ES2779126T3 - Using a PCSK9 Inhibitor to Treat Hyperlipidemia - Google Patents

Abstract

A pharmaceutical composition comprising 75 mg or 150 mg of an antibody or antigen-binding fragment thereof that specifically binds human PCSK9 for use in treating hypercholesterolemia in a patient who is intolerant to statins or who has a history of adverse reactions to statin therapy, wherein the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs having SEQ ID NOs: 2, 3, 4, 7, 8, and 10, and wherein the antibody or antigen-binding fragment thereof is administered in the absence of statin therapy at a frequency of once every two to four weeks at a dose of 75 mg or once every two to four weeks at a dose of 150 mg .

Description

DESCRIPTION

Using a PCSK9 Inhibitor to Treat Hyperlipidemia

The present invention relates to the field of therapeutic treatments for diseases and disorders that are associated with elevated levels of lipids and lipoproteins. More specifically, the invention relates to the use of anti-PCSK9 antibodies or antigen-binding fragments thereof to treat hyperlipidemic patients who are not on statin therapy, including patients who are insensitive to statins, poorly controlled with therapy. on statins, intolerant to statins, or who have a history of adverse reactions to statin therapy.

BACKGROUND

Hypercholesterolemia, particularly an increase in low-density lipoprotein (LDL) cholesterol (LDL-C) levels, constitutes a significant risk for the development of atherosclerosis and coronary heart disease (CHD) (Sharrett et al., 2001, Circulation 104: 1108-1113). Low-density lipoprotein cholesterol is identified as the primary target of cholesterol-lowering therapy and is accepted as a valid therapeutic endpoint. Numerous studies have shown that lowering LDL-C levels reduces the risk of CHD with a strong direct relationship between LDL-C levels and CHD events; For every 1 mmol / L (~ 40 mg / dL) reduction in LDL-C, mortality and morbidity from cardiovascular disease (CVD) is reduced by 22%. Greater reductions in LDL-C produce a greater reduction in events, and comparative data of treatment with these vats of intense versus standard suggest that the lower the level of LDL-C, the greater the benefit in patients at cardiovascular risk (CV ) very high.

Current LDL-C-lowering medications include statins, cholesterol absorption inhibitors (eg, ezetimibe [EZE]), fibrates, niacin, and bile acid sequestrants. While lifestyle modifications and treatment with conventional drugs are often successful in lowering cholesterol levels, not all patients are able to achieve recommended target cholesterol levels with such approaches. Various conditions, such as familial hypercholesterolemia (FH), appear to be resistant to lowering LDL-C levels despite aggressive use of conventional therapy. Specifically, treatment with statins, which lower LDL-C by inhibiting cholesterol synthesis and upregulating the hepatic LDL receptor, may have little effect in patients whose LDL receptors are absent, or defective. Additionally, many patients are insensitive to statins, are poorly controlled on statin therapy, cannot tolerate statins, and / or do not adhere to their prescribed therapeutic statin regimen due to statin-related side effects. Because hypercholesterolemia is largely asymptomatic, any unpleasant effects of pharmacological agents used to manage this disorder can weaken patient compliance. In multi-cohort studies, the reported 1-year statin therapy compliance rate ranged from 26% to 85%, with a rapid decline in compliance rates typically observed within the first few months. The inhibition of PCSK9 may be a promising strategy in reducing LDL-associated cholesterol to prevent cardiovascular disease or attenuate its progression and damage (Costet P, "PCSK9 inhibitors as LDL cholesterol-lowering agents: Rationale, concerns and preliminary outcomes", Drugs of the Future. Vol. 37, No. 5, pages 331-341, May 1, 2012). The effect of a monoclonal antibody targeting PCSK9 in combination with ezetimibe on LDL-C levels in statin-intolerant patients is evaluated in clinical trials, for example, the randomized GAUSS trial (Sullivan et al. "Effect of a Monoclonal Antibody to PCSK9 on Low-Density Lipoprotein Cholesterol Levels in Statin-intolerant Patients ", JAMA, Vol. 308, No. 23, page 2497, December 19, 2012).

Accordingly, there is a need in the art for alternative options for lowering LDL-C in patients.

BRIEF SUMMARY OF THE INVENTION

The present invention provides a pharmaceutical composition comprising 75 mg or 150 mg of an antibody or antigen-binding fragment thereof that specifically binds human PCSK9 for use in treating hypercholesterolemia in a patient who is intolerant to statins. or who has a history of adverse reactions to statin therapy, where the antibody or antigen-binding fragment thereof comprises the light and heavy chain CDRs that have SEQ ID NOs: 2, 3, 4, 7, 8 and 10 , and wherein the antibody or antigen-binding fragment thereof is administered in the absence of statin therapy at a frequency of once every two to four weeks at a dose of 75 mg or once every two to four weeks at a 150 mg dose. Examples of adverse reactions to statin therapy include, for example, skeletal muscle pain, discomfort, weakness, and / or crampy pain. Thus, according to certain embodiments, the present invention provides methods of lowering serum LDL-C levels in a patient without inducing skeletal muscle pain, discomfort, weakness or crampy pain, for example, by interrupting the statin therapeutic regimen. and administering an anti-PCSK9 antibody or antigen-binding fragment thereof to the patient.

The present invention provides a pharmaceutical composition comprising 75 mg or 150 mg of an antibody or antigen-binding fragment thereof that specifically binds to human PCSK9 for use in treating hypercholesterolemia in a patient, wherein the patient has a moderate, high or very high; and is statin intolerant or has a history of adverse reactions to statin therapy, where one or more initial doses of the pharmaceutical composition comprising 75 mg of the antibody or antigen-binding fragment thereof are administered approximately every two weeks, and wherein (a) one or more additional doses of the pharmaceutical composition comprising 75 mg of the antibody or antigen-binding fragment thereof are administered approximately every two weeks if the patient's LDL-C level after the initial doses is less than 70 mg / dL; or (b) one or more antigen-binding fragments thereof is administered approximately every two weeks if the LDL-C level of additional doses of the pharmaceutical composition comprising 150 mg of the antibody or the patient after the doses initials is greater than or equal to 70 mg / dL, wherein the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs that have SEQ ID NOs: 2, 3, 4, 7, 8 and 10 , and wherein after approximately 24 weeks of treatment with the antibody or antigen-binding fragment thereof, the improvement in the serum level of one or more lipid components is selected from the group consisting of:

(a) reduction of the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%;

(b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%;

(c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%;

(d) reduction of the patient's total cholesterol by at least 20%; and

(e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.

According to one aspect, patients with hyperlipidemia include patients with non-familial hypercholesterolemia, heterozygous or homozygous familial hypercholesterolemia, or mixed dyslipidemia. In certain respects, a patient with hyperlipidemia also has type 2 diabetes mellitus.

In some embodiments, the anti-PCSK9 antibody or antigen-binding fragment is administered to a patient as a monotherapy, in the absence of any other lipid-modifying therapy. In some embodiments, the anti-PCSK9 antibody or antigen-binding fragment is administered to a patient in combination with other non-statin lipid modifying therapy.

The present invention also provides methods of treating hypercholesterolemia in a patient who is intolerant to statins or who has a history of adverse reactions to statin therapy by selecting a patient with moderate, high, or very high cardiovascular risk who has previously experienced related symptoms. with skeletal muscles that started or increased while on a daily therapeutic statin regimen and administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragments thereof to the patient. According to certain embodiments, the patient is selected on the basis of having previously experienced skeletal muscle-related symptoms that began or increased while on at least two separate daily therapeutic statin regimens (eg, wherein at least one of the regimens therapeutic daily statins is the lowest authorized daily dose of a statin).

The present invention also provides pharmaceutical compositions comprising an anti-PCSK9 antibody or antigen-binding fragment thereof for use in treating hypercholesterolemic patients who are not on statin therapy.

One embodiment provides a pharmaceutical composition for use in treating hypercholesterolemia in a patient in need thereof, comprising: (a) selecting a patient who is intolerant to statins or who has a history of adverse reactions to statin therapy; and (b) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragments thereof to the patient.

Another embodiment provides a pharmaceutical composition for use in reducing serum LDL-C levels in a patient without inducing skeletal muscle pain, discomfort, weakness, or colicky pain, comprising: (a) selecting a patient who has experienced a symptom related to skeletal muscles that started or increased while taking a lower authorized daily dose of one or more statins; and (b) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragments thereof to the patient; which thus reduces serum LDL-C levels in the patient without inducing skeletal muscle pain, discomfort, weakness, or crampy pain.

Another embodiment provides a pharmaceutical composition for use in reducing serum LDL-C levels in a statin-intolerant hypercholesterolemic patient, comprising: (a) selecting a patient with moderate, high, or very high cardiovascular risk who is intolerant to statins or having a history of adverse reactions to statin therapy; and (b) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragments thereof to the patient.

Another embodiment provides a pharmaceutical composition for use in treating hypercholesterolemia in a patient who is intolerant to statins or who has a history of adverse reactions to statin therapy, comprising: (a) selecting a patient with moderate cardiovascular risk, high or very high that has previously experienced skeletal muscle-related symptoms that started or increased while on a daily therapeutic statin regimen; and (b) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to the patient.

In some embodiments, the patient previously experienced skeletal muscle-related symptoms that began or increased while on at least two separate daily therapeutic statin regimens. In some embodiments, at least one of the daily therapeutic statin regimens is the lowest authorized daily dose of a statin. In some embodiments, at least one of the daily therapeutic statin regimens is selected from the group consisting of: rosuvastatin 5 mg daily, atorvastatin 10 mg daily, simvastatin 10 mg daily, lovastatin 20 mg daily, 40 mg of pravastatin a day, 40 mg of fluvastatin a day and 2 mg of pitavastatin a day. In some embodiments, the anti-PCSK9 antibody or antigen-binding fragment thereof is administered to the patient in the absence of statin therapy.

One embodiment provides a pharmaceutical composition for use to eliminate the use of statins in a hypercholesterolemic patient who is intolerant to statins while reducing the patient's serum LDL-C levels, the method comprising: (a) selecting a patient who is or was on a daily therapeutic statin regimen and who is intolerant to statins or who has a history of adverse reactions to statin therapy; (b) discontinuing the patient's daily therapeutic statin regimen; and (c) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to the patient.

In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragments thereof, exhibits hypercholesterolemia defined as a level of low-density lipoprotein (LDL-C) cholesterol in serum greater than approximately 70 mg / dL. In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, exhibits hypercholesterolemia defined as a serum low-density lipoprotein (LDL-C) cholesterol level. greater than approximately 100 mg / dL.

In some embodiments, the patient has heterozygous familial hypercholesterolemia (heHF). In some embodiments, the patient has a form of hypercholesterolemia that is unfamiliar hypercholesterolemia (H not F). In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has moderate cardiovascular risk defined as a 10-year risk score for fatal cardiovascular disease greater than or equal to. to 1% and less than 5%. In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has a high cardiovascular risk defined as a 10-year risk score for fatal cardiovascular disease higher or higher. equal to 5% together with one or more of: (i) moderate chronic kidney disease, (ii) type 1 diabetes mellitus without affected organ damage, (iii) type 2 diabetes mellitus without affected organ damage, and / or (iv) HFhe. In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, is at very high cardiovascular risk defined as one or more of: (i) documented coronary heart disease; (ii) ischemic stroke; (iii) peripheral stroke; (iv) peripheral arterial disease (PAD); (v) transient ischemic attack (TIA); (vi) abdominal aortic aneurysm; (vii) carotid artery occlusion> 50% without symptoms; (viii) carotid endarterectomy; (ix) carotid artery endovascular graft procedure; (x) renal artery stenosis; (xi) renal artery endovascular graft procedure; (xii) type 1 diabetes mellitus with damage to affected organs; and / or (xiii) type 2 diabetes mellitus with damage to affected organs.

The anti-PCSK9 antibody or antigen-binding fragments thereof is an antibody or antigen-binding fragment thereof comprising amino acid sequences of heavy and light chain CDRs having SEQ ID NOs: 2, 3, 4, 7 , 8 and 10. In some embodiments, the antibody or antigen-binding fragment thereof 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: 6.

In some embodiments, the antibody or antigen-binding protein that specifically binds PCSK9 is administered to the patient at a dose of about 75 mg at a frequency of once every two weeks. In some embodiments, the dose of about 75 mg is maintained if the patient's LDL-C measured after five or more doses is <70 mg / dL. In some embodiments, the approximately 75 mg dose is discontinued if the patient's LDL-C measured after five or more doses remains> 70 mg / dL, and the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is subsequently administered to the patient at a dose of approximately 150 mg at a frequency of once every two weeks. In some embodiments, the antibody or antigen-binding protein that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg at a frequency of once every two weeks.

In some embodiments, the anti-PCSK9 antibody or antigen-binding fragment thereof is administered to the patient in combination with a non-statin lipid modifying therapy. In some embodiments, the non-statin lipid modifying therapy comprises a therapeutic agent selected from the group consisting of ezetimibe, a fibrate, niacin, an omega-3 fatty acid, and a bile acid resin.

In some embodiments, the pharmaceutical composition for use improves serum levels of one or more Lipid components selected from the group consisting of: (a) lowering the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%; (d) reduction of the patient's total cholesterol by at least 20%; and (e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.

One embodiment provides a pharmaceutical composition for use in improving the serum level of one or more lipid components in a statin intolerant hypercholesterolemic patient, the method comprising: (a) selecting a patient with moderate, high, or very high cardiovascular risk who you are statin intolerant or have a history of adverse reactions to statin therapy; and (b) administering multiple doses of an anti-PCSK9 antibody to the patient in an administration amount of about 75 to 150 mg per dose, and a frequency of administration of about once every two weeks, wherein after about 24 weeks After treatment with the anti-PCSK9 antibody, the improvement in the serum level of one or more lipid components is selected from the group consisting of: (a) lowering the low-density lipoprotein cholesterol (LDL-C) of the patient in at least 35%; (b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%; (d) reduction of the patient's total cholesterol by at least 20%; and (e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.

Another embodiment of the invention provides pharmaceutical compositions for use in the treatment of hypercholesterolemia in a patient in need thereof, comprising administering to the patient as a monotherapy a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding fragments thereof. , wherein the composition is administered every two weeks and the patient is not simultaneously taking other lipid modifying therapy, thus treating hypercholesterolemia in the patient.

Another embodiment of the invention provides pharmaceutical compositions for use in reducing low-density lipoprotein cholesterol (LDL-C) in a patient in need thereof, comprising administering to the patient as a monotherapy a pharmaceutical composition comprising an antibody. anti-PCSK9 or antigen-binding fragment thereof, wherein the composition is administered every two weeks and the patient is not simultaneously taking other lipid-modifying therapy, thereby lowering the LDL-C in the patient.

Another embodiment of the invention provides pharmaceutical compositions for use in maintaining constant low-density lipoprotein (LDL-C) cholesterol levels in a patient comprising administering to the patient as a monotherapy a pharmaceutical composition comprising an anti-PCSK9 antibody. or antigen-binding fragment thereof at an initial dose of approximately 75 mg, where the composition is administered every two weeks, and where the patient is not simultaneously taking other lipid-lowering therapy, thus keeping LDL-C levels constant. in the patient. In some embodiments, the anti-PCSK9 antibody or antigen-binding fragment thereof is administered to the patient for at least 24 weeks, and the patient's LDL-C levels are held constant for 20 weeks.

In some embodiments that provide the administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the patient is statin intolerant or has a history of adverse reactions to statin therapy. In some embodiments, the patient previously experienced skeletal muscle-related symptoms that began or increased while on at least two separate daily therapeutic statin regimens. In some embodiments, at least one of the daily therapeutic statin regimens is the lowest authorized daily dose of a statin. In some embodiments, at least one of the daily therapeutic statin regimens is selected from the group consisting of: rosuvastatin 5 mg daily, atorvastatin 10 mg daily, simvastatin 10 mg daily, lovastatin 20 mg daily, 40 mg of pravastatin a day, 40 mg of fluvastatin a day and 2 mg of pitavastatin a day.

In some embodiments that provide for administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the patient, before or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has hypercholesterolemia defined as a serum low-density lipoprotein (LDL-C) cholesterol level greater than approximately 70 mg / dL.

In some embodiments that provide for administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the patient, before or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has hypercholesterolemia defined as a serum low-density lipoprotein cholesterol (LDL-C) level greater than approximately 100 mg / dL.

In some embodiments that provide for administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the patient has heterozygous familial hypercholesterolemia (HeFH). In some embodiments that provide for administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the patient has a form of hypercholesterolemia that is unfamiliar hypercholesterolemia (H not F). In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has moderate cardiovascular risk defined as a 10-year risk score for fatal cardiovascular disease greater than or equal to. to 1% and less to 5 %. In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has a high cardiovascular risk defined as a calculated 10-year risk SCORE of higher or higher fatal cardiovascular disease. equal to 5% together with one or more of: (i) moderate chronic kidney disease, (ii) type 1 diabetes mellitus without damage to affected organs, (iii) type 2 diabetes mellitus without damage to affected organs, and / or (iv) HFhe. In some embodiments, the patient, prior to or at the time of administration of the anti-PCSK9 antibody or antigen-binding fragment thereof, has a very high cardiovascular risk defined as one or more of: (i) documented coronary heart disease ; (ii) ischemic stroke; (iii) peripheral stroke; (iv) peripheral arterial disease (PAD); (v) attack that transient ischemic (TIA); (vi) abdominal aortic aneurysm; (vii) carotid artery occlusion> 50% without symptoms; (viii) carotid endarterectomy; (ix) carotid artery endovascular graft procedure; (x) this nosis of the renal artery; (xi) renal artery endovascular graft procedure; (xii) type 1 diabetes mellitus with damage to affected organs; and / or (xiii) type 2 diabetes mellitus with damage to affected organs.

In some embodiments that provide for administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the anti-PCSK9 antibody or antigen-binding fragment thereof is an antibody or antigen-binding fragment thereof which comprises amino acid sequences of heavy and light chain CDRs having SEQ ID NOs: 2, 3, 4, 7, 8, and 10. In some embodiments, the antibody or antigen-binding fragment thereof 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: 6.

In some embodiments that provide for the administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the antibody or antigen-binding protein that specifically binds PCSK9 is administered to the patient at a dose of about 75 mg. at a frequency of once every two weeks. In some embodiments, the dose of about 75 mg is maintained if the patient's LDL-C measured after five or more doses is <70 mg / dL. In some embodiments, the approximately 75 mg dose is discontinued if the patient's LDL-C measured after five or more doses remains> 70 mg / dL, and the antibody or antigen-binding fragment thereof that specifically binds PCSK9 is subsequently administered to the patient at a dose of approximately 150 mg at a frequency of once every two weeks. In some embodiments, the antibody or antigen-binding protein that specifically binds to PCSK9 is administered to the patient at a dose of approximately 150 mg at a frequency of once every two weeks.

In some embodiments that provide for the administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as a monotherapy, the method improves serum levels of one or more lipid components selected from the group consisting of: (a) reduction of patient low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%; (d) reduction of the patient's total cholesterol by at least 20%; and (e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.

One embodiment provides a pharmaceutical composition for use in reducing free PCSK9 levels in a patient comprising administering to the patient as a monotherapy a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding protein at a dose of about 75 mg. , where the composition is administered every two weeks, and where the patient is not simultaneously taking other lipid-lowering therapy, thus reducing the levels of free PCSK9 in the patient.

One embodiment provides pharmaceutical compositions for use in improving the serum level of one or more lipid components in a patient in need thereof which comprises administering multiple doses of an anti-PCSK9 antibody as a monotherapy to the patient in an administration amount of approximately 75 to 150 mg per dose, at an administration frequency of approximately once every two weeks, where the patient is not simultaneously taking other lipid modifying therapy and where after approximately 24 weeks of treatment with the anti- PCSK9 improvement in the serum level of one or more lipid components is selected from the group consisting of: (a) reduction of the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%; (d) reduction of the patient's total cholesterol by at least 20%; and (e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.

Other embodiments of the present invention will be apparent from a review of the following detailed description.

BRIEF DESCRIPTION OF THE FIGURES

Figure 1 shows the design of the clinical trial study described in Example 2. Although the protocol required an LDL-C threshold of> 100 mg / dL for upward titration, a threshold of> 70 mg / dL was applied. dL in a blinded mode in this study. Arrows along the bottom of the figure indicate evaluation times. EOT, end of treatment; EZE, ezetimibe; LDL-C, low-density lipoprotein cholesterol; NCEP ATP III TCP, National Cholesterol Education Program Adult Treatment Panel III; Q2W, every 2 weeks; W, week.

Figure 2 shows the patient disposition from the clinical trial described in Example 2. * Life events made continuation very difficult. IDT, intention to treat.

Figure 3 is a graph showing LDL-C levels (mg / dL) versus study time point (analysis during treatment) for the clinical trial described in Example 2. Values above the Data from Week 12 and Week 24 indicate the change in% of the mean LC (SE) from baseline. LDL-C, low-density lipoprotein cholesterol; MC, least squares; SE, standard error.

Figure 4 is a group of four graphs showing the distribution of the percentage changes in LDL-C from baseline to Week 12 (Figure 4A) and Week 24 (Figure 4B) in patients treated with mAb316P (alirocumab), and Week 12 (Figure 4C) and Week 24 (Figure 4D) in patients treated with ezetimibe (Treatment Population) in the clinical trial described in Example 2.

Figure 5 is a set of two graphs showing subgroup analyzes of percent change from baseline in LDL-C at Week 24 based on demographic characteristics (Figure 5A) and other baseline characteristics (Figure 5B). (TDI population) for the clinical trial described in Example 2.

Figure 6 shows a series of graphs illustrating mean LDL-C levels (Figure 6A), mAb316P (alirocumab) Cvalle and C-tracking concentrations (Figure 6B), and free PCSK9 levels (Figure 6C) in patients treated with mAb316P according to the upward titration status in the clinical trial described in Example 2. Cvalle values were taken 14 ± 6 days after the previous injection; C follow-up values were taken> 21 days after the last injection. The triangles represent the group with upward dose adjustment at Week 12. The squares represent the group without upward dose adjustment at Week 12.

Figure 7 is a study flow chart illustrating the clinical trial described in Example 3 herein. "REGN727" is a designation for the antibody referred to herein as alirocumab or mAb316P.

DETAILED DESCRIPTION

Before describing the present invention, it should be understood that the present invention is not limited to the particular experimental methods and conditions described, and that such methods and conditions may vary. It should also be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.

Definitions

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as is commonly understood by one of ordinary skill in the art.

It is noted herein that as used in this specification and the appended claims, the singular forms "a", "an", "the" and "the" also include the plural reference, unless the context clearly dictates. else.

The term "about", when used in reference to a particular quoted numerical value, means that the value can vary from the quoted value by no more than 1%. For example, as used herein, the term "about 100" includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

The terms "administer" or "administration" refer to the act of physically injecting or otherwise delivering a substance as it exists outside the body (eg, a formulation of the invention) into a patient, such as by mucosal, intradermal, administration. intravenous, subcutaneous, intramuscular and / or any other method of physical administration described herein or known in the art. When treating a disease, or a symptom thereof, administration of the substance usually occurs after the onset of the disease or symptoms thereof. When a disease or symptoms of the disease are being prevented, the administration of the substance usually occurs before the onset of the disease or symptoms thereof.

The terms "composition" and "formulation" are intended to encompass a product containing the specified components (eg, an anti-PCSK9 antibody) in, optionally, the specified amounts, as well as any product that results, directly or indirectly, from the combination of specified components in, optionally, specified quantities.

The term "excipients" refers to inert substances that are commonly used as a diluent, carrier, preservative, binder, stabilizing agent, etc., for drugs and includes, but is not limited to, proteins (eg, serum albumin , etc.), amino acids (for example, aspartic acid, glutamic acid, lysine, arginine, glycine, histidine, etc.), fatty acids and phospholipids (for example, alkyl sulfonates, caprylate, etc.), surfactants (for example , SDS, polysorbate, non-ionic surfactant, etc.), saccharides (eg, sucrose, maltose, trehalose, etc.), and polyols (eg, mannitol, sorbitol, etc.). See, therefore, Remington's Pharmaceutical Sciences (1990) Mack Publishing Co., Easton, Pa.

In the context of a peptide or polypeptide, the term "fragment" refers to a peptide or polypeptide that comprises less than the full length amino acid sequence. Said fragment can arise, for example, from an amino-terminal truncation, a carboxy-terminal truncation, and / or an internal deletion of a residue (s) of the amino acid sequence. Fragments can result, for example, from alternative RNA splicing or from in vivo protease activity . In certain embodiments, PCSK9 fragments include polypeptides that comprise an amino acid sequence of at least 50, to 100 amino acid residues, at least 125 contiguous amino acid residues, at least 150 contiguous amino acid residues, at least 175 contiguous amino acid residues, contiguous amino acids, at least 200 contiguous amino acid residues, or at least 250 contiguous amino acid residues from the amino acid sequence of a PCSK9 polypeptide. In a specific embodiment, a fragment of a PCSK9 polypeptide or an antibody that specifically binds to a PCSK9 antigen retains at least 1, at least 2, or at least 3 functions of the full-length polypeptide or antibody.

