JP2020522544A - Method of treating hyperlipidemia in diabetic patients by administration of a PCSK9 inhibitor - Google Patents

Abstract

Methods are provided for treating patients at high cardiovascular risk with hypercholesterolemia and type 1 or type 2 diabetes mellitus who are receiving insulin therapy. These methods generally involve administering to a patient a pharmaceutical composition comprising an antibody or antigen-binding fragment thereof that specifically binds to the hPCSK9 antibody in combination with insulin therapy.

Description

Related Applications This application is related to US provisional patent application No. 62/517,672 filed on June 9, 2017, US provisional patent application No. 62/532,162 filed on July 13, 2017, And claim the benefit of priority to European Patent Application No. 183055565.6, filed May 4, 2018. The contents of each of these related applications are incorporated herein by reference in their entirety.

FIELD OF THE INVENTION The present invention relates to the field of therapeutic treatment of diseases and disorders associated with elevated levels of lipids and lipoproteins. More specifically, the present invention relates to the use of PCSK9 inhibitors for treating diabetic patients with hyperlipidemia, including hypercholesterolemia.

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

Hypercholesterolemia, especially increased low density lipoprotein (LDL) cholesterol (LDL-C) levels, constitutes a major risk of developing atherosclerosis and coronary heart disease (CHD). Reference 1). Low density lipoprotein cholesterol has been identified as a major target for cholesterol lowering therapy and has been accepted as an effective alternative therapeutic endpoint. Numerous studies have demonstrated that lowering LDL-C levels reduces the risk of CHD, which has a strong direct relationship between LDL-C levels and CHD events; 1 mmol/L in LDL-C. Every (about 40 mg/dL) reduction reduces cardiovascular disease (CVD) mortality and morbidity by 22%. A significant reduction in LDL-C results in a significant reduction in CHD events and comparative data from intensive versus standard statin treatments show that lower LDL-C levels are associated with a significantly higher cardiovascular (CV) risk in patients. Suggests that the profits in

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with type 1 (T1) or type 2 (T2) diabetes mellitus (DM), with insulin-treated diabetic patients being even higher. Have CV risk. Moreover, the presence of coexisting DM among persons with atherosclerosis (ASCVD) significantly increases the risk of CV events. Some studies and meta-analysis show that lowering LDL-C using statins resulted in a significant reduction in CV events in DM patients, and was associated with an additional lowering LDL-C using ezetimibe. It shows that the CV risk is reduced. However, even with the currently available treatments, many patients with DM continue to have persistent dyslipidemia and thus are at residual risk of CV events.

Sharrett et al., 2001, Circulation 104: 1108-1113.

Current LDL-C lowering drugs include proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors such as anti-PCSK9 antibodies. Although anti-PCSK9 antibodies have undergone extensive clinical research, the efficacy and safety of arilocumab in diabetic patients is not fully understood. Therefore, there is a need in the art to identify therapeutic regimens for anti-PCSK9 antibodies that provide optimal efficacy and safety for the treatment of hypercholesterolemia in diabetic patients undergoing insulin therapy at high CV risk.

The present disclosure provides a method of treating hypercholesterolemia in a diabetes mellitus (DM) patient undergoing insulin therapy. In certain embodiments, the method comprises administering one or more doses of an antibody or antigen-binding fragment thereof that specifically binds human PCSK9 to a patient with hypercholesterolemia and diabetes. In certain embodiments, the patient has an increased cardiovascular risk. In certain embodiments, the patient receives concomitant antidiabetic therapy in addition to insulin therapy.

According to one aspect, the method comprises a method of treating hypercholesterolemia in a patient having type 1 diabetes mellitus (T1DM), the method comprising:
(A) selecting (i) T1DM, and (ii) high cardiovascular risk patients receiving insulin therapy for hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and (b) The method comprises administering to a patient 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9), and the patient receives concomitant insulin therapy.

In certain embodiments, 75 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In another embodiment, 150 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In another embodiment, 300 mg of antibody or antigen-binding fragment is administered to the patient every 4 weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs of the HCVR/LCVR amino acid sequence pair comprising SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS: 2, 3 and 4 and the three light chain CDRs set forth in SEQ ID NOS: 7, 8 and 10. .. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. In certain embodiments, the antibody or antigen-binding fragment thereof competes for binding with an antibody or antigen-binding fragment thereof that comprises HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6. In a particular embodiment, the antibody or antigen-binding fragment thereof binds to the same epitope on PCSK9 as the antibody comprising HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope on PCSK9 that overlaps with an epitope of the antibody that includes HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NOs: 86, 87, 88, 90, 91, and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises HCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:85, and the amino acid set forth in SEQ ID NO:89. It includes an LCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the sequence.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of arilocumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504. In certain embodiments, the antibody or antigen-binding fragment thereof is arilocumab.

In certain embodiments, the methods disclosed herein include (c) about eight weeks later, if LDL-C levels in the patient are below a threshold level, about once every two weeks or more of the following: A dose of 75 mg of the antibody or antigen-binding fragment thereof is administered to the patient, or if LDL-C levels in the patient are above a threshold level, for example after 8 weeks, about once every 2 weeks or more of the following: It further comprises administering a dose of 150 mg of the antibody or antigen binding fragment thereof. In a particular embodiment, the threshold level is 70 mg/dL.

In certain embodiments, the methods disclosed herein include (c) about every four weeks, if after 8 weeks LDL-C levels in the patient are below a threshold level, one or more of the following: A dose of 300 mg of the antibody or antigen-binding fragment thereof is administered to the patient, or if LDL-C levels in the patient are above a threshold level, for example after 8 weeks, about once every 2 weeks or more of the following: It further comprises administering a dose of 150 mg of the antibody or antigen binding fragment thereof. In a particular embodiment, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid modification therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. In certain embodiments, LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. In certain embodiments, the statin therapy is a maximally resistant amount of statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe. In certain embodiments, the patient is intolerant to statins.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. In certain embodiments, the patient receives additional concomitant antidiabetic therapy in addition to insulin therapy. In certain embodiments, the additional concomitant anti-diabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. Or antagonist antagonist, ghrelin antagonist or inverse agonist, xenin, xenin analogue, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) Inhibitor, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 Agonists, GPR120 agonists, GPR142 agonists, systemic or low absorption TGR5 agonists, diabetic immunotherapeutic agents, anti-inflammatory agents for treating metabolic syndrome and diabetes, adenosine monopurine activated protein kinase (AMPK) stimulants, 11- Inhibitors of beta-hydroxysteroid dehydrogenase 1, activators of glucokinase, inhibitors of diacylglycerol O-acyltransferase (DGAT), modulators of glucose transporter-4, somatostatin receptor 3 agonists, lipid reducing agents, and the like Selected from the group consisting of:

In certain embodiments, the antibody or antigen-binding fragment thereof reduces LDL-C levels in a patient, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in a patient, eg, by at least 25%, 30%, 35%, or 40. In certain embodiments, the antibody or antigen-binding fragment thereof increases apolipoprotein C3 (ApoC3) levels in a patient (eg, at least about 6.0%, about 6.5%, about 7 weeks or 12 weeks after treatment). 0.0% or about 7.5%). In certain embodiments, the antibody or antigen-binding fragment thereof increases the number of lipoprotein particles in a patient (eg, at least about 20%, about 30%, about 40% or about 50% after 12 or 24 weeks of treatment). Reduce. In other embodiments, the antibody or antigen-binding fragment thereof increases the size of the patient's lipoprotein particles (eg, at least about 1.5%, about 2%, about 2.5% after 12 or 24 weeks of treatment). Or about 3%).

In certain embodiments, the antibody or antigen-binding fragment thereof does not (a) affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) affects the patient's fasting plasma glucose (FPG) levels. Does not reach

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having diabetes mellitus type 1 (T1DM), the method comprising:
Selecting (a) (i) T1DM, and (ii) patients with high cardiovascular risk receiving insulin therapy who have hypercholesterolemia that is not adequately controlled by maximally tolerated statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) after 8 weeks, for example. , If the LDL-C level in the patient is lower than 70 mg/dL, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or, for example, for 8 weeks. Later, when the LDL-C level in the patient is 70 mg/dL or more, the method comprises administering 150 mg of the antibody or antigen-binding fragment thereof at one or more subsequent doses about every two weeks, wherein the antibody or antigen-binding fragment thereof is administered. The binding fragment comprises HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6, and the patient undergoes concomitant insulin therapy.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having diabetes mellitus type 1 (T1DM), the method comprising:
Selecting (a) (i) T1DM, and (ii) patients with high cardiovascular risk receiving insulin therapy who have hypercholesterolemia that is not adequately controlled by maximally tolerated statin therapy;
(B) administering to a patient 300 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 4 weeks; and (c) after 8 weeks, If the LDL-C level in the patient is above the threshold level, the patient is administered one or more subsequent doses of 300 mg of the antibody or antigen binding fragment thereof about every four weeks, or after eight weeks, If the LDL-C level in the patient is below a threshold level, comprising administering 150 mg of the antibody or antigen-binding fragment thereof at one or more subsequent doses about every two weeks, the antibody or antigen-binding fragment thereof. Includes 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, wherein the patient receives concomitant insulin therapy. In one embodiment, the threshold level is 15 mg/dL. In another embodiment, the threshold level is 25 mg/dL.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having diabetes mellitus type 2 (T2DM), the method comprising:
(A) selecting (i) T2DM, and (ii) high cardiovascular risk patients receiving insulin therapy for hypercholesterolemia not adequately controlled by maximally tolerated statin therapy; and (b) Comprising administering to a patient 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9), the patient undergoing concomitant insulin therapy.

In certain embodiments, 75 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In another embodiment, 150 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In another embodiment, 300 mg of antibody or antigen-binding fragment is administered to the patient every 4 weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs of the HCVR/LCVR amino acid sequence pair comprising SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS: 2, 3 and 4 and the three light chain CDRs set forth in SEQ ID NOS: 7, 8 and 10. .. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. In certain embodiments, the antibody or antigen-binding fragment thereof competes for binding with an antibody or antigen-binding fragment thereof that comprises HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6. In a particular embodiment, the antibody or antigen-binding fragment thereof binds to the same epitope on PCK9 as the antibody comprising HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope on PCSK9 that overlaps with an epitope of the antibody that includes HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6.

In certain embodiments, the antibody or antigen-binding fragment thereof has a complementarity determining region (CDR) of a heavy chain variable region (HCVR) and a light chain variable region (LCVR) comprising the amino acid sequences set forth in SEQ ID NOS:85 and 89, respectively. including. In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NOs: 86, 87, 88, 90, 91, and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises HCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:85, and the amino acid set forth in SEQ ID NO:89. It includes an LCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the sequence.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of arilocumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504. In certain embodiments, the antibody or antigen-binding fragment thereof is arilocumab.

In certain embodiments, the methods disclosed herein include (c) if LDL-C levels in a patient are below a threshold level, about every two weeks at one or more subsequent doses of 75 mg of antibody. Alternatively, the antigen-binding fragment thereof is administered to the patient, or if the LDL-C level in the patient is above the threshold level, about every two weeks one or more subsequent doses of 150 mg antibody or antigen-binding fragment thereof are administered. Further comprising administering. In a particular embodiment, the threshold level is 70 mg/dL.

In certain embodiments, the methods disclosed herein include (c) about every four weeks, if after 8 weeks LDL-C levels in the patient are below a threshold level, one or more of the following: A dose of 300 mg of the antibody or antigen-binding fragment thereof is administered to the patient, or if LDL-C levels in the patient are above a threshold level, for example after 8 weeks, about once every 2 weeks or more of the following: Further comprising administering a dose of 150 mg of the antibody or antigen binding fragment thereof. In a particular embodiment, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid modification therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. In certain embodiments, LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. In certain embodiments, the statin therapy is a maximally resistant amount of statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe.

In certain embodiments, the patient is statin intolerant.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin.

In certain embodiments, the patient further receives concomitant antidiabetic therapy in addition to insulin therapy. In certain embodiments, the additional concomitant anti-diabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. Or antagonist, ghrelin antagonist or inverse agonist, xenin, xenin analogue, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibition Agent, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 agonist , GPR120 agonists, GPR142 agonists, systemic or low absorption TGR5 agonists, diabetic immunotherapeutic agents, anti-inflammatory agents for treating metabolic syndrome and diabetes, adenosine monopurinate activated protein kinase (AMPK) stimulants, 11-beta -Hydroxysteroid dehydrogenase 1 inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipid reducing agents, and Selected from the group consisting of combinations.

In certain embodiments, the antibody or antigen-binding fragment thereof reduces LDL-C levels in a patient, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in a patient by, for example, at least 20%, 25%, 30%, or 35%. In certain embodiments, the antibody or antigen-binding fragment thereof increases apolipoprotein C3 (ApoC3) levels in a patient (eg, at least about 6.0%, about 6.5%, about 7 weeks or 12 weeks after treatment). 0.0% or about 7.5%). In certain embodiments, the antibody or antigen-binding fragment thereof increases the number of lipoprotein particles in a patient (eg, at least about 20%, about 30%, about 40% or about 50% after 12 or 24 weeks of treatment). Reduce. In other embodiments, the antibody or antigen-binding fragment thereof increases the size of the patient's lipoprotein particles (eg, at least about 1.5%, about 2%, about 2.5% after 12 or 24 weeks of treatment). Or about 3%).

In certain embodiments, the antibody or antigen-binding fragment thereof does not (a) affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) affects the patient's fasting plasma glucose (FPG) levels. Does not reach.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having diabetes mellitus type 2 (T2DM), the method comprising:
(A) selecting patients with high cardiovascular risk receiving insulin therapy, who have hypercholesterolemia that is not adequately controlled by (i) T2DM, and (ii) maximally tolerated statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) after 8 weeks, for example. , If the LDL-C level in the patient is lower than 70 mg/dL, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks or, for example, for 8 weeks. Later, if the LDL-C level in the patient is 70 mg/dL or more, comprising administering 150 mg of the antibody or antigen-binding fragment thereof at one or more subsequent doses about every two weeks, the antibody or antigen thereof. The binding fragment comprises HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6, and the patient undergoes concomitant insulin therapy.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having diabetes mellitus type 2 (T2DM), the method comprising:
(A) selecting patients with high cardiovascular risk receiving insulin therapy, who have hypercholesterolemia that is not adequately controlled by (i) T2DM, and (ii) maximally tolerated statin therapy;
(B) administering to a patient 300 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 4 weeks; and (c) after 8 weeks, If the LDL-C level in the patient is above the threshold level, the patient is administered one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about every four weeks, or after 8 weeks, If the LDL-C level in the patient is below the threshold level, the method comprises administering 150 mg of the antibody or antigen-binding fragment thereof at one or more subsequent doses about every two weeks, the antibody or antigen-binding fragment thereof. Includes 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, wherein the patient receives concomitant insulin therapy. In one embodiment, the threshold level is 15 mg/dL. In another embodiment, the threshold level is 25 mg/dL.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having T2DM and atherosclerotic cardiovascular disease (ASCVD), the method comprising:
Select patients at high cardiovascular risk who are receiving insulin therapy for hypercholesterolemia not adequately controlled by (a) (i) T2DM, (ii) ASCVD, and (iii) maximally tolerated statin therapy And (b) administering to the patient 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9), the patient being Receive insulin therapy.

In certain embodiments, ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral arterial disease. In certain embodiments, CHD comprises acute myocardial infarction, subclinical myocardial infarction, and unstable angina.

In certain embodiments, 75 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In certain embodiments, 150 mg of antibody or antigen-binding fragment is administered to the patient every two weeks. In certain embodiments, 300 mg of antibody or antigen-binding fragment is administered to the patient every 4 weeks.

In certain embodiments, the antibody or antigen-binding fragment thereof comprises the heavy and light chain CDRs of the HCVR/LCVR amino acid sequence pair comprising SEQ ID NO: 1/6. In certain embodiments, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS: 2, 3 and 4 and the three light chain CDRs set forth in SEQ ID NOS: 7, 8 and 10. .. In certain embodiments, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. In a particular embodiment, the antibody or antigen-binding fragment thereof binds to the same epitope on PCSK9 as the antibody comprising HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6. In certain embodiments, the antibody or antigen-binding fragment thereof binds to an epitope on PCSK9 that overlaps with an epitope of the antibody that includes HCVR having the amino acid sequence of SEQ ID NO:1 and LCVR having the amino acid sequence of SEQ ID NO:6.

In certain embodiments, the antibody or antigen-binding fragment thereof has a complementarity determining region (CDR) of a heavy chain variable region (HCVR) and a light chain variable region (LCVR) comprising the amino acid sequences set forth in SEQ ID NOS:85 and 89, respectively. including. In certain embodiments, the antibody or antigen-binding fragment thereof comprises heavy and light chain CDR amino acid sequences having SEQ ID NOs: 86, 87, 88, 90, 91, and 92. In certain embodiments, the antibody or antigen-binding fragment thereof comprises HCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the amino acid sequence set forth in SEQ ID NO:85, and the amino acid set forth in SEQ ID NO:89. It includes an LCVR having an amino acid sequence that is at least 90%, 95%, or 99% identical to the sequence.

In certain embodiments, the antibody or antigen-binding fragment thereof is selected from the group consisting of arilocumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504. In certain embodiments, the antibody or antigen-binding fragment thereof is arilocumab.

In certain embodiments, the method comprises
(C) if the LDL-C level in the patient is below a threshold level, then administer to the patient one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient If the LDL-C level is above the threshold level, it further comprises administering about one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In certain embodiments, the method comprises
(C) if the LDL-C level in the patient is below a threshold level, the patient is administered with one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient If the LDL-C level is above the threshold level, it further comprises administering about once every two weeks or more of the next dose of 150 mg of the antibody or antigen-binding fragment thereof.

In a particular embodiment, the threshold level is 70 mg/dL.

In certain embodiments, the antibody or antigen-binding fragment thereof is administered subcutaneously.

In certain embodiments, the patient further receives concomitant lipid modification therapy (LMT). In certain embodiments, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. In certain embodiments, LMT is statin therapy. In certain embodiments, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. In certain embodiments, the statin therapy is a maximally resistant amount of statin therapy. In certain embodiments, the cholesterol absorption inhibitor is ezetimibe.

In certain embodiments, the patient is intolerant to statins.

In certain embodiments, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. In certain embodiments, the patient receives concomitant antidiabetic therapy in addition to insulin therapy. In certain embodiments, the additional anti-diabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist or antagonist. , Ghrelin antagonist or inverse agonist, xenin, xenin analog, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 agonist, GPR120 Agonists, GPR142 Agonists, Systemic or Low Absorption TGR5 Agonists, Diabetic Immunotherapeutic Agents, Anti-inflammatory Drugs for Treating Metabolic Syndrome and Diabetes, Adenosine Monopurinate Activated Protein Kinase (AMPK) Stimulators, 11-beta-Hydroxy From inhibitors of steroid dehydrogenase 1, activators of glucokinase, inhibitors of diacylglycerol O-acyltransferase (DGAT), modulators of glucose transporter-4, somatostatin receptor 3 agonists, lipid reducing agents, and combinations thereof Is selected from the group consisting of

In certain embodiments, the antibody or antigen-binding fragment thereof reduces LDL-C levels in a patient, eg, by at least 30%, 35%, 40%, or 45%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in a patient, eg, by at least 20%, 25%, 30%, 35%. In certain embodiments, the antibody or antigen-binding fragment thereof reduces ApoC3 levels in the patient. In certain embodiments, the antibody or antigen-binding fragment thereof reduces the number and/or size of lipoprotein particles in a patient. In a particular embodiment, the antibody or antigen-binding fragment thereof is:
(A) does not affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) does not affect the patient's fasting plasma glucose (FPG) levels.

According to another aspect, the method comprises a method of treating hypercholesterolemia in a patient having T2DM and ASCVD, the method comprising:
Select (a) high cardiovascular risk patients undergoing insulin therapy with hypercholesterolemia not adequately controlled by (i) T2DM, (ii) ASCVD, and (iii) maximally resistant statin therapy thing;
(B) administering to the patient every two weeks 75 mg of an antibody or antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9); and (c) LDL-C in the patient. If the level is less than 70 mg/dL, the patient is administered with about one or more subsequent doses of 75 mg of antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg/dL. The above comprises administering one or more subsequent doses of 150 mg of antibody or antigen binding fragment thereof about once every two weeks, wherein the antibody or antigen binding fragment thereof has the amino acid sequence of SEQ ID NO:1. The patient receives concomitant insulin therapy, including HCVR and an LCVR having the amino acid sequence of SEQ ID NO:6.

Other embodiments will be apparent from a consideration of the following detailed description.

FIG. 5 shows the overall design of the main stages of the study described in Example 2 herein. The study included a screening period, a double-blind treatment period, and a safety observation period. FIG. 6 is a graph showing LS mean (+/−SE) of calculated percent change in LDL-C levels from baseline in the ITT population of patients with IVRS type 1 diabetes. Least squares (LS) mean and standard error (SE) were obtained from the mixed effects model by repeated measures (MMRM) analysis. This model includes fixed category effects for treatment groups, randomized layer by IVRS, time points, and time points for each treatment group of interactions, time points for each layer, stratification for each treatment group, and for each treatment group. Stratified time points, as well as continuous fixed covariates of baseline-calculated LDL-C values, and baseline-based time point interactions. The MMRM model was run on all patients in the ITT population (ie type 1 and type 2 diabetic patients). FIG. 6 is a graph showing the LS mean (+/−SE) of calculated percent change in LDL-C levels from baseline in the ITT population of patients with type 2 diabetes by IVRS. Least squares (LS) mean and standard error (SE) were obtained from the mixed effects model by repeated measures (MMRM) analysis. This model includes fixed category effects for treatment groups, randomized layer by IVRS, time points, and time points for each treatment group of interactions, time points for each layer, stratification for each treatment group, and for each treatment group. Stratified time points, as well as continuous fixed covariates of baseline-calculated LDL-C values, and baseline-based time point interactions. The MMRM model was run on all patients in the ITT population (ie type 1 and type 2 diabetic patients). FIG. 6 is a graph showing percentage change from baseline to week 24 in non-HDL-C, LDL-C, ApoB, and LDL-PN in ITT populations with type 2 diabetes and ASCVD. FIG. 6 is a graph showing the percentage of individuals in the ITT population with type 2 diabetes and ASCVD who achieve non-HDL-C<100 mg/dL, LDL-C<70 mg/dL, and ApoB<80 mg/dL at 24 weeks.

