CN118450905A - Methods using anti-amyloid beta protofibril antibodies and anti-tau antibodies - Google Patents

Abstract

Disclosed herein are antibodies, pharmaceutical formulations for treating or preventing alzheimer's disease, methods of treating or preventing alzheimer's disease, and kits comprising pharmaceutical formulations containing anti-aβ protofibril antibodies and anti-tau antibodies for treating or preventing alzheimer's disease.

Description

Methods using anti-amyloid beta protofibril antibodies and anti-tau antibodies

This application claims the benefit of priority to U.S. Provisional Application No. 63/291,315, filed on December 17, 2021, and International Application No. PCT/IB2021/000937, filed on December 17, 2021, the contents of which are incorporated herein by reference in their entirety.

This application contains a sequence listing, which has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. The ASCII copy created on December 3, 2021 is named 08061_0053-00304_SL.txt and is 21,812 bytes in size.

This invention was made with government support under Grant Nos. U01AG042791, R01AG046179, R56AG053267, U01AG059798, R01AG053267, and R01AG068319 awarded by the National Institutes of Health. The government has certain rights in this invention.

Alzheimer's disease (AD) is a progressive neurodegenerative disorder and the most common form of dementia in the elderly. In 2006, there were 26.6 million cases of AD (range: 11.4-59.4 million) worldwide (Brookmeyer, R. et al., Forecasting the global burden of Alzheimer's Disease. [Forecasting the global burden of Alzheimer's disease] Alzheimer Dement. [Alzheimer's disease and dementia] 2007; 3: 186-91), and more than 5 million people in the United States are reported to suffer from AD (2010 Alzheimer's disease facts and figures. [2010 Alzheimer's disease facts and figures] Alzheimer Dement. [Alzheimer's disease and dementia] 2010; 6: 158-94). By 2050, the worldwide prevalence of AD is projected to grow to 106.8 million (range: 47.2 million-221.2 million), with an estimated prevalence of 11 to 16 million in the United States alone (Brookmeyer, supra, and 2010 Alzheimer's disease facts and figures, supra).

The disease typically involves an overall decline in cognitive function that slowly progresses and renders terminally ill subjects bedridden. AD subjects typically survive only 3 to 10 years after symptom onset, but extreme cases of 2 and 20 years have been known. (Hebert, L.E., et al., Alzheimer disease in the U.S. population: prevalence estimates using the 2000 census. Arch Neurol. 2003; 60: 1119-1122.) Despite the fact that deaths due to AD are greatly underestimated because death certificates rarely attribute the cause of death to AD, AD is still the seventh leading cause of all deaths in the United States and the fifth leading cause of death among Americans over 65 years of age. (2010 Alzheimer's disease facts and figures, supra.)

Histologically, the disease is characterized by neuritic plaques, which are found primarily in the association cortex, limbic system, and basal ganglia. The major component of these plaques is the amyloid beta peptide (Aβ). Aβ exists in various conformational states: monomers, oligomers, protofibrils, and insoluble fibrils.

In addition to Aβ plaques, Alzheimer's disease is also characterized by the accumulation of neurofibrillary tangles containing tau proteins. Human tau proteins are encoded by the microtubule-associated protein tau protein gene MAPT located on chromosome 17q21. The adult brain contains six major tau protein subtypes, which are produced by alternative splicing of exons 2 (E2), E3 and E10. These subtypes differ according to the number of repeat regions of 29 residues near the N-terminus. Tau protein subtypes containing 0, 1 or 2 insertion fragments are called 0N, 1N and 2N, respectively. Unprocessed tau protein subtypes also contain 3 ("3R") or 4 ("4R") microtubule binding repeat domains. The second of these repeat domains is encoded by E10 and is not included in the 3R tau protein subtype.

Although tau is normally highly soluble, under pathological conditions it can aggregate into paired helical filaments, neurofibrillary tangles, and other structures that define a broad spectrum of neurodegenerative diseases known as tauopathies. Tauopathies thus refer to a class of neurodegenerative diseases associated with aggregation of the microtubule-associated protein tau, including Alzheimer's disease (AD), progressive supranuclear palsy (PSP), and frontotemporal dementia (FTD).

The details of the mechanistic relationship between the onset of Alzheimer's disease, Aβ production, and tau-mediated neurotoxicity are poorly understood. There is still potential for improved therapies targeting both Aβ production and tau-containing neurofibrillary tangles. Therefore, specific and effective therapeutic agents targeting Aβ and tau are needed.

Provided herein is a method for treating and/or preventing Alzheimer's disease, comprising administering to a subject in need thereof an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils and an anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein.

In some embodiments, a method of treating or preventing Alzheimer's disease in a subject in need thereof comprises administering to the subject:

(i) an isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils, the isolated anti-Aβ protofibril antibody or the antigen-binding fragment thereof comprising

(a) a heavy chain variable domain comprising the amino acid sequence of SEQ ID NO: 13, and

(b) a light chain variable domain comprising the amino acid sequence of SEQ ID NO: 14, and

(ii) an anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein, wherein the anti-tau protein antibody or the antigen-binding fragment thereof comprises

(a) a heavy chain variable domain comprising the amino acid sequence of SEQ ID NO: 15, and

(b) a light chain variable domain comprising the amino acid sequence of SEQ ID NO: 16,

Wherein the anti-Aβ protofibril antibody or fragment thereof is administered in combination (e.g., simultaneously or sequentially) with the anti-tau protein antibody or fragment thereof. In some embodiments, the separated anti-Aβ protofibril antibody or fragment thereof is administered once every two weeks. In some embodiments, the anti-tau protein antibody or fragment thereof is administered once every four weeks. In some embodiments, the anti-Aβ protofibril antibody or fragment thereof is administered before the start of treatment with the anti-tau protein antibody or fragment thereof, for example, when the subject has symptoms of Alzheimer's disease. In some embodiments, the anti-tau protein antibody or fragment thereof is administered before the start of treatment with the anti-Aβ protofibril antibody or fragment thereof, for example, when the subject has no symptoms of Alzheimer's disease. In some embodiments, the anti-Aβ protofibril antibody or fragment thereof is administered at a dose of 5 mg/kg-20 mg/kg, for example, wherein the dose is 10 mg/kg. In some embodiments, the anti-tau protein antibody or fragment thereof is administered in an amount of 1000-45000 mg, for example, wherein the dose is 1500 mg. In some embodiments, the subject has a dominantly inherited genetic mutation for Alzheimer's disease, for example, wherein the subject has a genetic mutation in at least one of the three genes - PSEN1, PSEN2, or APP.

Also provided herein are kits and pharmaceutical combinations comprising

(i) an isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils, the isolated anti-Aβ protofibril antibody or the antigen-binding fragment thereof comprising

(a) a heavy chain variable domain comprising the amino acid sequence of SEQ ID NO: 13, and

(b) a light chain variable domain comprising the amino acid sequence of SEQ ID NO: 14, and

(ii) an anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein, wherein the anti-tau protein antibody or the antigen-binding fragment thereof comprises

(a) a heavy chain variable domain comprising the amino acid sequence of SEQ ID NO: 15, and

(b) a light chain variable domain comprising the amino acid sequence of SEQ ID NO: 16,

wherein the anti-Aβ protofibril antibody or fragment thereof is administered in combination (eg, simultaneously or sequentially) with the anti-tau protein antibody or fragment thereof.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG1 depicts the randomization scheme for concurrent treatment with E2814 and lecanemab.

Figure 2 depicts the E2814 or placebo and open-label lencanezumab treatment schedules.

definition

The following are definitions of terms used in this application.

As used herein, the singular terms "a," "an," and "the" include plural references unless the context clearly dictates otherwise.

As used herein, the phrase "and/or" means "either or both" of the elements so combined, i.e., elements that are present in combination in some cases and not in combination in other cases. Thus, as a non-limiting example, "A and/or B," when used in conjunction with open language such as "comprising," may refer to only A (optionally including elements other than B) in some embodiments; to only B (optionally including elements other than A) in other embodiments; to both A and B (optionally including other elements) in yet other embodiments; and so on.

As used herein, "at least one" means one or more elements in a list of elements, but does not necessarily include at least one of each element specifically listed in the list of elements, and does not exclude any combination of elements in the list of elements. This definition also allows for the optional presence of elements other than the elements specifically identified in the list of elements to which the phrase "at least one" refers, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, "at least one of A and B" (or equivalently, "at least one of A or B", or equivalently "at least one of A and/or B") may refer to at least one (optionally including more than one) A without B (and optionally including elements other than B) in one embodiment; to at least one (optionally including more than one) B without A (and optionally including elements other than A) in another embodiment; to at least one (optionally including more than one) B without A (and optionally including elements other than A) in yet another embodiment; and to at least one (optionally including more than one) A and at least one (optionally including more than one) B (and optionally including other elements); and so on.

When a number is recited alone or as part of a numerical range, it is understood that the value can vary above and below the stated value by a deviation of 10%.

As used herein, the term "antibody" is broad and includes immunoglobulins or antibody molecules, including polyclonal antibodies, monoclonal antibodies, including mouse, human, human-adapted, humanized and chimeric monoclonal antibodies and antibody fragments. Generally, antibodies are proteins or peptide chains that exhibit binding specificity to specific antigens. Complete antibodies are usually heterotetrameric glycoproteins, consisting of two identical light chains and two identical heavy chains. Typically, each light chain is connected to a heavy chain by a covalent disulfide bond, and the number of disulfide bonds varies between heavy chains of different immunoglobulin isotypes. Each heavy chain and light chain also has regularly spaced intrachain disulfide bonds. Each heavy chain has a variable domain (variable region) (VH) at one end, followed by multiple constant domains (constant regions). Each light chain has a variable domain (VL) at one end and a constant domain at the other end; the constant domain of the light chain is aligned with the first constant domain of the heavy chain, and the variable domain of the light chain is aligned with the variable domain of the heavy chain. The light chains of antibodies from any vertebrate species can be assigned to one of two clearly distinct types, kappa and lambda, based on the amino acid sequences of their constant domains.

According to the type of constant domain possessed by its heavy chain, immunoglobulins can be divided into five major classes or isotypes, namely IgA, IgD, IgE, IgG and IgM. According to the amino acid sequence of the heavy chain constant domain. IgA and IgG are further subdivided into isotypes IgA1, IgA2, IgG1, IgG2, IgG3 and IgG4. The heavy chain constant domains corresponding to the different classes of immunoglobulins are called α, δ, ε, γ and μ respectively.

An immunoglobulin light chain variable region or heavy chain variable region consists of a "framework" region interrupted by three complementary determining regions (CDRs) that provide the major determinants for antigen binding (Wu and Kabat, J. Exp. Med. 132:211-250, 1970). Typically, there are six CDRs in an antigen binding site; three in VH (HCDR1, HCDR2, HCDR3) and three in VL (LCDR1, LCDR2, LCDR3) (Kabat et al., Sequences of Proteins of Immunological Interest, 5th ed. Public Health Service, National Institutes of Health, Bethesda, Maryland, 1991). CDRs can be identified according to the Kabat numbering scheme. SEQUENCES OF PROTEINS OF IMMUNOLOGICAL INTEREST [protein sequences with immunological significance] (Kabat et al., 5th edition, U.S. Department of Health and Human Services, NIH publication number 91-3242, 1991, hereinafter referred to as the "Kabat report"). Alternatively, "IMGT-CDR" as proposed by Lefranc (Lefranc et al., Dev. Comparat. Immunol. [Development and comparative immunology] 27: 55-77, 2003) is based on a comparison of the V domains of immunoglobulins and T cell receptors. The International Immunogenetics (ImMunoGeneTics, IMGT) database (http://www_imgt_org) provides standardized numbering and definitions of these regions. The correspondence between the CDR and IMGT descriptions is described in Lefranc et al., Dev. Comparat. Immunol. [Development and comparative immunology] 27: 55-77, 2003.

Antigen binding fragments are composed of parts of intact antibodies that retain the antigen binding specificity of the parent antibody molecule. For example, an antigen binding fragment may contain at least one variable region (heavy chain or light chain variable region) or one or more CDRs in an antibody known to bind a specific antigen. Examples of suitable antigen binding fragments include, but are not limited to, diabodies and single-chain molecules, as well as Fab, F(ab')2, Fc, Fabc and Fv molecules, single-chain (Sc) antibodies, single antibody light chains, single antibody heavy chains, chimeric fusions between antibody chains or CDRs and other proteins, protein scaffolds, heavy chain monomers or dimers, light chain monomers or dimers, dimers consisting of one heavy chain and one light chain, etc. All antibody isotypes can be used to produce antigen binding fragments. In addition, antigen binding fragments can include non-antibody protein frameworks that can successfully incorporate polypeptide segments in a direction that confers affinity for a given target antigen (such as a protein scaffold). Antigen binding fragments can be recombinantly produced or produced by enzymatic or chemical cleavage of intact antibodies. The phrase "antibody or antigen binding fragment thereof" can be used to indicate that a given antigen binding fragment is incorporated into one or more amino acid segments of the antibody mentioned in the phrase.

The term "subject" refers to humans and non-human animals, including all vertebrates, such as mammals and non-mammals, such as non-human primates, mice, rabbits, sheep, dogs, cats, horses, cows, chickens, amphibians and reptiles. In many embodiments of the method, the subject is a human.

In some embodiments, the subject has "elevated amyloid" or "moderate amyloid". In some embodiments, the level of amyloid is measured using amyloid PET. One of ordinary skill in the art will recognize that the amyloid level from the amyloid PET can be reported in "centimeter units" (CL) using the centimeter unit method. (Klunk WE et al. The Centiloid Project: standardizing quantitative amyloid plaque estimation by PET. [Centimeter unit project: standardizing quantitative amyloid plaque estimation by PET] Alzheimer's Dement. [Alzheimer's disease and dementia] 2015; 11: 1-15e1-4). The centimeter unit method measures tracers in the range of 0CL to 100CL, where 0 is considered to be an anchor point and represents the average value of young healthy controls, and 100CL represents the average amyloid load present in subjects with mild to moderate severity dementia due to AD. (Ibid.) As known to those of ordinary skill in the art, the centimeter unit threshold can vary, for example, it can be improved based on new or additional scientific information. (See, e.g., http://www.gaain.org/centiloid-project.) Elevated amyloid levels can be set relative to a baseline threshold in healthy controls determined according to methods known from POSA. For example, a centimeter value of 32.5 can be used as a threshold for "elevated amyloid," and "moderate amyloid" levels can refer to Aβ amyloid PETs in the range of 20-32.5 CL. In another example, a centimeter value of 40 can be used as a threshold for "elevated amyloid," and "moderate amyloid" levels can refer to Aβ amyloid PETs in the range of 20-40 CL. Rowe et al., Eur J Nucl Med Mol I 44, 2053-2059 (2017); Salvadó et al., Alzheimer’s Res Ther 11, 27 (2019); Sabri et al., Alzheimers Dement 11:964-74 (2015); Rowe et al., Alzheimer’s Dementia 14, P634 (2018); Amadoru et al., Alzheimer’s Res Ther 12, 22 (2020); Roé-Vellvé et al., Alzheimer’s Dementia 16, (2020); Bullich et al., Alzheimer’s ResTher [Alzheimer's Disease Research and Treatment] 13, 67(2021).