The term "pharmaceutically acceptable" means that it is licensed by a federal or state government regulatory agency, or listed in the US Pharmacopoeia, European Pharmacopoeia, or other generally recognized pharmacopoeia for use in animals. , and more particularly in humans.

The terms "prevent", "prevent" and "prevention" refer to the total or partial inhibition of the development, reappearance, appearance or spread of a disease mediated by PCSK9 and / or symptom related thereto, resulting from the administration of a therapy or combination of therapies provided herein (eg, a combination of prophylactic or therapeutic agents).

The term "PCSK9 antigen" refers to that portion of a PCSK9 polypeptide to which an antibody specifically binds. A PCSK9 antigen also refers to an analog or derivative of a PCSK9 polypeptide or fragment thereof to which an antibody specifically binds. In some embodiments, a PCSK9 antigen is a monomeric PCSK9 antigen or a trimeric PCSK9 antigen. A region of a PCSK9 polypeptide that contributes to an epitope can be contiguous amino acids of the polypeptide, or the epitope can be joined from two or more non-contiguous regions of the polypeptide. The epitope may or may not be a three-dimensional surface feature of the antigen. A region located on the surface of a PCSK9 antigen that is capable of eliciting an immune response is a PCSK9 epiphit. The epitope may or may not be a three-dimensional surface feature of the antigen.

The term "human PCSK9", "hPCSK9" or "hPCSK9 polypeptide" and similar terms refer to polypeptides ("polypeptides", "peptides" and "proteins" are used interchangeably herein) that comprise the amino acid sequence of SEQ ID NO: 198 and related polypeptides, which include SNP variants thereof. Related polypeptides include allelic variants (eg, SNP variants); variants of cut and em palme; fragments; derivatives; substitution, deletion and insertion variants; fusion polypeptides; and interspecies homologs, preferably, that retain PCSK9 activity and / or are sufficient to elicit an anti-PCSK9 immune response. Also encompassed are soluble forms of PCSK9 that are sufficient to generate an anti-PCSK9 immune response. As will be appreciated by those of skill in the art, an anti-PCSK9 antibody can bind to a PCSK9 polypeptide, polypeptide fragment, antigen, and / or epitope, since the epitope is part of the larger antigen, which is part of the polypeptide fragment. larger, which, in turn, is part of the larger polypeptide. hPCSK9 can exist in a trimeric (native) or monomeric (denatured) form.

The terms "PCSK9-mediated disease", "PCSK9-mediated condition" and "PCSK9-mediated disorder" are used interchangeably and refer to any disease that is wholly or partially caused by or is the result of PCSK9, eg, hPCSK9. In certain embodiments, PCSK9 is abnormally expressed (eg, highly). In some embodiments, PCSK9 can be upregulated. In other embodiments, normal, abnormal, or excessive cell signaling is caused by the binding of PCSK9 to a PCSK9 ligand. In certain embodiments, the PCSK9 ligand is a PCSK9 receptor. In certain embodiments, the PCSK9-mediated disease or condition is selected from the group consisting of: elevated total cholesterol levels; elevated levels of low-density lipoprotein cholesterol (LDL-C); hyperlipidemia; dyslipidemia; hypercholesterolemia, particularly statin-uncontrolled hypercholesterolemia, hypercholesterolemia, such as familial hypercholesterolemia or unfamiliar hypercholesterolemia, and non-statin-controlled hypercholesterolemia; atherosclerosis; and cardiovascular diseases.

The terms "subject" and "patient" are used interchangeably. As used herein, a subject is preferably a mammal, such as a non-primate (eg, cows, pigs, horses, cats, dogs, rats, etc.) or a primate (eg, monkey and human). , most preferably a human. In one embodiment, the subject is a mammal, preferably a human, having a PCSK9-mediated disease. In another embodiment, the subject is a mammal, preferably a human, at risk of developing a PCSK9-mediated disease.

The term "therapeutic agent" refers to any agent that can be used in the treatment, management, or amelioration of a PCSK9-mediated disease and / or a symptom related thereto. In certain embodiments, the term "therapeutic agent" refers to an antibody against PCSK9 for use in the invention. In certain other In embodiments, the term "therapeutic agent" refers to an agent other than an antibody against PCSK9 for the use of the invention. Preferably, a therapeutic agent is an agent that is known to be useful for, or has been or is currently being used for the treatment, management, or amelioration of a PCSK9-mediated disease or one or more symptoms related thereto.

The term "therapy" refers to any protocol, method, and / or agent that can be used in the prevention, management, treatment, and / or amelioration of a PCSK9-mediated disease (eg, atherosclerosis or hypercholesterolemia). In certain embodiments, the terms "therapies" and "therapy" refer to biological therapy, adjunctive therapy, and / or other therapies useful in the prevention, management, treatment, and / or amelioration of a PCSK9-mediated disease known to one of skill. in the art, such as medical personnel.

The terms "treat", "treatment" and "treat" refer to the reduction or amelioration of the progression, severity and / or duration of a PCSK9-mediated disease (eg, atherosclerosis) resulting from the administration of one or more therapies. (including, but not limited to, the administration of one or more prophylactic or therapeutic agents). In specific embodiments, such terms refer to the reduction or inhibition of the binding of PCSK9 to a PCSK9 ligand.

Although any method and material similar or equivalent to those described herein can be used in the practice of the present invention, the preferred methods and materials are now described.

Patient selection

The present invention includes pharmaceutical compositions for use, among other things, to treat patients who have hypercholesterolemia who are not on statin therapy, including patients who are insensitive to statins, poorly controlled on statin therapy, intolerant to statins, or who have a history of adverse reactions to statin therapy.

The present invention comprises selecting patients who have, or are at risk of developing hypercholesterolemia and administering to these patients a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding fragment thereof. For example, a patient may be selected for treatment with the methods of the present invention if the patient is diagnosed with or has been identified as being at risk of developing a hyperlipidemic condition such as, for example, heterozygous familial hypercholesterolemia (HeFH). , homozygous familial hypercholesterolemia (HFho), autosomal dominant hypercholesterolemia (ADH, for example, ADH associated with one or more gain-of-function mutations in the PCSK9 gene), unfamiliar hypercholesterolemia (H not F), dyslipidemia and mixed dyslipidemia. In certain respects, the patient to be treated is indicated for LDL apheresis. In certain aspects, a patient with hyperlipidemia also has type 2 diabetes mellitus. In certain aspects, the patient to be treated is diagnosed with hypercholesterolemia and is statin intolerant, statin insensitive, or not controlled by statins. As used herein, hyperlipidemia includes primary hyperlipidemia, secondary hyperlipidemia, and Fredrickson class I-V phenotype.

As used herein, the term "a patient in need thereof" means a human or non-human animal that exhibits one or more symptoms or indications of hyperlipidemia or that has been diagnosed with hyperlipidemia, or that is otherwise would benefit from a reduction in total serum cholesterol, LDL, triglycerides, VLDL, lipoprotein (a) [Lp (a)], or would benefit from an increase in HDL.

The present invention comprises selecting patients who are not currently on statin therapy. As used herein, a statin therapy is an HMG-CoA reductase inhibitor and includes, but is not limited to, atorvastatin, cerivastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin, etc. In some embodiments, doses of an anti-PCSK9 antibody or antigen-binding fragment thereof are administered to a patient whose previous (or "background") statin therapy is discontinued prior to or concurrent with the administration of the first. dose of the anti-PCSK9 antibody or antigen-binding fragment thereof.

According to certain embodiments, the patient can be selected on the basis of having moderate, high, or very high CV risk. The degree of CV risk can be assessed and expressed in terms of a 10-year risk score calculated for fatal cardiovascular disease (CVD), as defined by The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS), as set out in ESC / EAS Guidelines for the Management of Dyslipidaemias, European Heart Journal, 2100; 32: 1769-1818 (referred to herein as "ESC / EAS 2011"). As used herein, "moderate CV risk" means a calculated 10-year risk SCORE of moral CVD greater than or equal to 1% and less than 5%. As used herein, "high CV risk" means a 10-year calculated SCORE of fatal CVD risk greater than or equal to 5%, and / or moderate renal disease (CKD), and / or type 1 diabetes mellitus or type 2 without affected organ damage, and / or HFhe. As used herein, "very high CV risk" means a history of documented coronary heart disease (CHD), ischemic stroke, peripheral arterial disease (PAD), transient ischemic attack (TIA), abdominal aortic aneurysm, carotid artery occlusion greater than 50% without symptoms, carotid endarterectomy or carotid artery stent procedure, renal artery stenosis, renal artery stent procedure, and / or type 1 or type 2 diabetes mellitus with damage to affected organs.

According to certain embodiments, the patient can be selected based on having 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) silent IM; (iii) unstable angina; (iv) coronary revascularization procedure (eg, percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]); and / or (v) clinically significant CHD diagnosed by invasive or non-invasive testing (such as coronary angiography, stress test using treadmill, stress echocardiography, or nuclear magnetic resonance imaging).

According to certain embodiments, the patient may be selected based on having one or more additional risk factors selected from the group consisting of age (eg, greater than 40, 45, 50, 55, 60, 65, 70, 75, or 80 age), race, national origin, gender (male or female), exercise habits (for example, person who exercises regularly, person who does not exercise), other pre-existing medical conditions (for example, type II diabetes, hypertension blood pressure, etc.), and current medication status (for example, currently taking beta-blockers, niacin, ezetimibe, fibrates, omega-3 fatty acids, bile acid resins, etc.).

The present invention comprises administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient who is not on statin therapy. Patients with hypercholesterolemia may not be on statin therapy because they are insensitive to statins, poorly controlled with statin therapy, intolerant to statins, have a history of adverse reactions to statin therapy, or for any other reason.

Although lifestyle modifications and conventional drug treatment are often successful in lowering cholesterol levels, not all patients are able to achieve recommended target cholesterol levels with these approaches. Various conditions, such as familial hypercholesterolemia (FH), appear to be resistant to lowering LDL-C levels despite aggressive use of conventional therapy. Homozygous and heterozygous familial hypercholesterolemia (HFho, HFH) are conditions associated with premature atherosclerotic vascular disease. However, patients diagnosed with HoFH are largely insensitive to conventional drug therapy and have limited treatment options. Specifically, statin treatment, which lowers LDL-C by inhibiting cholesterol synthesis and upregulating the hepatic LDL receptor, may have little effect in patients whose LDL receptors are absent or defective. A mean LDL-C reduction of only less than approximately 20% has recently been reported in genotype confirmed HFH patients treated with the highest dose of statins. The addition of ezetimibe 10 mg / day to this regimen produced a total reduction in LDL-C levels of 27%, which is still far from optimal. Also, many patients are insensitive to statins or poorly controlled with statin therapy.

In some aspects, the present invention comprises administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient who is "statin intolerant." As used herein, a patient is considered "statin intolerant" if the patient has a history of experiencing one or more adverse reactions that started or increased while on a daily statin regimen and stopped when statin therapy was discontinued. In certain embodiments, the adverse reactions are musculoskeletal in nature, eg, skeletal muscle pain, aches, weakness, or crampy pain (eg, myalgia, myopathy, rhabdomyolysis, etc.). In certain embodiments, the adverse reactions are skeletal muscle pain or pain that occurs or is intensified after exercise or exercise. Statin-related adverse reactions also include hepatic, gastrointestinal, and psychiatric symptoms that correlate with statin administration. According to certain embodiments, a patient is considered "statin intolerant" if the patient has a history of skeletal muscle-related symptoms associated with at least two separate and different daily statin regimens. According to certain embodiments, a patient is "statin intolerant" if the patient exhibits one or more statin-related adverse reaction (s) at the lowest authorized daily doses of one or more statins. In certain embodiments, a patient is "statin intolerant" if the patient is unable to tolerate a cumulative weekly statin dose of seven times the lowest authorized tablet size. According to other embodiments of the present invention, a patient is "statin intolerant" if the patient is able to tolerate low-dose statin therapy, but develops symptoms when the dose is high (eg, to achieve a target level. LDL-C).

According to the present invention, "a history of skeletal muscle-related symptoms associated with taking at least two different and separate statins" includes skeletal muscle-related pain, aches, weakness, and / or cramping pain, which began or increased during statin therapy and stopped when statin therapy was discontinued. In the context of the present invention, exemplary statin therapies associated with statin intolerance may include daily therapeutic statin regimens selected from the group consisting of: rosuvastatin 5 mg daily, atorvastatin 10 mg daily , 10 mg of simvastatin per day, 20 mg of lovastatin per day, 40 mg of pravastatin per day, 40 mg of fluvastatin per day and 2 mg of pitavastatin per day.

Patients who can be treated with the pharmaceutical composition of the present invention may be receiving one or more of other non-statin lipid modifying therapies. Alternatively, they may not be receiving any other lipid modifying therapy; in this case, the administration of the anti-PCSK9 antibody or antigen-binding fragment thereof can be described as a monotherapy. As used herein, use of the anti-PCSK9 antibody or antigen-binding fragment thereof as a "monotherapy" means in the absence of any other concurrent lipid modifying therapy.

Methods for treating hyperlipidemia and lowering serum LDL-C levels

According to certain embodiments, the patient who is treatable by the methods of the present invention has hypercholesterolemia (sometimes referred to herein as "a hypercholesterolemic patient"). '' Hypercholeste rolemia '', as used herein, includes a serum LDL-C concentration greater than or equal to 70 mg / dL, or a serum LDL-C concentration greater than or equal to 100 mg / dL. dL, depending on the cardiovascular risk of the patient ("CV risk"). For example, for patients with a very high CV risk (as defined elsewhere herein), the patient is considered to have hypercholesterolemia if the patient's serum LDL-C concentration is greater than or equal to approximately 70 mg. / dL. For patients with moderate or high CV risk (as defined elsewhere herein), the patient is considered to have hypercholesterolemia if the patient's serum LDL-C concentration is greater than or equal to approximately 100 mg / dL.

Hypercholesterolemia, for the purposes of the present invention, includes heterozygous familial hypercholesterolemia (HFhe), homozygous familial hypercholesterolemia (HFho), autosomal dominant hypercholesterolemia (ADH, for example ADH associated with one or more gain-of-function mutations in the gene PCSK9), as well as incidences of hypercholesterolemia that are different from familial hypercholesterolemia (H not F).

The present invention includes pharmaceutical compositions for reducing serum LDL-C levels in a patient. The patient may be a statin-intolerant hypercholesterolemic patient, or any other patient for whom a reduction in serum LDL-C is considered beneficial or desirable. Similarly, the present invention includes pharmaceutical compositions for reducing serum LDL-C levels in a patient without inducing skeletal muscle pain, discomfort, weakness, or crampy pain. As used in this context, "reducing serum LDL-C levels" means causing the patient's serum LDL-C level to drop by at least 10% (eg, at least 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or more).

Methods of elimination or reduction of statin use

The present invention includes a pharmaceutical composition for use, among other things, to eliminate or reduce the use of statins in a patient with hypercholesterolemia, including a hypercholesterolemic patient, eg, a hypercholesterolemic patient who is intolerant to statins. Methods according to this aspect of the invention comprise: (a) selecting a patient who is or was on a daily therapeutic statin regimen and who is intolerant to statins or who has a history of adverse reactions to statin therapy; and (b) interrupting or reducing the patient's daily therapeutic statin regimen; and (c) administering one or more doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to the patient. According to certain embodiments of this aspect of the invention, the patient's daily therapeutic statin regimen may be completely discontinued at the time of or just prior to the start of a therapeutic cycle of treatment comprising the administration of one or more doses of an anti- -PCSK9 or antigen-binding fragment thereof to the patient. In other embodiments, the patient's daily therapeutic statin regimen may be gradually reduced at the time of or just prior to the start of a therapeutic cycle of treatment comprising the administration of one or more doses of an anti-PCSK9 antibody or binding fragment. the antigen thereof to the patient. Gradual reduction of a statin regimen, in the context of this aspect of the invention, may comprise reducing the amount of statin administered to a patient, and / or decreasing the frequency of administration of statin to the patient. The gradual reduction of a statin regimen, in accordance with this aspect of the invention, may result in the complete elimination of statin use by the patient while the patient is receiving an anti-PCSK9 antibody or antigen-binding fragment thereof. instead of the statin. In this regard, the adverse effects of statins on a patient are reduced or eliminated by reducing or eliminating the use of statins by the patient, while still allowing adequate treatment of hypercholesterolemia in the patient by administration of an anti-body antibody. PCSK9 or antigen-binding fragment thereof.

Therapeutic efficacy

The pharmaceutical composition of the present invention results in the reduction in serum levels of one or more lipid components selected from the group consisting of LDL-C, ApoB100, non-HDL-C, total cholesterol, VC-LDL, triglycerides, Lp ( a) and / or remaining cholesterol, and increasing ApoA-1.

According to certain embodiments of the present invention, administration of a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient with hypercholesterolemia as a monotherapy, in the absence of any other lipid-modifying therapy, will give resulting in a mean percentage reduction from baseline in serum low-density lipoprotein cholesterol (LDL-C) of at least about 25%, 30%, 40%, 45%, 50%, 60%, or higher; a mean percentage reduction from baseline in ApoB100 of at least about 25%, 30%, 40%, 50%, 60%, or greater; a mean percentage reduction from baseline in non-HDL C of at least about 25%, 30%, 40%, 50%, 60%, or greater; a mean percentage reduction from baseline in total cholesterol of at least about 10%, 15%, 20%, 25%, 30%, 35%, or greater; and / or a mean percentage increase from baseline in ApoA-1 of at least about 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or greater. Percentage reductions in the various lipid parameters as discussed above can be achieved at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30, or more weeks after commencement of a therapeutic regimen comprising administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as disclosed herein (e.g., 75 mg or 150 mg of mAb316P administered once every two weeks, or other similar administration regimens; see, for example, Example 2 herein).

According to certain specific embodiments, the present invention includes a pharmaceutical composition for reducing serum LDL-C levels in a hypercholesterolemic patient in the absence of any other lipid modifying therapy. The pharmaceutical compositions used in accordance with this aspect of the invention comprise: (a) selecting a patient with LDL-C between 100 mg / dL (2.59 mmol / L) and 190 mg / dL (4.9 mmol / L) who is at moderate cardiovascular risk and not receiving any other lipid modifying therapy; and (b) administering multiple doses of an anti-PCSK9 antibody to the patient in an administration amount of about 75 to 150 mg per dose, and an administration frequency of about once every two weeks, wherein after about 24 weeks After treatment with the anti-PCSK9 antibody, the patient presents one or more improvements in the lipid parameters selected from the group consisting of: a reduction in the level of LDL-C from the baseline level of approximately 47%, a reduction in the non-HDL C level from baseline of about 41%, a reduction in Apo B level from baseline of about 37%, and / or a reduction in total cholesterol level from baseline of about 30% . Pharmaceutical compositions for use according to this aspect of the invention may comprise interrupting the background lipid modifying therapy of the patient prior to or concurrently with the initiation of anti-PCSK9 antibody treatment.

The pharmaceutical compositions for use of the present invention result in the reduction in serum levels of one or more lipid components selected from the group consisting of LDL-C, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides. , Lp (a) and / or remaining cholesterol. For example, according to certain embodiments of the present invention, the administration of a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient with hypercholesterolemia who is intolerant to statins or who has a history of adverse reactions Statin therapy (also referred to herein as a "statin-intolerant hypercholesterolemic patient") will result in a mean percentage reduction from baseline in serum low-density lipoprotein cholesterol (C- LDL) of at least about 25%, 30%, 40%, 45%, 50%, 60%, or greater; a mean percentage reduction from baseline in ApoB100 of at least about 25%, 30%, 40%, 50%, 60%, or greater; a mean percentage reduction from baseline in non-HDL C of at least about 25%, 30%, 40%, 50%, 60%, or greater; a mean percentage reduction from baseline in total cholesterol of at least about 10%, 15%, 20%, 25%, 30%, 35%, or greater; a mean percentage reduction from baseline in VLDL-C of at least about 5%, 10%, 15%, 20%, 25%, 30%, or greater; a mean percentage reduction from baseline in triglycerides (eg, fasting triglycerides) of at least about 5%, 10%, 15%, 20%, 25%, 30%, 35% or greater; and / or an average percentage reduction from baseline in Lp (a) of at least about 5%, 10%, 15%, 20%, 25%, or greater. Percentage reductions in the various lipid parameters as discussed above can be achieved in 1,2,3,4,5,6,7,8,9,10,11,12,14,16,18,20, 22, 24, 26, 28, 30, or more weeks after commencement of a therapeutic regimen comprising administration of an anti-PCSK9 antibody or antigen-binding fragment thereof as disclosed herein (e.g., 75 mg or 150 mg of mAb316P administered once every two weeks, or other similar administration regimens; see, for example, Example 3 herein).

According to certain specific embodiments, the present invention includes pharmaceutical compositions for use in reducing serum LDL-C levels in a statin-intolerant hypercholesterolemic patient. Pharmaceutical compositions for use in accordance with this aspect of the invention comprise: (a) selecting a patient with moderate, high or very high cardiovascular risk who is intolerant to statins or who has a history of adverse reactions to statin therapy; and (b) administering multiple doses of an anti-PCSK9 antibody to the patient in an administration amount of about 75 to 150 mg per dose, and an administration frequency of about once every two weeks, wherein after about 24 weeks of treatment with the anti-PCSK9 antibody, the patient presents one or more improvements in the lipid parameters selected from the group consisting of: a reduction in the level of LDL-C from the baseline level of approximately 45%, a reduction in the level of C non-HDL from baseline of about 40%, a reduction in Apo B level from baseline of about 36%, and / or a reduction in Lp (a) level from baseline of about 26 %. Pharmaceutical compositions for use in accordance with this aspect of the invention may comprise interrupting the background statin therapy of the patient prior to or simultaneously with the initiation of anti-PCSK9 antibody treatment.

Antibodies against PCSK9

Pharmaceutical compositions for use of the present invention comprise administering to a patient a therapeutic composition comprising an anti-PCSK9 antibody or antigen-binding fragment thereof. How Used herein, an "anti-PCSK9 antibody" is an agent that binds or interacts with human PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo. Examples of anti-PCSK9 antibodies or antigen-binding fragments thereof include antibodies or antigen-binding fragments of antibodies that specifically bind human PCSK9.

The term "proprotein convertase subtilisin / human kexin type 9" or "human PCSK9" or "hPCSK9", as used herein, refers to PCSK9 encoded by the nucleic acid sequence shown in

SEQ ID NO: 197 and comprising the amino acid sequence of SEQ ID NO: 198, or a biologically active fragment thereof.

The term "antibody", as used herein, is intended to refer to immunoglobulin molecules comprising four polypeptide chains, two heavy (H) chains, and two light (L) chains interconnected by disulfide bonds, as well as multimers of the themselves (eg IgM). Each heavy chain comprises a heavy chain variable region (abbreviated herein HCVR or Vh) and a heavy chain constant region. The heavy chain constant region comprises three domains, Ch1, Ch2, and Ch3. Each light chain comprises a light chain variable region (abbreviated herein LCVR or Vl) and a light chain constant region. The constant region of the light chain comprises a domain (Cl1). The VH and VL regions can be further subdivided into regions of hypervariability, called complementarity determining regions (CDRs), interspersed with regions that are more conserved, called structural regions (FR). Each Vh and Vl is composed of three CDRs and four FRs, arranged from the amino end to the carboxy end in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In different embodiments of the invention, the FRs of the anti-PCSK9 antibody (or antigen-binding portion thereof) may be identical to human germline sequences, or they may be naturally or artificially modified. A consensus amino acid sequence can be defined based on a direct comparative 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 obtainable, synthetic polypeptide or glycoprotein. , or genetically engineered, that specifically binds to an antigen to form a complex. Antigen-binding fragments of an antibody can be derived, for example, from whole antibody molecules using any suitable conventional technique, such as proteolytic digestion or recombinant genetic engineering techniques involving manipulation and expression of variable domains and optionally DNA-encoding antibody constants. Such DNAs are known as and / or readily available from, for example, commercial sources, DNA libraries (including, for example, phage-antibody 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 a suitable configuration, or to introduce codons, create cysteine residues, modify, add or delete 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 the hypervariable region of an anti body (eg, an isolated complementarity determining region (CDR) such as a CDR3 peptide), or a FR3-peptide CDR3-FR4 limited. Also encompassed within the term "antigen-binding fragment" as used herein are other engineered molecules, such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, antibodies grafted with CDRs, diabodies, tribodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.), small modular immunpharmaceuticals (SMIPs), and domains

Ignore shark variables.

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

In certain embodiments, an antigen-binding fragment of an antibody may contain at least one variable domain covalently linked to at least one constant domain. Exemplary non-limiting configurations of variable and constant domains that may be found within 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) Vh-Ch2-Ch3; (vii) Vh-Cl; (viii) Vl-Ch1; (ix) Vl-Ch2; (x) Vl-Ch3; (xi) Vl-Ch1-Ch2; (xii) Vl-C Ch2-Ch3; and (xiv) Vl-Cl. In any variable and constant domains configuration, including any of the exemplary configurations listed above, the variable and constant domains can be either directly linked to each other, or they can be linked by a total connector or hinge region or partial.