The method is not limited to the particular method and experimental conditions described. This is because such methods and conditions may change. Also, as the scope of the method is limited only by the scope of the appended claims, the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting. It should also be understood that not.

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art. As used herein, the term "about," when used in reference to a particular recited numerical value, means that the value may vary from the recited value by no more than 1%. For example, as used herein, the expression "about 100" includes 99 and 101 and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.). ..

Although any methods and materials similar or equivalent to those described herein can be used, the preferred methods and materials are described herein. All publications mentioned herein are incorporated herein by reference to describe their entirety.

Methods of Treating Patients with Hypercholesterolemia and Diabetes During Insulin Therapy Provided are methods and compositions for treating diabetic patients with hypercholesterolemia during insulin therapy. According to certain embodiments, these methods result in reduction of lipoprotein levels (eg, LDL-C and/or Lp(a)) in the serum of such patients.

The present disclosure also provides an antibody or antigen-binding fragment thereof that specifically binds to a PCSK9 inhibitor (eg, PCSK9 (eg, human PCSK9)) for use in the treatment of diabetic patients having hypercholesterolemia during insulin therapy. ), or a composition comprising a PCSK9 inhibitor. In certain embodiments, PCSK9 inhibitors or compositions are useful in reducing the levels of lipoproteins (eg, LDL-C and/or Lp(a)) in the serum of such patients.

As used herein, the term "lipoprotein" means a biomolecule particle that includes both proteins and lipids. Examples of lipoproteins include, for example, low density lipoprotein (LDL), very low density lipoprotein (VLDL), medium density lipoprotein (IDL), and lipoprotein (a) (Lp(a)).

Diabetes mellitus, often referred to simply as diabetes, is a group of metabolic disorders in which humans have high blood glucose levels, either because the body does not produce enough insulin or because cells do not respond to the insulin produced. The most common types of diabetes are: (1) type 1 diabetes where the body is unable to produce insulin; (2) the body is unable to properly use insulin, accompanied by an increase in insulin deficiency over time 2 Type 2 diabetes; and (3) gestational diabetes when a woman develops diabetes due to pregnancy. All forms of diabetes typically increase the risk of long-term complications that develop many years later. Most of these long-term complications are based on vascular injury, with two categories: "macrovascular" disease that results from atherosclerosis of the larger vessels and "microvascular" disease that results from small vessel damage. Is divided into Examples of macrovascular disease states are ischemic heart disease, myocardial infarction, stroke and peripheral vascular disease. Examples of microvascular diseases are diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy.

According to certain embodiments, the patient to be treated has type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) and is receiving insulin therapy. In certain embodiments, the patient has been diagnosed with T1DM or T2DM for at least 1 year. In certain embodiments, the patient was diagnosed with T1DM before age 30. In certain embodiments, T1DM patients have C-peptide levels below 0.2 pmol/mL. In certain embodiments, the patient has a glycosylated hemoglobin (HbA1c) level below 10%.

According to certain embodiments, the patient to be treated has hypercholesterolemia that is not adequately controlled by lipid modification therapy (LMT). The patient's serum LDL-C concentration falls below 70 mg/dL (taking into account the patient's relative risk of coronary heart disease) after a recognized medically acceptable level, eg, LMT, for at least 4 weeks. If not reduced, hypercholesterolemia is considered not properly controlled by LMT. In certain embodiments, LMT is a maximally tolerated statin therapy. As used herein, "maximum tolerable dose of statin therapy" means the highest dose of statin administered to a patient without causing unacceptable adverse side effects in the patient. For example, the methods disclosed herein include the group consisting of atorvastatin (including atorvastatin + ezetimibe), rosuvastatin, cerivastatin, pitavastatin, fluvastatin, lovastatin, simvastatin (including simvastatin + ezetimibe), pravastatin, and combinations thereof. Comprising treating a patient with T1DM or T2DM having hypercholesterolemia that is not adequately controlled by the daily dose of statin selected from In certain embodiments, if a patient is intolerant to this therapy, the patient will not receive concomitant statin therapy. Patients with statin intolerance include, for example, pain, pain, weakness, or convulsions, skeletal muscle-related factors other than those due to tension or trauma, such as those that start or increase during statin therapy and stop when statin therapy is stopped. There may be symptoms.

Patient Selection The methods and compositions of the invention are useful in treating patients with hypercholesterolemia and diabetes who are receiving insulin therapy. The patient to be treated may also exhibit one or more additional selection criteria. For example, if a patient's calculated LDL-C level is 70 mg/dL, 100 mg/dL, or 130 mg/dL or greater, the patient is selected for treatment. The patient is treated with a maximally tolerable amount of statin, optionally in combination with at least one other lipid modification therapy (LMT) for at least 4 weeks, or if the patient is statin intolerant, the patient is treated with at least one non- The maximum tolerated dose of statin LMT has been treated for at least 4 weeks. The maximum tolerated dose of a statin can be defined as the maximum tolerated dose due to adverse effects on, for example, doses prescribed according to local practice or local guidelines, or high doses specified in local prescribing information for pediatric patients. I will. Statin intolerance is defined as, for example, inability to tolerate at least two statins: one statin is the lowest daily starting dose, the other is any dose, and skeletal muscle-related symptoms It is due to. Except for pain, pain, weakness, or convulsions, tension or trauma, such as those that started or increased during statin therapy and stopped when statin therapy was discontinued. Patients who are not on a daily regimen of statins (eg, 1-3 times a week) are also considered tolerated daily doses.

Further, if a patient is at high cardiovascular (CV) risk, the patient is selected for treatment. In certain embodiments, high CV risk patients have a documented history of cardiovascular disease (CVD) and/or at least one additional CV risk factor. CVD includes, but is not limited to, coronary heart disease (CHD) and risk equivalents of CHD. CHD includes, but is not limited to, acute myocardial infarction (MI), silent MI, unstable angina, coronary revascularization (eg, percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG)), and Includes clinically important CHD (eg, non-invasive tests such as invasive diagnostics or coronary angiography, treadmill stress testing, stress echocardiography, or nuclear imaging). CHD risk equivalents include, but are not limited to, peripheral arterial disease (eg, those described in the study patient criteria of Example 2), and focal ischemic nerves of more than 24 hours of atherothrombotic origin. Includes a previous ischemic stroke with a biological defect. CV risk factors include, but are not limited to, hypertension, current smoking, males over 45 years old, females over 55 years old, history of micro/macroalbuminuria, history of diabetic retinopathy, family of early onset CHD. History (father or siblings under 55; mother or sister under 65), low HDL-C (male <40 mg/dL [1.0 mmol/L] and female <50 mg/dL [1.3 mmol/L]) , As well as the documented chronic kidney disease (CKD) (eg, as defined in the study patient criteria of Example 2).

In certain embodiments, the high CV risk patient has atherosclerotic cardiovascular disease (ASCVD). In certain embodiments, ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral arterial disease. In certain embodiments, CHD comprises acute myocardial infarction, subclinical myocardial infarction, and unstable angina. In certain embodiments, CHD is defined as acute myocardial infarction, subclinical myocardial infarction, or unstable angina.

Insulin Therapy As shown herein, diabetic patients selected for treatment by the methods of the invention have been and continue to receive insulin therapy comprising insulin or a derivative thereof. The insulins on the market influence the profile of action (onset of action and duration of action) due to the different origins of insulin (eg, bovine, porcine, human insulin), and even their composition. By combining different insulin products, it is possible to obtain a wide variety of action profiles and set blood glucose levels as close to physiological as possible. Exemplary insulin therapies include naturally occurring insulin, such as human insulin, as well as insulin glargine (Gly(A21)-Arg(B31)-Arg(B32) human insulin, such as Lantus®). Modified insulins with extended duration of action may be included. Insulin glargine is infused as an acid clear solution and is precipitated as a stable hexameric associate due to its solution properties in the physiological pH range of subcutaneous tissue. Insulin glargine is injected once daily and is more noteworthy than other long-acting insulins due to its flattened serum profile and associated reduction in nocturnal hypoglycemia risk (Schubert-Zsilavecz et al., 2:125-130. Page (2001)). Insulin glargine is administered at a concentration higher than 100 U/mL, eg 270-330 U/mL insulin glargine or 300 U/mL insulin glargine (disclosed in EP 2387989). Other exemplary insulin therapies include insulin glulisine (eg, Apidra®), insulin detemir (eg, Levemir®), insulin lispro (eg, Humalog®, Liprolog®). )), insulin degludec (eg, DegludecPlus®, IdegLira (NN9068)), insulin aspart and aspart formulations (eg, NovoLog®), basal insulin and analogs (eg mLY2605541, LY2963016, NN1436). ), PEGylated insulin lispro (e.g. LY-275585), long-acting insulin (e.g. NN1436, Insumera (PE0139), AB-101, AB-102, Sensulin LLC), intermediate-acting insulin (e.g. Humulin (e.g. (Registered trademark) N, Novolin (registered trademark) N), fast-acting and short-acting insulin (eg, Humulin (registered trademark) R, Novolin (registered trademark) R, Linjeta (registered trademark) (VIAject (registered trademark)) , PH20 insulin, NN1218, HinsBet®), premixed insulin, SuliXen®, NN1045, insulin+Symlin®, PE-0139, ACP-002 hydrogel insulin, oral, inhalation, transdermal and Oral or sublingual insulin (eg, Exubera®, Nasulin®, Afrezza®, insulin tregopyr, TPM-02 insulin, Capsulin®, Oral-lyn®, Cobalamin® Oral Insulin, ORMD-0801, Oshadi Oral Insulin, NN1953, NN1954, NN1956, VIAtab®). Also suitable are insulin derivatives linked to albumin or another protein by a bifunctional linker.

PCSK9 Inhibitor The method comprises administering to the patient a therapeutic composition comprising a PCSK9 inhibitor. As used herein, a "PCSK9 inhibitor" is any agent that binds or interacts with human PCSK9 and inhibits PCSK9's normal biological function in vitro or in vivo. Non-limiting examples of categories of PCSK9 inhibitors include small molecule PCSK9 antagonists, nucleic acid-based inhibitors of PCSK9 expression or activity (eg, siRNA or antisense), peptide-based molecules that specifically interact with PCSK9. (Eg, peptibodies), receptor molecules that specifically interact with PCSK9, proteins that include the ligand-binding portion of the LDL receptor, PCSK9-binding scaffold molecules (eg, DARPins, HEAT repeat proteins, ARM repeat proteins, tetratricopeptide repeats) Proteins, fibronectin-based scaffold constructs, and other scaffolds based on naturally occurring repeat proteins [eg Boersma and Pluckthun, 2011, Curr. Opin. Biotechnol. 22:849-857, and cited therein. Literature]), and anti-PCSK9 aptamers or parts thereof. According to a particular embodiment, the PCSK9 inhibitor used in the context of the method is an anti-PCSK9 antibody or an antigen-binding fragment of an antibody that specifically binds human PCSK9.

The term "human proprotein convertase subtilisin/kexin type 9" or "human PCSK9" or "hPCSK9", as used herein, has the nucleic acid sequence set forth in SEQ ID NO:197 and the amino acid sequence of SEQ ID NO:198. Refers to PCSK9, or a biologically active fragment thereof.

The term "antibody," as used herein, includes four polypeptide chains, two heavy (H) chains and two light (L) chains interconnected by disulfide bonds, and multimers thereof (eg, , IgM). Each heavy chain comprises a heavy chain variable region (herein abbreviated as HCVR or V _H) and a heavy chain constant region. The heavy chain constant region comprises three _domains, a C H 1, _{C H} 2 and _{C H} 3. Each light chain comprises a light chain variable region (abbreviated herein as LCVR or _VL ) and a light chain constant region. The light chain constant region contains one domain, C _L 1. The _VH and _VL regions are further subdivided into hypervariable regions called complementarity determining regions (CDRs) interspersed with more conserved regions called framework regions (FRs). Each V _H and V _L is composed of 3 CDRs and 4 FRs, arranged from the amino terminus to the carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In different embodiments, the FRs of the anti-PCSK9 antibody (or antigen binding portion thereof) are identical to human germline sequences or are naturally or artificially modified. Amino acid consensus sequences are defined based on a parallel analysis of two or more CDRs.

The term "antibody" as used herein also includes antigen binding fragments of whole antibody molecules. The term "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, etc., as used herein, refers to any naturally occurring enzyme that specifically binds an antigen to form a complex. Incorporated, synthetic, or genetically engineered polypeptides or glycoproteins. Antigen-binding fragments of antibodies may be prepared as a whole antibody using any suitable standard technique such as, for example, protein digestion, or recombinant genetic engineering techniques involving manipulation and expression of DNA encoding antibody variable domains and optionally constant domains. Derived from the molecule. Such DNAs are known and/or are readily available, eg, from commercial sources, DNA libraries (including, eg, phage antibody libraries), or synthesized. The DNA is sequenced and engineered chemically or by using molecular biology techniques to place, for example, one or more variable and/or constant domains in a suitable configuration, or codons. It is possible to introduce, create cysteine residues, modify, add or delete amino acids, etc.

Non-limiting examples of "antigen-binding fragment" include (i) Fab fragment; (ii) F(ab')2 fragment; (iii) Fd fragment; (iv) Fv fragment; (v) single chain Fv. (ScFv) molecule; (vi) dAb fragment; and (vii) amino acid residues that mimic the hypervariable region of the antibody (eg, isolated complementarity determining regions (CDRs) such as CDR3 peptides), or constrained A minimal recognition unit consisting of the FR3-CDR3-FR4 peptide can be mentioned. Domain-specific antibody, single domain antibody, domain-deleted antibody, chimeric antibody, CDR-grafted antibody, diabodies, triabodies, tetrabodies, minibodies, Nanobodies (eg monovalent Nanobodies, divalent Nanobodies, etc.), small Modular immunodrugs (SMIPs) and other engineered molecules such as shark variable IgNAR domains are also encompassed by the expression "antigen-binding fragment" as used herein.

Antigen-binding fragments of antibodies typically include at least one variable domain. Variable domains are of any size or amino acid composition and generally include at least one CDR in frame with, or adjacent to, one or more framework sequences. In an antigen binding fragment that has a V _H domain associated with a V _L , the V _H and V _L domains are located relative to each other in any suitable arrangement. For example, the variable region may be dimeric and may contain _VH - _VH , _VH - _VL , or _VL - _VL dimers. Alternatively, the antigen-binding fragment of an antibody may contain monomeric _VH or _VL domains.

In certain embodiments, antigen-binding fragments of antibodies may comprise at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary configuration of the variable and constant domains are found within the antigen-binding fragment of an _{antibody, (i) V H -C H} 1; (ii) V H -C H 2; (iii) V H _{-C H 3; (iv) V} H -C H 1-C H 2; (v) V H -C H 1-C H 2-C H 3; (vi) V H -C H 2-C H 3 _{; (vii) V H -C L} ; (viii) V L -C H 1; (ix) V L -C H 2; (x) V L -C H 3; (xi) V L -C H 1- _{C H 2; (xii) V} L -C H 1-C H 2-C H 3; (xiii) V L -C H 2-C H 3; and _(xiv) V _L -C L can be mentioned. In any of the variable and constant domain configurations, including any of the exemplary configurations listed above, the variable and constant domains are directly linked to each other or by a full or partial hinge or linker region. Be connected. The hinge region may consist of at least two (eg, 5, 10, 15, 20, 40, 60 or more) amino acids, which results in flexibility between adjacent variable and/or constant domains in a single polypeptide molecule. Provide a sexual or semi-flexible connection. In addition, the antigen-binding fragments of the antibodies of the invention may have variable domain configurations listed above in non-covalent association (eg, by disulfide bonds) with each other and/or one or more monomeric V _H or V _L domains. And a constant domain configuration of any homodimer or heterodimer (or other multimer).

Like whole antibody molecules, antigen-binding fragments are monospecific or multispecific (eg, bispecific). Multispecific antigen-binding fragments of antibodies typically contain at least two different variable domains, each variable domain capable of specifically binding to a distinct antigen or to different epitopes on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be labeled with an antigen-binding fragment of an antibody of this method using routine techniques available in the art. Adapted for use in the context of.

The constant region of an antibody is important in the ability of the antibody to fix complement and mediate cell-dependent cytotoxicity. Thus, antibody isotypes are selected based on whether it is desirable for the antibody to mediate cytotoxicity.

The term "human antibody", as used herein, is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies nevertheless have amino acid residues not encoded by human germline immunoglobulin sequences, eg, in CDRs, and in certain CDR3s (eg, by random or site-directed mutagenesis in vitro). Or mutations induced by somatic mutations in vivo). However, the term "human antibody" as used herein includes antibodies in which CDR sequences derived from the germ line of another mammal, such as a mouse, have been grafted into human framework sequences. Not intended.

The term "recombinant human antibody" as used herein is prepared, expressed, produced, or produced by recombinant means, such as an antibody expressed using a recombinant expression vector transformed into a host cell. All isolated human antibodies (further described below), antibodies isolated from recombinant, complex human antibody libraries (further described below), animals transgenic for human immunoglobulin genes ( For example, antibodies isolated from mice (see, eg, Taylor et al., (1992) Nucl. Acids Res. 20:6287-6295), or other DNA sequences of human immunoglobulin gene sequences. It is intended to include antibodies prepared, expressed, produced or isolated by any other means that involves splicing into. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies are subjected to in vitro mutagenesis (or in vivo somatic mutagenesis if animals transgenic for human Ig sequences are used). Thus, the amino acid sequences of the V _H and V _L regions of the recombinant antibody are derived from human germline V _H and V _L sequences while in vivo sequences that do not naturally occur within the human antibody germline repertoire. Can be

Human antibodies can exist in two forms associated with hinge heterogeneity. In one form, the immunoglobulin molecule comprises a stable four chain construct of about 150-160 kDa in which the dimers are held together by interchain heavy chain disulfide bonds. In the second form, the dimers are not linked via interchain disulfide bonds, forming a molecule of approximately 75-80 kDa composed of covalently bound light and heavy chains (half antibodies). These forms were very difficult to separate even after affinity purification.

The frequency of occurrence of the second form in various intact IgG isotypes is not limited, but is due to structural differences associated with the hinge region isotype of the antibody. Single amino acid substitutions in the hinge region of the human IgG4 hinge lead to the appearance of the second form (Angal et al., (1993) Molecular Immunology 30:105) to the level normally observed using the human IgG1 hinge. Can be significantly reduced. The method includes, in order to improve the yield of the desired antibody form, for example, preferably a hinge in the production, an antibody having one or more mutations in the C H ₂ or C _{H 3} region.

"Isolated antibody", as used herein, means an antibody that has been identified and separated from 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 naturally occurs or is naturally produced is an "isolated antibody" for the purposes of this method. is there. Isolated antibody also includes the antibody in situ within recombinant cells. An isolated antibody is one that has been subjected to at least one purification or isolation step. According to certain embodiments, the isolated antibody is substantially free of other cellular material and/or chemicals.

By "specifically binds" and the like is meant that the antibody or antigen binding fragment thereof forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance and the like. For example, an antibody that "specifically binds" to PCSK9 when used in the context of the present method, is less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, as measured in a surface plasmon resonance assay. <100 nM, <90 nM, <80 nM, <70 nM, <60 nM, <50 nM, <40 nM, <30 nM, <20 nM, <10 nM, <5 nM, <4 nM, <3 nM. comprising less than about 2 nM, less than about 1 nM, or antibodies that bind to PCSK9 or a portion thereof having a _{K D} of less than about 0.5 nM. However, isolated antibodies that specifically bind to human PCSK9 have cross-reactivity to other antigens, such as PCSK9 molecules from other (non-human) species.

Anti-PCSK9 antibodies useful in the present methods have one or more amino acid substitutions, insertions in the framework and/or CDR regions of the heavy and light chain variable domains as compared to the corresponding germline sequence from which the antibody was derived. And/or may include deletions. Such mutations can be readily identified by comparing the amino acid sequences disclosed herein with, for example, germline sequences available from public antibody sequence databases. The method comprises the use of antibodies and antigen-binding fragments thereof derived from any of the amino acid sequences disclosed herein and one or more within one or more framework and/or CDR regions. To the corresponding residue in the germline sequence from which the antibody is derived, or to the corresponding residue in another human germline sequence, or to a conservative amino acid substitution in the corresponding germline residue. (Such sequence changes are collectively referred to herein as "germline mutations"). One of skill in the art will begin with the heavy and light chain variable region sequences disclosed herein and will develop a large number of antibodies and antigen-binding fragments that include one or more individual germline mutations or combinations thereof. It can be easily produced. In certain embodiments, all of the framework and/or CDR residues within the _VH and/or _VL domain are mutated back to residues found in the original germline sequence from which the antibody was derived. In other embodiments, only certain residues are mutated back into the original germline sequence, eg, mutated residues found within the first 8 amino acids of FR1 or the last 8 amino acids of FR4. Only, or only the variant residues found within CDR1, CDR2 or CDR3. In other embodiments, one or more framework and/or CDR residues are at corresponding residues in a different germline sequence (ie, a germline sequence that differs from the germline sequence from which the antibody was originally derived). To be mutated. Further, the antibody may comprise any combination of two or more germline mutations within the framework and/or CDR regions, eg, where a particular individual residue corresponds to a particular germline sequence. , While maintaining certain other residues that differ from the original germline, or mutating to corresponding residues in different germline sequences. Once obtained, antibodies and antigen-binding fragments containing one or more germline mutations have improved binding specificity, increased binding affinity, improved antagonistic or agonistic biological properties. Alternatively, one can simply test for one or more desirable properties such as increase (as the case may be), decreased immunogenicity, and the like. The use of antibodies and antigen-binding fragments obtained by this general method is included in the method.

The method involves the use of an anti-PCSK9 antibody comprising a variant of any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein with one or more conservative substitutions. For example, the method comprises conservative amino acid substitutions, eg, 10 or less, 8 or less, 6 or less, 4 or less, with any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein. Comprising the use of an anti-PCSK9 antibody having an HCVR, LCVR, and/or CDR amino acid sequence.