As described herein, a subject with "no symptoms of Alzheimer's disease" is a cognitively normal subject with moderate or elevated levels of amyloid in the brain, and can be identified by an asymptomatic phase with or without memory impairment and emerging episodic memory and executive function deficits (e.g., based on the accumulation of Aβ in the brain and/or by CSF or blood-based biomarkers). Cognitively normal can include subjects with CDR 0, or subjects within the normal range of cognitive test scores. Asymptomatic AD occurs before significant irreversible neurodegeneration and cognitive impairment, and is typically characterized by the presence of in vivo molecular biomarkers of AD and the absence of clinical symptoms. Asymptomatic AD biomarkers that may be indicative of the development of Alzheimer's disease include, but are not limited to, one or more of moderate or elevated levels of amyloid and/or tau in the brain, e.g., as measured by amyloid or tau positron emission tomography (PET), cerebrospinal fluid levels of Aβ1-42, cerebrospinal fluid levels of total tau, cerebrospinal fluid levels of neurogranin, cerebrospinal fluid levels of neurofilament light chain, and blood biomarkers as measured in serum or plasma (e.g., levels of Aβ1-42, the ratio of two forms of amyloid beta peptide (Aβ42/Aβ40), plasma levels of total tau (T-tau), phosphorylated tau (P-tau) isoforms, including tau phosphorylated at 181 (P-tau 181), 217 (P-tau 217), and 231 (P-tau 231), and levels of neurofilament light chain (NfL)). For example, it has been found that subjects treated with elenbecestat (E2609), a beta-site amyloid precursor protein cleaving enzyme (BACE) inhibitor, who had a baseline amyloid positron emission tomography (PET) standardized uptake value ratio (SUVr value) of 1.4 to 1.9 exhibited the greatest slowing of cognitive decline during treatment. See Lynch, S.Y. et al., “Elenbecestat, a BACE inhibitor: results from a Phase 2 study in subjects with mild cognitive impairment and mild-to-moderatedementia due to Alzheimer’s disease.” Poster P4-389, Alzheimer’s Association International Conference, July 22-26, 2018, Chicago, IL. Similarly, it was found that subjects with baseline florbetapir amyloid PET SUVr levels below 1.2 did not show sufficient cognitive decline to be detected, while subjects with SUVr levels above 1.6 were associated with a plateau effect, in which amyloid levels reached saturation levels and treatment did not cause changes in cognitive measures. See Dhadda, S. et al., “Baseline florbetapir amyloid PET standard update value ratio (SUVr) can predict clinical progression inprodromal Alzheimer’s disease (pAD).” Poster P4-291, Alzheimer’s Association International Conference, July 22–26, 2018, Chicago, IL, USA; Sperling RA et al., Alzheimer’s Dement. 2011;7:280–92; Jack C.R. et al., Alzheimer’s Dement. 2018;14:535–62.

As used herein, "early-onset Alzheimer's disease" refers to a continuum of AD severity from mild cognitive impairment due to moderate likelihood of AD to mild Alzheimer's disease dementia. Subjects with early-onset AD include subjects with mild Alzheimer's disease dementia as defined herein and subjects with mild cognitive impairment (MCI) due to moderate likelihood of AD as defined herein. In some embodiments, subjects with early-onset AD have a score of 22-30 in the Mini-Mental State Examination (MMSE) and/or a total CDR range of 0.5 to 1.0.

As used herein, a subject with "mild Alzheimer's disease dementia" or "mild AD dementia" is a subject who meets the National Institute on Aging and Alzheimer's Association (NIA-AA) core clinical criteria for possible Alzheimer's disease dementia as described in McKhann, G.M. et al., "The diagnosis of dementia due to Alzheimer's disease: Recommendations from the National Institute on Aging–Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease." Alzheimer Dement. 2011; 7:263-9. Also included herein are subjects with a CDR score of 0.5 to 1.0 and/or a Memory Box score of 0.5 or higher at Screening and Baseline.

As used herein, subjects with "mild cognitive impairment due to moderate likelihood of AD" are subjects identified as such according to the NIA-AA core clinical criteria for mild cognitive impairment due to moderate likelihood of Alzheimer's disease (see McKhann, supra). For example, subjects may be symptomatic but not demented, with evidence of brain amyloid pathology making them less heterogeneous and more similar to mild Alzheimer's disease dementia subjects in terms of cognitive and functional decline, as measured by a CDR score of 0.5 and/or a memory box score of 0.5 or higher at screening and baseline. In addition, subjects who report a history of gradual onset and slowly progressive subjective memory decline within the last 1 year prior to screening (and confirmed by an informant) are also included herein.

The level of amyloid in a subject can be detected by biomarkers, such as, but not limited to: (a) amyloid detected by visual reading or semi-quantitative threshold (SUVr or percentile units) by PET scan; (c) cerebrospinal fluid (CSF) Aβ1-42 and/or Aβ1-42/1-40 ratio; and/or (d) blood biomarkers (i.e., plasma Aβ1-42, Aβ1-42/Aβ1-40, tau protein, total tau protein (T-tau protein), P-tau protein, and/or NfL). Secondary markers can confirm the primary amyloid determination and include, but are not limited to: (a) tau protein detected by PET scan; (b) CSF tau protein, phosphorylated tau protein (p-tau protein), neurofilament light chain peptide (NfL), and/or neurogranulin; (c) other blood biomarkers (i.e., tau protein, total tau protein (T-tau protein), P-tau protein, and/or NfL).

"Amyloid" refers to unbranched fibers, usually extracellular, and found in vivo; in addition, the fibers bind the dye Congo red and then show green birefringence when viewed between crossed polarizers. Amyloid-forming proteins have been identified and associated with serious diseases, including amyloid beta peptide (Aβ) associated with Alzheimer's disease (AD), islet amyloid polypeptide (IAPP) associated with type 2 diabetes, and prion protein (PrP) associated with spongiform encephalopathy. As used herein, "amyloid", "brain amyloid", and "amyloid beta peptide (Aβ)" are used interchangeably.

As used herein, the term "ARIA" refers to amyloid-associated imaging abnormalities, such as assessed using MRI. In some embodiments, ARIA includes amyloid-associated imaging abnormalities edema/effusion (ARIA-E). In some embodiments, ARIA includes amyloid-associated imaging abnormalities hemorrhage (ARIA-H). In some embodiments, subjects with ARIA experience headaches, confusion, and/or seizures, and these can be used to identify subjects with ARIA or indicate further evaluation for ARIA. In some embodiments, ARIA is evaluated at specified intervals during treatment. In some embodiments, ARIA is evaluated when the subject experiences symptoms of ARIA.

As used herein, the term "treat" refers to obtaining one or more beneficial or desired results, including but not limited to a therapeutic benefit, which means eradication or amelioration of the underlying disorder being treated or one or more physiological symptoms associated therewith. The term includes but does not require complete treatment.

As used herein, the term "prevention" refers to obtaining one or more beneficial or desired results, including but not limited to preventive benefits. The benefit may include delaying disease symptoms (e.g., one or more symptoms of Alzheimer's disease, such as progressive memory loss) or reducing the severity of the disease symptoms. For preventive benefits, a compound or formulation may be administered to a subject at risk of developing Alzheimer's disease; to a subject with one or more preclinical symptoms but not clinical symptoms of Alzheimer's disease; or to a subject reporting one or more physiological symptoms of Alzheimer's disease, even if a clinical diagnosis of Alzheimer's disease has not yet been made. As used herein, "prevention" may further include therapeutic benefits, which means eradication or improvement of the underlying condition being treated or one or more physiological symptoms associated therewith.

As will be appreciated by one of ordinary skill in the art, digital, computer and/or conventional (e.g., pen and paper) cognitive tests can be used to detect early cognitive changes that may indicate mild cognitive impairment and/or a risk of developing dementia, and therefore can be used to identify subjects in need of treatment as disclosed herein. For example, such tests can screen for cognitive impairment and potentially identify subjects with MCI. Tests can use artificial intelligence to analyze cognitive test results to determine whether a case of mild cognitive impairment will be upgraded to Alzheimer's disease within one year. Early diagnosis of a condition before symptoms begin to appear can be used to help doctors identify subjects in need of treatment as disclosed herein earlier, thereby potentially delaying the onset of a neurodegenerative disease or reducing the severity of a neurodegenerative disease.

As used herein, "MMSE" refers to the Mini-Mental State Examination, a cognitive tool commonly used for screening purposes, but also often measured longitudinally in AD clinical trials. The MMSE is a 30-point scale, with higher scores indicating less damage and lower scores indicating more damage, ranging from 0 (maximum damage) to 30 (no damage). In some embodiments, seven items measuring orientation, registration, recall, attention, language, and drawing of time and place can be assessed as part of the MMSE score. (Folstein, M.F. et al., "Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. [Simple mental state, a practical method for clinicians to score the cognitive state of patients]" J. Psychiatr. Res. [Journal of Psychiatric Research] 1975; 12: 189-98.)

As used herein, "ADAS-Cog" refers to Alzheimer's Disease Assessment Scale-Cognitive. ADAS-Cog is a cognitive scale commonly used in Alzheimer's disease trials, which has a structural scale for evaluating memory (word recall, delayed word recall and word recognition), reasoning (following orders), language (naming, understanding), orientation, concept practice (putting letters in envelopes) and construction practice (copying geometric designs). (Rosen, WG et al., "A new rating scale for Alzheimer's disease. [New Alzheimer's disease rating scale]" Am. J. Psychiatry [American Journal of Psychiatry] 1984; 141: 1356-64.) It is also possible to obtain oral language, language comprehension, difficulty in calling words, the ability to remember test instructions, mazes and digital cross-out levels. In some embodiments, ADS-Cog refers to the use of Alzheimer's Disease Assessment Scale-Cognitive Subscale ₁₁ (ADAS-Cog11). In some embodiments, ADAS-Cog ₁₁ is scored from 0 to 70 points, wherein a score of 0 indicates no impairment, and a score of 70 indicates maximum impairment. In some embodiments, ADAS-Cog refers to the use of the Alzheimer's Disease Assessment Scale-Cognitive Subscale ₁₄ (ADAS-Cog ₁₄ ). ADAS-Cog 14 includes 3 additional items: maze, digital crossout, and delayed recall test, and is scored from 0 to 90 points, wherein a score of 0 indicates no impairment, and a score of 90 indicates maximum impairment. In some embodiments, ADAS-Cog ₁₄ tasks include memory (word recall, delayed word recall, and word recognition), reasoning (following orders), language (naming, understanding), orientation, concept practice (putting letters in envelopes), construction practice (copying geometric designs), oral language, language comprehension, difficulty in calling words, ability to remember test instructions, mazes, and digital crossouts (Rosen, WG et al., Am. J. Psychiatry [American Journal of Psychiatry] 1984; 141: 1356-64.).

As used herein, "CDR-SB" refers to the clinical dementia rating-sum of boxes. CDR is a clinical scale describing 5 degrees of impairment in the performance of each of the 6 functional categories including memory, orientation, judgment and problem solving, group affairs, family and hobbies, and personal care. (Berg, L. et al., "Mild seniledementia of the Alzheimer type: 2. Longitudinal assessment. [Type 2 Alzheimer's disease mild senile dementia, longitudinal assessment] "Ann. Neurol. [Annals of Neurology] 1988; 23: 477-84.) The level of impairment obtained for each of the 6 functional categories is synthesized into a total level of dementia CDR score (ranging from 0 to 3). The sum of the box scores provides another measure of variation, wherein each category has a maximum possible score of 3 points, and the total score is the sum of the scores of each category, resulting in a total possible score of 0 to 18, wherein a higher score indicates a higher degree of impairment. The total score can be used as a clinical measure of the severity of dementia.

In some embodiments, the efficacy of the treatment of Alzheimer's disease can be measured by any one or a combination of, for example, medical observation, cognitive assessment, medical diagnosis, and medical imaging. In some embodiments, when an isolated anti-tau antibody or fragment thereof is administered concurrently with an isolated anti-Aβ protofibril antibody or fragment thereof from Week 24 to Week 104 and Week 208, the efficacy of the treatment is determined by measuring tau diffusion via tau PET.

In some embodiments, when an isolated anti-tau antibody or fragment thereof is administered concurrently with an isolated anti-Aβ protofibril antibody or fragment thereof, the efficacy of treatment in symptomatic patients is assessed by measuring the change in the Clinical Dementia Rating Scale Record Sum (CDR-SB) from baseline after a period of treatment (e.g., the change from Week 24 to Week 208). In some embodiments, when an isolated anti-tau antibody or fragment thereof is administered alone and then concurrently with an isolated anti-Aβ protofibril antibody or fragment thereof, the efficacy of treatment in asymptomatic patients is assessed by measuring the change in cerebrospinal fluid (CSF) phosphorylated tau protein (p-tau protein 217)/total tau protein after a period of treatment (e.g., the change from Week 0 to Week 104 and/or Week 208).

In some embodiments, the efficacy of treatment in symptomatic patients is assessed by measuring at least one of: 1) a change in cognitive composite score after a period of treatment (e.g., a change from week 24 to week 104 and/or week 208) when an isolated anti-tau antibody or an isolated fragment thereof is administered in combination with an isolated anti-Aβ protofibril antibody or fragment thereof; 2) a change in amyloid PET after a period of treatment (e.g., a change from week 0 to week 24) to assess the efficacy of an isolated anti-Aβ protofibril antibody or fragment thereof when administered alone; 3) the production of anti-Aβ protofibril antibodies when anti-Aβ protofibril antibodies or fragments thereof are administered alone to assess safety and tolerability after a period of treatment (e.g., changes after 24 weeks); and 4) changes in CSF neurofilament light chain (NFL) from week 24 to week 104 and/or week 208 when anti-tau antibodies or fragments thereof are administered in combination with anti-Aβ protofibril antibodies or fragments thereof (e.g., changes from week 24 to week 104 and week 208).

In some embodiments, efficacy of treatment in asymptomatic patients is determined by measuring at least one of: 1) a change in CSF p-tau 217/total tau after a period of treatment when an anti-tau antibody or fragment thereof is administered alone (e.g., a change from week 0 to week 52); 2) a change in CSF p-tau 217/total tau after a period of treatment when an anti-tau antibody or fragment thereof is administered in combination with an anti-Aβ protofibril antibody or fragment thereof (e.g., a change from week 52 to week 104 and/or week 208); 3) anti-tau antibody production after a period of treatment (e.g., week 52) when an anti-tau antibody or fragment thereof is administered alone; 4) a change in CSF neurofilament light chain (NFL) after a period of treatment when an anti-tau antibody or fragment thereof is administered in combination with an anti-Aβ protofibril antibody or fragment thereof (e.g., a change from week 52 to week 104 and/or week 208).

Anti-Aβ protofibril antibodies or antigen-binding fragments thereof

The methods, kits and combinations disclosed herein include anti-Aβ protofibril antibodies or antigen-binding fragments thereof that are capable of binding to human Aβ protofibrils.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3) comprising the amino acid sequence of SEQ ID NO: 1 (HCDR1), SEQ ID NO: 2 (HCDR2), SEQ ID NO: 3 (HCDR3), SEQ ID NO: 4 (LCDR1), SEQ ID NO: 5 (LCDR2), SEQ ID NO: 6 (LCDR3). See, e.g., Table 11. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3) from the heavy chain variable domain of SEQ ID NO: 13 and the light chain variable domain of SEQ ID NO: 14 (e.g., as defined by Kabat or IMGT). In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils comprises the heavy chain variable domain of SEQ ID NO: 13 and the light chain variable domain of SEQ ID NO: 14. See, e.g., Table 12.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils comprises a human constant region. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils comprises a heavy chain constant region selected from the group consisting of IgG1, IgG2, IgG3, IgG4, IgM, IgA, IgE, and any allelic variation thereof as disclosed in the Kabat report. Any one or more of such sequences may be used in the present disclosure. In some embodiments, the heavy chain constant region comprises SEQ ID NO: 17.