A hinge region can consist of at least 2 (eg, 5, 10, 15, 20, 40, 60 or more) amino acids that give

as a result a flexible or semi-flexible linkage between adjacent variable and / or constant domains in a single polypeptide molecule. Furthermore, an antigen-binding fragment of an antibody of the present invention may comprise a homodimer or heterodimer (or other multimer) of any of the variable and constant domain configurations listed above in non-covalent association with each other and / or with one or more monomeric Vh or Vl domains (eg, by disulfide bond (s)).

As with full length antibody molecules, antigen-binding fragments can be monospecific or multispecific (eg, bispecific). A multispecific antigen-binding fragment of an antibody will normally comprise at least two different variable domains, where each variable domain is capable of specifically binding a separate antigen or a different epitope on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be adapted for use in the context of an antigen-binding fragment of an antibody for use in the present invention, using routine techniques available in the art.

The constant region of an antibody is important in an antibody's ability to bind complement and mediate cell-dependent cytotoxicity. Thus, the isotype of an antibody can be selected based on whether it is desired that the antibody mediates cytotoxicity.

The term "human antibody", as used herein, is intended to include antibodies that have variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies for use in the invention may, however, include amino acid residues not encoded by human germline immunoglobulin sequences (for example, mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo), 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 have been grafted onto sequences of the human framework region. like a mouse.

The term "recombinant human antibody", as used herein, is intended to include all human antibodies that are prepared, expressed, created, or isolated by recombinant means, such as antibodies expressed using a recombinant expression vector transfected into a host cell. (described later), antibodies isolated from a recombinant combinatorial library of human antibodies (described later), antibodies isolated from an animal (e.g., mouse) that is transgenic for human immunoglobulin genes (see, for example, Taylor et al. (1992) Nucl. Acids Res. 20: 6287-6295) or antibodies prepared, expressed, created, or isolated by any other means involving splicing of human immunoglobulin gene sequences with other sequences of DNA. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. In certain embodiments, however, such recombinant human antibodies are subjected to in vitro mutagenesis (or, when using a transgenic animal for human Ig sequences, to somatic mutagenesis in vivo) and thus the amino acid sequences of the Vh and Recombinant antibody Vl are sequences that, although derived from and related to human germline Vh and Vl sequences, cannot naturally exist within the human antibody germline repertoire in vivo.

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

The frequency of occurrence of the second form in the various isotypes of intact IgG is due to, but is not limited to, structural differences associated with the isotype of the hinge region of the antibody. A single amino acid substitution in the hinge region of 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 using a human IgG1 hinge. . The present invention encompasses antibodies that have one or more mutations in the hinge, Ch2 or Ch3 region that may be desirable, for example, in production, to improve the performance of the desired form of antibody.

An "isolated antibody", as used herein, means an antibody that has been identified and separated and / or recovered from at least one component of its natural environment. For example, an antibody that has been separated or removed from at least one component of an organism, or from a tissue or cell in which the antibody exists naturally or occurs naturally, is an "isolated antibody" for the purposes herein. invention. An isolated anti-body also includes an antibody in situ within a recombinant cell. Isolated antibodies are antibodies that have undergone at least one purification or isolation step. According to certain embodiments, an isolated antibody can be substantially free of other cellular material and / or chemicals.

The term "specifically binds to", 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. They know each other well Methods of determining whether an antibody specifically binds an antigen in the art include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, an antibody that "specifically binds" PCSK9, as used in the context of the present invention, includes antibodies that bind to PCSK9 or a portion thereof with a Kd of less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than about 100 nM, less than about 90 nM, less than about 80 nM, less than about 70 nM, less than about 60 nM, less than about 50 nM, less than about 40 nM, less than about 30 nM, less than about 20 nM, less than about 10 nM, less than about 5 nM, less than about 4 nM, less than about 3 nM, less than about 2 nM, less at about 1 nM or less than about 0.5 nM, as measured in a surface plasma resonance assay. An isolated antibody that specifically binds human PCSK9 may, however, have cross-reactivity with other antigens, such as PCSK9 molecules from other (non-human) species.

Anti-PCSK9 antibodies comprised in pharmaceutical compositions for use in the present invention may comprise one or more amino acid substitutions, insertions and / or deletions in the structural region and / or CDR regions of the variable domains of the heavy and light chain compared to the corresponding germline sequences from which the antibodies were derived. Such mutations can be easily established by comparing the amino acid sequences disclosed herein with germline sequences available from, for example, public antibody sequence databases. The present invention includes pharmaceutical compositions for use comprising antibodies, and antigen-binding fragments thereof, which are derived from any of the amino acid sequences disclosed herein, wherein one or more amino acids within one or more regions Structural and / or CDR regions are mutated to the corresponding residue (s) of the germline sequence from which the antibody was derived, 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 as "germline mutations"). One of ordinary skill in the art, starting from the heavy and light chain variable region sequences disclosed herein, can readily produce numerous antibodies and antigen-binding fragments comprising one or more individual germline mutations or combinations. from the same. In certain embodiments, all framework region and / or CDR residues within the Vh and / or Vl domains are back-mutated to residues found in the original germline sequence from which the antibody was derived. In other embodiments, only certain residues are back-mutated to the original germline sequence, for example, only the mutated residues found within the first 8 amino acids of FR1 or within the last 8 amino acids of FR4, or only the mutated residues found within CDR1, CDR2 or CDR3. In other embodiments, one or more of the framework region and / or CDR residues are mutated to the corresponding residues of a different germline sequence (i.e., a germline sequence that is different from the germline sequence from which the antibody was originally derived). In addition, antibodies for use in the present invention may contain any combination of two or more germline mutations within framework and / or CDR regions, for example, where certain individual residues are mutated to the corresponding residue of a sequence. germline while certain other residues that differ from the original germline sequence remain or are mutated to the corresponding residue of a different germline sequence. Once obtained, antibodies and antigen-binding fragments containing one or more germline mutations can easily be tested for one or more desired properties such as improved binding specificity, increased binding affinity, antagonistic or agonist biological properties. enhanced or enhanced (as the case requires), reduced immunogenicity, etc. The use of pharmaceutical compositions comprising the antibodies and antigen-binding fragments obtained in this general way is encompassed within the present invention.

The present invention also includes pharmaceutical compositions for use that comprise anti-PCSK9 antibodies comprising 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 pharmaceutical compositions for use that comprise anti-PCSK9 antibodies having HCVR, LCVR and / or CDR amino acid sequences with, for example, 10 or less, 8 or less, 6 or less, 4 or fewer, etc., conservative amino acid substitutions with respect 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 allows analysis of interactions in real time by detecting alterations in protein concentrations within a biosensor matrix, for example using the BIAcore ™ system (Biacore Life Sciences, a division of GE Healthcare, Piscataway, NJ).

The term "KD", as used herein, is intended to refer to the equilibrium dissociation constant of 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 a paratope. A single antigen can have more than one epitope. Thus, different antibodies can bind to different areas on an antigen and can have different biological effects. Epitopes can be either conformational or linear. A conformational epitope It is produced by spatially juxtaposed amino acids of different segments of the linear polypeptide chain. A linear epitope is one produced by adjacent amino acid residues in a polypeptide chain. In certain circumstances, an epitope can include saccharide moieties, phosphoryl groups, or sulfonyl groups on the antigen.

According to certain embodiments, the anti-PCSK9 antibody comprised in pharmaceutical compositions for use in the present invention is an antibody with pH-dependent binding characteristics. As used herein, the term "pH-dependent binding" means that the antibody or antigen-binding fragment thereof exhibits "reduced binding to PCSK9 at acidic pH compared to neutral pH" (for the purposes of the present disclosure, both expressions can be used interchangeably). For example, antibodies "with pH-dependent binding characteristics" include antibodies and antigen-binding fragments thereof that bind PCSK9 with higher affinity at neutral pH than at acidic pH. In certain embodiments, the antibodies and antigen-binding fragments of the present invention bind to PCSK9 with an affinity of 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.

According to this aspect of the invention, pharmaceutical compositions for use comprising anti-PCSK9 antibodies with pH dependent binding characteristics may possess one or more amino acid variations relative to the parent anti-PCSK9 antibody. For example, an anti-PCSK9 antibody with pH slope binding characteristics can contain one or more histidine substitutions or insertions, for example, in one or more CDRs of a parent anti-PCSK9 antibody. Thus, according to certain embodiments of the present invention, pharmaceutical compositions are provided for use which comprise administering an anti-PCSK9 antibody comprising CDR amino acid sequences (eg, heavy and light chain CDRs) that are identical to those described. CDR amino acid counts of a parent anti-PCSK9 antibody, except for the substitution of one or more amino acids of one or more CDRs of the parent antibody with a histidine residue. Anti-PCSK9 antibodies with pH dependent binding may possess, for example, 1,2,3,4,5,6,7,8,9, or more, histidine substitutions, either within a single CDR of a parental antibody or distributed across multiple (eg, 2, 3, 4, 5 or 6) CDRs of a parental anti-PCSK9 antibody. For example, the present invention includes pharmaceutical compositions for use comprising pH-dependent binding anti-PCSK9 antibodies comprising one or more histidine substitutions in HCDR1, one or more histidine substitutions in HCDR2, one or more histidine substitutions in HCDR3, one or more histidine substitutions in LCDR1, one or more histidine substitutions in LCDR2, and / or one or more histidine substitutions in LCDR3, of a parental anti-PCSK9 antibody.

As used herein, the term "acidic pH" means a pH of 6.0 or less (eg, less than about 6.0, less than about 5.5, less than about 5.0, etc.). ). The term "acidic pH" includes pH values of about 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 term "neutral pH" means a pH of from about 7.0 to about 7.4. The term "neutral pH" includes pH values of about 7.0, 7.05, 7.1,7,15, 7.2, 7.25, 7.3, 7.35, and 7.4.

Non-limiting examples of anti-PCSK9 antibodies that can be used in the context of the present invention include alirocumab or antigen-binding portions thereof.

Preparation of human antibodies

Methods of generating human antibodies in transgenic mice are known in the art. Any such known method can be used in the context of the present invention to prepare human antibodies that specifically bind to human PCSK9.

Using VELOCIMMUNE ™ technology (see, for example, US Patent No. 6,596,541 B2, Regeneron Pharmaceuticals) or any other known method for generating monoclonal antibodies, high affinity chimeric antibodies to PCSK9 are initially isolated that they have a human variable region and a mouse constant region. The VELOCIMMUNE® technology involves generation of a transgenic mouse having a genome comprising variable regions of human heavy and light chains operably linked to constant region loci of endogenous mice such that the mouse produces an antibody comprising a human variable region and a mouse constant region in response to antigenic stimulation. DNA encoding the antibody heavy and light chain variable regions is isolated and operably linked to DNA encoding the human heavy and light chain constant regions. The DNA is then expressed in a cell capable of expressing the fully human antibody.

Generally, a VELOCIMMUNE ™ mouse is challenged with the antigen of interest, and lymphatic cells (such as B lymphocytes) are recovered from the mice expressing the antibodies. Lymph cells can be fused with a myeloma cell line to prepare immortal hybridoma cell lines, and such hybridoma cell lines are screened and selected to identify hybridoma cell lines that produce antibodies specific to the antigen of interest. DNA encoding the heavy chain and light chain variable regions can be isolated and linked to desirable isotypic heavy chain and light chain constant regions. Such an anti-body protein can be produced in a cell, such as a CHO cell. Alternatively, DNA encoding the antigen-specific chimeric antibodies or the variable domains of the heavy and light chains can be isolated. directly from antigen-specific lymphocytes.

Initially, high affinity chimeric antibodies having a human variable region and a mouse constant region are isolated. Antibodies are characterized and selected for desirable characteristics, including affinity, selectivity, epitope, etc., using standard procedures known to those of skill in the art. The mouse constant regions are substituted for a desired human constant region to generate the fully human antibody comprised in pharmaceutical compositions for use in the invention, eg, non-mutant or modified IgG1 or IgG4. While the selected constant region may vary according to specific use, high affinity antigen binding and target specificity characteristics reside in the variable region.

In general, the antibodies that can be used in the pharmaceutical compositions of the present invention possess high affinities, as described above, when measured by binding to antigen either immobilized on solid phase or in solution phase. The mouse constant regions are substituted for desired human constant regions to generate the fully human antibodies comprised in the pharmaceutical compositions of the invention. Although the constant region selected may vary according to specific use, high affinity antigen binding and target specificity characteristics reside in the variable region.

Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 that can be used in the context of pharmaceutical compositions for use in the present invention include any antibody or antigen-binding fragment comprising the three heavy chain CDRs (HCDR1, HCDR2 and HCDR3) contained within a heavy chain variable region (HCVR) having an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 and 11, or a sequence substantially similar thereof having at least 90%, at least 95%, at least 98% or at least 99% sequence identity. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 that can be used in the context of pharmaceutical compositions for use in the present invention include any antibody or antigen-binding fragment. comprising the three heavy chain CDRs (HCDR1, HCDR2 and HCDR3) contained within a heavy chain variable region (HCVR) having an amino acid sequence selected from the group consisting of SEQ ID NOs 37, 45, 53, 61,69, 77, 85, 93, 101, 109, 117, 125, 133, 141, 149, 157, 165, 173, 181 and 189, or a substantially similar sequence thereof having at least 90%, at minus 95%, at least 98% or at least 99% sequence identity. The antibody or antigen-binding fragment may comprise all three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from the group consisting of SEQ ID NOs 6 and 15, or a substantially similar sequence thereof that has at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. Alternatively, the antibody or antigen-binding fragment may comprise all three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from the group consisting in SEQ ID NOs 41,49, 57, 65, 73, 81,89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185 and 193, or a substantially similar sequence of the same one that has at least 90%, at least 95%, at least 98% or at least 99% sequence identity.

The sequence identity between two amino acid sequences is determined along the entire length of the reference amino acid sequence, that is, the amino acid sequence identified with SEQ ID NO, using the best sequence alignment and / or along of the region of the best sequence alignment between the two amino acid sequences, where the best sequence alignment can be obtained with tools known in the art, for example Align, using standard parameters, preferably EMBOSS :: needle, Matrix: Blosum62 , Gap Open 10.0, Gap Extend 0.5.

In certain embodiments of the present invention, the antibody or antigen-binding protein used comprises the six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3) of the pairs of the amino acid sequences of the variable region of the heavy chain. and light (HCVR / LCVR) selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. Alternatively, in certain embodiments of the present invention, the antibody or antigen-binding protein used comprises the six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) of the pairs of the amino acid sequences of the variable region of the heavy and light chain (HCVR / LCVR) selected from the group consisting of SEQ ID NOs: 37/41, 45/49, 53/57, 61/65, 69/73, 77/81, 85/89, 93/97 , 101/105, 109/113, 117/121, 125/129, 133/137, 141/145, 149/153, 157/161, 165/169, 173/177, 181/185 and 189/193.

In certain embodiments of the present invention, the anti-PCSK9 antibody, or antigen-binding protein, which can be used in pharmaceutical compositions for use in the present invention has the amino acid sequences HCDR1 / HCDR2 / HCDR3 / LCDR1 / LCDR2 / LCDR3 selected from SEQ ID NOs: 2/3/4/7/8/10 (mAb316P [also referred to as "REGN727," or "alirocumab"]) and 12/13/14/16/17/18 (mAb300N ) (see US Patent Application Publication No. 2010/0166768) and 12/13/14/16/17/18, where SEQ ID NO: 16 comprises a substitution of histidine for leucine in the moiety amino acid 30 (L30H).

In certain embodiments of the present invention, the antibody or antigen-binding protein used comprises the pairs of HCVR / LCVR amino acid sequences selected from the group consisting of SEQ ID NOs: 1/6 and 11/15. In certain exemplary embodiments, the antibody or antigen-binding protein comprises a HCVR amino acid sequence of SEQ ID NO: 1 and an LCVR amino acid sequence of SEQ ID NO: 6. In certain exemplary embodiments, the antibody or antigen-binding protein comprises an HCVR amino acid sequence of SEQ ID NO: 11 and an amino acid sequence of LCVR of SEQ ID NO: 15. In certain exemplary embodiments, the antibody or antigen-binding protein comprises an amino acid sequence of HCVR of SEQ ID NO: 11 and a LCVR amino acid sequence of SEQ ID NO: 15 comprising a substitution of histidine for leucine at amino acid residue 30 (L30H).

Pharmaceutical compositions and methods of administration

The present invention includes pharmaceutical compositions for use which comprise administering an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient, wherein the anti-PCSK9 antibody or antigen-binding fragment thereof is contained within the composition. pharmaceutical. Pharmaceutical compositions for use in the invention are formulated with suitable carriers, excipients, and other agents that provide adequate transfer, administration, tolerance, and the like. A multitude of suitable formulations can be found in the form known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, lipid-containing vesicles (cationic or anionic) (such as LIPOFECTIN ™), DNA conjugates, anhydrous absorption pastes, oil emulsions in water and water in oil, Carbowax emulsions (polyethylene glycols of various molecular weights), semisolid gels and semisolid mixtures containing Carbowax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52: 238-311.

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

A pharmaceutical composition for use in the present invention can be administered subcutaneously or intravenously with a standard needle and syringe. Furthermore, with respect to subcutaneous administration, a pen delivery device easily has applications in administering a pharmaceutical composition for use in the present invention. Such a pen delivery device can be reusable or disposable. A reusable pen delivery device generally uses a replaceable cartridge that contains a pharmaceutical composition. Once all of the pharmaceutical composition has been delivered into the cartridge and the cartridge is empty, the empty cartridge can easily be disposed of and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device can then be reused. In a disposable pen delivery device, there is no replaceable cartridge. Instead, the disposable pen delivery device comes pre-filled with the pharmaceutical composition contained in a reservoir within the device. Once the pharmaceutical composition reservoir is emptied, the entire device is discarded.

Numerous reusable pen and autoinjector delivery devices have applications in the subcutaneous administration of a pharmaceutical composition for use in the present invention. Examples include, but are not limited to, AUTOPEN ™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC ™ pen (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX 75/25 ™ pen, HUMALOG ™ pen, HUMALIN 70/30 ™ (Eli Lilly and Co., Indianapolis, iN), No VOp EN ™ I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR ™ (Novo Nordisk, Copenhagen, Denmark), BD ™ pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN ™, OPTIp En PRO ™, OPTIPEN STARLET ™ and OPTICLIK ™ (Sanofi-aventis, Frankfurt, Germany), to name just a few. Examples of disposable pen delivery devices that have applications in the subcutaneous administration of a pharmaceutical composition for use in the present invention include, but are not limited to, SOLOSTAR ™ (Sanofi-aventis), FLEXPEN ™ (Novo Nordisk) and KWIKPEN ™ (Eli Lilly), SURECLICK ™ autoinjector (Amgen, Thousand Oaks, cA), PENLET ™ (Haselmeier, Stuttgart, Germany), Ep IPEN (Dey, LP), and the HUMIRA ™ pen (Abbott Labs, Abbott Park IL), to name just a few.

In certain situations, the pharmaceutical composition can be administered in a controlled release system. In one embodiment, a pump can 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 (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, a controlled release system can be placed in close proximity to the composition target, thus requiring only a fraction of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, above , vol. 2, pp. 115-138). Other controlled release systems are discussed in the review by Langer, 1990, Science 249: 1527-1533.

Injectable preparations may include dosage forms for intravenous, subcutaneous, intracutaneous and intramuscular injections, drip infusions, etc. These injectable preparations can be prepared by known methods. For example, injectable preparations can be prepared, for example, by dissolving, suspending or emulsifying the antibody or its salt described above in a sterile aqueous medium or an oily medium conventionally used for injections. As the aqueous medium for injections there are, for example, physiological saline solution, an isotonic solution containing glucose and other auxiliary agents, etc., which can be used in combination with an appropriate solubilizing agent such as an alcohol (for example, ethanol), a polyalcohol (eg, propylene glycol, polyethylene glycol), a nonionic surfactant [eg, polysorbate 80, HCO-50 (hydrogenated castor oil polyoxyethylene (50 mole) adduct)], etc. As the oil medium, for example, sesame oil, soybean oil, etc. are employed, which can be used in combination with a solubilizing agent such as benzyl benzoate, benzyl alcohol, etc. The injection thus prepared is preferably filled into an appropriate ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteral use described above are prepared in pharmaceutical forms in a unit dose suitable to adjust to a dose of the active principles. Such dosage unit dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, etc.

Exemplary pharmaceutical formulations comprising an anti-PCSK9 antibody that can be used in the context of pharmaceutical compositions for use in the present invention are set forth, for example, in US patent application publication. 2013/0189277.

Dosage

The amount of an anti-PCSK9 antibody or antigen-binding fragment thereof administered to a patient in accordance with pharmaceutical compositions for use in the present invention is, in general, a therapeutically effective amount. As used herein, the term "therapeutically effective amount" means a dose of an anti-PCSK9 antibody or antigen-binding fragment thereof that 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 from baseline) in one or more parameters selected from the group consisting of LDL-C, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, Lp (a), and remaining cholesterol.

For an anti-PCSK9 antibody, a therapeutically effective amount can be from about 0.05 mg to about 600 mg, eg, about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, about 10 mg, about 20 mg, about 30 mg, about 40 mg, about 50 mg, about 60 mg, about 70 mg, about 75 mg, about 80 mg, about 90 mg, about 100 mg, about 110 mg, about 120 mg, about 130 mg, about 140 mg, about 150 mg, about 160 mg, about 170 mg, about 180 mg, about 190 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 310 mg, about 320 mg, about 330 mg, about 340 mg, about 350 mg, about 360 mg, about 370 mg, about 380 mg, about 390 mg, about 400 mg, about 410 mg, about 420 mg, about 430 mg, about 440 mg, about 450 mg, about 460 mg, about 470 mg, about 480 mg, about 490 mg, about 500 mg, about 510 mg, about 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 the anti-PCSK9 antibody. In certain embodiments, the therapeutically effective amount is 75 mg of the anti-PCSK9 antibody. In certain embodiments, the therapeutically effective amount is 150 mg of the anti-PCSK9 antibody.

The amount of anti-PCSK9 antibody contained within individual doses can be expressed in terms of milligrams of antibody per kilogram of the patient's body weight (ie, mg / kg). For example, the anti-PCSK9 antibody can be administered to a patient at a dose of from about 0.0001 to about 10 mg / kg of the patient's body weight.

Combination therapies

According to certain embodiments of the present invention, one or more non-statin lipid modifying therapies may be administered to the patient in combination with pharmaceutical compositions for use comprising an anti-PCSK9 antibody or antigen-binding fragment thereof. Examples of such non-statin lipid modifying therapies include, for example, (1) an agent that inhibits cholesterol absorption inhibitors (eg, ezetimibe); (2) an agent that increases the catabolism of lipoproteins (such as nicotinic acid, which includes niacin and slow-release niazines); (3) fibric acid, (4) a bile acid sequestrant, and / or (5) an activator of the LXR transcription factor that plays a role in the removal of cholesterol (such as 22-hydroxycholesterol).

Administration regimes

According to certain embodiments of the present invention, multiple doses of an anti-PCSK9 antibody or antigen-binding fragment thereof may be administered to a patient (i.e., a pharmaceutical composition for use comprising an anti-PCSK9 antibody or antigen-binding fragment thereof) during a defined time course (eg, in lieu of a daily therapeutic statin regimen). Pharmaceutical compositions for use according to this aspect of the invention comprise sequentially administering multiple doses of an anti-PCSK9 antibody or antigen-binding fragment thereof to a patient. As used herein, "administer sequentially" means that each dose of anti-PCSK9 antibody or antigen-binding fragment thereof is administered to the patient at a different point in time, for example, on different days separated by a predetermined interval (for example, hours, days, weeks, or months). The present invention includes pharmaceutical compositions for use which comprise sequentially administering to the patient a single initial dose of an anti-PCSK9 antibody or antigen-binding fragment thereof, followed by one or more secondary doses of the anti-PCSK9 antibody or fragment of antigen-binding thereof, and optionally followed by one or more tertiary doses of the anti-PCSK9 antibody or antigen-binding fragment thereof.

The terms "initial dose", "secondary dose" and "tertiary dose" refer to the sequence of temporary administration of individual doses of a pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding fragment thereof. Thus, the "starting dose" is the dose given at the beginning of the treatment regimen (also called the "starting level dose"); "Secondary doses" are the doses given after the initial dose; and "tertiary doses" are the doses that are administered after the secondary doses. The initial, secondary and tertiary doses may all contain the same amount of the anti-PCSK9 antibody or antigen-binding fragment thereof, but, in general, they can be differentiated from each other in terms of frequency of administration. In certain embodiments, however, the amount of anti-PCSK9 antibody or antigen-binding fragment of the same content in the initial, secondary, and / or tertiary doses varies from one another (eg, adjusted up or down as appropriate) during the course of treatment. In certain embodiments, two or more doses (eg, 2, 3, 4, or 5) are administered at the beginning of the treatment regimen as a "loading dose", followed by subsequent doses that are administered on a less frequent basis (eg , "maintenance dose").

