EA042876B1 - METHODS OF TREATMENT OF PATIENTS WITH FAMILY HYPERCHOLESTEROLEMIA - Google Patents

Description

This application contains a sequence listing that is filed electronically in ASCII format and is hereby incorporated by reference in its entirety. The specified ASCII copy, created on October 3, 2018, is named Sequence Lists.txt and is 8 KB in size.

Field of invention

The present invention relates to the field of therapeutic treatment of diseases and disorders that are associated with elevated levels of lipids and lipoproteins. More specifically, the invention relates to the use of an ANGPTL3 inhibitor with concomitant lipid-lowering therapy in order to treat patients with familial hypercholesterolemia in order to achieve optimal serum lipid and lipoprotein levels.

Prerequisites

Hyperlipidemia is a general term that encompasses diseases and disorders characterized by or associated with elevated levels of lipids and/or lipoproteins in the blood. Hyperlipidemias include hypercholesterolemia, hypertriglyceridemia, combined hyperlipidemia, and elevated lipoprotein a (Lp(a)). The particular predominant form of hyperlipidemia in many populations is hypercholesterolemia.

Hypercholesterolemia, in particular elevated low-density lipoprotein (LDL) cholesterol (LDL-C) levels, constitutes a major risk for atherosclerosis and coronary heart disease (CHD) (Sharrett et al., 2001, Circulation 104:1108-1113). LDL cholesterol has been identified as a major target of cholesterol-lowering therapy and is accepted as a valid indirect therapeutic endpoint. Many studies show that lowering LDL-C levels reduces the risk of CHD, with a strong positive relationship between LDL-C levels and CHD events; for every 1 mmol/L (~40 mg/dL) decrease in LDL-C, mortality and disease prevalence for cardiovascular disease (CVD) is reduced by 22%. A more pronounced decrease in LDL-C causes a more pronounced decrease in events, and comparative data for intensive and standard treatment with statins shows that the lower the level of LDL-C, the greater the effect in patients with a very high cardiovascular (CV) risk.

Familial hypercholesterolemia (FH) is an inherited disorder of lipid metabolism that predisposes an individual to premature severe cardiovascular disease (CVD) (Kolansky et al., (2008), Am J Cardiology, 102(11):1438-1443). FH can be an autosomal dominant or autosomal recessive disease that results from mutations in the low density lipoprotein receptor (LDLR) or at least 3 different genes that encode proteins involved in the hepatic clearance of LDL-C that can cause FH. Examples of such defects include mutations in the gene encoding the LDL receptor (LDLR), which removes LDL-C from circulation, and in the apolipoprotein (Apo) B gene, which is the main protein of the LDL particle. In all cases, FH is distinguished by accumulation of plasma LDL-C from birth and subsequent development of tendon xanthomas, xanthelasmas, atheromas, and CVD. FH can be classified as heterozygous FH (heFH) or homozygous FH (hoFH) depending on whether the individual has a genetic defect in one (heterozygous) or both (homozygous) copies of the gene involved.

Existing LDL-C lowering drug treatments include statins, cholesterol absorption inhibitors, fibrates, niacin, bile acid sequestrants, and subtilisin/kexin type 9 (PCSK9) proprotein convertase inhibitors. Statins are a commonly prescribed treatment for lowering LDL-C. However, despite the availability of such lipid-lowering therapies, many high-risk patients are unable to achieve their regulatory LDL-C target (Gitt et al., 2010, Clin Res Cardiol 99(11):723-733). Patients who remain unable to achieve a regulatory LDL-C target despite available lipid-modifying therapy (LMT) are sometimes given mechanical removal of LDL-C by lipoprotein apheresis (eg, LDL apheresis).

However, patients who do not achieve their LDL-C target despite taking an optimized LMT regimen will benefit significantly from alternative LDL-C lowering therapy or through the use of a combination of therapeutic agents, such as the agents and regimens described herein.

Brief summary of the invention

In its broadest aspect, the invention relates to methods of treating patients who suffer from familial hypercholesterolemia by administering an ANGPTL3 inhibitor in combination with other lipid-modifying therapy to achieve optimal serum lipid and lipoprotein levels.

In one embodiment, the method comprises administering to a patient suffering from familial hypercholesterolemia a therapeutically effective amount of a combination of (a) a statin; (b) one non-statin lipid-lowering agent; and (c) an ANGPTL3 inhibitor.

In one embodiment, the patient is administered (a) a statin; (b) one lipid-lowering agent other than a statin; (c) an ANGPTL3 inhibitor; and (d) a second lipid-lowering agent other than a statin.

In one embodiment, familial hypercholesterolemia is selected from the group consisting of heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH).

In one embodiment, the statin is selected from the group consisting of atorvastatin (LIPITOR®), pitavastatin (LIVALO®), lovastatin (MEVACOR®), simvastatin (ZOCOR®), pravastatin (PRAVACHOL®), fluvastatin (LESCOL®), and rosuvastatin ( CRESTOR®).

In one embodiment, the statin is rosuvastatin (CRESTOR®) administered orally once daily at a dose of about 5 mg to about 40 mg. In another embodiment, the statin is rosuvastatin (CRESTOR®) administered orally once a day at a dose of 5-40 mg.

In one embodiment, the statin is atorvastatin (LIPITOR®) administered orally once a day at a dose of about 10 mg to about 80 mg. In another embodiment, the statin is atorvastatin (LIPITOR®) administered orally once daily at a dose of 10-80 mg.

In one embodiment, one lipid-lowering agent other than a statin is an agent that inhibits cholesterol absorption.

In one embodiment, the cholesterol absorption inhibiting agent is ezetimibe (ZETIA®).

In one embodiment, ezetimibe (ZETIA®) is administered orally once a day at a dose of approximately 10 mg. In another embodiment, ezetimibe (ZETIA®) is administered orally once a day at a dose of 10 mg.

In one embodiment, the second lipid-lowering agent, other than a statin, is an agent that inhibits microsomal triglyceride transfer protein (MTTP).

In one embodiment, the agent that inhibits the microsomal triglyceride transport protein is lomitapide (JUXTAPID®).

In one embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of about 5 mg to about 60 mg. In another embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of 5-60 mg.

In one embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of approximately 20 mg. In another embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of 20 mg.

In one embodiment, the implementation of the second lipid-lowering agent, other than a statin, is an agent that inhibits PCSK9. In one embodiment, the PCSK9 inhibitor is alirocumab (PRALUENT®).

In one embodiment, the second lipid-lowering agent, other than a statin, is an agent that reduces the formation of apoB-containing lipoproteins. In one embodiment, the agent that reduces the formation of apoB-containing lipoproteins is mipomersen.

It is also contemplated that additional agents that act to lower lipids can replace the first and second lipid lowering agents described herein or alternatively can be combined with the first and second lipid lowering agents plus evinacumab to achieve normalization of at least one lipid parameter described in the present description.

In certain embodiments, the lipid-lowering therapy described herein can be combined for use in the treatment of patients undergoing apheresis to normalize the level of one or more of the lipid parameters described herein.

In one embodiment, the ANGPTL3 inhibitor is selected from the group consisting of a small molecule inhibitor, a nucleic acid (eg, siRNA), and an antibody that specifically binds to ANGPTL3.

In one embodiment, the anti-ANGPTL3 antibody is evinacumab.

In one embodiment, evinacumab is administered before, during, or after treatment with a statin, ezetimibe, lomitapide, mipomersen, a PCSK9 inhibitor, or any other lipid-lowering agent that has been shown to be effective in achieving normalization of at least one lipid parameter described herein. description.

In one embodiment, evinacumab is administered intravenously at a dose ranging from about 1 mg/kg to about 20 mg/kg of body weight.

In one embodiment, evinacumab is administered intravenously at a dose of approximately 15 mg/kg body weight. In another embodiment, evinacumab is administered intravenously at a dose of 15 mg/kg body weight.

In one embodiment, evinacumab is administered subcutaneously at a dose ranging from about 50 mg to about 750 mg.

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In one embodiment, evinacumab is administered subcutaneously at a dose ranging from about 250 mg to about 450 mg.

In one embodiment, evinacumab is administered every week, every two weeks, every 3 weeks, every 4 weeks, every 2 months, every 3 months, or every 4 months.

In a second aspect, the invention relates to a method for improving one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia, the method comprising administering one or more therapeutically effective doses of an ANGPTL3 inhibitor in combination with one or more therapeutically effective doses of a lipid-lowering agent selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, an agent that inhibits microsomal triglyceride transfer protein (MTTP), or combinations thereof, wherein the improvement in one or more lipid parameters is one or more of the following:

(a) lowering low-density lipoprotein (LDL-C) cholesterol from baseline (week 0);

(b) a decrease in apolipoprotein B (Apo B) from baseline;

(c) lowering non-high-density lipoprotein (non-HDL-C) cholesterol from baseline;

(d) lowering total cholesterol (total C) relative to baseline;

(e) a decrease in lipoprotein (a) (Lp(a) from baseline; and/or (f) a decrease in triglycerides (TG) from baseline.

In one embodiment, familial hypercholesterolemia is selected from the group consisting of heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH).

In one embodiment, the ANGPTL3 inhibitor is selected from the group consisting of a small molecule inhibitor, a nucleic acid (eg, siRNA), and an antibody that specifically binds to ANGPTL3.

In one embodiment, the antibody that specifically binds to ANGPTL3 is evinacumab.

In one embodiment, the statin is selected from the group consisting of atorvastatin (LIPITOR®), pitavastatin (LIVALO®), lovastatin (MEVACOR®), simvastatin (ZOCOR®), pravastatin (PRAVACHOL®), fluvastatin (LESCOL®), and rosuvastatin (CRESTOR ®).

In one embodiment, the statin is rosuvastatin (CRESTOR®) and is administered orally once a day at a dose of about 5 mg to about 40 mg. In another embodiment, the statin is rosuvastatin (CRESTOR®) and is administered orally once a day at a dose of 5-40 mg.

In one embodiment, the statin is atorvastatin (LIPITOR®) and is administered orally once a day at a dose of about 10 mg to about 80 mg. In another embodiment, the statin is atorvastatin (LIPITOR®) and is administered orally once a day at a dose of 10-80 mg.

In one embodiment, the cholesterol absorption inhibitor is ezetimibe (ZETIA®).

In one embodiment, ezetimibe (ZETIA®) is administered orally once a day at a dose of approximately 10 mg. In another embodiment, ezetimibe (ZETIA®) is administered orally once a day at a dose of 10 mg.

In one embodiment, the agent that inhibits the microsomal triglyceride transport protein is lomitapide (JUXTAPID®).

In one embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of about 5 mg to about 60 mg. In another embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of 5-60 mg.

In one embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of approximately 20 mg. In another embodiment, lomitapide (JUXTAPID®) is administered orally once a day at a dose of 20 mg.

In one embodiment, other lipid-lowering agents can be combined with the agents noted above to achieve an acceptable level of at least one of the lipid parameters described above. Other agents include, but are not limited to, PCSK9 inhibitors. In one embodiment, the PCSK9 inhibitor is an antibody that specifically binds to PCSK9. In one embodiment, the antibody that specifically binds to PCSK9 is alirocumab (PRALUENT®).

In one embodiment, an additional lipid-lowering agent that can be combined with the therapy described above includes an agent that reduces the formation of apoB-containing lipoproteins. In one embodiment, the agent that reduces the formation of apoB-containing lipoproteins is mipomersen.

