL- I[3 converting enzyme inhibitors (e.g., Vx740), anti-P7s, PSGL, TALE inhibitors, T-cell signaling inhibitors such as kinase inhibitors, metal loproteinase inhibitors, sulfasalazine, azathloprine, 6-mercaptopurines, angiotensin converting enzyme inhibitors, soluble cytokine receptors and derivatives thereof, as described herein, anti-inflammatory cytokines (e.g. IL-4, IL-10, IL-13 and TGF).
In some embodiments, a second agent may be used to treat one or more symptoms or side effects of MS. Such agents include, e.g., amantadine, baclofen, papaverine, meclizine, hydroxyzine, sulfamethoxazole, ciprofloxacin, docusate, pemoline, dantrolene, desmopressin, dexamethasone, tolterodine, phenytoin, oxybutynin, bisacodyl, venlafaxine, amitriptyline, methenamine, clonazepam, isoniazid, vardenafil, nitrofurantoin, psyllium hydrophilic mucilloid, alprostadil, gabapentin, nortriptyline, paroxetine, propantheline bromide, modafinil, fluoxetine, phenazopyridine, methylprednisolone, carbamazepine, imipramine, diazepam, sildenafil, bupropion, and sertraline. Many second agents that are small molecules have a molecular weight between 150 and 5000 Daltons.
Examples of TNF antagonists include chimeric, humanized, human or in vitro generated antibodies (or antigen-binding fragments thereof) to TNF (e.g., human TNF a), such as D2E7, (human TNFa antibody, US Pat. No. 6,258,562; BASF), CDP-571/CDP-870/BAY-10-3356 (humanized anti-TNFa antibody; CelltechlPharmacia), cA2 (chimeric anti-TNFa antibody; REMICADETM, Centocor); anti-TNF antibody fragments (e.g., CPD870); soluble fragments of the TNF receptors, e.g., p55 or p75 human TNF
receptors or derivatives thereof, e.g., 75 kdTNFR-IgG (75 kD TNF receptor-IgG fusion protein, ENBRELTM; Immunex; see e.g., Arthritis & Rheumatism (1994) Vol. 37, 5295; J.
Invest.
Med. (1996) Vol. 44, 235A), p55 kdTNFR-IgG (55 kD TNF receptor-IgG fusion protein (LENERCEPTTM)); enzyme antagonists, e.g., TNFa converting enzyme (TACE) inhibitors (e.g., an alpha-sulfonyl hydroxamic acid derivative, WO 01/55112, and N-hydroxyformamide TACE inhibitor GW 3333, -005, or -022); and TNF-bp/s-TNFR
(soluble TNF binding protein; see e.g., Arthritis & Rheumatism (1996) Vol. 39, No. 9 (supplement), 5284; Amen. J. Physiol. - Heart and Circulatory Physiology (1995) Vol.
268, pp. 37-42).

In addition to a second agent, it is also possible to deliver other agents to the subject. However, in some embodiments, no protein or no biologic, other than the first and second agents, are administered to the subject as a pharmaceutical composition. The first and second agents may be the only agents that are delivered by injection. In embodiments in which the first and second agents are recombinant proteins, the first and second agents may be the only recombinant agents administered to the subject, or at least the only recombinant agents that modulate immune or inflammatory responses.
Pharmaceutical Compositions A VLA-4 binding agent (e.g., natalizumab) and a second agent (e.g., interferon beta-la) can be formulated as pharmaceutical compositions, e.g., as a single pharmaceutical composition or as separate pharmaceutical compositions. When the VLA-4 binding agent (e.g., nata,lizumab) and the second agent are formulated separately, the respective pharmaceutical compositions can be mixed, e.g., just prior to administration or can be administered separately, e.g., at the same or different times.
Typically, a pharmaceutical composition includes a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible.
A "pharmaceutically acceptable salt" refers to a salt that retains the desired biological activity of the parent compound and does not impart any undesired toxicological effects (see e.g., Berge, S.M., et al. (I977) J. Pharm. Sci.
66:1-19).
Examples of such salts include acid addition salts and base addition salts.
Acid addition salts include those derived from nontoxic inorganic acids, such as hydrochloric, nitric, phosphoric, sulfuric, hydrobromic, hydroiodic, and the like, as well as from nontoxic organic acids such as aliphatic mono- and dicarboxylic acids, phenyl-substituted alkanoic acids, hydroxy alkanoic acids, aromatic acids, aliphatic and aromatic sulfonic acids and the like. Base addition salts include those derived from alkaline earth metals, such as sodium, potassium, magnesium, calcium and the like, as well as from nontoxic organic amines, such as N,N'-dibenzylethylenediamine, N-methylglucamine, chloroprocaine, choline, diethanolamine, ethylenediamine, procaine and the like.