The term “surface plasmon resonance” as used herein, for example, uses the BIAcore™ system (Biacore Life Sciences division of GE Healthcare, Piscataway, NJ) to determine the concentration of proteins within a biosensor matrix. By detecting changes, it refers to an optical phenomenon that allows analysis of real-time interactions.

The term “K _D ”, 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 particular antigen binding site in the variable region of an antibody molecule known as the paratope. A single antigen may have more than one epitope. Thus, different antibodies may bind to different regions on the antigen and may have different biological effects. Epitopes can be conformational or linear. Conformational epitopes are produced by spatially juxtaposed amino acids from different segments of a linear polypeptide chain. A linear epitope is an epitope produced by adjacent amino acid residues of a polypeptide chain. In certain circumstances, an epitope can include moieties of sugar, phosphoryl, or sulfonyl groups on the antigen.

According to a particular embodiment, the anti-PCSK9 antibody used in the method is an antibody with pH-dependent binding properties. As used herein, the phrase "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 this disclosure, both expressions are used interchangeably). For example, "antibodies with pH-dependent binding properties" include antibodies and antigen-binding fragments thereof that bind PCSK9 with higher affinity at neutral pH than at acidic pH. In certain embodiments, the antibody and antigen-binding fragment are at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70 at a neutral pH above the production pH. , 75, 80, 85, 90, 95, 100, or 100-fold or more affinity binding to PCSK9.

According to this aspect, the anti-PCSK9 antibody with pH-dependent binding properties may carry one or more amino acid mutations as compared to the parent anti-PCSK9 antibody. For example, an anti-PCSK9 antibody with pH-dependent binding properties can include, for example, one or more histidine substitutions or insertions in one or more CDRs of the parent anti-PCSK9 antibody. Thus, according to a particular embodiment, it is identical to the CDR amino acid sequence of the parent anti-PCSK9 antibody, except for the substitution of a histidine residue for one or more amino acids of one or more CDRs of the parent antibody. Methods are provided that include administering an anti-PCSK9 antibody that comprises CDR amino acid sequences (eg, heavy and light chain CDRs). Anti-PCSK9 antibodies with pH-dependent binding are distributed, for example, in a single CDR of the parent antibody or in multiple CDRs (eg, 2, 3, 4, 5, or 6) of the parent anti-PCSK9 antibody. , May carry 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions. For example, the method comprises one or more histidine substitutions of HCDR1 of the parent anti-PCSK9 antibody, one or more histidine substitutions of HCDR2, one or more histidine substitutions of HCDR3, one or more of LCDR1. Includes the use of anti-PCSK9 antibodies with pH-dependent binding, including histidine substitutions above, one or more histidine substitutions in LCDR2, and/or one or more histidine substitutions in LCDR3.

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

Non-limiting examples of anti-PCSK9 antibodies used in the context of the present method include, for example, allilocumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, LY301504, or an antigen-binding portion of any of the foregoing antibodies.

Preparation of Human Antibodies Methods for producing human antibodies in transgenic mice are known in the art. All such known methods are used in the context of this method to produce human antibodies that specifically bind human PCSK9.

Having human variable regions and mouse constant regions using VELOCIMMUNE™ technology (see, eg, US Pat. No. 6,596,541, Regeneron Pharmaceuticals) or any other known method of producing monoclonal antibodies. , A high affinity chimeric antibody to PCSK9 is first isolated. The VELOCIMMUNE® technology involves the generation of a transgenic mouse having a genome containing human heavy and light chain variable regions operably linked to an endogenous mouse constant region locus, whereby the mouse is In response to stimulation, it produces an antibody containing human variable regions and mouse constant regions. The DNA encoding the variable regions of the antibody heavy and light chains are isolated and operably linked to the DNA encoding the human heavy and light chain constant regions. The DNA is then expressed in cells capable of expressing fully human antibodies.

In general, VELOCIMMUNE (registered trademark) mice are challenged with an antigen of interest, and lymphocytes (B cells and the like) are recovered from mice expressing antibodies. Immortal hybridoma cell lines are prepared by fusing lymphocytes with myeloma cell lines, and such hybridoma cell lines are screened and selected to identify hybridoma cell lines that produce antibodies specific for the antigen of interest. .. DNA encoding the variable regions of the heavy and light chains are isolated and ligated to the desired isotype constant regions of the heavy and light chains. Such antibody proteins are produced in cells such as CHO cells. Alternatively, the DNA encoding the antigen-specific chimeric antibody or the variable domains of the light and heavy chains is isolated directly from the antigen-specific lymphocytes.

First, a high affinity chimeric antibody having human variable regions and mouse constant regions is isolated. Antibodies are characterized and selected for desirable properties including affinity, selectivity, epitope, etc. using standard procedures known to those of skill in the art. The mouse constant region is replaced with the desired human constant region to produce fully human antibodies, eg, wild-type or modified IgG1 or IgG4. The constant region chosen may vary depending on the particular application, but features of high affinity antigen binding and target specificity lie in the variable region.

Generally, the antibody used possesses high affinity, as described above, as measured by binding to the antigen immobilized either on the solid phase or in solution phase. The mouse constant region is replaced with the desired human constant region in order to produce a fully human antibody. The constant region chosen may vary depending on the particular application, but features of high affinity antigen binding and target specificity lie in the variable region.

Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 used in the context of this method include an amino acid sequence selected from the group consisting of SEQ ID NOs: 1 and 11, or at least 90%, Three heavy chain CDRs (HCDR1, HCDR2 and HCDR3) contained within a heavy chain variable region (HCVR) having practically similar sequences with at least 95%, at least 98% or at least 99% sequence identity. Included are any antibodies or antigen-binding fragments that include. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 used in the context of this method include SEQ ID NOs: 37, 45, 53, 61, 69, 77, 85, 93, An amino acid sequence selected from the group consisting of 101, 109, 117, 125, 133, 141, 149, 157, 165, 173, 181, and 189, or at least 90%, at least 95%, at least 98% or at least 99%. Any antibody or antigen-binding fragment comprising three heavy chain CDRs (HCDR1, HCDR2 and HCDR3) contained within a heavy chain variable region (HCVR) having practically similar sequences having the sequence identity of .. The antibody or antigen-binding fragment is an amino acid sequence selected from the group consisting of SEQ ID NOs: 6 and 15, or a substantially similar amino acid sequence thereof having at least 90%, at least 95%, at least 98% or at least 99% sequence identity. It may include three light chain CDRs (LCVR1, LCVR2, LCVR3) contained within a light chain variable region (LCVR) having a sequence. Alternatively, the antibody or antigen-binding fragment is SEQ ID NO: 41, 49, 57, 65, 73, 81, 89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185, and Within a light chain variable region (LCVR) having an amino acid sequence selected from the group consisting of 193, or an operatively similar sequence having at least 90%, at least 95%, at least 98% or at least 99% sequence identity. Can include the three light chain CDRs contained in (LCVR1, LCVR2, LCVR3).

Sequence identity between two amino acid sequences may be determined using the best sequence alignment between the two amino acid sequences over the entire length of the reference amino acid sequence, ie the amino acid sequence identified by SEQ ID NO:, and/or between the sequences. Regions of best sequence alignments were determined and the best sequence alignments were determined using known tools, eg Align using standard settings, preferably EMBOSS::needle, Matrix:Blosum62, Gap Open 10.0, Gap Extend 10.0. Obtained using 0.5.

In certain embodiments, the antibody or antigen-binding protein is a heavy chain and light chain variable region amino acid sequence pair selected from the group consisting of SEQ ID NOs: 1/6 and 11/15 and six CDRs (HCVR/LCVR) from the pair. HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3). Alternatively, in certain embodiments, the antibody or antigen binding protein is SEQ ID NO: 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 6 CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2 and LCDR3) from the heavy and light chain variable region amino acid sequence pairs (HCVR/LCVR) selected from

In certain embodiments, the anti-PCSK9 antibody or antigen binding protein used in the method is SEQ ID NOs: 2/3/4/7/8/10 (mAb316P [also referred to as "REGN727" or "arilocumab")) and 12 HCDR1/HCDR2/HCDR3/LCDR1/LCDR2 selected from /13/14/16/17/18 (mAb300N) (see U.S. Patent Application Publication No. 2010/0166768) and 12/13/14/16/17/18 /LCDR3 amino acid sequence, SEQ ID NO: 16 comprises a histidine substitution for leucine at amino acid residue 30 (L30H).

In certain embodiments, the antibody or antigen binding protein comprises an HCVR/LCVR amino acid sequence pair 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 the HCVR amino acid sequence of SEQ ID NO:1 and the LCVR amino acid sequence of SEQ ID NO:6. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO:11 and the LCVR amino acid sequence of SEQ ID NO:15. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO:11 and the LCVR amino acid sequence of SEQ ID NO:15 (L30H) that includes a histidine substitution for leucine at amino acid residue 30.

Pharmaceutical Compositions and Methods of Administration The methods include administering a PCSK9 inhibitor to a patient, the PCSK9 inhibitor being included within the pharmaceutical composition. The pharmaceutical composition is formulated with suitable carriers, excipients, and other agents that provide suitable transfer, delivery, resistance, etc. A number of suitable formulations are found in formulations 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 (cationic or anionic) containing vesicles (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water. And water-in-oil emulsions, emulsion carbowaxes (polyethylene glycols of various molecular weights), semisolid gels, and semisolid mixtures containing carbowaxes. See Powell et al., "Compendium of exclusives for parental formulations" PDA (1998) J Pharm Sci Technol 52:238-311.

Exemplary pharmaceutical formulations containing an anti-PCSK9 antibody for use in the context of the present method include US Pat. No. 8,795,669 (among others, an exemplary formulation comprising arilocumab) or WO 2013/166448. Also included are any of the formulations described in WO 2012/168491.

Various delivery systems are known and used to administer pharmaceutical compositions, including liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant virus, encapsulation into receptor-mediated endocytosis. (See, eg, Wu et al., 1987, J. Biol. Chem. 262:4429-4432). Modes of administration include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition is administered by any convenient route, such as infusion or bolus injection, absorption through the epithelial or mucosal lining (eg, oral mucosa, rectal and intestinal mucosa), and other biologically active Administered with drug.

The pharmaceutical composition is delivered subcutaneously or intravenously with a standard needle and syringe. In addition, for subcutaneous delivery, pen delivery devices have application in delivering pharmaceutical compositions easily. Such pen delivery devices can be reusable or disposable. Reusable pen delivery devices generally utilize replaceable cartridges containing the pharmaceutical composition. When all the pharmaceutical composition in the cartridge has been dispensed and the cartridge is empty, the empty cartridge is easily discarded and replaced with a new cartridge containing the pharmaceutical composition. Then reuse the pen delivery device. Disposable pen delivery devices do not have replaceable cartridges. Rather, the disposable pen delivery device is prefilled with the pharmaceutical composition held in a reservoir within the device. When the pharmaceutical composition is emptied from the reservoir, the entire device is discarded.

A number of reusable pens and auto-injector delivery devices find use in subcutaneous delivery of pharmaceutical compositions. Examples include, but are not limited to, AUTOPEN(TM) (Owen Mumford, Inc., Woodstock, UK), DISETRONIC(TM) pens (Distronic Medical Systems, Bergdorf, SwitzerlandMIUG/L). 25(TM) Pen, HUMALOG(TM) Pen, HUMALIN 70/30(TM) Pen (Eli Lilly and Co., Indianapolis, IN), NOVOPEN(TM) I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR™ (Novo Nordisk, Copenhagen, Denmark), BD™ pens (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN™, OPTIPEN PRO™ ™L, OPTEN™, OPTIPEN™. ) (Sanofi-eventis, Frankfurt, Germany). Examples of disposable pen delivery devices for use in subcutaneous delivery of the pharmaceutical compositions of the present methods include, but are not limited to, SOLOSTAR™ sanofi-eventis, FLEXPEN™ (Novo), to name but a few. Nordisk), and KWIKPEN(TM) (Eli Lilly), SURECLICK(TM) auto-injector (Amgen, Thousand Oaks, CA), PENLET(TM) (Haselmeier, Stuttgart, Germany), EPIPEN. And HUMIRA™ pens (Abbott Labs, Abbott Park I).

In certain situations, the pharmaceutical composition is delivered in a controlled release system. In one embodiment, a pump is used (see Langer (supra); Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another embodiment, polymeric materials are used; Medical Applications of Controlled Release, Langer and Wise, 1974, CRC Pres. , Boca Raton, Florida. In yet another embodiment, the controlled release system is placed in proximity to the target of the composition and thus requires only a portion of the systemic dose (eg Goodson, 1984, Medical Applications of Controlled Release, supra, 2, pp. 115-138). Other controlled release systems are discussed in Langer, 1990, Science 249:1527-1533.

Injectable formulations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injection, infusion and the like. These injectable preparations are prepared by known methods. For example, an injectable preparation is prepared, for example, by dissolving, suspending or emulsifying the above-mentioned antibody or a salt thereof in a sterile aqueous medium or oily medium conventionally used for injection. Aqueous vehicles for injection include, for example, isotonic solutions containing saline, glucose and other adjuvants, which are suitable solubilizers such as alcohols (eg ethanol), polyhydric alcohols. (Eg, propylene glycol, polyethylene glycol), a nonionic surfactant [eg, polysorbate 80, HCO-50 (polyoxyethylene (50 mol) adduct of hydrogenated castor oil)] and the like are used in combination. Oily media include, for example, sesame oil, soybean oil and the like, which are used in combination with a solubilizer such as benzyl benzoate, benzyl alcohol and the like. The injection solution thus prepared is preferably filled in a suitable ampoule.

Advantageously, the pharmaceutical compositions for oral or parenteral use described above are prepared into unit dose forms suitable for matching the dose of active ingredient. Such unit dose forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, and the like.

Dosage The amount of PCSK9 inhibitor (eg, anti-PCSK9 antibody) administered to a patient is generally a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount" refers to LDL-C, ApoB, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, ApoC3, TRL particles, Lp(a) and residual. Detectable reduction (at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40% from baseline in one or more parameters selected from the group consisting of cholesterol , 45%, 50%, 55%, 60%, 65%, 70%, 75% or more) of the PCSK9 inhibitor.

For anti-PCSK9 antibodies, a therapeutically effective amount is from about 0.05 mg to about 600 mg, such as 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 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 anti-PCSK9 antibody. According to certain exemplary embodiments, a therapeutically effective amount of an anti-PCSK9 antibody is 30 mg, 40 mg or 75 mg (eg, for arilocumab in a patient weighing less than 50 kg and/or 17 years or younger), 50 mg, 75 mg. Or 150 mg (eg in the case of arilocumab in patients weighing 50 kg or more and/or 17 years or younger), or 140 mg or 420 mg (eg in the case of evolocumab). Other dosages for PCSK9 inhibitors will be apparent to those of skill in the art.

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

Dosing Regimens According to certain embodiments, multiple doses of a PCSK9 inhibitor (ie, a pharmaceutical composition comprising a PCSK9 inhibitor) are administered over a defined time course (eg, a daily therapeutic statin regimen or other dosage regimen). It can be administered to the subject (in addition to Grand LMT). The method according to this aspect comprises sequentially administering to the subject multiple doses of a PCSK9 inhibitor. As used herein, "consecutively administered" means that each dose of PCSK9 inhibitor is separated at different time points, eg, at predetermined intervals (eg, hours, days, weeks or months). Means being administered to a subject on a different day. The method provides a patient with a single initial dose of PCSK9 inhibitor, followed by one or more secondary doses of PCSK9 inhibitor, and optionally one or more tertiary doses of PCSK9 inhibitor. Administration to.

The terms "primary dose," "secondary dose," and "tertiary dose" refer to the temporal sequence of administration of individual doses of a pharmaceutical composition comprising a PCSK9 inhibitor. Thus, a "primary dose" is a dose administered at the beginning of a treatment regimen (also called a "baseline dose"); a "secondary dose" is a dose administered after the initial dose; a "tertiary dose". Is the medication administered after the second dose. The first, second, and third doses may all contain the same amount of PCSK9 inhibitor, but may differ from one another, generally with respect to frequency of administration. However, in certain embodiments, the amount of PCSK9 inhibitor included in the initial, secondary, and/or tertiary dosing will be different (eg, adjusted up or down as appropriate) over the course of treatment. In certain embodiments, two or more (eg, 2, 3, 4, or 5) doses of the drug are administered as a “loading dose” at the beginning of the treatment regimen, and then on a less frequent basis (eg, “ Subsequent doses administered in a maintenance dose") are administered.

According to an exemplary embodiment, each secondary and/or tertiary dose is from 1 to 26 (eg 1, 1, 1 and 1/2, 2, 2 and 1/2, 3, 3 and 1/2, 4 and 1/2, 5, 5 and 1/2, 6, 6 and 1/2, 7, 7 and 1/2, 8, 8 and 1/2, 9, 9, and 1/2, 10, 10 and 1/2, 11, 11 and 1/2, 12, 12 and 1/2, 13, 13 and 1/2, 14, 14 and 1/2, 15, 15 and 1/ 2, 16, 16 and 1/2, 17, 17 and 1/2, 18, 18 and 1/2, 19, 19 and 1/2, 20, 20 and 1/2, 21, 21 and 1/2, (22, 22 and 1/2, 23, 23 and 1/2, 24, 24 and 1/2, 25, 25 and 1/2, 26, 26 and 1/2, or more) weeks later. The term "immediate dose" as used herein refers to an antigen-binding molecule that is administered to a patient in a series of multiple doses without intervening doses and prior to administration of the next dose. Means dose.

The method according to this aspect can include administering to the patient any number of secondary and/or tertiary doses of the PCSK9 inhibitor. 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. Similarly, 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 with multiple secondary doses, each secondary dose is administered at the same frequency as the other secondary doses. For example, each secondary dose is administered to the patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Similarly, in embodiments with multiple tertiary doses, each tertiary dose is administered at the same frequency as the other tertiary doses. For example, each tertiary dose is administered to the patient 1 to 2, 4, 6, 8 or more weeks after the immediately preceding dose. Alternatively, the frequency with which the secondary and/or tertiary doses are administered to the patient can be varied over the course of the treatment regimen. The frequency of dosing will also be adjusted by the physician during the course of treatment, depending on the needs of the individual patient following the clinical examination.

The method includes a dosing regimen that includes a titration option (also referred to herein as "dose modification"). As used herein, an "escalation option" is one in which a patient has not achieved a particular reduction in one or more defined therapeutic parameters after receiving a particular number of doses of a PCSK9 inhibitor. In some cases, the dosage of PCSK9 inhibitor is then increased. For example, in the case of a treatment regimen that involves administering to a patient a 75 mg dose of anti-PCSK9 antibody once every two weeks, 8 weeks later (ie, 0 weeks, 2 weeks, 4 weeks, 6 weeks). If the patient has not reached a serum LDL-C concentration of less than 70 mg/dL, then the dose of anti-PCSK9 antibody is then, for example, 1 every 2 weeks. The dose is increased to 150 mg (eg, starting at week 10 or week 12).

In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 75 mg, once every two weeks. In certain embodiments, a patient's LDL-C is <70 mg measured after one or more, two or more, three or more, four or more, or five or more doses. /DL, a dose of about 75 mg is maintained. In certain embodiments, a patient's LDL-C is ≧70 mg measured after one or more, two or more, three or more, four or more, or five or more doses. /DL remains, the dose of about 75 mg is discontinued and thereafter the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg once every two weeks. To be done.

In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 300 mg once every four weeks. In certain embodiments, a patient's LDL-C is <70 mg measured after one or more, two or more, three or more, four or more, or five or more doses. /DL, a dose of about 300 mg is maintained. In certain embodiments, a patient's LDL-C is ≧70 mg measured after one or more, two or more, three or more, four or more, or five or more doses. /DL, the dose of about 300 mg is discontinued, and then the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg once every two weeks. To be done.

In certain embodiments, the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg once every two weeks.

In certain embodiments, when the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg once every two weeks, the dose of about 150 mg is at least 1 Interrupted if the patient's LDL-C is <10, 15, 20, or 25 mg/dL measured after one dose or at least 2, 3, 4, or 5 consecutive doses, and then specific for PCSK9 The antibody or antigen-binding fragment thereof that specifically binds is administered to the patient at a dose of about 75 mg once every two weeks. Without wishing to be bound by theory, it is hypothesized that very low LDL-C levels (eg <10, 15, 20, or 25 mg/dL) exacerbate diabetes. In certain embodiments, a dose of about 150 mg is administered to a patient as a fixed dose. In certain embodiments, a dose of about 150 mg is administered to a patient after the dose adjustments disclosed herein (eg, about 75 mg every 2 weeks, or about 300 mg every 4 weeks).

Combination Therapy As described elsewhere herein, the method involves administering to a patient a PCSK9 inhibitor in combination (in addition to) a patient's previously prescribed lipid modification therapy (LMT). Can include doing. LMTs include, but are not limited to, statins, fibrates, niacin (eg, nicotinic acid and its derivatives), bile sequestrants, ezetimibe, romitapid, phytosterols, orlistat, and the like. For example, the PCSK9 inhibitor is administered to a patient in combination with a stable daily therapeutic statin regimen. Exemplary daily therapeutic statin regimens in which a PCSK9 inhibitor is administered in combination in the context of the present method include, for example, atorvastatin (10, 20, 40 or 80 mg daily), (atorvastatin/ezetimibe 10/10 or daily). 40/10), rosuvastatin (5, 10 or 20 mg daily), cerivastatin (0.4 or 0.8 mg daily), pitavastatin (1, 2 or 4 mg daily), fluvastatin (20, 40 or 80 mg daily), simvastatin ( 5, 10, 20, 40 or 80 mg daily, Simvastatin/ezetimibe (10/10, 20/10, 40/10 or 80/10 mg daily), Lovastatin (10, 20, 40 or 80 mg daily), Pravastatin (10 daily) , 20, 40 or 80 mg), and combinations thereof. In certain embodiments, the statin therapy is the most resistant statin therapy for the patient. Other LMTs to which a PCSK9 inhibitor is administered in combination in the context of this method include, for example, (1) agents that inhibit cholesterol uptake and/or bile acid reabsorption (eg, ezetimibe); (2) Agents that increase lipoprotein catabolism (eg, niacin); and/or (3) activators of LXR transcription factors that play a role in cholesterol removal, such as 22-hydroxycholesterol.

