CA3202097A1 - Cobitolimod dosage for self-administration - Google Patents

Abstract

The present invention provides an oligonucleotide comprising the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2) for use in the treatment of inflammatory bowel disease in a human subject, wherein individual doses of from 400mg to 600mg of said oligonucleotide are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart.

Description

COBITOLIMOD DOSAGE FOR SELF-ADMINISTRATION
Field of the Invention The present invention relates to new therapies for treating inflammatory bowel diseases, for instance active ulcerative colitis (UC), wherein an oligonucleotide, especially cobitolimod, is administered according to an optimised dosage regime.
Background of the Invention Ulcerative colitis (UC) is a disease characterized by chronic inflammation of the rectal and colonic mucosa, affecting the innermost lining in the first stage. The disease is recurrent, with both active and inactive stages that differ in pathology, symptoms and treatment. The underlying cause of UC is not understood, nor is it known what triggers the disease to recur between its inactive and active forms (Irvine, E. J. (2008) Inflamm Bowel Dis 14(4):
554-565). Symptoms of active UC include progressive loose stools with blood and increased frequency of bowel movements. Active mucosal inflammation is diagnosed by endoscopy.
The stools contain pus, mucous and blood and are often associated with abdominal cramping with urgency to evacuate (tenesmi). Diarrhoea may have an insidious onset or, more rarely, start quite suddenly. In severe cases the symptoms may include fever and general malaise. In severe stages, deep inflammation of the bowel wall may develop with abdominal tenderness, tachycardia, fever and risk of bowel perforation.
Furthermore, patients with UC may suffer extra intestinal manifestations such as arthralgia and arthritis, erythema nodosum, pyoderma gangrenosum and inflammation in the eyes. In the case of remission or inactive UC, patients are usually free of bowel symptoms.
The extent of inflamed and damaged mucosa differs among patients with UC. UC
that affects only the rectum is termed ulcerative proctitis. The condition is referred to as distal or left sided colitis when inflammatory changes are present in the left side of the colon up to the splenic flexure. In extensive UC the transverse colon is also affected, and pancolitis designates a disease involving the entire colon.
Active mucosal inflammation is diagnosed by endoscopy and is characterized by a loss of vascular patterning, oedema, petechia, spontaneous bleeding and fibrinous exudates. The endoscopic picture is that of continuous inflammation, starting in the rectum and extending proximally to a variable extent into the colon. Biopsies obtained at endoscopy and subjected to histological examination help to diagnose the condition.
Infectious causes, including clostridium difficile, camphylobacter, Salmonella and Shigella, may mimic UC
and can be excluded by stool cultures.
The medical management of UC is divided into treatment of active disease and maintenance of remission.
The treatment of patients with active UC aims to reduce inflammation and promote colon healing and mucosal recovery. In milder cases the disease may be controlled with conventional drugs including sulphasalazine, 5-aminosalicylic acid (5-ASA) (Sutherland, L., F. Martin, S. Greer, M. Robinson, N. Greenberger, F. Saibil, T. Martin, J.
Sparr, E.
Prokipchuk and L. Borgn (1987) Gastroenterology 92: 1894-1898) and glucocorticosteroids (GCS) (Domenech, E., M. Manosa and E. Cabre (2014). Dig Dis 32(4): 320-327).
GCS are generally used to treat disease flare-ups and are not recommended for maintenance of remission since there are significant side effects in long-term use, and the possible development of steroid dependent disease. Glucocorticoid drugs act non-selectively, so in the long run they may impair many healthy anabolic processes. As a result, maintenance treatment with systemic GCS is not advised (Prantera, C.
and S.
Marconi (2013) Therap Adv Gastroenterol 6(2): 137-156).
For patients who become refractory to GCS and suffer from severe or moderately severe attacks of UC, the addition of immunomodulatory agents such as cyclosporine, 6-mercaptopurine and azathioprine may be used. However, immunomodulators are slow-

2 acting and the induction of remission in these patients is often temporary (Khan, K. J., M.
C. Dubinsky, A. C. Ford, T. A. Ullman, N. J. Talley and P. Moayyedi (2011) Am J
Gastroenterol 106(4): 630-642).
Further treatment options for UC include biologic agents (Fausel, R. and A.
Afzali (2015) Ther Clin Risk Manag 11: 63-73). The three TNF-a inhibitors currently approved for the treatment of moderate to severe UC are infliximab, adalimumab, and golimumab.
All three carry potential risks associated with their use, and should be avoided in certain patients, e.g. those with uncontrolled infections, advanced heart failure, neurologic conditions and in patients with a history of malignancy, due to a potential risk of accelerating the growth of a tumour. Other potential adverse effects of TNF-a inhibitor therapy include neutropenia, hepatotoxicity, serum sickness, leukocytoclastic vasculitis, rash including psoriasiform rash, induction of autoimmunity, and injection or infusion site reactions, including anaphylaxis, convulsions, and hypotension.
All three TNF-a inhibitor agents and their related biosimilar / derivative counterparts may be used to induce and maintain clinical response and remission in patients with UC.
Combination therapy with azathioprine is also used for inducing remission.
However, more than 50% of patients receiving TNF-a inhibitor agents fail to respond to induction dosing, or lose response to the TNF-a inhibitor agents over time (Fausel, R. and A. Afzali (2015) Ther Clin Risk Manag 11: 63-73).
Vedolizumab, a a4137 integrin inhibitor, was recently approved for the treatment of UC. In the GEMINI 1 trial, vedolizumab was found to be more effective than placebo for inducing and maintaining clinical response, clinical remission, and mucosal healing (Feagan, B. G., P. Rutgeerts, B. E. Sands, S. Hanauer, J. F. Colombel, W. J. Sandborn, G. Van Assche, J.
Axler, H. J. Kim, S. Danese, I. Fox, C. Milch, S. Sankoh, T. Wyant, J. Xu, A.
Parikh and G.
S. Group (2013). "Vedolizumab as induction and maintenance therapy for ulcerative colitis."
N Engl J Med 369(8): 699-710.).
Ulcerative colitis patients, who are chronically active and refractory to known treatments pose a serious medical challenge and often the only remaining course of action is

3

4 colectomy. A total colectomy is a potentially curative option in severe UC, but is a life-changing operation that entails risks as complications, such as pouch failure, pouchitis, pelvic sepsis, infertility in women, and nocturnal faecal soiling, may follow.
Therefore, surgery is usually reserved for patients with severe refractory disease, surgical or other emergencies, or patients with colorectal dysplasia or cancer.
An emergent third line treatment for UC is cobitolimod (Kappaproct/DIMS0150), a modified single strand deoxyribonucleic acid (DNA)-based synthetic oligonucleotide of 19 bases in length. Cobitolimod has the sequence 5'- G*G*A*ACAGTTCGTCCAT*G*G*C-3' (SEQ ID NO:1), wherein the CG dinucleotide is unmethylated.
Cobitolimod functions as an immunomodulatory agent by targeting the Toll-like receptor 9 (TLR9) present in immune cells. These immune cells (i.e., B-cells and plasmacytoid dendritic cell (pDCs) reside in high abundance in mucosal surfaces, such as colonic and nasal mucosa. The immune system is the key mediator of the changes of UC. The mucosa of the colon and rectum of patients with UC is chronically inflamed and contains active immune cells. Cobitolimod may be topically administered in the region of inflammation, which places the drug in close contact with a high number of intended target cells, ensuring that the drug will reach an area rich in TLR9 expressing cells. The activation of these cells by cobitolimod induces various cytokines, such as type I interferons and interleukin 10 (IL-10) which are classical anti- inflammatory cytokines and are believed to be important factors for the clinical effect of cobitolimod.
The clinical efficacy of cobitolimod has been demonstrated in the "COLLECT"
(CSUC-01/10 ) clinical trial, which involved the administration to patients of 30 mg doses of cobitolimod, at 4 week intervals and also in the "CONDUCT" (CSUC-01/16 ) clinical trial, which involved testing different dosage regimes. The details of the "COLLECT"
trial were published in Journal of Crohns and Colitis (Atreya et al. J Crohns Colitis, 2016 May 20) and are summarised in Reference Example 1. The details of the "CONDUCT"
clinical trial were published in The Lancet Gastroenterology and Hepatology (Atreya et al 2020.
Lancet Gastroenterol Hepatol. 2020 Dec;5(12):1063-1075) and are summarised in Reference Example 2. Overall, data on cobitolimod support a positive benefit-risk assessment for patients with chronic UC which is in an active phase (occasionally referred to herein as "chronic active UC"). Cobitolimod is safe and well tolerated and has been shown to be effective to induce clinical response and remission in patients with chronic UC
which is in an active phase, as well as symptomatic and endoscopic remission in patients with treatment refractory, moderate to severe chronic UC which is in an active phase.
Despite the clinical trial results obtained this far, there still remains a need for additional effective dosages of cobitolimod which exhibit both good efficacy and safety.
In the COLLECT study, which involved administration of a relatively low (30mg) dose of cobitolimod, topical administration of cobitolimod was performed using a spray catheter device, administered during an endoscopy. This is an invasive medical procedure which is necessarily carried out by a medical professional. Further, before the topical administration of the cobitolimod to the patients, the colon of each patient was cleaned to remove faecal matter. That was done to enable the cobitolimod to reach the intestinal epithelial cells within the colon and to enable the endoscopist to view the colonic mucosa.
Thus, it is well known in the art that oligonucleotides such as cobitolimod bind to organic matter such as faeces. It was therefore thought necessary to remove any faecal coating and other faecal material from the colon to enable the cobitolimod to reach the target intestinal epithelial cells within the colon.
As noted above, patients suffering from chronic ulcerative colitis, who are in an active disease state and refractory to known treatments pose a serious medical challenge and often the only remaining course of action is colectomy. For this reason, patients will tolerate medical intervention which requires both colonic cleaning to remove faecal matter and topical administration via spray catheter, despite the inconvenience and discomfort involved in such invasive procedures. However, it would be therapeutically desirable to provide a topical treatment for ulcerative colitis patients which does not require colonic cleaning to remove faecal matter and which, preferably, can be self-administered by the patient.

5 Summary of the Invention It has now surprisingly been found that, for treatment of inflammatory bowel diseases such as UC, administration of cobitolimod at a dosage of greater than 350mg, for instance from 351 to 650mg, typically from 400mg to 600mg, preferably around 500mg, on at least two, preferably two, separate occasions three weeks apart is optimal, for instance to induce remission and/or retain a patient in remission (i.e. act as a maintenance therapy). The increase in efficacy of the drug at 500mg is more than would have been expected from the previous clinical studies carried out at lower doses. Further, this dosage is found to be safe and well-tolerated, and is effective even when faecal matter is present, despite the known propensity of cobitolimod to bind to faecal matter. Therefore, this dosage is suitable for administration to patients which have not been subjected to colonic cleaning.
Further, it has surprisingly been found that this dosage is suitable for self-administration via an enema device. Thus, it is not necessary to administer the active ingredient using a spray catheter device during an endoscopy. This avoids the need for administration by a medical professional and the use of complex medical equipment and more invasive procedures.
The patient does not therefore need to travel to a medical centre or hospital to receive the drug and can self-administer in their own home.
The present invention therefore provides an oligonucleotide comprising the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2) for use in the treatment of inflammatory bowel disease in a human subject, wherein individual doses of from 400mg to 600mg of said oligonucleotide are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart.
The present invention also provides a pharmaceutical composition comprising an oligonucleotide as defined herein, together with one or more pharmaceutically acceptable carriers, for use in the treatment of inflammatory bowel disease as defined herein in a human subject as defined herein, wherein individual administrations of said composition are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the composition delivers an amount of the oligonucleotide as defined herein.

6 The present invention also provides a method of treating inflammatory bowel disease as defined herein, in a human subject as defined herein, comprising administering to said subject an oligonucleotide as defined herein or a composition as defined herein, wherein individual administrations of said oligonucleotide or composition are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the oligonucleotide or composition delivers an amount of the oligonucleotide as defined herein.
In preferred embodiments, the oligonucleotide has the sequence 5'- G*G*A*ACAGTTCGTCCAT*G*G*C-3' (SEQ ID NO:1 ), wherein the CG
dinucleotide is unmethylated. Thus, in preferred embodiments, the oligonucleotide is cobitolimod.
Brief Description of the Figures Figure 1 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting blood in stool = zero (maximum patient reported outcome during 7 days) by week following administration of an oligonucleotide of the .. invention, or placebo (added to standard of care (S.o.C.)).
Figure 2 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting weekly stool frequency <18 (summary of patient reported outcome during 7 days) by week following administration of an oligonucleotide of the invention, or placebo (added to standard of care (S.o.C.)).
Figure 3 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting weekly stool frequency <35 (summary of patient reported outcome during 7 days) by week following administration of an oligonucleotide .. of the invention, or placebo (added to standard of care (S.o.C.)).