It is also contemplated that additional agents that act to lower lipids may replace the first and second lipid lowering agents described herein, or alternatively may be combined with the first and second lipid lowering agents, plus evinacumab to achieve normal levels of at least one lipid parameter described in the present description.

In certain embodiments, the lipid-lowering therapy described herein may be combined for use in the treatment of patients undergoing apheresis, the goal being to lower at least one or more of the lipid parameters described above to an acceptable range. In a related embodiment, the use of a combination of therapies described herein may eliminate the need for apheresis, or may help increase the time interval between apheresis sessions.

In one embodiment, the treatment results in at least a 40% reduction in at least one lipid parameter relative to baseline.

In one embodiment, the treatment results in at least a 75% reduction in at least one lipid parameter relative to baseline.

In one embodiment, treatment results in at least a 40% reduction in LDL-C levels relative to baseline.

In one embodiment, an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises a heavy chain variable region (HCVR) complementarity determining region (CDR) having the amino acid sequence of SEQ ID NO: 1 and a light chain variable region CDR (LCVR) with SEQ ID NO: 5.

In one embodiment, the antibody or antigen-binding fragment thereof that specifically binds to ANGTL3 comprises a heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and LCDR3 having the amino acid sequence of SEQ ID NO: 8.

In one embodiment, the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 5.

In additional aspects, the invention relates to the use of pharmaceutical compositions comprising a combination of a statin, at least one lipid-lowering agent other than statins, and an angiopoietin-like protein 3 (ANGPTL3) inhibitor in the treatment of a patient suffering from familial hypercholesterolemia. In other additional aspects, the invention relates to the use of pharmaceutical compositions comprising an angiopoietin-like protein 3 (ANGPTL3) inhibitor in combination with a lipid-lowering agent selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, and an agent that inhibits microsomal triglyceride transport protein ( MTTP), or combinations thereof, in improving one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia.

Other embodiments of the present invention will become apparent upon consideration of the following detailed description.

Detailed description

In anticipation of the description of the present invention, it should be understood that this invention is not limited to the specific methods and experimental conditions described, as such methods and conditions may vary. It should also be understood that the terminology used in this specification is only for the purpose of describing specific embodiments and is not intended to be limiting, as the scope of the present invention is only limited by the appended claims.

Unless otherwise defined, all technical and scientific terms used in the present description have the same meaning as they are commonly understood by a person skilled in the art to which this invention pertains. As used herein, the term approximately, when used in relation to a particular numerical value recited, means that the value may vary from the recited value by no more than 1%. For example, as used herein, approximately 100 includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

While any methods and materials similar or equivalent to those described herein may be used in the practice of the present invention, preferred methods and materials are described below. All publications mentioned in the present description are incorporated into the present description by reference in order to describe them in their entirety.

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Methods for the treatment of hyperlipidemia

The present invention relates generally to methods and compositions for lowering lipoprotein levels in patients suffering from familial hypercholesterolemia by administering a combination of (a) a statin; (b) a first lipid-lowering therapy other than a statin; and (c) an ANGPTL3 inhibitor. In certain embodiments, the combination comprises a second lipid-lowering agent other than a statin. In certain embodiments, the first non-statin lipid-lowering agent is an agent that inhibits cholesterol absorption, such as ezetimibe (ZETIA®). In certain embodiments, the second non-statin lipid-lowering agent is an agent that inhibits a microsomal triglyceride transport protein, such as lomitapide (JUSTAPID®). In one embodiment, the ANGPTL3 inhibitor is an antibody that specifically binds to ANGPTL3, such as evinacumab. In certain embodiments, treatment with a combination of an ANGPTL3 inhibitor (eg, evinacumab) with the other therapy noted above (statin, ezetimibe, and lomitapide) may serve to lower lipoprotein levels in these patients to an acceptable range, thereby reducing their risk of developing atherosclerosis, stroke, and other cardiovascular diseases. In certain embodiments, the described methods can be used to treat patients suffering from familial hypercholesterolemia, including heterozygous familial hypercholesterolemia (HeFH) and/or homozygous familial hypercholesterolemia (HoFH). In certain embodiments, a PCSK9 inhibitor can also be added to the combination therapy described above to further reduce the level of at least one lipid parameter described herein. In a related embodiment, a combination of therapies described above can also be used in patients who are undergoing apheresis in order to achieve normalization of at least one of the described lipid parameters. The combination of the described therapies can eliminate the need for apheresis or can increase the time interval between the necessary apheresis procedures. The combination of the described therapies, when used alone or in combination with apheresis, may serve to reduce the risk of developing atherosclerosis and coronary heart disease (CHD) in these patients.

As used herein, the term lipoprotein refers to a biomolecular particle containing a protein and a lipid. Examples of lipoproteins include, for example, low density lipoprotein (LDL), high density lipoprotein (HDL), very low density lipoprotein (VLDL), medium density lipoprotein (IDL), and lipoprotein (a) (Lp(a)).

The present invention, in accordance with certain embodiments, includes methods for treating patients who do not respond, are not adequately controlled, or do not tolerate lipid-modifying therapy other than what is described and included in the combination described herein. As used herein, a particular patient who is not responding, inadequately controlled, or intolerant of lipid-modifying therapy is determined by a physician, physician assistant, diagnostician, or other healthcare professional based on the level of one or more lipoproteins (e.g., LDL-C and /or not HDL-C) measured or otherwise detectable in the patient's serum following treatment with a lipid-modifying agent. A physician, physician assistant, diagnostician, or other health care professional may also determine if a patient is intolerant of a particular lipid-modifying therapy based on the lipid-modifying therapy side effect profile that the patient may tolerate, including, but not limited to, muscle pain, tenderness, or weakness (myalgia). ), headache, skin redness, sleep problems, abdominal cramps, flatulence, diarrhea, constipation, rash, nausea or vomiting. A patient who is unresponsive, inadequately controlled, or intolerant of certain lipid-modifying therapies may also be defined by other factors such as the patient's family history, medical background, current status of therapeutic treatment, and commonly accepted or predominant lipoprotein targets adopted. national medical associations and medical groups, or be influenced by them. For example, in a particular context, if a patient is undergoing therapy with a particular lipid-modifying agent and demonstrates an LDL-C level greater than or equal to approximately 70 mg/dL, this indicates that the patient is not responding to or is not sufficiently controlled or tolerant of that lipid-modifying agent. lipid therapy and may benefit from treatment using the therapy described herein. In another context, if a patient is on therapy with a particular lipid-modifying agent and demonstrates an LDL-C level greater than or equal to approximately 100 mg/dL, this indicates that the patient is not responding, not adequately controlled, or intolerant of that lipid-modifying therapy. and may benefit from treatment using the therapy described herein. In a specific context, if a patient is undergoing therapy with a certain lipid-modifying agent and demonstrates an LDL-C level greater than or equal to approximately 150 mg/dL, 200 mg/dL, 250 mg/dL, 300 mg/dL, 400 mg/dL, or higher, this indicates that the patient is not responding, is not adequately controlled, or is not

- 5 042876 tolerates certain lipid-modifying therapy and may benefit from treatment using the therapy described in the present description. In another context, whether or not a particular percentage reduction in LDL-C or non-HDL-C levels corresponds to a patient's LDL-C or non-HDL-C level at a particular starting point (baseline) can be used to determine whether the patient is responding to lipid modifying therapy or whether the patient is in need of additional treatment using the methods and agents of the present invention. For example, a decrease in LDL-C or non-HDL-C of less than 50% (eg, less than 40%, less than 35%, less than 30%, less than 25%, etc.) from baseline may indicate a need for therapy. using the methods and means of the invention.

The present invention accordingly includes methods of treatment comprising administering one or more doses of an ANGPTL3 inhibitor (e.g., evinacumab) and one or more doses of a combination of a statin, ezetimibe, PCSK9 inhibitor, mipomersen, and/or lomitapide to a patient who is undergoing other types of lipid-modifying therapy ( e.g., bile acid sequestrants, niacin, fenofibrate) but does not respond to or tolerate such therapy, where, after receiving one or more doses of the combination therapy described herein, the patient is able to achieve normal levels of total cholesterol, LDL-C or not HDL-C. In certain cases, the patient may be withdrawn from other lipid-modifying therapy or other lipid-modifying therapy may be continued but may be administered at lower doses and may be used in combination with an ANGPTL3 inhibitor and a statin plus ezetimibe and lomitapide and optionally, a PCSK9 inhibitor and/or mipomersen for in order to achieve and/or maintain a specific target lipoprotein level. Alternatively, the patient may be administered another lipid-modifying therapy at the normal prescribed dose, but the frequency of administration of the other lipid-modifying therapy may be reduced if the other lipid-modifying therapy is to be administered in combination with the combination described herein. In some instances, the need for a patient to be treated with another lipid-modifying therapy in order to achieve and/or maintain a particular target lipoprotein level may be eliminated entirely after administration of one or more doses of the combination therapy described herein.

In accordance with certain embodiments, the present invention includes methods of reducing or eliminating the need for a particular lipid-modifying therapy, wherein the methods include selecting a patient with hyperlipidemia (e.g., hypercholesterolemia) who has been treated with a particular lipid-modifying therapy within the last month, the last 2 months, the last 3 months, past 4 months, past 5 months, past 6 months, or longer, and administering one or more doses of an ANGPTL3 inhibitor in combination with the agents described herein (ezetimibe, lomitapide, and statin) to the patient. Methods in accordance with this aspect of the invention lead to a decrease in the level of at least one lipid or lipoprotein in the patient's serum and, therefore, make it possible to reduce or eliminate the need for treatment with another lipid-modifying therapy to which the patient has not responded (for example, a bile acid sequestrant , niacin or fenofibrate) or to which the patient has demonstrated intolerance. The methods described herein can also be used in patients undergoing apheresis, and the combination of lipid-lowering agents used in this patient population may eliminate the need for apheresis or may increase the time interval between apheresis procedures. For example, in certain embodiments of the present invention, following administration of one or more doses of an ANGPLT3 inhibitor in combination with a statin, ezetimibe, and/or lomitapide, the patient's serum LDL-C level is reduced to less than a certain level (e.g., less than 100 mg/dL). or less than 70 mg/dl), or total cholesterol is reduced to a certain level (eg, less than 200 mg/dl or less than 150 mg/dl or serum LDL-C shows at least a 40% reduction from baseline levels prior to treatment with the combination described herein.

In accordance with certain embodiments, the patient who may be treated with the methods of the present invention has hypercholesterolemia (for example, a serum LDL-C concentration greater than or equal to 70 mg/dL (for example, if the patient has a history of a cardiovascular event) or an LDL concentration -C in serum is greater than or equal to 100 mg/dL (for example, if the patient has no history of a cardiovascular event).In certain embodiments, the patient's hypercholesterolemia is not adequately controlled by certain standard lipid-modifying therapy, such as bile acid sequestrants, niacin, or fenofibrates The present invention also relates to methods for reducing total cholesterol, LDL-C, non-HDL-C, triglycerides (TG), ApoB, ApoCIII, and Lp(a) in a patient who has familial hypercholesterolemia, including HeFH and HoFH.

Patients eligible for treatment

The present invention includes methods and compositions useful in the treatment of patients diagnosed with or identified at risk of developing a hypercholesterolemia condition, such as, for example, heterozygous familial hypercholesterolemia (HeFH) or homozygous familial hypercholesterolemia.