According to exemplary embodiments of the present invention, each secondary and / or tertiary dose is administered 1 to 26 (eg, 1, 1 /, 2, 2 /, 3, 31/2, 4, 41/2, 5, 51/2, 6, 61/2, 7, 71/2, 8, 81/2, 9, 91/2, 10, 101/2, 11, 111/2, 12, 121/2, 13, 131/2, 14, 14 /, 15, 15 /, 16, 16 /, 17, 17 /, 18, 18 /, 19, 19 /, 20, 20 /, 21, 21 /, 22, 22 /, 23 , 23 /, 24, 24 /, 25, 25 /, 26, 26 /, or more) weeks after the immediately preceding dose. The term "immediately preceding dose", as used herein, means, in a sequence of multiple administrations, the dose of antigen-binding molecule that is administered to a patient prior to administration of the next dose in the sequence without intermediate doses.

The pharmaceutical composition for use according to this aspect of the invention may comprise administering to a patient any number of secondary and / or tertiary doses of an anti-PCSK9 antibody or antigen-binding fragment thereof. For example, in certain embodiments, only a single secondary dose is administered to the patient. In other embodiments, two or more (eg, 2, 3, 4, 5, 6, 7, 8, or more) secondary doses are administered to the patient. Also, in certain embodiments, only a single 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 involving multiple secondary doses, each secondary dose can be administered at the same frequency as the other secondary doses. For example, each secondary dose can be administered to the patient 1 to 2, 4, 6, 8, or more weeks after the immediately preceding dose. Similarly, in embodiments involving multiple tertiary doses, each tertiary dose can be administered at the same frequency as the other tertiary doses. For example, each tertiary dose can be administered to the patient 1 to 2, 4, 6, 8, or more weeks after the immediately preceding dose. Alternatively, the frequency at which secondary and / or tertiary doses are administered to a patient may vary over the course of the treatment regimen. The frequency of administration can also be adjusted during the course of treatment by a physician depending on the needs of the individual patient following the clinical examination.

According to certain embodiments of the present invention, multiple doses of a pharmaceutical composition comprising about 75 mg of anti-PCSK9 antibody are administered to a patient at a frequency of once every two weeks.

According to certain embodiments of the present invention, multiple doses of a pharmaceutical composition comprising about 150 mg of anti-PCSK9 antibody are administered to a patient at a frequency of once every two weeks.

According to certain embodiments of the present invention, multiple doses of a pharmaceutical composition comprising about 75 mg of anti-PCSK9 antibody are administered to a patient at a frequency of once every four weeks.

According to certain embodiments of the present invention, multiple doses of a pharmaceutical composition comprising about 150 mg of anti-PCSK9 antibody are administered to a patient at a frequency of once every four weeks.

The present invention includes administration regimens comprising an option of upward adjustment of the dose (also referred to herein as "dose modification"). As used herein, an "up-titration option" means that, after receiving a particular number of doses of an anti-PCSK9 antibody, if a patient has not achieved a specified reduction by one or more defined therapeutic parameters, the dose of the anti-PCSK9 antibody or antigen-binding fragment thereof is increased from here on. For example, in the case of a therapeutic regimen comprising the administration of 75 mg doses of an anti-PCSK9 antibody to a patient at a frequency of once every two weeks, if after 8 weeks (i.e. 5 doses administered at Week 0, Week 2 and Week 4, Week 6 and Week 8), the patient has not reached a serum LDL-C concentration below 70 mg / dL, then the dose of anti-PCSK9 antibody is increased to, for example 150 mg given once every two weeks thereafter (for example, starting at Week 10 or Week 12, or after).

In certain embodiments, the anti-PCSK9 antibody is administered to a patient at a dose of about 75 mg every two weeks, for example for at least three doses.

In certain embodiments, the anti-PCSK9 antibody is administered to a patient at a dose of about 150 mg every two weeks, for example for at least three doses.

In some embodiments, the antibody is administered to a patient at a dose of approximately 75 mg every two weeks for 12 weeks, and the dose remains at 75 mg every two weeks if, at Week 8, the LDL-C value of the patient was less than 100 mg / dL and a 30% reduction in LDL-C.

In other embodiments, the antibody is administered to a patient at a dose of about 75 mg every two weeks for 12 weeks, and the dose is adjusted up to about 150 mg every two weeks if, at Week 8, the value of The patient's LDL-C was greater than or equal to 100 mg / dL.

In some embodiments, the antibody is administered to a patient at a dose of approximately 75 mg every two weeks for 12 weeks, and the dose remains at 75 mg every two weeks if, at Week 8, the LDL-C value of the patient was less than 70 mg / dL and a 30% reduction in LDL-C.

In another embodiment, the antibody is administered to a patient at a dose of about 300 mg every four weeks.

In a further embodiment, the antibody is administered to a patient at a dose of approximately 300 mg every four weeks for a total of three doses, and the dose is changed up to 150 mg every two weeks for another 36 weeks if, at Week 8 , the patient did not reach a predetermined treatment goal, or the patient did not have at least a 30% reduction in LDL-C from baseline.

In certain embodiments, the anti-PCSK9 antibody is administered to a patient at a dose of about 150 mg every four weeks for at least three doses.

In some embodiments, the antibody is administered to a patient at a dose of approximately 150 mg every four weeks for 12 weeks, and the dose remains at 150 mg every four weeks if, at Week 8, the LDL-C value of the patient was less than 100 mg / dL and a 30% reduction in LDL-C.

In other embodiments, the antibody is administered to a patient at a dose of about 150 mg every four weeks for 12 weeks, and the dose is adjusted upward to about 300 mg every two weeks if, at Week 8, the value The patient's LDL-C was greater than or equal to 100 mg / dL.

In some embodiments, the antibody is administered to a patient at a dose of approximately 150 mg every four weeks for 12 weeks, and the dose remains at 150 mg every four weeks for another 12 weeks if, at Week 8, the value The patient's LDL-C was less than 70 mg / dL and a 30% reduction in LDL-C.

In another embodiment, the antibody is administered to a patient at a dose of about 300 mg every four weeks.

In a further embodiment, the antibody is administered to a patient at a dose of approximately 300 mg every four weeks for a total of three doses, and the dose is changed up to 150 mg every two weeks for another 36 weeks if, at Week 8 , the patient did not reach a predetermined treatment goal, or the patient did not have at least a 30% reduction in LDL-C from baseline.

Examples

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

Example 1. Generation of human antibodies against human PCSK9

Human anti-PCSK9 antibodies were generated as described in US Patent No. 8,062,640. The exemplary anti-PCSK9 anti body used in the following example is the human anti-PCSK9 antibody designated "mAb316P", also known as "REGN727", or "alirocumab". mAb316P has the following amino acid sequence characteristics: a heavy chain comprising SEQ ID NO: 5 and a light chain comprising SEQ ID NO: 9; a heavy chain variable region (HCVR) comprising SEQ ID NO: 1 and a light chain variable domain (LCVR) comprising SEQ ID NO: 6; a heavy chain complementarity determining region 1 (HCDR1) comprising SEQ ID NO: 2, an HCDR2 comprising SEQ ID NO: 3, an HCDR3 comprising SEQ ID NO: 4, a complementarity determining region 1 of the light chain (LCDR1) comprising SEQ ID NO: 7, an LCDR2 comprising SEQ ID NO: 8 and an LCDR3 comprising SEQ ID NO: 10.

Example 2: Monotherapy with an anti-PCSK9 antibody ("mAb316P") against ezetimibe in patients with hypercholesterolemia: Results of a 24-week, double-blind, randomized, phase 3 trial

BACKGROUND

Hypercholesterolemia, particularly an increase in low-density lipoprotein cholesterol (LDL-C) levels, constitutes a significant risk for the development of atherosclerosis and CHD, the leading cause of death and disability in the Western world. LDL-C is identified as the primary target of cholesterol-lowering therapy and is accepted as a valid surrogate endpoint. Numerous studies have shown that reducing LDL-C levels mainly by inhibiting 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMG CoA) with statin, reduces the risk of CHD, with a strong direct relationship between the levels LDL-C and ECC events; For every 1 mmol / L (~ 40 mg / dL) reduction in LDL-C, mortality and morbidity from cardiovascular disease (CVD) is reduced by 22%.

Three phase 1 studies with mAb316P have been performed and the safety, tolerability, and PK / PD profile were evaluated. Two single-dose administration studies (one study with IV administration of doses from 0.3 mg to 12 mg / kg and another study with SC administration of doses from 50 mg to 250 mg) were performed in healthy subjects with LDL-C> 100 mg / dL for whom statin therapy was not indicated. The third study was conducted in hypercholesterolemic patients (familial or non-familial) with single to multiple SC administration of 50 mg, 100 mg, 150 mg and 200 mg, either as a complement to stable doses of atorvastatin from 10 mg to 40 mg / day or as monotherapy.

The results of these phase 1 studies showed that mAb316P administered to healthy subjects and patients by either IV or SC administration was generally well tolerated at all doses; treatment emergent adverse events (TEAEs) did not show a dose relationship. No drug-related pattern of adverse events (AEs) was identified. In all these phase 1 studies, administration of mAb316P induced rapid, substantial, and sustained reductions from baseline in LDL-C, up to 60%. The magnitude and duration of these reductions were positively related to the administered dose. It should also be noted that in the third study, the results were similar in patients with familial and non-familial hypercholesterolemia. Overall, a total of 109 subjects were exposed to at least 1 dose of mAb316P in these 3 phase 1 studies.

Three phase 2 studies have also been conducted. The results of these studies have been previously reported.

INTRODUCTION

In the present example, a phase 3 clinical trial was conducted to evaluate the efficacy and safety of mAb316P when administered as a monotherapy.

The objective of this study was to provide information on the magnitude of effect and safety profile when the investigational product mAb316P is used as monotherapy. It is important to obtain data on the unique efficacy and safety of mAb316P to put into perspective with data obtained when using a statin supplement.

Another objective of this study was to provide monotherapy data to support the evaluation of mAb316P in statin intolerant patients. Current LDL-C-lowering medications that can be used as monotherapy when statins are considered inappropriate or not tolerated include ezetimibe, niacin, and bile acid sequestrants. The options that could be used in monotherapy are associated with an approximate 20% reduction in LDL-C.

The control arm that was selected for this study was ezetimibe 10 mg PO per day. This allowed for a study comparing mAb316P with a treatment option (ie, ezetimibe) that is available in routine clinical practice.

This specific study was carried out to demonstrate in patients with moderate CV risk and with LDL-C between 100 mg / dL (2.59 mmol / L) and 190 mg / dL (4.9 mmol / L) that mAb316P 75 mg and / or 150 mg Q2W as monotherapy caused a statistically significant and clinically significant reduction in LDL-C compared to ezetimibe.

Study population

The study population for the monotherapy study was patients with LDL-C between 100 mg / dL (2.59 mmol / L) and 190 mg / dL (4.9 mmol / L).

This study included patients with moderate CV risk, as defined by a 10-year risk of CVD death> 1% and <5% based on the SCORE chart, and no established CHD or CHD risk equivalents. Risk charts such as SCORE are intended to facilitate risk estimation in apparently healthy individuals without signs of clinical or preclinical disease. SCORE measures the 10-year risk of CV death based on total cholesterol, age, sex, smoker, and systolic BP. This level of risk was considered appropriate in the context of a monotherapy study with an active non-statin comparator.

The sample size of 100 patients (50 patients per group) with a double-blind study treatment duration of 24 weeks was planned to detect a 20% treatment difference in means of the percentage change in LDL-C from the level baseline until Week 24, with a bilateral significance level of 0.05 and assuming a common SD of 25% and 5% of non-evaluable primary endpoint.

Selecting the dose

All patients were initially treated with 75 mg Q2W, and only patients whose LDL-C levels remained equal to or greater than 100 mg / dL after 8 weeks of treatment had the dose adjusted up to 150 mg Q2W in Week 12 onwards.

The dose selection, the frequency of administration, and the up-titration approach are based on the reduction in LDL-C necessary to provide the best benefit in terms of reduction of CV disease, and possible safety considerations regarding low values. of LDL-C. Based on the results of the 2 dose-finding studies, the Q2W regimen is expected to maintain a constant LDL-C reduction throughout the dose interval, with maximum efficacy at 12 weeks provided by the 150 mg dose. Q2W. However, for many patients, the magnitude of the effects seen with the 150 mg Q2W dose may not be necessary to achieve the target LDL-C goal, and a lower dose can be started. Using a dose response model, 75 mg Q2W was selected to provide approximately 50% decrease in LDL-C from baseline: all patients were initially treated with 75 mg Q2W, and only in patients whose C- LDL remains equal to or greater than 100 mg / dL after 8 weeks of treatment, the dose was adjusted upwards to 150 mg Q2W (at Week 12). With this treatment regimen, the majority of patients with primary hypercholesterolemia were expected to achieve their target LDL-C level, with some patients reaching a level below 25 mg / dL.

Preliminary PK data from phase 2 studies showed that mAb316P exposure decreased during the 8-week follow-up period following the double-blind treatment period, with total serum concentrations of mAb316P still detectable, but at very low levels. . Therefore, to ensure sufficiently low ineffective serum mAb316P concentrations, patients were followed for a follow-up period of 8 weeks (ie, 10 weeks after the last dose). The pharmacokinetic results in this trial are important since there is no history of statins to attenuate the effect of mAb316P.

OBJECTIVES OF THE STUDY

The primary objective of the monotherapy study was to demonstrate the reduction of low-density lipoprotein cholesterol (LDL-C) by mAb316P every 2 weeks (Q2W) as monotherapy compared to ezetimibe (EZE) 10 mg daily after 24 weeks of treatment in patients with hypercholesterolemia at moderate cardiovascular (CV) risk.

The secondary objectives of the monotherapy study were as follows. (1) To evaluate the effect of mAb316P 75 mg compared to EZE on LDL-C after 12 weeks of treatment. (2) To evaluate the effect of mAb316P on other lipid parameters (i.e. Apo B, non-HDL C, total C, Lp (a), HDL-C, TG levels, and Apo A-1 levels). (3) To evaluate the safety and tolerability of mAb316P. (4) To evaluate the development of anti-mAb316P antibodies. (5) To evaluate the pharmacokinetics (PK) of mAb316P.

STUDY DESIGN

This was a randomized, double-blind, parallel-group, double-dummy, ezetimibe-controlled, balanced (1: 1, mAb316P: ezetimibe), multicenter, multinational study to evaluate the efficacy and safety of mAb316P in patients with hypercholesterolemia and a 10-year risk score (SCORE) 21% and <5%. Randomization was stratified according to DM status. After randomization, patients received double-blind study treatment (or mAb316P or placebo) every 2 weeks and ezetimibe or placebo for ezetimibe PO daily for a period of 24 weeks. Upward dose adjustment may also occur at Week 12 depending on LDL-C levels at Week 8 for patients randomized to mAb316P. Patients were followed for 8 weeks after the last visit of the double-blind treatment period (DBTP). The study design is shown in Figure 1.

Protocol description

The study consisted of 3 periods: screening, double-blind treatment, and follow-up.

Screening period - up to 2 weeks in length that includes an intermediate visit during which the patient (or other designated person such as spouse, relative, etc.) received training to self-inject / inject with placebo for mAb316P. Eligibility assessments were performed to allow for randomization of patients in the study. The investigators had the option of providing a second placebo training kit for mAb316P for patients who required additional self-injection training prior to the randomization visit. The patient or researcher could choose to have the patient inject at home or at the study site.

Double-blind treatment period (DBTP) - A 24-week randomized double-blind double-dummy study treatment period. The first injection during the double-blind period was made at the site on the day of randomization (Week 0 [D1] - V3) and as soon as possible after the call to the IVRS / IWRS for randomization in the study. Subsequent injections were made by the patient (self-injection) or another designated person (such as spouse, relative, etc.) at a location preferred by the patient (home, etc.). Patients randomized to mAb316P received a 75 mg dose of mAb316P from randomization (V3) through Week 12 (V6) (i.e. Weeks 0, 2, 4, 6, 8, and 10) placebo for ezetimibe PO daily. At the Week 12 visit (V6) these patients, in a blinded mode, or: (1) continued mAb316P 75 mg every 2 weeks (from Week 12 onwards until the last injection at Week 22), if the LDL-C at Week 8 was <100 mg / dL (1.81 mmol / L), or (2) dose titration up to mAb316P 150 mg every 2 weeks (from Week 12 onwards until the last injection at Week 22), if the Week 8 LDL-C was 2,100 mg / dL (1.81 mmol / L). Patients randomized to ezetimibe received placebo of mAb316P injected every 2 weeks with ezetimibe 10 mg PO daily from randomization (V3) to week 24 (V8).

Follow-up period - A period of 8 weeks after the end of the double-blind treatment period.

Duration of study participation

Study duration included a screening period of up to 2 weeks, a 24-week double-blind treatment period for efficacy and safety evaluation, and an 8-week post-treatment follow-up period for all patients after treatment. last visit of the DBTP. Thus, the duration of the study per patient was approximately 34 weeks.

PATIENT SELECTION

The target population for this study was patients with hypercholesterolemia at moderate cardiovascular (CV) risk defined with a 10-year risk score> 1% and <5%, based on the Systemic Coronary Risk Estimate (SCORE), and included a signed written informed consent.

Patients who met all of the above inclusion criteria were selected for the following exclusion criteria, which were classified and numbered in the following 3 subsections:

A. Exclusion criteria related to the study methodology

1. LDL-C <100 mg / dL or> 190 mg / dL (<2.59 mmol / L or> 4.9 mmol / L, respectively) at Week -2 (selection, V1).

2. Background of established CCP or CCP risk equivalents as defined as: (A). Documented history of CHD (includes one or more of the following): (1) Acute myocardial infarction (MI); (2) Silent IM; (3) Unstable angina; (4) Coronary artery bypass graft procedure (eg, percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]); (5) Clinically significant CHD diagnosed by invasive or non-invasive test (such as coronary angiography, stress test using treadmill, stress echocardiography, or nuclear magnetic resonance imaging) (B) Risk equivalents of CHD include manifestations Clinics of non-choronic forms of atherosclerotic disease: (1) Symptomatic peripheral arterial disease; (2) Aneurysm of the abdominal aorta; or (3) Transient ischemic attacks or ischemic stroke and "clinically significant carotid artery obstruction by invasive or non-invasive testing (such as angiography or ultrasound)."

3. Patients with DM associated with a risk SCORE> 5% or with any additional risk factor (as listed below): (1) documented history of ankle-brachial index <0.90; (2) in the presence of documented microalbuminuria or macroalbuminuria (30) or urine dipstick tests at the screening visit (Week -2) with> 2+ protein; or (3) a documented history of preproliferative or proliferative retinopathy or laser treatment for retinopathy.

4. Use of a statin, nicotinic acid, a bile acid binding sequestrant, an intestinal cholesterol absorption blocker (ICA) (ie, ezetimibe), or omega-3 fatty acids at doses> 1000 mg daily in he within 4 weeks from the screening visit (Week -2, V1) or between screening and randomization visits.

5. Use of a fibrate within 6 weeks of the screening visit (Week -2, V1) or between screening and randomization visits.

6. Use of nutraceutical products or over-the-counter therapies that may affect lipids that have not been in a stable dose / amount for at least 4 weeks prior to the screening visit (Week -2) or between screening and screening visits. randomization

7. Use of red yeast rice products within 4 weeks of screening visit (Week -2) or between screening and randomization visits.

8. Plan to undergo scheduled PCI, CABG, carotid or peripheral revascularization during the study.

9. Systolic blood pressure (BP)> 160 mmHg or diastolic BP> 100 mmHg at screening visits (Week -2, V1) or randomization (Week 0).

10. History of New York Heart Association (NYHA) Class III or IV heart failure within the past 12 months.

11. Known history of hemorrhagic stroke

12. Age <18 years or legal age of majority at the screening visit (Week -2), whichever is older.

13. Patients not previously informed about a low cholesterol diet before the screening visit (Week -2)

14. Diabetes newly diagnosed (within 3 months before randomization visit [Week 0]) or poorly controlled (HbA1 c> 8.5% at screening visit [Week -2])

15. Presence of any clinically significant uncontrolled endocrine disease known to influence serum lipids or lipoproteins. Note: Patients can be enrolled in thyroid replacement therapy if the dosage has been stable for at least 12 weeks prior to screening and the TSH level is within the normal range of the Central Laboratory at the screening visit.

16. History of bariatric surgery within 12 months prior to screening visit (Week -2) 17. Unstable weight defined by> 5 kg variation within 2 months prior to screening visit (Week -2 )

18. Known history of homozygous or heterozygous familial hypercholesterolemia

19. Known history of PCSK9 loss of function (ie gene mutation or sequence variation)

20. Use of systemic corticosteroids, unless used as replacement therapy for pituitary-adrenal disease with a stable regimen for at least 6 weeks prior to the randomization visit (Week 0). Note: Topical, intra-articular, nasal, inhaled, and ophthalmic steroid therapies are not considered 'systemic' and are allowed.

21. Use of continuous estrogen or testosterone hormone replacement therapy unless the regimen has been stable in the last 6 weeks prior to the screening visit (Week -2) and with no plans to change the regimen during the study.

22. History of cancer within the last 5 years, except adequately treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ

23. Known history of HIV positivity

24. Patient who has taken any investigational drug other than mAb316P placebo training kits within 1 month or 5 half-lives, whichever is longer

25. Patient who has previously participated in a clinical trial of mAb316P or any other anti-PCSK9 therapy.

26. Patient who withdraws consent during the selection period (patient who does not wish to continue or does not return).

27. Conditions / situations such as: (1) Any clinically significant abnormality identified in the timing of selection that, in the discretion of the investigator or any collaborating investigator, would prevent the safe termination of the study or restrict the assessment of endpoints such as major systemic diseases, patients with a short life expectancy; or (2) patients deemed by the investigator or any collaborating investigator as inappropriate for this study for any reason, for example: (a) deemed unable to meet specific protocol requirements, such as scheduled visits; (b) deemed unable to administer or tolerate long-term injections according to the patient or investigator; (c) researcher or any collaborating researcher, pharmacist, study coordinator, other study personnel or relatives directly involved in carrying out the protocol, etc .; or (d) presence of any other condition (eg, geographic, social), both current and anticipated, that the investigator feels would restrict or limit the patient's participation for the duration of the study.

28. Laboratory data during the selection period (which does not include randomization laboratories at Week 0): (1) Positive test for hepatitis B surface antigen or hepatitis C antibody (confirmed by reflex testing); (2) Positive for beta-hCG in serum or urine pregnancy test (including Week 0) in women of childbearing potential; (3) Triglycerides> 400 mg / dL (> 4.52 mmol / L) (1 repeat lab is allowed); (4) eGFR <60 ml / min / 1.73 m2 according to the equation of the MDRD Study of 4 variables (calculated by the central laboratory); (5) ALT or AST> 3 x ULN (1 repeat lab allowed); (6) CPK> 3 x ULN (1 repeat laboratory allowed); or (7) TSH <LLN or> ULN.

B. Exclusion criteria related to background therapy

29. All contraindications to the active comparator (ezetimibe) or warning / precaution for use (when appropriate) as presented in the respective national product labeling.

C. Exclusion criteria related to mAb316P

30. Known hypersensitivity to monoclonal antibody therapeutics

31. Pregnant or lactating women

32. Women of childbearing potential without effective contraceptive method of birth control and / or who are unwilling or unable to take a pregnancy test

Note: Women of childbearing potential must have a confirmed negative pregnancy test at screening and randomization visits. They must use effective contraception throughout the study, and agree to repeat the urine pregnancy test at designated visits. The contraceptive methods applied have to meet the criteria for a highly effective method of birth control according to the Note for Guidance on Non-clinical Safety Studies for Human Clinical Trials and the Marketing Authorization of Pharmaceutical Products. Postmenopausal women must be amenorrheic for at least 12 months.

STUDY TREATMENTS

Pharmaceutical specialty in research (IMP) and administration

Sterile mAb316P drug was delivered at a concentration of 75 mg / mL and 150 mg / mL both as 1 mL volume in an autoinjector. Sterile placebo for mAb316P was prepared in the same formulation as mAb316P without the addition of protein as 1 mL volume in an autoinjector.

Ezetimibe 10 mg over-encapsulated tablets. Placebo for ezetimibe capsules.

The IMP of mAb316P could be administered by self-injection or by another designated person (such as a spouse, relative, etc.). The used autoinjector was discarded in a sharps container provided to patients.

Patients were asked to store mAb316P IMP in a refrigerator. Before administration, the IMP had to be taken out in a safe location at room temperature for approximately 30 to 40 minutes. From here on, the IMP should be administered as soon as possible.

During the double-blind treatment period, mAb316P or placebo for mAb316P was administered subcutaneously every 2 weeks, starting at Week 0 continuing until the last injection (Week 22) 2 weeks before the end of the double-blind treatment period. .

IMP injection of mAb316P was ideally administered every 2 weeks subcutaneously at approximately the same time of day; however, it was acceptable to have a window period of ± 3 days.