7 Figure 4 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting daily stool frequency <3 (mean daily patient reported outcome during 7 days) by week following administration of an oligonucleotide of the invention, or placebo (added to standard of care (S.o.C.)).
Figure 5 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting daily stool frequency <4 (mean daily patient reported outcome during 7 days) by week following administration of an oligonucleotide of the invention, or placebo (added to standard of care (S.o.C.)).
Figure 6 shows the results from a placebo-controlled clinical trial of the proportion of the treatment and placebo groups reporting daily stool frequency <5 (mean daily patient reported outcome during 7 days) by week following administration of an oligonucleotide of the invention, or placebo (added to standard of care (S.o.C.)).
Detailed Description of the Invention All patents, patent applications, and publications cited herein are hereby incorporated by reference in their entirety.
As used herein, the term "subject" refers to a human subject/patient. The terms "subject"
and "patient" are used interchangeably herein.
As used herein, the term inflammatory bowel disease (IBD) refers to a group of inflammatory conditions of the colon and the gastrointestinal tract. The major types of IBD are ulcerative colitis (UC) and Crohn's disease. The main difference between UC and Crohn's disease is the location and nature of the inflammatory changes.
Crohn's disease can affect any part of the gastrointestinal tract, from mouth to anus, while UC is restricted to the colon and the rectum. In some cases, a definitive diagnosis of either Crohn's disease or UC cannot be made due to idiosyncrasies in the presentation. In these cases a diagnosis of indeterminate colitis may be made. Other forms of IBD include, but are not limited to,

8 collagenous colitis, lymphocytic colitis, ischaemic colitis, diversion colitis, Behcet's disease and indeterminate colitis.
Typically, the inflammatory bowel disease is ulcerative colitis (UC).
The disease ulcerative colitis (UC) is well known to one skilled in the art.
Ulcerative colitis treated in accordance with the present invention may involve treatment of ulcerative proctitis, distal or left sided colitis, extensive colitis, pancolitis and pouchitis. Typically, the patient is suffering from left sided ulcerative colitis.
Patients with UC typically present with a spectrum of disease severity ranging from remission to severely active. Clinical assessment can be used to classify UC
patients into 4 disease activity subgroups as defined in D'Haens, Gastroenterology 2007; 132:
763-786, the entirety of which is incorporated herein by reference: (1) remission (<2 or 3 stools/ day, without the presence of blood and/or pus in the stools, with no systemic symptoms); (2) mildly active disease (3 or 4 stools/day and/or presence of blood and/or pus in the stools less than daily, with no systemic symptoms of fever or weight loss); (3) moderately active disease (>4 stools/day and/or daily presence of blood and/or pus) with minimal systemic symptoms; and (4) severely active disease (>6 bloody stools/day, and evidence of toxicity, as demonstrated by fever, tachycardia, anemia, or an erythrocyte sedimentation rate ESR).
Typically, the patient is suffering from moderate to severe UC. Preferably, the patient is suffering from moderate to severe UC as defined above. For instance, the patient may be suffering from moderate to severe left sided UC.
As used herein, the words "treatment" and "treating" are to be understood as embracing treatment and/or amelioration and/or prevention of or reduction in aggravation/worsening of symptoms of a disease or condition as well as treatment of the cause of the disease or condition, and may include reversing, reducing, or arresting the symptoms, clinical signs, and underlying pathology of a condition in a manner to improve or stabilise a subject's condition.

9 In particular in the context of ulcerative colitis, "treating" typically refers to inducing response or remission in a patient having active ulcerative colitis. Thus, typically, the oligonucleotide is for inducing response or remission of active ulcerative colitis in a patient. Inducing response means improving the condition of a patient by e.g.
reducing and/or arresting the symptoms and clinical signs of the active disease.
Inducing remission means transitioning a patient from a state where they are considered to be in an active stage of the disease to a state where they are considered to be in remission.
Induction of response or remission in UC patients is typically assessed by one or more of endoscopy, histology, patient recorded outcomes and quality of life outcomes.
Thus, reference to induction of response or remission includes induction of one or more of endoscopic remission, endoscopic response, histological remission, histological response, response or remission as determined by physician or by patient recorded outcomes, and response or remission as determined by quality of life. This can typically be assessed by reference to one or more standard indices.
Typically, ulcerative colitis is chronic active ulcerative colitis, i.e. the patient is suffering from chronic ulcerative colitis which is in an active phase.
As used herein, the term "chronic active ulcerative colitis" refers to patients with ulcerative colitis that is both active and chronic. Active ulcerative colitis is typically as defined herein, i.e. the patient is not in remission. Ulcerative colitis is typically a chronic (long-term) condition which cycles between active and less active phases . As the skilled person would understand, a patient suffering from chronic ulcerative colitis goes through active phases ("flare ups" or relapses) with more extreme symptoms interspersed with periods where the patient experiences milder symptoms or is in remission. Thus, the term "chronic active UC" typically refers to a patient with chronic UC who is in an active disease state.
The patient may be suffering from chronic active moderate to severe UC. The patient may be suffering from chronic active moderate to severe left sided UC.

Preferably, reference herein to "treating" refers to inducing response or remission in a patient having chronic active ulcerative colitis. Thus, typically, the oligonucleotide is for inducing response or remission of chronic active ulcerative colitis in a patient.
Induction of response or remission in UC patients may be determined in accordance with one or more standard disease indices. Typical disease indices include but not limited to the ones mentioned below; (i) disease activity determined by clinical and biochemical disease activity, (ii) disease activity determined by endoscopic disease activity, (iii) disease activity determined by composite clinical and endoscopic disease activity indices, (iv) .. quality of life, (v) histologic disease activity. These indices are discussed in D'Haens (ibid).
Indices based on disease activity determined by clinical and biochemical disease activity include the Truelove and Witts Severity Index; Powell-Tuck (St. Mark's) Index;
Clinical Activity (Rachmilewitz) Index; Activity (Seo) Index; Physician Global Assessment;
Lichtiger (Modified Truelove and Witts Severity) Index; Investigators Global Evaluation;
Simple Clinical Colitis Activity Index; Improvement Based on Individual Symptom Scores; Ulcerative Colitis Clinical Score; and Patient-defined remission.
These indices are discussed in D'Haens (ibid).
Indices based on disease activity determined by endoscopic disease activity include the Truelove and Witts Sigmoidoscopic Assessment; Baron score; Powell-Tuck Sigmoidoscopic Assessment; Endoscopic (Rachmilewitz Endoscopic) Index;
Sigmoidoscopic Index; Sigmoidoscopic Inflammation Grade Score; Mayo Score Flexible Proctosigmoidoscopy Assessment; Sutherland Mucosal Appearance Assessment; and Modified Baron Score. These indices are discussed in D'Haens (ibid).
Indices based on disease activity determined by composite clinical and endoscopic disease activity indices include the Mayo Score (Mayo Clinic Score/Disease Activity Index);
.. Modified Mayo Score and Sutherland Index (Disease Activity Index/UC Disease Activity Index). Mayo Score and Sutherland Index are discussed in D'Haens (ibid).

Indices based on quality of life include the Rating Form of IBD Patient Concerns; and the Inflammatory Bowel Disease Questionnaire (IBDQ). These indices are discussed in D'Haens (ibid).
Indices based on histologic disease activity include those discussed in D'Haens (ibid) such as Geboes Index and Riley Index and further indices such as Nancy Index and Robarts Index.
Preferred indices for assessing UC patients include the Clinical Activity (Rachmilewitz) Index, Mayo Score and Modified Mayo Score.
The Clinical Activity (Rachmilewitz) Index is an index taking into account 7 variables:
number of stools, blood in stools, investigator's global assessment of symptomatic state, abdominal pain or cramps, temperature due to colitis, extraintestinal manifestations, and laboratory findings. This is discussed further in D'Haens (ibid) and Rachmilewitz D., BMJ
1989; 298: 82-86, the entirety of which is incorporated herein by reference.
Determination of the Clinical Activity (Rachmilewitz) Index produces a score for a patient ranging from 0 to 29 points (higher scores meaning more severe disease).
Clinical remission may be considered as a Clinical Activity (Rachmilewitz) Index score <4 points. Response as determined by the Clinical Activity (Rachmilewitz) Index means the patient has a lower score after treatment than before treatment.
The Mayo Score is an index taking into account 4 items: stool frequency, rectal bleeding, findings of lower GI endoscopy, and Physician's Global Assessment (PGA). This is discussed further in D'Haens (ibid) and Schroeder KW et al, N Engl J Med 1987;
317:
1625-1629, the entirety of which is incorporated herein by reference.
Determination of the Mayo Score produces a score ranging from 0 to 12 points (higher scores meaning more severe disease). In addition to the four specific items, a patient's functional assessment is also measured that is not meant to be included in the 12-point index calculation but should be used as a measure of general well-being when determining the PGA score.

Mayo scoring for each of the 4 items is determined as set out in the Table below.
Score Stool Rectal Physician's Colonoscopy/sigmoidoscopy frequencyb Bleeding' global finding assessmentd 0 Normal No blood Normal or no Normal or inactive disease number of seen disease stools for this patient 1 1 to 2 stools Streaks of Mild disease Mild disease (erythema, more than blood with decreased vascular pattern, normal stool less mild friability) than half of the time 2 3 to 4 stools Obvious Moderate Moderate disease (marked more than blood with disease erythema, lack of vascular normal stool most pattern, friability, erosions) of the time 3 5 or more Blood alone Severe Severe disease (spontaneous stools more passed disease bleeding, ulceration) than normal b Each patient serves as his or her own control to establish the degree of abnormality of the stool frequency.
' The daily bleeding score represents the most severe day of bleeding d The physician's global assessment acknowledges the 3 other criteria, the patient's daily record of abdominal discomfort and general sense of well-being, and other observations, such as physical findings and the patient's performance status.
Remission according to the Mayo Score may be defined as complete resolution of (1) stool frequency (normal stool frequency), (2) rectal bleeding (no rectal bleeding), (3) patient's functional assessment score (generally well), (4) endoscopy findings (normal), and a PGA
score of 0. Response as determined by Mayo Score typically requires improvement (a minimum 1-point decrease from baseline) in the PGA score and improvement in at least one other clinical assessment (stool frequency, rectal bleeding, patient's functional assessment, endoscopy findings) and no worsening in any other clinical assessment.
Alternatively, clinical remission may be defined as a Mayo Score of 0 and clinical improvement (response) as a decrease from baseline in the Mayo Score >3 points.