- 6 042876 lesterolemia (HoFH) due to mutations in the low density lipoprotein receptor (LDLR), autosomal dominant hypercholesterolemia (ADH, e.g. ADH associated with one or more gain-of-function mutations in the PCSK9 gene), documented presence of homozygous or combined heterozygous mutations in the Apo B gene, autosomal recessive hypercholesterolemia (ARH, for example, ARH associated with mutations in LDLRAP1), and the incidence of hypercholesterolemia that is different from familial hypercholesterolemia (not FH). A patient who is eligible for treatment with the methods of the invention may also include patients who exhibit LDLR mutations that fall into any of the following classes: class I: receptor null mutations, whereby no LDLR is synthesized at all; class II: alleles with transport defects, whereby LDLR is not properly transported from the endoplasmic reticulum to the Golgi apparatus for expression on the cell surface (class IIA (no receptor transport) and class IIB (impaired receptor transport); class III: alleles with binding defects, whereby LDLR does not properly bind LDL at the cell surface due to a defect in apolipoprotein B100 (R3500Q) or in LDL-R; class IV: alleles with internalization defects, whereby LDLR associated with LDL should does not cluster in clathrin-lined pits for receptor-mediated endocytosis; class V: alleles with turnover defects, whereby LDLR does not return to the cell surface.

The diagnosis of familial hypercholesterolemia (eg, heFH or hoFH) can be made using genotyping and/or clinical criteria. For patients who are not genotyped, the clinical diagnosis can be based on the Simon Broome criteria using the exact FH criteria or the WHO/Dutch Lipid Network criteria with a score of >8 points.

In accordance with certain embodiments, a patient may be eligible for treatment based on a history of coronary heart disease (CHD). As used herein, history of CHD (or documented history of CHD) includes one or more of: (i) acute myocardial infarction (MI); (ii) asymptomatic MI; (iii) unstable angina; (iv) coronary revascularization procedures (eg, percutaneous coronary intervention [PCI] or coronary artery bypass surgery [CABG]); and/or (v) clinically significant CHD diagnosed by invasive or non-invasive testing (such as coronary angiography, exercise stress test, stress echocardiography, or radionuclide imaging).

In accordance with certain embodiments, a patient may be eligible for treatment based on the presence of cardiovascular disease other than coronary heart disease (CVD other than CHD). As used herein, CVD in addition to CHD includes one or more of: (i) a documented previous ischemic stroke with focal ischemic neurological failure lasting more than 24 hours, which is considered to be atherothrombotic in origin; (ii) peripheral arterial disease; (iii) abdominal aortic aneurysms; (iv) atherosclerotic renal artery stenosis; and/or (v) carotid disease (transient ischemic attacks or carotid obstruction >50%).

In accordance with certain embodiments, a patient may be eligible for treatment based on the presence of one or more additional risk factors, such as (i) documented moderate chronic renal failure (CKD), which is defined as 30<eGFR<60 ml/min/ 1.73 m ² for 3 months or more; (ii) type 1 or type 2 diabetes mellitus with or without end organ damage (eg, retinopathy, nephropathy, microalbuminuria); (iii) a calculated 10-year risk estimate for fatal CVD >5% (ESC/EAS Guidelines for the management of dyslipidemias, Conroy et al., 2003, Eur. Heart J. 24:987-1003).

In accordance with certain embodiments, a patient may be eligible for treatment based on the presence of one or more additional risk factors selected from a group consisting of age (e.g., older than 40, 45, 50, 55, 60, 65, 70, 75, or 80 years), race, national origin, gender (male or female), exercise habits (eg, regular exercise, no exercise), other pre-existing medical conditions (eg, type II diabetes, high blood pressure, etc.) and current drug status (eg, current use of β-blockers, niacin, ezetimibe, fibrates, omega-3 fatty acids, bile resins, etc.).

In accordance with certain embodiments of the present invention, a subject that can be treated with the methods of the invention may exhibit elevated levels of one or more inflammatory markers. Any marker of systemic inflammation can be used for the purposes of the present invention. Suitable inflammatory markers include, without limitation, C-reactive protein, cytokines (eg, IL-6, IL-8, and/or IL-17), and cell adhesion molecules (eg, ICAM-1, ICAM-3, BL-CAM , LFA-2, VCAM-1, NCAM and RESAM).

In accordance with the present invention, patients may be eligible for treatment based on a combination of one or more of the above criteria or therapeutic characteristics.

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For example, in accordance with certain embodiments, a patient suitable for treatment with the methods of the present invention may additionally be selected based on the presence of

HeFH or non-FH in combination with: (i) a history of documented CHD, (ii) CVD other than CHD, and/or (iii) diabetes mellitus with end organ damage; such patients can also be selected based on the presence of a serum LDL-C concentration greater than or equal to 70 mg/dL.

In accordance with certain other embodiments, a patient suitable for treatment with the methods of the present invention, in addition to having hypercholesterolemia that is not adequately controlled by a daily moderate dose statin therapeutic regimen, can additionally be selected based on the presence of HeFH or non-FH without CHD or CVD other than CHD, but having either (i) a calculated estimate of a 10-year fatal risk of CVD>5%; or (ii) diabetes mellitus without target organ damage; such patients can also be selected based on the presence of a serum LDL-C concentration greater than or equal to 100 mg/dl.

In accordance with certain embodiments of the present invention, a subject that can be treated with the methods of the invention is a subject that has familial chylomicronemia syndrome (FCS; also known as lipoprotein lipase deficiency).

In accordance with certain embodiments of the present invention, a subject that can be treated with the methods of the invention is a subject who is undergoing or has recently undergone lipoprotein apheresis (e.g., in the past 6 months, in the past 12 weeks, in the past 8 weeks, in last 6 weeks, last 4 weeks, last 2 weeks, etc.)

Administration of an ANGPTL3 inhibitor as add-on therapy

The present invention includes methods of treatment in which a patient who is undergoing or has recently received a standard lipid-modifying therapy (e.g., a statin) is administered an ANGPTL3 inhibitor in accordance with a specific amount and frequency of dosing, and in which the ANGPTL3 inhibitor is administered as an adjunct to the previous the patient's lipid-modifying therapy (if applicable), such as an addition to the patient's previous daily statin regimen or another regimen, such as niacin. The methods also include the use of an ANGPTL3 inhibitor (eg, evinacumab) as adjunctive therapy with lipid modifying therapy in addition to statins, including use with ezetimibe and lomitapide in order to achieve maximum lipid lowering effects. Additional lipid-lowering agents to be used in the methods of the invention include PCSK9 inhibitors or mipomersen. The combination of agents can also be used in patients undergoing apheresis to achieve acceptable lipid levels.

For example, the methods of the present invention include complementary therapeutic regimens in which an ANGPTL3 inhibitor is administered as add-on therapy to the same stable daily statin regimen (i.e., the same amount of statin dosing) that the patient was on prior to taking the ANGPTL3 inhibitor. In addition to statin plus anti-ANGPTL3 antibody therapy, the addition of either ezetimibe alone or in combination with lomitapide results in significantly lower serum lipid or lipoprotein levels when the combination is administered. In other embodiments, ANGPTL3 inhibitors are administered as add-on therapy to a statin therapeutic regimen containing a statin in an amount greater than or less than the statin dose the patient was on prior to taking the ANGPTL3 inhibitor, or combination therapy described herein. For example, upon initiation of a therapeutic regimen containing an ANGPTL3 inhibitor administered at specific dosing frequencies and amounts, in addition to ezetimibe and lomitapide, the daily dose of a statin administered or prescribed to a patient may be (a) kept the same, (b) increased, or (c ) decrease (e.g., titrate up or down) from the daily dose of the statin that the patient was taking before starting the ANGPTL3 inhibitor, ezetimibe and/or lomitapide therapeutic regimen, depending on the patient's therapeutic needs.

Therapeutic effect

The methods of the present invention may lead to a decrease in serum levels of one or more lipid components selected from the group consisting of total cholesterol, LDL-C, IDL, non-HDL-C, ApoB 100, ApoB 48, Apo A-1, Apo CIII, VLDL-C, triglycerides, Lp(a), chylomicrons, chylomicron residues and cholesterol residues. For example, in accordance with certain embodiments of the present invention, administration of an ANGPTL3 inhibitor in combination with a statin, ezetimibe, and/or lomitapide to an eligible subject results in an average percentage reduction in serum low-density lipoprotein (LDL-C) cholesterol from baseline by at least about 25 %, 30%, 40%, 50%, 60% or more; an average percentage reduction in ApoB from baseline of at least about 25%, 30%, 40%, 50%, 60%, or more; an average percentage reduction in non-HDL-C from baseline of at least about 25%, 30%, 40%, 50%, 60%, or more; an average percentage reduction in total cholesterol from baseline of at least about 10%, 15%, 20%, 25%, 30%, 35%, or more; an average percentage reduction in VLDL-C from baseline of at least about 5%, 10%, 15%, 20%, 25%, 30%, or more; an average percentage reduction in triglycerides from baseline of at least about 5%, 10%, 15%, 20%, 25%, 30%,

35% or more; and/or an average percentage reduction in Lp(a) from baseline of at least about 5%, 10%, 15%, 20%, 25%, or more.

ANGPTL3 inhibitors

The methods of the present invention include administering to a patient a therapeutic composition comprising an ANGPTL3 inhibitor (e.g., an anti-ANGPTL3 antibody such as evinacumab) in combination with a statin, a cholesterol absorption inhibitor (e.g., ezetimibe), and an agent that inhibits microsomal triglyceride transport protein (e.g., lomitapide).

As used herein, an ANGPTL3 inhibitor is any agent that binds to or interacts with human ANGPTL3 and inhibits the normal biological function of ANGPTL3 in vitro or in vivo. Non-limiting examples of categories of ANGPTL3 inhibitors include small molecule antagonists of ANGPTL3, nucleic acid-based (e.g., siRNA or antisense) inhibitors of ANGPTL3 expression or activity, peptide molecules that specifically interact with ANGPTL3 (e.g., peptibodies), receptor molecules that specifically interact with ANGPTL3 , ANGPTL3 binding scaffolds (e.g., DARPin, HEAT repeat proteins, ARM repeat proteins, tetratricopeptide repeat proteins, fibronectin scaffolds, and other protein scaffolds with naturally occurring repeats, etc. [see eg Boersma and Pluckthun, 2011, Curr Opin Biotechnol 22:849-857 and references cited therein]), and anti-ANGPTL3 aptamers, or parts thereof. In certain embodiments, ANGPTL3 inhibitors that can be used in the context of the present invention are anti-ANGPTL3 antibodies or antigen-binding antibody fragments that specifically bind human ANGPTL3.

The term human angiopoietin-like protein-3 or human ANGPTL3 or hANGPTL3 as used herein refers to ANGPTL3 having the amino acid sequence of SEQ ID NO: 9 (see also NCBI accession number NP 055310) or a biologically active fragment thereof.

The term antibody, as used herein, is intended to refer to immunoglobulin molecules containing four polypeptide chains, two heavy (H) chains, and two light (L) chains linked by disulfide bonds, as well as their multimers (eg, IgM). Each heavy chain contains a heavy chain variable region (abbreviated herein as HCVR or VH) and a heavy chain constant region. The heavy chain constant region contains three domains, CH1, CH2 and CH3. Each light chain contains a light chain variable region (abbreviated herein as LCVR or VL) and a light chain constant region. The light chain constant region contains one domain (CL1). The VH and VL regions can be further subdivided into regions of hypervariability called complementarity determining regions (CDRs), which alternate with regions that are more conserved and called framework regions (FRs). Each VH and VL consists of three CDRs and four FRs, arranged from amino to carboxy in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In various embodiments, the FR of an anti-ANGPTL3 antibody (or antigen-binding portion thereof) may be identical to human germline sequences, or may be naturally or artificially modified. The amino acid consensus sequence can be determined based on parallel analysis of two or more CDRs.

