NZ795161A - Methods of inducing immune tolerance to clotting factors - Google Patents

Abstract

The present disclosure provides methods inducing immune tolerance in a human, comprising administering to the human an effective amount of a composition or a chimeric protein comprising a clotting factor and an Fc region.

Description

The present disclosure provides methods inducing immune nce in a human, comprising administering to the human an effective amount of a composition or a chimeric protein comprising a clotting factor and an Fc region.

NZ 795161 _ 1 _ IVIETHODS OF INDUCING IMIVIUNE NCE TO CLOTTING FACTORS CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of US. Provisional Application Serial Nos. 62/429,516 filed December 2, 2016, 62/466,937 filed March 03, 2017, 62/529,866 filed July 7, 2017, 62/558,790 filed September 14, 2017, and 62/582,829 filed November 7, 2017, each of which are incorporated herein by reference in their entirety.

FIELD OF THE DISCLOSURE The present disclosure relates generally to the field of therapeutics for hemostatic disorders.

BACKGROUND Hemophilia an X-linked ng disorder caused by mutations and/or deletions in genes ng coagulation proteins, in particular the Factor VIII (FVIII) gene, ing in a ncy of FVIII activity hilia A), or the Factor IX gene, resulting in a deficiency of FIX activity (hemophilia B) (see, e. g., Peyvandi, F. el al. Haemophilia 12:82-89 (2006)).

The disease is characterized by spontaneous hemorrhage and excessive bleeding after trauma.

Treatment of hemophilia is by replacement therapy targeting restoration of FVIII and/or FIX activity to prevent neous bleeding (see, e.g., Mannucci, P.M., er al., N. Engl. J. Med. 344:1773-1779 .

Clotting factor replacement therapy is the leading treatment of hemophilia. However, a substantial portion of hemophilia patients, including nearly 30% of patients with severe hemophilia A, p inhibitors against the clotting factor products, greatly reducing their efficacy in these patients. The immune se is a T-cell-dependent or B-cell-mediated immune response ed against the infused clotting factor, e.g., a FVIII replacement therapy.

While people with severe hemophilia are more likely to develop tors, approximately 5-8% of people with mild or moderate hemophilia A develop inhibitors.

Development of clotting factor inhibitors can be deadly because the antibodies can inhibit not only the factor concentrate infused but also any small percentage of factor protein that the _ 2 _ body was producing naturally. Therefore, a person with mild or moderate ilia who develops an inhibitor now, in effect, has severe hemophilia (<l% circulating ).

Approximately 2-3% of people with hemophilia B develop inhibitors. While tors in people with hemophilia B are less common than hemophilia A, it can be even more challenging as about half of hemophilia B inhibitor patients will develop an anaphylactic reaction to infused factor IX, which can be life-threatening.

Therefore, a need remains for methods of inducing immune tolerance in a human who has already developed an immune se to one or more clotting factors and who has not responded to a previous immune tolerance therapy.

BRIEF SUMIVIARY The present disclosure provides a method of inducing immune tolerance in a human with hemophilia, comprising administering to the human an effective amount of a chimeric n comprising a clotting factor and an Fc region or a composition comprising a clotting factor and an Fc region, n the human has developed an inhibitor against the clotting factor and failed to respond to one or more previous immune tolerance therapy against the clotting factor. In some aspects, the method further comprises measuring the level of an inhibitory immune response before the administration and measuring the level of an inhibitory immune response after the stration. In some aspects, the method further comprises comparing the level of the inhibitory immune response before the administration to the level of the inhibitory immune response after the administration.

The t invention further provides a method of inducing immune tolerance in a human with hemophilia, comprising (1) stering to the human an effective amount of a chimeric protein comprising a clotting factor and an Fc region or a ition sing a clotting factor and an Fc region, wherein the effective amount of the chimeric protein induces immune tolerance in the human, and (2) ing induction of immune tolerance, administering to the human a ng regimen of the chimeric protein. In certain aspects, the induction of immune tolerance occurs when the titer of the tory antibodies in the human is less than about 0.6 BU. In certain aspects, the method further comprises (3) following the tapering regimen, administering to the human a prophylactic dose of the clotting factor. In certain aspects, the human has not been treated with a previous immune tolerance therapy against the ng factor. _ 3 _ In some aspects, the human has developed an tory immune response to the clotting factor. In some embodiments, the inhibitory immune response comprises production of inhibitory antibodies against the clotting . In some embodiments, the titer of the inhibitory antibodies prior to the administration is at least about 0.6 Bethesda Units (BU). In some embodiments, the titer of the inhibitory antibodies after the administration is less than about 0.6 BU.

In some aspects, the immune response comprises a cell-mediated immune response.

In some embodiments, the cell-mediated immune response comprises the e of a cytokine. In some embodiments, the administration reduces the level of a cytokine in the human compared to the level in the human after a previous treatment with a polypeptide consisting of a FVIII polypeptide. In some embodiments, the cytokine selected from the group consisting of IL-l2, IL-4, IL-l7, TNF-oc, and any combination thereof.