In some embodiments, the human constant region of the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof comprises a light chain constant region selected from κ and λ chain constant regions and any allelic variation thereof as discussed in the Kabat report. Any one or more of such sequences may be used in the present disclosure. In some embodiments, the light chain constant region comprises SEQ ID NO: 18.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is lencanezumab, also known as BAN2401. Lencanezumab is a humanized IgG1 monoclonal form of mAb158, a murine monoclonal antibody generated to target protofibrils and disclosed in WO 2007/108756 and Journal of Alzheimer’s Disease 43:575-588 (2015). Lencanezumab is an isolated anti-Aβ protofibril antibody that exhibits low affinity for Aβ monomers while binding to soluble Aβ aggregate species with high selectivity. For example, it has been reported that lencanezumab exhibits selectivity for soluble Aβ protofibrils that is approximately 1000 times and 5 to 10 times higher than that for Aβ monomers or Aβ insoluble fibrils, respectively. The full-length sequence of lencanezumab is described in WO 2007/108756 and Journal of Alzheimer’s Disease 43:575-588 (2015), the disclosures of which are incorporated herein by reference.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered twice a day. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered once a day. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered weekly. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered twice a week. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered three times a week. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered every 2 weeks. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered monthly.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose ranging from 3 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 10 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 15 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 20 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 25 mg/kg to 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg to 25 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg to 20 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg to 15 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg to 10 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 5 mg/kg, 10 mg/kg, 15 mg/kg, 20 mg/kg, 25 mg/kg or 30 mg/kg. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 10 mg/kg.

In some embodiments, an isolated anti-Aβ protofibril antibody (eg, lencanezumab) or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 10 mg/kg every two weeks.

In some embodiments, an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered until a change in the level of a biomarker in the sample is observed (e.g., an increase in the ratio of Aβ42/40 in a sample collected from a subject prior to administration is observed in a plasma or CSF sample). Methods for measuring the Aβ42/40 ratio are known in the art, such as assays using LC MS/MS. The method may include a PrecivityAD ^™ assay for measuring Aβ42 and Aβ40 in a sample for calculating a ratio (see, e.g., Kirmess et al., J. Clinica Chimica Acta [Journal of Clinical Chemistry] 519: 267-275 (2021)) and an immunoassay using the HISCL ^™ platform (https://www.eisai.com/news/2019/news201990.html).

In some embodiments, the biomarker is brain amyloid levels, for example, as measured by PET SUVr. Methods for calculating PET SUVr are known in the art and may include those described herein. In some embodiments, the standard uptake value ratio quantitative analysis of amyloid levels is performed using PMOD Biomedical Image Quantification software (PMOD Technologies, Zurich, Switzerland). In some embodiments, the object motion of the PET image in the X, Y, and Z planes is first evaluated, and if necessary, motion correction is performed before averaging a single image (e.g., 5-minute radiation frame) using, for example, the PMOD average function (averaging the PET frames to increase the signal-to-noise ratio). In some embodiments, a corresponding MRI from a subject is prepared (e.g., using a matrix size reduction process, cropping the MRI to include only the brain, segmenting to divide the image into binary images of gray matter, white matter, and CSF, and stripping the skull image and leaving only the brain mask). In some embodiments, the averaged PET image and the prepared MRI are matched using the PMOD matching function to place the image in the same orientation. In some embodiments, a brain normalization function provided by the PMOD software, as well as a brain normalization and rigid matching transformation matrix are used to generate an averaged PET. In some embodiments, this averaged PET is normalized relative to MNInst space (Senjem et al., 2005), which is oriented identically to the segmented MRI of the subject for quantitative analysis. In some embodiments, the PMOD mask function is used to mask the brain and the image outside the mask is zeroed to create a normalized gray matter PET and a normalized white matter PET. The PMOD software can be used to calculate the standard uptake value (SUV) of all gray matter mapping areas and 3 white matter areas (pons, cerebellar white matter, and subcortical white matter), using normalized PET, subject weight, and injected dose of tracer to reach the unit of SUV. In some embodiments, SUVr is the ratio of the overall cortical mean value compared to the selected reference area. In some embodiments, a full cerebellum mask is used as a reference area. In some embodiments, the reference area is a composite reference area consisting of subcortical white matter, a derived full cerebellum, a full cerebellum corrected by subcortical white matter, cerebellar gray matter, and cerebellar cortex, pons subcortical white matter, and cerebellar white matter.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is in the form of a pharmaceutical composition. In some embodiments, the pharmaceutical composition comprising the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof is administered via one or more syringes and/or automatic injectors. In some embodiments, administration is via any suitable route, for example, intravenous.

Lencanicumab and methods comprising the use of lencanicumab are disclosed in U.S. Provisional Application No. 62/749,614 and PCT International Application No. PCT/US2019/043067, both of which are incorporated herein by reference in their entirety.

Methods involving the use of lencanezumab in subjects with preclinical AD are disclosed in Clinical Trial Identifier: NCT04468659 (ClinicalTrials.gov), which is incorporated herein by reference in its entirety.

Anti-tau protein antibody or antigen-binding fragment thereof

The methods, kits and combinations disclosed herein include anti-tau antibodies or antigen-binding fragments thereof that are capable of binding to human tau.

In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) comprising the amino acid sequence of SEQ ID NO:7 (HCDR1), SEQ ID NO:8 (HCDR2), SEQ ID NO:9 (HCDR3), SEQ ID NO:10 (LCDR1), SEQ ID NO:11 (LCDR2), and SEQ ID NO:12 (LCDR3), as defined by Kabat. In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau comprises six CDRs (CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) comprising the amino acid sequence of SEQ ID NO: 24 (HCDR1), SEQ ID NO: 25 (HCDR2), SEQ ID NO: 26 (HCDR3), SEQ ID NO: 27 (LCDR1), SEQ ID NO: 28 (LCDR2), and SEQ ID NO: 29 (LCDR3), as defined by IMGT. See, e.g., Table 11. In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) from a heavy chain variable domain of SEQ ID NO: 15 and a light chain variable domain of SEQ ID NO: 16 (e.g., as defined by Kabat or IMGT). In some embodiments, an anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau comprises SEQ The heavy chain variable domain of SEQ ID NO: 15 and the light chain variable domain of SEQ ID NO: 16. See, e.g., Table 12.

In some embodiments, the isolated anti-tau protein antibody or its antigen-binding fragment capable of binding to human tau protein comprises a human constant region. In some embodiments, the human constant region comprises a heavy chain constant region selected from: IgG1, IgG2, IgG3, IgG4, IgM, IgA, IgE, and any allelic variation thereof disclosed in the Kabat report. Any one or more of such sequences may be used in the present disclosure. In some embodiments, the heavy chain constant region comprises SEQ ID NO: 19.

In some embodiments, the human constant region of the isolated anti-tau protein antibody or its antigen-binding fragment comprises a light chain constant region selected from the constant regions of κ and λ chains and any allelic variation thereof as discussed in the Kabat report. Any one or more of such sequences can be used in the present disclosure. In some embodiments, the light chain constant region comprises SEQ ID NO: 20.

In some embodiments, the anti-tau protein antibody or antigen-binding fragment comprises E2814 or an antigen-binding fragment thereof. E2814 is disclosed in US2019/0112364 A1 as clone 7G6-HCzu25/LCzu18, the sequence of which is incorporated herein by reference.

In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is any of those disclosed in US2019/0112364A1, and its disclosure is incorporated herein by reference in its entirety. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment comprises CDR and/or variable domain sequences from antibody clone 7G6-HCzu25/LCzu18 as disclosed in US2019/0112364 A1, and these sequences are incorporated herein by reference. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is produced by antibody-producing cells preserved by the American Type Culture Collection (10801 University Blvd, Manassas, Virginia 20110-2209) with accession number PTA-124524 on October 11, 2017.

In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered twice a day. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered once a day. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered weekly. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered twice a week. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered three times a week. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered every 2 weeks. In some embodiments, the anti-tau antibody or antigen-binding fragment thereof is administered every four weeks or monthly.

In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose ranging from 200 mg to 4500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 500 mg to 4500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 1000 mg to 4500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 1500 mg to 4500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 3000 mg to 4500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 200 mg to 3000 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 200 mg to 1500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 200 mg to 1000 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dose of 200 mg to 500 mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dosage of 200mg, 500mg, 1000mg, 1500mg, 2000mg, 2500mg, 3000mg or 4500mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dosage of 1500mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dosage of 3000mg. In some embodiments, the anti-tau protein antibody or its antigen-binding fragment is administered at a dosage of 4500mg. Additional information about the administration and dosage form of the anti-tau protein antibody (e.g., anti-tau protein antibody E2814) or its antigen-binding fragment that can be used in the methods disclosed herein can be found in International Application No. PCT/IB2022/060604, the contents of which are incorporated herein by reference in their entirety.

In some embodiments, the anti-tau antibody is E2814 or an antigen-binding fragment thereof and is administered at a dose of 3000 mg, for example, once every four weeks.

In some embodiments, an isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered in combination with an isolated anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein, wherein the isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered at a dose of 10 mg/kg every two weeks, and the isolated anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein is administered at a dose of 1500 mg or 3000 mg every four weeks.

In some embodiments, an isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered until a change in the level of a biomarker in a sample relative to the level in a sample collected from a subject prior to administration is observed (e.g., a decrease in phosphorylated tau protein 217 is observed in a plasma sample). In some embodiments, p-tau protein 217 can be measured in a sample collected from a subject at one time point, and a second sample can be collected from a subject at a later time point to measure a change in p-tau protein 217 in the subject. In some embodiments, the level of p-tau protein 217 in a sample collected from a subject after administration is reduced relative to the level of phosphorylated tau protein 217 in a sample collected from a subject prior to administration.

In some embodiments, the administration of an isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein is increased due to an increase in the amount of p-tau protein 217 in the subject. In some embodiments, the administration of an isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein is reduced due to a decrease in the amount of p-tau protein 217 in the subject. Methods for measuring phosphorylated tau protein 217 in plasma are known in the art, such as immunoassays. Tatebe et al., Quantification of plasma phosphorylated tau to use as a biomarker for brain Alzheimer pathology, 12 Molecular Neurodegeneration 63 (September 4, 2017).

In some embodiments, an isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered until a change in the diffusion of tau protein as measured by PET is detected. In some embodiments, tau protein PET can be used to confirm the presence of tau protein in the brain of an AD subject and/or measure its amount. In some embodiments, a tau protein PET scan can be performed at one time point, and a second tau protein PET scan can be performed at a later second time point to measure the diffusion of tau protein in the subject. In some embodiments, since the diffusion of tau protein as measured by PET is observed in patients, the administration of an isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein is increased. In some embodiments, tau protein PET is MK-6240 tau protein PET.

Application

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered simultaneously with the isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered from the same vial as the isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered from different vials as the isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein.

In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered for a period of time prior to the administration of the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered for a period of time prior to the administration of the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered for fifty-two weeks prior to the administration of the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein. In some embodiments, the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered for twenty-four weeks prior to the administration of the isolated anti-Tau antibody or antigen-binding fragment thereof capable of binding to human tau protein.

In some embodiments, the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein and the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils are administered during the same clinical visit. In some embodiments, the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein and the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils are administered during separate clinical visits. In some embodiments, the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein and the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils are administered intravenously to the subject. In some embodiments, the timing of administration of the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein and the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils depends on whether the person has symptoms of Alzheimer's disease or no symptoms of Alzheimer's disease.

In some embodiments, an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered to a patient with symptoms of Alzheimer's disease prior to administration of an isolated anti-Tau antibody or antigen-binding fragment thereof capable of binding to human Tau protein. In some embodiments, an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered to a patient with symptoms of Alzheimer's disease for 24 weeks until the isolated anti-Tau antibody or antigen-binding fragment thereof capable of binding to human Tau protein and an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils are co-administered. In some embodiments, an isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered to a patient with symptoms of Alzheimer's disease for 24 weeks, followed by a combined administration of an isolated anti-tau protein antibody or an antigen-binding fragment thereof capable of binding to human tau protein and an isolated anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils from week 24 to week 52 and/or from week 24 to week 208.

In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered to a patient without symptoms of Alzheimer's disease prior to administration of an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils. In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered to a patient without symptoms of Alzheimer's disease for 52 weeks prior to co-administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein and an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils. In some embodiments, an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein is administered to a patient without symptoms of Alzheimer's disease for 52 weeks, followed by co-administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein and an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils from week 52 to week 208.

Family history and dominantly inherited Alzheimer's disease

In some embodiments, the subject has a family history of Alzheimer's disease, eg, a history of a family member being diagnosed with Alzheimer's disease before the age of 60.

In some embodiments, the subject suffers from dominantly inherited Alzheimer's disease (DIAD). In some embodiments, the subject has a mutation in at least one of the following three genes: amyloid precursor protein (APP), presenilin 1 (PSEN1) or presenilin 2 (PSEN2). In some embodiments, the subject has a mutation in the APP gene. In some embodiments, the subject has a mutation in the PSEN1 gene. In some embodiments, the subject has a mutation in the PSEN2 gene. Specific mutations in the APP, PSEN1 or PSEN2 genes that contribute to DIAD are known in the art (e.g., Cruts and Van Broeckhoven, 1998; Cruts, Theuns and Van Broeckhoven, 2012; Ryman et al., 2014; Sherva and Kowall, 2018).

Treatment Outcomes

In some embodiments, the subject's score is improved relative to the CDR-SB score before the administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein and/or an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils according to the methods disclosed herein. In some embodiments, the subject's score is improved relative to the ADAS-cog score before the administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein and/or an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils according to the methods disclosed herein. In some embodiments, the subject's score is improved relative to the MMSE score before the administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein and/or an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils according to the methods disclosed herein. In some embodiments, the subject's CDR score is improved relative to the subject's CDR score prior to administration of an isolated anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau and/or an isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils according to the methods disclosed herein.

Drug combinations and kits

In some embodiments, the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein described herein and/or the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils described herein are presented in the form of a pharmaceutical combination. In some embodiments, the isolated anti-tau protein antibody or antigen-binding fragment thereof capable of binding to human tau protein described herein and/or the isolated anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils described herein are presented in the form of a kit, for example, comprising one or more vials containing these antibodies or antigen-binding fragments and instructions for administration (e.g., concurrent administration). In some embodiments, the antibodies or antigen-binding fragments in the kit are formulated for administration, such as intravenous administration, for example, as disclosed above.

Subcutaneous administration

In some embodiments, a dose of anti-Aβ protofibril antibody or its antigen-binding fragment is administered subcutaneously to the subject. For example, 400mg to 800mg or 400mg to 1500mg (such as 720mg) of anti-Aβ protofibril antibody or its antigen-binding fragment can be administered to the subject. The antibody can be lencanetumab. The antibody can be administered at a specific frequency, such as twice a week, weekly (QW), every two weeks (every two weeks or Q2W) or monthly, for a period of time, such as for at least 52 weeks or 18 months, or until a specific standard (e.g., a specific behavior and/or biomarker standard) is reached. In some embodiments, a maintenance dose of anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is subsequently administered to the subject, for example, administered at a specific frequency and for a period of time or until a specific standard is reached. The dosage, frequency, time period of administration, and standard may be the same or different from the previous treatment dosage, frequency, time period of administration, and/or standard.