The term antibody, as used herein, also includes antigen-binding fragments of whole antibody molecules. The terms antigen-binding portion of an antibody, antigen-binding fragment of an antibody, and the like, as used herein, include any naturally occurring, enzymatically produced, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds an antigen to form a complex. Antigen-binding fragments of an antibody can be extracted, for example, from whole antibody molecules using any suitable standard methods such as proteolytic cleavage or recombinant genetic engineering methods involving the manipulation and expression of DNA encoding the variable and optionally constant domains of the antibody. Such DNA is known and/or readily available from, for example, commercial sources, DNA libraries (including, for example, antibody phage libraries), or can be synthesized. DNA can be sequenced and manipulated chemically or using molecular biology techniques, for example, to arrange one or more variable and/or constant domains in an appropriate configuration or introduce codons, create cysteine residues, modify, add or remove amino acids, etc.

Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv molecules (scFv); (vi) dAb fragments; and (vii) minimal recognition units consisting of amino acid residues that mimic an antibody hypervariable region (eg, a distinguished complementarity determining region (CDR) such as a CDR3 peptide) or a limited FR3-CDR3-FR4 peptide. Other engineered molecules such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, tribodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies, divalent nanobodies, etc.) .e.), small modular immunopharmaceuticals (SMIPs), and shark IgNAR variable domains are also encompassed by the term antigen binding fragment as used herein.

An antigen-binding fragment of an antibody typically contains at least one variable domain. The variable domain may be of any size or amino acid composition and generally contains at least one CDR that is adjacent to or in frame with one or more framework sequences. In antigen-binding fragments having a VH domain associated with a VL domain, the VH and VL domains can be arranged relative to each other in any suitable arrangement. For example, the variable region may be dimeric and include VH-VH, VH-VL, or VL-VL dimers. Alternatively, the antigen-binding antibody fragment may comprise a VH or VL monomeric domain.

In certain embodiments, an antigen-binding fragment of an antibody may comprise at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary variable and constant domain configurations that can be found in an antigen-binding fragment of an antibody of the present invention include: (i) VH-CH1; (ii) VH-CH2; (iii) VH-CH3; (iv) VH-CH1-CH2; (v) VH-CH1-CH2-CH3; (vi) VHCH2-CH3; (vii) VH-CL; (viii) VL-CH1; (ix) VL-CH2; (x) VL-CH3; (xi) VL-CH1-CH2; (xii) VL-CH1-CH2CH3; (xiii) VL-CH2-CH3; and (xiv) VL-CL. In any configuration of the variable and constant domains, including any of the exemplary configurations listed above, the variable and constant domains can be connected directly to each other, or can be connected using an entire or partial hinge or linker region. The hinge region may be composed of at least 2 (eg, 5, 10, 15, 20, 40, 60 or more) amino acids, resulting in a flexible or semi-flexible bond between adjacent variable and/or constant domains in a single polypeptide molecule. In addition, an antigen-binding fragment of an antibody of the present invention may comprise a homodimer or heterodimer (or other multimer) in any of the variable and constant domain configurations listed above, in non-covalent association with each other and/or with one or more VH or VL monomeric domains ( e.g. via disulfide bond(s)). As with whole antibody molecules, antigen-binding fragments can be monospecific or polyspecific (eg, bispecific). A polyspecific antigen binding fragment of an antibody typically contains at least two distinct variable domains, where each variable domain is capable of specifically binding to a separate antigen or to a different epitope on the same antigen. Any multispecific antibody format, including exemplary bispecific antibody formats, disclosed herein can be adapted for use in the context of an antigen-binding fragment of an antibody of the present invention using conventional techniques available in the art.

The constant region of an antibody is important for the ability of an antibody to fix complement and mediate cell-mediated cytotoxicity. Thus, the antibody isotype can be selected based on whether it is desirable for the antibody to mediate cytotoxicity.

The term human antibody, as used herein, is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies of the invention may, however, contain amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by in vitro random or site-directed mutagenesis, or by in vivo somatic mutation), for example, in CDRs and in particular , CDR3. However, the term human antibody, as used herein, is not intended to include antibodies in which CDR sequences derived from the germline of other mammalian species, such as the mouse, are grafted into human framework sequences. The term includes antibodies produced recombinantly in non-human mammals or in non-human mammalian cells. The term is not intended to include antibodies isolated or generated from a human subject.

The term recombinant human antibody, as used herein, is intended to include all human antibodies that are produced, expressed, generated, or isolated by recombinant means, such as antibodies expressed using a recombinant expression vector transfected into a host cell (described further below). ), antibodies isolated from a recombinant human combinatorial antibody library (described further below), antibodies isolated from an animal (e.g., mouse) that is transgenic for human immunoglobulin genes (see, e.g., Taylor et al. (1992) Nucl. Acids Res. 20:6287-6295) or antibodies produced, expressed, generated or isolated by any other means, which includes splicing human immunoglobulin gene sequences with other DNA sequences. Such recombinant human antibodies have variable and constant

- 10 042876 regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies are subjected to in vitro mutagenesis (or, when an animal transgenic for human Ig sequences is used, somatic mutagenesis in vivo), and thus the amino acid sequences of the VH and VL regions of the recombinant antibodies are sequences that , although derived from and related to human germline VH and VL sequences, may not naturally exist in the in vivo human germline antibody repertoire.

Human antibodies can exist in two forms that are associated with hinge heterogeneity. In one form, the immunoglobulin molecule contains a stable four chain construct of approximately 150-160 kDa, in which the dimers are held together by a disulfide bond between the heavy chains. In the second form, the dimers are not linked by interchain disulfide bonds, and a molecule of approximately 75-80 kDa is formed, consisting of covalently linked light and heavy chains (half-antibody). These forms are extremely difficult to separate, even after affine purification.

The frequency of occurrence of the second form in various intact IgG isotypes is due to, but not limited to, structural differences associated with the isotype of the hinge region of the antibody. A single amino acid change in the human IgG4 hinge can significantly reduce the occurrence of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels normally seen with a human IgG1 hinge. The present invention encompasses antibodies having one or more mutations in the hinge region, CH2 or CH3, which may be desirable, for example, upon preparation, in order to improve the yield of the desired antibody form.

An isolated antibody, as used herein, refers to an antibody that has been identified and isolated and/or recovered from at least one component of its natural environment. For example, an antibody that has been isolated or removed from at least one component of an organism, or from a tissue or cell in which the antibody exists or is naturally formed, is an isolated antibody for the purposes of the present invention. An isolated antibody also includes an antibody in situ in a recombinant cell. Isolated antibodies are antibodies that have undergone at least one purification or isolation step. In accordance with certain embodiments, the isolated antibody may be substantially free of other cellular material and/or chemical compounds.

The term specifically binds or the like means that an antibody, or antigen-binding fragment thereof, forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that specifically binds ANGPTL3, as used in the context of the present invention, includes antibodies that bind ANGPTL3, or a portion thereof, with a K _D of less than about 1000 nM, about less than 500 nM, about less than 300 nM, about less than 200 nM, about less than 100 nM, about less than 90 nM, about less than 80 nM, less than 70 nM approximately, less than 60 nM approximately, less than 50 nM approximately, less than 40 nM approximately, less than 30 nM approximately, less than 20 nM approximately, less than 10 nM approximately, less than 5 nM approximately , less than about 4 nM, about less than 3 nM, about less than 2 nM, about less than 1 nM, or about less than 0.5 nM, as measured in a surface plasmon resonance assay. However, an isolated antibody that specifically binds human ANGPTL3 is cross-reactive with other antigens, such as ANGPTL3 molecules from other (non-human) species.

Anti-ANGPTL3 antibodies useful in the methods of the present invention may contain one or more amino acid substitutions, insertions and/or deletions in the framework and/or CDR regions of the heavy and light chain variable domains compared to the corresponding germline sequences from which the antibodies are derived. Such mutations can be readily identified by comparing the amino acid sequences disclosed herein with germline sequences available, for example, in public antibody sequence databases. The present invention includes methods using antibodies and antigen-binding fragments thereof, which are derived from any of the amino acid sequences disclosed herein, wherein one or more amino acids in one or more framework and/or CDR regions are mutated into the corresponding germline sequence residue(s), from which the antibody originated, or to the corresponding residue(s) of another human germline sequence, or to a conservative amino acid substitution of the corresponding germline residue(s) (such sequence changes are collectively referred to herein as generative mutations). One skilled in the art, starting from the heavy and light chain variable region sequences disclosed herein, can easily generate a plurality of antibodies and antigen-binding fragments that contain one or more individuals.

- 11 042876 generative mutations or their combinations. In certain embodiments, all framework and/or CDR residues in the VH and/or VL domains are mutated back to residues found in the original germline sequence from which the antibody originated. In other embodiments, only certain residues are mutated back to the original germline sequence, e.g., only mutant residues found within the first 8 amino acids of FR1 or within the last 8 amino acids of FR4, or only mutant residues found within CDR1, CDR2, or CDR3. In other embodiments, one or more framework and/or CDR residues are mutated into the corresponding residue(s) of a different germline sequence (i.e., a germline sequence that differs from the germline sequence from which the antibody originally originated). In addition, the antibodies of the present invention may contain any combination of two or more generative mutations in the framework and/or CDR regions, for example, where certain individual residues mutate into the corresponding residue of a particular germline sequence, while certain other residues that differ from the original germline sequences are retained or mutated into the corresponding residue of another germline sequence. Once obtained, antibodies and antigen-binding fragments that contain one or more generative mutations can be easily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced antagonistic or agonistic biological properties (as appropriate) , reduced immunogenicity, etc. The use of antibodies and antigen-binding fragments obtained in this general manner is included in the present invention.

The present invention also relates to methods using anti-ANGPTL3 antibodies containing variants of any of the HCVR, LCVR and/or CDR amino acid sequences disclosed herein that have one or more conservative substitutions. For example, the present invention includes the use of anti-ANGPTL3 antibodies having the amino acid sequences of HCVR, LCVR and/or CDR, for example, 10 or less, 8 or less, 6 or less, 4 or less, etc. conservative amino acid substitutions relative to any of the HCVR, LCVR and/or CDR amino acid sequences disclosed herein.

The term surface plasmon resonance, as used herein, refers to an optical phenomenon that makes it possible to analyze interactions in real time by detecting changes in protein concentrations in a biological sensor array, for example, using the BIAcore™ system (Biacore Life Sciences division of GE Healthcare, Piscataway, NJ).

The term KD, as used herein, is intended to mean the equilibrium dissociation constant for a particular antibody-antigen interaction.

The term epitope refers to an antigenic determinant that interacts with a specific antigen-binding site in the variable region of an antibody molecule, known as the paratom. One antigen may have more than one epitope. Thus, different antibodies can bind to different sites on the antigen and can cause different biological effects. Epitopes may be conformational or linear. A conformational epitope is obtained by spatial approximation of amino acids from different segments of a linear polypeptide chain. A linear epitope is one that is formed by adjacent amino acid residues in a polypeptide chain. In certain circumstances, an epitope may contain fragments of saccharides, phosphoryl groups or sulfonyl groups on the antigen.