Natalizumab and other agents described herein can be formulated according to standard methods. Pharmaceutical formulation is a well-established art, and is further described in Gennaro (ed.), Remington: The Science and Practice of Pharmacy, 20~' ed., Lippincott, Williams & Wilkins (2000) (ISBN: 0683306472); Ansel et al., Pharmaceutical Dosage Forms and Drug Delivery Systems, 7~' Ed.., Lippincott Williams & Wilkins Publishers (1999) (ISBN: 0683305727); and Kibbe (ed.), Handbook of Pharmaceutical Excipients American Pharmaceutical Association, 3rd ed. (2000) (ISBN:
091733096X).
In one embodiment, natalizumab or another agent can be formulated with excipient materials, such as sodium chloride, sodium dibasic phosphate heptahydrate, sodium monobasic phosphate, and polysorbate 80. It can be provided, for example, in a buffered solution at a concentration of about 20 mg/ml and can be stored at 2-8°C.
Interferon beta-la can be formulated according to the manufacturer's label, e.g., the Iabel for AVONEX~ or Rebif~. For example, it can be provided as a sterile, white to off white lyophilized powder fvr intramusculax injection after reconstitution with supplied diluent (sterile water for injection, USP). A vial can contain 30 mcg of interferon beta-la; 15 mg Albumin (Human), USP; 5.8 mg sodium chloride, USP;
5.7 mg dibasic sodium phosphate, USP; and 1.2 mg monobasic sodium phosphate, USP, in 1.0 mL at a pH of approximately 7.3. It can also be formulated as a sterile liquid for intramuscular injection. Each 0.5 mL (30 mcg dose) can contain 30 mcg of interferon beta-la, 0.79 mg sodium acetate trihydrate, USP; 0.25 mg glacial acetic acid, USP; 15.8 mg arginine hydrochloride, USP; and 0.025 mg polysorbate 20 in water for injection, USP at a pH of approximately 4.8.
The pharmaceutical compositions may be in a variety of forms. These include, for example, liquid, semi-solid and solid dosage forms, such as liquid solutions (e.g., injectable and infusible solutions), dispersions or suspensions, tablets, pills, powders, liposomes and suppositories. The preferred form can depend on the intended mode of administration and therapeutic application. Typically compositions for the agents described herein are in the form of injectable or infusible salutions.
Such compositions can be administered by a parenteral mode (e.g., intravenous, subcutaneous, intraperitoneal, or intramuscular injection). The phrases "paxenteral _.___.~....___-.~..e.~________.._ _. __ administration" and "administered parenterally" as used herein mean modes of administration other than enteral and topical administration, usually by injection, and include, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsulax, subarachnoid, intraspinal, epidural and intrasternal inj ection and infusion.
Pharmaceutical compositions typically must be sterile and stable under the conditions of manufacture and storage. A pharmaceutical composition can also be tested to insure it meets regulatory and industry standards for administration.
The composition can be formulated as a solution, microemulsion, dispersion, liposome, or other ordered structure suitable to high drug concentration.
Sterile injectable solutions can be prepared by incorporating an agent described herein in the required amount in an appropriate solvent with one or a combination of ingredients enumerated above, as required, followed by filtered sterilization. Generally, dispersions are prepared by incorporating an agent described herein into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze-drying that yields a powder of an agent described herein plus any additional desired ingredient from a previously sterile-filtered solution thereof. The proper fluidity of a solution can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants.
Prolonged absorption of injectable compositions can be brought about by including in the composition an agent that delays absorption, for example, monostearate salts and gelatin.
Administration The agents described herein can be administered to a subject, e.g., a human subject, by a variety of methods. For many applications, the route of administration is one of: intravenous injection or infusion, subcutaneous injection, or intramuscular inj ection.
A VLA-4 binding antibody, such as natalizumab, can be administered as a fixed dose, or in a mg/kg dose, but preferably as a fixed dose. The antibody can be administered intravenously (IV) or subcutaneously (SC). Natalizumab is typically administered at a fixed unit dose of between SO-600 mg IV, e.g., every 4 weeks, or between 50-100 mg SC (e.g., 75 mg), e.g., once a week. It can also be administered in a bolus at a dose of between 1 and 10 mg/kg, e.g., about 6.0, 4.0, 3.0, 2.0, 1.0 mg/kg.
Modified dose ranges include a dose that is less than 600, 400, 300, 250, 200, or 150 mg/subject, typically for administration every fourth week or once a month.
The VLA-4 binding antibody can administered, for example, every three to five weeks, e.g., every fourth week, or monthly.
The dose can also be chosen to reduce or avoid production of antibodies against the VLA-4 binding antibody, to achieve greater than 40, 50, 70, 75, or 80%
saturation of the a4 subunit, to achieve to less than 80, 70, 60, 50, or 40% saturation of the a4 subunit, or to prevent an increase the level of circulating white blood cells Interferon beta-la can be administered, e.g., intramuscularly, in an amount of between 10 and 50 ~,g. For example, AVONEX~ can be administered every five to ten days, e.g., once a week, while Rebif~ can be administered three times a week.
The route and/or mode of administration of these and other agents can vary depending upon the desired results. For example, the doses of the VLA-4 binding antibody and the second agent (e.g., interferon beta) can be chosen such that the therapeutic effect is at least 10, 20, 25, 30, 40, 50, or 60% greater than that achieved with either agent alone (i.e., in the absence of the other). Such effects can be recognized by those skilled in the art, e.g., using standard parameters associated with multiple sclerosis, e.g., number of Gd+ lesions as detected by MRI, EDSS score, length of time without a relapse or exacerbation, and so forth.
In certain embodiments, the active agent may be prepared with a carrier that will protect the compound against rapid release, such as a controlled release formulation, including implants, and microencapsulated delivery systems. Biodegradable, biocompatible polymers can be used, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid. Many methods for the preparation of such formulations are patented or generally known. See, e.g., Sustained and Controlled Release Drug Delivery Systems, J.R. Robinson, ed., Marcel Dekker, Inc., New York, 1978.