In some embodiments, the therapeutic dose is administered as two simultaneous or sequential subcutaneous injections, e.g., at a total dose of 720 mg per week. In some embodiments, the treatment lasts for at least 52 weeks, or for at least 18 months. In some embodiments, the treatment is administered by subcutaneous injection. In some embodiments, the treatment is administered by subcutaneous automatic injector.

In some embodiments, after receiving a treatment dose (e.g., two simultaneous or sequential subcutaneous injections, e.g., at a total dose of 720 mg per week) for a period of time, e.g., after 18 months, for example, a maintenance dose is administered subcutaneously, e.g., twice a week or weekly, e.g., at 720 mg per dose. In some embodiments, more than one treatment dose and more than one maintenance dose of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered, wherein the maintenance dose is administered in a lower amount and/or at a reduced frequency relative to the treatment dose. In some embodiments, the criteria for switching to a maintenance dose or selecting a maintenance dose of a lower amount or frequency may include changes in biomarkers, such as an increase in the Aβ42/40 ratio observed in a sample (e.g., a plasma sample) relative to the ratio in a sample collected from a subject before treatment, a decrease in the level of pτ protein 217 or pτ protein 181 in a sample collected from a subject after treatment, and/or a decrease in amyloid protein PET SUVr after treatment.

In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is in the form of a pharmaceutical composition. In some embodiments, the pharmaceutical composition comprising the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered via one or more syringes and/or automatic injectors. In some embodiments, the pharmaceutical composition comprising the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered to the abdomen.

In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of at least 80 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of at least 100 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of at least 200 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of at least 250 mg/mL. In some embodiments, the antibody is present in the pharmaceutical composition at a concentration of 80 mg/mL to 300 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 85 mg/mL to 275 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 90 mg/mL to 250 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 95 mg/mL to 225 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 100 mg/mL to 200 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 80 mg/mL, 90 mg/mL, 100 mg/mL, 110 mg/mL, 120 mg/mL, 130 mg/mL, 140 mg/mL, 150 mg/mL, 160 mg/mL, 170 mg/mL, 180 mg/mL, 190 mg/mL, 200 mg/mL, 210 mg/mL, 220 mg/mL, 230 mg/mL, 240 mg/mL, 250 mg/mL, 260 mg/mL, 270 mg/mL, 280 mg/mL, 290 mg/mL or 300 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 100 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 200 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 250 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is present in the pharmaceutical composition at a concentration of 300 mg/mL. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is lencanezumab.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof further comprises at least one additional component. In some embodiments, at least one additional component in the pharmaceutical composition is selected from a pharmaceutically acceptable buffer. In some embodiments, a pharmaceutically acceptable buffer is a citrate buffer. In some embodiments, a pharmaceutically acceptable buffer is a histidine buffer. In some embodiments, at least one additional component in the pharmaceutical composition is selected from an emulsifier. In some embodiments, at least one additional component in the pharmaceutical composition is selected from citric acid (or citric acid monohydrate), sodium chloride, histidine (and/or histidine hydrochloride), arginine (and/or arginine hydrochloride), and polysorbate 80. In some embodiments, at least one additional component in the pharmaceutical composition is selected from citric acid (and/or citric acid monohydrate), arginine (and/or arginine hydrochloride), and polysorbate 80. In some embodiments, at least one additional component in the pharmaceutical composition is selected from histidine (and/or histidine hydrochloride), arginine (and/or arginine hydrochloride), and polysorbate 80.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof comprises arginine (and/or arginine hydrochloride). In some embodiments, the concentration of arginine (and/or arginine hydrochloride) in the pharmaceutical composition is in the range of 100mM to 400mM. In some embodiments, the concentration of arginine (and/or arginine hydrochloride) in the pharmaceutical composition is in the range of 110mM to 380mM, 120mM to 360mM, 125mM to 350mM, 140mM to 340mM, 160mM to 325mM, 175mM to 300mM, or 200mM to 250mM. In some embodiments, the concentration of arginine (and/or arginine hydrochloride) in the pharmaceutical composition is in the range of 110mM to 150mM, 150mM to 200mM, 200mM to 250mM, 250mM to 300mM, 300mM to 350mM, or 350mM to 380mM. In some embodiments, the concentration of arginine (and/or arginine hydrochloride) is 125mM. In some embodiments, the concentration of arginine (and/or arginine hydrochloride) is 200mM. In some embodiments, the concentration of arginine (and/or arginine hydrochloride) is 350mM.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof comprises histidine. In some embodiments, the concentration of histidine in the pharmaceutical composition is in the range of 10mM to 100mM. In some embodiments, the concentration of histidine in the pharmaceutical composition is in the range of 10mM to 100mM, 12mM to 80mM, 14mM to 60mM, 15mM to 55mM, 15mM to 35mM, or 15mM to 25mM. In some embodiments, the concentration of histidine is 25mM. In some embodiments, the concentration of histidine is 50mM.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or antigen-binding fragment thereof comprises polysorbate 80. In some embodiments, the concentration of polysorbate 80 in the pharmaceutical composition is in the range of 0.01% w/v to 0.1% w/v, 0.01% w/v to 0.08% w/v, 0.02% w/v to 0.08% w/v, 0.03% w/v to 0.07% w/v, or 0.04% w/v to 0.06% w/v. In some embodiments, polysorbate 80 is present in the pharmaceutical composition at a concentration of 0.01% w/v, 0.02% w/v, 0.03% w/v, 0.04% w/v, 0.05% w/v, 0.06% w/v, 0.07% w/v, or 0.08% w/v. In some embodiments, polysorbate 80 is present in the pharmaceutical composition at a concentration of 0.02% w/v. In some embodiments, polysorbate 80 is present in the pharmaceutical composition at a concentration of 0.05% w/v.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof comprises citric acid monohydrate. In some embodiments, the concentration of citric acid monohydrate in the pharmaceutical composition is in the range of 10mM to 100mM. In some embodiments, the concentration of citric acid monohydrate in the pharmaceutical composition is in the range of 10mM to 100mM, 10mM to 90mM, 15mM to 85mM, 20mM to 80mM, 25mM to 75mM, 30mM to 70mM, 30mM to 60mM, or 30mM to 50mM. In some embodiments, the concentration of citric acid monohydrate in the pharmaceutical composition is 50mM.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or antigen-binding fragment thereof has a pH in the range of 4.5 to 5.5. In some embodiments, the pH in the pharmaceutical composition is in the range of 4.0 to 6.0, 4.2 to 5.8, 4.3 to 5.7, 4.4 to 5.6, or 4.5 to 5.5. In some embodiments, the pH is 4.5, 4.6, 4.7, 4.8, 4.9, 5.0, 5.1, 5.2, 5.3, 5.4, or 5.5. In some embodiments, the pH is 5.0.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof can be in the form of a solution and/or any other suitable liquid formulation deemed suitable by a person of ordinary skill in the art. In some embodiments, the pharmaceutical composition is formulated as a sterile, pyrogen-free liquid for subcutaneous administration. In some embodiments, the pharmaceutical composition is a saline solution.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof is a liquid dosage form, which comprises an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils (such as lencanetumab) that binds to Aβ protofibrils, and further comprises, for example, citric acid monohydrate, arginine, arginine hydrochloride and polysorbate 80.

In some embodiments, the pharmaceutical composition comprises 100 mg/mL of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof (such as lencanezumab), 50 mM citric acid monohydrate, 110 mM arginine, 240 mM arginine hydrochloride, and 0.05% (w/v) polysorbate 80, and has a pH of 5.0±0.4.

In some embodiments, the pharmaceutical composition comprising an anti-Aβ protofibril antibody or an antigen-binding fragment thereof is a liquid dosage form comprising an anti-Aβ protofibril antibody (such as lencanetumab) that binds to Aβ protofibrils, and further comprising, for example, histidine, arginine hydrochloride, and polysorbate 80. In some embodiments, the pharmaceutical composition comprises 100 mg/mL or 200 mg/mL of an anti-Aβ protofibril antibody (such as lencanetumab) that binds to Aβ protofibrils, 25 mM histidine and histidine hydrochloride, 200 mM arginine hydrochloride, and 0.05% (w/v) polysorbate 80, and has a pH of 5.0±0.4. In some embodiments, the pharmaceutical composition comprises 200 mg/mL lencanetumab, 200 mM arginine, 25 mM histidine and histidine hydrochloride, and 0.05% (w/v) polysorbate 80 as a sterile aqueous solution.

In some embodiments, the pharmaceutical composition is a liquid dosage form comprising an anti-Aβ protofibril antibody (such as lencanezumab) that binds to Aβ protofibrils, and further comprising, for example, histidine, histidine hydrochloride, arginine hydrochloride, and polysorbate 80. In some embodiments, the pharmaceutical composition comprises 200 mg/mL of an anti-Aβ protofibril antibody (such as lencanezumab) that binds to Aβ protofibrils, 50 mM histidine and histidine hydrochloride, 125 mM arginine hydrochloride, and 0.02% (w/v) polysorbate 80, and has a pH of 5.0±0.4.

In some embodiments, the pharmaceutical composition is a liquid dosage form comprising an anti-Aβ protofibril antibody (such as lencanezumab) that binds to Aβ protofibrils, and further comprising, for example, histidine, histidine hydrochloride, arginine hydrochloride, and polysorbate 80. In some embodiments, the pharmaceutical composition comprises 200 mg/mL of an anti-Aβ protofibril antibody (such as lencanezumab) that binds to Aβ protofibrils, 50 mM citric acid (and/or citric acid monohydrate), 125 mM arginine (and/or arginine hydrochloride), and 0.02% (w/v) polysorbate 80, and has a pH of 5.0±0.4.

Exemplary formulations for subcutaneous administration are also disclosed in PCT/IB2021/000155, the contents of which are incorporated herein by reference in their entirety.

As used herein, the term "maintenance dose" refers to the dose administered to a subject to maintain the desired therapeutic effect. In some embodiments, the maintenance dose of the subject is the same as the dose during the treatment period. In some embodiments, the maintenance dose is administered subcutaneously. In some embodiments, the maintenance dose is administered once or multiple times. In some embodiments, the maintenance dose is administered weekly, every two weeks, every 4 weeks, every 6 weeks, every 8 weeks, every 10 weeks, every 12 weeks (every three months or every quarter), every 16 weeks, every 24 weeks (every six months or every half a year), every 48 weeks, every month, every 2 months, every 3 months, every 4 months, every 6 months, or every 12 months. In some embodiments, the maintenance dose comprises an anti-Aβ protofibril antibody or an antigen-binding fragment thereof that can bind to human Aβ protofibrils. In some embodiments, the maintenance dose is 300 mg to 800 mg, 300 mg to 400 mg, 400 mg to 500 mg, 400 mg to 450 mg, 450 mg to 500 mg, 500 mg to 600 mg, 500 mg to 550 mg, 550 mg to 600 mg, 600 mg to 700 mg, 600 mg to 650 mg, 650 mg to 700 mg, 700 mg to 800 mg, 700 mg to 750 mg, or 750 mg to 800 mg. In some embodiments, the maintenance dose is 300 mg, 310 mg, 320 mg, 330 mg, 340 mg, 350 mg, 360 mg, 370 mg, 380 mg, or 390 mg. In some embodiments, the maintenance dose is 400 mg, 410 mg, 420 mg, 430 mg, 440 mg, 450 mg, 460 mg, 470 mg, 480 mg, or 490 mg. In some embodiments, the maintenance dose is 500 mg, 510 mg, 520 mg, 530 mg, 540 mg, 550 mg, 560 mg, 570 mg, 580 mg, or 590 mg. In some embodiments, the maintenance dose is 600 mg, 610 mg, 620 mg, 630 mg, 640 mg, 650 mg, 660 mg, 670 mg, 680 mg, or 690 mg. In some embodiments, the maintenance dose is 700 mg, 710 mg, 720 mg, 730 mg, 740 mg, 750 mg, 760 mg, 770 mg, 780 mg, or 790 mg. In some embodiments, the maintenance dose is 800 mg to 1600 mg, 800 mg to 1000 mg, 800 mg to 900 mg, 900 mg to 1000 mg, 1000 mg to 1200 mg, 1000 mg to 1100 mg, 1100 mg to 1200 mg, 1200 mg to 1400 mg, 1200 mg to 1300 mg, 1300 mg to 1400 mg, 1400 mg to 1600 mg, 1400 mg to 1500 mg, or 1500 mg to 16000 mg. In some embodiments, the maintenance dose is 800 mg, 820 mg, 840 mg, 860 mg, 880 mg, 900 mg, 920 mg, 940 mg, 960 mg, or 980 mg. In some embodiments, the maintenance dose is 1000 mg, 1020 mg, 1040 mg, 1060 mg, 1080 mg, 1100 mg, 1120 mg, 1140 mg, 1160 mg, or 1180 mg. In some embodiments, the maintenance dose is 1200 mg, 1220 mg, 1240 mg, 1260 mg, 1280 mg, 1300 mg, 1320 mg, 1340 mg, 1360 mg, or 1380 mg. In some embodiments, the maintenance dose is 1400 mg, 1420 mg, 1440 mg, 1460 mg, 1480 mg, 1500 mg, 1520 mg, 1540 mg, 1560 mg, or 1580 mg. In some embodiments, the maintenance dose is provided in a single administration, for example, as a single 1440 mg subcutaneous injection, or in two or more administrations, 720 mg is administered twice to reach a total of 1440 mg, 360 mg is administered four times to reach a total of 1440 mg. In some embodiments, the maintenance dose is 3600 mg. In some embodiments, the maintenance dose is 440 mg. In some embodiments, the maintenance dose is 580 mg. In some embodiments, the maintenance dose is 720 mg. In some embodiments, a maintenance dose of 720 mg is administered in a single administration or in two administrations of 360 mg. In some embodiments, the maintenance dose is 1440 mg. In some embodiments, the maintenance dose is provided in a single administration, for example, as a single 720 or 1440 mg subcutaneous injection, or in two or more administrations, for example, two concurrent administrations of 360 mg to reach a total of 720 mg or two administrations of 720 mg to reach a total of 1440 mg, or four administrations of 360 mg to reach a total of 1440 mg. In some embodiments, the maintenance dose is 120 mg. In some embodiments, the maintenance dose is 180 mg. In some embodiments, the maintenance dose is 240 mg. In some embodiments, the maintenance dose is 360 mg. In some embodiments, the maintenance dose is 440 mg. In some embodiments, the maintenance dose is 480 mg. In some embodiments, the maintenance dose is 540 mg. In some embodiments, the maintenance dose is 440 mg. In some embodiments, the maintenance dose is 580 mg. In some embodiments, the maintenance dose is 600 mg. In some embodiments, the maintenance dose is 720 mg. In some embodiments, the maintenance dose is 840 mg. In some embodiments, the maintenance dose is 900 mg. In some embodiments, the maintenance dose is 960 mg. In some embodiments, the maintenance dose is 1080 mg. In some embodiments, the maintenance dose is 1200 mg. In some embodiments, the maintenance dose is 1260 mg. In some embodiments, the maintenance dose is 1320 mg. In some embodiments, the maintenance dose is 1440 mg. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection per week. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection per week, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every two weeks. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every two weeks, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 1440 mg subcutaneous injection every two weeks. In some embodiments, the maintenance dose is provided in a single 1440 mg administration every two weeks, including two concurrent (e.g., two sequential) administrations of 720 mg subcutaneous formulations to reach a total of 1440 mg or four sequential administrations of 360 mg to reach a total of 1440 mg.