In certain embodiments, the anti-ANGPTL3 antibodies used in the methods of the present invention are antibodies with pH dependent binding characteristics. As used herein, the expression pH-dependent binding means that an antibody or antigen-binding fragment thereof exhibits reduced binding to ANGPTL3 at acidic pH compared to neutral pH (both expressions can be used interchangeably for the purposes of this disclosure). For example, antibodies with pH dependent binding characteristics include antibodies and antigen binding fragments thereof that bind to ANGPTL3 with higher affinity at neutral pH than at acidic pH. In certain embodiments, the antibodies and antigen-binding fragments of the present invention bind ANGPTL3 with an affinity that is at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70 , 75, 80, 85, 90, 95, 100 or more times higher at neutral pH than at acidic pH.

In accordance with this aspect of the invention, anti-ANGPTL3 antibodies with pH dependent binding characteristics may have one or more amino acid variations relative to the parent anti-ANGPTL3 antibody. For example, an anti-ANGPTL3 antibody with pH dependent binding characteristics may contain one or more histidine substitutions or insertions, for example, in one or more CDRs of the parent anti-ANGPTL3 antibody. Thus, in accordance with certain embodiments of the present invention, methods are provided that include administering an anti-ANGPTL3 antibody that contains amino acid sequences of CDRs (e.g., heavy and light chain CDRs) that are identical to the amino acids after

- 12 042876 CDRs of the parental anti-ANGPTL3 antibody, except for the replacement of one or more amino acids in one or more CDRs of the parental antibody with a histidine residue. Anti-ANGPTL3 antibodies with pH dependent binding may have, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions, either in one CDR of the parent antibody or distributed throughout several (e.g., 2, 3, 4, 5 or 6) CDR of the parent anti-ANGPTL3 antibody. For example, the present invention includes the use of pH-dependent binding anti-ANGPTL3 antibodies comprising one or more HCDR1 histidine substitutions, one or more HCDR2 histidine substitutions, one or more HCDR3 histidine substitutions, one or more LCDR1 histidine substitutions, one or more multiple histidine substitutions in LCDR2 and/or one or more histidine substitutions in LCDR3 of the parent anti-ANGPTL3 antibody.

As used herein, acidic pH means pH 6.0 or less (eg, less than about 6.0, less than about 5.5, less than about 5.0, etc.). The expression acidic pH includes pH values approximately 6.0, 5.95, 5.90, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5 , 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0, or less. As used herein, the expression neutral pH means a pH of about 7.0 to about 7.4. The expression neutral pH includes pH values of approximately 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35 and 7.4.

A non-limiting example of an anti-ANGPTL3 antibody that can be used in the context of the present invention includes evinacumab.

Obtaining human antibodies

Anti-ANGPTL3 antibodies can be generated according to any antibody production/isolation method known in the art. For example, antibodies for use in the methods of the present invention can be generated using hybridoma technologies, phage display, yeast display, and the like. Antibodies for use in the methods of the present invention may be, for example, chimeric antibodies, humanized antibodies, or fully human antibodies.

Methods for generating human antibodies in transgenic mice are known in the art. Any such known methods are used in the context of the present invention to generate human antibodies that specifically bind ANGPTL3.

For example, using VELOCIMMUNE™ technology (see, for example, US 6596541, Regeneron Pharmaceuticals) or any other known method for generating monoclonal antibodies, high affinity anti-ANGPTL3 chimeric antibodies having a human variable region and a mouse constant region are initially isolated. The VELOCIMMUNE® technology involves generating a transgenic mouse having a genome containing human heavy and light chain variable regions operably linked to endogenous mouse constant region loci such that the mouse produces an antibody containing a human variable region and a mouse constant region in response to antigen challenge. The DNA encoding the heavy and light chain variable regions of the antibody is isolated and operably linked to the DNA encoding the human heavy and light chain constant regions. The DNA is then expressed in a cell capable of fully expressing the human antibody.

In general, a VELOCIMMUNE® mouse is stimulated with an antigen of interest and lymphatic cells (such as B cells) are obtained from mice that express antibodies. The lymphatic cells can be fused with a myeloma cell line to generate immortal hybridoma cell lines, and such hybridoma cell lines are screened and selected to identify hybridoma cell lines that produce antibodies with specificity for the antigen of interest. The DNA encoding the heavy chain and light chain variable regions can be isolated and fused to the desired isotypic heavy chain and light chain constant regions. Such an antibody protein can be produced in a cell, such as a CHO cell. Alternatively, DNA encoding antigen-specific chimeric antibodies or light and heavy chain variable domains can be isolated directly from antigen-specific lymphocytes.

Initially, high-affinity chimeric antibodies are isolated having a human variable region and a mouse constant region. The antibodies are characterized and selected for the desired characteristics, including affinity, selectivity, epitope, etc., using standard procedures known to those skilled in the art. The mouse constant regions are replaced with the desired human constant region in order to generate a fully human antibody of the invention, eg wild-type or modified IgG1 or IgG4. Although the selected constant region may be varied according to the particular application, the characteristics of high affinity antigen binding and target specificity are retained in the variable region.

In general, antibodies that can be used in the methods of the present invention have high affinity, as described above, as measured by antigen binding or immobilized on the solid phase or in the dissolved phase. The mouse constant regions will be replaced with the desired human constant regions to generate fully human antibodies of the invention.

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Although the selected constant region may be varied according to the particular application, the characteristics of high affinity antigen binding and target specificity are retained in the variable region.

Specific examples of human antibodies or antigen-binding antibody fragments specifically binding ANGPTL3 that can be used in the context of the methods of the present invention include antibodies or antigen-binding proteins containing six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) from a pair of variable amino acid sequences. heavy and light chain regions (HCVR/LCVR) containing SEQ ID NO: No. 1/5.

In certain embodiments, an anti-ANGPTL3 antibody or antigen-binding fragment thereof useful in the methods of the present invention comprises heavy and light chain complementarity determining regions (HCDR1-HCDR2HCDR3/LCDR1-LCDR2-LCDR3) containing the amino acid sequences of SEQ ID NO :#2, 3, 4, 6, 7 and 8.

In certain embodiments, an anti-ANGPTL3 antibody or antigen-binding fragment thereof useful in the methods of the present invention comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 5.

Pharmaceutical compositions and routes of administration

The present invention includes methods that include administering an ANGPTL3 inhibitor to a patient in combination with a statin, a cholesterol absorption inhibitor, and an inhibitor of a microsomal triglyceride transfer protein, wherein the ANGPTL3 inhibitor and additional agents are in the same or different pharmaceutical compositions. Pharmaceutical compositions of the invention are formulated using suitable carriers, excipients, and other means that provide suitable transfer, delivery, tolerability, and the like. Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, vesicles containing lipids (cationic or anionic) (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water emulsions, and water-in-oil, Carbowax emulsions (polyethylene glycols of various molecular weights), semi-solid gels and semi-solid mixtures containing Carbowax. See also Powell et al. Compendium of excipients for parenteral formulations PDA (1998) J Pharm Sci Technol 52:238-311.

Exemplary pharmaceutical formulations containing antibodies against ANGPTL3 that can be used in the context of the present invention include any of the formulations as set forth in US 8795669 (which describes, inter alia, exemplary formulations containing alirocumab) or in WO 2013/166448 or WO 2012/ 168491.

Various delivery systems are known that can be used to administer the pharmaceutical composition of the invention, such as encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endocytosis (see, for example, Wu et al., 1987, J Biol Chem 262:4429-4432). Routes of administration include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition may be administered by any convenient route, for example, by infusion or bolus injection, by absorption through epithelial or mucocutaneous linings (eg, oral mucosa, rectal and intestinal mucosa, etc.), and may be administered with other biologically active agents.

The pharmaceutical composition of the present invention can be delivered subcutaneously or intravenously using a standard needle and syringe. In addition, with respect to subcutaneous delivery, the pen-shaped delivery device clearly has application to the delivery of the pharmaceutical composition of the present invention. Such a pen delivery device may be reusable or disposable. A reusable pen-style delivery device typically uses a replaceable cartridge that contains a pharmaceutical composition. When all of the pharmaceutical composition in the cartridge has been introduced and the cartridge is empty, the empty cartridge can be easily discarded and replaced with a new cartridge that contains the pharmaceutical composition. The pen delivery device can then be reused. There is no replaceable cartridge in the pen-style disposable delivery device. Conversely, a pen-shaped disposable delivery device comes pre-filled with a pharmaceutical composition contained in a reservoir within the device. When the pharmaceutical composition in the reservoir has run out, the entire device is discarded.

Many reusable pen and auto-injector delivery devices have applications in subcutaneous delivery of the pharmaceutical composition of the present invention. Examples include, but are not limited to, AUTOPEN™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC™ handle (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX 75/25™ handle, HUMALOG™ handle, HUMALIN 70 handle /30™ (Eli Lilly and Co., Indianapolis, IN), NOVOPEN™ I, II and III (Novo

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Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR™ (Novo Nordisk, Copenhagen, Denmark), BD™ Pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN™, OPTIPEN PRO™, OPTIPEN STARLET™ and OPTICLIK™ (Sanofi-Aventis, Frankfurt, Germany), among others. Examples of a pen-style disposable delivery device having applications in subcutaneous delivery of the pharmaceutical composition of the present invention include, but are not limited to, SOLOSTAR™ pen (Sanofi-Aventis), FLEXPEN™ (Novo Nordisk) and KWIKPEN™ (Eli Lilly), autoinjector SURECLICK™ (Amgen, Thousand Oaks, CA), PENLET™ (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, L.P.), and HUMIRA™ pen (Abbott Labs, Abbott Park IL), among others.

In certain situations, the pharmaceutical composition may be delivered in a controlled release system. In one embodiment, a pump may be used (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another embodiment, polymeric materials can be used; see, Medical Applications of Controlled Release, Langer and Wise (ed.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, the controlled release system can be placed close to the target of the composition, thus requiring only a fraction of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, supra, vol. 2, p. 115-138). Other controlled release systems are reviewed by Langer, 1990, Science 249:1527-1533.

Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injections, drip infusions, and the like. These injectable preparations can be obtained by known methods. For example, injectable preparations can be prepared, for example, by dissolving, suspending, or emulsifying an antibody or salt thereof, as described above, in a sterile aqueous or oily medium commonly used for injection. As an aqueous injection medium, there are, for example, physiological saline, isotonic solution containing glucose and other adjuvants, etc., which can be used in combination with a suitable solubilizing agent such as an alcohol (for example, ethanol), polyhydric an alcohol (eg, propylene glycol, polyethylene glycol), a non-ionic surfactant (eg, polysorbate 80, HCO-50 (adduct of polyoxyethylene (50 mol) and hydrogenated castor oil)) and the like. As the oil medium, for example, sesame oil, soybean oil, etc. are used, which can be used in combination with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injection thus obtained is preferably filled into a suitable ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteral use described above are prepared in unit dose dosage forms adapted to match the dose of the active ingredients. Such unit dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, and the like.

Dose

The amount of an ANGPTL3 inhibitor (eg, an anti-ANGPTL3 antibody) administered to a subject in accordance with the methods of the present invention is generally a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount of an ANGPTL3 inhibitor" refers to the dose of an ANGPTL3 inhibitor that, when administered in combination with a statin, ezetimibe, and lomitapide, results in a detectable reduction (at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or more relative to the base level) of one or more parameters selected from the group, consisting of total cholesterol, LDL-C, ApoB, ApoA-1, Apo CIII, non-HDL-C, VLDL-C, triglycerides, and Lp(a), or an amount that reduces or eliminates the patient's need for other therapeutic agents or interventions such as lipoprotein apheresis.