In certain aspects, an expression of one or more tolerogenic molecules is increased after the administration relative to the expression level of the one or more tolerogenic molecules prior to the administration. In some ments, the one or more genic molecules is selected from IL-lO, TGF-B, IL-35, 1130-1, and any combination thereof. In other embodiments, the immune response comprises a clinical symptom selected from the group consisting of: sed bleeding cy, high clotting factor ption, lack of response to clotting factor therapy, decreased efficacy of clotting factor therapy, and shortened ife of the clotting factor.

In some ments, the human was previously diagnosed as having developed an inhibitory immune response to the clotting factor at least about 1 month, at least about 2 months, at least about 3 months, at least about 6 months, at least about 12 months, at least about 18 months, at least about 24 months, at least about 30 months, at least about 36 months, at least about 42 months, at least about 48 years, at least about 54 months, at least about 60 months, at least about 6 years, at least about 7 years, at least about 8 years, or at least about years prior to the administration. In some embodiments, the time to tolerance is about 1 to about 24 weeks, about 1 to about 23 weeks, about 1 to about 22 weeks, about 1 to about 21 weeks, about 2 to about 20 weeks, about 2 to about 19 weeks, about 2 to about 18 weeks, about 2 to about 17 weeks, about 3 to about 16 weeks, about 3 to about 15 weeks, about 3 to about 14 weeks, about 3 to about 13 weeks, about 4 to about 12 weeks, about 4 to about 11 weeks, about 4 to about 10 weeks, about 4 to about 9 weeks, about 5 to about 8 weeks, about _ 4 _ to about 7 weeks, about 5 to about 6 weeks, about 1 to about 12 weeks, about 1 to about 11 weeks, about 1 to about 10 weeks, about 1 to about 9 weeks, about 1 to about 8 weeks, about 1 to about 7 weeks, about 1 to about 6 weeks, about 1 to about 5 weeks, or about 1 to about 4 weeks.

In some aspects, the clotting factor is factor VIII ). In some embodiments, the chimeric n comprises FVIII-Fc. In certain embodiments, the chimeric protein ses a FVIII portion and a VWF portion, wherein the FVIII portion comprises a FVIII polypeptide or a nt thereof, wherein the VWF portion comprises a VWF polypeptide or a fragment thereof, wherein the FVIII portion is linked to a first Fc region, n the VWF portion is linked to a second Fc region, and n the first Fc region and the second Fc region are associated with each other.

In some aspects, the chimeric protein further comprises a half-life extending moiety.

In n embodiments, the half-life extending moiety comprises albumin or a fragment thereof, an albumin binding , a PAS sequence, a HAP sequence, transferrin or a nt thereof, polyethylene glycol (PEG), polysialic acid, hydroxyethyl starch (HES), a derivative thereof, or any combination thereof.

In some embodiments, the ive amount of the chimeric protein comprising FVIII and an Fc region is from about 20 IU/kg to about 300 IU/kg. In some embodiments, the chimeric protein comprising FVIII-Fc is administered at a dosing interval of about one day, about two days, about three days, about four days, about five days, about siX days, about seven days, about eight days, about nine days, about ten days, about 11 days, about 12 days, about 13 days, about 14 days, about 15 days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days, or about 24 days.

In certain aspects, the human previously developed a FVIII inhibitory immune response. In some embodiments, the human has a bleeding condition selected from the group consisting of a bleeding coagulation disorder, hemarthrosis, muscle bleed, oral bleed, hemorrhage, hemorrhage into muscles, oral hemorrhage, trauma, trauma capitis, gastrointestinal bleeding, intra cranial hemorrhage, intra-abdominal hemorrhage, intrathoracic hemorrhage, bone fracture, central nervous system bleeding, ng in the retropharyngeal space, ng in the retroperitoneal space, and bleeding in the illiopsoas sheath. _ 5 _ ElVlBODIlVIENTS E1.A method of inducing immune nce in a human with hemophilia, comprising administering to the human an effective amount of a chimeric protein comprising a clotting factor and an Fc region, wherein the human has ped an inhibitor against the clotting factor and failed to respond to one or more previous immune nce therapy against the clotting factor.

E2. The method of El, further comprising measuring the level of an inhibitory immune response before the administration and measuring the level of an inhibitory immune response after the administration.

E3. The method of E2, further comprising comparing the level of the inhibitory immune response before the administration to the level of the inhibitory immune response after the administration.

E4. The method of any one of E1 to E3, wherein the human has developed an inhibitory immune response to the clotting factor.

E5. The method of E4, wherein the tory immune response comprises production of inhibitory antibodies against the clotting factor.

E6.The method of E5, wherein the titer of the inhibitory antibodies prior to the administration is at least about 0.6 Bethesda Units (BU).