In some embodiments, the maintenance dose is administered one or more times. In some embodiments, the maintenance dose is administered at a lower dose than during an earlier course of treatment and/or is administered less frequently than during an earlier course of treatment.

In some embodiments, the therapeutic dose is administered as a subcutaneous injection. In some embodiments, the therapeutic dose is administered as a weekly subcutaneous injection. In some embodiments, the therapeutic dose is administered as a biweekly subcutaneous injection. In some embodiments, the therapeutic dose is administered as a monthly subcutaneous injection. In some embodiments, the therapeutic dose is administered as a quarterly subcutaneous injection.

In some embodiments, the maintenance dose is administered as a subcutaneous injection. In some embodiments, the maintenance dose is administered as a weekly subcutaneous injection. In some embodiments, the maintenance dose is administered as a biweekly subcutaneous injection. In some embodiments, the maintenance dose is administered as a monthly subcutaneous injection. In some embodiments, the maintenance dose is administered as a quarterly subcutaneous injection.

In some embodiments, the frequency of the maintenance dose is weekly. In some embodiments, the maintenance dose is every two weeks (every two weeks). In some embodiments, the maintenance dose is every four weeks (monthly). In some embodiments, the subcutaneous maintenance dose is administered every six weeks. In some embodiments, the subcutaneous maintenance dose is administered every eight weeks (2 months). In some embodiments, the maintenance dose is every three months (every twelve weeks or every quarter). In some embodiments, the maintenance dose is every six months (every 24 weeks or every half a year). In some embodiments, the maintenance dose of the subject is the same as the dose during the treatment period. In some embodiments, the maintenance dose has the same dosage amount as the dose before the maintenance dose is administered. In some embodiments, the dosage of the maintenance dose is lower than the dosage before the maintenance dose is administered. In some embodiments, the maintenance dose has the same dosage frequency as the dose before the maintenance dose is administered. In some embodiments, the dosage frequency of the maintenance dose is lower than the dosage before the maintenance dose is administered.

In some embodiments, the maintenance dose is administered as a subcutaneous injection of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils. In some embodiments, the maintenance dose is administered as a weekly subcutaneous injection of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils. In some embodiments, the maintenance dose is administered as a weekly subcutaneous injection of 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a monthly 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a quarterly 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every two weeks, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every month, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every quarter, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the subcutaneous maintenance dose is administered weekly. In some embodiments, the subcutaneous maintenance dose is administered every two weeks. In some embodiments, the subcutaneous maintenance dose is administered every four weeks (monthly). In some embodiments, the subcutaneous maintenance dose is administered every six weeks. In some embodiments, the subcutaneous maintenance dose is administered every eight weeks (2 months). In some embodiments, the subcutaneous maintenance dose is administered every three months (twelve weeks or quarterly). In some subcutaneous embodiments, the maintenance dose is administered weekly, every two weeks, every 4 weeks, every 6 weeks, every 8 weeks, every 10 weeks, every 12 weeks, every 16 weeks, every 24 weeks, every 48 weeks, monthly, every 2 months, every 3 months, every 4 months, every 6 months, or every 12 months. In some embodiments, the subcutaneous maintenance dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at a dose of 300 to 800 mg, 300 to 400 mg, 400 to 500 mg, 400 to 450 mg, 450 to 500 mg, 500 to 600 mg, 500 to 550 mg, 550 to 600 mg, 600 to 700 mg, 600 to 650 mg, 650 to 700 mg, 700 to 800 mg, 700 to 750 mg, or 750 to 800 mg. In some embodiments, the maintenance dose is 300 mg, 310 mg, 320 mg, 330 mg, 340 mg, 350 mg, 360 mg, 370 mg, 380 mg, or 390 mg. In some embodiments, the maintenance dose is 400 mg, 410 mg, 420 mg, 430 mg, 440 mg, 450 mg, 460 mg, 470 mg, 480 mg, or 490 mg. In some embodiments, the maintenance dose is 500 mg, 510 mg, 520 mg, 530 mg, 540 mg, 550 mg, 560 mg, 570 mg, 580 mg, or 590 mg. In some embodiments, the maintenance dose is 600 mg, 610 mg, 620 mg, 630 mg, 640 mg, 650 mg, 660 mg, 670 mg, 680 mg, or 690 mg. In some embodiments, the maintenance dose is 700 mg, 710 mg, 720 mg, 730 mg, 740 mg, 750 mg, 760 mg, 770 mg, 780 mg, or 790 mg. In some embodiments, the maintenance dose is 800 mg to 1600 mg, 800 mg to 1000 mg, 800 mg to 900 mg, 900 mg to 1000 mg, 1000 mg to 1200 mg, 1000 mg to 1100 mg, 1100 mg to 1200 mg, 1200 mg to 1400 mg, 1200 mg to 1300 mg, 1300 mg to 1400 mg, 1400 mg to 1600 mg, 1400 mg to 1500 mg, or 1500 mg to 16000 mg. In some embodiments, the maintenance dose is 800 mg, 820 mg, 840 mg, 860 mg, 880 mg, 900 mg, 920 mg, 940 mg, 960 mg, or 980 mg. In some embodiments, the maintenance dose is 1000 mg, 1020 mg, 1040 mg, 1060 mg, 1080 mg, 1100 mg, 1120 mg, 1140 mg, 1160 mg, or 1180 mg. In some embodiments, the maintenance dose is 1200 mg, 1220 mg, 1240 mg, 1260 mg, 1280 mg, 1300 mg, 1320 mg, 1340 mg, 1360 mg, or 1380 mg. In some embodiments, the maintenance dose is 1400 mg, 1420 mg, 1440 mg, 1460 mg, 1480 mg, 1500 mg, 1520 mg, 1540 mg, 1560 mg, or 1580 mg. In some embodiments, the maintenance dose is provided in a single administration, for example, as a single 720 or 1440 mg subcutaneous injection, or in two or more administrations, for example, two concurrent administrations of 360 mg to reach a total of 720 mg or two administrations of 720 mg to reach a total of 1440 mg, or four administrations of 360 mg to reach a total of 1440 mg. In some embodiments, the maintenance dose is 440 mg. In some embodiments, the maintenance dose is 580 mg. In some embodiments, the maintenance dose is administered as a single administration of 720 mg or two administrations of 360 mg. In some embodiments, the maintenance dose is 1440 mg. In some embodiments, the maintenance dose is administered as a weekly 720 mg subcutaneous injection. In some embodiments, the maintenance dose is administered as a weekly 360 mg subcutaneous injection. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every two weeks. In some embodiments, the maintenance dose is administered as a 1440 mg subcutaneous injection every two weeks. In some embodiments, the maintenance dose is provided in a single biweekly 1440 mg administration comprising two concurrent (eg, sequential) administrations of 720 mg subcutaneous formulation to achieve a total of 1440 mg.

In some embodiments, treatment includes subcutaneous administration of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils before switching to an intravenous maintenance dose. In some embodiments, treatment includes subcutaneous administration of lencanerumab weekly, such as a subcutaneous injection of 720 mg, including two parallel (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL), for example until the patient is amyloid negative or, for example, for a period of time, such as at least 18 months. In some embodiments, treatment includes subcutaneous administration of lencanerumab weekly, such as at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a maintenance dose. In some embodiments, treatment includes subcutaneous administration of lencanerumab weekly, such as at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to an intravenous maintenance dose of 10 mg/kg per week. In some embodiments, treatment comprises weekly subcutaneous administration of lencanezumab, for example at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, followed by a conversion to an intravenous maintenance dose of 10 mg/kg every two weeks. In some embodiments, treatment comprises weekly subcutaneous administration of lencanezumab, for example, at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, followed by a conversion to an intravenous maintenance dose of 10 mg/kg per month. In some embodiments, treatment comprises weekly subcutaneous administration of lencanezumab, for example, at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, followed by a conversion to an intravenous maintenance dose of 10 mg/kg every six weeks. In some embodiments, treatment comprises weekly subcutaneous administration of lencanezumab, for example, at a dose of 720 mg, for example, for at least 18 months or, for example, until the patient is amyloid negative, followed by a conversion to an intravenous maintenance dose of 10 mg/kg every eight weeks. In some embodiments, treatment comprises weekly subcutaneous administration of lencanezumab, e.g., at a dose of 720 mg, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, followed by switching to a quarterly intravenous maintenance dose of 10 mg/kg. In some embodiments, the subject's maintenance dose is administered in the same amount and/or frequency as the dose during the treatment period. In some embodiments, the subject's maintenance dose is 50% of the dose during the treatment period.

In some embodiments, the maintenance dose is administered intravenously, for example, after the intravenous treatment period disclosed above. In some embodiments, the intravenous maintenance dose, such as 10 mg/kg of lencanezumab, is administered weekly, every two weeks, every month, every two months, or every three months (quarterly). In some embodiments, the intravenous maintenance dose is administered every two weeks. In some embodiments, the intravenous maintenance dose is administered every four weeks. In some embodiments, the intravenous maintenance dose is administered every six weeks. In some embodiments, the intravenous maintenance dose is administered every eight weeks (2 months). In some embodiments, the intravenous maintenance dose is administered every three months (quarterly). In some embodiments, the intravenous maintenance dose is administered every 24 weeks (every six months or every half a year). In some embodiments, the intravenous maintenance dose is 2.5 mg/kg-10 mg/kg. In some embodiments, the maintenance dose is administered every two weeks as a 10 mg/kg intravenous dose of lencanezumab. In some embodiments, the maintenance dose is administered every four weeks (monthly) as a 10 mg/kg intravenous dose. In some embodiments, the maintenance dose is administered every six weeks as a 10 mg/kg intravenous dose. In some embodiments, the maintenance dose is administered as an intravenous dose of 10 mg/kg every eight weeks (2 months). In some embodiments, the maintenance dose is administered as an intravenous dose of 10 mg/kg every twelve weeks (every three months or every quarter). In some embodiments, the maintenance dose is administered as an intravenous dose of 10 mg/kg every 24 weeks (every six months or every half a year). In some embodiments, the treatment comprises intravenously administering an anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a weekly intravenous maintenance dose. In some embodiments, the treatment comprises intravenously administering an anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to an intravenous maintenance dose every two weeks. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a monthly intravenous maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to an intravenous maintenance dose every six weeks. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to an intravenous maintenance dose every eight weeks. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a quarterly intravenous maintenance dose.

In some embodiments, the patient starts an intravenous maintenance dose, e.g., administration of 10 mg/kg of lencanezumab as disclosed above, and then switches to a subcutaneous maintenance dose, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) of a subcutaneous formulation. In some embodiments, the patient starts a subcutaneous maintenance dose, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) of a subcutaneous formulation, and then switches to an intravenous maintenance dose, e.g., administration of 10 mg/kg of lencanezumab as disclosed above.

In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously (SC). In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered in an injection volume of 1.1 mL. In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered in an injection volume of 1.4 mL. In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered in an injection volume of 1.45 mL. In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered in an injection volume of 1.8 mL.

In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered once a day. In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered twice a day. In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered once or more; for example, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered as a single administration of 720 mg or as two administrations of 720 mg (a total of 1440 mg). In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered once or more; for example, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered as a single administration of 720 mg or as two administrations of 360 mg (a total of 720 mg). In some embodiments, an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered weekly. In some embodiments, an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered weekly. In some embodiments, an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered three times a week. In some embodiments, an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered every 2 weeks. In some embodiments, an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered monthly. In some embodiments, the dosage amount and/or dosage frequency can be reduced after achieving the desired therapeutic effect. The reduced frequency can be every two weeks, or every 4 weeks, every 6 weeks, every 8 weeks, every 10 weeks, every 12 weeks, every 16 weeks, every month, every 2 months, every 3 months, every 4 months, every 6 months, or every 12 months. In some embodiments, the desired therapeutic effect associated with a reduction in the dose amount or dose frequency may be selected from one or more of the following: a reduction in brain amyloid, a reduction in amyloid PET SUVr, an increase in the plasma Aβ42/40 ratio, a reduction in plasma p-τ protein 181, and a sufficient or predetermined level of changes in other biomarkers associated with a reduction in brain amyloid. In some embodiments, when the desired therapeutic effect is maintained after reducing the dose amount or the dosing frequency, the administration of an anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is discontinued. In some embodiments, if the desired therapeutic effect or the expected sufficient or predetermined level is not achieved in the subject, the administration of an anti-Aβ protofibril antibody or its antigen-binding fragment that binds to human Aβ protofibrils is discontinued, and the desired therapeutic effect can be evaluated by one or more of the following: a reduction in brain amyloid, a reduction in the amyloid PET SUVr, an increase in the plasma Aβ42/40 ratio, a reduction in plasma p-τ protein 181, and a change in other biomarkers associated with a reduction in brain amyloid.

In some embodiments, treatment includes weekly subcutaneous administration of Lencanezumab, for example, at a dose of 720 mg, for example, for at least 18 months. In some embodiments, treatment includes subcutaneous administration of Lencanezumab twice a week, for example, at 720 mg per dose, for example, for at least 18 months. In some embodiments, treatment is continued until the desired improvement in one or more biomarkers or other treatment outcome measures is achieved, for example, when the Aβ42/40 ratio in a sample (e.g., a plasma sample) is observed relative to the ratio in a sample collected from a subject before treatment (e.g., before 18 months of treatment) increases. In some embodiments, the subject has been diagnosed with early AD. In some embodiments, the subject has been diagnosed with mild cognitive impairment due to moderate likelihood of Alzheimer's disease, and/or has been diagnosed with mild Alzheimer's dementia.

In some embodiments, the method of treatment includes measuring the concentration of amyloid β1-42 (Aβ42) and the concentration of amyloid β1-40 (Aβ40) in a first blood sample obtained from the subject to determine a first ratio of Aβ42 to Aβ40 (Aβ42/40 ratio). In some embodiments, a therapeutically effective dose of anti-amyloid β (Aβ) protofibril antibodies is then administered to the subject. In some embodiments, a second blood sample is obtained after the first sample to determine a second Aβ42/40 ratio. In some embodiments, a second blood sample is obtained from the subject after stopping or reducing treatment. In some embodiments, changes in the Aβ42/40 ratio are used to determine a second therapeutically effective dose. In some embodiments, a second therapeutically effective dose is administered to a subject whose second ratio is increased relative to the first ratio, the second therapeutically effective dose comprising the same or lower amount of anti-Aβ protofibril antibodies or antigen-binding fragments thereof capable of binding to human Aβ protofibrils as compared to the subject's first dose. In some embodiments, a second therapeutically effective dose is administered to a subject whose second ratio is lower than the first ratio, and the second therapeutically effective dose comprises an anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils in a higher amount than the first dose. In some embodiments, a different treatment for AD is administered to a subject whose second ratio is lower than the first ratio. After measuring the second Aβ42/40 ratio, the first therapeutically effective dose may be administered multiple times (e.g., every two weeks or monthly for 6-18 months) before changing to a second therapeutically effective dose or dosing regimen. In some embodiments, the first therapeutically effective dose may be administered for at least 18 months and then converted to a maintenance dose. In some embodiments, the first therapeutically effective dose may be administered until the patient is amyloid negative and then converted to a maintenance dose. In some embodiments, the first therapeutically effective dose can be administered until the patient is amyloid negative (e.g., as measured by amyloid or tau positron emission tomography (PET), cerebrospinal fluid Aβ1-42 levels and/or Aβ1-42/1-40 ratio, levels of cerebrospinal fluid total tau, cerebrospinal fluid neurogranin levels, cerebrospinal fluid neurofilament light peptide (NfL) levels, and blood biomarkers as measured in serum or plasma (e.g., levels of Aβ1-42, ratio of the two forms of amyloid beta peptide (Aβ1-42/1-40 ratio), plasma levels of total plasma tau (T-tau)). The first therapeutically effective dose may be administered until the patient is amyloid negative, for example, as determined by an Aβ42/40 ratio of equal to or greater than 0.092-0.094 (e.g., equal to or greater than 0.092) or a flubitapyr amyloid PET equal to or less than 1.17. In some embodiments, the first therapeutically effective dose may be administered until the patient is amyloid negative, for example, as measured by an Aβ42/40 ratio above 0.092 or a flubitapyr amyloid PET SUVr negative equal to or below 1.17, and then converted to a maintenance dose. In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils administered intravenously at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to a maintenance dose.