The amount of an ANGPTL3 inhibitor (eg, an anti-ANGPTL3 antibody) administered to a subject in accordance with the methods of the present invention is generally a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount of an ANGPTL3 inhibitor" means that the dose of an ANGPTL3 inhibitor, in combination with the therapeutic agents described herein, results in a detectable reduction (at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or more of the base level) of one or more parameters selected from the group, consisting of total cholesterol, LDL-C, ApoB, ApoA-1, Apo CIII, non-HDL-C, VLDL-C, triglycerides, and Lp(a).

In the case of an anti-ANGPTL3 antibody, a therapeutically effective amount may be from about 0.05 mg to about 600 mg, for example, about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2 .0 mg, approximately 10 mg, approximately 20 mg, approximately 30 mg, approximately 40 mg, approximately 50 mg, approximately 60 mg, approximately 70 mg, approximately 80 mg, approximately 90 mg, approximately 100 mg, approximately 110 mg, approximately 120 mg, approximately 130 mg, approximately 140 mg,

- 15 042876 approximately 160 mg, approximately 170 mg, approximately 180 mg, approximately 190 mg, approximately 200 mg, approximately 210 mg, approximately 220 mg, approximately 230 mg, approximately 240 mg, approximately 250 mg, approximately 260 mg, approximately 270 mg , approximately 280 mg, approximately 290 mg, approximately 300 mg, approximately 310 mg, approximately 320 mg, approximately 330 mg, approximately 340 mg, approximately 350 mg, approximately 360 mg, approximately 370 mg, approximately 380 mg, approximately 390 mg, approximately 400 mg, approximately 410 mg, approximately 420 mg, approximately 430 mg, approximately 440 mg, approximately 450 mg, approximately 460 mg, approximately 470 mg, approximately 480 mg, approximately 490 mg, approximately 500 mg, approximately 510 mg, approximately 520 mg, about 530 mg, about 540 mg, about 550 mg, about 560 mg, about 570 mg, about 580 mg, about 590 mg, or about 600 mg of anti-ANGPTL3 antibody. Other dosing amounts for ANGPTL3 inhibitors will be apparent to those skilled in the art and are contemplated within the scope of the present invention.

The amount of anti-ANGPTL3 antibody contained in individual doses can be expressed in units of milligrams of antibody per kilogram of patient body weight (ie, mg/kg). For example, an anti-ANGPTL3 antibody may be administered to a patient at a dose of about 0.0001 to about 20 mg/kg of the patient's body weight.

Combination Therapy

The methods of the present invention may also include administering an ANGPTL3 inhibitor in combination with a statin, ezetimibe, and lomitapide to a patient who is unresponsive, inadequately controlled, or intolerant of other standard lipid-lowering therapy. In certain embodiments, the need for additional administration of standard lipid-lowering therapy may be eliminated altogether. In certain embodiments, the combined use of an ANGPTL3 inhibitor with other agents described herein can be used in combination with (on top of) a patient's lipid-lowering therapy. For example, in the context of lowering at least one lipid/lipoprotein parameter in a patient suffering from hyperlipidemia (eg, hypercholesterolemia), where the patient is unresponsive to, inadequately controlled, or intolerant of standard lipid-lowering therapy, the combination of an ANGPTL3 inhibitor with ezetimibe and lomitapide can be administered to a patient in combination with a stable daily statin regimen. Exemplary daily statin regimens that can be used in the context of the present invention include, for example, atorvastatin (10, 20, 40 or 80 mg daily), (atorvastatin/ezetimibe 10/10 or 40/10 mg daily), rosuvastatin (5 , 10 or 20 mg daily), cerivastatin (0.4 or 0.8 mg daily), pitavastatin (1, 2 or 4 mg daily), fluvastatin (20, 40 or 80 mg daily), simvastatin (5, 10, 20 , 40 or 80 mg daily), simvastatin/ezetimibe (10/10, 20/10, 40/10 or 80/10 mg daily), lovastatin (10, 20, 40 or 80 mg daily), pravastatin (10, 20 , 40 or 80 mg daily) and combinations thereof. Other lipid-modifying therapy in combination with which an ANGPTL3 inhibitor can be administered in the context of the present invention includes, for example, (1) an agent that increases lipoprotein catabolism (such as niacin); and/or (2) activators of the transcription factor LXR, which plays a role in the elimination of cholesterol, such as 22-hydroxycholesterol.

A non-limiting example of an anti-ANGPTL3 antibody to be used in the context of the present invention includes evinacumab.

Introduction schemes

In accordance with certain embodiments of the present invention, multiple doses of an ANGPTL3 inhibitor (i.e., a pharmaceutical composition containing an ANGPTL3 inhibitor) may be administered to a subject over a period of time (e.g., over a daily statin regimen or other background lipid-modifying therapy), in addition to the administration of ezetimibe and lomitapide. Methods in accordance with this aspect of the invention include sequential administration of several doses of an ANGPTL3 inhibitor to a subject. As used herein, sequential administration means that each dose of an ANGPTL3 inhibitor is administered to a subject at a different point in time, eg, on a different day separated by a predetermined interval (eg, hours, days, weeks, or months). The present invention includes methods that include sequentially administering to a patient a single initial dose of an ANGPTL3 inhibitor, followed by one or more secondary doses of an ANGPTL3 inhibitor, and optionally followed by one or more tertiary doses of an ANGPTL3 inhibitor.

The terms initial dose, secondary doses and tertiary doses refer to the time sequence of administration of individual doses of a pharmaceutical composition containing an ANGPTL3 inhibitor. Thus, the initial dose is the dose that is administered at the beginning of the treatment regimen (also referred to as the base dose); secondary doses are doses that are administered after the initial dose; and tertiary doses are doses that are administered after secondary doses. Initial, secondary and tertiary doses may contain the same amount of ANGPTL3 inhibitor, but may generally differ from each other with respect to the frequency of administration. However, in

- 16 042876 certain embodiments, the amount of ANGPTL3 inhibitor contained in the initial, secondary and/or tertiary doses varies relative to each other (eg, adjusted up or down depending on the situation) during the course of treatment. In certain embodiments, two or more (eg, 2, 3, 4, or 5) doses are administered at the beginning of the treatment regimen as loading doses, followed by subsequent doses that are administered on a less frequent basis (eg, maintenance doses).

In accordance with exemplary embodiments of the present invention, each secondary and/or tertiary dose is administered at 1-26 (e.g., 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 13, 5, 14, 14.5, 15, 15.5, 16, 16.5, 17, 17.5, 18, 18.5, 19, 19.5, 20, 20.5, 21, 21.5, 22, 22.5, 23, 23.5, 24, 24.5, 25, 25.5, 26, 26.5 or more) weeks after the immediately preceding dose. The phrase immediately preceding dose, as used herein, means, in a multi-dose sequence, the dose of an antigen-binding molecule that is administered to a patient prior to the next next dose in the sequence, with no intermediate doses.

Methods in accordance with this aspect of the invention may include administering any number of secondary and/or tertiary doses of an ANGPTL3 inhibitor to a patient. For example, in certain embodiments, only one secondary dose is administered to the patient. In other embodiments, the patient is administered two or more (eg, 2, 3, 4, 5, b, 7, 8 or more) secondary doses. Similarly, in certain embodiments, only one tertiary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses are administered to the patient.

In embodiments using multiple secondary doses, each secondary dose may be administered at the same frequency as the other secondary doses. For example, each secondary dose may be administered to a patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Similarly, in multiple tertiary dose embodiments, each tertiary dose may be administered at the same frequency as the other tertiary doses. For example, each tertiary dose may be administered to a patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Alternatively, the frequency with which secondary and/or tertiary doses are administered to a patient may vary over the course of a treatment regimen. The frequency of administration can also be adjusted by the physician during the course of treatment, depending on the needs of the individual patient, after clinical examination. Similarly, doses of concomitant therapy, such as statin, ezetimibe, and lomitapide, may be adjusted by the clinician during the course of treatment according to the normalization of lipid levels observed during the course of treatment.

Examples

The following examples are provided to provide those of ordinary skill in the art with a full disclosure and description of how to make and use the methods and compositions of the invention, and are not intended to limit the scope of what the inventors consider to be their invention. Efforts have been made to ensure accuracy with respect to the numbers used (eg amounts, temperatures, etc.), but some experimental errors and deviations should be taken into account. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is at or near atmospheric pressure.

Example 1 Generation of human antibodies to human ANGPTL3.

The exemplary anti-ANGPTL3 antibody used in the following example is a human anti-ANGPTL3 antibody known as evinacumab. Evinacumab has the following amino acid sequence characteristics: heavy chain variable region (HCVR) contains SEQ ID NO: 1 and light chain variable domain (LCVR) contains SEQ ID NO: 5; heavy chain complementarity determining region 1 (HCDR1) contains SEQ ID NO: 2, HCDR2 contains SEQ ID NO: 3, HCDR3 contains SEQ ID NO: 4, light chain complementarity determining region 1 (LCDR1) contains SEQ ID NO: 6, LCDR2 contains SEQ ID NO: 7 and LCDR3 contains SEQ ID NO: 8.

Example 2 Safety and effect of evinacumab, an anti-ANGPTL3 monoclonal antibody, in patients with homozygous familial hypercholesterolemia receiving concomitant lipid-lowering therapy.

Homozygous familial hypercholesterolemia (HoFH) includes a severe genetic deficiency in the low-density lipoprotein (LDL) receptor pathway that leads to catastrophically elevated LDL-cholesterol (LDL-C) and severe premature atherosclerosis; response to statins and anti-PCSK9 antibodies is limited. Preclinical studies and human genetic analysis suggest that inhibition of the angiopoietin-like protein (ANGPTL3) reduces LDL-C and provides cardiovascular benefits, independent of the LDL receptor. Evinacumab, a human anti-ANGPTL3 antibody, was administered to nine adults with HoFH (three null homozygotes) already on maximally tolerated standard therapy. LDL-C decreased by 49% (range -25% to -90%) at week 4 (primary endpoint). The overall mean peak reduction in LDL-C was -58±18% (-90% to -33%) between

- 17 042876 weeks 4 and 12, showing that inhibition of ANGPTL3 with evinacumab essentially reduces LDL-C in HoFH patients.

Low density lipoproteins (LDL) play an important role in the initiation and progression of atherosclerosis and the risk of cardiovascular disease. Familial hypercholesterolemia (FH) is usually a disorder that occurs through mutations in genes encoding proteins that regulate LDL clearance. These include genes for low density lipoprotein receptor (LDLR), apolipoprotein B (APOB), subtilisin/kexin type 9 proprotein convertase (PCSK9), and low density lipoprotein receptor adapter protein 1 (LDLRAP1) (Cuchel, et al. 2014 Eur Heart J 35: 2146-57). Patients with untreated heterozygous FH typically have plasma levels of LDL-cholesterol (LDL-C) in the range of 350 to 550 mg per dl and are generally responsive to lipid-lowering therapy, including moderate to high doses of highly potent statins, ezetimibe, and antibodies to PCSK9 (Goldberg, et al. 2011 J Clin Lipidol 2011;5:S1-8; Kastelein, et al. 2014 Cardiovasc Drugs Ther 28:281-9). Homozygous FH (HoFH) is a rare disease that affects 1 in 160,000-300,000 people. HoFH patients who carry two FH-causing mutations (homozygous or combined heterozygous) have significantly higher LDL-C levels without treatment, generally in the range of 500 to 1000 mg/dl (Kolansky, et al. 2008 The American journal of Cardiology 102:1438-43), and are significantly less responsive or non-responsive to standard lipid-lowering therapy. Most individuals with HoFH develop severe xanthomatosis, coronary heart disease, and peripheral atherosclerosis at an early age, and death can occur before the age of 30 if untreated (Nordestgaard, et al. 2013 Eur Heart J 34:3478-90a).