Alternatively, clinical remission may be defined as a Mayo Score of 0 and clinical improvement (response) as a decrease from baseline in the Mayo Score >3 points (or a decrease of >2 points if the baseline Mayo Score was <3 points).
Alternatively, remission as determined by Mayo Score may be defined as requiring subscores of 0 for both sigmoidoscopy and rectal bleeding and a score of 0 or 1 for stool frequency and PGA subscores. Response may be defined as a decrease from baseline in the Mayo Score >3 points; clinical response may be defined as a decrease from baseline in the Mayo Score (without the endoscopy subscore, also known as a Partial Mayo Score) >2 points, and endoscopic response may be defined as a decrease from baseline in the endoscopic subscore >1 point.
Alternatively, clinical remission may be defined as a total Mayo score of <2 points with no individual subscore >1 point, clinical response may be defined as a decrease from baseline in the total Mayo score >3 points and >30% and a decrease in the rectal bleeding subscore >1 point or an absolute rectal bleeding subscore of 0 or 1, and mucosal healing may be defined as an absolute endoscopy subscore of 0 or 1.
In one embodiment, patients having active ulcerative colitis have a Mayo Score >2.
Patients who are in a remission phase of ulcerative colitis typically have a Mayo Score <2.
Modified Mayo Score is related to the Mayo Score, which is defined above.
Modified Mayo Score differs from Mayo Score in that the Colonoscopy/sigmoidoscopy scoring takes less account of friability. Thus, the scoring table for the Modified Mayo Score is as set out below.
Score Stool Rectal Physician's Colonoscopy/sigmoidoscopy frequencyb Bleeding' global finding assessmentd 0 Normal No blood Normal or no Normal or inactive disease number of seen disease stools for this patient 1 1 to 2 stools Streaks of Mild disease Mild disease (erythema, more than blood with decreased vascular pattern) normal stool less than half of the time 2 3 to 4 stools Obvious Moderate Moderate disease (marked more than blood with disease erythema, lack of vascular normal stool most pattern, friability, erosions) of the time 3 5 or more Blood alone Severe Severe disease (spontaneous stools more passed disease bleeding, ulceration) than normal b Each patient serves as his or her own control to establish the degree of abnormality of the stool frequency.
' The daily bleeding score represents the most severe day of bleeding d The physician's global assessment acknowledges the 3 other criteria, the patient's daily record of abdominal discomfort and general sense of well-being, and other observations, such as physical findings and the patient's performance status.
Remission and response values for the Modified Mayo Score are as set out above for the Mayo Score. Modified Mayo Score is typically assessed in accordance with the FDA's draft guidance document "Ulcerative Colitis: Clinical Trial Endpoints Guidance for Industry" found at http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guid an ces/UCM515143.pdf Alternatively, Modified Mayo Score may differ from Mayo Score in that the Colonoscopy/sigmoidoscopy scoring takes less account of friability and also in that Physician's Global Assessment is not determinative. Thus, the scoring table for the Modified Mayo Score may also be as follows.
Score Stool Rectal Colonoscopy/sigmoidoscopy frequency' Bleeding' finding 0 Normal No blood Normal or inactive disease number of seen stools for this patient 1 1 to 2 stools Streaks of Mild disease (erythema, more than blood with decreased vascular pattern) normal stool less than half the time 2 3 to 4 stools Obvious Moderate disease (marked more than blood with erythema, lack of vascular normal stool most of pattern, friability, erosions) the time 3 5 or more Blood alone Severe disease (spontaneous stools more passed bleeding, ulceration) than normal b Each patient serves as his or her own control to establish the degree of abnormality of the stool frequency.
C The daily bleeding score represents the most severe day of bleeding Remission and response values for this alternative Modified Mayo Score are typically as set out above for the Mayo Score. Alternatively, remission may be defined in accordance with this alternative Modified Mayo Score by sub-scores of i) rectal bleeding of 0, ii) stool frequency of 0 or 1 (with at least one point decrease from Baseline, Week 0), and iii) endoscopy score of 0 or 1 (excluding friability).
Induction of remission of UC may be in accordance with the criteria set out in S. P. L.
Travis, Aliment Pharmacol Ther 2011; 34: 113-124, the entirety of which is incorporated herein by reference, i.e. complete cessation of rectal bleeding, urgency and increased stool frequency, preferably confirmed by endoscopic mucosal healing.
Alternatively, induction of response or remission may be in accordance with the criteria set out in E.F. Stange, Journal of Crohn's and Colitis (2008) 2,1-23; S.P.L.
Travis, Journal of Crohn's and Colitis (2008) 2,24-62; K Geboes, Gut 2000; 47: 404-409; the entirety of which are incorporated herein by reference.
Induction of response or remission in Crohn's disease patients may be determined in accordance with one or more standard disease indices. Typical indices include the Crohn's Disease Activity Index (CDAI). The CDAI is discussed in Love, "Pharmacotherapy for Moderate to Severe Inflammatory Bowel Disease: Evolving Strategies", Am J
Manag Care. 2016;22:539-550; Peyrin-Biroulet et al "Defining disease severity in inflammatory bowel diseases: current and future directions" Clin Gastroenterol Hepatol.
2015; pii:
S1542-3565(15)00787-00789. doi: 10.1016/j.cgh.2015.06.001; and Ungar et al "Advances in the development of new biologics in inflammatory bowel disease", Annals of Gastroenterology (2016) 29, 243-248. Alternative indices for assessing Crohn's disease patients include the Harvey-Bradshaw index and the Inflammatory Bowel Disease Questionnaire.
CDAI is a composite score taking into account a large number of symptoms associated with Crohn's disease, including number of liquid or soft stools; abdominal pain; general well-being; presence of complications (the presence of joint pains (arthralgia) or frank arthritis; inflammation of the iris or uveitis; presence of erythema nodosum, pyoderma gangrenosum, or aphthous ulcers; anal fissures, fistulae or abscesses; other fistulae; fever during the previous week); use of lomotil or opiates for diarrhea; presence of an abdominal mass; hematocrit value; and percentage deviation from standard weight.
Clinical remission according to the CDAI is typically indicated by a score of <150.
Typically, the subject is in clinical remission at week 6, following commencement of treatment with the oligonucleotide at week 0. Clinical remission may be any of the definitions of clinical remission as described herein. Typically, the subject is in clinical remission at week 6, following commencement of treatment with the oligonucleotide at week 0, wherein clinical remission is as defined by the 3- component Mayo scores: i) rectal bleeding of 0, ii) stool frequency of 0 or 1 (with at least one point decrease from Baseline, Week 0), and iii) endoscopy score of 0 or 1.
Typically, the subject exhibits an endoscopic improvement at week 6, following commencement of treatment with the oligonucleotide at week 0. Typically, the subject is in symptomatic remission at week 6, following commencement of treatment with the oligonucleotide at week 0. Symptomatic remission is typically defined as a blood in stool score of 0 and stool frequency score of 0 or 1 according to the Mayo scoring system.

The subject treated in accordance with the present invention is typically refractory or responds insufficiently or is intolerant to anti-inflammatory therapy and/or demonstrates or has previously demonstrated an inadequate response, loss of response, or intolerance to at least one immunomodulator, TNF-a inhibitor, anti-integrin, JAK inhibitors or inhibitor. The subject treated in accordance with the present invention is typically refractory or responds insufficiently or is intolerant to anti-inflammatory therapy. The subject treated in accordance with the present invention is typically refractory or responds insufficiently or is intolerant to at least one immunomodulator. The subject treated in accordance with the present invention is typically refractory or responds insufficiently or is intolerant to at least one TNF-a inhibitor.
Thus, typically, the subject has previously received or is currently receiving anti-inflammatory therapy, preferably anti-inflammatory therapy for UC and/or immunomodulatory, TNF-a inhibitor or anti-integrin therapy, preferably such therapy for UC.
Anti-inflammatory therapies for UC are discussed herein and typically include oral corticosteroids, and glucocorticosteroids (GCS), sulfasalazine and 5-ASA.
Thus, the subject treated in accordance with the present invention is typically refractory or responds .. insufficiently or is intolerant to GCS, sulfasalazine and/or 5-ASA.
Typically, the subject treated in accordance with the present invention is refractory or responds insufficiently or is intolerant to oral corticosteroids.
Immunomodulators, TNF-a inhibitors and anti-integrins are discussed herein and typically include azathioprine, 6-mercaptopurine and biologicals including the TNF-a inhibitors infliximab and biosimilars and derivatives thereof, golimumab and biosimilars and derivatives thereof, adalimumab and biosimilars and derivatives thereof and anti-integrins vedolizumab and biosimilars and derivatives thereof Thus, the subject treated in accordance with the present invention is typically refractory or responds insufficiently or is intolerant to azathioprine, 6-mercaptopurine, infliximab and biosimilars and derivatives thereof, golimumab and biosimilars and derivatives thereof, adalimumab and biosimilars and derivatives thereof and anti-integrin vedolizumab and biosimilars and derivatives thereof. Typically, the subject treated in accordance with the present invention is refractory or responds insufficiently or is intolerant to azathioprine and/or mercaptopurine. Typically, the subject treated in accordance with the present invention is refractory or responds insufficiently or is intolerant to infliximab and/or adalimumab. The subject treated in accordance with the present invention may be refractory or respond insufficiently or is intolerant to JAK inhibitors (for instance tofacitinib).
The subject treated in accordance with the present invention may be refractory or respond insufficiently or is intolerant to IL-12/IL23 inhibitor (for instance ustekinumab).
A refractory disease or disease that responds insufficiently to therapy is typically a disease where signs and symptoms of active disease persist despite a history of at least one course of therapy, for instance anti-inflammatory therapy or immunomodulatory therapy, in the context of the present invention. Typically in the context of treatment of UC, signs and symptoms of active disease persist despite a history of two or more courses of anti-inflammatory therapy or immunomodulatory therapy. A typical course of treatment with anti-inflammatory or immunomodulatory therapy for UC would be well understood by a person skilled in the art, and would typically involve a sufficient number of doses at sufficient dosage to induce remission in a typical patient.
Intolerance to therapy, for instance anti-inflammatory therapy or immunomodulatory therapy, in the context of the present invention, means that the therapy has caused side effects in the subject that are not tolerated, e.g. that typically lead to discontinuation of therapy.
Typically, the subject has previously received or is currently receiving Aminosalicylic acid (5-ASA), preferably 5-ASA therapy for UC.
Typically, the subject has previously received or is currently receiving oral Glucocorticosteroids (GCS), preferably oral GCS therapy for UC.
Typically, the subject has previously received or is currently receiving budesonide, for instance oral MMX Budesonide therapy.

Typically, the subject has previously received or is currently 5-aminosalicylic acid and/or Salazopyrin compounds.
.. Typically, the subject has previously received or is currently receiving azathioprine and/or 6-mercaptopurine.
Typically, the subject who is refractory or responds insufficiently or is intolerant to anti-inflammatory therapy shows or has previously shown an inadequate response to, or loss of response to (i.e. is refractory to) or intolerance of rectal, oral, and/or parenteral GCS
treatment (including no GCS treatment due to earlier side effect).
Typically, the subject who is refractory or responds insufficiently or is intolerant to anti-inflammatory therapy has a history of or current status of an inadequate response (e.g.
steroid refractory) to, OR steroid dependency, OR loss of response to, OR
intolerance of GCS treatment. The steroids/GCS will typically have been received by the subject in the course of treating ulcerative colitis.
Steroid-refractory typically refers to a subject lacking a meaningful clinical response, i.e.
showing signs and symptoms of persistently active ulcerative colitis, despite a history of at least one course of steroid treatment, for instance an induction regimen that included a dose equivalent to prednisone 40-60 mg daily over a period of 30 days for oral administration or over a period of 7 to 10 days for intravenous (IV) administration.
Steroid dependence typically refers to a patient who is either unable to reduce steroids below the equivalent of prednisolone 10 mg/d within 3 months of starting steroids, without recurrent active ulcerative colitis, or who has a relapse within 3 months of stopping steroids.
Intolerance of GCS treatment typically means the subject has experienced side effects not tolerated by the subject following GCS treatment, such as but not limited to Cushing's syndrome, osteopenia/osteoporosis, hyperglycemia, insomnia, or infection.

Typically, the subject who is refractory or responds insufficiently or is intolerant to an immunomodulator shows or has previously shown an inadequate response to, or loss of response to (i.e. is refractory to) or intolerance of an immunomodulator. For instance, the subject who is refractory or responds insufficiently or is intolerant to a TNF-a inhibitor shows or has previously shown an inadequate response to, or loss of response to (i.e. is refractory to) or intolerance of a TNF-a inhibitor.
An inadequate response, or loss of response to an immunomodulator typically means signs and symptoms of active ulcerative colitis persist despite previous treatment with at least one immunomodulator, for instance one 8 Week regimen of oral azathioprine (>1.5 mg/kg) or 6-mercaptopurine (>0.75 mg/kg).
Intolerance to an immunomodulator typically means the subject has experienced nausea/vomiting, abdominal pain, pancreatitis, liver function test (LFT) abnormalities, lymphopenia, Thiopurine Methyltransferase (TPMT) genetic mutation, or infection or other side effects after receiving an immunomodulator.
An inadequate response, or loss of response to a TNF-a inhibitor means signs and symptoms of active ulcerative colitis persist despite previous treatment with at least one TNF-a inhibitor, such as 4-Week induction regimen (or doses as recommended according to the current labels) of infliximab (5 mg/kg (IV), 2 doses at least 2 weeks apart) or a biosimilar or derivative thereof; golimumab (200 /100 mg (SC), 2 doses at least 2 weeks apart) or a biosimilar or derivative thereof; or adalimumab (160/80 mg (SC), 2 doses at least 2 weeks apart) or a biosimilar or derivative thereof or recurrence of symptoms during maintenance dosing following prior clinical benefit.
Intolerance to a TNF-a inhibitor means an infusion-related reaction, demyelination, congestive heart failure, infection or other side effects following receipt of a TNF-a inhibitor.