Pharmaceutical compositions can be administered with medical devices. For example, pharmaceutical compositions can be administered with a needleless hypodermic injection device, such as the devices disclosed in US Pat. Nos. 5,399,163, 5,383,851, 5,312,335, 5,064,413, 4,941,880, 4,790,824, or 4,596,556. Examples of well-known implants and modules include: US Pat. No. 4,487,603, which discloses an implantable micro-infusion pump for dispensing medication at a controlled rate; US Pat.
No. 4.,486,194, which discloses a therapeutic device for administering medicants through the skin; US Pat. No. 4,447,233, which discloses a medication infusion pump for delivering medication at a precise infusion rate; US Pat. No. 4,447,224, which discloses a variable flow implantable infusion apparatus for continuous drug delivery; US
Pat.
No. 4,439,196, which discloses an osmotic drug delivery system having mufti-chamber compartments; and US Pat. No. 4,475,196, which discloses an osmotic drug delivery system. Of course, many other such implants, delivery systems, and modules are also known.
This disclosure also features a device for administering a first and second agent.
The device can include, e.g., one or more housings for storing pharmaceutical preparations, and can be configured to deliver unit doses of the first and second agent.
The first and second agents can be stored in the same or separate compartments. For example, the device can combine the agents prior to administration. It is also possible to use different devices to administer the first and second agent.
Dosage regimens are adjusted to provide the desired response, e.g., a therapeutic response or a combinatorial therapeutic effect. Generally, any combination of doses (either separate or co-formulated) of the VLA-4 binding agent and the second agent can be used in order to provide a subject with both agents in bioavailable quantities.
Dosage unit form or "fixed dose" as used herein refers to physically discrete units suited as unitary dosages for the subjects to be treated; each unit contains a predetermined quantity of active compound calculated to produce the desired therapeutic effect in association with the required pharmaceutical carrier and optionally in association with the other agent.
A pharmaceutical composition may include a "therapeutically effective amount"
of an agent described herein. Such effective amounts can be determined based on the combinatorial effect of the administered first and second agent. A
therapeutically effective amount of an agent may also vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the compound to elicit a desired response in the individual, e.g., amelioration of at least one disorder parameter, e.g.; a multiple sclerosis parameter, or amelioration of at least one symptom of the disorder, e.g., multiple sclerosis. A therapeutically effective amount is also one in which any toxic or detrimental effects of the composition is outweighed by the thexapeutically beneficial effects.
Antibody Generation Antibodies that bind to VLA-4 can be generated by immunization, e.g., using an animal, or by in vitro methods such as phage display. All or part of VLA-4 can be used as an immunogen. For example, the extracellular region of the a4 subunit can be used as an immunogen. In one embodiment, the immunized animal contains immunoglobulin producing cells with natural, human, or partially human immunoglobulin loci.
In one embodiment, the non-human animal includes at least a part of a human immunoglobulin gene. For example, it is possible to engineer mouse strains deficient in mouse antibody production with large fragments of the human Ig loci. Using the hybridoma technology, antigen-specific monoclonal antibodies derived from the genes with the desired specificity may be produced and selected. See, e.g., XenoMouseTM, Green et al.
Nature Genetics 7:13-21 (1994), US 2003-0070185, US Pat. No. 5,789,650, and WO
96/34096.
Non-human antibodies to VLA-4 can also be produced, e.g., in a rodent. The non-human antibody can be humanized, e.g., as described in US Pat. No.
6,602,503, EP
239 400, US Pat. No. 5,693,761, and US Pat. No. 6;407,213.
EP 239 400 (Winter et al.) describes altering antibodies by substitution (within a given variable xegion) of their complementarity determining regions (CDRs) for one species with those from another. CDR-substituted antibodies can be less likely to elicit an immune response in humans compared to true chimeric antibodies because the CDR-substituted antibodies contain considerably less non-human components.
(Riechmann et al., 1988, Nature 332, 323-327; Verhoeyen et al., 1988, Science 239, 1534-1536).
Typically, CDRs of a marine antibody substituted into the corresponding regions in a human antibody by using recombinant nucleic acid technology to produce sequences encoding the desired substituted antibody. Human constant region gene segments of the desired isotype (usually gamma I for CH and kappa for CL) can be added and the humanized heavy and light chain genes can be co-expressed in mammalian cells to produce soluble humanized antibody.
Queen et al., 1989 and WC) 90/07861 have described a process that includes choosing human V framework regions by computer analysis for optimal protein sequence homology to the V region framework of the original marine antibody, and modeling the tertiary structure of the marine V region to visualize framework amino acid residues that are likely to interact with the marine CDRs. These marine amino acid residues are then superimposed on the homologous human framework. See also US Pat. Nos.
5,693,762;
5,693,761; 5,585,089; and 5,530,101. Tempest et al., 1991, Biotechnology 9, 266-271, utilize, as standard, the V region frameworks derived from NEWM and REI heavy and light chains, respectively; for CDR-grafting without radical introduction of mouse residues. An advantage of using the Tempest et al. approach to construct NEWM
and REI based humanized antibodies is that the three dimensional structures of NEWM and REI variable regions are known from x-ray crystallography and thus specific interactions between CDRs and V region framework residues can be modeled.
Non-human antibodies can be modified to include substitutions that insert human immunoglobulin sequences, e.g., consensus human amino acid residues at particular positions, e.g., at one or more (preferably at Least five, ten, twelve, or all) of the following positions: (in the FR of the variable domain of the light chain) 4L, 35L, 36L, 38L, 43L, 44L, 58L, 46L, 62L, 63L, 64L, 65L, 66L, 67L, 68L, 69L, 70L, 71L, 73L, 85L, 87L, 98L, and/or (in the FR of the variable domain of the heavy chain) 2H, 4H, 24H, 36H, 37H, 39H, 43H, 45H, 49H, 58H, 60H, 67H, 68H, 69H, 70H, 73H, 74H, 7SH, 78H, 91H, 92H, 93H, and/or 103H (according to the Kabat numbering). See, e.g., US Pat. No.
6,407,213.
Fully human monoclonal antibodies that bind to VLA-4 can be produced, e.g., using in vitro-primed human splenocytes, as described by Boerner et al., 1991, J.
Immunol., 147, 86-95. They may be prepared by repertoire cloning as described by Persson et al., 1991, Proc. Nat. Acad. Sci. USA, 88: 2432-2436 or by Huang and Stollar, 1991, J. Immunol. Methods 141, 227-236; also US Pat. No. 5,798,230. Large nonimmunized human phage display libraries may also be used to isolate high affinity antibodies that can be developed as human therapeutics using standard phage technology (see, e.g., Vaughan et al, 1996; Hoogenboom et al. (1998) Immunotechnology 4:1-20; and Hoogenboom et al. (2000) Immunol Today 2:371-8; US 2003-0232333).
Antibody Production Antibodies can be produced in prokaryotic and eukaryotic cells. In one embodiment, the antibodies (e.g., scFv's) are expressed in a yeast cell such as Pichia (see, e.g., Powers et al. (2001) Jlmmunol Methods. 251:123-35), Hanseula, or Saccharomyces.
In one embodiment, antibodies, particularly full length antibodies, e.g., IgG's, are produced in mammalian cells. Exemplary mammalian host cells for recombinant expression include Chinese Hamster Ovary (CHO cells) (including dhfr- CHO
cells, described in Urlaub and Chasin ( 1980) Proc. Natl. Acad. Sci. USA 77:4216-4220, used with a DHFR selectable marker, e.g., as described in Kaufman and Sharp (1982) Mol.
Biol. 159:601-621), lymphocytic cell lines, e.g., NSO myeloma cells and SP2 cells, COS
cells, K562, and a cell from a transgenic animal, e.g., a transgenic mammal.
For example, the cell is a mammary epithelial cell.
In addition to the nucleic acid sequence encoding the immunoglobulin domain, the recombinant expression vectors may carry additional nucleic acid sequences, such as sequences that regulate replication of the vector in host cells (e.g., origins of replication) and selectable marker genes. The selectable marker gene facilitates selection of host cells into which the vector has been introduced (see e.g., US Pat. Nos. 4,399,216, 4,634,665 and 5,179,017). Exemplary selectable marker genes include the dihydrofolate reductase (DHFR) gene (for use in dhf~- host cells with methotrexate selection/amplification) and the neo gene (for 6418 selection).
In an exemplary system for recombinant expression of an antibody (e.g., a full length antibody or an antigen-binding portion thereofj, a recombinant expression vector encoding both the antibody heavy chain and the antibody light chain is introduced into dhfr- CHO cells by calcium phosphate-mediated transfection. Within the recombinant expression vector, the antibody heavy and light chain genes are each operatively linked to enhancer/promoter regulatory elements (e.g., derived from SV40, CMV, adenovirus and the like, such as a CMV enhancer/AdMLP promoter regulatory element or an SV40 enhancer/AdMLP promoter regulatory element) to drive high levels of transcription of the genes. The recombinant expression vector also carries a DHFR gene, which allows for selection of CHO cells that have been transfected with the vector using methotrexate selection/amplification. The selected transformant host cells are cultured to allow for expression of the antibody heavy and light chains and intact antibody is recovered from the culture medium. Standard molecular biology techniques are used to prepare the recombinant expression vector, to transfect the host cells, to select for transformants, to culture the host cells, and to recover the antibody from the culture medium.
For example, some antibodies can be isolated by affinity chromatography with a Protein A or Protein G.
Antibodies may also include modifications, e.g., modifications that alter Fc function, e.g., to decrease or remove interaction with an Fc receptor or with Clq, or both.
For example, the human IgG 1 constant region can be mutated at one or more residues, e.g., one or more of residues 234 and 237, e.g., according to the numbering in US Pat.
No. 5,648,260. Other exemplary modifications include those described in US
Pat.
No. 5,648,260.
For some antibodies that include an Fe domain, the antibody production system may be designed to synthesize antibodies in which the Fc region is glycosylated. For example, the Fe domain of IgG molecules is glycosylated at asparagine 297 in the CH2 domain. This asparagine is the site for modification with biantennary-type oligosaccharides. This glycosylation participates in effector functions mediated by Fc~y receptors and complement C 1 q (Burton and Woof ( 1992) Adv Immuhol. 51:1-84;
Jefferis et al. (1998) Immunol. Rev 163:59-76). The Fc domain can be produced in a mammalian expression system that appropriately glycosylates the residue corresponding to asparagine 297. The Fc domain can also include other eukaryotic post-translational modifications.
Antibodies can also be produced by a transgenic animal. For example, US Pat.
No. 5,849,992 describes a method for expressing an antibody in the mammary gland of a transgenic mammal. A transgene is constructed that includes a milk-specific promoter and nucleic acid sequences encoding the antibody of interest, e.g., an antibody described herein, and a signal sequence for secretion. The milk produced by females of such transgenic mammals includes; secreted-therein, the antibody of interest, e.g., an antibody described herein. The antibody can be purified from the milk, or far some applications, used directly.
Antibodies can be modified, e.g., with a moiety that improves its stabilization and/or retention in circulation, e.g., in blood, serum, lymph, bronchoalveolar lavage, or other tissues, e.g., by at least 1.5, 2, 5, 10, or 50 fold.
For example, a VLA-4 binding antibody can be associated with a polymer, e.g., a substantially non-antigenic polymer, such as a polyalkylene oxide or a polyethylene oxide. Suitable polymers will vary substantially by weight. Polymers having molecular number average weights ranging from about 200 to about 35,000 daltons (or about 1,000 to about 15,000, and 2,000 to about 12,500) can be used.
For example, a VLA-4 binding antibody can be conjugated to a water soluble polymer, e.g., a hydrophilic polyvinyl polymer, e.g. polyvinylalcohol or polyvinylpyrrolidone. A non-limiting list of such polymers include polyalkylene oxide homopolymers such as polyethylene glycol (PEG) or polypropylene glycols, polyoxyethylenated polyols, copolymers thereof and block copolymers thereof, provided that the water solubility of the block copolymers is maintained. Additional useful polymers include polyoxyalkylenes such as polyoxyethylene, polyoxypropylene, and block copolymers of polyoxyethylene and polyoxypropylene (Pluronics);
polymethacrylates; carbomers; branched or unbranched polysaccharides that comprise the saccharide monomers D-mannose, D- and L-galactose, fucose, fructose, D-xylose, L-arabinose, D-glucuronic acid, sialic acid, D-galacturonic acid, D-mannuronic acid (e.g.
polymannuronic acid, or alginic acid), D-glucosamine, D-galactosamine, D-glucose and neuraminic acid including homopolysaccharides and heteropolysacchaxides such as lactose, amylopectin, starch, hydroxyethyl starch, amylose, dextrane sulfate, dextran, dextrins, glycogen, or the polysaccharide subunit of acid mucopolysaccharides, e.g.
hyaluronic acid; polymers of sugar alcohols such as polysorbitol and polymannitol;
heparin or heparon.