Ezetimibe 10 mg or placebo for ezetimibe capsules were taken orally once a day at approximately the same time of day, with or without food.

STUDY ASSESSMENT CRITERIA

Primary efficacy endpoint

The primary efficacy endpoint was the percent change in LDL-C calculated from baseline to Week 24, defined as: 100 x (LDL-C value calculated at Week 24 - LDL-C value calculated at baseline) / LDL-C value calculated at baseline.

The LDL-C value calculated at baseline was the last LDL-C level obtained before the first double-blind IMP, defined as the earliest between the first double-blind injection date and the first capsule ingestion.

The calculated LDL-C at Week 24 was the LDL-C level obtained within the Week 24 time window and during the main efficacy period. The primary efficacy period was defined as the time from the first double-blind IMP to 21 days after the last double-blind IMP injection or to the upper limit of the Week 24 analysis window, whichever came first.

All calculated LDL-C values (scheduled or unscheduled, fasting or non-fasting) can be used to provide a value for the primary efficacy endpoint if appropriate as defined above. Secondary efficacy endpoint

Key secondary efficacy criteria

(1) The percentage change in LDL-C calculated from baseline to Week 12: definition and rules similar to before, except that the LDL-C calculated at Week 12 was at the LDL-C level obtained within from the Week 12 analysis window and during the 12 week efficacy period. The 12-week efficacy period was defined as the time from the first double-blind IMP to the IVRS re-supply contact at Visit 6 or up to 21 days after the last double-blind IMP injection, whichever is first. . The blood sample collected on the day of the IVRS re-supply contact from Visit 6 was considered as prior to assessment.

(2) The percentage change in Apo B from baseline to Week 24. Same definition and rules as for primary endpoint.

(3) The percent change in non-HDL C from baseline through Week 24. Same definition and rules as for primary endpoint.

(4) The percent change in total C from baseline to Week 24. Same definition and rules as for primary endpoint.

(5) The percentage change in Apo B from baseline to Week 12. Same definition and rules as for the percentage change in LDL-C calculated from baseline to Week 12.

(6) The percentage change in non-HDL-C from baseline to Week 12. Same definition and rules as for percent change in LDL-C calculated from baseline to Week 12.

(7) The percentage change in total C from baseline to Week 12. Same definition and rules as for percent change in LDL-C calculated from baseline to Week 12.

(8) Proportion of patients achieving target LDL-C <100 mg / dL (2.59 mmol / L) at Week 24, using definition and rules used for primary endpoint.

(9) Proportion of patients achieving target LDL-C <70 mg / dL (1.81 mmol / L) at Week 24, using the definition and rules used for the primary endpoint.

(10) The percentage change in Lp (a) from baseline to Week 24. Same definition and rules as for primary endpoint.

(11) The percent change in HDL-C from baseline to Week 24. Same definition and rules as for primary endpoint.

(12) The percent change in HDL-C from baseline to Week 12. Same definition and rules as for percent change in LDL-C calculated from baseline to Week 12.

(13) The percent change in Lp (a) from baseline to Week 12. Same definition and rules as for percent change in LDL-C calculated from baseline to Week 12.

(14) The percent change in fasting TG from baseline to Week 24. Same definition and rules as for primary endpoint.

(15) The percentage change in fasting TG from baseline to Week 12. Same definition and rules as for percent change in LDL-C calculated from baseline to Week 12.

(16) The percentage change in Apo A-1 from baseline to Week 24. Same definition and rules as for primary endpoint.

(17) The percentage change in Apo A-1 from baseline to Week 12. Same definition and rules as for percentage change in LDL-C calculated from baseline to Week 12.

Other secondary efficacy endpoints

(18) The proportion of patients achieving LDL-C <100 mg / dL (2.59 mmol / L) at Week 12.

(19) The proportion of patients achieving LDL-C <70 mg / dL (1.81 mmol / L) at Week 12.

(20) The absolute change in LDL-C (mg / dL and mmol / L) from baseline through Weeks 12 and 24.

(21) The change in Apo B / Apo A-1 ratio from baseline to Weeks 12 to Week 24.

(22) The proportion of patients with Apo B <80 mg / dL (0.8 g / L) at Week 12 and Week 24.

(23) The proportion of patients with non-HDL C <100 mg / dL (2.59 mmol / L) at Weeks 12 and 24.

(24) The proportion of patients with LDL-C <70 mg / dL (1.81 mmol / L) and / or? 50% reduction in LDL-C (if LdL-C? 70 mg / dL [1.81 mmol / L]) at Weeks 12 and 24.

Efficacy evaluation method

Lipid parameters

Total C, HDL-C, TG, Apo B, Apo A-1 and Lp (a) were directly measured. LDL-C was calculated using Friedewald's formula at all visits (except Week -1 and the follow-up visit). If TG values exceeded 400 mg / dL (4.52 mmol / L), then the central laboratory reflexively measured (using the beta quantification method) LDL-C instead of calculating it. HDL-C was not calculated by subtracting HDL-C from total C. The Apo B / Apo A-1 ratio was calculated. Safety Assessment Criteria - Observation Period

The observation of safety data was as follows:

PRE-TREATMENT period: The PRE-TREATMENT observation period was defined from the signed informed consent until the first dose of double-blind IMP.

TEAE period: The TEAE observation period was defined as the time from the first double-blind IMP dose to the last double-blind IMP injection dose 70 days (10 weeks) as the residual effect of mAb316P is expected. up to 10 weeks after stopping double-blind IMP injection.

POST-TREATMENT period: The POST-TREATMENT observation period was defined as the time from the day after the end of the TEAE period to the end of the study

Safety Assessment Criteria - Laboratory Safety

Clinical laboratory data consisted of urinalysis and blood tests, hematology (RBC count, red blood cell distribution width (RDW), reticulocyte count, hemoglobin, hematocrit, platelets, WBC count with leukocyte formula), standard chemistry (glucose, sodium, potassium, chloride, bicarbonate, calcium, phosphorous, urea nitrogen, creatinine, uric acid, total protein, LDH, albumin, Y-glutamyltransferase [yGT]), hepatitis C antibody, liver panel ( ALT, AST, ALP and total bilirubin) and CPK.

Safety evaluation criteria - Measurement of vital signs: Vital signs included: HR, systolic and diastolic BP while sitting.

Other evaluation criteria for anti-mAb316P antibody evaluations: Anti-mAb316P antibodies included antibody status (positive / negative) and antibody titers.

Sampling time: Serum samples were collected periodically for the determination of anti-imAb316P antibodies throughout the study. The first sample scheduled at the randomization visit was obtained prior to IMP injection (predose).

Patients who have a titer of 240 or higher for anti-mAb316P antibody at the follow-up visit presented additional antibody sample (s) 6 to 12 months after the last dose and approximately every 3 to 6 months thereafter. until the titer fell back below 240. To keep the In the study, requests for post-study anti-mAb316P antibody sample collection were made from patients with titers below 240 at the follow-up visit.

Sampling Procedure: Five (5) mL of blood volume were collected for each antimAb316P antibody sample.

Bioanalytical method: All samples were tested for anti-mAb316P antibodies (ADA; anti-drug antibody).

Anti-mAb316P antibody samples were analyzed using a non-quantitative validated titer-based double capture immunoassay. It involved an initial screening, a confirmatory assay based on drug specificity, and a measurement of the anti-mAb316P antibody titer in the sample. The lower limit of detection was approximately 1.5 ng / mL.

Samples that tested positive for ADA were evaluated for neutralizing antibodies using a competitive, non-quantitative, validated ligand binding assay. The lower limit of detection based on a monoclonal positive control neutralizing antibody is 390 ng / mL.

hs-CRP: The percentage change in hs-CRP from baseline through Week 12 and Week 24.

HbA1C: The absolute change in HbA1c (%) from baseline through Week 12 and Week 24.

EQ-5D Patient Questionnaire: EQ-5D is a standardized measure of health status developed by the EuroQol Group to provide a simple generic measure of health for clinical and economic assessment. EQ-5D, as a health-related quality of life measure, defines health in terms of 5 dimensions: mobility, self-care, usual activities, pain / discomfort, anxiety / depression. Each dimension can adopt one of three responses (3 ordinal levels of severity): "no problem" (1) "some problems" (2) "serious problems" (3). General health status is defined as a five-digit number. The health states defined by the 5-dimensional classification can be converted into corresponding index scores that quantify health status, where 0 represents "death" and 1 represents "perfect health." If the answer to one or more dimensions was missing, the index score will be missing.

The EQ-5D variables included the response for each EQ-5D point, the index score, and the change in index score from baseline.

Pharmacokinetics: Pharmacokinetic variables included total serum mAb316P concentration. If needed, free and total PCSK9 concentrations could be measured from the same PK sample.

Sampling time: Serum samples for total mAb316P concentration were collected prior to IMP (predose) at Week 0 (randomization visit) and then at multiple visits until the end of the follow-up period. To collect information on the absorption phase, an optional PK sample was collected at 5 days (± 2) after the Week 22 IMP injection or at 5 days (± 2) after any subsequent IMP injection while subject was on treatment.

Sampling Procedure: Five (5) mL of blood volume were collected for each PK sample.

Bioanalytical method: All PK samples were analyzed for the determination of the concentrations of total mAb316P (i.e., free mAb316P and mAb316P present in PCSK9: mAb316P complexes) using a validated enzyme-linked immunosorbent assay (ELISA). The lower limit of quantification (LLQ) for this assay is 0.078 pg / mL.

If required, PK samples could be analyzed for the determination of total and free PCSK9 levels using validated ELISA. The LLQ is 0.156 pg / mL for the total PCSK9 assay and 0.0312 pg / mL for the free PCSK9 assay.

STUDY PROCEDURES

For all visits after Day 1 / Week 0 (randomization visit), a time period of a certain number of days was allowed. The window period for visits at Weeks 12 and 24 was ± 3 days and for all other site visits it was ± 7 days during the double-blind treatment period, and follow-up period. A 3-day window period was allowed for the randomization visit (Day 1 / Week 0) and for the screening visit for injection training (Week -1).

Blood sampling: Blood sampling for the determination of lipid parameters (i.e. total C, LDL-C, HDL-C, TG, non-HDL C, Apo B, Apo A-1, Apo B / Apo ratio A-1, Lp [a]) should be performed in the morning, fasting (ie overnight, fasting at least 10-12 hours and abstaining from smoking) for all site visits throughout the study. It was recommended not to consume alcohol within 48 hours and not to do intense physical exercise within 24 hours prior to blood sampling.

Laboratory tests: Laboratory data were collected and forwarded to the central laboratory, which includes hematology; chemistry; liver panel (in case of total bilirubin values above the normal range, the differentiation into conjugated and unconjugated bilirubin will occur automatically); creatine phosphokinase (CPK); Hepatitis B surface antigen; Hepatitis C antibody (positive reflex test confirmed); and serum pregnancy test.

Urine Samples: Urinalysis - A dipstick was performed in the central laboratory and evaluated for pH, specific gravity, and for the presence of blood, protein, glucose, ketones, nitrates, leukocyte esterase, urobilinogen, and bilirubin. If the test strip was abnormal, then standard microscopy was performed.

Assessment methods for other endpoints: All other blood parameters were measured by a central laboratory during the study. It was recommended not to consume alcohol within 48 hours and not to do intense physical exercise within 24 hours prior to blood sampling. Glycemic parameters (HbA1c and serum glucose) were measured by a central laboratory, periodically throughout the study. The blood sample for the inflammatory parameter, hs-CRP, was collected periodically throughout the study.

Pharmacokinetic Samples: Serum samples were obtained periodically for evaluation of mAb316P concentration throughout the study.

Physical examination: A general physical examination must have been performed.

Blood pressure (BP) / heart rate: BP should be measured in a sitting position under standardized conditions, at approximately the same time of day, in the same arm, with the same device (after the patient has rested comfortably in a sitting position for at least 5 minutes). The values were recorded in the e-CRF; both systolic and diastolic BP should be recorded. At the first screening visit, TA should be measured in both arms. The arm with the highest diastolic pressure will be determined at this visit, and TA should be measured in this arm throughout the study. This higher value will be recorded in the e-CRF. Heart rate will be measured at the time of TA measurement.

Electrocardiogram: 12-lead ECGs should be performed after at least 10 minutes of rest and in the supine position.

Body weight and height: Body weight should be obtained with the patient wearing very light underwear or clothing and without shoes, and with an empty bladder.

STATISTIC ANALYSIS

A sample size of 45 patients per treatment arm was calculated to have 95% power to detect a mean difference between mAb316P and ezetimibe of 20% in percent change in LDL-C from baseline to Week 24 using a test. of the bilateral t with 5% significance, assuming a common standard deviation (SD) of 25% based on a previous mAb316P assay (McKenney et al., "Safety and efficacy of a monoclonal antibody to proprotein convertase subtilisin / kexin type 9 serine protease, SAR236553 / REGN727, in patients with primary hypercholesterolemia receiving ongoing stable atorvastatin therapy ", J Am Coll Cardiol, vol. 59, pp. 2344-2353 (2012)) and with an expected exclusion rate of 5%.

The primary endpoint was evaluated in the intention-to-treat (IDT) population, which included all randomized patients who had at least 1 calculated LDL-C value at baseline and at one of the planned time points from the start. Weeks 4 to 24. An on-treatment analysis (corresponding to modified TDI or mTDI) was also carried out that included all randomized and treated patients who had at least 1 calculated LDL-C value at baseline and at one of the planned time points from Weeks 4 to 24 on treatment, defined as the period between the first dose of study treatment and up to 21 days after the last injection or 3 days after the last capsule ingestion, whichever out first.

Missing data were taken into account by means of a mixed effect model with the repeated measures approach (MMRM) (Siddiqui et al., MMRM vs. LOCF: a comprehensive comparison based on simulation study and 25 NDA datasets ", J Biopharm Stat, vol. 19, pp. 227-246 (2009); National Research Council, "The Prevention and Treatment of Missing Data in Clinical Trials" Panel on Handling Missing Data in Clinical Trials. Committee on National Statistics, Division of Behavioral and Social Sciences and Education. 2010. Washington, DC: The National Academies Press; Andersen et al., "On the practical application of mixed effects models for repeated measures to clinical trial data", Pharm Stat., vol. 12, pp. 7-16 (2013)) For the IDT analysis, all available measurements at the planned time points from Weeks 4 to 24 (meaning Week 4, 8, 12, 16 and 24) were used in MMRM, ie whatever your status on treatment or without treatment An MMRM model for LDL-C was used to provide estimates of least squares means and comparison between treatment arms at Weeks 24 and 12. More details on the model are given below. For in-treatment analysis, all available measurements were used during treatment (i.e., up to 21 days after last injection / 3 days after last capsule, whichever came first) at planned time points from Weeks 4 to 24 in the MMRM model. In the same way as for the IDT analysis, a model was used to provide estimates and the comparison at Week 24 and Week 12 for the analysis during treatment. Continuous key secondary endpoints other than Lp (a) and triglycerides were analyzed in a similar way to the primary endpoint and the description of the statistical methodology for the secondary endpoints is provided below. assessment and subgroup analysis.

The safety analysis included all randomized and treated patients. The safety data were analyzed by descriptive statistics. All statistical analyzes were performed using SAS® version 9.2 or higher (SAS Institute Inc., Gary, n C).

Mixed effects model with repeated measures (MMRM)

The MMRM included fixed categorical effects of treatment group (mAb316P vs ezetimibe), time point (weeks 4, 8, 12, 16, and 24), and treatment interaction by time point, as well as continuous fixed covariates of value of low-density lipoprotein cholesterol (LDL-C) at baseline and treatment interaction per moment of time at baseline. Model outputs were baseline-adjusted least squares (LS) mean estimates at Week 24 for both treatment groups with their corresponding standard error (SE). The appropriate contrast instruction was used to test the difference between these estimates at the 2-sided 5% alpha level. To assess the robustness of the primary analysis and to compare the results during treatment between groups, the MMRM model was also applied to the LDL-C values collected during treatment.

Subgroup analysis

To assess the homogeneity of the treatment effect across various subgroups, the interaction terms of treatment factor by subgroup, moment-in-time factor by subgroup and treatment by moment of time by subgroup, and a factor term per subgroup were added to the MMRM primary model. Subgroups of interest included body mass index (BMI)> 30 kg / m2; sex; region (North America, Western Europe); age> 65 years; LDL-C at baseline (> 130 or> 160 mg / dL); baseline high-density lipoprotein cholesterol (HDL-C) <40 mg / dL; fasting triglycerides at baseline> 150 mg / dL; lipoprotein (a) at baseline [Lp (a)]> 30 mg / dL; and levels of proprotein convertase subtilisin / free kexin type 9 (PCSK9) at baseline (below / above median).

Statistical Analysis of Key Secondary Endpoints

To analyze the key secondary endpoints, a hierarchical procedure was used to control for type I error and deal with multiplicity. Secondary efficacy endpoints were tested sequentially using the order given above, in the intention-to-treat population. Continuous key secondary endpoints (including secondary endpoints at Week 12), except Lp (a) and triglycerides, were analyzed using the same MMRM model as for the primary endpoint with categorical fixed effects of the group treatment, planned time points up to Week 24, and treatment interaction by time point, as well as the continuous fixed covariates of value at the corresponding baseline and value interaction by time point at baseline. Lp (a) and triglycerides (which have a non-Gaussian distribution) and binary endpoints (proportion of patients with LDL-C <100 mg / dL and <70 mg / dL) were analyzed using a multiple imputation approach for the manipulation of missing values. For Lp (a) and triglycerides, multiple imputation was followed by the robust regression model with treatment groups and corresponding baseline value as effects. For the binary endpoints, multiple imputation was followed by logistic regression with treatment group as the effect and corresponding baseline value as the covariate. A sensitivity analysis of key secondary endpoints was applied using the same statistical approach as described above using values during treatment.

RESULTS

Of the 204 selected patients, 103 met the eligibility criteria for the study and were randomized (52 to the mAb316P arm and 51 to the ezetimibe arm; Figure 2 ). Baseline characteristics and lipid parameters were, in general, uniformly distributed across the 2 arms of the study (Table 1). A total of 4 patients were identified as having diabetes mellitus at screening (3 in the mAb316P arm and 1 in the ezetimibe arm). Mean baseline LDL-C levels were 141.1 mg / dL (3.65 mmol / L) in the mAb316P arm and 138.3 mg / dL (3.58 mmol / L) in the arm of ezetimibe (Table 1).

Fourteen patients in the mAb316P arm at Week 12 were titrated up in a blinded fashion to the 150 mg Q2W regimen because their LDL-C at Week 8 was> 70 mg / dL; only one of these patients had LDL-C> 100 mg / dL. Mean baseline LDL-C values were 153.2 mg / dL (3.96 mmol / L) in patients in whom the dose was titrated up to mAb316P 150 mg Q2W and 134.7 mg / dL (3.48 mmol / L) in patients in whom the dose was not adjusted upwards. The baseline values of other lipid values according to whether the patient dose was adjusted upward or not are shown in Table 2.

Overall, 44/52 (85%) patients in the mAb316P arm and 44/51 (86%) patients in the ezetimibe arm completed the 24-week treatment period (Figure 2). The main reason for discontinuation of study treatment was TEAEs in both treatment arms (Figure 2). Of the 15 patients who discontinued treatment prematurely, 3 (6%) patients in the mAb316P arm and 5 (10%) patients in the ezetimibe arm did not have a calculated LDL-C value at Week 24.

Forty-eight patients in each arm self-injected all injections (94% in the ezetimibe arm, 92% in the mAb316P arm). Three patients in the ezetimibe arm and 4 in the mAb316P arm self-injected some of the injections and asked someone else to do it for the other injections. No patient asked another person to do all their injections.

All randomized patients received at least 1 dose of their assigned drug and were included in the intention-to-treat (IDT) and safety populations (Figure 2). One patient from each treatment arm withdrew from treatment before any post-randomization LDL-C measurement was made and thus were excluded from the analysis during treatment. However, they continued the study and had their LDL-C measurements taken while they were off treatment, but before the end of the 24-week study period, so they were included in the TDI analysis.

Table 1. Characteristics at baseline (All patients randomized)

Ezetimibe 10 mg mAb316P 75 mg Q2W Characteristic (mean [SD] unless stated from

otherwise) (N = 51) (N = 52) Age, years 59.6 (5.3) 60.8 (4.6)> 65 years, n (%) 8 (15.7) 11 (21, 2) Male gender, n (%) 27 (52.9) 28 (53.8) Race, n (%)

White 47 (92.2) 46 (88.5) Black or African American 4 (7.8) 6 (11.5) BMI, kg / m2 28.4 (6.7) 30.1 (5.9) HbA1c ,% 5.6 (0.4) 5.7 (0.5) Fasting blood glucose, mg / dL 97.4 (9.0) 101.4 (14.3) Time since hypercholesterolemia diagnosis, years 4 .5 (7.8) 4.0 (4.7) 10-year risk of fatal CVD (SCORE),% 2.68 (1.14) 2.97 (1.29) Lipid parameters, mg / Dl

LDL-C 138.3 (24.5) 141.1 (27.1)

Range (min: max) 73: 186 77: 207 Apolipoprotein B 104.3 (19.1) 104.3 (18.4) Total cholesterol 223.9 (30.2) 221.7 (33.7) C no HDL 164.0 (29.7) 167.4 (30.3) Lipoprotein (a), median (IQR) 16.0 (6.0: 34.0) 13.0 (4.0: 39.0) Triglycerides, median (IQR) 117.0 (87.0: 154.0) 119.0 (89.0: 153.0)

HDL-C 59.9 (19.2) 54.3 (16.1)

Apolipoprotein A-1 163.8 (33.4) 153.1 (29.2) A total of 4 patients with diabetes mellitus were identified in the screening (3 in the mAb316P arm and 1 in the ezetimibe arm). There were no clinically or statistically significant differences between groups.

To convert glucose measurements to mmol / L, multiply by 0.0555; to convert cholesterol measurements to mmol / L, multiply by 0.02586; To convert triglyceride measurements to mmol / L, multiply by 0.01129.

BMI, body mass index; HbA1c, glycated hemoglobin; HDL-C, high-density lipoprotein cholesterol; IQR, interquartile range; LDL-C, low-density lipoprotein cholesterol; Q2W, every 2 weeks; SCORE, Systemic Estimation of Coronary Risk; SD, standard deviation.

Table 2. Baseline Lipid Parameters by Upward Dose Adjustment Status (Safety Population Patients With At Least One Injection After Week 12)

No Upward Dose Adjustment in Upward Dose Adjustment in mAb316P group mAb316P group

Lipid parameter

(mg / dL) (N = 32) (N = 14)

LDL-C

Mean (SD) 134.7 (26.7) 153.2 (24.6) *

Interval (Min: max) 77: 206 122: 207

C-HDL

Mean (SD) 51.3 (16.3) 60.3 (15.2) t

Interval (Min: max) 30: 98 33: 96

Total cholesterol

Mean (SD) 215.1 (32.9) 236.6 (30.6) *

Interval (Min: max) 159: 289 184: 296

C not HDL

Mean (SD) 163.7 (32.5) 176.4 (24.0) §

Interval (Min: max) 100: 233 144: 231

Fasting triglycerides

Mean (SD) 145.3 (80.5) 115.4 (34.1) »

Interval (Min: max) 36: 373 62: 183

P values compared to patients without upward dose adjustment: * P = 0.0436; t P = 0.0280; * P = 0.0546; §P = 0.2989, »P = 0.3455. The p- values were not adjusted for multiplicity and are for descriptive purposes only.

HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol;

SD, standard deviation.

Efficacy results

For the primary efficacy analysis (TDI analysis), percent reductions in mean least squares (MC) in LDL-C from baseline to Week 24 were 47 (3)% in the mAb316P group versus 16 ( 3)% in the ezetimibe group, with a statistically significant difference in mean MC (SE) between groups of -32 (4)% (P <0.0001) (Table 3). The results of the on-treatment analyzes were similar to those of the IDT analysis: the mean LDL-C reductions of MC (SE) from baseline to Week 24 were 54 (2)% vs 17 (2)% ( P <0.0001), with mAb316P and ezetimibe, respectively (Table 3).

At Week 12, when all patients in the mAb316P arm were receiving 75 mg Q2W, LDL-C levels were reduced by 48 (3)% with mAb316P versus 20 (3)% with ezetimibe in the TDI analysis, with a mean difference of MC (SE) between groups of -28 (4)% (P <0.0001). The corresponding LDL-C reductions in the analysis during treatment at Week 12 were 53 (2)% with mAb316P vs 20 (2)% with ezetimibe, with a mean MC (SE) difference between groups of -33 ( 3) %.

Figure 3 shows the time course of changes in LDL-C levels during the study period for patients treated with mAb316P and ezetimibe. The values during treatment are shown here since the aim is to understand the durability of the drug effect without confusion by abandonment. There was a dramatic decrease in LDL-C from baseline through Week 4 in patients receiving mAb316P, with robust LDL-C reductions maintained from Week 4 through the end of the treatment period at Week 24. The analysis Statistical interaction between treatment and time point in the MMRM model was not significant, suggesting the stability of the LDL-lowering effect of mAb316P versus ezetimibe over time (as illustrated in Figure 3 ).