In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to an intravenous maintenance dose (e.g., at 10 mg/kg, for example, every two weeks or every 4, 6, 8, 10 or 12 weeks). In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to an intravenous maintenance dose every two weeks. In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils (e.g., lencanetumab administered at 10 mg/kg) intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to a monthly intravenous maintenance dose. In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to an intravenous maintenance dose every six weeks. In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils (e.g., lencanetumab administered at 10 mg/kg) every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to an intravenous maintenance dose every eight weeks. In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to an intravenous maintenance dose every two months. In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils (e.g., lencanezumab administered at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a quarterly intravenous maintenance dose.

In some embodiments, the first therapeutically effective dose comprises subcutaneous administration of 720 mg of anti-Aβ protofibril antibody weekly, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to a subcutaneous maintenance dose (e.g., at 720 mg, for example, weekly, biweekly, or every 4, 6, 8, 10, or 12 weeks). In some embodiments, the maintenance dose is 360 mg per week.

In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to a weekly subcutaneous maintenance dose (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to a weekly subcutaneous maintenance dose (e.g., at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then converted to a weekly subcutaneous maintenance dose (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to a monthly subcutaneous maintenance dose (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils (e.g., lencanetumab is administered at 10 mg/kg) intravenously every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switched to a subcutaneous maintenance dose every six weeks (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every eight weeks (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every two months (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every quarter (e.g., at a dose of 720 mg or at a dose of 360 mg).

In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a weekly subcutaneous maintenance dose (e.g., at a dose of 720 mg or at a dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a biweekly subcutaneous maintenance dose (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a weekly subcutaneous maintenance dose (e.g., at a single dose of 360 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a monthly subcutaneous maintenance dose (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every six weeks (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every eight weeks (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose every two months (e.g., at a dose of 720 mg). In some embodiments, the first therapeutically effective dose comprises weekly subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, e.g., 720 mg subcutaneously, including two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations in a given week, e.g., for at least 18 months or, e.g., until the patient is amyloid negative, and then switching to a quarterly subcutaneous maintenance dose (e.g., at a dose of 720 mg).

In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils, and then switching to a maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months, and then switching to a maintenance dose. In some embodiments, the subject is converted to a maintenance dose without an initial step-wise adjustment step for the maintenance dose. In some embodiments, the subject is converted to a maintenance dose with at least one step-wise adjustment step for the maintenance dose, for example, the subject's administration dose or frequency can be reduced in multiple steps until the final maintenance dosing regimen is achieved (e.g., via an intermediate dose with an intermediate amount or time period (e.g., 540 mg per week or 720 mg every 10 days) from a weekly 720 mg subcutaneous treatment dosing regimen to a maintenance dosing regimen of 360 mg per week or 720 mg every two weeks). In some embodiments, the subject's maintenance dose is the same as the dose during the treatment period. In some embodiments, the subject's maintenance dose is 50% of the dose during the treatment period.

In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a weekly intravenous maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a weekly intravenous maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a monthly intravenous maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a quarterly intravenous maintenance dose.

In some embodiments, the maintenance dose is administered subcutaneously (e.g., as a subcutaneous injection). In other embodiments, the treatment comprises subcutaneously administering an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils before switching to an intravenous maintenance dose. In some embodiments, the treatment comprises intravenously administering an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils, and then switching to a subcutaneous maintenance dose. In some embodiments, the treatment comprises intravenously administering an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose. In some embodiments, the treatment comprises intravenously administering an anti-Aβ protofibril antibody or an antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a weekly subcutaneous maintenance dose. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose of 360 mg per week. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose of 720 mg per week. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a subcutaneous maintenance dose of 720 mg per week. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a monthly subcutaneous maintenance dose of 720 mg. In some embodiments, treatment comprises intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, for example, for at least 18 months or, for example, until the patient is amyloid negative, and then switching to a quarterly subcutaneous maintenance dose of 720 mg.

In some embodiments, the patient will start treatment comprising intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at a dose of 10 mg/kg, and then switch to treatment comprising, for example, subcutaneous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at a dose of 720 mg. In some embodiments, the patient will start treatment comprising intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, and then switch to treatment comprising, for example, subcutaneous administration of lencanezumab weekly at a dose of 720 mg, for example, for a total treatment period of at least 18 months or until the patient is amyloid negative. In some embodiments, the patient will start treatment comprising intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, and then switch to treatment comprising, for example, subcutaneous administration of lencanezumab weekly at a dose of 720 mg, and then switch to a maintenance dose of 360 mg subcutaneously weekly. In some embodiments, patients will begin treatment comprising intravenous administration of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils at 10 mg/kg every two weeks, then switch to treatment comprising subcutaneous administration of lencanezumab weekly, for example at a dose of 720 mg, and then switch to a monthly maintenance dose of 720 mg subcutaneously.

In some embodiments, the maintenance dose is administered as a subcutaneous injection of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils (e.g., lencanetumab). In some embodiments, the maintenance dose is administered as a weekly subcutaneous injection of a subcutaneous formulation of an anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils. In some embodiments, the maintenance dose is administered as a weekly 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a monthly 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a quarterly 720 mg subcutaneous injection, including two concurrent (e.g., sequential) injections of 360 mg (2x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every two weeks, comprising two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every month, comprising two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations. In some embodiments, the maintenance dose is administered as a 720 mg subcutaneous injection every quarter, comprising two concurrent (e.g., sequential) injections of 360 mg (2 x 1.8 mL of 400 mg/2 mL) subcutaneous formulations.

In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose ranging from 300 mg to 800 mg or 400 to 1500 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 300 mg to 400 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 400 mg to 500 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 400 mg to 450 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 450 mg to 500 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 500 mg to 600 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 500 mg to 550 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 550 mg to 600 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 600 mg to 700 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 600 mg to 650 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 650 mg to 700 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 700 mg to 800 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 700 mg to 750 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 750 mg to 800 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 300 mg, 310 mg, 320 mg, 330 mg, 340 mg, 350 mg, 360 mg, 370 mg, 380 mg, or 390 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 400 mg, 410 mg, 420 mg, 430 mg, 440 mg, 450 mg, 460 mg, 470 mg, 480 mg, or 490 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 500 mg, 510 mg, 520 mg, 530 mg, 540 mg, 550 mg, 560 mg, 570 mg, 580 mg, or 590 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 600 mg, 610 mg, 620 mg, 630 mg, 640 mg, 650 mg, 660 mg, 670 mg, 680 mg, or 690 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 700 mg, 710 mg, 720 mg, 730 mg, 740 mg, 750 mg, 760 mg, 770 mg, 780 mg, or 790 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 440 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 580 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 720 mg.

In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose ranging from 800 mg to 1600 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 800 mg to 1000 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 800 mg to 900 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 900 mg to 1000 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1000 mg to 1200 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1000 mg to 1100 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1100 mg to 1200 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1200 mg to 1400 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1200 mg to 1300 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1300 mg to 1400 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1400 mg to 1600 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1400 mg to 1500 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1500 mg to 1600 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 800 mg, 820 mg, 840 mg, 860 mg, 880 mg, 900 mg, 920 mg, 940 mg, 960 mg, or 960 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1000 mg, 1020 mg, 1040 mg, 1060 mg, 1080 mg, 1100 mg, 1120 mg, 1140 mg, 1160 mg, or 1180 mg. In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1200 mg, 1220 mg, 1240 mg, 1260 mg, 1280 mg, 1300 mg, 1320 mg, 1340 mg, 1360 mg, or 1380 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1400 mg, 1400 mg, 1440 mg, 1460 mg, 1480 mg, 1500 mg, 1520 mg, 1540 mg, 1560 mg, or 1580 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 880 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1160 mg. In some embodiments, the anti-Aβ protofibril antibody or its antigen-binding fragment capable of binding to human Aβ protofibrils is administered subcutaneously at a dose of 1440 mg.

Additional exemplary subcutaneous doses, dosing frequencies, maintenance doses, and formulations for subcutaneous administration that can be used in the methods discussed herein are disclosed in International Application No. PCT/US2022/041926, the contents of which are incorporated herein by reference in their entirety.

In some embodiments, the anti-Aβ protofibril antibody or antigen-binding fragment thereof used in the methods disclosed herein is delivered by an automatic injector. In some embodiments, the automatic injector delivers the anti-Aβ protofibril antibody or antigen-binding fragment thereof subcutaneously. In some embodiments, the automatic injector delivers an injection volume of 1.1 mL. In some embodiments, the automatic injector delivers an injection volume of 1.4 mL. In some embodiments, the automatic injector delivers an injection volume of 1.8 mL. In some embodiments, the automatic injector delivers about 400-800 mg (e.g., 360 mg) of anti-Aβ protofibril antibody or antigen-binding fragment thereof subcutaneously.

Examples

The present disclosure is further illustrated by the following examples which should not be construed as limiting.The contents of all references, patents and published patent applications cited throughout this application, as well as the Figures, are incorporated herein by reference in their entirety for all purposes.

Example 1: Combination of Lencanezumab and E2814 for the treatment of Alzheimer's disease

1.1 Double-blind dose selection

1.1.1E2814

1500 mg of E2814 (anti-tau antibody or antigen-binding fragment thereof) is administered intravenously (IV) every 4 weeks. Based on the safety, PK and TE data of the higher dose, higher doses (3000 mg or 4500 mg) may be considered for study in future protocol amendments.

1.1.2 Lencanezumab

Lencananizumab treatment will be administered at a dose of 10 mg/kg via intravenous infusion Q2W.

1.2 Drug-specific study designs

This is a placebo-controlled, double-blind Phase II/III study of safety, tolerability, biomarkers, cognition, and clinical efficacy to evaluate the therapeutic effect of E2814 when administered alone or concurrently with lencanezumab.

Inclusion criteria included:

Individuals aged 18-80 years;

●Individuals who know they have the mutation that causes Alzheimer's disease;

●Within -10 to +10 years of predicted or actual age at onset of cognitive symptoms;

●Normal cognition or mild cognitive impairment or mild dementia, with a Clinical Dementia Rating (CDR) of 0-1 (inclusive);

● Fluency in the approved test language and evidence of adequate premorbid intellectual function;

●Ability to perform magnetic resonance imaging (MRI), lumbar puncture (LP), positron emission tomography (PET), and complete all study-related tests and evaluations.

●For women of childbearing potential, participants must agree to use effective contraception (hormonal contraception, intrauterine device, sexual abstinence, barrier method with spermicide) if their partner is not sterilized;

● Adequate visual and auditory abilities to perform all aspects of cognitive and functional assessments;

● Have a research partner who, in the investigator's judgment, is able to provide accurate information about the subject's cognitive and functional abilities and agrees to provide information at study visits, which requires input to complete the scales.

Exclusion criteria include:

● Significant neurological disease (except AD) or psychiatric disease that may affect cognition or the participant's ability to complete the study, either currently or during the study;

● High suicide risk, such as significant suicidal ideation or attempt in the past 12 months, currently stable mild depression or current use of antidepressants are not excluded;

●History or presence of a brain MRI scan indicating any other significant abnormality;

●Substance or alcohol use disorder currently or within the past year;

The presence of a pacemaker, aneurysm clip, artificial heart valve, ear implant, or foreign metal object in the eye, skin, or body that would interfere with the MRI scan;

●History or presence of clinically significant cardiovascular disease, liver/renal disorder, infectious disease or immune disorder, or metabolic/endocrine disorder;

●Currently taking anticoagulants other than low-dose (≤325 mg) aspirin;

●Exposure to monoclonal antibodies against beta-amyloid peptide within the past six months;

● History of cancer in the past 5 years, excluding basal cell carcinoma, non-squamous skin cancer, prostate cancer, or carcinoma in situ that has not progressed significantly in the past 2 years;

●Positive urine or serum pregnancy test or planning or hoping to become pregnant during the test;

●The subject was unable to complete all study-related testing, including inability to remove implanted metal for MRI scans, need for anticoagulation, and pregnancy.

Approximately 168 participants will be enrolled in the blinded study drug arm of E2814, with 84 participants in each of two cohorts. All 168 participants within -10 to +10 estimated years from symptom onset (EYO) will be divided into 2 cohorts based on their baseline (week 0) CDR score as follows:

Symptomatic group (cohort 1): at least 84 participants with CDR = 0.5-1 (with symptoms of mild cognitive impairment)

Asymptomatic group (cohort 2): at least 84 participants with CDR = 0 (cognitively normal)

Participants will be randomized 1:1 active E2814 to placebo (Figure 1) via a minimization algorithm that includes the following factors at randomization:

1. Clinical Dementia Rating-Box Sum (CDR-SB; 0, 0.5 to 1, 1.5 to 3, >3)

2. Estimated years since symptom onset (EYO) (-10 to -5, -4 to -1, 0 to 4, 5 to 10)

3. Genotype (APP, PSEN1, PSEN2)

4. Years of education (<12, 12, 13 to 16, >16)

5. Age (18 to 40, 41 to 55, 56 to 80)

6. Presence of APOE4 allele (APOE4 positive, APOE4 negative)

7. Region (US/Australia/Canada, Europe, Rest of the World)

8. The location of the study, and

9. Gender (male, female).

A minimization randomization algorithm will be used to achieve the following two goals: 1) balance prognostic factors that affect clinical and cognitive progression or non-prognostic factors that may affect clinical and cognitive progression (these factors include baseline CDR-SB, EYO, age at randomization, years of education, and region), and 2) balance factors that may affect adverse events or interfere with drug effects (these factors include genotype, APOE4 allele, and sex).

E2814 or placebo will be administered in parallel with open-label lencanezumab as part of the E2814 blinded study drug group. E2814 or placebo will be administered intravenously at a dose of 1500 mg every 4 weeks (Q4W), and lencanezumab will be administered intravenously at 10 mg/kg every two weeks (Q2W), with each cohort starting their respective treatments at different time points, as specified in Figure 2. Participants will continue to receive treatment until all participants enrolled in parallel receive at least 4 years (210 weeks) of treatment or exit (common closure). Each cohort will start treatment with E2814 or placebo and lencanezumab for concurrent administration, as follows:

Symptomatic group (cohort 1)

At Week 0, participants will receive open-label lencanezumab 10 mg/kg administered intravenously every two weeks (Q2W) throughout the treatment period.

At Week 24, participants will be randomized in a 1:1 ratio to receive either E2814 1500 mg intravenously Q4W or placebo in a blinded fashion for the remainder of their treatment period.