E7. The method of E5 or E6, wherein the titer of the inhibitory antibodies prior to the stration is at least about 1 BU, at least about 2 BU, at least about 3 BU, at least about 4 BU, at least about 5 BU, at least about 6 BU, at least about 7 BU, at least about 10 BU, at least about 20 BU, at least about 30 BU, at least about 40 BU, at least about 50 BU, at least about 100 BU, at least about 150 BU, or at least about 200 BU.

E8. The method of any one of E5 to E7, n the titer of the inhibitory antibodies prior to the administration is at least about 5 BU.

E9. The method of any one of E5 to E8, wherein the titer of the inhibitory antibodies after the administration is less than about 0.6 BU.

E10. The method of any one of E5 to E9, n the titer of the inhibitory antibodies after the administration is 0 BU.

E11. The method of claim any one of E1 to E10, wherein the immune response comprises a cell-mediated immune response. _ 6 _ E12. The method of E11, wherein the cell-mediated immune response comprises the release of a cytokine.

E13. The method of E12, wherein the administration reduces the level of a ne in the human compared to the level in the human after a previous treatment with a polypeptide consisting of a FVIII ptide.

E14. The method of E12 or E13, wherein the cytokine selected from the group consisting of IL-12, IL-4, IL-17, TNF-oc, and any combination thereof.

E15. The method of any one of E1 to E14, wherein an expression of one or more tolerogenic molecules is increased after the administration relative to the expression level of the one or more tolerogenic molecules prior to the administration.

E16. The method of E15, wherein the one or more tolerogenic molecules is selected from IL-lO, TGF-B, IL-3 5, IDO-l, and any combination thereof.

E17. The method of any one of E1 to E14, wherein the immune se comprises a clinical symptom selected from the group consisting of: increased ng tendency, high clotting factor consumption, lack of response to clotting factor therapy, sed efficacy of clotting factor therapy, and shortened half-life of the clotting factor.

E18. The method of any one of E1 to E17, wherein the human was previously diagnosed as having developed an tory immune response to the clotting factor at least about 3 months, at least about 6 months, at least about 12 months, at least about 18 months, at least about 24 months, at least about 30 months, at least about 36 months, at least about 42 months, at least about 48 years, at least about 54 months, at least about 60 months, at least about 6 years, at least about 7 years, at least about 8 years, or at least about 10 years prior to the administration.

E19. The method of any one of E1 to E18, wherein the human was previously diagnosed as having developed an tory immune response to the ng factor at least about 5 years prior to the administration.

E20. The method of any one of E1 to E19, n the time to tolerance is about 1 to about 24 weeks, about 1 to about 23 weeks, about 1 to about 22 weeks, about 1 to about 21 weeks, about 2 to about 20 weeks, about 2 to about 19 weeks, about 2 to about 18 weeks, about 2 to about 17 weeks, about 3 to about 16 weeks, about 3 to about 15 weeks, about 3 to about 14 weeks, about 3 to about 13 weeks, about 4 to about 12 weeks, about 4 to about 11 weeks, about 4 to about 10 weeks, about 4 to about 9 weeks, about 5 to about 8 _ 7 _ weeks, about 5 to about 7 weeks, about 5 to about 6 weeks, about 1 to about 12 weeks, about 1 to about 11 weeks, about 1 to about 10 weeks, about 1 to about 9 weeks, about 1 to about 8 weeks, about 1 to about 7 weeks, about 1 to about 6 weeks, about 1 to about 5 weeks, or about 1 to about 4 weeks.

E21. The method of any one of E1 to E20, wherein the time to tolerance is less than about 24 weeks, less than about 23 weeks, less than about 22 weeks, less than about 21 weeks, less than about 20 weeks, less than about 19 weeks, less than about 18 weeks, less than about 17 weeks, less than about 16 weeks, less than about 15 weeks, less than about 14 weeks, less than about 13 weeks, less than about 12 weeks, less than about 11 weeks, less than about 10 weeks, less than about 9 weeks, less than about 8 weeks, less than about 7 weeks, less than about 6 weeks, less than about 5 weeks, less than about 4 weeks, less than about 3 weeks, less than about 2 weeks, or less than about 1 week.

E22. The method of any one of E1 to E21, wherein the time to tolerance is about 4 to about 12 weeks.

E23. The method of any one of E1 to E22, wherein the time to tolerance is about 4 weeks.

E24. The method of any one of E1 to E23, wherein the human is receiving interferon therapy.

E25. The method of any one of E1 to E24, wherein the human is receiving anti- Viral therapy.

E26. The method of any one of E1 to E25, wherein the human has a genetic polymorphism associated with increased TNF-oc.

E27. The method of E26, wherein the rphism is TNF -308G>A.

E28. The method of any one of E1 to E27, wherein the human has a genetic polymorphism ated with increased lLlO.

E29. The method of E28, wherein the rphism is allele 134 of the ILlOG microsatellite.

E30. The method of any one of E1 to E29, wherein the human has had less than 150 eXposure days (ED) to the clotting factor.

E31. The method of E30, wherein the human has had less than 50 ED.