An inadequate response, or loss of response to an anti-integrin means signs and symptoms of active ulcerative colitis persist despite previous treatment with an anti-integrin, for instance at least 10 weeks regimen of vedolizumab 300 mg (IV) or a biosimilar or derivative thereof, or as recommended in the current label, or recurrence of symptoms during maintenance dosing following prior clinical benefit.
Typically, the subject has been diagnosed with left sided ulcerative colitis, i.e. distal colitis, including proctosigmoiditis. For instance, the subject may have been diagnosed with moderate to severe left sided ulcerative colitis.
Typically, said subject is elective for colectomy.
As used herein, the term "colectomy" refers to surgical resection of any extent of the large intestine (colon). Herein, colectomy includes, but is not limited to, right hemicolectomy, left hemicolectomy, extended hemicolectomy, transverse colectomy, sigmoidectomy, proctosigmoidectomy, Hartmann operation, "double-barrel" or Mikulicz colostomy, total colectomy (also known as Lane's Operation), total procto-colectomy and subtotal colectomy. As used herein, the phrase "elective for colectomy" refers to a subject who may choose to undergo the procedure of non-emergency colectomy based on physician and surgeon assessment. Subjects elective for colectomy may be, but are not limited to, subjects refractory to available therapy (for ulcerative colitis) or intolerant of available therapy (for ulcerative colitis). This differs from emergency colectomy, which is an acute intervention for subjects with acute illnesses or injuries and who require immediate medical attention. The phrase also includes subjects that are elected for colectomy.
As used herein, the term "oligonucleotide" refers to a polynucleoside formed from a plurality of linked individual nucleoside units. Such oligonucleotides can be obtained from existing nucleic acid sources, including genomic DNA or cDNA, plasmids, vectors, or bacterial DNA, but are preferably produced by synthetic methods. The nucleoside residues can be coupled to each other by any of the numerous known internucleoside linkages.
Such internucleoside linkages include, without limitation, the natural internucleoside phosphodiester bond or indeed modified internucleosides such as, but not limited to, phosphorothioate, phosphorodithioate, alkylphosphonate, alkylphosphonothioate, phosphotriester, phosphoramidate, siloxane, carbonate, carboalkoxy, acetamidate, carbamate, morpholino, borano, thioether, bridged phosphoramidate, bridged methylene phosphonate, bridged phosphorothioate, and sulfone internucleoside linkages.
The term "oligonucleotide" also encompasses polynucleosides having one or more stereospecific internucleoside linkages (e. g., (Rp)- or (Sp)-phosphorothioate, alkylphosphonate, or phosphotriester linkages). As used herein, the terms "oligonucleotide" and "dinucleotide"
are expressly intended to include polynucleosides and dinucleosides having any such internucleoside linkage, whether or not the linkage comprises a phosphate group. In certain preferred embodiments, these internucleoside linkages may be phosphodiester, phosphorothioate, or phosphorodithioate linkages, or combinations thereof The term "oligonucleotide" also encompasses polynucleosides having additional substituents including, without limitation, protein groups, lipophilic groups, intercalating agents, diamines, folic acid, cholesterol and adamantane. The term "oligonucleotide" also encompasses any other nucleobase containing polymer, including, without limitation, peptide nucleic acids (PNA), peptide nucleic acids with phosphate groups (PHONA), locked nucleic acids (LNA), morpholino-backbone oligonucleotides, and oligonucleotides having backbone sections with alkyl linkers or amino linkers. The alkyl linker may be branched or unbranched, substituted or unsubstituted, and chirally pure or a racemic mixture.
The oligonucleotides of the invention can include naturally occurring nucleosides, modified nucleosides, or mixtures thereof As used herein, the term "modified nucleoside"
is a nucleoside that includes a modified heterocyclic base, a modified sugar moiety, or a combination thereof In some embodiments, the modified nucleoside is a non-natural pyrimidine or purine nucleoside, as herein described. In some embodiments, the modified nucleoside is a 2'-substituted ribonucleoside, an arabinonucleoside or a 2'-deoxy-2'-substituted-arabinoside.
As used herein, the term "a hybrid oligonucleotide" is an oligonucleotide having more than one type of nucleoside.

Herein, the term "oligonucleotide" includes hybrid and chimeric oligonucleotides. A
"chimeric oligonucleotide" is an oligonucleotide having more than one type of internucleoside linkage within its sequence structure. One preferred example of such a chimeric oligonucleotide is a chimeric oligonucleotide comprising a phosphorothioate, phosphodiester or phosphorodithioate region and non-ionic linkages such as alkylphosphonate or alkylphosphonothioate linkages (US5635377 and US5366878).
Herein, the term "oligonucleotide" also includes circularized variants and circular oligonucleotides.
Preferably, the oligonucleotide comprises at least one naturally occurring phosphodiester, or one modified phosphorothioate, or phosphorodithioate internucleoside linkage, however preferred linkages or indeed backbone modifications including, without limitation, methylphosphonates, methylphosphonothioates, phosphotriesters, phosphothiotriesters, phosphorothioates, phosphorodithioates, triester prodrugs, sulfones, sulfonamides, sulfamates, formacetal, N-methylhydroxylamine, 2' OMe (OxyMethyl group at 2'position), carbonate, carbamate, morpholino, boranophosphonate, phosphoramidates, especially primary amino-phosphoramidates, N3 phosphoramidates and N5 phosphoramidates, and stereospecific linkages (e. g., (Rp)-or (Sp)-phosphorothioate, alkylphosphonate, or phosphotriester linkages) are also envisaged.
The sugar moiety of the nucleoside can be a non-naturally occurring sugar moiety. Herein, a "naturally occurring sugar moiety" is a sugar moiety that occurs naturally as part of a nucleic acid, e. g., ribose and 2'- deoxyribose, and a "non-naturally occurring sugar moiety" is any sugar that does not occur naturally as part of a nucleic acid, but which can be used in the backbone for an oligonucleotide, for example but not limited to hexose.
Arabinose and arabinose derivatives are examples of preferred sugar moieties.
Modified or substituted oligonucleotides are often preferred over native forms because of desirable properties such as, for example, enhanced cellular uptake, enhanced affinity for nucleic acid target and increased stability in the presence of nucleases. An oligonucleotide is usually comprised of more than ten (10) and up to one hundred (100) or more deoxyribonucleotides or ribonucelotides, although preferably between about eight (8) and about forty (40), most preferably between about eight (8) and about twenty (20). The exact size will depend on many factors, which in turn depends on the ultimate function or use of the oligonucleotide. The oligonucleotide may be generated in any manner, including chemical synthesis, DNA replication, reverse transcription, or a combination thereof.
The oligonucleotide for use in the present invention comprises the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2). Typically, at least one CG
dinucleotide is unmethylated.
Typically, at least one nucleotide in said oligonucleotide has a backbone modification.
Typically, at least one nucleotide in said oligonucleotide has a phosphate backbone modification. The backbone modification is typically a phosphorothioate or a phosphorodithioate modification.
Phosphorothioate linkages can be illustrated with asterisks (*) in a sequence, e.g. in the sequence:
5'-G*G*A*ACAGTTCGTCCAT*G*G*C-3' (SEQ ID NO:1), wherein the CG
dinucleotide is unmethylated.
Preferably, said oligonucleotide has the sequence 5'-G*G*A*ACAGTTCGTCCAT*G*G*C-3' (SEQ ID NO:1), wherein the CG
dinucleotide is unmethylated. Thus, preferably said oligonucleotide is cobitolimod.
The present invention therefore preferably provides cobitolimod for use in the treatment of active ulcerative colitis as defined herein in a human subject as defined herein, wherein individual doses of an amount as defined herein of cobitolimod are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart.

In the therapies of the present invention, individual doses of from 400mg to 600mg of said oligonucleotide, preferably cobitolimod, are administered. Typically, the same dosage of oligonucleotide is administered in each individual dose/administration, but different dosages may also be used.
Usually, individual doses of greater than 350mg of said oligonucleotide, preferably cobitolimod, are administered. For instance, typically, individual doses of greater than 350 mg, for instance from 351 up to 650mg of said oligonucleotide, preferably cobitolimod, are administered.
Typically, from 425mg to 575mg of said oligonucleotide, preferably cobitolimod, are administered in each dose/administration, preferably from 450mg to 550mg, more preferably from 460 to 540, still more preferably from 470 to 530, yet more preferably from 480 to 520, even more preferably from 490 to 510, even more preferably from 495 to 505, even more preferably from 499 to 501mg.
Preferably, about 500mg of said oligonucleotide, preferably cobitolimod, is administered.
Thus, about 500mg of said oligonucleotide, preferably cobitolimod, is administered on each of the at least two occasions.
In the context of dosage of an active agent, "about" as used herein means +/-

10%, typically +/- 5%, preferably +/- 1%.
More preferably, 500mg of said oligonucleotide, preferably cobitolimod, is administered.
In the therapies of the present invention, individual doses (of an amount as specified herein) of said oligonucleotide are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart. This means that the patient does not receive any additional oligonucleotide between the specified doses/administrations three weeks apart. In the three week window between specified doses/administrations three weeks apart, the patient does not receive an oligonucleotide as defined herein, but may receive one or more additional therapeutic agents for the treatment of ulcerative colitis.
When doses of said oligonucleotide are administered to the patient on more than two occasions, then typically each occasion is three weeks after the previous occasion.
Typically, doses (of an amount as specified herein) of said oligonucleotide are administered to the patient on, for instance, 2, 3, 4, 5, 6, 7, 8, 9, or 10 separate occasions, each occasion being three weeks after the previous occasion. Typically, doses of said oligonucleotide are administered to the patient until that patient is in remission, as defined above. In some embodiments, individual doses are administered to the subject on only two separate occasions, the separate occasions being 3 weeks apart.
It should be understood that reference to administration on at least two separate occasions, where said separate occasions are 3 weeks apart, refers to a single treatment regime for inducing remission. Thus, following a course of treatment in accordance with the present invention, further treatment with the oligonucleotide is not ruled out in the future, e.g.
following relapse to an active disease state after remission.
In the context of a patient receiving only two doses, a first dose would be delivered at day zero, and a second dose would be delivered three weeks after that. In the context of a patient receiving three doses, a first dose would be delivered at day zero, a second dose would be delivered three weeks after that, and a third dose would be delivered a further three weeks after that, i.e. six weeks from day zero.
As used herein, the term "3 weeks apart" means in certain embodiments administration of the doses exactly 21 days apart, i.e. a first dose is administered on day zero and a further dose is administered on day twenty one. However, it will be appreciated that minor variations from this are still within the scope of the present invention. Such minor variations may be unavoidable due to e.g. illness of the patient or unavailability of the drug. Thus, as used herein "3 weeks apart" means administration 14-28 days apart, typically 18-24 days apart, alternatively 19-23 days apart, or 20-22 days apart.

Thus, in certain embodiments the present invention provides an oligonucleotide, as defined herein, for use in the treatment of ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of an amount as defined herein of said oligonucleotide are administered to the patient on at least two, for instance two, separate occasions, wherein said separate occasions are 18-24 days apart, 19-23 days apart, or 20-22 days apart.
The drugs for use in the present invention may be administered as monotherapy treatment for the indication or with other drug(s) as adjunct therapy for the indication, as described in more detail below. In the case of adjunct (or "add-on") therapy, the drugs for use in the present invention may be administered simultaneously, separately or sequentially with the other drug(s), for example in fixed dose combination or in separate doses.
As used herein, the term "add-on" refers to administering of said oligonucleotide in .. addition to a current therapy or drug regime, without discontinuing the current therapy or drug regime.
Thus, the oligonucleotide may be administered as a monotherapy, or in combination with one or more additional therapeutic agents for the treatment of ulcerative colitis. Typically, the oligonucleotide may be administered as a monotherapy, or in combination with one or more additional therapeutic agents for the treatment of ulcerative colitis chosen from anti-inflammatories, immunomodulatory drugs, anti-TNF therapy drugs or other suitable drugs for treating ulcerative colitis.
Examples of such drugs suitable for use in combination with said oligonucleotide include, but are not limited to GCS or derivatives; prednisolone, Decortin, anti-TNF or derivative;
infliximab and biosimilars and derivatives thereof, adalimumab and biosimilars and derivatives thereof, golimumab and biosimilars and derivatives thereof, anti-integrin or derivatives; vedolizumab and biosimilars and derivatives thereof, natural IFN-13, thiopurine .. or derivatives; azathioprine, 6-mercaptopurine, 5-ASA, sulphasalazine, methotrexate, cylclosporine, and equivalents thereof Typically, the subject receiving said oligonucleotide also receives one or more other drugs chosen from GCS, Decortin, 5-ASA, azathioprine, 6-mercaptopurine, sulphasalazine, methotrexate, prednisolone and equivalents thereof or derivatives.
Preferably, the subject receiving said oligonucleotide also receives one or more other drugs chosen from GCS, 5-ASA, azathioprine, 6-mercaptopurine, sulphasalazine and methotrexate.
More preferably, the subject receiving said oligonucleotide also receives one or more other drugs chosen from oral GCS, oral 5-ASA, oral MMX budesonide, azathioprine, 6-mercaptopurine, and oral methotrexate.
In some embodiments, the subject receiving said oligonucleotide also receives one or more steroid drugs, for example corticosteroids and glucocorticosteroids.
For purposes of the invention, the terms "in combination with" and "add-on"
mean in the course of treating the same disease in the same patient, and include administering the oligonucleotide and one or more additional therapeutic agents in any order, including simultaneous administration, as well as temporally spaced order of up to several months apart.
Typically, said oligonucleotide is administered topically, such as topically to the mucous membrane.
Typically, said oligonucleotide is administered intracolonically.
Intracolonical administration is typically effected rectally. Thus, preferably said oligonucleotide is administered rectally. Intracolonical administration is typically effected using an enema or catheter. Intracolonical administration may involve administration by a rectal enema.
Intracolonical administration may be topical, for example performed during colonoscopy with the aid of a spraying catheter, or other suitable medical equipment, inserted though the colonoscopies biopsy channel.