Asymptomatic group (cohort 2)

At Week 0, participants will be randomized in a 1:1 ratio to receive either 1500 mg E2814 or placebo intravenously Q4W throughout the treatment period in a blinded fashion.

At Week 52, all participants will begin open-label lencanezumab 10 mg/kg administered intravenously Q2W for the remainder of their treatment period.

By staggering the administration of each drug in this manner, it is possible to evaluate the effects of lencanezumab and E2814 alone and then evaluate the effects of the drugs together.

1.3 Theoretical Basis for Biomarker Targets and Endpoints

Based on the pathophysiological evolution of tau protein in different stages of DIAD, the primary study endpoint of the symptomatic population (cohort 1) was tau protein PET, and the key secondary study endpoint of the asymptomatic population (cohort 2) was the cerebrospinal fluid (CSF) phosphorylated tau protein (p-tau protein 217)/total tau protein ratio (p-tau protein 217/total tau protein ratio).

After a single E2814 infusion of 3, 10, and 30 mg/kg, there was a dose-related decrease in free MTBR-τ protein, confirming that E2814 was able to reduce MTBR-τ protein levels in CSF. Target engagement (TE) was estimated as the fraction (%) of bound MTBR-τ protein relative to total MTBR-τ protein (free plus bound) using E2814-bound and free MTBR-τ proteins. These preliminary data showed that the dose-related increase in TE was approximately 26%, 45%, and 60% (3, 10, and 30 mg/kg, respectively), with sustained TE until day 29.

1.4 Main study objectives and endpoints

The primary study endpoint was to determine whether E2814 was superior to placebo in changes in tau protein diffusion (as measured by tau protein PET) from Week 24 to Week 104 (interim analysis) and Week 208 (final analysis) in the symptomatic population (Cohort 1) when each was administered concurrently with lencanezumab.

1.5 Secondary Study Endpoints

1.5.1 Key secondary endpoints

Key secondary endpoints are as follows:

Symptomatic population (Cohort 1): To determine whether E2814 is superior to placebo in terms of change in Clinical Dementia Rating Scale-Recorded Sum (CDR-SB) from Week 24 to Week 208 when each is administered concurrently with lencanezumab.

Asymptomatic population (Cohort 2): To determine whether E2814 is superior to placebo in changes in cerebrospinal fluid (CSF) phosphorylated tau (p-tau 217)/total tau from Week 0 to Week 104 (interim analysis) and Week 208 (final analysis) when each is administered alone and then concurrently with lencanezumab.

1.5.2 Additional Secondary End Points

Additional secondary endpoints for the individual and combined population cohorts were as follows:

Symptomatic population (Cohort 1) : 1) To determine whether E2814 is superior to placebo in changes in cognitive composite scores from Week 24 to Week 104 and Week 208 when each is administered concurrently with lencanezumab; 2) To evaluate the effect of lencanezumab in changes in amyloid PET from Week 0 to Week 24 when administered alone; 3) To determine whether lencanezumab is superior to an external control in changes in CDR-SB from Week 0 to Week 208 when administered alone or with placebo; 4) To evaluate the safety and tolerability of lencanezumab, including assessment of immunogenicity (production of anti-lencanezumab antibodies), when administered alone for 24 weeks; and 5) To determine whether E2814 is superior to placebo in changes in CSF neurofilament light chain (NFL) from Week 24 to Week 104 and Week 208 when each is administered concurrently with lencanezumab.

Asymptomatic population (Cohort 2) : 1) When each is administered alone, to evaluate whether E2814 is superior to placebo in terms of changes in CSF p-tau protein 217/total tau protein from week 0 to week 52; 2) When each is administered concurrently with lencanezumab, to determine whether E2814 is superior to placebo in terms of changes in CSF p-tau protein 217/total tau protein from week 52 to week 104 (interim analysis) and week 208 (final analysis); 3) When administered alone for 52 weeks, to evaluate the safety and tolerability of E2814, including the evaluation of immunogenicity (production of anti-E2814 antibodies); 4) When each is administered concurrently with lencanezumab, to determine whether E2814 is superior to placebo in terms of changes in CSF neurofilament light chain (NFL) from week 52 to week 104 and week 208.

1.6 Exploratory Endpoints

The following are exploratory endpoints for each population cohort in the E2814 arm of the study:

Symptomatic group (cohort 1):

○ To evaluate the effect of E2814 compared to placebo on the change in CSF p-tau 217/total tau from Week 24 to Week 104 and decreasing at Week 208 when each was administered concurrently with lencanezumab

○ When administered alone, the effect of lencanezumab was evaluated on changes in tau PET, CSF, and blood biomarkers (amyloid β [Aβ] 42, Aβ40, p-tau, total tau, NFL) from Week 0 to Week 24

Asymptomatic group (cohort 2):

○ To evaluate whether E2814 is superior to placebo in terms of change in CSF p-tau 217/total tau from Week 52 to Week 104 and Week 208 when each is administered concurrently with lencanezumab

○ To evaluate the effect of E2814 compared with placebo on the change in cognitive composite score from Week 52 to Week 104 and Week 208 when each was administered concurrently with lencanezumab

o To evaluate the effect of E2814 compared to placebo in terms of change in decreasing brain tau diffusion as measured by tau PET from Week 52 to Week 104 and Week 208 when each was administered concurrently with lencanezumab

○ When administered alone, to evaluate whether E2814 is superior to placebo in changes in tau PET, CSF biomarkers (NFL and MTBR-tau), and blood biomarkers (p-tau 217/total tau and NFL) from Week 0 to Week 52

Symptomatic group (cohort 1) and asymptomatic group (cohort 2):

○ To evaluate the effect of E2814 compared with placebo in the change in CDR-SB from Week 24 to Week 104 (Cohort 1) and from Week 52 to Week 104 and Week 208 (Cohort 2) when each was administered concurrently with lencanezumab

○ To evaluate the effect of E2814 compared with placebo on changes in CSF microtubule-binding region (MTBR)-tau protein from Week 24 to Week 104 and Week 208 (Cohort 1) and from Week 52 to Week 104 and Week 208 (Cohort 2) when each was administered concurrently with lencanezumab

o To evaluate whether E2814 is superior to placebo in changes in plasma NFL from Week 24 to Week 104 and Week 208 (Cohort 1) and from Week 52 to Week 104 and Week 208 (Cohort 2) when each is administered concurrently with lencanezumab

o To evaluate whether E2814 is superior to placebo in changes in CSF and blood biomarkers of neurodegeneration, neuroinflammation, amyloid, and tau (in addition to those already listed above) from Week 24 to Week 104 and Week 208 (Cohort 1) and from Week 52 to Week 104 and Week 208 (Cohort 2) when each is administered concurrently with lencanezumab

○ When each was administered concurrently with lencanezumab, the effects of E2814 compared to placebo were evaluated in changes from Week 24 to Week 208 (Cohort 1) and from Week 52 to Week 208 (Cohort 2) in cognitive and functional endpoints including the following:

■ Geriatric Depression Scale (GDS)

■ Neuropsychiatric Inventory-Q (NPI-Q)

■ Functional Assessment Scale (FAS)

Mini-Mental State Examination (MMSE)

■DIAN Memory Complaint Questionnaire (MAC-Q)

■Buschke and Grober Free and Cued Selective Recall Test-Immediate Recall (FCSRT-IR)

Wechsler Memory Scale-Revised (WMS-R) Logical Memory/Paragraph Memory (Immediate and Delayed Recall), Alternative Paragraph for Logical Memory I and II - Version A (Immediate and Delayed), and Alternative Paragraph for Logical Memory I and II - Version B (Immediate and Delayed)

Category Fluency (Animals)

■Wechsler Adult Intelligence Scale-Revised (WAIS-R), Digit Symbol Substitution Test

■Connection test parts A and B

■Wechsler Memory Scale-Revised (WMS-R), forward and backward digit spatial span

■ Dynamic Research of Cognition (ARC), cognitive assessment based on smartphones (grids, prices, symbols)

o The effects of E2814 compared to placebo were evaluated in changes in imaging measures from Week 24 to Week 104 and Week 208 (Cohort 1) and from Week 52 to Week 104 and Week 208 (Cohort 2) when each was administered concurrently with lencanezumab, including the following:

■ Amyloid loading based on (11)C-labeled Pittsburgh compound B ([11C]PiB) PET

Fluorodeoxyglucose (FDG)-PET metabolism in specific target areas (e.g., precuneus)

■ Rate of brain atrophy, as measured by cortical thickness of the region of interest, including whole-brain volume and ventricular volume (volume magnetic resonance imaging [vMRI])

■ Functional connectivity MRI (fc-MRI)

■ Parameters in diffusion tensor imaging (DTI) MRI (including diffusion-based spectral imaging (DBSI))

■Blood flow measured by arterial spin labeling (ASL) MRI

■Evaluation of clinical MRI features such as microhemorrhages (MCH), white matter hyperintensities (WMH), cerebral infarctions, and amyloid-related imaging abnormalities (ARIA) using conventional MRI sequences

○Evaluate the population pharmacokinetics (PK) of E2814 in plasma and serum

○ Evaluate the population PK of lencanezumab in serum

○ Explore the relationship between PK (E2814/lencanerumab exposure) and pharmacodynamics (PD) (CSF, blood, and imaging biomarkers)

○Collect pharmacogenomic (PG) samples for future analysis

1.7 Safety Goals and Endpoints

This study will evaluate the safety and tolerability of treatment with E2814 and lencanezumab in individuals with DIAD. Safety endpoints include AEs, clinical laboratory results, vital signs, ECG, CSSRS, and physical and neurological examinations.

The immunogenicity (production of anti-E2814 antibodies and anti-lencanezumab antibodies) of concurrent administration of E2814 and lencanezumab was evaluated.

Safety measures related to plasma fibrinogen binding include monitoring of functional fibrinogen using the Clauss method.

Safety MRI for monitoring ARIA will also be evaluated.

1.8 Drug-Specific Testing

1.8.1 Pharmacokinetic evaluation

1.8.1.1 Blood PK of E2814 and Lencanerzumab

Blood samples for PK assessment of E2814 (plasma and serum) and Lencanermab (serum) will be collected before dosing, i.e., before any drug administration is started at this visit; and after dosing at any time after 30 minutes after all drug administrations are completed at this visit. Based on the allocated cohort as described below, blood will be collected in the first year, and approximately every 26 weeks (approximately 6 months) until the 4th year, and then annually and during safety follow-up. Samples should also be collected if the participant terminates early.

Table 1 E2814 and Lencanerumab Blood PK-Cohort-Specific Collection Schedule

Serum and plasma concentrations of E2814 will be measured by a validated electrochemiluminescence (ECL) assay method.

1.8.1.2 E2814 and Lencanerumab Cerebrospinal Fluid (CSF) PK-Cohort-Specific Collection Schedule

CSF samples for E2814 and lencanezumab PK assessments will be collected prior to dosing via lumbar puncture (LP) at the following designated visits based on the assigned cohort.

Table 2 E2814 and lencanerumab CSF PK-cohort-specific collection schedule

The CSF concentration of E2814 will be measured by a validated electrochemiluminescence (ECL) assay. The CSF concentration of lencanezumab will be measured by a validated immunoprecipitation-liquid chromatography-tandem mass spectrometry (IP/LC-MS/MS) method.

1.8.2 Immunogenicity Assessment

Blood samples for immunogenicity will be collected at annual visits immediately prior to LP when LP is required and at all other visits immediately prior to drug administration. Immunogenicity will be assessed by measuring the presence of anti-E2814 antibodies and anti-lencanezumab antibodies in serum based on the assigned cohort as described below, approximately every 26 weeks (approximately 6 months) until Year 4 and until Early Termination (ET) occurs.

Table 3 Cohort-specific collection schedule for anti-E2814 and anti-lencanerumab serum antibodies

For participants with significant immunogenicity at the last collected assessment (Week 208 or ET visit), anti-E2814 antibodies or anti-lencanerumab antibodies will continue to be assessed every 24 weeks until resolution (when possible/where possible). In addition, clinical measurements (such as CRP) may be performed to monitor inflammation that may be related to immunogenicity.

Serum anti-E2814 antibodies will be measured by an appropriately validated ECL assay. Serum anti-lencanerumab antibodies will be measured using a validated Meso Scale (MSD) bridging assay.

1.8.3 Pharmacodynamics and biomarker evaluation

Blood samples for plasma pharmacodynamic (PD) biomarkers will be collected immediately prior to LP at annual visits where LP is required, and immediately prior to drug administration at all other visits. Samples will be collected on the same schedule for both cohorts as described below: approximately every 12 weeks in Year 1, approximately every 26 weeks (approximately every 6 months) until Year 4, and annually thereafter, including safety follow-up.

●Year 1: Week 0 (V2), Week 12 (V5), Week 24 (V8), Week 36 (V11), Week 52 (V15)

●Year 2: Week 76 (V21) and Week 104 (V28)

●Year 3: Week 128 (V34) and Week 156 (V41)

●Year 4: Week 180 (V47) and Week 208 (V54)

Year 5: Week 260 (V67) (if applicable)

●Year 6: Week 312 (V80) (if applicable)

Year 7: Week 364 (V93) (if applicable)

Safety follow-up

● Early termination (if applicable)

CSF samples for PD biomarkers will be collected prior to dosing via lumbar puncture at the following visits:

Week 0 (V2), baseline

●Week 24 (V8) - Cohort 1 only

●Week 52 (V15)

●Week 104 (V28)

●Week 208 (V54) or ET

●Week 260 (V67)

●Early termination (if terminated before week 260) (V67)

CSF and blood concentrations of AD-associated biomarkers (including but not limited to Aβ [1-42], neurogranin, neurofilament light chain [NFL], MTBR-τ protein [bound, free, and total], total τ protein [t-τ protein], and phosphorylated τ protein [p-τ protein]) will be measured.

1.8.4 Genomic DNA blood samples for library construction

Pharmacogenomic and biomarker samples obtained from participants in this study can be analyzed by global proteomics, metabolomics, or lipidomics as well as single or multiplexed assays to attempt to identify predictive biomarkers for PK and PD. In addition, biomarkers identified in other clinical studies can also be evaluated in samples collected from participants enrolled in this study.

Example 2: Subcutaneous administration of lencanezumab in combination with E2814 for the treatment of Alzheimer's disease

Double-blind dose selection

E2814: 3000 mg of E2814 (anti-tau antibody or antigen-binding fragment thereof) administered intravenously (IV) every 4 weeks. Based on the safety, PK and TE data of the higher dose, a higher dose (4500 mg) study may be considered in a future protocol amendment.

Lencanicarboretumab: Lencanicarboretumab treatment will be administered subcutaneously using two autoinjectors, each delivering 360 mg of lencanicarboretumab for a total dose of 720 mg of lencanicarboretumab. Patients will receive two 360 mg doses weekly or every two weeks.

Symptomatic population (Cohort 1): At Week 0, participants will receive 720 mg (two consecutive 360 mg doses delivered using an autoinjector throughout the treatment period) of open-label lencanezumab administered subcutaneously.

At Week 24, participants will be randomized in a 1:1 ratio to receive either E2814 3000 mg intravenously Q4W or placebo in a blinded fashion for the remainder of their treatment period.

Asymptomatic population (Cohort 2): At Week 0, participants will be randomized in a 1:1 ratio to receive either E2814 3000 mg intravenously Q4W or placebo in a blinded fashion throughout the treatment period.