Estimated proportions of patients with LDL-C reductions> 50% at Week 12, before adjustment dose ascending, were 58% in the mAb316P arm, compared with 3% of patients in the ezetimibe (IDT) arm. The corresponding values in the on-treatment analysis were 65% in the mAb316P arm and 2% in the ezetimibe arm. All patients responded to mAb316P while exposed to treatment (treatment population) ( Figure 4 ).

To estimate the impact of upward dose adjustment based on LDL-C> 70 mg / dL instead of> 100 mg / dL on the primary efficacy parameter, an additional analysis was performed excluding LDL-C values after adjustment. ascending dose for the 13 patients in whom the dose was adjusted upwards despite the fact that they had LDL-C values <100 mg / dL; this analysis gave similar results to the global IDT analysis ( Table 4 ).

The percentage of reductions from baseline in Apo B, total cholesterol, and non-HDL C was significantly higher for mAb316P versus ezetimibe at Week 24 and similar in the TDI analyzes and during treatment ( Table 5 ). Moderate reductions in Lp (a), TGs, and increases in HDL-C were observed following both of the study treatments, with no differences between the mAb316P and ezetimibe arms ( Table 5 ).

Subgroup analyzes did not suggest significant differences in the efficacy of mAb316P versus ezetimibe in the IDT population for various parameters ( Figure 5 ).

Table 3. Percentage change in LDL-C from baseline to Week 24 (TDI analysis or during treatment as indicated)

mAb316P vs. ezetimibe

Ezeti- mAb316P

miba 75 mg Mean difference of CI from

LDL-C 10 mg Q2W MC (SE)% 95% p- value

IDT N = 51 N = 52

MC mean change (SE) -47.2 -31.6 (4.3) -40.2 to - <0.0001 * from baseline (%) 15.6 (3.1) (3, 0) 23.0

In treatment * N = 50 N = 51

LDL-C at baseline, mean 137.5 141.1

(SD), mg / dL (24.1) (27.4)

Min: max 73: 186 77: 207

MC mean change (SE) -17.2 -54.1 -36.9 (2.9) -42.7 to - <0.0001 * from baseline (%) (2.0) (2 .0) 31.2

'Statistically significant according to the fixed surgical approach used to control the global type I error rate.

* Includes all patients in the IDT population with at least 1 LDL-C value calculated at a planned time point between the first dose of study treatment and up to 21 days after the last injection or 3 days after the last ingestion capsule, whichever comes first.

* The p- value is shown for descriptive purposes only.

CI, confidence intervals; IDT, intention to treat; LDL-C, low-density lipoprotein cholesterol; MC, least squares; Q2W, every 2 weeks; SD, standard deviation; SE, standard error.

Table 4. Percentage change in LDL-C from baseline to Week 24, excluding data from subsequent upward dose adjustment of patients whose dose from mAb316P 75 mg to 150 mg Q2W was adjusted upward. LDL-C <100 mg / dL (intention-to-treat population) mAb316P vs ezetimibe Ezetimibe mAb316P 75 mg Mean difference IC of LDL-C value, mean MC (SE) 10 mg (N = 51) Q2W (N = 52) from MC (SE)% 95% p Change in Week 24 -15.6 (3.2) -44.3 (3.4) -28.7 (4.6) -37.9 to - < 0.0001 * from baseline (%) 19.5

* The p- value is shown for descriptive purposes only.

CI, confidence interval; LDL-C, low-density lipoprotein cholesterol; MC, least squares; Q2W, every 2 weeks.

Table 5. Percentage change from baseline in lipid secondary parameters (_____________________________ IDT analysis or during treatment as indicated) ____________________________

mAb316P vs. ezetimibe

Change in% of mean MC Difference me- (SE) from baseline to Ezetimibe mAb316P day of MC Week 24 Value 10 mg 75 mg Q2W (SE)% 95% CI p TDI N = 51 N = 52

Apo B -11.0 (2.4) -36.7 (2.3) -25.8 (3.3) -32.3 to -19.2 <0.0001 * C no HDL -15.1 (2.9) -40.6 (2.8) -25.5 (4.1) -33.5 to -17.4 <0.0001 * Total cholesterol -10.9 (2.2) -29 .6 (2.1) -18.7 (3.0) -24.7 to -12.7 <0.0001 * Lp (a) * -12.3 (3.8) -16.7 (3 .7) -4.4 (5.3) -14.8 to 5.9 0.4013 TGs * -10.8 (4.3) -11.9 (4.2) -1.2 (5, 9) -12.7 to 10.3 0.8433 * HDL-C 1.6 (1.9) 6.0 (1.9) 4.4 (2.7) -1.0 to 9.8 0 , 1116 * Apo A-1 -0.6 (1.6) 4.7 (1.6) 5.3 (2.2) 0.9 to 9.8 0.0196 * During treatment N = 50 N = 51

Apo B -11.5 (1.9) -40.8 (1.9) -29.2 (2.6) -34.4 to -24.0 <0.0001§ C no HDL -16.6 (1.9) -47.1 (1.9) -30.5 (2.7) -35.9 to -25.1 <0.0001§ Total cholesterol -12.0 (1.6) -34 .2 (1.6) -22.2 (2.3) -26.7 to -17.7 <0.0001§ Lp (a) * -12.3 (4.0) -17.7 (4 .1) -5.4 (5.7) -16.6 to 5.9 0.3506§ TGs * -12.7 (4.2) -14.7 (4.4) -1.9 (6 .0) -13.7 to 9.8 0.7452§ C-HDL 1.7 (1.9) 8.0 (1.9) 6.2 (2.7) 0.8 to 11.6 0 .0241§ Apo A-1 -0.7 (1.6) 5.3 (1.6) 6.1 (2.3) 1.6 to 10.6 0.0084§ * Statistically significant according to the hierarchical approach fixed used to control the global type I error rate. * The pooled estimate for percentage changes from the adjusted mean (SE) are shown for Lp (a) and TGs. ♦ As the difference in Lp (a) at Week 24 was not significant for mAb316P versus ezetimibe, no further significance test was performed according to the established hierarchical approach. P values for TGs, HDL-C, and Apo A-1 are shown for descriptive purposes only.

§ The p values are shown only for descriptive purposes.

Apo, apolipoprotein; CI, confidence intervals; HDL-C, high-density lipoprotein cholesterol; IDT, intention to treat; Lp (a), lipoprotein (a); MC, least squares; Q2W, every 2 weeks; SE, standard error; TGs, triglycerides.

Safety results

The overall percentage of patients who had at least one TEAE was 69% in the mAb316P arm and 78% in the ezetimibe arm ( Table 6 ). There were no deaths. Two SAEs were reported during the TEAE period: one patient, who had received mAb316P 75 mg Q2W for 3 months and had a history of atrial fibrillation and chronic obstructive pulmonary disorder, had a pulmonary embolism; Study treatment was discontinued and the patient was hospitalized, where he recovered. One patient on the ezetimibe arm with a personal history of arthritis had erosion of the glenoid and was hospitalized for surgery (shoulder arthroplasty). The patient recovered in hospital and completed the study. None of the SAEs were considered by the investigator to be related to the study treatment. TEAEs that occur in 5% or more patients in any of the treatment arms are shown in Table 6.

Nine patients prematurely discontinued study treatment after one or more TEAEs (5 [10%] patients in the mAb316P arm and 4 [8%] in the ezetimibe arm). In the ezetimibe group, TEAEs leading to discontinuation were gout in 1 patient, fatigue, back pain, and frequent urination in 1 patient, crampy abdominal pain and injection site reaction in 1 patient, and overly intense dreams in 1 patient. In the ezetimibe mAb316P group, the TEAEs that led to discontinuation were pulmonary embolism in 1 patient, nausea, fatigue, headache and flushing in 1 patient, arthralgia (generalized pain) in 1 patient, injection site reaction in 1 patient, and diarrhea in another patient.

The most common class of TEAEs was infection (42.3% for mAb316P vs 39.2% for ezetimibe), mainly respiratory. Muscle-related TEAEs occurred in 2 (4%) of mAb316P patients and 2 (4%) of ezetimibe patients. Elevated creatine kinase levels greater than 10 times the upper limit of normal were reported in 1 patient in the ezetimibe group (Table 6). All three patients had a local injection site reaction (1 [2%] patient in the mAb316P group and 2 [4%] in the ezetimibe group). These events were of mild intensity. The patient in the mAb316P arm had 3 episodes of local injection site reaction following consecutive injections. Three patients treated with mAb316P 75 mg Q2W had at least 1 LDL-C value <25 mg / dL; No particular safety concern associated with low LDL-C levels was seen with these 3 patients.

Some patients (2 or fewer) in the ezetimibe group and no patients in the mAb316P group had abnormalities in vital signs (blood pressure, heart rate). In addition, there were no increases greater than 3 times the upper limit of normal in alanine aminotransferase or aspartate aminotransferase ( Table 6 ). More patients had blood glucose> 126 mg / dL (7 mmol / L) in the mAb316P arm than in the ezetimibe arm (6 patients vs 1 patient; Table 6 ). All 6 patients in the mAb316P arm who had high glycemia during the treatment period had abnormal fasting glucose at baseline or baseline and no pattern was observed in changes in either glycemic or HbA1c from screening to Week 24 ( Table 7 ).

Treatment-emergent anti-drug antibodies were found in 6 (12%) patients in the mAb316P arm and were not observed in patients in the ezetimibe arm. For all anti-drug antibody positive patients, titers were low (<240 in the assay used) and no neutralizing anti-drug antibody was detected that could affect mAb316P pharmacokinetics, LDL-C effects, or safety.

Table 6. TEAEs and laboratory parameters (safety population)

Ezetimibe mAb316P 75 mg 10 mg Q2W AE category or laboratory parameter, n (%) (n = 51) (n = 52) Patients with any TEAE 40 (78.4) 36 (69.2) Patients with any emergent SAE treatment 1 (2.0) 1 (1.9) Patients with any TEAE leading to death 0 0 Patients with any TEAE leading to treatment interruption 4 (7.8) 5 (9.6) TEAEs occurring in > 5% of patients in any group

Nasopharyngitis 8 (15.7) 12 (23.1) Diarrhea 2 (3.9) 6 (11.5) Flu 3 (5.9) 6 (11.5) Arthralgia 2 (3.9) 3 (5, 8) Headaches 2 (3.9) 3 (5.8) Nausea 3 (5.9) 3 (5.8) Upper respiratory tract infection 5 (9.8) 2 (3.8) Back pain * 3 (5.9) 1 (1.9) Dizziness 3 (5.9) 1 (1.9) Urinary tract infection 3 (5.9) 0 Patients with TEAEs of interest

Musculoskeletal and connective tissue disorders 11 (21.6) 8 (15.4) Muscle disorders 2 (3.9) 2 (3.8) Myalgia 1 (2.0) 2 (3.8)

Muscle spasms 1 (2.0) 0 Musculoskeletal and connective tissue disorders NEC 5 (9.8) 2 (3.8) Musculoskeletal pain 1 (2.0) 1 (1.9) General disorders and administration site conditions 5 (9.8) 5 (9.6) Injection site reaction 2 (3.9) 1 (1.9) Laboratory parameters n / N (%)

Alanine aminotransferase (ALT)

> 3x ULN (if ALT at initial level <ULN) or> 2x value at initial level 0/51 0/52 (if ALT at initial level> ULN)

> 3x ULN 0/51 0/52 Aspartate aminotransferase

> 3x ULN 0/51 0/52 Glucose

Ezetimibe mAb316P 75 mg 10 mg Q2W AE category or laboratory parameter, n (%) (n = 51) (n = 52) <70 mg / dL (3.9 mmol / L) and <LLN 0/50 0 / 52> 126 mg / dL (7 mmol / L) (fasting) 1/50 (2.0) 6/51 (11.8) ** Albumin

<25 g / L 0/50 0/51 Creatine kinase

> 3x ULN 1/50 (2.0) 0/51> 10x ULN 1/50 (2.0) 0/51 * Back pain was also counted as a TEAE of special concern (musculoskeletal and connective tissue disorders NEC ).

** Three of these patients were identified as having diabetes mellitus at screening and all 6 patients had abnormal fasting blood glucose at screening or baseline; no pattern was observed in changes in blood glucose over time (see Supplementary Table 6).

TEAEs are adverse events that developed or worsened or became serious during the TEAE period (defined as the time from the first dose of double-blind study treatment to the last injection plus 70 days [10 weeks], as it was expected the residual effect of mAb316P up to 10 weeks after the last injection.

LLN, lower limit of normal; NEC, not elsewhere classified; Q2W, every 2 weeks; SAE, serious adverse event; TEAE, treatment emergent adverse event; and ULN, upper limit of normality.

Table 7. Blood glucose levels for patients in the mAb316P arm who reported high blood glucose during the study (n = 6)

Patient (arbitrary number) Time point Fasting blood glucose (mg / dL) HbA1c (%) 1 Selection (Week -2) 121 5.7

Initial level (Week 0) 115

Week 24 112 5.9 2 Selection (Week -2) 128 6.2

Initial level (Week 0) 119

Week 24 121 6.5 3 * Selection (Week -2) 126 6.2

Week 24 112 5.9 4 * Selection (Week -2) 105 7.0

Initial level (Week 0) 97

Week 24 70 6.2 5 * Selection (Week -2) 164 7.5

Initial level (Week 0) 142

Week 24 183 7.7 6 Selection (Week -2) 125 6.7 Patient (arbitrary number) Time point Fasting blood glucose (mg / dL) HbA1c (%)

Initial level (Week 0) 129

Week 12 135 6.3

Values were not available at all time points for all patients.

* Identified as having diabetes mellitus on screening.

This was the first phase 3 mAb316P study, the first mAb316P monotherapy study, and the first study to use the 75 mg Q2W regimen. MAb316P demonstrated superior efficacy as monotherapy compared to ezetimibe during 24 weeks of treatment. LDL-C reductions of 48% were observed at Week 12 (before up-titration) in patients receiving mAb316P 75 mg Q2W, compared with 20% for ezetimibe 10 mg daily, in the TDI analysis. The corresponding reductions for patients who were on treatment were 53% with mAb316P 75 mg Q2W versus 20% with ezetimibe.

The efficacy of mAb316P was consistent across baseline parameters including levels of LDL-C and PCSK9, and demographic characteristics. In fact, all mAb316P-treated patients responded to 75 mg Q2W monotherapy in the on-treatment analysis. MAb316P monotherapy showed a sustained LDL lowering effect from Weeks 4 to 24.

Consistent with the marked reductions in LDL-C, mAb316P also provided robust reductions in total cholesterol, Apo B, and non-HDL C. mAb316P produced an 18% reduction in Lp (a) in the present study, compared to 12% in the ezetimibe arm.

MAb316P demonstrated comparable tolerability and safety with ezetimibe. Muscle-related AEs occurred at a similar frequency in both treatment arms (4% of patients on mAb316P and 4% on ezeti miba). In addition, the development of anti-drug antibodies was low in patients treated with mAb316P.

In summary, this is the first blinded 6-month, phase 3, blinded evaluation of an anti-PCSK9 antibody. A reduction in LDL-C of -50% was observed in the mAb316P 75 mg Q2W arm at 12 weeks in a monotherapy population, which was substantially greater than that observed in the ezetimibe arm (20%). This study extends safety observations from phase 2 trials, with no evidence of safety signals that appear to limit use and tolerability. This was also the first randomized controlled trial of an injectable monoclonal antibody against PCSK9 using a disposable autoinjector, which produced fewer injection-related ESAs (<2% mAb316P patients and <4% ezetimibe).

Pharmacokinetic results

The relationship between mAb316P, free PCSK9, and LDL-C concentrations was evaluated in patients receiving mAb316P monotherapy. Changes in free PCSK9 and LDL-C were also evaluated in the ezetimibe arm.

Serum mAb316P and free PCSK9 levels were determined using validated enzyme immunoassays.

Pharmacokinetic analyzes were performed in 46 patients in the mAb316P treatment arm who had not been withdrawn before Week 12 ( Table 8 ). Of the 46 patients treated with mAb316P, 32 patients reached LDL-C <70 mg / dL at Week 8 and were maintained with mAb316P 75 mg Q2W, and 14 patients were titrated up to mAb316P 150 mg Q2W.

Baseline LDL-C levels were higher in mAb316P patients with upward titration compared to mAb316P patients without upward titration (P = 0.044) ( Table 9 ). In the group without upward dose adjustment, the LDL-C reductions observed at Week 4 were sustained through Week 24 ( Figure 6A ) . In the up-titration group, LDL-C levels were also reduced at Week 4, but to a lesser relative degree than the no-dose titration group ( Figure 6A ). The reductions in LDL-C with mAb316P were similar at Weeks 12 and 24, regardless of whether the mAb316P dose was adjusted upward at Week 12 ( Figure 6A ), and were consistently higher than with ezetimibe ( Table 9 ).

Serum mAb316P levels were similar in the dose-up and no-dose titration groups during the first 12 weeks of the study when all patients received the 75 mg dose, and approximately doubled in patients with Upward dose adjustment at Week 12 ( Figure 6B ;

Table 9 ).

Baseline free and total PCSK9 levels were slightly higher in the up-titrated group compared to the non-dose-titrated and ezetimibe groups ( Table 9 ). Levels Free PCSK9 reached the lowest point at Week 4 in the group without upward titration; Free PCSK9 levels were also reduced at Weeks 4-12 in the up-titration group but were 2-3 times higher than in the no-up-titration group ( Figure 6C ; Table 9). Upward titration to mAb316P 150 mg Q2W at Week 12 was associated with additional suppression of free PCSK9 levels; the reductions were maintained until Week 24 ( Figure 6C; Table 9 ). Free PCSK9 levels remained relatively unchanged from baseline through Week 12 in the ezetimibe group, but decreased at Week 24 ( Table 9 ). Total PCSK9 levels increased after treatment with mAb316P but not ezetimibe ( Table 9 ), possibly because the antibody: PCSK9 complex had a longer half-life than free PCSK9.

In patients maintained on mAb316P 75 mg Q2W monotherapy through Week 24, free PCSK9 levels were maximally reduced at Week 4; LDL-C lowering efficacy was maintained from Week 4 to 24. In patients titrated upward to mAb316P 150 mg Q2W at Week 12, serum mAb316P concentrations increased as expected and there was a further decrease in free PCSK9 levels, but there was little additional effect on LDL-C. The results suggest that monotherapy with mAb316P 75 mg Q2W is sufficient to block free PCSK9 and maintain the efficacy of LDL-C reduction for 24 weeks in most patients not receiving a statin or other lipid-modifying therapies. As the target-mediated clearance of mAb316P is accelerated by its binding to free PCSK9, higher doses of mAb316P may be required in the clinical setting where patients are receiving concurrent statin or other lipid modifying agents that increase free PCSK9.

The present invention is not to be limited in scope by the specific embodiments described herein. Indeed, various modifications of the invention, in addition to those described herein, will be apparent to those skilled in the art from the foregoing description and the accompanying figure. Such modifications are intended to fall within the scope of the appended claims.

Table 8. Characteristics of the mean initial level (SD)

Table 9 . Mean concentrations (SD) of mAb316P in serum, total and free PCSK9, and LDL-C

Example 3: A randomized, double-blind study of the efficacy and safety of an anti-PCSK9 antibody ("mAb316P") in patients with primary hypercholesterolemia who are intolerant to statins

Introduction

The aim of the present study was to evaluate the ability of an anti-PCSK9 antibody ("mAb316P," also known as REGN727 or alirocumab) to lower LDL-C compared to ezetimibe (EZE) in patients with primary hypercholesterolemia (HFhe and H no F) who are intolerant to statins.

Muscle-related symptoms in clinical trials, involving highly selected patient groups with high adherence to treatment and tolerance to statins, may not reflect the true prevalence of myalgia in the clinic, as evidenced by study findings observational. The discrepancy in the incidence of muscle-related adverse events (AEs) may be secondary to some patients who have multi-medication ESAs, and this may not represent true statin intolerance. Therefore, to take into account patients who may have ESAs with multiple medications and not only with statins, a sufficient number of patients were selected and included in the single-blind placebo run-in period of the present study to ensure the sample size of the double-blind treatment period of 250 patients (100: 100: 50; mAb316P : EZE: atorvastatin).

The sample size of 250 patients (100: 100: 50; mAb316P: EZE: atorvastatin), with a double-blind study treatment duration of 24 weeks, was aimed at obtaining efficacy information and obtaining descriptive experience with events of safety in general, all skeletal muscle related events, and skeletal muscle related dropouts in particular. Hypercholesterolemic patients with moderate, high, or very high CV risk were included in this study, as a population in which obtaining the LDL-C goal is more difficult to achieve when only non-statin alternatives are used. The definition of CV risk is based on existing guidelines (see, for example, The Task Force for the management of dyslipidaemias of the European Society of Cardiology [ESC] and the European Atherosclerosis Society [EAS], ESC / EAS Guidelines for the management of dyslipidaemias. European Heart Journal 2011; 32: 1769-1818); Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the Third Report of the National Cholesterol Education Program [NCEP] Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel III], JAMA 2001; 285: 2486-2497).

The use of a 2 week washout period ensured that there was no residual effect of background therapy in the comparative arms.

The 4-week placebo run-in period was used to eliminate patients who could develop muscle-related symptoms with other medications, including placebo.

Preliminary pharmacokinetic data from phase 2 mAb316P studies showed that exposure to mAb316P decreased during the 8-week follow-up period following the double-blind treatment period, with total serum mAb316P concentrations still detectable, but at levels very low. Therefore, to ensure sufficiently low, ineffective serum mAb316P concentrations, patients were followed for a follow-up period of 8 weeks (ie, 10 weeks after the last dose).

Ezetimibe was used as the active comparator because it is the current gold standard for patients who are unable to tolerate statins, and the primary objective of the study was to assess the reduction in LDL-C after 24 weeks for mAb316P compared to EZE. Atorvastatin was also included as a comparator to conclude that the population selected in the study was a truly statin intolerant population, evaluating the incidence and frequency of discontinuation due to skeletal muscle-related AEs (Fung and Crook, Cardiovasc. Ther 2012 Oct, 30 (5): e212-218).

Two doses of mAb316P were used in the present study: 75 mg and 150 mg administered subcutaneously every two weeks (Q2W). Dose selection was based on data from the Phase 1 and Phase 2 programs. Dose selection, frequency of administration, and the dose-titration approach were also based on the reduction in LDL-C needed to provide the required dose. better benefit in terms of CVD reduction, and possible safety considerations regarding low LDL-C values.

The Q2W regimen is expected to maintain constant LDL-C reduction throughout the interval between dosing, providing maximum efficacy at 12 weeks for the 150 mg Q2W dose. However, for many patients, the magnitude of effect seen with the 150 mg Q2W dose may not be necessary to achieve the LDL-C goal, and treatment may begin with a lower dose. Therefore, in the present study, all patients were initially treated with 75 mg Q2W, and only patients with high and very high CV risk and an LDL-C> 70 mg / dL and patients with moderate CV risk and a C- LDL> 100 mg / dL after 8 weeks of treatment underwent upward titration to 150 mg Q2W at Week 12.

Based on the clinical data available at the time of the present study, treatment with mAb316P has demonstrated a significant LDL-C-lowering effect and was generally well tolerated in a population of patients with unfamiliar hypercholesterolemia or with Heterozygous familial hypercholesterolemia. Efficacy on LDL-C reduction was associated with consistent results in total C, ApoB, non-HDL C, and ApoB / ApoA-1 ratio and a positive trend for HDL-C, TG, and Lp (a). There was no evidence that mAb316P adversely affected other cardiovascular (CV) risk factors, eg, body weight, blood pressure, glucose, or C-reactive protein.

OBJECTIVES OF THE STUDY

The primary objective of the study was to demonstrate the reduction of LDL-C by mAb316P compared to EZE 10 mg orally once daily (PO QD) after 24 weeks in patients with primary hypercholesterolemia (HFhe and H not F) who were intolerant to statins.

The secondary objectives of the study were: (1) To evaluate the effect of mAb316P 75 mg compared to EZE on LDL-C after 12 weeks of treatment; (2) Evaluate the effect of mAb316P on other lipid parameters (eg ApoB, non-HDL C, total C, Lp (a), HDL-C, TG levels, and ApoA-1 levels); (3) To assess the safety and tolerability of mAb316P, including characterization of the incidence rate and the rate of discontinuation of treatment of skeletal muscle-related AEs; and (4) Evaluate the development of anti-mAb316P antibodies.

STUDY DESIGN

The present study was a randomized, double-blind, double-dummy, active-control, parallel-group, multinational, multicenter study in patients with primary hypercholesterolemia and moderate, high, or very high CV risk who are intolerant to statins. The study design is illustrated in Figure 7.

Statin intolerance was defined as the inability to tolerate at least 2 statins prior to the lowest authorized daily dose due to symptoms related to skeletal muscles, other than those due to strain or trauma, such as pain, weakness, or crampy pain, which started or increased during statin therapy and stopped when statin therapy was stopped.