According to certain embodiments, a PCSK9 inhibitor (eg, an anti-PCSK9 antibody, such as allilocumab, evolocumab, bokocizumab, rodercizumab, ralpancizumab, or LY30105014) is an inhibitor of angiopoietin-like protein 3 (eg, an anti-ANGPTL3 antibody, eg, REGN1500). , An angiopoietin-like protein 4 inhibitor (eg, an anti-ANGPTL4 antibody, eg, an anti-ANGPTL4 antibody referred to as “H1H268P” or “H4H284P” in US Pat. No. 9,120,851), or an angiopoietin-like protein 8 inhibitor ( For example, a method comprising administering to a patient in combination with an anti-ANGPTL8 antibody) is provided.

According to certain embodiments, in addition to insulin therapy, administration of a PCSK9 inhibitor (eg, an anti-PCSK9 antibody, such as allilocumab, evolocumab, bococizumab, rodercizumab, ralpancizumab or LY301504) to the patient in combination with an additional antidiabetic therapy. A method including is provided. Exemplary additional antidiabetic therapies include, but are not limited to:
(A) All drugs listed in Rote Liste 2016 (eg, all anti-diabetic drugs listed in Chapter 12, Rote Liste 2014), all listed in Chapter 06, Rote Liste 2016 Weight loss agents or appetite suppressants, All Lipid-reducing drugs listed in Chapter 58, Rote Liste 2016, All antihypertensive agents listed in Chapter 17, Rote Liste 2016, All listed in Rote Liste Or a diuretic listed in Chapter 36, Rote Liste 2016;
(B) Glucagon-like peptide 1 (GLP-1) therapy including GLP-1, GLP-1 analogs, and GLP-1 receptor agonists, eg: GLP-1(7-37), GLP-1(7- 36) Amide, lixisenatide (eg Lyxumia®), exenatide (eg Exendin-4, rExendin-4, Byetta®, Bydureon®, exenatide NexP), exenatide-LAR, liraglutide. , Victoza (registered trademark), semaglutide, taspoglutide, albiglutide, dulaglutide, arbugon, oxyntomodulin, geniproside, ACP-003, CJC-1131, CJC-1134-PC, GSK-2374697, PB-1023, TTP-054. , Langlenatide (HM-11260C), CM-3, GLP-1 Eligen, AB-201, ORMD-0901, NN9924, NN9926, NN9927, Nodexen, Viador-GLP-1, CVX-096, ZYOG-1, ZYD-1. , ZP-3022, CAM-2036, DA-3091, DA-15864, ARI-2651, ARI-2255, Exenatide-XTEN(VRS-859), Exenatide-XTEN+Glucagon-XTEN(VRS-859+AMX-808) and polymer bond. GLP-1 and GLP-1 analogs;
(C) Dual GLP-1/GIP agonist (for example, RG-7697 (MAR-701), MAR-709, BHM081, BHM089, BHM098); Dual GLP-1/glucagon receptor agonist (for example, BHM-034, OAP -189 (PF-05212389, TKS-1225), TT-401/402, ZP2929, LAPS-HMOXM25, MOD-6030);
(D) dual GLP-1/gastrin agonist (eg ZP-3022);
(E) gastrointestinal peptides such as peptide YY3-36 (PYY3-36) or analogs thereof and pancreatic polypeptide (PP) or analogs thereof;
(F) Glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist or antagonist, ghrelin antagonist or inverse agonist, xenin and analogs thereof.
(G) dipeptidyl peptidase-IV (DPP-4) inhibitors, for example: alogliptin (eg Nesina (registered trademark), Kazano (registered trademark)), linagliptin (eg Ondero (registered trademark), Trajenta (registered trademark)). , Trajenta®, Trayenta®, saxagliptin (eg, Onglyza®, Komboglyze XR®), sitagliptin (eg, Januvia®, Xelevia®, Tesave). (Registered trademark), Janumet (registered trademark), Velmetia (registered trademark), Juvissync (registered trademark), JanumetXR (registered trademark), anagliptin, teneligliptin (for example, Tenelia (registered trademark)), trellagliptin, vildagliptin (for example, Galvus (registered trademark)). Registered trademark), Galvumet (registered trademark)), gemigliptin, omalipliptin, evogliptin, dutogliptin, DA-1229, MK-3102, KM-223, KRP-104, PBL-1427, pinoxacin hydrochloride, and Ari-2243;
(H) Sodium-dependent glucose transporter 2 (SGLT-2) inhibitors, for example: canagliflozin, dapagliflozin, remogliflozin, remogliflozin etabonate, sergliflozin, empagliflozin, ipragliflozin, tofogliflozin, Luceogliflozin, Ertugliflozin, EGT-0001442, LIK-066, SBM-TFC-039, and KGA-3235 (DSP-3235);
(I) dual inhibitors of SGLT-2 and SGLT-1 (eg LX-4211, LIK066);
(J) SGLT-in combination with an antiobesity agent such as an SGLT-1 inhibitor (eg, LX-2761, KGA-3235, etc.) or an ileal bile acid transfer (IBAT) inhibitor (eg, GSK-1614235+GSK-2330672). 1 inhibitor;
(K) biguanides (eg, metformin, buformin, phenformin);
(L) thiazolidinediones (eg, pioglitazone, rosiglitazone), glitazone analogs (eg, lobeglitazone);
(M) Peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonists or modulators (e.g. salogritazar (e.g. Lipagulin(R)), GFT-505), or PPAR gamma partial agonists. (For example, Int-131);
(N) Sulfonylureas (eg tolbutamide, glibenclamide, glimepiride, amaryl®, glipizide) and meglitinides (eg nateglinide, repaglinide, mitiglinide);
(O) alpha-glucosidase inhibitors (eg acarbose, miglitol, voglibose);
(Q) amylin and amylin analogues (eg pramlintide, Symlin®);
(P) G protein-coupled receptor 119 (GPR119) agonist (for example, GSK-1292263, PSN-821, MBX-2982, APD-597, ARRY-981, ZYG-19, DS-8500, HM-47000, YH-). Chem1);
(Q) GPR40 agonist (for example, TUG-424, P-1736, P-11187, JTT-851, GW9508, CNX-011-67, AM-1638, AM-5262);
(R) a GPR120 agonist and a GPR142 agonist;
(S) Systemic or low-absorbing TGR5 (GPBAR1=G protein-coupled bile acid receptor 1) agonist (eg, INT-777, XL-475, SB756050);
(T) Diabetic immunotherapeutic agents, for example: oral CC chemokine receptor type 2 (CCR-2) antagonist (for example CCX-140, JNJ-41434352), interleukin 1 beta (IL-1β) antagonist (for example AC- 201), or an oral monoclonal antibody (MoA) (for example, metallozamide, VVP808, PAZ-320, P-1736, PF-05175157, PF-04739719);
(V) anti-inflammatory agents for the treatment of metabolic syndrome and diabetes, eg: nuclear factor kappa B inhibitors (eg Triolex®);
(W) adenosine monophosphate-activated protein kinase (AMPK) stimulants, for example: imeglymine (PXL-008), debio-0930 (MT-63-78), R-118;
(X) inhibitors of 11-beta-hydroxysteroid dehydrogenase 1 (11-beta-HSD-1) (e.g., LY2523199, BMS770767, RG-4929, BMS816336, AZD-8329, HSD-016, BI-135585);
(Y) Activator of glucokinase (for example, PF-04991532, TTP-399 (GK1-399), GKM-001 (ADV-1002401), ARRY-403 (AMG-151), TAK-329, TMG-123. , ZYGK1);
(Z) an inhibitor of diacylglycerol O-acyltransferase (DGAT) (for example, prazistat (LCQ-908)), an inhibitor of protein tyrosine phosphatase 1 (for example, troduscumin), an inhibitor of glucose-6-phosphatase, An inhibitor of fructose-1,6-bisphosphatase, an inhibitor of glycogen phosphorylase, an inhibitor of phosphoenolpyruvate carboxykinase, an inhibitor of glycogen synthase kinase, an inhibitor of pyruvate dehydrogenase kinase;
(Aa) a modulator of glucose transporter-4, a somatostatin receptor 3 agonist (eg, MK-4256);
(Bb) one or more lipid-lowering agents are also suitable as combination partners, for example 3-hydroxy-3-methylglutaryl-coenzyme-A-reductase (HMG-CoA-reductase) inhibitors, for example: Simvastatin (eg, Zocor®, Inegy®), Simcor®), atorvastatin (eg Sortis®, Caduet®), rosuvastatin (eg Crestor®). ), pravastatin (eg, Lipostat®, Seliplan®), fluvastatin (eg, Lescol®), pitavastatin (eg, Livazo®, Livalo®), lovastatin (). For example, Mevacor®, Advicor®), mevastatin (eg Compactin®), rivastatin, cerivastatin (Lipobay®), fibrates, eg bezafibrate (eg Cedur®). Delay), ciprofibrate (e.g. Hyperlipen(R)), fenofibrate (e.g. Antara(R), Lipofen(R), Ripanchir(R)), gemfibrozil (e.g. Lipoid(R), Geviron. (Registered trademark), etofibrate, synfibrate, ronifibrate, clinofibrate, clofibride, nicotinic acid and its derivatives (such as niacin including a sustained-release preparation of niacin), nicotinic acid receptor 1 agonist (for example, GSK) -256073), a PPAR-delta agonist, an acetyl-CoA-acetyltransferase (ACAT) inhibitor (eg, avasimive), a cholesterol absorption inhibitor (eg, ezetimibe, Ezetrol®, Zetia®, Liptruzet®). ), Vytorin (registered trademark), S-556971), bile acid-binding substances (eg, cholestyramine, colesevelam), ileal bile acid transport (IBAT) inhibitors (eg, GSK-2330672, LUM-002), microsomal triglyceride transfer. Protein (MTP) inhibitors (eg, lomitapide (AEGR-733), SLx-4090, granotapid), protan A modulator of the protein converting enzyme subtilisin/kexin type 9 (PCSK9) (for example, allilocumab (REGN727/SAR236553), AMG-145, LGT-209, PF-049550615, MPSK3169A, LY3015014, ALD-306, ALN-PCS, BMS-. 962476, SPC5001, ISIS-394814, 1B20, LGT-210, 1D05, BMS-PCSK9Rx-2, SX-PCK9, RG7652), LDL receptor upregulators, such as liver-selective thyroid hormone receptor beta agonists (e.g., epilotyrome). (KB-2115), MB07811, sovetilomem (QRX-431), VIA-3196, ZYT1), HDL-elevating compound protein, for example, cholesteryl ester transfer protein (CETP) inhibitor (for example, anacetrapib (MK0859), darcetrapib, evacetrapib, JTT-302, DRL-17822, TA-8995, R-1658, LY-2484595, DS-1442), or dual CETP/PCSK9 inhibitors (e.g. K-312), ATP binding cassette (ABC1) regulators, lipid metabolism. Modulator (for example, BMS-823778, TAP-301, DRL-21994, DRL-21995), phospholipase A2 (PLA2) inhibitor (for example, Darapradive, Tyrisa (registered trademark), Valles Pradib, Lirapradib), ApoA-I enhancer (For example, RVX-208, CER-001, MDCO-216, CSL-112), cholesterol synthesis inhibitor (for example, ETC-1002), lipid metabolism regulator (for example, BMS-823778, TAP-301, DRL-21994). , DRL-21995) and omega-3 fatty acids and their derivatives (eg icosapentatoethyl (AMR101), Epanova®, AKR-063, NKPL-66, PRC-4016, CAT-2003);
(Cc) Bromocriptine (eg Cycloset®, Parlodel®), phentermine and phentermine formulations or combinations (eg Adipex-P, Ionamine, Qsymia®), benzphetamine (eg Didrex(TM)). )), diethylpropion (eg Tenuate®), phendimetrazine (eg Adipost®), Bontril®), bupropion and combinations (eg Zyban®), Wellbutrin XL (registered trademark), Contrave (registered trademark), Empatic (registered trademark)), sibutramine (for example, Reductil (registered trademark), Merida (registered trademark)), topiramate (for example, Topamax (registered trademark)), zonisamide (registered trademark). For example, Zonegran®), tesofensine, opioid antagonists such as naltrexone (eg Naltrexin®, naltrexone+bupropion), cannabinoid receptor 1 (CB1) antagonists (eg TM-38837), melanin-concentrating hormone. (MCH-1) antagonists (eg BMS-830216, ALB-127158(a)), MC4 receptor agonists and partial agonists (eg AZD-2820, RM-493), neuropeptide Y5 (NPY5) or NPY2 antagonists (eg. For example, berneperito, S-234462), NPY4 agonists (eg PP-1420), beta-3-adrenergic receptor agonists, leptin or leptin mimetics, 5-hydroxytryptamine 2c (5HT2c) receptor agonists (eg locazelin). , Belviq®), pramlintide/metreleptin, lipase inhibitors such as cetilistat (eg Cametor®), orlistat (eg Xenical®, Calobalin®), angiogenesis inhibitors. (E.g. ALS-L1023), betahistidine and histamine H3 antagonists (e.g. HPP-404), AgRP (agouti-related protein) inhibitors (e.g. TTP-435), serotonin reuptake inhibitors e.g. fluoxetine (e.g. Fluctine (registered trademark), duloxet (Eg Cymbalta®), dual or triple monoamine uptake inhibitors (dopamine, norepinephrine, serotonin reuptake), eg sertraline (eg Zoloft®), tesofensine, methionine aminopeptidase 2) (MetAP2). ) Inhibitors (eg belaranib), and antisense oligonucleotides (eg ISIS-FGFR4Rx) or the production of fibroblast growth factor receptor 4 (FGFR4) or prohibited targeting peptide-1 (eg Adipotide®). ); and (dd) nitric oxide donors, AT1 antagonists or angiotensin II (AT2) receptor antagonists such as telmisartan (eg Kinzal®, Micardis®), candesartan (eg Atacand®). , Blopress(R), Valsartan (e.g. Diovan(R), Co-Diovan(R)), Losartan (e.g. Cosaar(R)), Eprosartan (e.g. Teveten(R)), Irbesartan (eg, Aprovel®, CoAprovel®), Olmesartan (eg, Votum®, Olmetec®), Tasosartan, Azilsartan (eg, Edarbi®), Dual Angiotensin Receptor blocker (dual ARB), angiotensin converting enzyme (ACE) inhibitor, ACE-2 activator, renin inhibitor, prorenin inhibitor, endothelin converting enzyme (ECE) inhibitor, endothelin receptor (ET1/ETA) blockade Drugs, endothelin antagonists, diuretics, aldosterone antagonists, aldosterone synthase inhibitors, alpha blockers, alpha-2 adrenergic receptor antagonists, beta blockers, mixed alpha/beta blockers, calcium antagonists, calcium channel blockers (CCB ), a nasal formulation of the calcium channel blocker diltiazem (eg CP-404), dual mineralocorticoid/CCB, centrally acting antihypertensive agents, inhibitors of neutral endopeptidases, aminopeptidase-A inhibitors, vasopeptide inhibitors, Heavy vascular peptide inhibitors such as neprilysin-ACE inhibitor or neprilysin-ECE inhibitor, dual action Sex AT receptor-neprilysin inhibitor, dual AT1/ETA antagonist, advanced glycation end-product (AGE) breaker, recombinant renalase, blood pressure vaccine, eg anti-RAAS (renin-angiotensin-aldosterone system) vaccine, AT1- or AT2 -Vaccines, drugs based on hypertensive pharmacogenomics, such as modulators of genetic polymorphisms associated with hypertensive responses, platelet aggregation inhibitors, and others; and (ee) suitable combinations thereof.

In certain embodiments, the additional antidiabetic therapy is GLP-1 therapy (eg, lixisenatide). In certain embodiments, GLP-1 therapy is formulated with methionine (eg, L-methionine or D-methionine). In certain embodiments, is polysorbate (eg, polysorbate 20, polysorbate 80), poloxamer (eg, poloxamer 188), benzalkonium chloride, histidine, lysine, and/or EDTA not present in the formulation for GLP-1 therapy? , Or substantially nonexistent. In certain embodiments, formulations of GLP-1 therapy include surfactants such as polyols (eg, polypropylene glycol, polyethylene glycol, poloxamers, pluronics, tetronics), partial and fatty acid esters and esters of polyhydric alcohols such as esters. , Or free of esters of glycerol and sorbitol (eg, Span®, Tween®, Myrj®, Brij®, Cremophor®) .. Formulations of GLP-1 therapy include suitable preservatives (eg, phenol, m-cresol, benzyl alcohol, and/or p-hydroxybenzoate) and suitable tonicity agents (eg, glycerol, dextrose, lactose, sorbitol, mannitol, glucose, NaCl, calcium or magnesium compound, for example, may include CaCl _2). Glycerol, dextrose, lactose, sorbitol, mannitol, and glucose concentrations are typically in the range 100-250 mM, with NaCl at concentrations up to 150 mM.

In certain embodiments, the insulin therapy that the patient receives is combined with an additional anti-diabetic therapy (eg, any of the aforementioned anti-diabetic therapies that is not insulin therapy). For example, in certain embodiments, antidiabetic therapy comprises a combination of insulin therapy (eg, insulin glargine) and GLP-1 therapy (eg, lixisenatide). These therapies can be provided individually or in a single pharmaceutical composition. For example, insulin glargine and lixisenatide can be formulated into a single pharmaceutical composition (eg, Soliqua® 100/33) for daily injection.

In the context of this method, the additional therapeutically active ingredient, eg, any of the agents listed above or derivatives thereof, is administered immediately prior to, concurrently with, or shortly after administration of the PCSK9 inhibitor; For purposes of such administration, such a dosing regimen is considered as administration of a PCSK9 inhibitor "in combination with" an additional therapeutically active ingredient). The methods include pharmaceutical compositions and methods of use thereof in which a PCSK9 inhibitor is co-formulated with one or more of the additional therapeutically active ingredients described elsewhere herein.

Administration of PCSK9 Inhibitors as Add-on Therapy The method of treatment comprises treating a patient with hypercholesterolemia and diabetes with a PCSK9 inhibitor, such as an antibody that specifically binds to PCKS9 or an antigen-binding fragment thereof, The PCSK9 inhibitor can be administered as an add-on to the patient's existing insulin therapy and/or LMT (if applicable), such as an add-on to the patient's existing daily therapeutic insulin and/or statin regimen.

For example, the method includes an add-on therapy regimen, wherein the PCSK9 inhibitor is administered as an add-on therapy to the same stable multiple daily insulin regimen and/or daily therapeutic statin regimen (ie, the same dosage as the statin). And the patient was prior to receiving the PCSK9 inhibitor. In other embodiments, the PCSK9 inhibitor is administered as an add-on therapy to a therapeutic insulin and/or statin regimen that includes an insulin and/or statin in an amount greater or less than the insulin and/or statin dosage. Before administration of the PCSK9 inhibitor. For example, after initiating a therapeutic regimen comprising a PCSK9 inhibitor administered at a particular dosing frequency and dosage, a daily dose of insulin and/or statin administered or prescribed to a patient initiates a PCSK9 inhibitor therapeutic regimen. (A) stays the same, (b) increases, or (c) decreases compared to the daily statin dose that the patient was taking prior to taking (eg, Gradually increase or decrease).

Therapeutic effect The present method comprises LDL-C, ApoB, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglyceride, Lp(a), HDL-C, LDL particle number, LDL particle size, ApoC3, ApoA-1. , Lipoprotein cholesterol rich in triglycerides (TRL-C), and a decrease in serum levels of one or more lipid components selected from the group consisting of residual cholesterol. According to certain embodiments, administering to the patient a pharmaceutical composition comprising a PCSK9 inhibitor is at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, or Further reduction in mean percentage of serum low density lipoprotein cholesterol (LDL-C) from baseline; at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, Or more average percent reduction from baseline of ApoB; at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, or more of baseline ApoB100 An average percent reduction from non-HDL-C baseline of at least about 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, or more; At least about 10%, 15%, 20%, 25%, 30%, 35%, 40%, or more, an average percent reduction in total cholesterol from baseline; at least about 5%, 10%, 15%, 20%, 25%, 30%, or more, an average percent reduction from baseline of VLDL-C; at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, or A greater average percent reduction in triglyceride from baseline; from a baseline number of LDL particles of at least about 20%, 25%, 30%, 35%, 40%, 45%, 50%, or more. Average percent reduction; at least about 1.5%, 2.5%, 2.5%, 3%, 3.5% or 4%, or more, average percent reduction from baseline in LDL particle size; at least About 5%, 5.5%, 6.0%, 6.5%, 7.0%, 7.5%, 8.0%, 9.0%, 10%, or more apolipoprotein C3( ApoC3) decrease in mean percent from baseline; increase in mean percent from baseline of HDL-C of at least about 1%, 2%, 3%, 4%, 5% or more; at least about 1% 2%, 3%, 4%, 5%, or more increase in mean percentage from baseline of ApoA-1; at least about 5%, 10%, 15%, 20%, 25%, 30%, Or more reduction in average percent of TRL-C from baseline; and/or at least about 5%, 10%, 15%, 20%, 25%, or more. Results in an average percent reduction from baseline of Lp(a) above.

The method comprises treating a patient with hypercholesterolemia and T1DM undergoing insulin therapy, the method comprising a dosage of about 75-150 mg/dose, about every 2 or 4 weeks. Administering multiple doses of anti-PCSK9 antibody or antigen-binding fragment thereof to a patient at a single dosing frequency, or in a dosing regimen according to the escalating dosing regimen disclosed herein. After about 8,10,12,14,16,18,20,22,24 or more weeks of treatment with anti-PCSK9 antibody, patients have at least 35%, 50%, or 60% LDL-C levels from baseline. Can show a decrease in In certain embodiments, after treatment with anti-PCSK9 antibody for one week or more, the patient exhibits a decrease in LDL-C levels of about 35%, 50%, or 60% or more from baseline.