E32. The method of E3 1, wherein the human has had less than 20 ED. _ 8 _ E33. The method of any one of E1 to E32, wherein the clotting factor is factor VIII (FVIII).

E34. The method of any one of E1 to E33, wherein the chimeric protein comprises Fc.

E35. The method of any one of E1 to E34, wherein the chimeric protein comprises a FVIII portion and a VWF portion, wherein the FVIII portion comprises a FVIII polypeptide or a nt thereof, wherein the VWF portion comprises a VWF polypeptide or a nt thereof, wherein the FVIII portion is linked to a first Fc , wherein the VWF n is linked to a second Fc region, and wherein the first Fc region and the second Fc region are associated with each other.

E36. The method of any one of E33 to E35, wherein the FVIII polypeptide comprises mature FVIII.

E37. The method of any one of E33 to E35, wherein the FVIII polypeptide comprises a B domain deleted FVIII.

E38. The method of E37, wherein the B domain deleted FVIII comprises a deletion of all or part of the B domain of FVIII.

E39. The method of E37 or E38, wherein the B domain deleted FVIII comprises a deletion of amino acid residues 746 to 1648 of mature FVIII.

E40. The method of any one of E33 to E39, wherein the VWF polypeptide comprises a VWF fragment comprising a D' domain and a D3 domain of VWF.

E41. The method of any one of E1 to E40, wherein the chimeric protein further comprises a half-life extending moiety.

E42. The method of E41, wherein the ife extending moiety comprises albumin or a fragment f, an albumin binding , a PAS ce, a HAP sequence, transferrin or a fragment thereof, polyethylene glycol (PEG), polysialic acid, hydroxyethyl starch (HES), a derivative thereof, or any combination thereof.

E43. The method of E4l or E42, wherein the half-life extending moiety is inserted within the clotting factor.

E44. The method of E4l or E42, wherein the half-life extending moiety is inserted between the clotting factor and the Fc region. _ 9 _ E45. The method of any one of E33 to E44, wherein the effective amount of the chimeric protein comprising FVIII and an Fc region is from about 20 IU/kg to about 300 IU/kg.

E46. The method of E45, wherein the effective amount of the chimeric n comprising Fc is from about 100 IU/kg to about 300 IU/kg, from about 100 IU/kg to about 200 IU/kg, from about 100 IU/kg to about 290 IU/kg, from about 100 IU/kg to about 280 IU/kg, from about 100 IU/kg to about 270 IU/kg, from about 100 IU/kg to about 260 IU/kg, from about 100 IU/kg to about 250 IU/kg, from about 100 IU/kg to about 240 IU/kg, from about 100 IU/kg to about 230 IU/kg, from about 100 IU/kg to about 220 IU/kg, from about 100 IU/kg to about 210 IU/kg, from about 150 IU/kg to about 300 IU/kg, from about 150 IU/kg to about 290 IU/kg, from about 150 IU/kg to about 280 IU/kg, from about 150 IU/kg to about 270 IU/kg, from about 150 IU/kg to about 260 IU/kg, from about 150 IU/kg to about 250 IU/kg, from about 150 IU/kg to about 240 IU/kg, from about 140 IU/kg to about 250 IU/kg, from about 130 IU/kg to about 260 IU/kg, from about 120 IU/kg to about 270 IU/kg, from about 110 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 290 IU/kg, from about 200 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 270 IU/kg, from about 200 IU/kg to about 260 IU/kg, from about 200 IU/kg to about 250 IU/kg, from about 200 IU/kg to about 240 IU/kg, from about 200 IU/kg to about 230 IU/kg, from about 200 IU/kg to about 220 IU/kg, or from about 200 IU/kg to about 210 IU/kg.

E47. The method of E45 or E46, wherein the effective amount of the chimeric protein comprising FVIII-Fc is about 100 IU/kg, about 105 IU/kg, about 110 IU/kg, about 115 IU/kg, about 120 IU/kg, about 125 IU/kg, about 130 IU/kg, about 135 IU/kg, about 140 IU/kg, about 145 IU/kg, about 150 IU/kg, about 155 IU/kg, about 160 IU/kg, about 165 IU/kg, about 170 IU/kg, about 175 IU/kg, about 180 IU/kg, about 185 IU/kg, about 190 IU/kg, about 195 IU/kg, about 200 IU/kg, about 225 IU/kg, about 250 IU/kg, about 275 IU/kg, or about 300 IU/kg.