Multiple Sclerosis Multiple sclerosis (MS) is a central nervous system disease that is characterized by inflammation and loss of myelin sheaths.
Patients having MS may be identified by criteria establishing a diagnosis of clinically definite MS as defined by the workshop on the diagnosis of MS
(Poser et al., Ann. Neurol. 13:227, 1983). Briefly, an individual with clinically definite MS
has had two attacks and clinical evidence of either two lesions or clinical evidence of one lesion and paraclinical evidence of another, separate lesion. Definite MS may also be diagnosed by evidence of two attacks and oligoclonal bands of IgG in cerebrospinal fluid or by combination of an attack, clinical evidence of two lesions and oligoclonal band of IgG in cerebrospinal fluid. The McDonald criteria can also be used to diagnose MS.
(McDonald et al., 2001, Recommended diagnostic criteria for multiple sclerosis:
guidelines from the International Panel oh the Diagnosis of Multiple Sclerosis, Ann Neurol 50:121-127). The McDonald criteria include the use of MRI evidence of CNS
impairment over time to be used in diagnosis of MS, in the absence of multiple clinical attacks. Effective treatment of multiple sclerosis may be evaluated in several different ways. The following parameters can be used to gauge effectiveness of treatment. Two exemplary criteria include: EDSS (extended disability status scale), and appearance of exacerbations on MRI (magnetic resonance imaging). The EDSS is a means to grade clinical impairment due to MS (Kurtzke, Neurology 33:1444, 1983). Eight functional systems are evaluated for the type and severity of neurologic impairment.
Briefly, prior to treatment, patients are evaluated for impairment in the following systems:
pyramidal, cerebella, brainstem, sensory, bowel and bladder, visual, cerebral, and other.
Follow-ups are conducted at defined intervals. The scale ranges from 0 (normal) to 10 (death due to MS). A decrease of one full step indicates an effective treatment (Kurtzke, Ann. Neurol.
36:573-79, 1994).
Exacerbations are defined as the appearance of a new symptom that is attributable to MS and accompanied by an appropriate new neurologic abnormality (IFNB MS
Study Group, supra). In addition, the exacerbation must last at least 24 hours and be preceded by stability or improvement for at least 30 days. Briefly, patients are given a standard neurological examination by clinicians. Exacerbations are either mild, moderate, or severe according to changes in a Neurological Rating Scale (Sipe et al., Neurology 34:1368, 1984). An annual exacerbation rate and proportion of exacerbation-free patients are determined.
Therapy can be deemed to be effective if there is a statistically significant difference in the rate or proportion of exacerbation-free or relapse-free patients between the treated group and the placebo group for either of these measurements. In addition, time to first exacerbation and exacerbation duration and severity may also be measured.
A measure of effectiveness as therapy in this regard is a statistically significant difference in the time to first exacerbation or duration and severity in the treated group compared to control group. An exacerbation-free or relapse-free period of greater than one year, 18 months, or 20 months is particularly noteworthy.
Efficacy of administering a first and second agent can also be evaluated based on one or more of the following criteria: frequency of MBP reactive T cells determined by limiting dilution, proliferation response of MBP reactive T cell lines and clones, cytokine profiles of T cell lines and clones to MBP established from patients. Efficacy is indicated by decrease in frequency of reactive cells, a reduction in thymidine incorporation with altered peptide compared to native, and a reduction in TNF and IFN-a,.
Clinical measurements include the relapse rate in one and two-year intervals, and a change in EDSS, including time to progression from baseline of 1.0 unit on the EDSS
that persists for six months. On a Kaplan-Meier curve, a delay in sustained progression of disability shows efficacy. Other criteria include a change in area and volume of T2 images on MRI, and the number and volume of lesions determined by gadolinium enhanced images.
MRI can be used to measure active lesions using gadolinium-DTPA-enhanced imaging (McDonald et al. Ann. Neurol. 36:14, 1994) or the location and extent of lesions using T2 -weighted techniques. Briefly, baseline MRIs are obtained.
The same imaging plane and patient position are used for each subsequent study.
Positioning and imaging sequences can be chosen to maximize lesion detection and facilitate lesion tracing. The same positioning and imaging sequences can be used on subsequent studies.
The presence, location and extent of MS lesions can be determined by radiologists.
Areas of lesions can be outlined and summed slice by slice fox total lesion area. Three __ _.___ _ ....~ ._ . .~..__... wy_ .~.~~~.".~~:~~.,A"ax..,. ~~~.. ~.,~._...
... _ _ __ . , _ _.