At week 52, all participants will begin receiving open-label lencanezumab 720 mg administered subcutaneously (two consecutive 360 mg doses delivered using an autoinjector during the remainder of their treatment period).

Example

Example 1: Background anti-amyloid therapy with lencanezumab in the next generation clinical trial evaluating investigational therapies targeting tau protein for dominantly inherited Alzheimer's disease (Tau NexGen trial)

People with the gene mutation that is known to cause DIAD will develop AD and are likely to develop symptoms at about the same age as their parents did, usually in their 50s, 40s, or even 30s. The Tau NexGen trial is designed to evaluate the safety, tolerability, biomarkers, and cognitive efficacy of the investigational therapy in people with the gene mutation that causes Alzheimer's disease. The trial will evaluate whether treatment with the investigational drug slows the rate of progression of cognitive impairment and improves disease-related biomarkers.

In the modified Tau NexGen trial, symptomatic participants will be administered lencanezumab for six months and then randomized to receive E2814 or placebo. Because amyloid plaques accumulate before tau tangles in AD, the trial design allows researchers to assess whether amyloid removal clears the way for anti-tau drugs to work most effectively. Pre-symptomatic participants will be randomized to receive the anti-tau drug E2814 or placebo for one year before starting lencanezumab. Staggering the drugs in this way will allow the effects of anti-tau drugs to be evaluated alone and then the effects of the two drugs together. Lencanezumab will be administered at a dose of 10 mg/kg every two weeks, which does not require step-wise dosing, and the incidence of amyloid-related image abnormalities is 9.9%, with less than 2% of people having symptoms. The primary endpoint is a slowing of tau accumulation in the brains of symptomatic participants (as a result of adding E2814), as seen on PET brain scans. A secondary endpoint will be the effect of E2814 alone or in combination with lencanezumab on levels of a specific type of tau protein (phospho-tau 217) in the cerebrospinal fluid (CSF) of pre-symptomatic participants. If these primary and secondary endpoints are met in the analysis two years after the start of the trial, the trial will be extended for an additional two years to assess whether the drug slows cognitive decline and has further effects on tau pathology.

Selected sequence

Table 11. Amino acid sequences of mAb CDRs

Table 12. Amino acid sequences of mAb variable regions

Table 13. Amino acid sequences of mAb constant regions

Table 14. Amino acid sequences of biomarkers

Claims (66)

1. A method for treating or preventing alzheimer's disease in a subject in need thereof, the method comprising administering to the subject:

(i) An isolated anti-aβ protofibril antibody or antigen binding fragment thereof capable of binding to human aβ protofibrils, the isolated anti-aβ protofibril antibody or antigen binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 13, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 14, and

(Ii) An anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein, the anti-tau antibody or antigen-binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 15, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 16,

Wherein the anti-aβ protofibril antibody or fragment thereof is administered in combination (e.g., simultaneously or sequentially) with the anti-tau antibody or fragment thereof.

2. The method of claim 1, wherein the isolated anti-aβ protofibril antibody or fragment thereof comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 17, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 18.

3. The method of any one of claims 1 or 2, wherein the anti-tau antibody or fragment thereof comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 19, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 20.

4. The method of any one of claims 1-3, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered once weekly or once every two weeks.

5. The method of any one of claims 1-4, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered intravenously, e.g., at a dose of 5mg/kg to 20mg/kg (e.g., 10 mg/kg).

6. The method of any one of claims 1-5, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered intravenously at a dose of 10mg/kg every two weeks, e.g., for at least 52 weeks.

7. The method of any one of claims 1-4, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered subcutaneously, e.g., in a weekly manner, comprising two consecutive subcutaneous injections, e.g., 360mg, of the isolated anti-aβ protofibril antibody or fragment thereof, for a total dose of 720mg, e.g., for at least 52 weeks.

8. The method of any one of claims 1-4 or 7, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered subcutaneously for a period of time, e.g., at least 52 weeks or 18 months, followed by administration of a maintenance dose.

9. The method of claim 8, wherein the maintenance dose comprises administering 720mg subcutaneously weekly or biweekly.

10. The method of claim 8, wherein the maintenance dose comprises intravenous administration of 10mg/kg once every two weeks, once every four weeks, or once every twelve weeks.

11. The method of any one of claims 1-10, wherein the anti-tau antibody or fragment thereof is administered once every four weeks.

12. The method of any one of claims 1-11, wherein the anti-tau antibody or fragment thereof is administered in an amount of 1000-4500mg (e.g., 1500, 3000, 4500 mg) once every four weeks.

13. The method of any one of claims 1-12, wherein the anti-tau antibody or fragment thereof is administered in an amount of 1500mg once every four weeks.

14. The method of claims 1-12, wherein the anti-tau antibody or fragment thereof is administered in an amount of 3000mg once every four weeks.

15. The method of any one of claims 1-11, wherein the anti-tau protein antibody or fragment thereof is administered at a dose of 3, 10 or 30mg/kg once every four weeks.

16. The method of any one of claims 1-15, wherein the anti-tau antibody or fragment thereof is administered intravenously.

17. The method of any one of claims 1-16, wherein the anti-aβ protofibril antibody or fragment thereof is administered prior to initiating treatment with the anti-tau antibody or fragment thereof.

18. The method of any one of claims 1-17, wherein the anti-aβ protofibril antibody or fragment thereof is administered for at least 10 weeks (e.g., at least 15, 20, 24, or 25 weeks) before treatment with the anti-tau antibody or fragment thereof begins.

19. The method of claim 17 or 18, wherein the subject has symptoms of alzheimer's disease.

20. The method of claim 19, wherein the subject has early-onset alzheimer's disease.

21. The method of claim 16, wherein the anti-tau antibody or fragment thereof is administered alone for 52 weeks before commencing combination therapy with the anti-tau antibody or fragment thereof and the anti-aβ protofibril antibody or fragment thereof.

22. The method of any one of claims 1-16, wherein the anti-tau antibody or fragment thereof is administered prior to commencing treatment with the anti-aβ protofibril antibody or fragment thereof.

23. The method of any one of claims 1-16, wherein the anti-tau antibody or fragment thereof is administered for at least 25 weeks (e.g., at least 30, 40, 50, or 52 weeks) prior to administration of the anti-aβ protofibril antibody or fragment thereof.

24. The method of claim 22 or 23, wherein the subject is free of symptoms of alzheimer's disease.

25. The method of any one of claims 1-24, wherein the subject has a dominant inherited gene mutation of alzheimer's disease, e.g., wherein the subject has a gene mutation in at least one of three genes-PSEN 1, PSEN2, or APP.

26. The method of claim 25, wherein the subject has a mutation in APP.

27. The method of any one of claims 1-26, wherein the subject has a family history of alzheimer's disease, e.g., family members were diagnosed with a medical history of alzheimer's disease before 60 years of age.

28. The method of any one of claims 1-27, wherein tau protein diffusion, e.g., as measured by tau protein PET (e.g., MK-6240 tau protein-PET) and/or MRI, is reduced after administration compared to untreated control subjects.

29. The method of any one of claims 1-28, wherein the level of phosphorylated tau protein 217 in a sample (e.g., cerebrospinal fluid or blood sample) taken from the subject after administration is reduced relative to the level of phosphorylated tau protein 217 in a sample taken from the subject prior to administration.

30. The method of any one of claims 1-29, wherein the subject's clinical dementia rating scale score sum score is improved after administration relative to the subject's score prior to administration.

31. The method of any one of claims 1-30, wherein the subject has improved ADAS-cog (alzheimer's disease assessment scale-cognition sub-scale), MMSE (simple mental state assessment), and/or clinical dementia assessment (CDR) scores after administration relative to scores prior to administration.

32. The method of any one of claims 1-31, wherein the ratio of aβ42/40 in a sample (e.g., a blood sample, such as a plasma sample, or CSF sample) collected from the subject after administration is increased relative to the ratio in a sample collected from the subject prior to administration.

33. The method of any one of claims 1-32, wherein the level of aβ protofibrils in the subject after administration is reduced compared to the level of aβ protofibrils in the subject prior to administration and/or compared to an untreated control or subject, e.g., as measured by PET (e.g., FDG-PET) and/or MRI.

34. A kit, the kit comprising:

(i) An isolated anti-aβ protofibril antibody or antigen binding fragment thereof capable of binding to human aβ protofibrils, the isolated anti-aβ protofibril antibody or antigen binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 13, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 14, and

(Ii) An anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein, the anti-tau antibody or antigen-binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 15, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 16.

35. The kit of claim 34, wherein the anti-aβ protofibril antibody or fragment thereof is present in an amount suitable for intravenous administration at a dose of 10mg/kg or suitable for subcutaneous administration of two consecutive 360mg doses, the total dose being 720mg, and the anti-tau protein antibody or fragment thereof is present in an amount suitable for administration at a dose of 1500 or 3000 mg.

36. The kit of any one of claims 34 or 35, wherein the anti-aβ protofibril antibody or fragment thereof is present in an amount suitable for subcutaneous administration of two consecutive 360mg doses, a total dose of 720mg, and the anti-tau protein antibody or fragment thereof is present in an amount suitable for administration at a dose of 3000 mg.

37. The kit of any one of claims 34-36, wherein the anti-aβ protofibril antibody or fragment thereof and the anti-tau antibody or antigen binding fragment thereof are formulated in separate containers within the kit.

38. The kit of any one of claims 34-37, wherein the isolated anti-aβ protofibril antibody, or fragment thereof, comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 17, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 18.

39. The kit of any one of claims 34-38, wherein the anti-tau antibody or fragment thereof comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 19, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 20.

40. A pharmaceutical combination comprising:

(i) An isolated anti-aβ protofibril antibody or antigen binding fragment thereof capable of binding to human aβ protofibrils, the isolated anti-aβ protofibril antibody or antigen binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 13, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 14, and

(Ii) An anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein, the anti-tau antibody or antigen-binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 15, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 16.

41. The pharmaceutical combination of claim 40, wherein the anti-aβ protofibril antibody or fragment thereof is present in an amount suitable for intravenous administration at a dose of 10mg/kg or suitable for subcutaneous administration at a dose of 720mg and the anti-tau protein antibody or fragment thereof is present in an amount suitable for administration at a dose of 1500 or 3000 mg.

42. Use of an anti-aβ protofibril antibody or fragment thereof and an anti-tau antibody or fragment thereof for the treatment or prevention of alzheimer's disease, wherein:

(i) An isolated anti-aβ protofibril antibody or antigen binding fragment thereof capable of binding to human aβ protofibrils, the isolated anti-aβ protofibril antibody or antigen binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 13, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 14, and

(Ii) An anti-tau antibody or antigen-binding fragment thereof capable of binding to human tau protein, the anti-tau antibody or antigen-binding fragment thereof comprising

(A) A heavy chain variable domain comprising the amino acid sequence of SEQ ID NO. 15, and

(B) A light chain variable domain comprising the amino acid sequence of SEQ ID NO. 16.

43. The use of claim 42, wherein the anti-aβ protofibril antibody or fragment thereof is present in an amount suitable for intravenous administration at a dose of 10mg/kg or suitable for subcutaneous administration at a dose of 720mg and the anti-tau protein antibody or fragment thereof is present in an amount suitable for intravenous administration at a dose of 1500 or 3000 mg.

44. The use according to any one of claims 42 or 43 for the treatment or prevention of early-onset alzheimer's disease in a subject.

45. The use of any one of claims 42-44, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered once weekly or once every two weeks.

46. The use of any one of claims 42-45, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered intravenously at a dose of 10 mg/kg.

47. The use of any one of claims 42-45, wherein the isolated anti-aβ protofibril antibody or fragment thereof is administered subcutaneously in two consecutive 360mg doses, a total dose of 720mg.

48. The use of any one of claims 42-47, wherein the anti-tau antibody or fragment thereof is administered once every four weeks.

49. The use of any one of claims 42-48, wherein the anti-tau protein antibody or fragment thereof is administered intravenously every four weeks at a dose of 1500 or 3000 mg.

50. The use of any one of claims 42-49, wherein the anti-tau protein antibody or fragment thereof is administered intravenously at a dose of 3000mg every four weeks.

51. The use of any one of claims 42-48, wherein the anti-tau protein antibody or fragment thereof is administered intravenously every four weeks at a dose of 3, 10, or 30 mg/kg.

52. The use of any one of claims 42-51, wherein the anti-aβ protofibril antibody or fragment thereof is administered prior to initiation of treatment with the anti-tau antibody or fragment thereof.

53. The use of any one of claims 42-52, wherein the anti-aβ protofibril antibody or fragment thereof is administered for at least 10 weeks (e.g., at least 15, 20, 24, or 25 weeks) before treatment with the anti-tau antibody or fragment thereof begins.

54. The use of any one of claims 42-53, wherein the anti-tau antibody or fragment thereof is administered alone for 52 weeks before commencing combination therapy with the anti-tau antibody or fragment thereof and the anti-aβ protofibril antibody or fragment thereof.

55. The use of any one of claims 42-51, wherein the anti-tau antibody or fragment thereof is administered prior to onset of treatment with the anti-aβ protofibril antibody or fragment thereof.

56. The use of any one of claims 42-51 or 55, wherein the anti-tau antibody or fragment thereof is administered for at least 25 weeks (e.g., at least 30, 40, 50 or 52 weeks) prior to administration of the anti-aβ protofibril antibody or fragment thereof.

57. The use of any one of claims 42-56, wherein the subject has a dominant inherited gene mutation of alzheimer's disease, e.g., wherein the subject has a gene mutation in at least one of the three genes PSEN1, PSEN2 or APP.

58. The use of any one of claims 42-57, wherein the subject has a family history of alzheimer's disease, e.g., family members were diagnosed with a medical history of alzheimer's disease before 60 years of age.

59. The use of any one of claims 42-58, wherein tau protein diffusion, e.g., as measured by tau protein PET (e.g., MK-6240 tau protein-PET) and/or MRI, is reduced after administration compared to untreated control subjects.

60. The use of any one of claims 42-59, wherein the level of phosphorylated tau protein 217 in a sample (e.g., cerebrospinal fluid or blood sample) taken from the subject after administration is reduced relative to the level of phosphorylated tau protein 217 in a sample taken from the subject prior to administration.

61. The use of any one of claims 42-60, wherein the subject's clinical dementia rating scale score sum score is improved after administration relative to the subject's score prior to administration.

62. The use of any one of claims 42-61, wherein the subject has improved ADAS-cog (alzheimer's disease assessment scale-cognition sub-scale), MMSE (simple mental state assessment) and/or clinical dementia assessment (CDR) scores after administration relative to scores prior to administration.

63. The use of any one of claims 42-62, wherein the ratio of aβ42/40 in a sample (e.g., a blood sample, such as a plasma sample, or CSF sample) collected from the subject after administration is increased relative to the ratio in a sample collected from the subject prior to administration.

64. The use of any one of claims 42-63, wherein the level of aβ protofibrils in the subject after administration is reduced compared to the level of aβ protofibrils in the subject prior to administration and/or compared to an untreated control or subject, e.g., as measured by PET (e.g., FDG-PET) and/or MRI.

65. The use of any one of claims 42-64, wherein the isolated anti-aβ protofibril antibody or fragment thereof comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 17, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 18.

66. The use of any one of claims 42-65, wherein the anti-tau antibody or fragment thereof comprises

(I) A heavy chain comprising the amino acid sequence of SEQ ID NO. 19, and

(Ii) A light chain comprising the amino acid sequence of SEQ ID NO. 20.