Preferably, the oligonucleotide is administered intracolonically by rectal enema. The rectal enema is typically suitable for self-administration by the subject. In this way, the oligonucleotide may be administered without a medical professional present allowing the subject to administer the oligonucleotide at home, without travelling to and from a clinic or hospital. Further, this avoids the use of more complex and expensive equipment such as a spray catheter device during an endoscopy.
Preferably, the oligonucleotide is self-administered rectally by the subject.
For instance, the oligonucleotide may be self-administered by rectal enema by the subject.
Thus, typically topical administration is effected via an enema which is suitable for self-administration by the subject.
Preferably, the subject has not been subjected to colonic cleaning prior to said administration. Thus, for any subject as described herein, and for any amount of oligonucleotide as described herein, typically, the subject has not been subjected to colonic cleaning prior to said administration.
As used herein, reference to a subject "which has not been subjected to colonic cleaning" is intended to define a subject which has not been subject to colonic cleaning in a time period prior to the administration of the oligonucleotide to reduce the amount of faecal matter in the colon treated with the oligonucleotide. Thus, typically the subject has not been subjected to colonic cleaning for 1 hour prior to the treatment with the oligonucleotide, typically for 4 hours prior to the treatment with the oligonucleotide, preferably for 8 hours prior to the treatment with the oligonucleotide, more preferably for 12 hours prior to the treatment with the oligonucleotide, more preferably for 24 hours prior to the treatment with the oligonucleotide, most preferably for 48 hours prior to the treatment with the oligonucleotide.
Typically, said colonic cleaning can be effected by any method known in the art, for example administration of a laxative.

Typically, said subject has luminal faecal material. Typically, said subject has faecal material which coats or is proximal to the colonic epithelial cells treated with the oligonucleotide. Said subject may have faecal material in the lumen which is not directly in contact with the colonic epithelial cells treated with the oligonucleotide.
Said subject may have faecal material in the lumen which is coats or is proximal to the colonic epithelial cells treated with the oligonucleotide and faecal material in the lumen which is not directly in contact with the colonic epithelial cells treated with the oligonucleotide.
More preferably, the amount of said faecal material is the normal amount which would be expected in a patient which had never been subjected to colonic cleaning.
Preferably, said topical administration is effected via an enema which is suitable for self-administration by the patient. Typically, the enema has an elongate tip configured so as to enable insertion into the rectum. Typically, said tip is from 4 to 15 cm long, typically from 4 to 10 cm long, preferably 5 to 6 cm long. Thus, typically the cobitolimod is administered via a method which involves the insertion into the rectum only of an elongate enema tip which is from 4 to 15 cm long, preferably from 4 to 10 cm long.
The said oligonucleotide may be delivered to the upper portion of the descending colon or to the transverse region of the colon; however other regions are also possible when suited.
.. Topical administration to other parts of the gastrointestinal tract is also possible.
Yet in another embodiment of this aspect, the said oligonucleotide can be administered by any appropriate administration route, such as, but not limited to, inhalation, intranasal, parenteral, oral, intradermal, subcutaneous, vaginal and rectal administration. Further, in .. certain embodiments, systemic administration of said oligonucleotide may be used.
The oligonucleotide may be administered in the form of a pharmaceutical composition comprising the oligonucleotide as defined herein together with one or more pharmaceutically acceptable carriers. As used herein, the term "carrier"
encompasses any excipient, diluent, filler, salt, buffer, water, stabilizer, solubilizer, lipid, or other material well known in the art for use in pharmaceutical formulations. It will be understood that the characteristics of the carrier will depend on the route of administration for a particular application.
As used herein, the term "pharmaceutically acceptable" refers to a material that does not interfere with the effectiveness of the immunomodulatory oligonucleotide and is compatible with a biological system such as a cell, cell culture, tissue, organ, or organism.
Preferably, the biological system is a living organism, such as a vertebrate.
Typically, the composition is a solution of the oligonucleotide in a liquid carrier.
Typically, the carrier is water, preferably sterile water. Thus, typically the composition comprises the oligonucleotide as defined herein and water.
Preferably, the carrier is water and the oligonucleotide (in the form of a composition) is administered intracolonically, for instance as a rectal enema.
The concentration of an oligonucleotide in a pharmaceutical composition will vary depending on several factors, including the dosage of the oligonucleotide to be administered. Typical concentrations of oligonucleotides in compositions that are solutions are 1 mg/ml to 20 mg/ml, preferably 5 to 15 mg/m1õ preferably 8 mg/ml to 12 mg/ml, more preferably about 10 mg/ml.
Preferably, the present invention provides cobitolimod for use in the treatment of ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart.
Alternatively, the present invention provides cobitolimod for use in the treatment of ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on two or more separate occasions 3 weeks apart until the subject is in remission, typically remission as determined by an index as defined herein.

More preferably the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is administered in the form of a pharmaceutical composition comprising cobitolimod and water.
For instance, the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on two or more separate occasions 3 weeks apart, wherein cobitolimod is administered intracolonically or rectally. Preferably, the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on two or more separate occasions 3 weeks apart, wherein cobitolimod is self-administered rectally by the subject. For instance, the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on two or more separate occasions 3 weeks apart, wherein cobitolimod is self-administered by rectal enema by the subject.
More preferably the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is administered intracolonically or rectally. For instance, the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is self-administered rectally by the subject. For instance, the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is self-administered by rectal enema by the subject.
More preferably the present invention provides cobitolimod for use in the treatment of active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is administered intracolonically or rectally in the form of a pharmaceutical composition comprising cobitolimod and water.
Even more preferably the present invention provides cobitolimod for use in the treatment of chronic active ulcerative colitis, as defined herein, in a human subject, as defined herein, wherein individual doses of about 500mg of cobitolimod are administered to the patient on only two separate occasions, said separate occasions being 3 weeks apart, wherein cobitolimod is administered intracolonically or rectally in the form of a pharmaceutical composition comprising cobitolimod and water.
The present invention also provides a pharmaceutical composition comprising an oligonucleotide as defined herein, together with one or more pharmaceutically acceptable carriers, for use in the treatment of an inflammatory bowel disease as defined herein in a human subject as defined herein, wherein individual administrations of said composition are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the composition delivers an amount of the oligonucleotide as defined herein.
Preferred features of the oligonucleotide for use as defined above are also preferred features of the composition for use.
The present invention also provides use of an oligonucleotide as defined herein, or a pharmaceutical composition as defined herein, in the manufacture of a medicament for use in treating an inflammatory bowel disease as defined herein, in a human subject as defined herein, wherein individual administrations of said oligonucleotide or composition are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the oligonucleotide or composition delivers an amount of the oligonucleotide as defined herein.
Preferred features of the oligonucleotide for use as defined above are also preferred features of the use of the oligonucleotide or composition.
The present invention also provides a method of treating an inflammatory bowel disease as defined herein, in a human subject as defined herein, comprising administering to said subject an oligonucleotide as defined herein or a composition as defined herein, wherein individual administrations of said oligonucleotide or composition are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the oligonucleotide or composition delivers an amount of the oligonucleotide as defined herein.
The present invention also provides a method of treating an inflammatory bowel disease as defined herein, in a human subject as defined herein, which method comprises:
(a) selecting a patient as defined herein; and (b) administering to said patient an oligonucleotide as defined herein or a composition as defined herein, wherein individual administrations of said oligonucleotide or composition are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the oligonucleotide or composition delivers an amount of the oligonucleotide as defined herein.
Preferred features of the oligonucleotide for use as defined above are also preferred features of the claimed method.

Maintenance therapy The invention also provides an oligonucleotide for use in preventing the recurrence of active ulcerative colitis in a patient, wherein the oligonucleotide comprises the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2). The oligonucleotide may be any oligonucleotide of SEQ ID NO:2 as described herein. Preferably said oligonucleotide is cobitolimod.
Thus, the oligonucleotide may be for use as a maintenance therapy. In the context of this aspect of the present invention, reference to preventing the recurrence of active ulcerative colitis is intended to refer to preventing recurrence of the active phase of the disease, i.e.
maintaining a patient in remission and providing a maintenance therapy. Thus, the present invention relates to the use of an oligonucleotide as defined herein to prevent the recurrence of or relapse into the active phase of ulcerative colitis. The oligonucleotide as herein above can be used as maintenance therapy to prevent the recurrence of or relapse into symptoms associated with active ulcerative colitis, and/or to improve the patient's condition.
The patient may be any patient or subject as described herein. For instance the patient may be suffering with any type of ulcerative colitis as described herein.
Typically, the subject has been diagnosed with left-sided ulcerative colitis, i.e. distal colitis, including proctosigmoiditis.
Typically, the patient has previously been treated for active ulcerative colitis, for instance the patient may have previously received one or more therapeutic agents for the treatment of active ulcerative colitis. The one or more therapeutic agents may comprise the oligonucleotide of SEQ ID NO:2 as described herein. Thus, the patient may have received the oligonucleotide as described herein, wherein individual doses of from 400mg to 600mg of said oligonucleotide are administered to the subject on at least two separate occasions, .. wherein said separate occasions are 3 weeks apart to bring the patient into remission (i.e. to treat active ulcerative colitis). The one or more therapeutic agents may comprise any other therapeutic agent used to treat ulcerative colitis, as described herein.

Typically, individual doses of said oligonucleotide are administered to the patient with regular intervals between those individual doses. The interval between individual doses may be from 1 week to 12 months, for instance, the interval between individual doses is 1 week, 2 weeks, 3 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 6 months or 12 months.
Preferably, the interval between individual doses is 3 weeks.
The individual doses are doses of from 10mg to 600mg of said oligonucleotide.
For instance the individual doses may be from 150 to 350 mg of said oligonucleotide. For instance, the individual doses may be about 250 mg of said oligonucleotide.
The individual doses may be from 350 to 600 mg of said oligonucleotide, preferably from 400 to 600 mg of said oligonucleotide. For instance, the individual doses may be from 425mg to 575mg of said oligonucleotide, from 450mg to 550mg, from 460 to 540, from 470 to 530, from 480 to 520, preferably from 490 to 510, more preferably from 495 to 505, even more preferably from 499 to 501 mg. Typically, the individual doses may be about 500 mg of said oligonucleotide.
To maintain the patient in remission it may be necessary to repeatedly administer the oligonucleotide over a longer time frame. The above dosage regime, i.e. of administering individual doses of said oligonucleotide to the patient at regular intervals is continued for a time period such that it provides an ongoing maintenance therapy. Given that ulcerative colitis is chronic condition that cannot be cured, this means in practice that patients will generally receive the regimes as described herein for extended periods of time, typically for at least 6 months, preferably for at least 1 year or 2 years, for example for at least 5 year or 10 years. In practice, some patients may need to be administered the regimes as described herein for as long as needed (as determined e.g. by a physician) or indefinitely.
Thus, the patient may be administered the individual doses at regular intervals for at least 6 months, preferably for at least 1 year or 2 years, more preferably for at least 5 years or 10 years or indefinitely.
The patient may receive multiple doses of the said oligonucleotide at regular intervals, the individual doses of said oligonucleotide are between 150 and 350 mg, and interval between those individual doses is 1 week, 2 weeks, 3 weeks or 4 weeks. Thus, in a preferred aspect of the invention, the patient receives multiple doses of the said oligonucleotide at regular intervals, the individual doses of said oligonucleotide are about 250mg, and interval between those individual doses is 3 weeks. These regimes are typically continued for at least 6 months, preferably for at least 1 year or 2 years, for example for at least 5 year or 10 years or indefinitely.
The patient may receive multiple doses of the said oligonucleotide at regular intervals, the individual doses of said oligonucleotide are between 400 and 600 mg, and interval between those individual doses is 1 week, 2 weeks, 3 weeks or 4 weeks, with 3 weeks preferred. In another preferred aspect of the invention, the patient receives multiple doses of the said oligonucleotide at regular intervals, the individual doses of said oligonucleotide are about 500mg, and interval between those individual doses is 3 weeks. These regimes are typically continued for at least 6 months, preferably for at least 1 year or 2 years, for example for at least 5 year or 10 years or indefinitely.
In the above dosage regimes individual doses (of an amount as specified herein) of said oligonucleotide are administered to the patient on multiple occasions spaced apart by particular numbers of weeks. This means that the patient does not receive any additional oligonucleotide between the specified doses/administrations divided by the specified time periods.
The oligonucleotide may be for use as a monotherapy. Alternatively, the patient may receive one or more additional therapeutic agents for preventing the recurrence of active ulcerative colitis. The additional therapeutic agents may be any therapeutic agents as described herein used in treating ulcerative colitis. For instance, the patient may receive one or more additional anti-inflammatory agents for preventing the recurrence of active ulcerative colitis. Therefore, the oligonucleotide may be administered combination with one or more additional therapeutic agents for the prevention of recurrence of active ulcerative colitis chosen from anti-inflammatory drugs, immunomodulatory drugs, anti-integrin therapy drugs, TNF-a inhibitors, immunosuppressive drugs, JAK
inhibitors or other suitable drugs for treating ulcerative colitis or other suitable drugs for treating ulcerative colitis. Examples of such drugs suitable for use in combination with said oligonucleotide include, but are not limited aminosalicylates (such as 5-ASA
[also known as mesalamine], sulfasalazine, olsalazine and balsalazide), GCS (such as prednisone, methylprednisolone, hydrocortisone and budesonide), azathioprine (AZA), 6-mercaptopurine (6-MP), tacrolimus, methotrexate, cyclosporine, infliximab (REMICADECD), etanercept (ENBREL CD), adalimumab (HUMIRACD), certolizumab (CIMZIACD), golimumab (SIMPONICD), ustekinumab (STELARACD), vedolizumab (ENTYVIOCD), SMAD7 antisense oligonucleotide (Mongersen), natural IFN-13, Decortin, tofacitinib (XELJANZCD), etrolizumab, ozanimod, SHP647, filgotinib, mirikizumab, apremilast (OTEZLACD), estrasimod, AJM300, upadacitinib, risankizumab, BI655130, PF-06700841, PF-06651600 and IMU-83, and equivalents thereof.
For purposes of the invention, the terms "in combination with" and "add-on"
mean in the course of treating the same disease in the same patient, and include administering the oligonucleotide and one or more additional therapeutic agents in any order, including simultaneous administration, as well as temporally spaced order of up to several months apart.
The oligonucleotide may be administered via any administration route as described herein.
Typically, said oligonucleotide is administered topically, such as topically to the mucous membrane. Typically, said oligonucleotide is administered intracolonically.
Intracolonical administration is typically effected rectally. Intracolonical administration is typically effected using an enema or catheter. Intracolonical administration preferably involves administration by an enema (i.e. by rectal enema). Typically, the oligonucleotide administered by rectal enema, preferably the oligonucleotide is self-administered by rectal enema.
Preferably, for this aspect of the invention, the subject has not been subjected to colonic cleaning prior to said administration.
The following non-limiting Examples illustrate the invention.