Genetic and phenotypic heterogeneity in HoFH can translate into wide variability in cardiovascular disease manifestations and responses to lipid-lowering therapy. Some FH-causing mutations result in defective LDL receptors with residual activity, while others lack activity and therefore do not respond to standard lipid-lowering drugs such as statins and PCSK9 antibodies, which preferentially target the receptor expression process. LDL (Santos PC, Pereira AC. 2015 Pharmacogenomics 16:1743-50; Rader DJ, Kastelein JJ. 2014 Circulation 129:1022-32). Drugs with non-LDL receptor mechanisms of action, such as lomitapide and mipomersen, have recently received approval for the treatment of HoFH, but their use may be hampered by tolerability and safety issues.

Angiopoietin-like protein 3 (ANGPTL3) is a secreted protein expressed in the liver. It acts to increase plasma levels of triglycerides, LDL-C, and high-density lipoprotein (HDL-C) cholesterol by inhibiting lipoprotein lipase and endothelial lipase activity or by modulating the clearance of triglyceride-rich lipoproteins above LDL formation (Wang, et al. 2015 J Lipid Res 56:1296-307 Musunuru, et al 2010 N Engl J Med 363:2220-7). Preclinical studies indicate that ANGPTL3 knockout or blockade by an antibody can reduce triglycerides and LDL-C independently of LDL-R and is effective in models of atherosclerosis (Ando, et al. 2003 J Lipid Res 44:1216-23; Dewey, et al 2017 New Engl J Med; in press). Consistently, large-scale genetic studies in males show that loss-of-function mutations in ANGPTL3 lead to decreased plasma levels of triglycerides, LDL-C, and HDL-C (Robciuc, et al. 2013 Arteriosclerosis, thrombosis, and vascular biology 33:1706 -13; Pisciotta, et al. 2012 Circ Cardiovasc Genet 5:42-50; Minicocci, et al. 2013 J Lipid Res 54:3481-90; Wang, et al. 2015 Proc Natl Acad Sci USA 112:11630-5; Noto, et al. 2012 Arteriosclerosis, thrombosis, and vascular biology 32:805-9; Martin-Campos, et al. 2012 Clinica chimica acta; International Journal of Clinical Chemistry 413:552-5), and even more importantly, these lipid changes associated with ANGPTL3 mutations are also associated with protection against cardiovascular disease (Stitziel, et al. 2017 Journal of the American College of Cardiology). In general, preclinical studies as well as human genetic analysis show that ANGPTL3 inhibitory therapy can reduce LDL-C and provide an effect in patients with FH, including those with severe homozygous disease, evinacumab is a fully human monoclonal antibody, which specifically blocks ANGPTL3 (Gusarova, et al. 2015 J Lipid Res 56:1308-17). Normal healthy volunteers tolerated evinacumab well and reduced three major lipid fractions. A phase 2 study was conducted to determine whether evinacumab reduced LDL-C levels in nine patients with genetically and phenotypically confirmed HoFH, including patients homozygous for null mutations with complete absence of LDLR activity.

Ways

Patients: Nine patients (5 males, 4 females) were selected based on their genotypes and phenotypes. All had a history of LDL-C >500mg/dL or >400mg/dL after porto-caval shunt, premature atherosclerosis (8 of 9 had a history of prior CV events), and severe xanthomatosis, and all were homozygous or concomitantly heterozygous for known LDLR mutations , causing FH (Hobbs, et al. 1992 Hum Mutat 1:445-66). Three patients were null homozygotes. All patients were on maximally tolerated lipid-lowering therapy.

Study Treatment: Patients were required to maintain their usual background reducing

- 18 042876 pida therapy and diet and exercise regimens throughout the study. All patients received one unmasked dose of evinacumab 250 mg subcutaneously in the abdominal area at the baseline visit and one intravenous dose of evinacumab 15 mg/kg 2 weeks later. The sterile lyophilized drug product evinacumab was supplied in a 5 ml disposable glass vial for reconstitution to a concentration of 100 mg per ml for subcutaneous doses and 50 mg per ml for intravenous doses. Patients were followed for up to 24 weeks after the intravenous dose to allow washout of evinacumab and offered to participate in an extension study.

Pharmacodynamic evaluation: fasting blood samples were taken before study drug administration, at baseline, and at regular intervals during the unmasked treatment period and the follow-up safety period, to measure LDL-C, non-HDL-C, total cholesterol, HDL-C, apolipoprotein B, lipoprotein (a), triglycerides, apolipoprotein A-1 and other parameters. The primary endpoint was the percentage change in mean ± standard deviation (SD) in LDL-C from baseline to week 4.

results

Even though most patients were on maximally tolerated therapy, the baseline mean+SD for LDL-C was 376.0±240.9 milligrams per deciliter (mg/dL); one patient who failed statin therapy and was removed from weekly apheresis had a baseline LDL-C level of 756 mg/dL. All nine patients reported at least one adverse event, but none resulted in treatment discontinuation. One event (coronary artery disease due to underlying disease) was serious but was not considered related to study drug treatment. Six events were considered related to study drug treatment, two of which were mild injection site reactions, one was moderate myalgia, and one was severe epistaxis.

Drug response: The percentage change in mean±SD for LDL-C from baseline to week 4 (previously determined primary endpoint) after evinacumab administration was -49±23% (range: -90% to -25%), with absolute change from baseline 157 ± 90 (range: -323 to -71) mg per dl (Table 1, below). The achieved mean±SD for LDLC at week 4 was 219±191 mg/dL. Over the same period, the percentage change in apolipoprotein B fell by 46 ± 18% (Table 2, below), non-HDL-C by 49 ± 22% (Table 3, below), triglycerides by 47% (median, interquartile range from - 57% to -38%) and HDL-C by 36±16%. The overall peak reduction in mean ± SD in LDL-C occurring between weeks 4 and 12 was -58 ± 18% (range -90% to -33%), with an absolute peak reduction in LDL-C of 202 mg/dL. At week 4 (2 weeks after the intravenous dose), one patient achieved an LDL-C reduction greater than 80%. In 3 null homozygous patients, the peak reduction in mean ± SD for LDL-C up to week 12 was -48 ± 13% (range -60% to -33%).

Table 1

Effect of AngPTL3 Inhibition on Plasma LDL-C Concentrations

LDL-C Visit Average percent change from baseline ± SE (%) BL (week 0) 0 Day 4 -12.8±3.7 Week 1 -24±7.0 Week 2 -30.2±8.1 Week 3 -41.4±8.3 Week 4 -49.2±7.7 Week 5 -46.8±5.1 Week 6 -52.1±4.9 Week 8 -51.6±6.0 Week 10 -45.6±4.6 Week 12 -36.6±6.4

- 19 042876

table 2

Effect of AngPTL3 Inhibition on Apolipoprotein B Concentrations

Apolipoprotein B Visit Average percentage change from baseline + SE (%) BL (week 0) 0 Week 2 -24.2±7 Week 3 Week 4 Week 5 Week 6 Week 8 Week 12 Effect of inhibition - 38.6 + 7.3 - 45.9 + 6.1 - 42.3 +4.7 - 43, 1 + 4.9 - 42.7 +4.8 -29.5+7.2 Table 3 ) AngPTL3 effect on concentrations of non-HDL-C Not HDL-C Visit Average percentage change from baseline + SE (%) BL (week 0) 0 Day 4 -13.6+3.6 Week 1 -24.1+6.7 Week 2 -29.6+7.8 Week 3 -41.6+8 Week 4 -48.9+7.4 Week 5 -46.6+5.0 Week 6 -51.5 + 4.8 Week 8 -50.6+5.7 Week 10 -44.8+4.4 Week 12 -36.4+6.2

Administration of the fully human monoclonal ANGPTL3-blocking antibody evinacumab to nine adults with HoFH, including three null homozygotes, resulted in a significant decrease in LDL-C. Importantly, this reduction occurred on top of baseline levels already achieved on stable maximally tolerated lipid-lowering therapy with or without lomitapide, anti-PCSK9 monoclonal antibodies, or portocaval shunt. These results provide a proof of concept for significant additional LDL-C reduction with evinacumab, over standard treatment, in the treatment of HoFH, with the potential to normalize LDL-C in some patients who have extremely high LDL-C levels. Evinacumab, given as a 250 mg subcutaneous injection at baseline and as an intravenous infusion of 15 mg/kg at week 2, was well tolerated. The first recently reported human study in healthy human volunteers also shows that evinacumab lowers LDL-C and is also well tolerated in more patients (Dewey, et al. 2017 New Engl J Med; in press) . All nine patients, including three homozygous null patients lacking LDLR activity, showed a clinically significant decrease in LDLC from baseline. Together with recent preclinical studies and human genetic analysis, the results show that Angptl3 inhibition not only reduces LDL-C and triglycerides, but also provides protection against cardiovascular disease. These studies offer real hope for a well-tolerated and effective treatment for patients suffering from severe familial hypercholesterolemia. Based on cholesterol analysis Cholesterol Treat

- 20 042876 ment Trialists' Collaboration (CTTC) (Cholesterol Treatment Trialists (CTT) Collaboration 2010 Lancet 376:1670-81), an absolute reduction in LDL-C of 39 mg/dl corresponds to a 22% relative risk reduction over 4-5 years of statin treatment; recent outcome data with PCSK9 antibody support a similar reduction in risk per unit reduction in LDL-C, given shorter duration of treatment (Sabatine, et al. 2017 N Engl J Med 3-17-2017, online; in press). Together with genetic data on the protective effects of ANGPTL3 mutations on cardiovascular risk (Stitziel, et al. 2017 Journal of the American College of Cardiology 69(16):2054-2063), an absolute reduction of 150-200 mg/dl, which was achieved with the use of evinacumab in HoFH patients may have unprecedented benefit in these very high-risk patients.

Research is ongoing into the mechanism that led to this dramatic decrease in LDL-C. Evinacumab attenuates normal inhibition, via ANGPTL3, of both lipoprotein lipase (a major regulator of triglycerides) and endothelial lipase (a regulator of HDL-C (Shimamura, et al. 2007 Arteriosclerosis, thrombosis, and vascular biology 27:366-72); thus, both triglycerides and HDL-C are reduced by evinacumab.Current results, combined with those from a recent in vivo study (Wang, et al. 2015 J Lipid Res 56:1296-307), show that C, use a combination of the canonical and non-canonical mechanisms above for LDL particle formation.In a mouse model, inactivation of ANGPTL3 with evinacumab does not affect the number of VLDLs secreted by the liver, but qualitatively alters the VLDL particles formed.After secretion, VLDLs are rapidly hydrolyzed to form poor triglycerides of VLDL residues due to evinacumab-induced upregulation of lipoprotein lipase, which can increase their clearance through receptors other than LDL receptors. In relation to the modest reduction that was observed for HDL-C, extensive previous genetic analysis with endothelial lipase recruitment (Voight, et al. 2012 Lancet 380:572-80) as well as recent genetic findings regarding ANGPTL3 protection (Dewey 2017, Stitziel 2017 ) are consistent with the emerging view that HDL-C levels do not directly affect cardiovascular risk (Ko, et al. 2016 Journal of the American College of Cardiology 68:2073-83). Patients C and G received concomitant lomitapide, a microsomal triglyceride transporter protein inhibitor, during the study. These patients showed a 90% and 44% decrease in LDL-C, respectively, 2 weeks after IV evinacumab, suggesting a multiplicative synergy between lomitapide (which affects VLDL formation) and evinacumab (which affects secreted VLDL characteristics). However, patient D did not receive lomitapide and showed a 77% reduction in LDL-C at week 4.