E48. The method of any one of E33 to E47, wherein the chimeric protein comprising FVIII-Fc is administered at a dosing interval of about two days, about three days, about four days, about five days, about siX days, about seven days, about eight days, about nine days, about ten days, about 11 days, about 12 days, about 13 days, about 14 days, about days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days, or about 24 days. _ 10 _ E49. The method of any one of E33 to E47, wherein the chimeric protein comprising FVIII-Fc is stered at a dosing interval of about 1 to about 14 days, about 1 to about 13 days, about 1 to about 12 days, about 1 to about 11 days, about 1 to about 10 days, about 1 to about 9 days, about 1 to about 8 days, about 1 to about 7 days, about 1 to about 6 days, about 1 to about 5 days, about 1 to about 4 days, about 1 to about 3 days, about 1 to about 2 days, about 2 to about 14 days, about 3 to about 14 days, about 4 to about 14 days, about 5 to about 14 days, about 6 to about 14 days, about 7 to about 14 days, about 8 to about 14 days, about 9 to about 14 days, about 10 to about 14 days, about 11 to about 14 days, about 12 to about 14 days, about 13 to about 14 days, or about 5 to about 10 days.

E50. The method of any one of E33 to E49, wherein the chimeric n comprising FVIII—Fc is administered at a dosing interval about 3 days to about 5 days.

E51. The method of any one of E1 to E33, wherein the chimeric protein comprises a FVIII portion, a VWF n, a first Fc region, and a second Fc region, wherein the FVIII portion comprises a FVIII polypeptide or a fragment thereof, wherein the VWF n comprises a VWF polypeptide or a fragment thereof, wherein the FVIII portion is linked to the first Fc region, wherein the VWF portion is linked to the second Fc region, and wherein the first Fc region and the second Fc region are associated with each other.

E52. The method of any one of E1 to E51, wherein the human previously developed a FVIII inhibitory immune response.

E53. The method of E52, wherein the inhibitory FVIII immune response developed in se to a FVIII product selected from the group consisting of: ADVATE®, RECOMBINATE®, KOGENATE FS®, TE FS®, XYNTHA/REFACTO AB®, L-M®, MONARC-M®, MONOCLATE-P®, HUMATE-P®, ALPHANATE®, KOATE-DVI®, AFSTYLA®, AND HYATE:C®.

E54. The method of E52, wherein the inhibitory FVIII immune se is developed in response to a recombinant FVIII product.

E55. The method of any one of E1 to E54, wherein the human has a bleeding condition selected from the group ting of a bleeding coagulation disorder, hemarthrosis, muscle bleed, oral bleed, hemorrhage, hemorrhage into muscles, oral hemorrhage, trauma, trauma capitis, gastrointestinal bleeding, intra cranial hemorrhage, intra- abdominal hemorrhage, intrathoracic hemorrhage, bone fracture, central nervous system _ 11 _ bleeding, bleeding in the retropharyngeal space, bleeding in the retroperitoneal space, and bleeding in the illiopsoas sheath.

E56. The method of E55, wherein the bleeding coagulation er is ilia A.

E57. The method of any one of E33 to E56, wherein the effective amount of the ic protein comprising FVIII and an Fc region is about 50 IU/kg to about 300 IU/kg.

E58. The method of any E57, wherein the effective amount of the chimeric protein comprising FVIII and an Fc region is about 50 IU/kg, about 60 IU/kg, about 70 IU/kg, about 80 IU/kg, about 90 IU/kg, about 100 IU/kg, about 110 IU/kg, about 120 IU/kg, about 130 IU/kg, about 140 IU/kg, about 150 IU/kg, about 160 IU/kg, about 170 IU/kg, about 180 IU/kg, about 190 IU/kg, about 200 IU/kg, about 225 IU/kg, about 250 IU/kg, about 275 IU/kg, or about 300 IU/kg.

E59. The method of E57 or E58, wherein the effective amount of the chimeric protein is about 200 IU/kg and is administered daily.

E60. The method of E57 or E58, wherein the ive amount of the chimeric protein is about 50 IU/kg and is administered about three times a week.

E61. The method of any one of E57 to E60, wherein the effective amount of the chimeric protein is administered in two or more doses throughout a day.

E62. The method of any one of E57 to E6l, n the chimeric protein is administered until immune tolerance is observed, wherein immune tolerance is observed when the titer of the inhibitory antibodies in the human is less than about 0.6 BU.

E63. The method of E62, wherein following immune tolerance, the human is administered a tapering regimen of the ic protein comprising FVIII and an Fc region.

E64. The method of E63, wherein the tapering regimen comprises administering a tapering dose of about 50 IU/kg to about 100 IU/kg of the chimeric protein sing FVIII and an Fc region.

E65. The method of E63 or E64, wherein the tapering dose is administered once a day or once every other day.

E66. The method of any one of E63 to E65, wherein the tapering dose is administered for at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 9 weeks, at least about 10 weeks, at least about 11 weeks, at _ 12 _ least about 12 weeks, at least about 13 weeks, at least about 14 weeks, at least about 15 weeks, at least about 16 weeks, at least about 17 weeks, at least about 18 weeks, at least about 19 weeks, at least about 20 weeks, at least about 21 weeks, at least about 22 weeks, at least about 23 weeks, at least about 24 weeks, at least about 25 weeks, at least about 26 weeks, at least about 27 weeks, at least about 28 weeks, at least about 29 weeks, at least about 30 weeks, at least about 31 weeks, or at least about 32 weeks.