Examples Reference Example 1 ¨ Clinical trial results showing optimum dosing frequency In a randomized, double-blind, placebo-controlled trial, 131 patients with moderate-to-severe active ulcerative colitis were randomized to receive two single doses of cobitolimod/Kappaproct (30mg) or placebo administered topically during lower GI
endoscopy at baseline and week 4.
Patients in the treatment group and placebo group monitored the maximum amount of blood in their stool by week (as none, a little, or a lot), weekly stool frequency (as <18, 18-35, 36-60 or 61+) and daily stool frequency (as <1, 1-1.99, 2-2.99, 3-3.99, 4-4.99, 5-5.99, 6-6.99, 7-7.99 or 8+) using an e-diary for twelve weeks.
.. Results were collated and the treatment delta for the treatment group over the placebo group calculated. From these results, it can be seen that there is a particularly high treatment delta 3 weeks after initial administration.
The results for the treatment group and the placebo group are represented in the following figures:
Figure 1 shows the proportion of the treatment and placebo groups reporting blood in stool = zero (maximum patient reported outcome during 7 days) by week.
Figure 2 shows the proportion of the treatment and placebo groups reporting weekly stool frequency <18 (summary of patient reported outcome during 7 days) by week.
Figure 3 shows the proportion of the treatment and placebo groups reporting weekly stool frequency <35 (summary of patient reported outcome during 7 days) by week.
Figure 4 shows the proportion of the treatment and placebo groups reporting daily stool frequency <3 (mean daily patient reported outcome during 7 days) by week.

Figure 5 shows the proportion of the treatment and placebo groups reporting daily stool frequency <4 (mean daily patient reported outcome during 7 days) by week.
Figure 6 shows the proportion of the treatment and placebo groups reporting daily stool frequency <5 (mean daily patient reported outcome during 7 days) by week.
Treatment deltas for the various clinical outcomes assessed in the trial are given in the Tables below.

Table 1 - maximum blood in stool reported weekly by e-diary data (delta in favour of treatment is shown for patients with no blood in stool) w o w w w a g ig 11 12 w w 4.
n n n n n n n n n n n n D'acebo None 2 .' 3 8 9 10 10 10:
13 : 11 12 9 Little .15 .zu 19 16 19 17 .1 iii .16 16 15 14 15 A lot .16 7 10 7 6 7 ei ' :3 Total 3.1 32 3.1 17 23 23 2;3 27 :jj 2 2 g 33 31 Little 3!--i 33 36 24 30 27 28 P
A lot z.D 15 15 21 13 12 a ,,,9 8 10 9 .
Total 71) 68 68 68 65 65 63 53 62: 62 61 60 2 4.

, u9 , Aace:-_,,D None 6.1.:.:::: 12.9.:y6 9.2--._: 2.5.8':._:
27.::1_ 30.3'..: 3111.3z::. :=1.:=:-.
Little i5.5:',.:. 3,1.5:6 7!.:: '11..=-:.- ,1HH- - -, -:1111--..-: = I j.0 .õ.
A lot .-;.1.3:. 22.6::,- 15 2:-i8.2:. 2.1.2.::
Total 11:10.0;:: 100Ø 100.0-_, 100.0;:
ill iD. 0 - .. .1 u i 1 1 1 --, .. 1 1 ili 1 1 -.- .. .1 u 0.0 ry::
cc; -..:1 :ohmod None 8.6% 22.1% 25.0% 23.8H 34.8%
40.0% =2H-D.::::: Lii.;-:L.) 46.8% 54.1' 51.7::
Little 55.7c-_, 55.L=H.-, E2.!-Dc...:, SE.Sr:,::
LHE.EH =/1:5'..-., ,I..L:;.:: ,-.1.3::--_ lij.:-=''....) 40.:3 . I Ct :3E.TH: 22..1:, 22.1 :r...-_, ::;1.1.Y -..-_, 1 ]D.7 '...:: 18 :' 12.7c::: 1.L.:3--:::
.12._=1'..-_, .12.:D I , .16.1., 15.0_: *0 n 1 cio.LH-_, 10,:i.lii--..-_, 11_10.1".:.-; 101n !,-..-: lei-, ,-; 1,--,c,ii::.:, 10,-).0:..:: 1I 1l] .1 oi.j.iir;.:, 1,-,-.J.,-:,:;õ 11-.)0.1:::
m c=,e,it.:3 in favour -2,5 L-,1..2...., 1,5.65..: 8.0 7 .:, 7.157.:: 9.7'7.3 ......2.67.:, :3. 27 :D 6.:::L 10.1%
1.1.2:::::
o of Oio,..i w 1-, o oe w o, w Table 2 - weekly stools frequency (delta in favour of treatment)

11 12 <18 2.3% 5.6% 10.2% 5.3% 4.0% 13.0% 13.0% 11.4% 11.8% 6.2% 6.4% 2.4%
18-35 3.0% 10.0% 7.4% 21.8% 9.8% 4.1% 7.4% 6.8% -1.1% 6.0% 6.3% 6.7%
>35 5.8% 15.6% 17.6% 27.1% 13.8% 17.1% 20.4% 18.2% 10.7% 12.2% 12.7%
9.1%
Table 3 - Mean daily stool frequency (delta in favour of treatment) <2 0.0% 4.4% 7.2% 4.1% 3.0% 6.3% 6.9% 9.7% 2.1% 7.6% 9.3% 6.9%
<3 3.9% 8.0% 17.3% 9.4% 12.1% 14.2% 19.9% 9.9% 16.8% 15.4% 16.7% 19.1%
<4 4.7% 22.4% 21.0% 17.7% 13.6% 25.1% 29.9% 29.0% 22.0% 11.6% 22.9%
17.6%
<5 3.8% 22.7% 12.3% 24.2% 21.2% 14.5% 22.7% 19.7% 13.0% 11.1% 10.4%
7.8%
1-d Table 4 - symptomatic remission: blood in stool=0 and weekly stool frequency <35 t..) o 3 odd in stod =0 and ',..'e.e.,:: .y. S7.00 freque.ncy _______________________________________________________________________________ ____________________________________________ n.) Wee:4. 1 2 3 4 5 6 7 8 9 10 11 12 1-' 1-, n.) N
D a ce :a o Flo 32 30 31 27 27 27 2.E 24 23 7,2 __ 19 Yes 1 1 1 4 6 Total 3-3 31 ,,,, -,..i 3.]: .-õ.-_, 33 32 31 fu 26 27 C 0 :--iod Ho 67 ,r2 _:!_-_!
_:. 43 39 Total 70 68 68 68 66 ifh- 132 .:;.-_ ,i, 1 62 60 P
.
N) .
N) .6.
.
4=, Blood in stool = 0 and weekly stool frequency <35 r., Week 1 2 3 4 5 6 7 8 9 10 11 12 .
r., , u, , Placebo No 97.0% 96.8% 96.9% 87.1% 81.8% 81.8% 75.8%
75.0% 74.2% 73.3% 67.9% 77.8%
Yes 3.0% 3.2% 3.1% 12.9% 18.2% 18.2% 24.2%
25.0% 25.8% 26.7% 32.1% 22.2%
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
cobitolimod No 95.7% 80.9% 76.5% 72.1% 68.2% 67.2% 62.9%
60.3% 59.0% 56.5% 51.7% 51.7%
Yes 4.3% 19.1% 23.5% 27.9% 31.8% 32.8% 37.1%
39.7% 41.0% 43.5% 48.3% 48.3%
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
_______________________________________________________________________________ ____________________________________________ IV
Delta in favor of cobitolimod 1.3% 15.9% 20.4% 15.0% 13.6% 14.6% 12.9% 14.7% 15.2%
16.9% 16.2% 26.1% n 1-i i-=1--Iv t..) =
t..) ,-, -a-, oe t..) c, t..) Reference Example 2 ¨ Clinical trial study A randomised double-blind, placebo controlled, trial assesses the efficacy and safety of topical cobitolimod in moderate to severe active ulcerative colitis patients in accordance with established methods.
Methods: Men and women are selected for trial according to standard inclusion criteria in the field including the following:
1. Male or female? 18 years of age 2. Established diagnosis of UC, with minimum time from diagnosis of >3 months 3. Moderately to severely active left sided UC (disease should extend 15 cm or more above the anal verge and not beyond the splenic flexure) determined by a Modified Mayo score (excluding the friability at grade 1 for the endoscopic sub score) of 6 to 12 with an endoscopic sub score >2 assessed by central reading of endoscopy performed at screening visit lb (Day -7 to -10- screening visit), and no other individual sub score <1 4. Current oral 5-ASA/SP use or a history of oral 5-ASA/SP use 5. Current GCS use or history of GCS dependency, refractory, or intolerance, including no GCS treatment due to earlier side-effects (only one of the GCS criteria have to be fulfilled, see definition in European Crohn's and Colitis organisation (ECCO) guidelines) 6. Demonstrated an inadequate response, loss of response, or intolerance to at least one of the following agents:
= Immunomodulators, e.g. cyclosporine, methotrexate, AZA/6-MP, tacrolimus o For example,signs and symptoms of persistently active disease despite previous treatment with at least one 8 week regimen of oral AZA (>1.5 mg/kg) or 6-MP (>0.75 mg/kg) or lower doses prompted by intolerance or thiopurine methyltransferase (TPMT) deficiency or o For example, previous intolerance (including, but not limited to, nausea/vomiting, abdominal pain, pancreatitis, liver function test (LFT) abnormalities, lymphopenia, TPMT genetic mutation, infection) to at least one immunomodulator = TNF-a inhibitors and/or anti-integrins:
o Signs and symptoms of persistently active disease despite previous treatment with at least one induction regimen with 2 doses at least 2 weeks apart (or doses as recommended according to the current labels) of for e.g.:
= Infliximab 5 mg/kg (intravenous (IV)) or = Golimumab 200/100 mg (subcutaneous (SC)) or = Adalimumab 160/80 mg (SC) or = Vedolizumab 300 mg (IV) or o History of intolerance (including but not limited to infusion-related reaction, demyelination, congestive heart failure, infection) Recurrence of symptoms during maintenance dosing with any of the above medications following prior clinical benefit, (secondary failure) [discontinuation despite clinical benefit does not qualify]
7. Allowed to receive a therapeutic dose of following UC drugs during the study:
a) Oral GCS therapy (<20 mg prednisone or equivalent/daily) providing that the dose has been stable for 2 weeks prior to visit la (Day -14) b) Oral MMX Budesonide therapy (9mg/daily) initiated at least 8 weeks before visit 1 a c) Oral 5-ASA/SP compounds, providing that the dose has been stable for 2 weeks prior to visit 1 a and initiated at least 8 weeks before visit la d) AZA/6-MP providing that the dose has been stable for 8 weeks prior to visit lb and been initiated at least 3 months before visit la 8. Ability to understand the treatment, willingness to comply with all study requirements and ability to provide informed consent Patients may be excluded from trial in accordance with known exclusion criteria in the field including the following:
1. Suspicion of differential diagnosis such as; Crohn's enterocolitis, ischaemic colitis, radiation colitis, indeterminate colitis, infectious colitis, diverticular disease, associated colitis, microscopic colitis, massive pseudopolyposis or non-passable stenosis 2. Acute fulminant UC and/or signs of systemic toxicity 3. UC limited to the rectum (disease which extend <15 cm above the anal verge) 4. History of malignancy, except for:
= Treated (cured) basal cell or squamous cell in situ carcinoma = Treated (cured) cervical intraepithelial neoplasia or carcinoma in situ of the cervix with no evidence of recurrence within the previous 5 years prior to the screening visit 1 a 5. History or presence of any clinically significant disorder that, in opinion of the investigator, could impact on patient's possibility to adhere to the protocol and protocol procedures or would confound the study result or compromise patient safety 6. Concomitant treatment with cyclosporine, methotrexate, tacrolimus, TNF-a inhibitors, anti-integrins or similar immunosuppressants and immunomodulators at enrolment. Any prior treatment with such drugs must have been discontinued at least 8 weeks prior to visit la or have non-measurable serum concentration levels 7. Treatment with rectal GCS, 5-ASA/SP or tacrolimus within 2 Weeks before visit lb 8. Long term treatment with antibiotics or non-steroidal anti-inflammatory drugs (NSAIDs) within two weeks prior to visit la (one short treatment regime for antibiotics and occasional use of NSAIDS are allowed) 9. Serious active infection 10. Gastrointestinal infections including positive Clostridium difficile stool assay 11. Currently receiving parenteral nutrition or blood transfusions