analyses may be done: evidence of new lesions, rate of appearance of active lesions, percentage change in lesion area (Paty et al., Neurology 43:665, 1993).
Improvement due to therapy can be established by a statistically significant improvement in an individual patient compared to baseline or in a treated group versus a placebo group.
Exemplary symptoms associated with multiple sclerosis, which can be treated with the methods described herein, include: optic neuritis, diplopia, nystagmus, ocular dysmetria, internuclear ophthalmoplegia, movement and sound phosphenes, afferent pupillary defect, paresis, monoparesis, paraparesis, hemiparesis, quadraparesis, plegia, paraplegia, hemiplegia, tetraplegia, quadraplegia, spasticity, dysarthria, muscle atrophy, spasms, cramps, hypotonia, clonus, myoclonus, myokymia, restless leg syndrome, footdrop, dysfunctional reflexes, paraesthesia, anaesthesia, neuralgia, neuropathic and neurogenic pain, fhermitte's, proprioceptive dysfunction, trigeminal neuralgia, ataxia, intention tremor, dysmetria, vestibular ataxia, vertigo, speech ataxia, dystonia, dysdiadochokinesia, frequent micturation, bladder spasticity, flaccid bladder, detrusor-sphincter dyssynergia, erectile dysfunction, anorgasmy, frigidity, constipation, fecal urgency, fecal incontinence, depression, cognitive dysfunction, dementia, mood swings, emotional lability, euphoria, bipolar syndrome, anxiety, aphasia, dysphasia, fatigue, uhthoff s symptom, gastroesophageal reflux, and sleeping disorders.
Each case of MS displays one of several patterns of presentation and subsequent course. Most commonly, MS first manifests itself as a series of attacks followed by complete or partial remissions as symptoms mysteriously lessen, only to return later after a period of stability. This is called relapsing-remitting (RR) MS. Primary-progressive (PP) MS is characterized by a gradual clinical decline with no distinct remissions, although there may be temporary plateaus or minor relief from symptoms.
Secondary-progressive (SP) MS begins with a relapsing-remitting course followed by a later primary-progressive course. Rarely, patients may have a progressive-relapsing (PR) course in which the disease takes a progressive path punctuated by acute attacks. PP, SP, and PR are sometimes lumped together and called chronic progressive MS.
A few patients experience malignant MS, defined as a swift and relentless decline resulting in significant disability or even death shortly after disease onset.
This decline may be arrested or decelerated by administration of a combination therapy described herein.
In addition to or prior to human studies, an animal model can be used to evaluate the efficacy of using the two agents. An exemplary animal model for multiple sclerosis is the experimental autoimmune encephalitis (EAE) mouse model, e.g., as described in (Tuohy et al. (J. Immunol. (I988) I41: I 126-I I30), Sobel et al. (J. Immunol.
(1984) 132:
2393-2401), and Traugott (Cell Immunol: (1989) 119: 114-129). Mice can be administered a first and second agent described herein prior to EAE induction.
Then the mice are evaluated for characteristic criteria to determine the efficacy of using the two agents in the model.
Other Disorders The methods described herein can also be used to treat other inflammatory, immune, or autoimmune disorders, e.g., inflammation of the central nervous system (e.g., in addition to multiple sclerosis, meningitis, neuromyelitis optica, neurosarcoidosis, CNS
vasculitis, encephalitis, and transverse myelitis), tissue or organ graft rejection or graft-versus-host disease, acute CNS injury, e.g., stroke or spinal cord injury;
chronic renal disease; allergy, e.g., allergic asthma; type 1 diabetes; inflammatory bowel disorders, e.g., Crohn's disease, ulcerative colitis; myasthenia gravis; fibxomyalgia;
arthritic disorders, e.g., rheumatoid arthritis, psoriatic arthritis;
inflammatorylimmune skin disorders, e.g., psoriasis, vitiligo, dermatitis, lichen planus; systemic lupus erythematosus; Sjogren's Syndrome; hematological cancers, e.g., multiple myelorna, leukemia, lymphoma; solid cancers, e.g., sarcomas or carcinomas, e.g., of the lung, breast, prostate, brain; and fibrotic disorders, e.g., pulmonary fibrosis, myelofibrosis, liver cirrhosis, mesangial proliferative glomerulonephritis, crescentic glomerulonephritis, diabetic nephropathy, and renal interstitial fibrosis.
For example, a combination therapy that includes a VLA-4 binding agent (e.g., a VLA-4 binding antibody, e.g., natalizumab) and a second agent (e.g., interferon beta or other second agent described herein) can be administered to treat these and other inflammatory, immune, or autoimmune disorders.