The method also includes treating a patient with hypercholesterolemia and T2DM undergoing insulin therapy, the method comprising: a dosage of about 75-150 mg/dose, about every 2 or 4 weeks. Comprising administering to the patient multiple doses of an anti-PCSK9 antibody or antigen-binding fragment thereof, at a dosing frequency of about once, or a dosing regimen according to the escalating dosing regimen disclosed herein. After about 8, 10, 12, 14, 16, 18, 20, 22, 24 or more weeks of treatment with anti-PCSK9 antibody, patients have LDL-C levels of at least 40%, 48%, or 54% from baseline. Can show a decrease in In certain embodiments, after treatment with anti-PCSK9 antibody for one week or more, the patient exhibits a decrease in LDL-C levels of about 40%, 48%, or 54% or more from baseline.

As disclosed herein, the method does not alter the patient's diabetes parameters. For example, in certain embodiments, the method does not affect the patient's hemoglobin A1c (HbA1c) levels (eg, 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8). %, 9%, or no more than 10%). In certain embodiments, the method does not affect fasting plasma glucose (FPG) levels in the patient (eg, 2%, 4%, 6%, 8%, 10%, 12%, 15%, 18). %, or does not change by more than 20%).

In a further embodiment, the invention provides an antibody that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9) for treating hypercholesterolemia in a patient with type 1 diabetes mellitus (T1DM). Or to the use of antigen-binding fragments thereof.

In yet a further embodiment, the invention relates to a method of treating hypercholesterolemia in a patient with type 1 diabetes mellitus (T1DM).

In one embodiment, the use and/or method comprises
(A) a patient at high cardiovascular risk receiving insulin therapy,
(I) selecting a patient with hypercholesterolemia that is not adequately controlled by T1DM, and (ii) maximally resistant statin therapy; Administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds to PCSK9), the patient undergoing concomitant insulin therapy.

In one embodiment of the above uses and/or methods, 75 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 150 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 300 mg of antibody or antigen binding fragment is administered to the patient every 4 weeks.

In one embodiment of the above uses and/or methods, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs:2, 3, and 4, and the 3 set forth in SEQ ID NOs:7, 8 and 10. Contains one light chain CDR.

In one embodiment of the above use and/or method, the antibody or antigen binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. )including.

In one embodiment of the use and/or method above, the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bococizumab, rodercizumab, ralpancizumab and LY301504.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is arilocumab.

In one embodiment, the use and/or method comprises
(C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient If the LDL-C level is above the threshold level, the method further comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In one embodiment, the use and/or method comprises
(C) if the LDL-C level in the patient is below a threshold level, the patient is administered with one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient If the LDL-C level is above the threshold level, the method further comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In one embodiment of the uses and/or methods above, the threshold level is 70 mg/dL.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is administered subcutaneously.

In one embodiment of the above uses and/or methods, the patient further undergoes concomitant lipid modification therapy (LMT).

In one embodiment of the use and/or method above, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants.

In one embodiment of the above uses and/or methods, LMT is statin therapy.

In one embodiment of the use and/or method above, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin.

In one embodiment of the above uses and/or methods, the statin therapy is the most resistant statin therapy.

In one embodiment of the above uses and/or methods, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the above uses and/or methods, the patient is statin intolerant.

In one embodiment of the use and/or method above, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. It

In one embodiment of the above uses and/or methods, the patient receives insulin therapy along with concomitant antidiabetic therapy.

In one embodiment of the above uses and/or methods, the additional concomitant antidiabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide. (GIP) receptor agonist or antagonist, ghrelin antagonist or inverse agonist, xenin, xenin analogue, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 ( GPR119) Agonist, GPR40 Agonist, GPR120 Agonist, GPR142 Agonist, Systemic or Low Absorption TGR5 Agonist, Diabetic Immunotherapeutic, Anti-inflammatory Drug for Treating Metabolic Syndrome and Diabetes, Adenosine Monopurinate Activated Protein Kinase (AMPK) Stimulants, 11-beta-hydroxysteroid dehydrogenase 1 inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipids Selected from the group consisting of reducing agents, as well as combinations thereof.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 30%, 35%, 40%, or 45%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces non-HDL-C levels in the patient by at least 25%, 30%, 35%, or 40%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces apolipoprotein C3 (ApoC3) levels in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is:
(A) does not affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) does not affect the patient's fasting plasma glucose (FPG) levels.

In a further embodiment, the invention relates to a use and/or method for treating hypercholesterolemia in a patient with type 1 diabetes mellitus (T1DM), the method comprising:
(A) a patient at high cardiovascular risk receiving insulin therapy,
(I) selecting T1DM, and (ii) patients with hypercholesterolemia not adequately controlled by maximally resistant statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) LDL- in the patient. If the C level is less than 70 mg/dL, the patient is administered about one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg/dL. In the case of dL or more, it comprises the step of administering the following doses of about 150 mg of the antibody or its antigen-binding fragment once or more about every two weeks, wherein the antibody or its antigen-binding fragment has the amino acid sequence of SEQ ID NO: 1. Having HCVR, and an LCVR having the amino acid sequence of SEQ ID NO:6, the patient undergoes concomitant insulin therapy.

In a further embodiment, the invention relates to a use and/or method for treating hypercholesterolemia in a patient with diabetes mellitus type 2 (T2DM), the method comprising:
(A) a patient at high cardiovascular risk receiving insulin therapy,
(I) selecting a patient with hypercholesterolemia not adequately controlled by T2DM, and (ii) maximally resistant statin therapy; Administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds (PCSK9), and the patient receives concomitant insulin therapy.

In one embodiment of the above uses and/or methods, 75 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 150 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 300 mg of antibody or antigen binding fragment is administered to the patient every 4 weeks.

In one embodiment of the above uses and/or methods, the antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOs:2, 3, and 4, and the 3 set forth in SEQ ID NOs:7, 8 and 10. Contains one light chain CDR.

In one embodiment of the above use and/or method, the antibody or antigen binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region having the amino acid sequence of SEQ ID NO:6 ( LCVR).

In one embodiment of the above uses and/or methods, the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is arilocumab.

In one embodiment of the above uses and/or methods,
(C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient If the LDL-C level is above the threshold level, the method further comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In one embodiment of the above uses and/or methods,
(C) if the LDL-C level in the patient is below a threshold level, the patient is administered with one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient If the LDL-C level is above the threshold level, the method further comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In one embodiment of the uses and/or methods above, the threshold level is 70 mg/dL.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is administered subcutaneously.

In one embodiment of the above uses and/or methods, the patient further undergoes concomitant lipid modification therapy (LMT).

In one embodiment of the use and/or method above, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants.

In one embodiment of the above uses and/or methods, LMT is statin therapy.

In one embodiment of the use and/or method above, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin.

In one embodiment of the above uses and/or methods, the statin therapy is a maximally resistant amount of statin therapy.

In one embodiment of the above uses and/or methods, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the above uses and/or methods, the patient is statin intolerant.

In one embodiment of the use and/or method above, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. It

In one embodiment of the above uses and/or methods, the patient receives insulin therapy along with concomitant antidiabetic therapy.

In one embodiment of the above uses and/or methods, the additional concomitant antidiabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide. (GIP) receptor agonist or antagonist, ghrelin antagonist or inverse agonist, xenin, xenin analogue, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 ( GPR119) Agonist, GPR40 Agonist, GPR120 Agonist, GPR142 Agonist, Systemic or Low Absorption TGR5 Agonist, Diabetic Immunotherapeutic, Anti-inflammatory Drug for Treating Metabolic Syndrome and Diabetes, Adenosine Monopurinate Activated Protein Kinase (AMPK) Stimulants, 11-beta-hydroxysteroid dehydrogenase 1 inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipids Selected from the group consisting of reducing agents, as well as combinations thereof.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 30%, 35%, 40%, or 45%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces non-HDL-C levels in the patient by at least 20%, 25%, 30%, or 35%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces ApoC3 levels in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is:
(A) does not affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) does not affect the patient's fasting plasma glucose (FPG) levels.

In a further embodiment, the invention relates to a use and/or method for treating hypercholesterolemia in a patient with diabetes mellitus type 2 (T2DM), the method comprising:
(A) a patient at high cardiovascular risk receiving insulin therapy,
Selecting (i) T2DM, and (ii) patients with hypercholesterolemia not adequately controlled by maximally tolerant statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) LDL- in the patient. If the C level is less than 70 mg/dL, the patient is administered about one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg/dL. In the case of dL or more, it comprises the step of administering the following doses of about 150 mg of the antibody or its antigen-binding fragment once or more about every two weeks, wherein the antibody or its antigen-binding fragment has the amino acid sequence of SEQ ID NO: 1. Having HCVR, and an LCVR having the amino acid sequence of SEQ ID NO:6, the patient undergoes concomitant insulin therapy.

In a further embodiment, the invention provides a human proprotein convertase subtilisin/kexin for treating hypercholesterolemia in patients with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease (ASCVD). It relates to the use of an antibody or an antigen-binding fragment thereof which specifically binds to type 9 (PCSK9).

In yet a further embodiment, the invention relates to a method of treating hypercholesterolemia in a patient having T2DM and ASCVD.

In one embodiment, the use and/or method comprises
(A) a patient at high cardiovascular risk receiving insulin therapy,
(I) T2DM,
(Ii) selecting a patient with hypercholesterolemia that is not adequately controlled by ASCVD, and (iii) maximally resistant statin therapy; Administering 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds (PCSK9), and the patient receives concomitant insulin therapy.

In one embodiment of the above uses and/or methods, ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral arterial disease.

In one embodiment of the above uses and/or methods, CHD comprises acute myocardial infarction, subclinical myocardial infarction, and unstable angina.

In one embodiment of the above uses and/or methods, 75 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 150 mg of antibody or antigen binding fragment is administered to the patient every two weeks.

In one embodiment of the above uses and/or methods, 300 mg of antibody or antigen binding fragment is administered to the patient every 4 weeks.

In one embodiment of the above uses and/or methods, it comprises the three heavy chain CDRs set forth in SEQ ID NOs: 2, 3 and 4 and the three light chain CDRs set forth in SEQ ID NOs: 7, 8 and 10.

In one embodiment of the above use and/or method, the antibody or antigen binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region having the amino acid sequence of SEQ ID NO:6 ( LCVR).

In one embodiment of the above uses and/or methods, the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is arilocumab.

In one embodiment, the use and/or method comprises
(C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient If the LDL-C level is above the threshold level, the method further comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about once every two weeks.

In one embodiment, the use and/or method comprises
(C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient If the LDL-C level is above the threshold level, it comprises the step of administering one or more subsequent doses of 150 mg of the antibody or antigen binding fragment thereof about once every two weeks.

In one embodiment of the uses and/or methods above, the threshold level is 70 mg/dL.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is administered subcutaneously.

In one embodiment of the above uses and/or methods, the patient further undergoes concomitant lipid modification therapy (LMT).

In one embodiment of the use and/or method above, the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants.

In one embodiment of the above uses and/or methods, LMT is statin therapy.

In one embodiment of the use and/or method above, the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin.

In one embodiment of the above uses and/or methods, the statin therapy is the most resistant amount of statin therapy.

In one embodiment of the above uses and/or methods, the cholesterol absorption inhibitor is ezetimibe.

In one embodiment of the above uses and/or methods, the patient is statin intolerant.

In one embodiment of the use and/or method above, the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. It

In one embodiment of the above uses and/or methods, the patient receives insulin therapy along with concomitant antidiabetic therapy.

In one embodiment of the above uses and/or methods, the additional concomitant antidiabetic therapy is glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide. (GIP) receptor agonist or antagonist, ghrelin antagonist or inverse agonist, xenin, xenin analogue, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibitor, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 ( GPR119) Agonist, GPR40 Agonist, GPR120 Agonist, GPR142 Agonist, Systemic or Low Absorption TGR5 Agonist, Diabetic Immunotherapeutic, Anti-inflammatory Drug for Treating Metabolic Syndrome and Diabetes, Adenosine Monopurinate Activated Protein Kinase (AMPK) Stimulants, 11-beta-hydroxysteroid dehydrogenase 1 inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipids Selected from the group consisting of reducing agents, as well as combinations thereof.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 30%, 35%, 40%, or 45%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces non-HDL-C levels in the patient by at least 20%, 25%, 30%, or 35%.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces ApoC3 levels in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient.

In one embodiment of the above uses and/or methods, the antibody or antigen binding fragment thereof is:
(A) does not affect the patient's hemoglobin A1c (HbA1c) levels; and/or (b) does not affect the patient's fasting plasma glucose (FPG) levels.

In a further embodiment, the invention relates to a use and/or method for treating hypercholesterolemia in a patient having T2DM and ASCVD, the method comprising:
(A) a patient at high cardiovascular risk receiving insulin therapy,
(I) T2DM,
Selecting patients with hypercholesterolemia not adequately controlled by (ii) ASCVD, and (iii) maximally resistant statin therapy;
(B) administering to the patient every two weeks 75 mg of an antibody or antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9); and (c) LDL in the patient. If the -C level is less than 70 mg/dL, the patient is administered with about one or more subsequent doses of 75 mg of antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg. /DL or more, comprising administering 150 mg of the antibody or antigen-binding fragment thereof once or more about once every two weeks, wherein the antibody or antigen-binding fragment is the amino acid sequence of SEQ ID NO: 1. And an LCVR having the amino acid sequence of SEQ ID NO: 6, wherein the patient receives concomitant insulin therapy.

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

Generation of Human Antibodies to Human PCSK9 Human anti-PCSK9 antibodies were generated as described in US Pat. No. 8,062,640. An exemplary PCSK9 inhibitor used in the examples below is the human anti-PCSK9 antibody called "mAb316P", also known as "REGN727" or "arilocumab". 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 comprising SEQ ID NO:6 ( LCVR); heavy chain complementarity determining region 1 (HCDR1) containing SEQ ID NO:2, HCDR2 containing SEQ ID NO:3, HCDR3 containing SEQ ID NO:4, light chain complementarity determining region 1 (LCDR1) containing SEQ ID NO:7, sequence LCDR2 comprising number 8 and LCDR3 comprising SEQ ID NO:10.

To assess the efficacy and safety of arilocumab in insulin-treated patients with hypercholesterolemia with high cardiovascular risk who have type 1 or type 2 diabetes and are not adequately controlled by maximally tolerated LDL-C reduction therapy Randomized, double-blind, placebo-controlled, parallel-group study Introduction Over 380 million people worldwide suffer from diabetes, most of whom die of cardiovascular disease (CVD). Compared to people without diabetes, people with diabetes are at increased risk of developing CVD, develop relevant clinical complications at an early age, and have a reduced life expectancy of approximately 6-7 years. In addition to the high labor costs of the disease, CVD contributes significantly to the overall medical costs of these patients.

This study, termed Odyssey DM-Insulin, has type 1 or type 2 diabetes mellitus during insulin therapy with high cardiovascular (CV) risk hypercholesterolemia and is associated with other lipid-modifying therapies (LMT). Included adult patients with and without well-controlled maximal tolerated doses of statins.

Objectives of the study The main objectives of the study were: (a) high cardiovascular risk patients with insulin-treated diabetes mellitus with hypercholesterolemia not adequately controlled by maximally tolerant LDL-C reduction therapy. Assessing the efficacy of alilocumab in comparison to placebo in reducing calculated low density lipoprotein cholesterol (LDL-C) after 24 weeks of treatment in; and (b) patients with diabetes treated with insulin. To assess the safety and resistance of alilocumab in.

Secondary objectives of the study were other lipid parameters at weeks 12 and 24 (eg measured LDL-C, non-high density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (Apo B). , Total cholesterol (TC), lipoprotein a (Lp(a)), high density lipoprotein cholesterol (HDL-C), triglyceride (TG) levels, triglyceride-rich lipoprotein (TGRL), apolipoprotein A-1 ( It was to assess the efficacy of arilocumab compared to placebo on Apo A-1), apolipoprotein C3 (ApoC3), and LDL particle numbers).

Study Design This is administered by subcutaneous (SC) injection to insulin-treated patients who have a high CV risk of type 1 or type 2 diabetes mellitus and whose hypercholesterolemia is not adequately controlled by maximally tolerated LDL-C lowering therapy. Was a phase 3b, randomized, double-blind, placebo-controlled, multinational and multicenter study to assess the efficacy and safety of allilocumab. The study consisted of a screening period of up to 3 weeks, a double-blind treatment period of 24 weeks, and a safety observation period of 8 weeks after the end of the double-blind treatment period.

Patients were receiving stable maximally tolerated doses of statin therapy with or without other lipid modification therapy (LMT), unless they were statin intolerant. Statin doses and dosing regimens, as well as doses and dosing regimens for other lipid-modifying therapies (if applicable), were stable for 4 weeks prior to the screening period, during the screening period, and throughout the study, including from screening to randomization. It was Patients had a stable diet for glucose and lipid control throughout the study, from screening to the Week 24 visit. The patient was treated for diabetes according to local/regional care standards.

Patients were stratified by type of diabetes (ie, type 1 diabetes vs. type 2 diabetes). Recruitment of patients with type 2 diabetes was completed when approximately 400 patients were randomized. Recruitment of patients with type 1 diabetes was completed at the end of the recruitment period.

Arilocumab was administered subcutaneously at a starting dose of 75 mg Q2W for 12 weeks, and if LDL-C was ≧70 mg/dL (1.81 mmol/L) at the 8th week visit, then arilocumab 150 mg Q2W was administered at 12th week. Blinded titration. Patients with LDL-C <70 mg/dL (1.81 mmol/L) at Week 8 visit continued alilocumab 75 mg Q2W until the end of the treatment period.

Data on lipid parameters from blood samples were masked after randomization. The investigator or patient did not attempt to independently evaluate the patient's lipid levels until the 24th visit after randomization, except for patient safety at the investigator's discretion.

Patients visited the study site at -3, 0, 8, 12, 20, and 24 weeks and underwent laboratory work at each visit. In addition, telephone answers were given at the 4th and 32nd weeks.

Adverse events (AEs) that occurred within 70 days of the last dose of study drug (IMP) were documented. Patients with Serious Adverse Events (SAE) or Adverse Events of Special Interest (AESI) were followed up until resolution, stabilization, or death.

Patient Selection This study enrolled a total of 517 patients, including 76 patients with T1DM and 441 patients with T2DM.

Patient inclusion criteria Patients enrolled in this study met all of the following criteria:

(1) Patients with type 1 or type 2 diabetes treated with insulin, LDL-C level of 70 mg/dL (1.81 mmol/L) or more, and with or without other LMT before screening visit ( Patients not adequately controlled by a stable maximal dose/regimen of statin that is resistant to the patient for at least 4 weeks (3 weeks). The patient's tolerated maximum statin dose/regimen was the patient's tolerated highest registered dose/regimen based on the investigator's judgment or concerns. Some examples of reasons why patients with low statin doses may be tolerated include, but are not limited to, adverse effects of high dose, older age, low body mass index (BMI), local practice, local prescribing information, or concomitant medications. Included. Patients could have been receiving statins every other day as long as the dose was taken consistently (eg, every Monday, Wednesday, Friday, etc.). No combination therapy with more than one statin was allowed. Patients who documented statin intolerance, and as a result discontinued statin therapy, as judged by the investigator, were also included in the study. The reasons for not maximum dose/regimen of statins (including statin intolerance) were documented in the case report form.

(2) Patients who are 18 years of age or older at the screening visit or legal age of adulthood.

(3) Patients with type 1 or type 2 diabetes diagnosed at least 1 year before the screening visit (-3 weeks). Patients diagnosed with type 1 diabetes had to meet all of the following criteria:
(A) Diagnosed before the age of 30.
(B) Treated with multiple daily injection regimens/basal-dietary insulin regimens or insulin pump regimens within 6 months of diagnosis; and (c) C-peptide <0.2 pmol/mL at screening visit.

(4) Glycosylated hemoglobin (HbA1c) at screening visit <10% (-3 weeks). Patients with elevated HbA1c (up to 10%) were eligible, based on the investigator's discretion, provided that there were no plans to target reduction of HbA1c during the study.

(5) Patients with a documented history of CVD (including CHD and/or CHD risk equivalents) and/or at least one additional CV risk factor.

The history of CHD included at least one of the following:
(A) acute myocardial infarction (MI);
(B) Silent MI;
(C) unstable angina;
(D) coronary revascularization (eg, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG)); and (e) invasive or non-invasive examination (eg, using coronary angiography, treadmill). Clinically significant CHD diagnosed by stress testing, stress echocardiography, or nuclear imaging).

Equivalent CHD risk includes at least one of the following:
(A) Documentation of peripheral arterial disease that meets at least one of the following criteria:
(I) Current intermittent claudication of recurrent probable atherosclerosis (reproducible, exercise-induced, with rest within 10 minutes, with resting ankle-brachial index ≤ 0.90 of either leg). Discomfort in the muscles of the lower limbs that is relieved);
(Ii) Intermittent claudication (reproducible, exercise-induced lower limb muscle deficiency relieved by rest within 10 minutes) with endovascular treatment or surgical intervention of one or both feet due to atherosclerosis. (Iii) a history of pleasing); and (iii) a history of severe limb ischemia with atherosclerotic thrombolysis, endovascular treatment or surgical intervention of one or both legs; and (b) atherosclerotic causes. Documented prior ischemic stroke with focal ischemic neurological deficits lasting for >24 hours. Computed tomography or magnetic radioimaging should be done to rule out hemorrhage and non-ischemic neurological disease.

Cardiovascular risk factors included at least one of the following:
(A) Hypertension (established with antihypertensive drug);
(B) current smokers;
(C) Men over 45 years old, women over 55 years old;
(D) History of micro/macroalbuminuria;
(E) History of diabetic retinopathy (pre-proliferative or proliferative);
(F) Family history of premature CHD (father or siblings under 55; mother or sister under 65);
(G) low HDL-C (male <40 mg/dL (1.0 mmol/L) and female <50 mg/dL (1.3 mmol/L)); and (h) 3 months or more, including screening visit, 15 Documented chronic kidney disease (CKD) defined by ≦eGFR<60 mL/min/1.73 m ² .