The study consisted of 5 periods: selection; washed; single-blind placebo run-in; double blind treatment; and monitoring.

(1) Selection:

The selection lasted approximately 1 week (Week -7). Patients were asked to maintain a stable diet equivalent to the Therapeutic Lifestyle Changes (TLC) diet of the National Cholesterol Education Program's Adult Treatment Panel III (NCEP-ATP III) throughout the entire period. duration of the study, starting at screening until the end of treatment visit.

(2) Washing:

Patients meeting all selection inclusion and exclusion criteria entered a 2-week washout period (Week -6 to Week -4) of EZE, statins (for patients taking an unauthorized dose or regimen), and rice red yeast.

(3) Single-blind placebo run-in:

After washout, patients entered a 4-week placebo run-in period (Week -4 to Week 0), single-blind (only patients are blinded to treatment) that consisted of 4 weeks of placebo treatment for mAb316P Q2W (a total of 2 doses) plus a placebo for EZE / atorvastatin PO QD capsule (28 doses).

Only patients who did not have skeletal muscle-related AEs, other than those due to exertion or trauma, during the single-blind placebo run-in period were eligible to enter the double-blind treatment period, described below.

Patients who had skeletal muscle-related AEs other than those due to exertion or trauma during the 4-week single-blind placebo run-in period were informed to stop therapy and were withdrawn from the study.

At the first scheduled visit of the single-blind placebo run-in period (Week -4), patients (or their caregivers) were instructed on study drug administration using a single-blind autoinjector containing placebo for mAb316P and self-administered. -administered the first dose (at Week -4) in the clinic. The second dose of study drug during the single-blind placebo run-in period (at Week -2) was administered by the patient or caregiver at home using the second single-blind placebo autoinjector for mAb316P. Patients took a placebo for EZE / atorvastatin QD capsule for 4 weeks during the placebo run-in period.

(4) Double blind treatment:

Patients who met all the inclusion criteria, and who did not meet any of the exclusion criteria, which include having had skeletal muscle-related AEs, other than those due to stress or trauma, were randomized during the placebo run-in period. 4-week single-blind, to receive any of: (A) mAb316P 75 mg Sc Q2W a placebo for EZE / atorvastatin PO QD; or (B) EZE 10 mg PO QD placebo for mAb316P SC Q2W; or (C) Atorvastatin 20 mg PO QD placebo for mAb316P Sc Q2W.

Ezetimibe 10 mg and atorvastatin 20 mg were over-encapsulated in a capsule to match the placebo for EZE / atorvastatin to ensure double blindness. Ezetimibe 10 mg, atorvastatin 20 mg and placebo were indistinguishable from each other.

Randomization was stratified by a history of documented myocardial infarction (MI) or ischemic stroke, (Yes / No).

The first injection during the double-blind treatment period was administered at the site on the day of randomization (Week 0 [Day 1] - Visit 4) and as soon as possible after the call to the interactive voice response system. (IVRS) / interactive web response system (IWRS) for randomization in the study. Subsequent injections were administered by the patient (self-injection) or a designated caregiver (spouse, relative, etc.) at a location preferred by the patient (eg, home or workplace). Patients were allowed to choose to return to the Q2W site for the injection to be administered by study personnel. Patients randomized to mAb316P received 75 mg of study drug from randomization through Week 12 (weeks 0, 2, 4, 6, 8, and 10).

At the Week 12 visit, based on their LDL-C at Week 8 and CV risk at baseline (defined elsewhere herein), patients either continued to receive mAb316P 75 mg Q2W or adjusted accordingly. ascending your doses, as follows:

(A) Very high CV risk patients, in a blinded mode, or: (i) continued receiving mAb316P 75 mg Q2W from Week 12 onwards until the last injection at Week 22, if their LDL-C at Week 8 it was <70 mg / dL (1.81 mmol / L); or (ii) received a dose that is titrated up to mAb316P 150 mg Q2W from Week 12 onward to the last injection at Week 22, if their LDL-C at Week 8 was> 70 mg / dL (1 , 81 mmol / L).

(B) High or moderate CV risk patients, in a blinded mode, or: (i) continued to receive mAb316P 75 mg Q2W from Week 12 onward until the last injection at Week 22, if their LDL-C at Week 8 was <100 mg / dL (2.59 mmol / L), or (ii) received a dose that was adjusted upward to mAb316P 150 mg Q2W from Week 12 onwards to the last injection at Week 22, if her LDL-C at Week 8 was> 100 mg / dL (2.59 mmol / L).

(5) Tracking:

Patients were followed for a period of 8 weeks after the end of the double-blind treatment period, or after premature discontinuation of study treatment.

Throughout the study:

Patients were instructed to continue taking their background lipid modifying therapy (TML) throughout the study (with the exception of EZE, statins, red yeast rice, and fibrates [other than fenofibrate]).

Allowable TMLs (if applicable) were stable (including dose) from screening to end-of-treatment visit, except for exceptional circumstances where primary concerns (including, but not limited to, TG alert reported by the central laboratory) will guarantee said changes, according to the criteria of the researcher.

The maximum study duration per patient was up to approximately 39 weeks (9 months): up to 1 week for screening; 2 weeks to wash; 4 weeks for single-blind placebo run-in; 24 weeks for double-blind treatment; and 8 weeks of follow-up. End of study was defined as the patient's last site visit, as scheduled by protocol.

PATIENT SELECTION

A sufficient number of patients were selected and included in the single-blind placebo run-in period to ensure that at least 250 patients (100: 100: 50; mAb316P: EZE: atorvastatin) were eligible for randomization into the period of double blind treatment.

Study Population: The study population consisted of patients with hypercholesterolemia (HFhe or H nonF) and moderate, high, or very high CV risk who were intolerant to statins. Moderate CV risk was defined as a 10-year risk of fatal CVD calculated SCORE> 1 and <5% (ESC / EAS 2011). High CV risk was defined as a 10-year risk SCORE for fatal CVD> 5% (ESC / EAS 2011), moderate chronic kidney disease (CKD), type 1 or type 2 diabetes mellitus with no affected organ damage, or HFhe. Very high CV risk was defined as a history of documented CHD, ischemic stroke, peripheral arterial disease (PAD), transient ischemic attack (TIA), abdominal aortic aneurysm, carotid artery occlusion> 50% without symptoms, carotid endarterectomy, or carotid artery stent procedure, renal artery stenosis, renal artery stent procedure, type 1 or type 2 diabetes mellitus with affected organ damage.

Documented history of CHD was defined as the occurrence of one or more of the following: (i) acute MI; (ii) silent IM; (iii) Unstable angina; (iv) Coronary revascularization procedure (eg, percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]); and / or (v) clinically significant CHD diagnosed by invasive or non-invasive testing (such as coronary angiography, treadmill stress test, stress echocardiography, or nuclear magnetic resonance imaging).

Inclusion criteria: To be eligible for the present study, patients must have primary hypercholesterolemia (heHF or non-FH) with moderate, high, or very high cardiovascular risk, and a history of statin intolerance.

The diagnosis of heHF was made either by genotyping or by clinical criteria. For patients who were not genotyped, the clinical diagnosis was required to be a certain / determinate diagnosis and could be based on or the criteria by Simon Broome or the WHO / Dutch Lipid NetWork criteria. The moderate, high and very high CV risk was as defined above.

Definition of statin intolerance: Inability to tolerate at least 2 statins prior to the lowest authorized daily dose due to symptoms related to skeletal muscles, other than those due to exertion or trauma, such as pain, weakness, or pain in the colicky type, which started or increased during statin therapy and stopped when statin therapy was stopped.

Exclusion criteria: Potential patients who met any of the following criteria (subcategorized in points A, B and C, below) were excluded from the study:

A. Exclusion criteria related to the study methodology:

1. Calculated serum LDL-C <70 mg / dL (1.81 mmol / L) and very high CV risk (as defined elsewhere herein) at screening visit (Week -7);

2. Calculated serum LDL-C <100 mg / dL (2.59 mmol / L) and high or moderate CV risk (as defined elsewhere herein) at screening visit (Week -7) ;

3. A 10-year risk SCORE for fatal CVD <1% at screening visit (Week -7); 4. Use of a statin that is or is above the lowest authorized daily dose within 4 weeks prior to the screening visit (Week -7);

5. Had skeletal muscle-related adverse events (SEs) other than those due to exertion or trauma during the 4-week single-blind placebo run-in;

6. Had skeletal muscle-related AE (s) other than those due to exertion or trauma at the time of screening (Week -7), beginning of the single-blind placebo run-in period (Week -4), or day 1 / week 0;

7. Not on a stable dose of lipid modifying therapy (TML) for at least 4 weeks and / or fenofibrate for at least 6 weeks, as applicable, prior to the screening visit (Week -7) or from screening to randomization, as applicable;

8. Use of fibrates, other than fenofibrate, within 6 weeks of the screening visit (Week -7); 9. Use of nutraceuticals or non-prescription therapies known to affect lipids, at a dose / amount that has not been stable for at least 4 weeks prior to the screening visit (Week -7) or between screening and screening visits. randomization;

10. Use of red yeast rice from the screening visit (Week -7) to the end of study visit (Week 32);

11. Use of analgesics for which the dose is not planned to be stable from the screening visit to the end of study visit (Week 32);

12. Diagnosis of fibromyalgia;

13. History of severe neuropathic pain;

14. History of rheumatological disease associated with symptoms that can be confused with symptoms of statin intolerance (for example, rheumatoid arthritis);

15. History of myalgia or myopathy that started or increased during TML treatment, other than statin therapy, and stopped when TML was stopped;

16. Known history of seizure disorder;

17. History of previous transplant surgery;

18. Use of medications that require intramuscular administration, or planned intramuscular injections during the study;

19. Known history of myopathy, other than statin-associated myopathy;

20. History of rhabdomyolysis (defined as evidence of organ damage with creatine kinase> 10,000 IU / L);

21. Presence of any clinically significant uncontrolled endocrine disease known to influence in serum lipids or lipoproteins. [Note: Patients on thyroid replacement therapy were allowed to be included if thyroxine dosage was stable for at least 12 weeks prior to screening and thyroid-stimulating hormone (TSH) level was within the normal central laboratory range. on the screening visit (Week -7)];

22. History of bariatric surgery within 12 months prior to screening visit (Week -7); 23. Unstable weight (variation> 5 kg) within 2 months before the screening visit (Week -7); 24. Known history of PCSK9 loss of function (eg, genetic mutation or sequence variation);

25. Known history of homozygous FH;

26. Newly diagnosed diabetes mellitus (within 3 months before the randomization visit [Week 0 / Day 1]) or poorly controlled diabetes (hemoglobin A1c [HbA1c]> 8.5%);

27. Use of systemic corticosteroids, unless used as replacement therapy for pituitary-adrenal disease with a stable regimen for at least 6 weeks prior to randomization. Note: Topical, intra-articular, nasal, inhaled and ophthalmic steroid therapies were not considered "systemic" and were allowed;

28. Use of estrogen or testosterone therapy unless the regimen had been stable in the 6 weeks prior to the screening visit (Week -7), and with no plans to change the regimen during the study;

29. History of receiving plasmapheresis treatment within 2 months before the screening visit (Week -7), or plans to receive plasmapheresis during the study;

30. Systolic blood pressure> 160 mm Hg or diastolic blood pressure> 100 mm Hg at the screening visit (Week -7) or randomization time (Week 0 / Day 1);

31. History of myocardial infarction (MI), unstable angina leading to hospitalization, coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), uncontrolled heart arrhythmia, carotid surgery, or endovascular graft , cerebrovascular accident, transient ischemic attack, carotid revascularization, endovascular procedure, or surgical intervention for peripheral vascular disease within 3 months prior to screening visit (Week -7);

32. Patients currently participating in a rehabilitation or exercise program

33. New York Heart Association history of class III or IV heart failure within the past 12 months;

34. Age <18 years or legal age of majority at the screening visit (Week -7), whichever is older; 35. Not previously informed about a low cholesterol diet before the screening visit (Week -7); 36. Known history of hemorrhagic stroke;

37. History of cancer within the last 5 years, except properly treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ ;

38. Known history of HIV positivity;

39. Use of any active investigational drug within 1 month or 5 half-lives, whichever is longer;

40. Prior participation in any clinical trial of mAb316P (alirocumab) or any other anti-PCSK9 monoclonal antibody;

41. Conditions / situations such as: (A) Any clinically significant abnormality identified at the time of selection that, in the discretion of the investigator or any collaborating investigator, would prevent the safe termination of the study or restrict the assessment of evaluation criteria; for example, major systemic diseases, patients with a short life expectancy; (B) Considered by the investigator or any collaborating investigator as inappropriate for this study for any reason, for example: (i) Considered unable to meet specific protocol requirements, such as scheduled visits; (ii) Considered unable to administer or tolerate long-term injections according to the patient or the investigator; (iii) Researcher or any collaborating researcher, pharmacist, study coordinator, other study personnel or relatives of the same directly involved in carrying out the protocol, etc .; (iv) Presence of any other condition (eg, geographic or social), both current and anticipated, that the investigator feels would restrict or limit the patient's participation for the duration of the study;

42. Laboratory data during the selection period (not including randomization laboratories): (A) Positive test for Hepatitis B surface antigen and / or Hepatitis C antibody; (B) Positive for beta-hCG in serum or urine pregnancy test in women of childbearing potential; (C) TG> 400 mg / dL (> 3.95 mmol / L) (1 repeat lab allowed); (D) eGFR <30 mL / min / 1.73 m2 according to the equation of the MDRD 4-Variable Study (calculated by the central laboratory); (E) Alanine aminotransferase (ALT) or aspartate aminotransferase (AST)> 3 x upper limit of normal (ULN) (1 repeat laboratory allowed); (F) CPK> 2 x Ul N; (g) TSH <lower limit of normal (LLN) or> ULN from central laboratory; (H) Vitamin D3 <20 ng / mL [50 nmol / L];

B. Exclusion criteria related to the active comparator or other study drugs:

43. All contraindications to the other study drugs (atorvastatin and EZE) or warnings / precautions for use (where appropriate) as presented in the respective national product labeling;

C. Exclusion criteria related to the active agent (mAb316P):

44. Known hypersensitivity to monoclonal antibody therapeutics;

45. Pregnant or lactating women;

46. Women of childbearing potential without effective birth control contraception and / or who are unwilling or unable to take a pregnancy test.

Patients who prematurely discontinued the study were not replaced.

STUDY TREATMENTS

The study treatment was a single 1 mL subcutaneous (SC) injection for a 75 or 150 mg dose of mAb316P or placebo provided in an autoinjector, administered in the abdomen, thigh, or outer upper arm area. During the double-blind treatment period (Week 0 to 24), eligible patients were randomized to receive: (1) mAb316P 75 mg SC once every two weeks (Q2W) placebo to oral ezetimibe (EZE) / atorvastatin once per day (PO QD); or (2) EZE 10 mg PO QD placebo for mAb316P SC Q2W; or (3) Atorvastatin 20 mg PO QD placebo for mAb316P SC Q2W.

Ezetimibe 10 mg and atorvastatin 20 mg were over-encapsulated in a capsule to match the placebo for EZE / atorvastatin to ensure double blindness. Ezetimibe 10 mg, atorvastatin 20 mg and placebo were indistinguishable from each other. Study drug was administered by SC Q2W injection, beginning at Week 0 and continuing until the last injection (Week 22), 2 weeks prior to the end of the double-blind treatment period.

The first injection of the double-blind study drug was administered at the clinical site as soon as possible after the patient was randomized into the study. The patient was observed at the clinical site for 30 minutes after the first injection. Subsequent injections were administered by the patient / caregiver outside the clinic according to the administration schedule. On days where the study clinic visit coincided with administration, the study drug dose was administered after all study evaluations had been performed and all laboratory samples had been collected.

The study drug was ideally administered Q2W SC at approximately the same time of day; however, a window period of ± 3 days was considered acceptable. Time of day was based on patient preference.

In the event that an injection was delayed for more than 7 days or missed completely, the patient was instructed to return to the original study drug administration schedule without administering additional injections. If the delay was less than or equal to 7 days from the missed date, the patient was instructed to administer the delayed injection and then resume the original administration schedule. Patients were allowed to choose to have the study site staff administer their injections and return to the Q2W site for their injections. Placebo for EZE / atorvastatin, EZE 10 mg, or atorvastatin 20 mg capsules were taken orally once daily. Detailed instructions for the transport, storage, preparation, and administration of study drug will be provided by site to the patient / caregiver.

Dose modification ( "up-titration option")

At the Week 12 visit, based on their LDL-C at Week 8 and CV risk at baseline (defined elsewhere herein), patients either continued to receive mAb316P 75 mg Q2W or adjusted accordingly. ascending your doses, as follows:

(A) Very high CV risk patients, in a blinded mode, or: (1) continued to receive mAb316P 75 mg Q2W from Week 12 onward until the last injection at Week 22 if their LDL-C at Week 8 was <70 mg / dL (1.81 mmol / L); or (2) received a dose that was titrated up to mAb316P 150 mg Q2W from Week 12 onward to the last injection at Week 22 if their LDL-C at Week 8 was> 70 mg / dL (1, 81 mmol / L).

(B) High or moderate CV risk patients, in a blinded mode, or: (1) continued to receive mAb316P 75 mg Q2W from Week 12 onward until the last injection at Week 22, if their LDL-C at Week 8 was <100 mg / dL (2.59 mmol / L); or (2) received a dose that was titrated up to mAb316P 150 mg Q2W from Week 12 onward to the last injection at Week 22 if their LDL-C at Week 8 was> 100 mg / dL (2, 59 mmol / L).

Injection training

During the first scheduled visit of the single-blind placebo run-in period (at Week -4), patients were instructed on the administration of study drug using a single-blind autoinjector containing placebo for mAb316P and self-administered the first dose at the clinic. The second dose of study drug during the single-blind placebo run-in period (at Week -2) was administered by the patient or caregiver at home using the second single-blind placebo autoinjector for mAb316P.

The first injection during the double-blind treatment period was administered at the site on the day of randomization (Week 0 [day 1] - visit 4) and as soon as possible after randomization in the study, using an autoinjector. of the kit to which the patients were randomized. Subsequent injections were administered by the patient (self-injection) or by a designated caregiver, or patients had the option of returning to the Q2W site for the injection to be administered by study personnel. All patients and caregivers who planned to inject the study drug were trained by study staff prior to administering the injections.

Investigational treatment

Sterile mAb316P drug was delivered at a concentration of 75 mg / mL or 150 mg / mL in histidine, pH 6.0, polysorbate 20, and sucrose in an autoinjector. Placebo equivalent to mAb316P in the same formulation as mAb316P, without the addition of protein, was delivered into an autoinjector. Ezetimibe 10 mg and atorvastatin 20 mg were over-encapsulated in one capsule to match placebo for EZE / atorvastatin to ensure double blindness. Ezetimibe 10 mg, atorvastatin 20 mg, and placebo were indistinguishable from each other.

Background treatment

Patients were required to be on stable TML for at least 4 weeks (6 weeks for fenofibrate) prior to the screening visit (Week -7). Patients were instructed to continue taking their background TML throughout the study (other than EZE, statins, red yeast rice, and fibrates [other than fenofibrate]). The lipid profile values of the samples obtained after randomization were blinded. No change was made in the patient's background TML from the screening visit (Week -7) to the end of study visit (Week 32). No dose adjustment, interruption or initiation of another TML (including prohibited TML) occurred during this time, except for exceptional circumstances whereby the main concerns warranted such changes, at the discretion of the investigator.

In summary, the background TML did not change from the selection to the follow-up visit. Other background treatments allowed in the study included: nucleic acid binding sequestrants (such as cholestyramine, colestipol, colesevelam); nicotinic acid; fenofibrate; and omega-3 fatty acids (> 1000 mg per day).

Randomization

Patients were randomized to receive mAb316P, EZE, or atorvastatin during the treatment period of the double-blind study using a 2: 2: 1 ratio, with permuted block randomization. Randomization was stratified according to a history of documented MI or ischemic stroke [Yes / No].

Blind

Inclusion of single-blind placebo. For the single-blind placebo run-in and according to the single-blind design, only study patients remained blind to treatment; investigators were not blinded to study treatment. Placebo for mAb316P was delivered in autoinjectors. Oral placebo for EZE / atorvastatin was given in a capsule to preserve blinding.

Double-blind treatment period. For the double-blind treatment period, mAb316P and placebo for mAb316P were provided in identically corresponding autoinjectors, and were packaged and labeled identically to preserve blinding. Ezetimibe and atorvastatin were over-encapsulated in a capsule to match the placebo for EZE / atorvastatin to ensure double blindness. Ezetimibe 10 mg, atorvastatin 20 mg, and placebo were indistinguishable from each other.

Each double-blind treatment kit was labeled with a number, which was generated by a computer program. Treatment kit numbers were obtained by the investigator at the time of patient randomization and subsequent scheduled patient visits by a centralized treatment allocation system that was available 24 hours a day, 7 days a week.

According to the double-blind design, study patients, investigators, and study site personnel followed blinded to study treatment and did not have access to randomization (treatment codes), except in specifically defined circumstances.

The lipid parameter values of the blood samples obtained after the randomization visit, analyzed by the central laboratory, were not communicated to the sites so that they were not able to deduce the treatment group of their patients based on the level of LDL-C obtained. The sponsor's operations team did not have access to lipid parameters after randomization and until after the final database closure occurred. Sponsor sites and operations team were blinded to up-titration of the dose from 75 mg to 150 mg, if one patient met the criteria for up-titration. Blind study drug kits coded with a medication numbering system were used. To maintain blinding, the lists connecting these codes with the batch numbers of products involved in conducting the study were not accessible to individuals.

Anti-drug antibody (ADA) results were not reported to the sites, and the sponsor's operations team did not have access to the results associated with patient identification until after the final closure of the database. Additional antibody sample (s) were obtained 6 to 12 months after the last dose, and approximately every 3 to 6 months thereafter from patients who had anti-mAb316P antibody titers of 240 or higher at the follow-up visit. , until the titer returned to low 240. To maintain study blinding, requests for post-study anti-mAb316P antibody sample collection were made from patients with titers less than 240 at the follow-up visit.

Simultaneous medications

If deemed necessary for the well-being of the patient and unlikely to interfere with the study drug, concurrent medications (other than those prohibited during the study) were allowed at the investigator's discretion, at a stable dose (where possible ). Any other concurrent medications (medications) were allowed and recorded as appropriate.

Nutraceuticals or over-the-counter therapies that can affect lipids were allowed only if they had been used at a stable dose for at least 4 weeks prior to the screening visit (Week -7) and were maintained from the screening visit to the end study (Week 32). Examples of such nutraceuticals or over-the-counter therapies include: omega-3 fatty acids at doses <1000 mg, plant stanols such as those found in Benecol, flax seed oil, and psyllium.

Concurrent medications prohibited from the initial screening visit to the follow-up visit included the following: statins; fibrates, other than fenofibrate; EZE; and red yeast rice products.

STUDY ASSESSMENT CRITERIA

Baseline characteristics included standard demographics (eg, age, race, weight, height, etc.), disease characteristics including personal history, and medication history for each patient. Historical information regarding statins, doses and events related to actual skeletal muscles leading to the diagnosis of "statin intolerance" were collected as part of the medical / surgical history.

Primary efficacy endpoint: The primary efficacy endpoint was the percent change in LDL-C calculated from baseline to Week 24, which was defined as: 100 x (LDL-C value calculated at Week 24 - LDL-C value calculated at baseline) / LDL-C value calculated at baseline. A baseline LDL-C value was required for each patient as the baseline LDL-C value was the last LDL-C level obtained before the first injection of the double-blind study drug.

The calculated LDL-C at Week 24 was the LDL-C level obtained within the Week 24 analysis window and during the main efficacy period. The primary efficacy period was defined as the time from the first injection of the double-blind study drug to 21 days after the last injection of the double-blind study drug or to the upper limit of the Week 24 analysis window. , The thing that happens first.

All calculated LDL-C values (scheduled or unscheduled, fasting or non-fasting) were used to provide a value for the primary efficacy endpoint if appropriate as defined above. The analysis window used to assign a moment of time to a measurement was defined in a statistical analysis plan (SAP).

Secondary efficacy endpoints: The secondary endpoints for the present study included the following:

(1) The percent change in LDL-C calculated from baseline to Week 12: The LDL-C calculated at Week 12 was the LDL-C level obtained within the Week 12 analysis window and during the efficacy period of 12 weeks. The 12-week efficacy period is defined as the time from the first injection of double-blind study drug to contact at visit 6 or up to 21 days later. of the last double-blind injection of study drug, whichever occurs first.

(2) The percentage change in ApoB from baseline to Week 24.

(3) The percent change in non-HDL C from baseline through Week 24.

(4) The percent change in total C from baseline through Week 24.

(5) The percentage change in ApoB from baseline to Week 12.

(6) The percent change in non-HDL C from baseline through Week 12.

(7) The percent change in total C from baseline through Week 12.