Kits A VLA-4 binding agent (e.g., natalizumab) and a second agent (e.g., interferon beta-la) can be provided in a kit. In one embodiment, the kit includes (a) a container that contains a composition that includes both VLA-4 binding agent (e.g., natalizumab) and the second agent (e.g., interferon beta-la), and, optionally (b) informational material. In an embodiment, the kit includes (a) a first container that contains a composition that includes the VLA-4 binding agent, (b) a second container that includes the second agent, and, optionally (c) informational material. The informational material can be descriptive, instructional, marketing or other material that relates to the methods described herein andlor the use of the agents for therapeutic benefit.
The informational material of the kits is not limited in its form. In one embodiment, the informational material can include information about production of the compound, molecular weight of the compound, concentration, date of expiration, batch or production site information, and so forth. In one embodiment, the informational material relates to methods of administering the VLA-4 binding and second agent, e.g., in a suitable dose, dosage form, or mode of administration (e.g., a dose, dosage form, or mode of administration described herein). The method can be a method of treating multiple sclerosis.
The informational material of the kits is not limited in its form. In many cases, the informational material, e.g., instructions, is provided in printed matter, e.g., a printed text, drawing, and/or photograph, e.g., a label or printed sheet. However, the informational material can also be provided in other formats, such as Braille, computer readable material, video recording, or audio recording. In another embodiment, the informational material of the kit is contact information, e.g., a physical address, email address, website, or telephone number, where a user of the kit can obtain substantive information about agents therein and/or its use in the methods described herein. Of course, the informational material can also be provided in any combination of formats.
In addition to the VLA-4 binding agent and the second agent, the composition of the kit can include other ingredients, such as a solvent or buffer, a stabilizer, or a preservative. The kit may also include other agents, e.g., a third or fourth agent, e.g., other therapeutic agents.

The agents can be provided in any form, e.g., liquid, dried or lyophilized form. It is preferred that the agents are substantially pure (although they can be combined together or delivered separate from one another) and/or sterile. When the agents are provided in a liquid solution, the liquid solution preferably is an aqueous solution, with a sterile aqueous solution being preferred. When the agents are provided as a dried form, reconstitution generally is by the addition of a suitable solvent. The solvent, e.g., sterile water or buffer, can optionally be provided in the kit.
The kit can include one or more containers for the composition or compositions containing the agents. In some embodiments, the kit contains separate containers, dividers or compartments for the composition and informational material. For example, the composition can be contained in a bottle, vial, or syringe, and the informational material can be contained in a plastic sleeve or packet. In other embodiments, the separate elements of the kit are contained within a single, undivided container. For example, the composition is contained in a bottle, vial or syringe that has attached thereto the informational material in the form of a label. In some embodiments, the kit includes a plurality (e.g., a pack) of individual containers, each containing one or more unit dosage forms (e.g., a dosage form described herein) of the agents. The containers can include a combination unit dosage, e.g., a unit that includes both the VLA-4 binding agent and the second agent, e.g., in a desired ratio. For example, the kit includes a plurality of syringes, ampules, foil packets, blister packs, or medical devices, e.g., each containing a single combination unit dose. The containers of the kits can be air tight, waterproof (e.g., impermeable to changes in moisture or evaporation), and/or light-tight.
The kit optionally includes a device suitable for administration of the composition, e.g., a syringe or other suitable delivery device. The device can be provided pre-loaded with one or both of the agents or can be empty, but suitable for loading.
All references and publications included herein are incorporated herein by reference. The following example is not intended to be limiting.
EXAMPLES
Example 1: Combination of ANTEGREN and AVONEX~

10274-087P01 / POb08 US001 Disease-modifying agents have been shown to reduce disease activity and clinical progression of MS. However, many patients experience breakthrough relapses while on therapy.
ANTEGREN~ (natalizumab) has demonstrated efficacy in reducing new gadolinium enhancing (Gd+) lesions and clinical relapses in patients with multiple sclerosis (MS). The SENTINEL study was conducted using a patient population experiencing breakthrough relapses while on AVONEX~ therapy. SENTINEL is designed to determine the efficacy and safety of natalizumab when added to the standard regimen of AVONEX~ in patients with relapsing-remitting MS (RRMS). SENTINEL is an ongoing, phase III, multicenter, randomized, placebo-controlled trial that has enrolled 1196 patients with RRMS treated with AVONEX~ for greater or equal to 12 months prior to randomization. Patients were randomized to either monthly intravenous (IV) infusions of 300 mg ~of nata.lizumab in addition to their weekly regimen of 30 pg AVONEX~ intramuscularly (IM), or placebo plus their weekly regimen of AVONEXC~.
The planned treatment duration is 116 weeks. Primary outcomes include reduction in the clinical relapse rate and slowing of disability progression. Disease progression is defined as an increase of >_I.0 point in the Expanded Disability Status Scale (EDSS) score in patients with a baseline EDSS score of >1.0 (or a >1.5-point increase in patients with a baseline EDSS score of 0) sustained for 12 weeks.
RESULTS: Baseline data are unique because they provide characteristics of patients with RRMS who experience breakthrough relapses during interferon beta (IFN(3) therapy. Patient demographics and baseline clinical characteristics are presented below.
Patients on combination therapy including administration of AVONEX~ and natalizumab have been found to have an effective combinatorial therapeutic response at the one year time point.
CONCLUSIONS: This ongoing, randomized, placebo-controlled trial is designed to evaluate the efficacy and safety of the combination of natalizumab and AVONEX~ in the treatment of patients with RRMS. Baseline patient characteristics are descriptive of the clinical status of patients with MS who experience breakthrough relapse on IFN(3-1 a therapy.