(6) Signed Written Informed Consent Exclusion Criteria Patients who meet all of the above inclusion criteria are screened for the following exclusion criteria:

(1) Exclusion criteria related to research methodology:
(A) Plan to start a new LMT during the study or change the current LMT dose;
(B) Stable doses of LMT (including statins or other LMTs) prior to screening visit (-3 weeks) or at least 4 weeks from screening to randomization, unless statin intolerant, and in this case screening 4 weeks prior to visit/no statins during screening;
(C) Use of dietary supplements or over-the-counter medications that may affect lipids that were not at stable doses for at least 4 weeks prior to screening visit (-3 weeks) or between screening and randomized visits;
(D) Pre-screening visit (-3 weeks) or within 4 weeks between screening and randomized visits, using yeast rice product;
(E) Use of systemic corticosteroids unless used as an alternative therapy for pituitary/adrenal disease in a stable regimen for at least 6 weeks prior to randomization. Topical, intraarticular, nasal, inhalation and ocular steroid therapy are not considered "whole body" and are permitted;
(F) Use of continuous hormone replacement therapy unless the regimen was stable during the last 6 weeks (third week) prior to the screening visit and there is no plan to change the regimen during the study;
(G) Recent MI (within 3 months prior to screening visit (-3 weeks) or between screening and randomized visit), unstable angina leading to hospitalization, uncontrolled cardiac arrhythmia, CABG, PCI, cervical Endovascular surgery or surgical intervention for arterial surgery or stent placement, stroke, transient ischemic attack (TIA), peripheral vascular disease;
(H) Will undergo PCI, CABG, carotid or peripheral revascularization scheduled during the study;
(I) History of New York Heart Association (NYHA) Class III or IV heart failure (see Table 1) within the last 12 months;
(J) systolic blood pressure >180 mmHg or diastolic blood pressure >110 mmHg at screening or randomized visit;
(K) Patients who have undergone or are planned to receive treatment for plasmatic ataxia within 2 months (-3 weeks) before screening visit, between screening and randomization.
(L) History of hemorrhagic stroke;
(M) History of PCSK9 loss of function (ie, genetic or sequence mutations) or homozygous familial hypercholesterolemia;
(N) New cancer or active progression of cancer within the last 5 years, excluding appropriately treated basal cell skin cancer, squamous cell carcinoma, or intraepithelial cervical cancer;
(O) History of positive HIV test;
(P) Patients taking any active study drug within one month or five half-lives, whichever is longer;
(Q) Patients who have not been previously instructed on a cholesterol-reduced diet prior to the screening visit (-3 weeks);
(R) Patients withdrawing consent during screening (starting with signed ICF);
(S) Unstable body weight, defined by the Investigator, defined as a variation of more than 5 kg within 2 months prior to the screening visit;
^{(T) BMI> 45kg / m} 2, or bariatric surgery, weight loss program or plan to start a weight-loss drugs during the study;
(U) Recent onset of weight-loss drug (ie, within 3 months prior to screening visit, or between screening and randomization) or recent bariatric surgery (within the last 6 months) and aggressiveness determined by the investigator. In a general weight loss stage;
(V) Patients who have not been treated with insulin for at least 6 months prior to the screening visit, or who have not been treated with a stable insulin regimen for at least 3 months before the screening visit (ie, type of insulin, General timing/frequency, dosing mode or pattern such as basal only (Type 2 diabetes), basal dietary changes, etc.), or possibly changes in insulin type/frequency or injection method during the study period Patients with
(W) It is not a stable insulin dosage for at least 3 months prior to screening (ie total daily insulin dosage varies by more than 30%, as judged by the investigator), or Possibly determined to require enhanced insulin/antihyperglycemic regimen in the course of the study (eg, addition of new drugs, insulin escalation regimen, etc.);
(X) Other hypoglycemic drugs taken by the patient are not stable for at least 3 months before the screening visit;
(Y) A recent history of decompensation of diabetes within the two months prior to the screening visit (ie diabetic ketoacidosis or hyperosmolar hyperglycemia (HHS));
(Z) undergoing or planning to undergo renal replacement therapy during the study (eg, hemodialysis, renal transplant, etc.);
(Aa) Presence of clinically significant uncontrolled endocrine disorders known to affect serum lipids or lipoproteins. Patients undergoing thyroid replacement therapy had thyroxine dosages stable for at least 3 months prior to screening and their sensitive thyroid stimulating hormone (s-TSH) levels at the screening visit normal range. Can be included if within ±10% of;
(Bb) Laboratory findings during the screening period (excluding pregnancy tests, not including randomized tests):
(I) Serum TG>400 mg/dL (4.52 mmol/L) (one repeat test allowed);
(Ii) Positive serum or urine pregnancy test for women of childbearing potential;
(Iii) hepatitis B surface antigen or hepatitis C antibody positive test;
(Iv) eGFR<15 mL/min/1.73 m ² due to 4 variable changes in the diet for renal disease;
(MDRD) formula;
(V) ALT or AST>3xULN (one repeat test allowed); or (vi) creatine phosphokinase (CPK)>3xULN (one repeat test allowed); or ( cc) Conditions/situations such as:
(I) Patients with short life expectancy;
(Ii) requirements for combination treatments that may bias the primary assessment;
(Iii) unable to meet certain protocol requirements (eg need for hospitalization, ability to visit the study, etc.);
(Iv) Patient was the investigator or co-investigator, research assistant, pharmacist, study coordinator, other staff member or his relatives directly involved in the implementation of the protocol;
(V) non-cooperative or conditions in which the patient may not be compatible with the study procedure;
(Vi) some technical/administrative reason that makes it impossible to randomize patients in the study; or (vii) the investigator or co-investigator's decision may interfere with the safe completion of the trial. , Clinically significant abnormalities identified at screening that limit the evaluation of endpoints such as major systemic disease, and patients with short life expectancy.

(2) Exclusion Criteria for Active Controls and/or Essential Background Therapies: All Contraindications to Background Therapies or Warnings/Warnings of Use (if Appropriate) Shown on Each Domestic Product Label

(3) Exclusion criteria related to the current knowledge of Arilokumab:
(A) Hypersensitivity to Arilocumab or any component of Arilocumab;
(B) Pregnant or lactating women;
(C) Women of childbearing potential (as defined in the ICF and/or the local protocol addendum for certain local requirements) not protected by highly effective methods of contraception and/or pregnancy. Women who are unwilling or unable to undergo the test. Women of childbearing potential need to confirm a negative pregnancy test at screening and enrollment visits. They must use effective contraception throughout the study treatment for at least 10 weeks after the last injection of IMP. The contraceptive method applied is: “International Conference on Harmonization of Technical Requirements for Registration of Drugs for Human Use. M3 (R2): Nonclinical Safety for the Implementation of Human Clinical Trials and Drug Manufacturing Approval. Trial guidance. ICH. June 2009: 1-25” had to meet the criteria for a very effective method of contraception. Postmenopausal women must be amenorrhea for at least 12 months.

Research Therapeutics Investigational Drugs A sterile Arilocumab formulation is an automatic syringe (also known as a prefilled pen), 75 mg/mL in an aqueous buffer pH 6.0 containing sucrose, histidine, and polysorbate 20 together in a volume of 1 mL. And a concentration of 150 mg/mL. Arilocumab's sterile placebo was prepared in the same formulation as arilocumab without the addition of the protein as a 1 mL volume prefilled pen for patients to do injection training and for patients in the placebo treatment group. During the screening period, the patient (or another designated person) had to perform a placebo self-injection training using a prefilled pen prior to the first dose of IMP.

For patients randomized to alilocumab, the initial dose was 75 mg, given subcutaneously once in Q2W. If the LDL-C value at week 8 was ≧70 mg/dL (1.81 mmol/L), the dose was blindly increased to 150 mg Q2W at week 12 for patients randomized to alilocumab. Patients randomized to placebo received a Q2W subcutaneous injection during the 24-week treatment period.

Route of Administration and Method of Administration A pre-filled pen training guide (auto-injector training guide) was provided to the scene and instructions for use (auto-injector for use) were provided to the patient. Each dose of IMP consisted of a 1 mL subcutaneous injection in the lateral region of the abdomen, thigh, or upper arm (the deltoid region). Patients were advised to use another site for the administration of IMP if another concomitant drug was injected at the same site as the IMP injection.

IMP can be administered by self-injection or by another designated person (eg, spouse, relatives, etc.). If a person designated during the study decided to inject a patient with alilocumab, it was confirmed that this person was properly trained prior to administering the injection. Those planning to manage the IMP were trained by research staff.

Instructions were given to the patient (or another designated person (eg, spouse, relative, etc.) receiving the injection) during training and as needed during the course of the study. Close supervision and feedback were provided at the first visit and, if necessary, at other visits.

The used prefilled pen was discarded in the sharps container provided to the patient. Subcutaneous IMP injections were recommended to be rotated within the anatomical region (eg, right thigh, then left thigh or right abdomen, then left abdomen). Patients also had the option of injecting into another anatomical region during the study, such as the thigh, abdomen, or lateral region of the upper arm.

The patient was asked to store the IMP in the refrigerator. Prior to administration, place IMP in a safe place at room temperature for about 30-40 minutes. Then IMP should be administered as soon as possible.

Timing of Dosing During the screening period, patients or designated persons had to perform placebo self-injection training using pre-filled pens prior to the first IMP injection.

At the randomized visit, the first IMP injection was performed on-site by the patient or another designated entity (eg, spouse, relative, etc.) under the supervision of direct field staff. In this study, patients were monitored on-site for at least 30 minutes after this first injection. If the designated person changed during the course of the study, the new designated person was trained on placebo.

Subcutaneous IMP injections were then performed off-clinically, from Q2W to the last injection. If injections were scheduled for the same day as the site visit, IMP was administered after blood collection was completed. In exceptional cases, if the patient wanted to make an injection at the study site and was ready to administer the injection at that site, it was also allowed.

IMP should ideally be administered subcutaneously Q2W at about the same time. However, it was allowed even if the window period was ±3 days. The time of day was based on patient preference.

Inadvertently or due to other circumstances, if the injection is delayed more than 7 days after the missed date or is missed altogether, the patient should return to the original schedule of IMP administration without giving the delayed injection. Requested to. Inadvertently or due to other circumstances, if the injection was delayed by less than 7 days from the day it was missed, the patient was required to make the delayed injection and then restart the original schedule of IMP administration.

Non-investigated Drugs The following classes of drugs have been identified as non-IMP because the drug is either a background therapy or a potential rescue drug:
(A) statin;
(B) cholesterol absorption inhibitor (ezetimibe);
(C) bile acid-binding sequestrants (eg cholestyramine, colestipol, colesevelam);
(D) nicotinic acid;
(E) fibrate (eg, fenofibrate);
(F) omega-3 fatty acids (>1000 mg daily); and (g) insulin.

For background LMT containing statins, the site followed a domestic product label for patient safety monitoring and management. Patients received a stable maximal dose/regimen of statin therapy for which they were resistant, with or without other LMTs during the study. Lipid profile values were blinded from the samples obtained after randomization. Nevertheless, for safety reasons, the scene recognized the TG alert to determine the patient's background LMT.

Background LMT was unchanged from the Screening Visit (Week 3) to Week 24 Visit. During this period, investigators decided that other important concerns (including but not limited to TG warnings posted by the Central Laboratory) were in exceptional circumstances unless warranted such changes. No statin or other LMT was titrated, discontinued, or initiated. For TG warnings confirmed by repeated testing, the investigator investigated, managed the patient, and altered the background LMT according to medical judgment.

All fibrates were allowed at entry if the patient was resistant to drug therapy and maintained a stable dose. If patients needed the introduction of fibrate during the course of the study (ie, as a rescue treatment in response to TG alerts), only fenofibrate was allowed to be added. Background LMT and insulin were provided by the sponsor. Patients obtained these medications in compliance with local regulations.

Blinding Procedures Arilocumab and placebo for Arilocumab were provided with similarly adapted prefilled pens, similarly packaged, and included labeling to protect the blind. Each treatment kit was labeled with a number generated by a computer program from the sponsor. The treatment kit number was obtained by the Investigator at the time of patient randomization and at the patient's visit scheduled via IVRS/IWRS available 24 hours a day, 7 days a week.

The double-blind design allows study patients, investigators, and staff at the study site to remain blind to study treatment and will not have access to randomization (treatment code) except in the circumstances described below. There wasn't.

Adverse Events Treatment Code indicates any suspicious and unexpected serious side effects (SUSAR), ie any unexpected (according to a particular section of the CIB), and use of IMP at the discretion of the Investigator and/or Sponsor Was not blinded by the Drug Safety Oversight Department to report a serious adverse event reasonably related to

Lipid Parameters Lipid parameter values from blood samples obtained after randomized visits conducted by the Central Research Institute were unable to infer the treatment group of patients based on the achieved LDL-C levels, thus Not transmitted. The sponsor's operations team had no access to the lipid parameters associated with patient identification until the eventual database lock occurred. For safety purposes, the TG will alert if the TG value ≧500 mg/dL, whenever randomization is sent to the Investigator.

At the end of the double-blind treatment period (Week 24 visit), the Investigator continued to control the patient's lipids according to standard practice. Randomized lipid levels were compiled in the source material and not shared with the sponsor.

Anti-arilocumab antibody Patient anti-arilocumab antibody results were not transmitted to the site during the course of the study. The sponsor's operations team had no access to the anti-arilocumab antibody results associated with the patient identification number until the eventual database lock occurred. Laboratory technicians involved in determining the patient's anti-arilocumab titer were excluded from the operations team and a process in place to prevent any potential unblinding.

Randomized Code Breaking During the Study In the case of AE, the code was broken in situations where knowledge of IMP was required to treat patients. If possible, contact with the monitoring team/research physician was initiated before breaking the code. All calls were properly documented by the surveillance team, including the date and time of the call, the name of the person contacted within the surveillance team, the patient ID, the request documentation, and the unblinded decision.

Depending on which system was used locally and/or by calling any other telephone number provided by the sponsor for that purpose, an interactive voice response system (IVRS)/web automated voice response system ( Code breaking can be performed at any time by using the appropriate modules of IWRS). However, it was preferable to contact the investigator to discuss the case before unblinding the case. If the blinds were destroyed, the investigator was required to document the date, time, and reason why the code was corrupted and report this information on the appropriate page of the e-CRF. When documenting the reasons for unblinding, the investigator did not provide any details regarding the nature of the IMP. The Investigator did not reveal IMP details to the sponsor's representative or any staff member until the database was closed. Further, when filling out forms (eg, AE, SAE), the form's study treatment was not disclosed.

The decryption material was also stored in the entity responsible for the "24 hour alarm system", but this system should only be used in very exceptional cases (ie IVR/IWR systems are not available, Or unable to contact the investigator and/or field staff). However, open-labeling using IVRS is the preferred option. The Investigator was notified by the clinical oversight team about the availability of local cryptanalysis material. Patient cards containing the associated "24-hour alert system" telephone numbers were provided to all patients participating in the study. In order to comply with regulatory reporting requirements, sponsor unblinding was also permitted for some SAEs (ie for some relevant and unexpected SAEs).

If the code was destroyed, the patient permanently discontinued IMP administration.

How to Assign Patients to Treatment Groups A randomized list of treatment kit numbers was centrally generated by the sponsor. IMP (arilocumab 75 or 150 mg kit, or placebo kit) was packaged according to this list.

The trial supply operations manager provided a randomized list of treatment kit numbers, and the research biostatist provided a randomized scheme to the intensive care allocation system provider. The intensive care distribution system provider then generated a patient randomized list that allocated the treatments to the patients.

Patients were randomized to receive either placebo or arilocumab during the double-blind treatment period. The randomized arilocumab:placebo ratio was 2:1. Each randomized patient had a corresponding treatment kit number (refill visit), which was distributed by the intensive care distribution system. Randomization was stratified by type of diabetes (ie, type 1 vs. type 2).

Treatment kit numbers will be distributed using the intensive care distribution system at randomized visits (1st day, 0th week) and then at 12th week as a restocking visit, as needed at unscheduled visits. Was distributed.

For patients in the arilocumab treatment group, treatment kits distributed at 12 weeks were based on LDL-C levels at 8 weeks according to the titration rules. Periodic data transfer was planned between the central laboratory and the provider of the intensive care distribution system to proceed blindly to the research site and sponsors.

The investigator or designee had to contact the intensive care distribution system before randomizing patients.

Randomized patients were defined as patients enrolled and assigned a treatment kit number from the Intensive Care Distribution System, as documented from their log files. The study could not randomize patients multiple times. If treatment was used without contacting the intensive care allocation system, patients were considered non-randomized and removed from the study.

Two types of intensive care distribution systems were used, IVRS and IWRS, depending on site preference.

Packaging and Labeling During the double-blind treatment period, a double-blind treatment kit, either arilocumab or a placebo for arilocumab, was prepared to contain 6 pre-filled pens in a child-resistant package. To protect the blinds, the boxes of all double-blind treatment kits for injection had the same look and feel and are therefore labeled with double-blind labels.

In addition to a double-blind treatment kit for injections, a training kit with a placebo for an alilocumab-filled pen was prepared to instruct the patient about injections to be performed prior to randomization at screening visits Yes (Third week, Visit 1). If deemed necessary, a second injection training with placebo of alilocumab was performed using an additional training kit prior to randomization. Injection training with placebo was performed and documented on the CRF. This also includes whether the designated person who administered IMP to the patient changed during the study.

Packaging followed the dosing schedule. The labeling content complied with local regulatory specifications and requirements.

Storage Conditions and Storage Period The investigator or other authorized person (eg, pharmacist) was responsible for storing the IMP in a robust and secure location in accordance with local regulations, labeling specifications, policies, and procedures. Information on IMP storage conditions, in particular temperature control (such as refrigeration) and stability during use and instructions on handling the IMP were governed by rules provided by the sponsor.

The IMP was stored in the refrigerator at +2°C to +8°C (36°F to 46°F) in the field. The temperature of the on-site refrigerator was checked daily and recorded on a log sheet. The IMP, which had been stored at the study site, was stored in an appropriate locked room under the responsibility of the investigator or designee or other authorized person, according to the storage conditions indicated on the label.

After provision of the IMP kit to the patient at the study site visit, the appropriate preparations for transport of the IMP kit from the study site to the patient's refrigerator were in place.

Study endpoints Baseline characteristics included standard demographics (eg age, race, weight, height, etc.), disease characteristics including medical history, and medication history for each patient.

Primary Efficacy Endpoints The primary efficacy endpoints are all LDL-C values (ITT estimates) regardless of treatment adherence, LDL from baseline to 24 weeks in the global analysis (ITT) population. It was the rate of change of -C. The rate of change was defined as 100 x (LDL-C value calculated at 24 weeks-LDL-C value calculated at baseline)/LDL-C value calculated at baseline.

The LDL-C value calculated at baseline was the final LDL-C level obtained before the first double-blind IMP injection. The LDL-C calculated at 24 weeks was the LDL-C level obtained within the 24 week analysis window. All calculated LDL-C values from 8-24 weeks (scheduled or unscheduled, fasted or not fasted) are used to provide values for the primary efficacy endpoint, when appropriate, according to the definition above. We were able to.

Main safety endpoints Safety parameters (AE, laboratory parameters, vital signs) were assessed throughout the study. Observations of safety data were as follows:
(A) Pretreatment period was defined as from signed informed consent to the first dose of double-blind IMP injection.
(B) The treatment emergency adverse event (TEAE) period was defined as the time from the first dose of double-blind IMP injection to the last dose of IMP injection + 70 days (10 weeks). This is because the residual effect of the treatment is expected up to 10 weeks after stopping the double-blind IMP.
(C) The post-treatment period was defined as the time from the day after the end of the TEAE period to the resolution/stabilization of all SAE and AESI last visitors.

An AE is any adverse medical event in a patient who received the drug or in a clinical study patient and did not necessarily have a causal relationship with this treatment.

SAE was any adverse medical event at any dose, such as:
(A) died;
(B) It was life-threatening. The term "life-threatening" in the definition of "serious" refers to an event in which the patient is at risk of death at the time of the event; if it is more serious, it may hypothetically cause death. No mention was made of the events that occurred;
(C) requires hospitalization or extends existing hospital stay;
(D) resulted in permanent or significant disability/incapacity;
(E) Birth defects/natal defects; or (f) Medically significant events.

Prompt reporting does not result in death or hospitalization in other situations, for example, not an immediate life-threatening event, but may endanger the patient, or is listed in the medical or definition above. Medical and scientific judgment should be used in determining whether it is appropriate in a serious medical event requiring surgical intervention (specific measures or orthodontic treatment) to prevent one of the other outcomes Is.

The following list of medically significant events was intended to serve as a guideline for determining which conditions should be considered medically significant events. The list was not intended to be exhaustive:
(A) Allergic bronchospasm, blood diseases (ie, agranulocytosis, aplastic anemia, myelodysplasia, myelodysplasia, pancytopenia, etc.) or convulsions (seizures, epilepsy, seizures, absences, etc.) ) Emergency room or home intensive care;
(B) occurrence of drug dependence or substance abuse;
(C) ALT>3×ULN+total bilirubin>2×ULN or asymptomatic ALT increase>10×ULN;
(D) Attempted suicide or any event suggesting suicide.
(E) Syncope, loss of consciousness (except when recorded as a result of blood sampling);
(F) Bullous skin rash;
(G) Cancers diagnosed during the study or aggravated during the study;
(H) Chronic neurodegenerative disease (newly diagnosed) or worse during the study; and (i) Transmission of the infectious agent if there is a suspicion of transmission of the infectious agent via a drug (eg, product contamination). Is suspected.