12. Females who are lactating or have a positive serum pregnancy test during the screening period

13. Women of childbearing potential not using reliable contraceptive methods (reliable methods are barrier protection, hormonal contraception, intra-uterine device or abstinence) throughout the duration of the study

14. Concurrent participation in another clinical study with investigational therapy or previous use of investigational therapy within 5 half-lives and within at least 30 days after last treatment of the experimental product prior to enrolment

15. Previous exposure to cobitolimod Patients selected for trial are randomised to treatment sequences comprising cobitolimod or placebo according to the study arms set out below. Cobitolimod or placebo was administered topically to the colon via rectal enema which is suitable for self-administration. Unlike in the COLLECT study, no special steps were taken to ensure the colon was clean prior to enema administration.
Study arms:
- Two 31 mg doses of cobitolimod at weeks 0 and 3 (placebo at weeks 1 and 2);
- Two 125 mg doses of cobitolimod at weeks 0 and 3 (placebo at weeks 1 and 2);
- Two 250 mg doses of cobitolimod at weeks 0 and 3 (placebo at weeks 1 and 2);
- Four 125 mg doses of cobitolimod at weeks 0, 1, 2 and 3.
The primary outcome measure was established as follows:
- Proportion of patients in clinical remission at week 6 as defined by Modified Mayo subscores satisfying all of the following three criteria: i) rectal bleeding of 0, ii) stool frequency of 0 or 1 (with at least one point decrease from baseline), iii) endoscopy score of 0 or 1 (excluding friability) The secondary outcome measures are as follows:

= Proportion of patients with induction of symptomatic remission, at Week 4 or 6, defined by the Mayo subscores, i) rectal bleeding of 0, ii) stool frequency of 0 or 1 (with at least one point decrease from Baseline) = Proportion of patients with absence of rectal bleeding at Week 4 or 6 defined by the Mayo subscore rectal bleeding of 0 = Proportion of patients with normal or enhanced stool frequency at Week 4 or 6 defined by the Mayo sub score stool frequency of 0 or 1 (with at least one point decrease from Baseline) = Endoscopic remission at week 6 defined by the Modified Mayo endoscopic subscore of 0 or 1 = Proportion of patients in clinical response at Week 6 defined as a clinical remission or a three point and >30% decrease from Baseline = Proportion of patients with histological remission at week 6 as defined by the Nancy histological index = Proportion of patients with histological response at Week 6 as defined by the Nancy histological index score = Proportion of patients with reduced defecation urgency score = Mean change in faecal calprotectin at Week 1, 2, 3, and 6 compared to Week 0 = Mean change in each of the inflammatory bowel disease questionnaire (IBDQ) sub domains at Week 6 compared to Week 0 Results Primary Efficacy Analysis: Analysis of Clinical Remission at Week 6 Clinical Statistical Cobitolimod Cobitolimod Cobitolimod Cobitolimod Placebo remission Parameter 2x31mg 2x125mg 2x250mg 4x125mg (N=44) (N=40) (N=43) (N=42) (N=42) Yes n (%) 5 (12.5) 2 (4.7) 9 (21.4) 4 (9.5) 3 (6.8) No n (%) 28 (70.0) 39 (90.7) 26 (61.9) 35 (83.3) 36 (81.8) Missing n (%) 7 (17.5) 2 (4.7) 7 (16.7) 3 (7.1) 5 (11.4) Conclusion Treatment with two doses of 250mg cobitolimod three weeks apart in patients suffering from moderate to severe ulcerative colitis leads to a higher percentage of patients in clinical remission at week 6 compared to placebo. The percentage of patients receiving two doses of 250 mg cobitolimod in remission at week 6 was also higher than the percentage of patients in remission for the other dosage regimes (2x31 mg, 2x125 mg and 4x125 mg). In particular, the percentage of patients in remission who received two doses of 250 mg cobitolimod was higher than for the patients who received four doses of 125 mg cobitolimod. This is a surprising outcome in that it shows that administration of the same total amount of active ingredient via a reduced number of higher doses provides an improved clinical outcome.
The results also demonstrate that, surprisingly, clinical efficacy can be obtained without removal of faecal material from the colon and/or colonic epithelial cells.
Further, clinical efficacy can be achieved by administration from an enema device which is suitable for self-administration.
Example 1 A dose of 2x500 mg will be evaluated in addition to the 2x250mg dose in this study.
Cobitolimod will be administered rectally with a prefilled enema, which places the drug in close contact with a high number of intended target cells.
Potential Risks and Benefits Cobitolimod has been studied in treatment refractory UC patients administered rectally.
The target groups for treatment are patients with chronic active left-sided UC
in whom previous treatments with conventional drugs, have not resulted in adequate response.
Results from the clinical studies showed that cobitolimod can induce remission in these patients.

Non-clinical safety studies in rodents and cynomolgus monkey have indicated that cobitolimod is well tolerated and no evidence of systemic or local toxicity has been found.
Safety assessments from the five placebo-controlled trials with cobitolimod have not indicated any significant toxicity. Administration of cobitolimod is straightforward and drug compliance has been reported as excellent. Overall, cobitolimod has been well tolerated.
The overall data on cobitolimod, as well as extensive clinical experience from similar oligonucleotides, would therefore support a positive benefit risk assessment when administered according to the proposed protocol to moderate to severe active left-sided UC
patients. For more detailed information, about the known and expected benefits and risks and reasonably expected adverse events of cobitolimod may be found in the Investigator's Brochure.
Study Objectives Primary Objective Induction Study To evaluate the efficacy of cobitolimod treatment compared to placebo in inducing clinical remission, in participants with moderate to severe active left-sided ulcerative colitis (UC).
Secondary Objectives Induction Study = To explore the most efficacious and clinically relevant dose of the cobitolimod 250 mg and cobitolimod 500 mg versus placebo and in balance to the safety = To evaluate the safety and tolerability of cobitolimod = To evaluate the efficacy of cobitolimod treatment in clinical symptoms and in endoscopic improvement = To evaluate the efficacy of cobitolimod treatment compared to placebo in other endpoints = To evaluate health related quality of life (QOL) and health economics Induction Study The induction study will target participants with moderate to severe active left-sided UC
who demonstrate an inadequate response or failure to tolerate conventional or biological therapy. The study will have two parts (la and lb), where the objective in the first part is to explore a clinically relevant and the most efficacious dose between cobitolimod 250 and 500 mg versus placebo.
After an adequate number of the participants (-150) has been randomized and has eligible data for the primary endpoint an interim analysis will be performed to evaluate the "winning" dose. After decision has been made which dose is most efficacious, the winning dose will be used for the randomisation of the remaining participants. The participants who have received the "losing" dose will be included into the overall safety evaluation.
In the first induction study, 450 eligible participants will be randomly assigned in a 1:1:1 allocation to either receive rectal doses of cobitolimod 250 mg or 500 mg, or placebo.
Active left-sided UC participants with a 3-component Mayo score of 5-9, with an endoscopic sub score >2 and no other individual sub score <1, who are at least 18 years of age will be eligible for enrolment.
Randomisation in the two induction studies will be stratified for the following categories of participants: concomitant use of glucocorticoidsteroid (GCS) treatment (Yes/No) and previously treated with biologics (infliximab, adalimumab, golimumab, vedolizumab, ustekinumab) and JAK inhibitors (tofacitinib) (Yes/No).
Study treatment will be administered rectally using an enema.
There will be two screening visits in the induction studies. At the first screening visit la, a written informed consent will be obtained before any other study procedure is done. The participants will be assigned a participant identification number and enrolment procedures will commence. At the second screening visit lb, a full colonoscopy will be performed.
Visits for the induction studies will be performed at Day -14, Day-5-7, Week 0, 3 and 6.
Participants will self-administer the study drug at clinic under supervision of study staff, to ensure the participant can manage to administrate the study drug appropriate if continuing in post-induction studies with self-administration.

All UC specific medical therapies e.g. GCS, 5-ASA, AZA/6-MP must be maintained at a stable dose through to the end of the induction study (Week 6).
Study Evaluation Criteria Endpoints including the Mayo sub scores of blood in stool and stool frequency will be derived using eDiary data.
Induction Study 1 and 2 - Primary Efficacy Endpoint Induction Study 1 and 2 = Proportion of participants with clinical remission at Week 6, defined by the 3-component Mayo scores, i) rectal bleeding of 0, ii) stool frequency of 0 or 1 (with at least one point decrease from Baseline, Week 0), and iii) endoscopy score of 0 or Main Secondary Endpoints Induction Study 1 and 2 = Proportion of participants with endoscopic improvement at Week 6 = Proportion of participants with symptomatic remission at Week 6 Secondary Endpoints Induction 1 and 2 = Proportion of participants with clinical response at Week 6 = Proportion of participants with histological improvement at Week 6 = Proportion of participants with normal or >1 points reduction in stool frequency from baseline at Week 6 = Proportion of participants with absence of rectal bleeding at Week 6 = Proportion of participants with the composite of endoscopic improvement and histological improvement at Week 6 = Mean change in Stool Frequency at Week 6 compared to Baseline, Week 0 = Proportion of participants with improvement in urgency at Week 6 = Mean change in the total score of the inflammatory bowel disease questionnaire (IBDQ) at Week 6 compared to Baseline, Week 0 = Mean change in ln-transformed faecal calprotectin at Week 6 compared to Baseline, Week 0 Exploratory Endpoints Induction 1 and 2 = Proportion of participants with faecal calprotectin values <250 mg/kg at Week 6 = Proportion of participants with CRP <5 mg/L at Week 6 = Proportion of participants with endoscopic remission at Week 6 = Proportion of participants with histological remission at Week 6 = Proportion of participants with histological response at Week 6 = Proportion of participants with the composite of endoscopic remission and histological remission at Week 6 = Proportion of participants with clinical remission at Week 6, based on the 4-component Mayo score = Proportion of participants with clinical response at Week 6, based on the component Mayo score = Proportion of participants with total score of the inflammatory bowel disease questionnaire (IBDQ) at Week 6, above threshold 170 = Proportion of participants with a change in the total score of the inflammatory bowel disease questionnaire (IBDQ) at Week 6 compared to Baseline, Week 0 above 16 point increase = Proportion of participants with symptomatic remission Week 2 and 4 = IBDQ sub-scores = EQ-5D-5L
= Mean change in ln-transformed CRP values at Week 6 compared to Baseline, Week Safety = Incidence of adverse events (AEs) = Incidence of serious adverse events (SAEs) = Vital signs = Physical Examination = Laboratory Findings Study population All relevant medical and non-medical conditions should be taken into consideration when deciding whether a particular participant is suitable to participate in this study. Participant eligibility should be reviewed and documented by an appropriately qualified member of the investigator's study team prior to inclusion in the study. Endoscopic eligibility and PRO2 criteria eligibility will be approved centrally and communicated to investigator before final randomization occur. If participant fails to fulfil the inclusion/exclusion criteria, participant can be considered to be re-screened at a later time if eligible.
Inclusion Criteria Induction Study 1 and 2 Participants must meet all the following inclusion criteria to be randomized in the study:
1. Male or female? 18 years of age 2. Established diagnosis of UC, with minimum time from diagnosis of at least 3 months before visit la 3. Moderate to severe active left-sided UC (disease should extend 15 cm or more above the anal verge and not beyond the splenic flexure) determined by a 3-component Mayo score of 5 to 9 with an endoscopic sub score >2 (in sigmoid or descending segments) assessed by central reading of endoscopy, and the stool frequency and rectal bleeding sub scores, assessed by e-diary, individually >1 4. Have failed or be intolerant of at least one of the following treatments:
a. Oral corticosteroids b. Azathioprine or 6-mercaptopurine (6-MP) c. Anti-TNF therapy: infliximab or adalimumab 5. Allowed to receive a therapeutic dose of following UC drugs during the study:
a. Oral GCS therapy (<20 mg prednisone or equivalent/daily) providing that the dose has been stable for 2 weeks prior to visit lb b. Oral MMX Budesonide therapy (9mg/daily) initiated at least 8 weeks before visit lb.
c. Oral 5-ASA/SP compounds, providing that the dose has been stable for 2 weeks prior to visit la and initiated at least 8 weeks before visit lb.
d. AZA/6-MP providing that the dose has been stable for 8 weeks prior to visit lb and been initiated at least 3 months before visit lb.