(8) The proportion of patients who reach the LDL-C goal at Week 24; for example, LDL-C <70 mg / dL (1.81 mmol / L) for very high CV risk, or LDL-C <100 mg / dL (2.59 mmol / L) for patients with moderate CV risk or high, defined as: (number of patients whose calculated LDL-C value at Week 24 reaches the LDL-C target / number of patients in the modified intention-to-treat population [mTDI]) * 100, using the definition and the rules used for the primary endpoint.

(9) The proportion of patients achieving LDL-C <70 mg / dL (1.81 mmol / L) at Week 24.

(10) The percent change in Lp (a) from baseline through Week 24.

(11) The percent change in HDL-C from baseline through Week 24.

(12) The percent change in HDL-C from baseline through Week 12.

(13) The percent change in Lp (a) from baseline through Week 12.

(14) The percent change in fasting TG from baseline through Week 24.

(15) The percent change in fasting TG from baseline to Week 12.

(16) The percentage change in ApoA-1 from baseline to Week 24.

(17) The percentage change in ApoA-1 from baseline to Week 12.

(18) The proportion of patients who reach their LDL-C goal at Week 12; for example, LDL-C <70 mg / dL (1.81 mmol / L) in case of very high CV risk, and LDL-C <100 mg / dL (2.59 mmol / L) in case of moderate CV risk or high, defined as: (number of patients whose calculated LDL-C at Week 12 reaches the LDL-C target / number of patients in the mTDI population) * 100.

(19) The proportion of patients achieving LDL-C <100 mg / dL (2.59 mmol / L) at Week 24.

(20) The proportion of patients achieving LDL-C <100 mg / dL (2.59 mmol / L) at Week 12.

(21) The proportion of patients achieving LDL-C <70 mg / dL (1.81 mmol / L) at Week 12.

(22) The absolute change in calculated LDL-C (mg / dL and mmol / L) from baseline to weeks 12 and 24. (23) The change in ApoB / ApoA-1 ratio from baseline to weeks 12 and 24.

(24) The proportion of patients with ApoB <80 mg / dL (0.8 mmol / L) at Weeks 12 and 24.

(25) The proportion of patients with non-HDL C <100 mg / dL at Weeks 12 and 24.

(26) Proportion of patients with calculated LDL-C <70 mg / dL (1.81 mmol / L) and / or> 50% reduction in calculated L-C-L (if calculated LDL-C> 70 mg / dL [1.81 mmol / L]) at Weeks 12 and 24.

Other endpoints: (1) Anti-drug anti-mAb316P antibody status (positive / negative) and titers assessed throughout the study; (2) The percent change in high sensitivity C-reactive protein (hs-CRP) from baseline to Week 24; (3) The absolute change in HbA1c (%) from baseline to Week 24. STUDY PROCEDURES

All laboratory samples were collected prior to administering the study drug dose. Blood samples for lipid panels were collected in the morning, fasting (ie overnight, at least a 10-hour fast and abstaining from smoking) for all clinic visits. It was recommended not to consume alcohol within 48 hours and not to do intense physical exercise within 24 hours prior to blood sampling. Note: if the patient was not fasting, the blood sample was not collected and a new appointment was scheduled the day after (or as soon as possible on that date) with a reminder that the blood sample should be taken on an empty stomach (at least 10 hours).

Total C, HDL-C, TG, ApoB, ApoA-1 and Lp (a) were directly measured by a central laboratory according to a predetermined schedule. Low-density lipoprotein cholesterol was calculated using Friedewald's formula at all visits (except Week -15 and the follow-up visit). If TG values exceeded 400 mg / dL (4.52 mmol / L), then the central laboratory measured (using the beta quantification method) LDL-C instead of calculating it. HDL-C was not calculated by subtracting HDL-C from total C. The ApoB / ApoA-1 ratio was calculated.

Lipid panel (fasting): Blood samples were collected for the lipid panel (total C, TG, HDL-C, and calculated LDL-C) after at least a 10 hour fast at previously specified time points.

Specialized lipid panel (fasting): Blood samples were collected for the specialized lipid panel (ApoB, ApoA-1, ApoB / ApoA-1 ratio and Lp [a]) after at least a 10 hour fast at times previously specified times.

Blood pressure and heart rate: Blood pressure and heart rate were evaluated at previously specified time points. Blood pressure was preferably measured while sitting under standard conditions, at approximately the same time of day, on the same arm, with the same apparatus (after the patient had rested comfortably in a sitting position for at least 5 minutes). At the first screening visit, blood pressure was measured in both arms. The arm with the highest diastolic pressure was determined at the first visit, and blood pressure was measured in that arm throughout the study. The highest value was recorded in the electronic data collection notebook (eCRF). Heart rate was measured at the time of blood pressure measurement.

Physical examination: A thorough and complete physical examination, including height and weight, was performed at the screening visit (visit 1). The physical examination was performed with body weight at previously specified time points.

Body weight and height: Body weight was obtained with the patient wearing very light underwear and clothing and without shoes, with an empty bladder. The same scale was preferably used throughout the study. The use of calibrated scales was recommended, if possible.

Electrocardiogram: Electrocardiograms were performed before blood was drawn during visits that required blood draws. A standard 12-lead ECG was performed at previously specified time points. The 12-lead ECGs were performed after at least 10 minutes of rest and in the supine position. Electrodes were placed in the same location, as much as possible, for each ECG trace throughout the study. The ECG was madly interpreted by the investigator. Each trace was analyzed in comparison to the trace recorded in the selection.

Laboratory tests: All laboratory samples were collected before the study drug dose was administered. Samples for laboratory testing were collected at pre-specified time points and analyzed by a central laboratory during the study.

RESULTS

Arrangement of subjects

A total of 519 patients were selected for this study, of which 361 (69.6%) patients completed the selection and entered the single-blind placebo run-in period. For patients who entered the single-blind placebo run-in period, 47 (13%) patients discontinued placebo treatment prematurely, among which 29 (8%) patients discontinued due to skeletal muscle-related adverse events ( that is, they met the specified exclusion criteria). Therefore, 314 patients (87%) completed the run-in period and were eligible to be randomized in the double-blind period.

A total of 314 patients (63 to the atorvastatin group, 125 to the ezetimibe group, and 126 to the mAb316P group) were randomized, with a single patient in the randomized ezetimibe group, but who did not receive study treatment due to reason of "Others" (problems setting the required protocol visits). Therefore, the safety population contained 313 patients. This patient did not return for any evaluation afterwards and was therefore not included in the TDI population. Furthermore, 3 more patients were excluded from the IDT population, 1 (in the ezetimibe group) due to a lack of LDL-C value at baseline and the other 2 (1 in the atorvastatin group and 1 in the ezetimibe) due to a lack of post-baseline evaluations. Finally, 9 additional patients (2 in the atorvastatin group, 4 in the ezetimibe group, and 3 in the mAb316P group) were excluded from the mTDI population due to the lack of post-baseline assessments during treatment.

Regarding the data cutoff of the first stage, the status of the patients during the study was as follows: 220 (70.1%) patients completed the 24-week double-blind treatment period: 42 (66.7% ) in the atorvastatin group, 82 (65.6%) in the ezetimibe group and 96 (76.2%) in the ezetimibe group.

93 (29.6%) patients discontinued study treatment prematurely before completing the double-blind treatment period: 21 (33.3%) in the atorvastatin group, 42 (33.6%) in the ezetimibe group and 30 (23.8%) in the mAb316P group. 70 (22.3%) patients terminated study treatment prematurely due to adverse events: 16 (25.4%) in the atorvastatin group, 31 (24.8%) in the ezetimibe group, and 23 (18, 3%) in the mAb316P group. 2 (3.2%) patients terminated study treatment prematurely due to poor protocol compliance, and both patients were in the atorvastatin group. 21 (6.7%) patients terminated study treatments prematurely due to various other reasons: 3 (4.8%) in the atorvastatin group, 11 (8.8%) in the ezetimibe group, and 7 (5 , 6%) in the mAb316P group.

281 (89.5%) patients were administered at least one open-label mAb316P treatment, and are therefore included in the OLE population.

9 (3.2%) patients terminated study treatment in the OLE period, regarding the data cutoff for this KRM, and 8 (2.8%) of patients terminated due to an adverse event.

The remaining 272 (96.8%) patients in the OLE population are ongoing and receiving study treatment in the OLE period.

The baseline characteristics of the patients included in the study are summarized in Table 10.

Table 10. Initial level characteristics

The lipid parameters at baseline are summarized in Table 11.

Table 11. Lipids at the baseline level

Efficacy results

The placebo run-in was completed by 87.0% (314/361) of patients. Overall, demographic characteristics, baseline disease characteristics, statin intolerance questionnaire, baseline efficacy lipid parameters, history of TML, and background TML use were comparable among randomized patients. to each of the three study treatment groups. Fifteen percent of the patients had heterozygous FH. The mean LDL-C at baseline was 187.3 mg / dL in the atorvastatin group, 194.2 mg / dL in the ezetimibe group, and 191.1 mg / dL in the mAb316P group. In total, 89.5% of the randomized patients entered the open-label extension.

Analysis of the efficacy endpoints of the double-blind period results in the order of statistical hierarchical tests as specified in the previous protocol (with the multiple controlled trials at the 0.05 level of significance) shown in Table 12. Key primary and secondary efficacy analyzes were performed comparing mAb316P-treated patients with ezetimibe-treated patients. For clarification, IDT analysis is defined for patients in the IDT population and includes all endpoint assessments in one analysis window, regardless of treatment or study treatment dosage status (i.e., includes post-treatment assessments ). During-treatment analysis is defined for patients in the mTDI population and includes all endpoint assessments from the first drug in the double-blind study (capsule or injection, whichever is first) to 21 days after the last injection of double-blind study drug, or 3 days after last capsule ingestion, whichever comes first (ie, includes efficacy treatment period evaluations). Note: A result is statistically significant if the P value is <0.05, in the hierarchical test order.

Table 12. Summary of efficacy analysis results (percent change from baseline)

For patients treated with mAb316P, the mean MC LDL-C at Week 24 was 108.5 mg / dL which represents a change in LDL-C level from baseline of -84 mg / dL (that is, say, -45.0%). In contrast, for patients treated with EZE, the mean MC LDL-C value at Week 24 was 159.9 mg / dL representing a change in LDL-C level from baseline of -33 mg / dL. dL (i.e. -14.6%). The difference in% of the mean MC in LDL-C at Week 24 for mAb316P-treated patients versus ezetimibe-treated patients was -30.4% (SE = 3.1, p <0.0001).

Fifty-two mAb316P patients (41.9%) reached the LDL-C goal at Week 24, while only 5 EZE patients (4.4%) reached the LDL-C goal at Week 24 (value of p <0.0001). For the purposes of this analysis, the LDL-C target was defined as less than 70 mg / dL for very high risk patients, and less than 100 mg / dL for moderate and high risk patients. Additionally, 54/109 mAb316P patients (49.5%) underwent upward titration from 75 mg Q2W to 150 mg Q2W at Week 12 (based on Week 8 LDL-C level) .

A summary of reductions in selected secondary lipid parameters (C non-HDL, Apo B, and Lp (a)) at Week 24 is shown in Table 13.

Table 13. Reductions in Secondary Lipid Parameters at Week 24

The primary efficacy endpoint and more than two-thirds of the key secondary efficacy endpoints achieved statistically significant benefit in favor of patients treated with mAb316P according to the hierarchical testing procedure.

Safety results

A total of 313 patients were randomized and received at least a partial dose of double-blind treatment of the study (Safety Population), and 281 patients received study treatment OLE (OLE Population). Treatment-emergent SAEs occurred in a total of 29 patients, specifically, 7 (11.1%) patients in the atorvastatin treatment group, 10 (8.1%) patients in the ezetimibe treatment group, and 12 ( 9.5%) patients in the mAb316P treatment group. There was no more than 1 report on any preferred event term for each of the three treatment groups, with the sole exception of 4 (3.2%) patients who reported non-cardiac chest pain in the ezetimibe treatment group.

A total of 70 (22.4%) patients prematurely discontinued study treatment due to TEAE. Specifically, 16 (25.4%) patients in the atorvastatin treatment group, 31 (25.0%) patients in the ezetimibe treatment group, and 23 (18.3%) patients in the ezetimibe treatment group. mAb316P terminated study treatment early. The most predominant events causing premature termination were contained in the SOC Musculoskeletal and connective tissue disorders (14 [22.2%] patients in the atorvastatin group, 26 [21.0%] patients in the ezetimibe group and 20 [15.9%] patients in the ezeti miba group), with the most frequently reported preferred term myalgia.

No patient deaths were reported at the time of interim analysis.

TEAEs occurred in 54 (85.7%) patients in the atorvastatin treatment group, 100 (80.6%) patients in the ezetimibe treatment group, and 104 (82.5%) patients in the ezetimibe treatment group. mAb316P. TEAEs that occurred in> 5% of patients in any treatment group are: - nasopharyngitis (3.2% / 8.1% / 6.3% for atorvastatin / ezetimibe / mAb316P, respectively); - upper respiratory tract infection (3.2% / 4.0% / 5.6% for atorvastatin / ezetimibe / mAb316P, respectively); - headache (6.3% / 4.8% / 4.8% for atorvastatin / ezetimibe / mAb316P, respectively); - paresthesia (6.3% / 0 / 3.2% for atorvastatin / ezeti miba / mAb316P, respectively); - arthralgia (7.9% / 7.3% / 5.6% for atorvastatin / ezetimibe / mAb316P, respectively); - back pain (7.9% / 5.6% / 4.0% for atorvastatin / ezetimibe / mAb316P, respectively); - muscle spasms (11.1% / 7.3% / 4.0% for atorvastatin / ezetimibe / mAb316P, respectively); - muscle weakness (6.3% / 1.6% / 0.8% for atorvastatin / ezetimibe / mAb316P, respectively); - myalgia (27% / 23.4% / 24.6% for atorvastatin / ezetimibe / mAb316P, respectively); - and fatigue (7.9% / 3.2% / 4.8% for atorvastatin / ezetimibe / mAb316P, respectively).

The SOCs with a patient frequency> 5% in the mAb316P group and a higher frequency in the mAb316P group compared to both the atorvastatin and EZE treatment groups were: "Psychiatric Disorders" occurred in 9 (7 , 1%) patients in the mAb316P treatment group, versus 2 (3.2%) in the atorvastatin treatment group and 5 (4.0%) patients in the EZE treatment group. The most common event was 5 (4.0%) insomnia reports in the mAb316P treatment group versus 1 (1.6%) of such events in the atorvastatin treatment group versus 2 (1.6%) of these reports in the ezetimibe treatment group. "Ear and labyrinth disorders" occurred in 8 (6.3%) patients in the mAb316P treatment group, compared with 1 (1.6%) patient in the atorvastatin treatment group and 4 (3.2 %) patients in the EZE treatment group. The most common event was 6 (4.8%) reports of vertigo in the mAb316P treatment group versus 1 (1.6%) of such reports in the atorvas tatin treatment group versus 2 (1.6%). ) of these reports in the ezetimibe treatment group. "Cardiac disorders" occurred in 10 (7.9%) patients in the mAb316P treatment group, compared with 2 (3.2%) patients in the atorvastatin treatment group and 6 (4.8%) patients in the EZE treatment group. The most common event was 4 (3.2%) reports of palpitations in the mAb316P treatment group versus 0 of those reports in the atorvastatin treatment group versus 2 (1.6%) of those reports in the group. treatment with ezetimibe. The "Investigations" occurred in 9 (7.1%) patients in the mAb316P treatment group, compared with 3 (4.8%) patients in the atorvastatin treatment group and 7 (5.6%) patients in the EZE treatment group. The only SOC with a higher frequency in both the atorvastatin and EZE treatment groups compared to the mAb316P treatment group was musculoskeletal and connective tissue disorders.

For TEAEs of special interest (AESIs), results are presented by groupings of pre-defined SMQ or CMQ preferred terms: Treatment-emergent injection site reactions (ISRs) occurred in 1 (1.6%) patient in the treatment group with atorvastatin, 6 (4.8%) patients in the ezetimibe treatment group and 6 (4.8%) patients in the mAb316P treatment group. General allergic TEAEs, identified using the MedDRA SMQ of "Hypersensitivity" occurred in 4 (6.3%) patients in the atorvas tatin treatment group, 9 (7.3%) patients in the ezetimibe treatment group, and 12 (9.5%) patients in the mAb316P treatment group. Treatment-emergent neurological AEs occurred in 8 (12.7%) patients in the atorvastatin treatment group, 4 (3.2%) patients in the ezetimibe treatment group, and 11 (8.7%) patients in the mAb316P treatment group. The most common preferred terms were paresthesia (6.3% / 0 / 3.2% for atorvastatin / ezetimibe / mAb316P, respectively) and muscle weakness (6.3% / 1.6% / 0.8% for atorvas tatin / ezetimibe / mAb316P, respectively). Treatment-emergent neurocognitive disorders occurred in zero patients in the atorvastatin treatment group, 2 (1.6%) patients in the ezetimibe treatment group, and 3 (2.4%) patients in the mAb316P treatment group.

For patients with cardiovascular events identified for adjudication, one (0.8%) patient was positively adjudicated for nonfatal MI, and this patient was in the mAb316P treatment group.

Regarding the frequency of patients with 2 consecutive calculated LDL-C measurements lower than 25 mg / dL, no patient had a manifestation in any of the three treatment groups.

Skeletal muscle-related TEAEs are defined twice for this study, specifically for events collected in the skeletal muscle-related CRF and again by CMQ (as defined in the protocol appendix). A total of 99 (31.6%) patients reported a preferred term of CMQ, specifically 25 (39.7%) patients in the atorvastatin treatment group, 40 (32.3%) patients in the treatment group with ezetimibe and 34 (27.0%) patients in the mAb316P treatment group. The most prevalent CMQ-defined preferred terms causing skeletal muscle-related events were myalgia (27% / 23.4% / 24.6% for atorvastatin / ezetimibe / mAb316P, respectively), muscle spasms (11.1% / 7, 3% / 4.0% for atorvastatin / ezetimibe / mAb316P, respectively) and muscle weakness (6.3% / 1.6% / 0.8% for atorvastatin / ezetimibe / mAb316P, respectively), all of which are contained in SCO Musculoskeletal and connective tissue disorders.

Treatment-emergent skeletal muscle-related events resulting in premature discontinuation of treatment were reported in 55 (17.6%) patients, specifically 13 (20.6%) patients in the atorvastatin treatment group, 23 (18.5%) patients in the ezetimibe treatment group and 19 (15.1%) patients in the mAb316P treatment group. No treatment-emergent serious skeletal muscle-related events were reported in any treatment group. No patient deaths due to TEAE from skeletal muscle-related events were reported in any treatment group.

Conclusions

The present study evaluated patients with a history of intolerance to at least two different statins, including one at the lower dose, due to muscle-related symptoms. Patients were randomized to receive mAb316P, ezetimibe, or atorvastatin 20 mg (one calibrator arm). The patients treated in this study had very high LDL-C levels when they first entered the trial (between 187-193.5 mg / dL on average). In clinical practice, 10-25 percent of patients report statin intolerance.

The present study achieved the primary efficacy endpoint in the IDT population of a statistically significant reduction in percentage change from baseline LDL-C calculated in patients treated with mAb316P (mean MC = -45.0 %), compared to ezetimibe-treated patients (mean MC = -14.6%), with a mean MC difference between treatment groups of -30.4%. For more than two-thirds of the key secondary efficacy endpoints, this study achieved statistically significant benefit in mAb316P-treated patients, compared to ezetimibe-treated patients. Based on the data available from this study, subcutaneous administration of mAb316P in patients with primary hypercholesterolaemia (heHF and nonFH) who are intolerant to statins was generally safe and well tolerated. The rate of skeletal muscle-related AEs for mAb316P-treated patients was lower in any control group, and this difference was found to be statistically significant in patients treated with atorvastatin 20 mg (as assessed at the time of the first AE skeletal muscle, p = 0.042). Furthermore, the dropout rate from the skeletal muscle-related ESA study for mAb316P-treated patients was lower than the two control groups. A similar rate of AEs was observed among all treatment groups (mAb31682 5 percent, ezetimibe 81 percent, atorvastatin 86 percent) in the present study. The most common AEs were myalgia (25 percent for mAb316, 23 percent for ezetimibe, 27 percent for atorvastatin), nasopharyngitis (6 percent for mAb316, 8 percent for ezetimibe, 3 percent for atorvastatin), arthralgia (6 percent for mAb316, 7 percent for ezetimibe, 8 percent for atorvastatin) and upper respiratory infection (6 percent for mAb316, 4 percent for ezetimibe, 3 percent for atorvastatin).

The present invention is not to be limited in scope by the specific embodiments described herein. In fact, various modifications of the invention, in addition to those described herein, will be apparent to those skilled in the art from the foregoing description and the accompanying figures.

Claims (11)

1. A pharmaceutical composition comprising 75 mg or 150 mg of an antibody or antigen-binding fragment thereof that specifically binds to human PCSK9 for use in the treatment of hypercholesterolemia in a patient who is intolerant to statins or who has history of adverse reactions to statin therapy, wherein the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs having SEQ ID NOs: 2, 3, 4, 7, 8 and 10, and wherein the antibody or antigen-binding fragment thereof is administered in the absence of statin therapy at a frequency of once every two to four weeks at a dose of 75 mg or once every two to four weeks at a dose of 150 mg. The pharmaceutical composition for use of claim 1, wherein the patient previously experienced a symptom related to skeletal muscles that started or increased while taking a lower authorized daily dose of one or more statins. The pharmaceutical composition for use of claim 1 or 2, wherein the patient previously experienced a symptom related to skeletal muscles that started or increased while taking at least two separate daily therapeutic statin regimens. The pharmaceutical composition for use of claim 3, wherein at least one of the daily therapeutic statin regimens is (a) the lowest authorized daily dose of a statin; or (b) is selected from the group consisting of: 5 mg rosuvastatin daily, 10 mg atorvastatin daily, 10 mg simvastatin daily, 20 mg lovastatin daily, 40 mg pravastatin daily, 40 mg fluvastatin a day, and 2 mg of pitavastatin a day. 5. The pharmaceutical composition for the use of any one of claims 1 to 4, wherein the patient, before or at the time of administration of the antibody or antigen-binding fragment thereof, presents hypercholesterolemia defined as a cholesterol level serum low-density lipoprotein (LDL-C) greater than approximately 70 mg / dL or greater than approximately 100 mg / dL. The pharmaceutical composition for use of any one of claims 1 to 5, wherein the patient has heterozygous familial hypercholesterolemia (HFhe) or a form of hypercholesterolemia that is non-familial hypercholesterolemia (H not F). 7. The pharmaceutical composition for the use of any one of claims 1 to 6, wherein the patient has a moderate, high or very high cardiovascular risk. The pharmaceutical composition for use of claim 7, wherein the patient, prior to or at the time of administration of the antibody or antigen-binding fragment thereof, has (a) a moderate cardiovascular risk defined as a 10-year risk score for fatal cardiovascular disease greater than or equal to 1% and less than 5%; (b) a high cardiovascular risk defined as a 10-year risk SCORE for fatal cardiovascular disease greater than or equal to 5% along with one or more of: (i) moderate chronic kidney disease, (ii) type 1 diabetes mellitus no affected organ damage, (iii) type 2 diabetes mellitus without affected organ damage, and / or (iv) heHF; or (c) a very high cardiovascular risk defined as one or more of: (i) documented coronary heart disease; (ii) ischemic stroke; (iii) peripheral stroke; (iv) peripheral arterial disease (PAD); (v) transient ischemic attack (TIA); (vi) abdominal aortic aneurysm; (vii) carotid artery occlusion> 50% without symptoms; (viii) carotid endarterectomy; (ix) carotid artery endovascular graft procedure; (x) renal artery stenosis; (xi) renal artery endovascular graft procedure; (xii) type 1 diabetes mellitus with damage to affected organs; and / or (xiii) type 2 diabetes mellitus with damage to affected organs. 9. The pharmaceutical composition for use of any one of claims 1 to 8, wherein the antibody or antigen-binding fragment thereof comprises a HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6. The pharmaceutical composition for the use of any one of claims 1 to 9, wherein five initial doses of the pharmaceutical composition comprising 75 mg of the antibody or antigen-binding fragment thereof are administered every two weeks, and wherein (a) One or more additional doses of the pharmaceutical composition comprising 75 mg of the antibody or antigen-binding fragment thereof are administered every two weeks if the patient's LDL-C level after the initial doses is less than 70 mg / dL; or (b) one or more additional doses of the pharmaceutical composition comprising 150 mg of the antibody or fragment antigen-binding thereof are administered every two weeks if the patient's LDL-C level after the initial doses is greater than or equal to 70 mg / dL. 11. Pharmaceutical composition for use in one of claims 1 to 10, wherein the pharmaceutical composition improves serum levels of one or more lipid components selected from the group consisting of: (a) reduction of the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) reduction of the patient's apolipoprotein B (ApoB) by at least 25%; (c) reduction of the patient's non-high-density lipoprotein (non-HDL C) cholesterol by at least 30%; (d) reduction of the patient's total cholesterol by at least 20%; and (e) reduction of the patient's lipoprotein a (Lp (a)) by at least 15%.