Adverse events (AESI) of particular interest are AEs (significant or non-significant) that need to be monitored, documented, and managed in a predesignated manner. In this study, AESI was as follows:
(A) Increase in ALT: ALT≧3×ULN (if baseline ALT<ULN) or ALT≧2 times baseline value (if baseline ALT≧ULN);
(B) Allergic event: Allergic drug reaction and/or local injection site reaction that the investigator considers to be allergic (or includes allergic components). This should be reported as an AESI that, according to the investigator's medical judgment, had to consult with another physician for further evaluation of hypersensitivity/allergy;
(C) Pregnancy: Pregnancy that occurs in a female or male patient partner (if permitted by the female partner and local regulatory authority) during the study or within 70 days after the last dose of study drug. Pregnancy was recorded as AESI in all cases. Pregnancy was certified as SAE only if it met one or more SAE criteria. In the case of pregnancy of a female patient included in the study, the study product was discontinued. Follow-up of pregnancy was mandatory until outcome was determined;
(D) Symptomatic overdose with IMP. Overdose (accidental or intentional) is an event suspected by the investigator or voluntarily notified by the patient (not based on a systematic number of injections) and is intended within the intended treatment interval. Defined as at least two doses (that is, two or more injections administered in less than seven calendar days), reported using the term "symptomatic overdose (accidental or intentional)", This indicated the situation in brackets (eg, "symptomatic overdose (accidental)" or "symptomatic overdose (intentional)"; the patient was monitored and appropriate symptomatic treatment was initiated. Overdose status was clearly identified by verbal and symptom (if any) entered on individual AE/SAE forms. Asymptomatic overdose was required to report as standard AE;
(E) Neurological events: Neurological events requiring additional examination/procedure and/or referral to a specialist were required to be reported as AESI. If the event did not require any additional testing/procedures and/or referrals to experts, it was required to report as a standard AE; and (f) Neurocognitive events: All neurocognitive events were considered AESI. It was

Secondary efficacy endpoints The primary secondary endpoints of this study were:
(A) Efficacy rate of change in calculated LDL-C from baseline to week 24, using all LDL-C values during the treatment period (treatment estimate);
(B) Change rate of LDL-C measured from baseline to week 24 (ITT estimated value);
(C) Calculated rate of change in LDL-C from baseline to Week 12 (ITT estimate);
(D) Rate of change in LDL-C measured from baseline to Week 12 (ITT estimate);
(E) Non-HDL-C change rate from baseline to week 24 (ITT estimate);
(F) Apo B change rate from baseline to 24th week (ITT estimated value);
(G) Rate of change in total cholesterol from baseline to week 24 (ITT estimate);
(H) Percentage of patients who reached LDL-C <70 mg/dL at 24 weeks (estimate during treatment);
(I) Percentage of patients who reached LDL-C <50 mg/dL at 24 weeks (estimate during treatment);
(J) Proportion of patients reaching non-HDL-C<100 mg/dL at 24 weeks (treatment estimate);
(K) Percentage of patients who reached non-HDL-C <80 mg/dL at 24 weeks (estimate at the time of treatment);
(L) Change rate of Lp(a) from baseline to 24th week (ITT estimated value);
(M) Change rate of HDL-C from baseline to 24th week (ITT estimated value);
(N) Change rate of TG from baseline to 24th week (ITT estimated value);
(O) Change rate of LDL-C particle number from baseline to 24th week (ITT estimated value); and (p) Change rate of LDL-C particle size from baseline to 24th week (ITT estimated value) ..

The following diabetes-related endpoints were also measured in the study:
(A) Absolute change in HbA1c from baseline to weeks 12 and 24 (estimated during ITT and treatment);
(B) Absolute change in FPG from baseline to Week 12 and Week 24 (ITT and treatment estimates);
(C) Absolute change in total daily insulin dose from baseline to Weeks 12 and 24 (ITT and estimated during treatment); and (d) Baseline to Weeks 12 and 24. Absolute Change in Number of Glucose-Lowering Treatments (ITT and Treatment Estimates).

Other endpoints of this study's efficacy included:
(A) Calculated change rate of LDL-C from baseline to Week 12 (estimated value at treatment);
(B) Rate of change in LDL-C measured from baseline to week 12 and week 24 (estimate at treatment);
(C) Non-HDL, Apo B, total cholesterol, Lp(a), HDL-C, from baseline to Week 12 (ITT and estimated dose during treatment) and Week 24 (estimated amount during treatment), and TG change rate;
(D) Percentage of patients reaching LDL-C <50 and even <70 mg/dL calculated at Week 12 (ITT and treatment estimates) and Week 24 (ITT estimates);
(E) Percentage of patients with 50% or more reduction from baseline LDL-C calculated at weeks 12 and 24 (ITT estimate);
(F) Percentage of those who reached non-HDL-C <80 mg/dL, and even <100 mg/dL at Week 12 (ITT and treatment estimates) and Week 24 (ITT estimates);
(G) Percentage of patients who reached Apo B<80 mg/dL at 12 and 24 weeks (ITT and treatment estimates);
(H) Percent change in LDL-C particle number and size from baseline to week 12 (ITT and treatment estimates) and 24 weeks (treatment estimates);
(I) Percent change in TGRL, Apo A-1, and Apo C-III from baseline to Week 12 and Week 24 (ITT and treatment estimate);
(J) Absolute changes in the ratios Apo B/Apo A-1 and TC/HDL-C from baseline to Week 12 and Week 24 (ITT and estimated values during treatment);
(K) Percentage of patients who reached LDL-C <70 and <50 mg/dL calculated at weeks 12 and 24 according to baseline A1c of <8% or ≧8% (ITT and during treatment). Estimates); and (l) patients who reach LDL-C <70 mg/dL and <50 mg/dL calculated at weeks 12 and 24 according to baseline A1c with median A1c or ≧median A1c. % (Estimated during ITT and treatment).

Study Procedure The week 0 window period was +3 days. Window periods of 8, 12, and 24 weeks were ±3 days. The 4, 20, and 32 week window periods were ±7 days. Day 1/For all visits after the enrollment visit, if one visit was changed, the next visit was performed according to the original schedule outlined in FIG.

Blood collection related to lipid parameters (eg TC, LDL-C, HDL-C, TG, non-HDL-C, Apo A, Apo B, Apo C-III, Lp(a), LDL particle size and number) and also plasma glucose. All blood draws, including blood draws, were done in the morning in the fasted state (ie, refrain from smoking fast for at least 10 to 12 hours overnight) prior to IMP injection for all field visits throughout the study. Alcohol consumption within 48 hours and vigorous exercise within 24 hours prior to blood collection were not recommended. If the patient was not hungry, no blood sample was collected and the next day (or as close as possible to this date) the patient was given a new appointment with a fasting instruction (see conditions above).

Laboratory Testing Laboratory data were collected according to the study schedule outlined in Figure 1 and the following guidelines:
(A) Hematology: All visits except 4th and 20th week; if necessary, it can be performed at 0th week based on the clinical judgment of the investigator;
(B) Chemistry: All visits except Visits 3 and 6; 0 as needed based on the clinical judgment of the Investigator, except plasma glucose, which should be performed at Week 0 for all patients. Can be performed in the week;
(C) HbA1c: at screening and at weeks 0, 12, and 24;
(D) Lipid panel: at screening and at 0, 8, 12, 20, and 24 weeks;
(E) Measurement of LDL-C by beta quantification: weeks 0, 12, and 24;
(F) Other lipid evaluations (Apo B, Apo A-1, Apo C-III, LDL particle size and number, Lp[a]): 0, 12 and 24 weeks;
(G) Liver panel: All visits except Visits 3 and 6; can be performed at Week 0 based on the clinical judgment of the Investigator, if necessary. If the total bilirubin value exceeds the normal range, the differentiation into conjugated bilirubin and unconjugated bilirubin occurs automatically;
(H) Creatine Phosphokinase (CPK): All visits except Visits 3 and 6; can be given at Week 0 based on clinical investigator's clinical judgment, if necessary;
(I) Hepatitis B surface antigen: screening only;
(J) Hepatitis C antibody: at screening and at week 24; if ALT increases during the study, hepatitis C antibody needs to be measured; if hepatitis C antibody is positive during the study, reflex The test was conducted;
(K) Pregnancy test (only for women who may be pregnant): serum pregnancy test only at screening, urine pregnancy test at 0 and 24 weeks;
(L) Thyroid stimulating hormone: screening only for patients undergoing thyroid hormone replacement therapy;
(M) C-peptide: screening only;
(N) PCSK9 levels only at week 0; and (o) anti-arilocumab antibody (week 0, 12 and 24).

Urine sampling Urinalysis was performed at screening and at Week 24 visit. Dipsticks were performed to assess pH, specific gravity and the presence of blood, protein, glucose, ketones, nitrates, leukocyte esterases, urobilinogen, and bilirubin. If the dipstick was abnormal, standard microscopy was performed. By microscopic examination, red blood cells (RBCs), RBC clusters, white blood cells (WBCs), WBC clusters, epithelial cells (transition, renal tubules, and squamous epithelium), columns (glass, epithelium, WBC, RBCs, granules, fat, cells, Broad, waxy), crystals (triphosphate, calcium oxalate, calcium phosphate, calcium carbonate, uric acid, amorphous, ammonium biurinate, bilirubin, leucine, tyrosine, cystine), bacteria, yeast budding, yeast hyphae, trichomonas, eggs Type fat pad, fat, mucus, and sperm).

Spot urinalysis for albumin and creatinine was performed to calculate the albumin: creatinine ratio at screening and at Week 24 visit. Any clinically relevant abnormal laboratory values were immediately rechecked for confirmation before making any decision on the patients involved.

Physical Examination A general physical examination was performed. If new clinically significant abnormalities or exacerbations from baseline were detected after enrollment, AEs were reported and patients were considered for further clinical trials and/or specialist consultation according to the investigator's medical judgment.

Blood pressure and heart rate Blood pressure (BP) is measured in the sitting position under standardized conditions, approximately at the same time on the same day, on the same arm, using the same device (after the patient has been comfortably rested in the sitting position for at least 5 minutes). Was measured. Values were recorded on e-CRF; both systolic and diastolic blood pressures were recorded. At the first screening visit, BP was measured on both arms. The arm with the highest diastolic blood pressure was determined at this visit and blood pressure was measured on this arm during the study. This highest value was recorded on the e-CRF.

Heart rate was measured at the time of BP measurement.

Weight and Height Patients wore underwear or very light clothing, no shoes, empty bladder and weighed. The same scale was used throughout the study.

Height was measured as self-reported height is unacceptable.

iTAQ Interview The iTAQ was a patient-reported outcome (PRO) measure to assess the acceptability of treatment for 4 weeks prior to completing the questionnaire. Patients were required to complete at the Week 8 and Week 24 visits.

Insulin Log Patients should record their daily insulin doses (for basal and prandial insulin, if applicable) at least 7 days before each visit and use this information to bring this information to the next study visit. Was instructed to complete. Patients can record their daily insulin doses prior to 7 days prior to study visit, however, only the information collected during the last 7 days prior to each visit was entered into the CRF.

Results A total of 76 patients with T1DM and 441 patients with T2DM were enrolled.

All 76 patients randomized with T1DM were treated and therefore included in the safety population. Two randomized patients with T1DM, both in the arilocumab group, were not included in the global analysis (ITT) population.

Of the 441 patients with T2DM, 3 were untreated (1 in the arilocumab group and 2 in the placebo group) and were therefore not included in the safety population. Twelve patients with randomized T2DM (7 in the arilocumab group and 5 in the placebo group) were not included in the ITT population.

Patients were not included in the ITT population if there were no calculated LDL-C values available at either baseline or the analysis window up to week 24.

Study Patients Six (7.9%) patients with T1DM discontinued study treatment prematurely (3 [5.9%] in the alilocumab group (2 patients discontinued due to AE) and 3). [12.0%] placebo (2 patients discontinued due to AE) All 3 patients in the arilocumab group also did not complete the study period, but 2 patients in the placebo group also studied The period was not completed and one patient remained in the study until the completion of the study period.

Thirty-nine (8.8%) patients with T2DM discontinued study treatment prematurely (29 (9.9%) in the alilocumab group and 10 (6.8%) in the placebo group). Of the 29 patients in the arilocumab group, 18 also discontinued the study and 11 remained in the study until the study period was completed. Of the 10 patients in the placebo group, 7 patients did not complete the study period and 3 patients remained until the study period was completed.

Demographic and Baseline Characteristics Baseline characteristics were generally similar for the arilocumab and placebo groups. 60.5% of the randomized patients with T1DM were male and 54.2% of the randomized patients with T2DM were male. Patients with T1DM with an average age of 56.1 (SD=9.5) were younger than those with T2DM with an average age of 64.0 (SD=9.1). Patients with T1DM had an average BMI of 30.0 kg/m ² (SD=5.9) and patients with T2DM had an average BMI of 32.6 kg/m ² (SD=5.06).

LDL-C calculated at baseline was higher in patients with T1DM (mean=121.0 mg/dL, SD=51.2) than in patients with T2DM (mean=110.4 mg/dL, SD=37.3). ) Was high. Triglyceride at baseline had median T1DM (Q1:Q3)=102.0 mg/dL (76.5:135.0) and median T2DM (Q1:Q3)=147.0 mg/dL(105 0.0:212.0).

For other lipid parameters, T1DM patients had a reduction in LDL-C particle count (LS mean) from baseline of 40.7% at 12 weeks and 44.4% at 24 weeks, indicating that LDL- The reduction rate of C particle size was 2.3% at the 12th week and 2.3% at the 24th week. ApoC3 was reduced in these patients by 6.9% at 12 weeks and 7.5% at 24 weeks.

For other lipid parameters, T2DM patients had a decrease in LDL-C particle count (LS mean) from baseline of 37.6% at 12 weeks, 38.3% at 24 weeks, and 2.6% at 12 weeks. , And the reduction rate of LDL-C particle size of 2.8% at 24 weeks. ApoC3 in these patients was reduced by 6.3% at 12 weeks and 5.8% at 24 weeks.

In patients with T1DM, the mean duration of diabetes and insulin use was similar between treatment groups. The average duration of diabetes was 34.92 years (SD = 12.67) and the average duration of insulin use was 34.81 years (SD = 12.77). In T2DM patients, the mean duration of diabetes and insulin use was similar between treatment groups. The average duration of diabetes in T2DM was 16.75 years (SD=8.13) and the average duration of insulin use was 8.01 years (SD=6.90).

The duration of hypercholesterolemia was generally similar between treatment groups and between patients with T1DM and T2DM.

As reported by the investigators, the proportion of patients with statin intolerance was 31.6% in patients with T1DM and 23.8% in patients with T2DM.

The proportion of patients receiving fibrate at randomization was 2.6% in patients with T1DM and 8.8% in patients with T2DM.

The proportion of patients with cholesterol absorption inhibitors (including ezetimibe) at randomization was higher in the alilocumab group (13.6%) than in the placebo group (7.6%), especially in patients with T2DM, with 45 patients ( 15.3%) vs. 10 patients (6.8%).

Cardiovascular history and risk factors were generally similar between treatment groups. The following differences were observed between patients with T1DM and T2DM.
(1) ASCVD has a high frequency of coronary heart disease (34.7% vs. 15.8%) and stroke (8.2% vs. 2.6%) in patients with T2DM vs. T1DM and PAD (4.3%). T2DM patients were more frequent (40.1% vs. 21.1%) than T1DM patients with a lower frequency (vs. 9.2%).
(2) Among patients without ASCVD, 56.7% of patients with T1DM had target organ damage (microalbuminuria, macroalbuminuria) and/or CKD and/or retinopathy, In patients with T2DM it was 39.4%. The following additional cardiovascular risk factors were also observed among patients without ASCVD:
(A) More frequent in T1DM than in T2DM patients: current smokers (20.0% vs 14.0%), preproliferative diabetic retinopathy (36.7% vs 12.9%) and proliferative. Diabetic retinopathy (20.0% vs 5.7%).
(B) T1DM frequency is lower than in T2DM patients: hypertension (55.0% vs 84.8%), microalbuminuria (10.0% vs 19.7%), low HDL-C (16.7%). 28.0%)
(3) The presence of three or more additional CV risk factors in patients without ASCVD was observed in 45% of T1DM patients and 55.7% of T2DM patients.

Overall, T1DM and T2DM patients were treated with high and moderate intensity statins in both treatment groups, with a higher proportion of patients treated with moderate intensity statins (58.9%). Overall, 59.0% of T1DM and T2DM patients were treated with statins alone.

The exposure of the safety population to the study drug is summarized in Table 10.

Efficacy Primary Efficacy Endpoints Arilokumab was superior to placebo in the percentage of calculated LDL-C change from baseline to week 24 in the ITT population of patients with T1DM and T2DM (Table 11 and 12 and shown in FIGS. 2 and 3). Among T1DM patients, the proportion of individuals achieving LDL-C<70 mg/dL (<1.8 mmol/L) was 70.2% in the alilocumab group and 5.1% in the placebo group (P<0.0001). The proportion of individuals who achieved LDL-C<50 mg/dL (1.3 mmol/L) was 55.1% in the alilocumab group and 0% in the placebo group (P value cannot be calculated). The proportion of individuals who achieved LDL-C<70 mg/dL (<1.8 mmol/L) among T2DM patients was 76.4% in the alilocumab group and 7.4% in the placebo group (P<0.0001). The proportion of individuals who achieved LDL-C<50 mg/dL (1.3 mmol/L) was 50.7% in the alilocumab group and 2.4% in the placebo group (P<0.0001). .. Sensitivity analysis of the primary efficacy endpoint showed similar results in both populations (data not shown).

Secondary efficacy endpoints Arilocumab significantly reduced non-HDL-C, ApoB, total cholesterol, and Lp(a) levels from baseline to week 24 (difference from placebo), and T1DM and T2DM. Resulted in an increase in HDL-C in the ITT population of patients with (shown in Tables 13 and 14, respectively).

Diabetes-related endpoints Overall, FPG and HbA1c, and glucose-lowering treatment remained stable over time in patients with T1DM and T2DM in both treatment groups.

Regarding HbA1c, in the T1DM cohort the mean HbA1c% was 7.84% (SD=0.94) at baseline and mean absolute change=−0.03% (0.6) in the allilocumab group. On the other hand, in the placebo group, the average HbA1c was 7.68% (0.78) at baseline and the average absolute change was −0.23% (0.36). In the T2DM cohort, mean HbA1c was 7.52% (0.96) at baseline and mean absolute change=0.18% (0.74) in the allilocumab group, while mean in placebo group. HbA1c had a baseline of 7.54% (1.02) with an average absolute change of 0.06% (0.66).

Regarding FPG, in the T1DM cohort, the mean FPG was 173 mg/dL (SD=70.6) at baseline, mean absolute change=−0.03 mg/dL (0.6) in the allilocumab group, while placebo. In the group, the mean FPG was 166.5 mg/dL (75.6) at baseline, mean absolute change=14.6 mg/dL (75.9). In the T2DM cohort, the mean FPG was 154.1 mg/dL (50.1) at baseline and mean absolute change = 9.5 mg/dL (61.8) at baseline in the arilocumab group, while mean in the placebo group. FPG was 153.5 mg/dL (52.5) at baseline, mean absolute change=10.0 mg/dL (47.0).

Safety A total of 344 patients (51 T1DM and 293 T2DM) were exposed to arilocumab and 170 patients (25 T1DM and 145 T2DM) were exposed to placebo.

Overall, in the safe population of patients with T1DM or T2DM, the proportion of patients with adverse events (TEAEs) that occurred during treatment was similar across treatment groups (see Table 15).

TEAEs were reported more frequently (≧10%) with the following organ classifications (SOC):
(A) Infection and invasion (21.8% for allilocumab vs. 21.8% for placebo);
(B) Gastrointestinal disorders (13.1% for Arilokumab vs. 12.4% for placebo);
(C) Musculoskeletal and connective tissue disorders (21.5% for allilocumab vs. 15.9% for placebo); and (d) General disorders and administration site conditions (11.0% for allilocumab vs 8. for placebo). 8%)

Differences in PT levels between TEAEs (≥2%) most frequently reported in the alilocumab group and placebo groups were ≥0.5% due to the reduced frequency of the alilocumab group: myalgia (4.4% vs 1.8%), arthralgia (2.9% vs 1.8%), bronchitis (2.6% vs 0.6%), dizziness (2.6% vs 1.2). %), and peripheral edema (2.0% vs. 0.6%). In contrast, the most frequently reported TEAEs (≥2%) in the placebo group and ≥0.5% between the allilocumab group were flu (2.3% vs. 2.9%). , Limb pain (1.7% vs 2.9%), hypoglycemia (1.7% vs 2.4%), cough (1.5% vs 2.9%), musculoskeletal pain (1.2%). % Vs 2.4%), upper respiratory tract infection (0.9% vs 2.4%), hyperglycemia (0.9% vs 2.4%), and pneumonia (0.6% vs 2.4%). Met.

Overall, SAEs that occurred during treatment were reported in 25 patients (7.3%) in the arilocumab group and 14 patients (8.2%) in the placebo group. SAE (PT levels) reported in 2 or more patients in either treatment group was pneumonia (1 patient in the allilocumab group (0.3%) vs. 2 patients in the placebo group (1.2%). )), vertebral foraminal stenosis (2 patients in the allilocumab group (0.6%) vs no placebo group), and urinary tract infections (2 patients (0.6%) vs no placebo group). )Met. One month after the first IMP administration (Visit 3), one T2DM patient in the placebo group reported one death due to myocardial infarction. Overall, 17 patients in the arilocumab group (4.9%) and 4 patients in the placebo group (2.4%) experienced TEAEs, resulting in permanent treatment discontinuation. At the PT level, the proportion of TEAE patients with permanent discontinuation of treatment in 2 or more patients in the treatment group was as follows: Headache (2 patients in the allilocumab group (0.6%) vs placebo group). No patient), cognitive impairment (2 patients (0.6%) vs no patient), allergic dermatitis (2 patients (0.6%) vs no patient) and myalgia (3 patients). (0.9%) vs. 2 patients (1.2%)).

For adverse events of special interest (AESI), an increase in ALT that meets the AESI criteria is ALT≧3×ULN (if baseline ALT<ULN) or ALT≧twice the baseline value (baseline ALT≧ULN). If defined as). These events were reported in 2 patients (0.6%) in the arilocumab group and 1 patient (0.6%) in the placebo group.

An allergic drug response that meets the AESI criteria was defined as an allergic event that required consultation with another physician for further evaluation. These events were reported in 4 patients (2.4%) in the placebo group compared to 5 patients (1.5%) in the arilocumab group. These reactions were mainly skin and subcutaneous tissue disorders, with 3 patients (0.9%) in the allilocumab group (1 allergic dermatitis, 1 eczema, 1 photosensitivity reaction) and 2 patients in the placebo group. It was reported in humans (1.2%) (dermatitis 1, drug eruption 1). The other two AESI allergic drug reactions in the alilocumab group were drug hypersensitivity and eosinophilia.

Neurological events that met the AESI criteria were defined as neurological events that required additional testing/procedures and/or referral to a specialist. Such events were reported in 1 patient (0.3%) (paresthesia) in the allilocumab group and 1 patient (0.6%) in the placebo group (dysphagia). Both events were reported in T2DM patients.