E67. The method of any one of E63 to E66, n the ng regimen comprises administering a tapering dose of the chimeric protein of about 50 IU/kg or about 100 IU/kg.

E68. The method of any one of E63 to E67, wherein the tapering regimen comprises administering a tapering dose of the chimeric n of about 50 IU/kg once a day from week 1 to week 6 following immune tolerance.

E69. The method of any one of E63 to E67, wherein the tapering regimen comprises administering a tapering dose of the chimeric protein of about 100 IU/kg once a day from week 1 to week 6 following immune tolerance.

E70. The method of E68 or E69, wherein the tapering regimen further comprises administering a ng dose of the chimeric protein of about 50 IU/kg or about 100 IU/kg once every other day from week 6 to week 12 following immune tolerance.

E71. The method of E70, wherein the tapering regimen further comprises administering a tapering dose of the chimeric n of about 50 IU/kg or about 100 IU/kg once every other day from week 12 to week 16.

E72. The method of any one of E66 to E71, further comprising administering a prophylactic dose of the clotting factor following the tapering regimen.

E73. The method of E72, n the prophylactic dose comprises from about 50 IU/kg to about 100 IU/kg.

E74. The method of E72 or E73, wherein the prophylactic dose is administered about one time per week, about two times per week, about three times per week, or about one time every three to five days.

E75. A method of inducing immune tolerance in a human with hemophilia, comprising _ 13 _ (1) administering to the human an effective amount of a chimeric protein comprising a clotting factor and an Fc region, wherein the effective amount of the chimeric protein comprising a clotting factor and an Fc region induces immune tolerance in the human; and (2) following induction of immune tolerance, administering to the human a tapering regimen of the ic protein.

E76. The method of E75, wherein induction of immune tolerance occurs when the titer of the inhibitory antibodies in the human is less than about 0.6 BU E77. The method of E75 or E77, r comprising: (3) following the tapering regimen, administering to the human a prophylactic dose of a clotting factor.

E78. The method of any one of E75 to E77, wherein the human has not been treated with a previous immune tolerance y against the clotting factor.

E79. The method of any one of E75 to E78, further comprising measuring the level of an tory immune response before the administration and measuring the level of an inhibitory immune response after the administration.

E80. The method of E79, further comprising comparing the level of the inhibitory immune response before the administration to the level of the inhibitory immune response after the administration.

E81. The method of any one of E75 to E80, wherein the human has ped an inhibitory immune response to the clotting factor.

E82. The method of E81, wherein the inhibitory immune response comprises production of inhibitory dies against the clotting .

E83. The method of E82, wherein the titer of the tory antibodies prior to the administration is at least about 0.6 Bethesda Units (BU).

E84. The method of E82 or E83, wherein the titer of the inhibitory antibodies prior to the administration is at least about 1 BU, at least about 2 BU, at least about 3 BU, at least about 4 BU, at least about 5 BU, at least about 6 BU, at least about 7 BU, at least about BU, at least about 20 BU, at least about 30 BU, at least about 40 BU, at least about 50 BU, at least about 100 BU, at least about 150 BU, or at least about 200 BU.

E85. The method of any one of E82 to E84, wherein the titer of the inhibitory antibodies prior to the administration is at least about 5 BU. _ 14 _ E86. The method of any one of E82 to E85, wherein the titer of the inhibitory antibodies after the administration is less than about 0.6 BU.

E87. The method of any one of E82 to E86, wherein the titer of the inhibitory antibodies after the administration is O BU.

E88. The method of claim any one of E79 to E87, wherein the immune response comprises a cell-mediated immune response.

E89. The method of E88, wherein the cell-mediated immune response comprises the e of a cytokine.

E90. The method of E88, wherein the stration reduces the level of a cytokine in the human compared to the level in the human after a previous treatment with a polypeptide consisting of a FVIII polypeptide.

E91. The method of any one of E75 to E90, wherein an expression of one or more tolerogenic les is increased after the administration relative to the expression level of the one or more genic molecules prior to the administration.

E92. The method of any one of E75 to E91, wherein the human was previously diagnosed as having developed an inhibitory immune response to the clotting factor at least about 3 months, at least about 6 , at least about 12 months, at least about 18 months, at least about 24 months, at least about 30 months, at least about 36 months, at least about 42 months, at least about 48 years, at least about 54 months, at least about 60 months, at least about 6 years, at least about 7 years, at least about 8 years, or at least about 10 years prior to the administration.

E93. The method of any one of E75 to E92, wherein the human was previously diagnosed as having developed an inhibitory immune response to the ng factor at least about 5 years prior to the administration.