INCLUSION AND EXCLUSION CRITERIA. For inclusion in the study: (i) Patients must have had at least one relapse of sufficient severity and duration deemed by the study investigator to be consistent with a MS relapse; (ii) The relapse must have occurred within 12 months of randomization while the patient was being treated with IFN(3-la; (iii) The patient must have been receiving IFN[3-la therapy for at least 2 months prior to the relapse. Additional inclusion criteria and exclusion criteria are as follows:
Inclusion criteYia ~ MS diagnosis (McDonald criteria, types 1-4) ~ Men and women 18 to 55 years of age, inclusive ~ Treatment with IFN(3-la for 12 months prior to randomization ~ Baseline EDSS score of 0-5, inclusive (EDSS scores can range from 0 to 10, with higher scores indicating more severe disease.) ~ Brain MRI demonstrating lesions consistent with MS
~ Written informed consent Exclusion criteria ~ Any MS diagnosis other than the relapsing-remitting type ~ Relapses within 50 days of randomization, or lack of stabilization from any previous relapse ~ Clinically significant infection ~ Significant major disease other than MS
~ Abnormal laboratory blood test results ~ History of severe allergy or hypersensitivity ~ Inability to perform the MSFC
Abbreviations: MS = multiple sclerosis; IFN = interferon; EDSS = Expanded Disability Status Scale; MRI = magnetic resonance imaging; MSFC = Multiple Sclerosis Functional Composite Scale consisting of the Timed 25-Foot Walk, 9-Hole Peg Test, and 3-Second Paced Auditory Serial Addition Test.

STUDY DESIGN. This study is an ongoing multicenter, randomized, double-blind, placebo-controlled, parallel-group, phase III clinical trial. Patients were randomized 1:1 to treatment with: (i) Natalizumab 300-mg IV infusion every four weeks in addition to a weekly IFN(3-la 30-~,g IM injection, or (ii) Placebo IV
infusion every four weeks in addition to a weekly IFN (3-la 30-~g IM injection. Planned treatment duration is I 16 weeks (over 2 years).
KEY STUDY ENDPOINTS. Primary endpoints are: reduction in the clinical relapse rate after a mean of 1 year of treatment; slowing of disability progression, as measured by EDSS after 2 years of treatment. Additional endpoints are:
reduction in the clinical relapse rate after 2 years of treatment; increasing the proportion of relapse-free patients; slowing of disability progression, as measured by the change in MSFC
scores from baseline; reduction in number and volume of new or newly enlarging T2 hyperintense lesions on brain MRI; reduction in number and volume of TI
hypointense lesions; and reduction in number and volume of Gd+ lesions on brain MRI.
BASELINE PATIENT DEMOGRAPHICS. 1196 patients were randomized.
Most patients were female (74%), white (93%), and between 30 and 49 years of age (80%). Patient baseline demographics are summarized in Table 1. Age demographics are summarized in Figure 1 (mean, 38.9 ~ 7.66 years) and Table 2.
Table 1: Summary of Patient Baseline Demographics Patients Characteristic n = 1168 ____________.._________________ _________________________________________________ Gender, ~t (%) Female 859 (74) __Male ________________________________________ 30~_~2~_)__________ Race, n (%) White 1091 (94) Black 39 (3) Hispanic 21 (2) Asian 6 (<1) Other 1 I (< 1 ) Table 2: Age Distribution Age (years) Patients (%) 18-19 0.90%

20-29 12%

30-39 39%

50-59 8%

BASELINE EDSS SCORES. Most patients (76%) had an EDSS score of from 1.5 to 3.5 at baseline (median, 2; range, 1-6) (Figure 2). Data for Figure 2 (n = 1166) is summarized in Table 3. This level of disability is also similar to the populations of previous MS treatment studies. Comparison of this baseline data with the untreated population from the AFFIRM study of natalizumab fox the treatment of MS
demonstrates a similar distribution of EDSS scores and median EDSS (2.0) despite a longer disease duration and older age.
Table 3 EDSS scorePatients (%) 0 4%

1 7%

1.5 18%

2 22%

2.5 14%

3 12%

3.5 10%

4 8%

4.5 4%

2%

> 5 I%

MS HISTORY AND RELAPSE RATE. The median time since the first MS
symptoms appeared was seven years; the median time to diagnosis was four years (Table 4). When compared with the untreated population from the AFFIRM study of natalizumab for the treatment of MS, patients with breakthrough relapses had a longer median time since the first MS symptoms appeared (seven years for patients with breakthrough relapses; five years for untreated patients) and a longer median time since diagnosis (four years for patients with breakthrough relapses; two yeaxs for untreated patients). Disease activity at prestudy entry was similar between studies.
Over the 3 years prior to study entry, 27% of patients had 2 relapses, 27% had relapses, and 34% had >_4 relapses (Table 4). In the twelve months prior to study entry, the majority of patients (64%) had one relapse, and the median number of relapses was one (xange, 0-7; FIG. 3). Data from FIG. 3 is also presented in Table 5.

Table 4: Multiple Sclerosis History (n =1164) Patients Histor~n = 1166 Time since first symptoms (y) Median 7 _Ran~e_~___~_________~____________________1 X34 ___________________ Time since diagnosis (y) Median 4 .__Range____________________________________________.________________~-3~
___________________ Number of relapses withinn (%) last 3 y 1 140(12) 2 3 I 7(27) 3 316(27) >_4 391(34) Median 3 Ran a 1-16 Table 5: Distribution by Relapse Incidence Number of Rela ses in revious 12 months Patients (%) 1 relapse 64%
2 relapses 28%
3 relapses 6%
2%
>4 relapses CONCLUSIONS. Baseline data indicate that we have identified an active MS
population with a similar disability level to that seen in prior MS studies and the AFFIRM study. A comparison with the AFFIRM study of natalizumab in patients with MS indicates a similar level of disability, despite a longer disease duration and higher mean age. The population identified by the SENTINEL study should prove valuable in defining the characteristics of patients with RRMS experiencing breakthrough relapses on IFN(3-la treatment.
The study has shown that combination of natalizumab and interferon beta-1 a is an improved and effective therapy for MS.
Other embodiments are within the scope of the following claims.

Claims (57)

1. A method of treating multiple sclerosis, the method comprising, administering, to a subject that has multiple sclerosis, a VLA-4 binding antibody in combination with a recombinant interferon, each in an amount and for a time to provide an overall therapeutic effect.