All neurocognitive events were considered AESI. Neurocognitive events by sponsor or FDA group were reported in 4 patients (1.2%) in the arilocumab group and no patients in the placebo group. All events were reported in T2DM patients: cognitive impairment was reported in 2 patients (0.6%) and memory impairment and memory loss were reported in 1 patient each (0.3%). Of note, two cognitive impairments also resulted in permanent treatment discontinuation.

Local injection site reactions that meet the AESI criteria are allergic and require local consultation with another physician, or clinically significant non-allergic local injection site reactions (eg, diameter >2. Swelling or erythema reaction with 5 cm; reaction preventing activity). Investigator-confirmed (“per eCRF”) LISR associated with IMP was reported in 6 patients (1.7%) in the arilocumab group versus 8 patients (4.7%) in the placebo group. (Placebo injection site reaction to arilocumab). No local injection site reaction (LISR) was reported that met the AESI criteria, which was defined as a reaction that needed to be consulted with another physician for further evaluation.

There were no reports of symptomatic overdose or pregnancy.

Analysis of liver function tests (ALT, AST, ALP, total bilirubin), CPK and renal function tests (creatinine, eGFR, BUN) did not reveal differences between treatment groups in time course for any of the parameters studied It was PCSA analysis did not identify ALT-increasing PCSA in any treatment group during the study. In patients with normal baseline CPK levels, there was a >3ULN (and ≤10ULN) increase in 1 placebo (0.6%) vs. 7 patients (2.1%) in the allilocumab group. Reported. All patients had T2DM. No increase in CPK above 10 ULN was reported.

Numerically small differences were observed in the proportion of patients with mild, moderate, or severe reductions in glomerular filtration rate (GFR) during the treatment period regardless of baseline status: 49 each in the alilocumab group Mild, moderate, and severe reduction in GFR in 0.7%, 28.1%, and 3.8% of patients, and in 50.6%, 24.4%, and 3.6% of patients in the placebo group, respectively. .. Similarly, increases in blood creatinine (≧30% and <100%) were measured in 13 (3.8%) patients in the alilocumab group and 5 (3.0%) in the placebo group. .. None of the patients had blood creatinine increased by more than 100%. There was no significant difference in renal function.

No significant difference in vital signs was observed between treatment groups.

Analysis of Individuals With ASCVD from Type 2 Diabetes Mellitus and Odyssey DM-Insulin Clinical Trials Individuals with diabetes have high levels of atherogenic lipoproteins and cholesterol, which are low density lipoprotein cholesterol (LDL-C). ), non-high density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (ApoB), and low density lipoprotein particle number (LDL-PN). The presence of arteriosclerotic cardiovascular disease (ASCVD) increases the risk of future cardiovascular events.

In this analysis, we evaluate the efficacy and safety of arilocumab among individuals with T2DM, high LDL-C, or non-HDL-C and receive the most resistant statins in the DM-insulin study. Established ASCVD. Participants in the DM-insulin study of ASCVD and T1DM were not included in this analysis due to the low population in this group (arilocumab: n=11; placebo: n=5). As used in this example, ASCVD is defined as coronary heart disease (CHD; acute and subclinical myocardial infarction (MI), and unstable angina), ischemic stroke, or peripheral arterial disease. It was

Baseline and efficacy data were analyzed according to the study. Efficacy analysis included a non-HDL-C, LDL-C, ApoB, and LDL-PN percentage reduction from baseline at week 24, and non-HDL-C <100 mg/dL at week 24 (<2. 59 mmol/L), LDL-C<70 mg/dL (<1.81 mmol/L), and the percentage of individuals achieving ApoB<80 mg/dL. The global analysis (ITT) analysis included all randomized individuals with a baseline LDL-C value and at least one LDL-C value up to 24 weeks.

This analysis included 177 DM-insulin individuals with established ASCVD and T2DM (Table 16).

In addition to ASCVD, regardless of treatment allocation, 89.3% of individuals analyzed had a history of hypertension and 28.2% had chronic kidney disease (CKD). In total, 20.3% had a history of ischemic stroke and 10.7% had peripheral arterial disease (PAD). At baseline, mean (standard deviation [SD]) non-HDL-C levels were 144.2 (46.2) mg/dL [3.73 (1.20) mmol/L]; mean LDL-C. The level was 108.7 (39.1) mg/dL [2.82 (1.01) mmol/L] regardless of treatment distribution.

Efficacy Arilocumab reduced non-HDL-C, ApoB, LDL-PN, and LDL-C from baseline at 24 weeks relative to controls (Figure 4). At week 24, non-HDL-C<100 mg/dL (<2.59 mmol/L), LDL-C<70 mg/dL (<1.81 mmol/L), and ApoB<80 mg/dL relative to controls. The proportion of individuals achieved was significantly increased (all P<0.0001; Figure 5).

Safety Safety analysis was conducted for T2DM, high LDL-C or non-HDL-C, individuals with ASCVD established by receiving a maximally resistant statin in the DM-insulin study, as well as T1DM or T2DM, high LDL-C or non-high. HDL-C, and DM-Dyslipidemia studies were performed on individuals with ASCVD established and pooled populations who received the most resistant statins (Chan et al., incorporated herein by reference in its entirety). (2017) Ann Transl Med. 5(23):477). In total, 66.4% (arilocumab) and 67.0% (control) of individuals reported treatment-emergent adverse events (TEAE; Table 17). The pattern of adverse events was similar in both groups. Mean (SD) levels of HbA1c were baseline (arilocumab: 7.3 [0.9]%; control: 7.3 [0.9]%) and week 24 (arilocumab: 7.6 [1.2]. ]; control: 7.5 [1.2]%; safety analysis) were similar in each treatment group. FPG levels were also measured at baseline (arilocumab: 154.2 [47.9] mg/dL, 8.6 [2.7] mmol/L; control: 149.5 [43.7] mg/dL, 8. 3 [2.4] mmol/L) and week 24 (arilocumab: 164.7 [54.9] mg/dL, 9.1 [3.0] mmol/L; control: 159.4 [48.4]. ] Mg/dL, 8.9 [2.7]mmol/L; safety analysis) were similar regardless of treatment distribution.

Conclusions In individuals with T2DM and ASCVD who had high LDL-C levels despite maximally tolerant statins, alilocumab significantly reduced atherogenic cholesterol content and LDL-PN relative to controls.

Claims (86)

A method of treating hypercholesterolemia in a patient having type 1 diabetes mellitus (T1DM), the method comprising:
(A) selecting (i) T1DM, and (ii) patients with high cardiovascular risk receiving insulin therapy who have hypercholesterolemia not adequately controlled by maximally resistant statin therapy; and (b) ) Administering to a patient 75 mg, 150 mg or 300 mg of an antibody or antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9), wherein the patient receives the associated insulin therapy Method. The method of claim 1, wherein 75 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. The method of claim 1, wherein 150 mg of the antibody or antigen-binding fragment is administered to the patient every two weeks. The method of claim 1, wherein 300 mg of the antibody or antigen-binding fragment is administered to the patient every 4 weeks. The antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS: 2, 3 and 4 and the three light chain CDRs set forth in SEQ ID NOS: 7, 8 and 10. The method according to any one of 1. The antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO: 6. The method according to paragraph 1. 7. The method of any one of claims 1-6, wherein the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bococizumab, rodercizumab, ralpancizumab and LY301504. The method according to claim 7, wherein the antibody or the antigen-binding fragment thereof is allilocumab. (C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient 9. Any of claims 1-8, further comprising the step of administering one or more subsequent doses of 150 mg of antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. (C) if the LDL-C level in the patient is below a threshold level, the patient is administered with one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient 10. Any of claims 1-9, further comprising the step of administering one or more subsequent doses of 150 mg of the antibody or antigen-binding fragment thereof about every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. The method according to claim 9 or 10, wherein the threshold level is 70 mg/dL. The method according to any one of claims 1 to 11, wherein the antibody or antigen-binding fragment thereof is administered subcutaneously. 13. The method of any one of claims 1-12, wherein the patient further undergoes concomitant lipid modification therapy (LMT). 14. The method of claim 13, wherein the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. 15. The method of claim 14, wherein LMT is statin therapy. 16. The method of claim 15, wherein the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. The method according to any one of claims 14 to 16, wherein the statin therapy is the most resistant statin therapy. 15. The method of claim 14, wherein the cholesterol absorption inhibitor is ezetimibe. 19. The method of any one of claims 1-14 and 18, wherein the patient is intolerant to statins. 20. The insulin therapy according to any one of claims 1 to 19, wherein the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. The method described in. 21. The method of any one of claims 1-20, wherein the patient undergoes concomitant antidiabetic therapy in addition to insulin therapy. Additional concomitant anti-diabetic therapies include glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist or antagonist, ghrelin antagonist or Inverse agonist, xenin, xenin analog, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibition Agent, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 agonist, GPR120 agonist, GPR142 agonist , Systemic or low absorbability TGR5 agonists, diabetic immunotherapeutic agents, anti-inflammatory agents for treating metabolic syndrome and diabetes, adenosine monopurine acid activated protein kinase (AMPK) stimulants, 11-beta-hydroxysteroid dehydrogenase 1 Selected from the group consisting of inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof 22. The method of claim 21, which is performed. 23. The method of any one of claims 1-22, wherein the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 40%. 24. The method of any one of claims 1-23, wherein the antibody or antigen binding fragment thereof reduces non-HDL-C levels in the patient by at least 35%. 25. The method of any one of claims 1-24, wherein the antibody or antigen binding fragment thereof reduces apolipoprotein C3 (ApoC3) levels in the patient. 26. The method of any one of claims 1-25, wherein the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient. The antibody or antigen-binding fragment thereof is:
27. Any of claims 1-26, wherein (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) does not affect the patient's fasting plasma glucose (FPG) level. the method of. A method of treating hypercholesterolemia in a patient having type 1 diabetes mellitus (T1DM), the method comprising:
(A) selecting patients at high cardiovascular risk undergoing insulin therapy with hypercholesterolemia not adequately controlled by (i) T1DM, and (ii) maximally resistant statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) LDL- in the patient. If the C level is less than 70 mg/dL, the patient is administered about one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg/dL. In the case of dL or more, it comprises the step of administering the following doses of about 150 mg of the antibody or its antigen-binding fragment once or more about every two weeks, wherein the antibody or its antigen-binding fragment has the amino acid sequence of SEQ ID NO: 1. And HCLC having the amino acid sequence of SEQ ID NO: 6, wherein the patient receives concomitant insulin therapy. A method of treating hypercholesterolemia in a patient with type 2 diabetes mellitus (T2DM), the method comprising:
(A) selecting (i) T2DM, and (ii) patients at high cardiovascular risk receiving insulin therapy who have hypercholesterolemia not adequately controlled by maximally resistant statin therapy; b) comprising the step of administering to the patient 75 mg, 150 mg or 300 mg of an antibody or an antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9), the patient receiving concomitant insulin therapy. The method of receiving. 30. The method of claim 29, wherein 75 mg of antibody or antigen binding fragment is administered to the patient every two weeks. 30. The method of claim 29, wherein 150 mg of antibody or antigen binding fragment is administered to the patient every two weeks. 30. The method of claim 29, wherein 300 mg of the antibody or antigen binding fragment is administered to the patient every 4 weeks. 33. The antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS:2, 3, and 4 and the three light chain CDRs set forth in SEQ ID NOS:7, 8 and 10. The method according to any one of 1. 34. Any of claims 29-33, wherein the antibody or antigen binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. The method described in paragraph 1. 33. The method of any one of claims 29-32, wherein the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bokocizumab, rodercizumab, ralpancizumab, and LY301504. 36. The method of claim 35, wherein the antibody or antigen-binding fragment thereof is allilocumab. (C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient 37. Any of claims 29-36, further comprising the step of administering one or more subsequent doses of 150 mg of the antibody or antigen binding fragment thereof about once every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. (C) if the LDL-C level in the patient is below the threshold level, administer to the patient one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient 37. Any of claims 29-36, further comprising the step of administering one or more subsequent doses of 150 mg of the antibody or antigen binding fragment thereof about once every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. 39. The method of claim 37 or 38, wherein the threshold level is 70 mg/dL. 40. The method of any one of claims 29-39, wherein the antibody or antigen binding fragment thereof is administered subcutaneously. 41. The method of any one of claims 29-40, wherein the patient further undergoes concomitant lipid modification therapy (LMT). 42. The method of claim 41, wherein the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. 43. The method of claim 42, wherein LMT is statin therapy. 44. The method of claim 43, wherein the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. 45. The method of any of claims 42-44, wherein the statin therapy is a maximally resistant statin therapy. 43. The method of claim 42, wherein the cholesterol absorption inhibitor is ezetimibe. 47. The method of any one of claims 29-42 and 46, wherein the patient is intolerant to statins. 48. The insulin therapy according to any one of claims 29 to 47, wherein the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. The method described in. 49. The method of any one of claims 29-48, wherein the patient receives concomitant antidiabetic therapy in addition to insulin therapy. Additional concomitant anti-diabetic therapies include glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist or antagonist, ghrelin antagonist or Inverse agonist, xenin, xenin analog, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibition Agent, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 agonist, GPR120 agonist, GPR142 agonist , Systemic or low absorbability TGR5 agonists, diabetic immunotherapeutic agents, anti-inflammatory agents for treating metabolic syndrome and diabetes, adenosine monopurine acid activated protein kinase (AMPK) stimulants, 11-beta-hydroxysteroid dehydrogenase 1 Selected from the group consisting of inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof 50. The method of claim 49, which is performed. 51. The method of any one of claims 29-50, wherein the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 40%. 52. The method of any one of claims 29-51, wherein the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient by at least 35%. 53. The method of any one of claims 29-52, wherein the antibody or antigen-binding fragment thereof reduces ApoC3 levels in a patient. 54. The method of any one of claims 29-53, wherein the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient. The antibody or antigen-binding fragment thereof is:
55. Any of claims 29-54, wherein (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) does not affect the patient's fasting plasma glucose (FPG) level. the method of. A method of treating hypercholesterolemia in a patient with type 2 diabetes mellitus (T2DM), the method comprising:
(A) selecting patients at high cardiovascular risk undergoing insulin therapy with hypercholesterolemia not adequately controlled by (i) T2DM and (ii) maximally resistant statin therapy;
(B) administering to the patient 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to the human proprotein convertase subtilisin/kexin type 9 (PCSK9) every 2 weeks; and (c) LDL- in the patient. If the C level is less than 70 mg/dL, the patient is administered about one or more of the following doses of 75 mg of the antibody or antigen-binding fragment thereof about every two weeks, or the LDL-C level in the patient is 70 mg/dL. In the case of dL or more, it comprises the step of administering the following doses of about 150 mg of the antibody or its antigen-binding fragment once or more about every two weeks, wherein the antibody or its antigen-binding fragment has the amino acid sequence of SEQ ID NO: 1. And HCLC having the amino acid sequence of SEQ ID NO: 6, wherein the patient receives concomitant insulin therapy. A method of treating hypercholesterolemia in a patient having T2DM and atherosclerotic cardiovascular disease (ASCVD), the method comprising:
Selecting patients at high cardiovascular risk undergoing insulin therapy for hypercholesterolemia not adequately controlled by (a) (i) T2DM, (ii) ASCVD, and (iii) maximally resistant statin therapy And (b) the step of administering to the patient 75 mg, 150 mg or 300 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9), and the patient is incidental The above method of receiving insulin therapy. 57. The method of claim 56, wherein ASCVD is defined as coronary heart disease (CHD), ischemic stroke, or peripheral arterial disease. 59. The method of claim 58, wherein CHD comprises acute myocardial infarction, subclinical myocardial infarction, and unstable angina. 60. The method of any one of claims 57-59, wherein 75 mg of the antibody or antigen binding fragment is administered to the patient every two weeks. 60. The method of any one of claims 57-59, wherein 150 mg of the antibody or antigen binding fragment is administered to the patient every two weeks. 60. The method of any one of claims 57-59, wherein 300 mg of antibody or antigen binding fragment is administered to the patient every 4 weeks. 63. The antibody or antigen-binding fragment thereof comprises the three heavy chain CDRs set forth in SEQ ID NOS:2, 3, and 4 and the three light chain CDRs set forth in SEQ ID NOS:7, 8 and 10. The method according to any one of 1. 64. Any of claims 57-63, wherein the antibody or antigen binding fragment thereof comprises a heavy chain variable region (HCVR) having the amino acid sequence of SEQ ID NO: 1 and a light chain variable region (LCVR) having the amino acid sequence of SEQ ID NO:6. The method described in paragraph 1. 63. The method of any one of claims 57-62, wherein the antibody or antigen-binding fragment thereof is selected from the group consisting of allilocoumab, evolocumab, bococizumab, rodercizumab, ralpancizumab, and LY301504. 66. The method of claim 65, wherein the antibody or antigen-binding fragment thereof is arilocumab. (C) if the LDL-C level in the patient is below the threshold level, the patient is administered with one or more subsequent doses of 75 mg of the antibody or antigen-binding fragment thereof about once every two weeks, or in the patient 67. Any of claims 57-66, further comprising the step of administering one or more subsequent doses of 150 mg of antibody or antigen binding fragment thereof about once every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. (C) if the LDL-C level in the patient is below the threshold level, administer to the patient one or more subsequent doses of 300 mg of the antibody or antigen-binding fragment thereof about once every four weeks, or in the patient 67. Any of claims 57-66, further comprising the step of administering one or more subsequent doses of 150 mg of antibody or antigen binding fragment thereof about once every two weeks if the LDL-C level is above the threshold level. The method described in paragraph 1. 69. The method of claim 67 or 68, wherein the threshold level is 70 mg/dL. 70. The method of any one of claims 57-69, wherein the antibody or antigen binding fragment thereof is administered subcutaneously. 71. The method of any one of claims 57-70, wherein the patient further undergoes concomitant lipid modification therapy (LMT). 72. The method of claim 71, wherein the LMT is selected from the group consisting of statins, cholesterol absorption inhibitors, fibrates, niacin, omega-3 fatty acids, and bile sequestrants. 73. The method of claim 72, wherein LMT is statin therapy. 74. The method of claim 73, wherein the statin is selected from the group consisting of atorvastatin, rosuvastatin, simvastatin, pravastatin, lovastatin, fluvastatin, pitavastatin, and cerivastatin. 75. The method of any of claims 72-74, wherein the statin therapy is a maximally tolerated amount of statin therapy. 73. The method of claim 72, wherein the cholesterol absorption inhibitor is ezetimibe. 77. The method of any one of claims 57-72 and 76, wherein the patient is intolerant to statins. 78. The insulin therapy of any one of claims 57-77, wherein the insulin therapy is selected from the group consisting of human insulin, insulin glargine, insulin glulisine, insulin detemir, insulin lispro, insulin degludec, insulin aspart, and basal insulin. The method described in. 79. The method of any one of claims 57-78, wherein the patient undergoes concomitant antidiabetic therapy in addition to insulin therapy. Additional concomitant anti-diabetic therapies include glucagon-like peptide 1 (GLP-1) therapy, gastrointestinal peptide, glucagon receptor agonist or antagonist, glucose-dependent insulinotropic polypeptide (GIP) receptor agonist or antagonist, ghrelin antagonist or Inverse agonist, xenin, xenin analog, biguanide, sulfonylurea, meglitinide, thiazolidinedione, DPP-4 inhibitor, alpha-glucosidase inhibitor, sodium-dependent glucose transporter 2 (SGLT-2) inhibitor, SGLT-1 inhibition Agent, peroxisome proliferator-activated receptor (PPAR-) (alpha, gamma or alpha/gamma) agonist or modulator, amylin, amylin analog, G protein coupled receptor 119 (GPR119) agonist, GPR40 agonist, GPR120 agonist, GPR142 agonist , Systemic or low absorbability TGR5 agonists, diabetic immunotherapeutic agents, anti-inflammatory agents for treating metabolic syndrome and diabetes, adenosine monopurine acid activated protein kinase (AMPK) stimulants, 11-beta-hydroxysteroid dehydrogenase 1 Selected from the group consisting of inhibitors, glucokinase activators, diacylglycerol O-acyltransferase (DGAT) inhibitors, glucose transporter-4 modulators, somatostatin receptor 3 agonists, lipid-lowering agents, and combinations thereof 80. The method of claim 79, wherein the method is performed. 81. The method of any one of claims 57-80, wherein the antibody or antigen binding fragment thereof reduces LDL-C levels in the patient by at least 40%. 82. The method of any one of claims 57-81, wherein the antibody or antigen-binding fragment thereof reduces non-HDL-C levels in the patient by at least 35%. 83. The method of any one of claims 57-82, wherein the antibody or antigen-binding fragment thereof reduces ApoC3 levels in the patient. 84. The method of any one of claims 57-83, wherein the antibody or antigen binding fragment thereof reduces the number and/or size of lipoprotein particles in the patient. The antibody or antigen-binding fragment thereof is:
85. Any of claims 57-84, wherein (a) does not affect the patient's hemoglobin A1c (HbA1c) level; and/or (b) does not affect the patient's fasting plasma glucose (FPG) level. the method of. A method of treating hypercholesterolemia in a patient having T2DM and ASCVD, the method comprising:
(A) Selecting patients at high cardiovascular risk receiving insulin therapy with hypercholesterolemia not adequately controlled by (i) T2DM, (ii) ASCVD, and (iii) maximally resistant statin therapy ;
(B) a step of administering to the patient every 2 weeks, 75 mg of an antibody or an antigen-binding fragment thereof that specifically binds to human proprotein convertase subtilisin/kexin type 9 (PCSK9), every 2 weeks; and (c) If the LDL-C level in the patient is less than 70 mg/dL, the patient is administered with one or more subsequent doses of 75 mg antibody or antigen-binding fragment thereof about once every two weeks, or LDL-C in the patient. When the level is 70 mg/dL or higher, the method comprises the step of administering 150 mg of the antibody or antigen-binding fragment thereof at a dose of about once every two weeks or more, wherein the antibody or the antigen-binding fragment is SEQ ID NO: 1 A HCVR having the amino acid sequence of SEQ ID NO: 6 and an LCVR having the amino acid sequence of SEQ ID NO: 6, wherein the patient receives concomitant insulin therapy.

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