The results provided herein provide a proof of concept that inhibition of ANGPTL3 by evinacumab leads to a significant additional reduction in LDL-C in HoFH patients on stable lipid-lowering therapy, including those with null/null mutations. Adjunctive evinacumab therapy allowed normalization of LDLC concentrations in four participants with HoFH in this study. For example, Patient C, a 47 year old female, had LDL-C values above 800 mg per dl at 26 years of age. Her lipid profile gradually improved (reaching 150 to 170 mg per dl) with sequential inclusion of high doses of statins, ezetimibe and lomitapide. LDL-C reached 15 mg/dl at week 4, 2 weeks after IV evinacumab.

EXAMPLE 3 Inhibition of ANGPTL3 with evinacumab reduced triglycerides (TG) and LDL-C in subjects showing moderate increases in TG and/or LDL-C.

An increase in LDL-C and TG is associated with an increased risk of CHD. Recent discoveries have demonstrated the central role of angiopoietin-like - 3 (ANGPTL3) in lipid metabolism. Loss of function (LoF) of ANGPTL3 in humans is associated with a decrease in TG, LDL-C and HDL-C. Evinacumab is a human monoclonal antibody with specificity for ANGPTL3 that has been developed for the treatment of dyslipidemia, including hypertriglyceridemia and hypercholesterolemia.

Methods: This study constituted the first human, single-dose escalation, placebo-controlled (PBO), double-blind, phase 1 study of evinacumab administered subcutaneously (SC) or intravenously (IV) to subjects with elevated TG (150<TG<450 mg /dl) and/or LDL-C (>100 mg/dl). Eighty-three subjects were randomized in the study (9 to RBO SC; 12 to RBO IV; 11 to 75 mg SC: 12 to 150 mg SC, 9 to 250 mg SC, 10 to 5 mg/kg IV, 9 to 10 mg/kg IV and 11 at 20 mg/kg IV).

Results: Evinacumab was shown to be well tolerated in this study. Forty-one (41) subjects reported at least one on-treatment adverse event (TEAE): 32[±51.6%] in the evinacumab group versus 9[±42.9%] in the PBO group. Not a single serious, and not a single subject interrupted due to TEAE. The most common TEAEs were headache (7 [11.3%] vs. 0 [0%]) and increased ALT/AST [>2X ULN] (5 treated subjects versus 1 RVO subject). There was no dose-related trend in terms of safety. The maximum decrease in TG was observed at day 4, with a median % change from baseline ranging from -1.0% to -75.0% for evinacumab doses and +25.3% for PVO. The mean % change in LDL-C from baseline on day 11 ranged from -

Claims (36)

3.4% to -25.5% for evinacumab doses and +10.2 for RVO. The duration of the decrease in TG and LDL was dose dependent and lasted up to 64 and 43 days, respectively, after IV administration of evinacumab 20 mg/kg. A dose-dependent decrease in HDL-C, VLDL-C, total cholesterol, non-HDL-C, ApoA1 and ApoB was also observed, but there were no clear effects on Lp(a). Administration of evinacumab to healthy subjects with moderately elevated TG and/or LDL-C was generally well tolerated. In addition, evinacumab induced a rapid and significant decrease in TG as well as a decrease in LDL-C and HDL-C, summarizing the observed hypolipoproteinemia in individuals homozygous for ANGPTL3 LOF mutations. CLAIM 1. A method of treating a patient suffering from familial hypercholesterolemia, the method comprising administering to the patient a therapeutically effective amount of a combination of (a) a statin; (b) at least one non-statin lipid-lowering agent, wherein the at least one non-statin lipid-lowering agent is an agent that inhibits cholesterol absorption; and (c) an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 contains a heavy chain CDR1 (HCDR1), having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and an LCDR3 having the amino acid sequence of SEQ ID NO: 8. 2. The method of claim 1 further comprising administering a therapeutically effective amount of a second lipid lowering agent other than a statin. 3. The method of claim 1 or 2, wherein the familial hypercholesterolemia is selected from the group consisting of heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH). 4. The method according to any one of claims 1 to 3, wherein the statin is atorvastatin (LIPITOR®) administered orally once a day at a dose of 10 to 80 mg. 5. The method according to any one of claims 1 to 4, wherein the cholesterol absorption inhibiting agent is ezetimibe (ZETIA®). 6. The method of claim 5, wherein ezetimibe (ZETIA®) is administered orally once a day at a dose of 10 mg. 7. The method of claim 2, wherein the second lipid-lowering agent, other than a statin, is an agent that inhibits microsomal triglyceride transfer protein (MTTP). 8. The method of claim 7 wherein the agent that inhibits MTTP is lomitapide (JUXTAPID®). 9. The method of claim 8, wherein lomitapide (JUXTAPID®) is administered orally once a day at a dose of 5 to 60 mg. 10. The method of claim 9 wherein lomitapide (JUXTAPID®) is administered orally once a day at a dose of 20 mg. 11. The method of any one of claims 1-10, wherein the anti-ANGPTL3 antibody is evinacumab. 12. The method of claim 11, wherein evinacumab is administered before, during, or after treatment with a statin, ezetimibe, or lomitapide. 13. The method of claim 11 or 12, wherein evinacumab is administered intravenously at a dose ranging from 1 to 20 mg/kg body weight. 14. The method of claim 13 wherein evinacumab is administered intravenously at a dose of 15 mg/kg body weight. 15. The method according to any one of claims 11 or 12, wherein evinacumab is administered subcutaneously at a dose in the range of 50 to 750 mg. 16. The method of claim 15 wherein evinacumab is administered subcutaneously at a dose in the range of 250 to 450 mg. 17. The method according to any one of claims 11 to 16, wherein evinacumab is administered every week, every two weeks, every 3 weeks, every 4 weeks, every 2 months, every 3 months, or every 4 months. 18. A method for improving one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia, the method comprising administering one or more therapeutically effective doses of an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises a heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and LCDR3 having the amino acid sequence of SEQ ID NO: 8, in combination with one or more therapeutic effective doses of a lipid-lowering agent, - 22 042876 selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, and an agent that inhibits microsomal triglyceride transfer protein (MTTP), or combinations thereof, where the improvement in one or more lipid parameters is one or more of the following : (a) lowering low-density lipoprotein (LDL-C) cholesterol from baseline (week 0); (b) a decrease in apolipoprotein B (Apo B) from baseline; (c) lowering non-high-density lipoprotein (non-HDL-C) cholesterol from baseline; (d) lowering total cholesterol (total C) relative to baseline; (e) a decrease in lipoprotein (a) (Lp(a)) from baseline; and/or (f) lowering triglycerides (TG) from baseline. 19. The method of claim 18, wherein the familial hypercholesterolemia is selected from the group consisting of heterozygous familial hypercholesterolemia (HeFH) and homozygous familial hypercholesterolemia (HoFH). 20. The method of claim 18 or 19, wherein the antibody that specifically binds to ANGPTL3 is evinacumab. 21. The method according to any one of claims 18-20, wherein the statin is atorvastatin (LIPITOR®) administered orally once a day at a dose of 10 to 80 mg. 22. The method of claim 18 wherein the cholesterol absorption inhibiting agent is ezetimibe (ZETIA®). 23. The method of claim 22 wherein ezetimibe (ZETIA®) is administered orally once a day at a dose of 10 mg. 24. The method of claim 18 wherein the agent that inhibits MTTP is lomitapide (JUXTAPID®). 25. The method of claim 24, wherein lomitapide (JUXTAPID®) is administered orally once a day at a dose of 5 to 60 mg. 26. The method of claim 25, wherein lomitapide (JUXTAPID®) is administered orally once a day at a dose of 20 mg. 27. The method according to any one of claims 1 to 26, wherein the administration results in at least a 40% reduction in at least one lipid parameter from baseline. 28. The method according to any one of claims 1-26, wherein the administration results in at least a 75% reduction in at least one lipid parameter from baseline. 29. The method of claim 27 or 28, wherein administration results in at least a 40% reduction in LDL-C levels relative to baseline. 30. The method according to any one of claims 1-10, 18 and 19, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 5. 31. Use of a combination of a statin, a single lipid-lowering agent other than statins, and an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically bind to ANGPTL3, contain heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1), having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and LCDR3 having the amino acid sequence of SEQ ID NO: 8, in the treatment of a patient suffering from familial hypercholesterolemia. 32. Use of a combination of a statin, one non-statin lipid-lowering agent, and an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically bind to ANGPTL3, contain heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1), having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and LCDR3 having the amino acid sequence of SEQ ID NO: 8, in the preparation of a medicament for the treatment of a patient suffering from familial hypercholesterolemia. 33. A pharmaceutical composition for the treatment of a patient suffering from familial hypercholesterolemia, wherein the composition comprises a therapeutically effective amount of a combination of a statin, one lipid-lowering agent other than statins, and an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or an antigen-binding fragment thereof. - 23 042876 ment that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises a heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid sequence of SEQ ID NO: 7, and LCDR3 having the amino acid sequence of SEQ ID NO: 8. 34. Use of an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 contains a heavy chain CDR1 (HCDR1) having amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid the sequence of SEQ ID NO: 7, and an LCDR3 having the amino acid sequence of SEQ ID NO: 8, in combination with a lipid-lowering agent selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, and an agent that inhibits microsomal triglyceride transport protein ( MTTP), or combinations thereof, to improve one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia. 35. Use of an angiopoietin-like protein 3 (ANGPTL3) inhibitor, wherein the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, wherein the antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 contains a heavy chain CDR1 (HCDR1) having amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4, light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, LCDR2 having the amino acid the sequence of SEQ ID NO: 7, and an LCDR3 having the amino acid sequence of SEQ ID NO: 8, in combination with a lipid-lowering agent selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, and an agent that inhibits microsomal triglyceride transport protein ( MTTP), or combinations thereof, in the preparation of a medicament for improving one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia. 36. A pharmaceutical composition for improving one or more lipid parameters in a patient diagnosed with familial hypercholesterolemia, where the composition contains a therapeutically effective amount of an angiopoietin-like protein 3 (ANGPTL3) inhibitor, where the ANGPTL3 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3, where an antibody or antigen-binding fragment thereof that specifically binds to ANGPTL3 comprises a heavy chain CDR1 (HCDR1) having the amino acid sequence of SEQ ID NO: 2, HCDR2 having the amino acid sequence of SEQ ID NO: 3, HCDR3 having the amino acid sequence of SEQ ID NO: 4 , a light chain CDR1 (LCDR1) having the amino acid sequence of SEQ ID NO: 6, an LCDR2 having the amino acid sequence of SEQ ID NO: 7, and an LCDR3 having the amino acid sequence of SEQ ID NO: 8, in combination with a lipid-lowering agent selected from the group consisting of a statin, an agent that inhibits cholesterol absorption, and an agent that inhibits microsomal triglyceride transfer protein (MTTP), or combinations thereof. Eurasian Patent Organization, EAPO Russia, 109012, Moscow, Maly Cherkassky per., 2