E94. The method of any one of E75 to E93, n the time to tolerance is about 1 to about 24 weeks, about 1 to about 23 weeks, about 1 to about 22 weeks, about 1 to about 21 weeks, about 2 to about 20 weeks, about 2 to about 19 weeks, about 2 to about 18 weeks, about 2 to about 17 weeks, about 3 to about 16 weeks, about 3 to about 15 weeks, about 3 to about 14 weeks, about 3 to about 13 weeks, about 4 to about 12 weeks, about 4 to about 11 weeks, about 4 to about 10 weeks, about 4 to about 9 weeks, about 5 to about 8 weeks, about 5 to about 7 weeks, about 5 to about 6 weeks, about 1 to about 12 weeks, about 1 to about 11 weeks, about 1 to about 10 weeks, about 1 to about 9 weeks, about 1 to about 8 _ 15 _ weeks, about 1 to about 7 weeks, about 1 to about 6 weeks, about 1 to about 5 weeks, or about 1 to about 4 weeks.

E95. The method of any one of E75 to E94, n the time to tolerance is less than about 24 weeks, less than about 23 weeks, less than about 22 weeks, less than about 21 weeks, less than about 20 weeks, less than about 19 weeks, less than about 18 weeks, less than about 17 weeks, less than about 16 weeks, less than about 15 weeks, less than about 14 weeks, less than about 13 weeks, less than about 12 weeks, less than about 11 weeks, less than about 10 weeks, less than about 9 weeks, less than about 8 weeks, less than about 7 weeks, less than about 6 weeks, less than about 5 weeks, less than about 4 weeks, less than about 3 weeks, less than about 2 weeks, or less than about 1 week.

E96. The method of any one of E75 to E95, wherein the time to tolerance is about 4 to about 12 weeks.

E97. The method of any one of E75 to E96, wherein the time to tolerance is about 4 weeks.

E98. The method of any one of E75 to E97, wherein the human is receiving interferon therapy.

E99. The method of any one of E75 to E98, n the human is receiving anti-Viral therapy.

E100. The method of any one of E75 to E91, wherein the human has a genetic polymorphism associated with increased TNF-oc.

E101. The method of E100, wherein the polymorphism is TNF -308G>A.

E102. The method of any one of E75 to E101, wherein the human has a c polymorphism associated with increased lLlO.

] E103. The method of E102, wherein the polymorphism is allele 134 of the ILlOG microsatellite.

E104. The method of any one of E75 to E103, wherein the human has had less than 150 re days (ED) to the clotting factor.

E105. The method of E104, wherein the human has had less than 50 ED.

E106. The method of E105, wherein the human has had less than 20 ED.

E107. The method of any one of E75 to E106, wherein the clotting factor is factor VIII (FVIII). _ 16 _ ] E108. The method of any one of E75 to E107, wherein the chimeric protein ses FVIII-Fc.

E109. The method of any one of E75 to E108, wherein the chimeric protein comprises a FVIII portion and a VWF portion, wherein the FVIII portion comprises a FVIII polypeptide or a fragment thereof, wherein the VWF portion comprises a VWF polypeptide or a fragment thereof, n the FVIII portion is linked to a first Fc region, wherein the VWF portion is linked to a second Fc , and wherein the first Fc region and the second Fc region are associated with each other.

E110. The method of any one of E75 to E109, wherein the FVIII polypeptide comprises mature FVIII.

E111. The method of any one of E75 to E109, wherein the FVIII polypeptide comprises a B domain deleted FVIII.

E112. The method of E110, wherein the B domain deleted FVIII comprises a deletion of all or part of the B domain of FVIII.

E113. The method of E110 or E111, n the B domain deleted FVIII comprises a deletion of amino acid residues 746 to 1648 of mature FVIII.

E114. The method of any one of E109 to E113, n the VWF polypeptide comprises a VWF fragment comprising a D' domain and a D3 domain of VWF.

E115. The method of any one of E75 to E114 wherein the chimeric protein further comprises a half-life extending moiety.

E116. The method of E115, wherein the half-life extending moiety comprises albumin or a fragment thereof, an albumin binding , a PAS sequence, a HAP ce, transferrin or a fragment thereof, hylene glycol (PEG), polysialic acid, hydroxyethyl starch (HES), a derivative thereof, or any combination thereof.

E116. The method of E115 or E116, wherein the half-life extending moiety is inserted within the clotting .

E117. The method of E115 or E116, wherein the half-life extending moiety is inserted between the clotting factor and the Fc region.