2. The method of claim 1, wherein the subject has previously received a VLA-4 binding antibody or an interferon since being diagnosed with multiple sclerosis.

3. The method of claim 2, wherein the subject has previously received a VLA-4 binding antibody therapy, in the absence of interferon therapy, since being diagnosed with multiple sclerosis.

4. The method of claim 2, wherein the subject has previously received interferon therapy, in the absence of VLA-4 binding antibody therapy, since being diagnosed with multiple sclerosis.

5. The method of claim 1, wherein the subject has not previously received a recombinant interferon therapy since being diagnosed with multiple sclerosis.

6. The method of claim 1, wherein the subject has not previously received a recombinant interferon therapy nor a VLA-4 binding antibody therapy since being diagnosed with multiple sclerosis.

7. The method of claim 1, wherein the subject receives multiple doses of the VLA-4 binding antibody.

8. The method of claim 1, further comprising monitoring the subject for an improvement in EDSS score.

9. The method of claim 1, wherein the subject is not examined for interferon bioavailability after administering the VLA-4 binding antibody and the recombinant interferon.

10. The method of claim 1, wherein the recombinant interferon is administered at a dosage that is about the same as would be administered in interferon monotherapy.

11. The method of claim 1, wherein at least two doses of the VLA-4 binding antibody are administered.

12. The method of claim 1, wherein the VLA-4 binding antibody is administered at a dosage that is about the same as would be administered in VLA-4 antibody monotherapy.

13. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are provided as a co-formulation, and the step of administering comprises administering the co-formulation.

14. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are provided as separate formulations, and the step of administering comprises sequentially administering the VLA-4 binding antibody and the interferon.

15. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered as regimens, and the regimen for the VLA-4 binding antibody has a different periodicity from the regimen for the interferon.

16. The method of claim 1, wherein the VLA-4 binding antibody inhibits VLA-4 interaction with VCAM-1.

17. The method of claim 1, wherein VLA-4 binding antibody binds at least the .alpha.
chain of VLA-4.

18. The method of claim 1, wherein the VLA-4 binding antibody comprises natalizumab.

19. The method of claim 1, wherein the VLA-4 binding antibody competes with HP1/2 or natalizumab for binding to VLA-4.

20. The method of claim 1, wherein the VLA-4 binding antibody is human or humanized.

21. The method of claim 1, wherein no biologic, other than the VLA-4 binding antibody and the interferon, is administered to the subject.

22. The method of claim 1, further comprising administering a third therapeutic agent.

23. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to provide symptom relief during an acute relapse.

24. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to prevent or delay a relapse.

25. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to prevent or retard disease progression.

26. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to prevent an increase in EDSS score of greater than 1 point.

27. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to prevent the appearance or reduce the rate of appearance of new Gd+ lesions.

28. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in multiple doses and in amounts that together are effective to maintain an exacerabation or relapse free period for at least six months.

29. The method of claim 1, wherein the VLA-4 binding antibody and the interferon are administered in amounts that together are effective to reduce relapse frequency.

30. The method of claim 1, wherein the subject is greater than 16 years of age.

31. The method of claim 1, wherein the subject has relapsed remitting multiple sclerosis.

32. The method of claim 1, wherein the subject has chronic progressive multiple sclerosis.

33. The method of claim 32, wherein the subject has primary-progressive (PP) multiple sclerosis.

34. The method of claim 32, wherein the subject has secondary progressive multiple sclerosis.

35. The method of claim 32, wherein the subject has progressive relapsing multiple sclerosis.

36. The method of claim 4, wherein, prior to administering the VLA-4 binding antibody and the interferon as a combination therapy, the subject had at least one breakthrough while on interferon beta therapy in the absence of a VLA-4 binding antibody therapy.

37. The method of claim 1, wherein the subject has not been previously administered the interferon.

38. The method of claim 4, wherein the subject received the plurality of doses of the interferon for no longer than 11.9, eleven, or ten months prior to also receiving the VLA-4 binding antibody.

39. The method of claim 38, wherein the subject is administered about the same dose of the interferon after receiving the VLA-4 binding antibody as prior to receiving the VLA-4 binding antibody.

40. The method of claim 38, wherein the subject is administered a reduced dose of the interferon after receiving the VLA-4 binding antibody.

41. The method of claim 1, wherein the subject is administered the VLA-4 binding antibody and the interferon in at least two separate or combined doses for greater than 14 weeks.

42. The method of claim 1, wherein the subject is administered a plurality of doses of the VLA-4 binding antibody, each dose being between 200-400 mg.

43. The method of claim 1, wherein the subject is administered a plurality of doses of the VLA-4 binding antibody, each dose being about 300 mg.

44. The method of claim 1, wherein the interferon is administered intramuscularly in an amount of between 10-50 µg every five to ten days.

45. A method comprising:
providing a therapeutic regimen comprising doses of a first agent, but not a second agent, to a subject;
evaluating responsiveness of the subject to the therapeutic regimen; and if a deficiency in responsiveness is detected, providing a second agent to the subject, in addition to the first agent, wherein one of the first and second agent is a VLA-4 binding antibody, and the other is a recombinant interferon.

46. The method of claim 45, wherein the first agent is the VLA-4 binding antibody and the second agent is an interferon.

47. The method of claim 45, wherein the second agent is the VLA-4 binding antibody and the first agent is an interferon.

48. The method of claim 45, wherein evaluating responsiveness of a subject comprises detecting a relapse for multiple sclerosis

49. The method of claim 45, wherein evaluating responsiveness of a subject comprises evaluating the subject for Gd+ lesions or an EDSS score.

50. A method of treating multiple sclerosis, the method comprising, administering, to a subject, a VLA-4 binding antibody and glatiramer acetate, each in an amount and for a time to jointly provide a therapeutic effect.

51. The method of claim 50, wherein the subject does not respond to glatiramer acetate in the absence of a VLA-4 binding antibody.

52. The method of claim 50, wherein the subject does not respond to the VLA-4 binding antibody in the absence of glatiramer acetate.

53. The method of claim 50, wherein the VLA-4 binding antibody comprises natalizumab.

54. The method of claim 1, wherein the interferon is interferon beta 1a.

55. The method of claim 54, wherein the interferon beta 1a is selected from the group consisting of AVONEX® (interferon beta 1a) and Rebif®
(interferon beta 1a).

56. The method of claim 1, wherein the interferon is interferon beta-1b.

57. The method of claim 54, wherein the interferon beta-1b is Betaseron®
(interferon beta-1b).