6. Ability to understand the treatment, willingness to comply with all study requirements and ability to provide informed consent Exclusion Criteria Participants presenting with any of the following should not be randomised in the study:
1. Suspicion of differential diagnosis such as Crohn's enterocolitis, ischaemic colitis, radiation colitis, indeterminate colitis, infectious colitis, diverticular disease, associated colitis, microscopic colitis, massive pseudopolyposis or non-passable stenosis 2. Acute fulminant UC, toxic megacolon and/or signs of systemic toxicity 3. UC limited to the rectum (disease which extend <15 cm above the anal verge) 4. Have failed treatment with more than 3 advanced therapies (infliximab, adalimumab, golimumab, vedolizumab, ustekinumab or tofacitinib) of 2 different classes (anti-TNF, anti-integrins, anti-IL12/23 or JAK-inhibitors) of agents 5. Have had a surgery for treatment of UC
6. History of malignancy, except for:
= Treated (cured) basal cell or squamous cell in situ carcinoma = Treated (cured) > 5 years since last treatment 7. History or presence of any clinically significant disorder that, in opinion of the investigator, could impact on participant's possibility to adhere to the protocol and protocol procedures or would confound the study result or compromise participant safety 8. Concomitant treatment with cyclosporine, methotrexate, tacrolimus, modern/targeted therapies such as infliximab, adalimumab, golimumab, vedolizumab, ustekinumab, tofacitinib or similar immunosuppressants and immunomodulators at enrolment.
Any prior treatment with such drugs must have been discontinued at least 12 weeks prior to visit lb or have non-measurable serum concentration levels Treatment with rectal GCS, 5-ASA/SP or tacrolimus within 2 Weeks before visit lb 9. Long term treatment with antibiotics or non-steroidal anti-inflammatory drugs (NSAIDs) within two weeks prior to visit lb (one short treatment regime for antibiotics and occasional use of NSAIDs and low dose NSAIDS, prophylactic therapy is allowed) 10. Serious active infection (including; history of latent or active tuberculosis, documented history of past or current tuberculosis, participants living with or having frequent close contact with people with active tuberculosis or with a positive tuberculosis test according to current regulations for 12 weeks preceding randomisation. Chronic Human Immunodeficiency Virus (HIV); Hepatitis B Virus (HBV), or Hepatitis C Virus (HCV) infections.
11. Gastrointestinal infections including positive Clostridium difficile stool assay 12. Females who are lactating or have a positive serum pregnancy test during the screening period 13. Women of childbearing potential not using highly effective (failure rate < 1%) contraceptive methods throughout the duration of the study.
14. Concurrent participation in another clinical study with investigational therapy or previous use of investigational therapy within 5 half-lives and within at least 30 days after last treatment of the experimental product prior to enrolment 15. Previous exposure to cobitolimod Randomisation and Stratification Participants in the Induction study 1 will initially be randomised to one of three treatment arms in a 1:1:1 ratio. After interim analysis, and selection of "winning" dose randomization will be done in a 1:1 ratio. Randomisation will be stratified for the following factors: concomitant use of GCS treatment (Yes/No) and previously treated with "modern"/targeted therapies (infliximab, adalimumab, golimumab, vedolizumab, ustekinumab) and JAK inhibitors (tofacitinib) (Yes/No). A computer-generated randomisation schedule will be used to assign participants to treatment sequences.
Treatment assignments will be obtained through the interactive voice response system (IVRS). Information regarding the treatment assignments will be kept secure.
Concomitant Medications All medications that the participant is prescribed and has taken during the study must be recorded in the eCRF. Any changes need to be reported in eCRF.

The following concomitant UC medications are allowed:
= Oral GCS therapy (<20 mg prednisone or equivalent/daily) providing that the dose has been stable for 2 weeks prior to visit lb and need to be kept stable up to primary endpoint (Week 6).
= Oral MMX Budesonide therapy (9mg/daily) initiated at least 8 weeks before screening visit lb and need to be kept stable up to primary endpoint (Week 6).

Tapering should start after Week 6 visit, if participants are in remission, see suggested tapering scheme below.
= Oral 5-ASA and/or SP compounds, providing that the dose has been stable for 2 weeks prior to visit lb and initiated at least 8 weeks before visit lb. Stable dose up to end of study (Week 54).
= AZA/6-MP providing that the dose has been stable for 8 weeks prior to visit lb and been initiated at least 3 months before visit la. Stable dose up to end of study (Week 54).
Prohibited Medications The following concomitant medications are prohibited throughout the duration of study:
= Cyclosporine = Methotrexate = tacrolimus or similar immunosuppressants/ immunomodulators.
= Biologics such as infliximab, adalimumab, golimumab, vedolizumab and ustekinumab = JAK-inhibitor = anti-IL23 Any prior treatment with these drugs must be discontinued at least 8 weeks prior to visit lb or have non-measurable serum concentration levels.
Example 2 ¨ Dextran sulfate sodium (DSS) induced colitis mouse model Materials and methods Mice: Balb/c mice are obtained from Charles River Laboratories, Research Models and Services (Sulzfeld, Germany). Eight week old female Balb/c mice are used for the experiments and were kept in individually ventilated cages in compliance to the Animal Welfare Act. Water and food are available ad libitum.
DSS induced colitis: 2% or 3% (w/v) Dextran sulfate sodium (DSS) is administrated for 10 days to the drinking water of 8 week old female Balb/c mice. An additional control group of mice which were completely untreated is also part of the experimental set up. Food uptake and bodyweight are monitored.
Rectal administration of cobitolimod: 1000ng, 2000 i_tg or 4000ng cobitolimod per mouse is rectally administered twice (on days 4 and 8). A dose of 1000ng in mice is approximately equivalent to a 250mg dose in a human (see "Guidance for Industry ¨
Estimating the Maximum Safe Starting Dose in Initial Clinical Trials for Therapeutics in Adult Health Volunteers", US Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research, July 2005). The results observed in this mouse model could be considered predictive of the effects observed in humans administered with individual doses of 250mg, 500 mg and 1000mg of cobitolimod on two separate occasions, 3 weeks apart.
Vehicle without cobitolimod was rectally applied to a control group of mice (placebo).
Mice from different treated groups were randomly mixed per cage before initiation of the experiment to ensure comparable experimental conditions.
Details of each study arm are provided below:
= Vehicle/DSS 2%
= Vehicle/DSS 3%
= Cobitolimod A /DSS 2%
= Cobitolimod A /DSS 3%
= Cobitolimod B/DSS 2%
= Cobitolimod B/DSS 3%
= Cobitolimod C /DSS 2%
= Cobitolimod C /DSS 3%
= Cobitolimod C/no DSS
Dose A= 1000 i_tg (250 mg human equivalent) Dose B= 2000 iJg (500 mg human equivalent) Dose C= 4000 iJg (1000 mg human equivalent) Evaluation of DSS induced colitis: The following parameters are to be monitored during the experiment:
1) Disease Activity Index (DAI) Score/global score = Sum of the scores for weight loss, stool consistency and blood in stool, (day 0, 2, 4, 6, 7, 8, 9 and 10) (The Disease Activity Index (DAI) is the combined score of body weight loss compared to initial body weight, stool consistency, and visible blood in feces. The maximum score per mouse is 12) 2) Clinical behaviour scoring (day 0, 2, 4, 6, 7, 8, 9 and 10) 3) Temperature measurement (twice) SEQUENCE LISTINGS
SEQ ID NO:1 5'-G*G*A*ACAGTTCGTCCAT*G*G*C-3', wherein the asterisk (*) indicates a phosphorothioate linkage SEQ ID NO:2 5'-GGAACAGTTCGTCCATGGC-3'

Claims (25)

1. An oligonucleotide comprising the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2) for use in the treatment of an inflammatory bowel disease in a human subject, wherein individual doses of from 400mg to 600mg of said oligonucleotide are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart.

2. The oligonucleotide for use according to claim 1, wherein said inflammatory bowel disease is ulcerative colitis.

3. The oligonucleotide for use according to claim 2, wherein said ulcerative colitis is active ulcerative colitis.

4. The oligonucleotide for use according to claim 2 or 3, wherein said ulcerative colitis is chronic active ulcerative colitis.

5. The oligonucleotide for use according to any of the preceding claims, wherein the subject is refractory or responds insufficiently or is intolerant to an anti-inflammatory therapy, optionally wherein said subject is elective for colectomy.

6. The oligonucleotide for use according to any of the preceding claims, wherein at least one CG dinucleotide is unmethylated.

7. The oligonucleotide for use according to any of the preceding claims, wherein at least one nucleotide in said oligonucleotide has a backbone modification.

8. The oligonucleotide for use according to claim 7, wherein said backbone modification is a phosphate backbone modification represented by a phosphorothioate or a phosphorodithioate modification.

9. The oligonucleotide for use according to any of claims 7 and 8, wherein said backbone modification is located in the 5'- and/or the 3'- end of said oligonucleotide.

10. The oligonucleotide for use according to any of the preceding claims, wherein said oligonucleotide has the sequence 5'-GGAACAGTTCGTCCATGGC-3' (SEQ ID NO:2), wherein the CG dinucleotide is unmethylated.

11. The oligonucleotide for use according to any of the preceding claims, wherein said oligonucleotide has the sequence 5'-G*G*A*ACAGTTCGTCCAT*G*G*C-3' (SEQ ID NO:1), wherein the CG
dinucleotide is unmethylated.

12. The oligonucleotide for use according to any of the preceding claims, wherein said oligonucleotide is cobitolimod.

13. The oligonucleotide for use according to any of the preceding claims, wherein individual doses of 490mg to 510mg of said oligonucleotide are administered.

14. The oligonucleotide for use according to any of the preceding claims, wherein individual doses of about 500mg of said oligonucleotide are administered.

15. The oligonucleotide for use according to any of the preceding claims, wherein individual doses of said oligonucleotide are administered to the subject on only two separate occasions 3 weeks apart.

16. The oligonucleotide for use according to any of claims 1 to 14, wherein individual doses of said oligonucleotide are administered to the subject on two or more separate occasions 3 weeks apart until the subject is in remission.

17. The oligonucleotide for use according to any of the preceding claims, wherein the subject receives one or more additional therapeutic agents for the treatment of an inflammatory bowel disease, typically ulcerative colitis.

18. The oligonucleotide for use according to any of the preceding claims, wherein said oligonucleotide is administered topically to mucosal membranes.

19. The oligonucleotide for use according to any of the preceding claims, wherein said oligonucleotide is administered rectally.

20. The oligonucleotide for use according to any of the preceding claims, wherein the subject has not been subjected to colonic cleaning prior to said administration.

21. The oligonucleotide for use according to any one of claims 18 to 20, wherein said topical administration is effected via an enema which is suitable for self-administration by the subject.

22. The oligonucleotide for use according to any preceding claim, wherein the subject has not been subjected to colonic cleaning for 48 hours prior to the treatment with the oligonucleotide, preferably for 24 hours prior to the treatment with the oligonucleotide.

23. The oligonucleotide for use according to any of the preceding claims, wherein the oligonucleotide is cobitolimod, and individual doses of about 500mg of cobitolimod are administered to the subject on only two separate occasions 3 weeks apart.

24. A pharmaceutical composition comprising an oligonucleotide as defined in any of claims 1 and 6 to 12, together with one or more pharmaceutically acceptable carriers, for use in the treatment of an inflammatory bowel disease as defined in any of claims 1 to 4 in a human subject as defined in any of claims 1, 5, 17, 20 and 22, wherein individual administrations of said composition are administered to the subject on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the composition delivers an amount of the oligonucleotide as defined in any of claims 1, 13, 14 and 23.

25. A method of treating an inflammatory bowel disease as defined in any of claims 1 to 4, in a human subject as defined in any of claims 1, 5, 17, 20 and 22, comprising administering to said subject an oligonucleotide as defined in any of claims 1 and 6 to 12 or a composition as defined in claim 24, wherein individual administrations of said oligonucleotide or composition are administered to the patient on at least two separate occasions, wherein said separate occasions are 3 weeks apart, and wherein each administration of the oligonucleotide or composition delivers an amount of the oligonucleotide as defined in any of claims 1, 13, 14 and 23.