E118. The method of any one of E75 to E118, wherein the effective amount of the chimeric protein comprising FVIII and an Fc region is from about 50 IU/kg to about 300 IU/kg. _ 17 _ E120. The method of E1 19, wherein the ive amount of the ic protein comprising FVIII—Fc is from about 100 IU/kg to about 300 IU/kg, from about 100 IU/kg to about 200 IU/kg, from about 100 IU/kg to about 290 IU/kg, from about 100 IU/kg to about 280 IU/kg, from about 100 IU/kg to about 270 IU/kg, from about 100 IU/kg to about 260 IU/kg, from about 100 IU/kg to about 250 IU/kg, from about 100 IU/kg to about 240 IU/kg, from about 100 IU/kg to about 230 IU/kg, from about 100 IU/kg to about 220 IU/kg, from about 100 IU/kg to about 210 IU/kg, from about 150 IU/kg to about 300 IU/kg, from about 150 IU/kg to about 290 IU/kg, from about 150 IU/kg to about 280 IU/kg, from about 150 IU/kg to about 270 IU/kg, from about 150 IU/kg to about 260 IU/kg, from about 150 IU/kg to about 250 IU/kg, from about 150 IU/kg to about 240 IU/kg, from about 140 IU/kg to about 250 IU/kg, from about 130 IU/kg to about 260 IU/kg, from about 120 IU/kg to about 270 IU/kg, from about 110 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 290 IU/kg, from about 200 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 270 IU/kg, from about 200 IU/kg to about 260 IU/kg, from about 200 IU/kg to about 250 IU/kg, from about 200 IU/kg to about 240 IU/kg, from about 200 IU/kg to about 230 IU/kg, from about 200 IU/kg to about 220 IU/kg, or from about 200 IU/kg to about 210 IU/kg.

E121. The method of E119 or E120, wherein the effective amount of the chimeric protein comprising FVIII—Fc is about 50 IU/kg, about 60 IU/kg, about 70 IU/kg, about 80 IU/kg, about 90 IU/kg, about 100 IU/kg, about 110 IU/kg, about 120 IU/kg, about 130 IU/kg, about 140 IU/kg, about 150 IU/kg, about 160 IU/kg, about 170 IU/kg, about 180 IU/kg, about 190 IU/kg, about 200 IU/kg, about 225 IU/kg, about 250 IU/kg, about 275 IU/kg, or about 300 IU/kg..

E122. The method of any one of E75 to E121, wherein the effective amount of the chimeric protein is about 200 IU/kg and is administered daily.

E123. The method of any one of E75 to E122, n the chimeric protein comprising FVIII-Fc is administered at a dosing interval of about two days, about three days, about four days, about five days, about siX days, about seven days, about eight days, about nine days, about ten days, about 11 days, about 12 days, about 13 days, about 14 days, about days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days, or about 24 days.

E124. The method of any one of E75 to E121, wherein the chimeric protein comprising FVIII-Fc is administered at a dosing interval of about 1 to about 14 days, about 1 _ 18 _ to about 13 days, about 1 to about 12 days, about 1 to about 11 days, about 1 to about 10 days, about 1 to about 9 days, about 1 to about 8 days, about 1 to about 7 days, about 1 to about 6 days, about 1 to about 5 days, about 1 to about 4 days, about 1 to about 3 days, about 1 to about 2 days, about 2 to about 14 days, about 3 to about 14 days, about 4 to about 14 days, about 5 to about 14 days, about 6 to about 14 days, about 7 to about 14 days, about 8 to about 14 days, about 9 to about 14 days, about 10 to about 14 days, about 11 to about 14 days, about 12 to about 14 days, about 13 to about 14 days, or about 5 to about 10 days.

E125. The method of any one of E75 to E122, wherein the ic protein comprising FVIII—Fc is administered at a dosing interval about 3 days to about 5 days.

] E126. The method of any one of E75 to E125, wherein the chimeric protein comprises a FVIII portion, a VWF portion, a first Fc region, and a second Fc region, wherein the FVIII portion comprises a FVIII polypeptide or a fragment thereof, wherein the VWF portion comprises a VWF polypeptide or a fragment thereof, n the FVIII portion is linked to the first Fc , wherein the VWF portion is linked to the second Fc region, and wherein the first Fc region and the second Fc region are associated with each other.

E127. The method of any one of E75 to E126, wherein the human previously developed a FVIII inhibitory immune response.

E128. The method of E127, wherein the inhibitory FVIII immune se developed in response to a FVIII product selected from the group consisting of: ADVATE®, RECOMBINATE®, KOGENATE FS®, HELIXATE FS®, XYNTHA/REFACTO AB®, HEMOFIL-M®, MONARC-M®, MONOCLATE-P®, TE-P®, ALPHANATE®, DVI®, AFSTYLA®, AND HYATE:C®.

E129. The method of E128, wherein the inhibitory FVIII immune response is developed in response to a recombinant FVIII product.

E130. The method of any one of E75 to E129, n the human has a bleeding condition selected from the group consisting of a bleeding coagulation disorder, hemarthrosis, muscle bleed, oral bleed, hemorrhage, hemorrhage into muscles, oral hemorrhage, trauma, trauma capitis, gastrointestinal bleeding, intra cranial hemorrhage, intra- abdominal hemorrhage, intrathoracic hemorrhage, bone fracture, central nervous system ng, bleeding in the retropharyngeal space, ng in the retroperitoneal space, and bleeding in the illiopsoas sheath. _ 19 _ E131. The method of E130, wherein the bleeding coagulation disorder is hemophilia A.

E132. The method of any one of E75 to E131, wherein the effective amount of the chimeric protein is administered in two or more doses throughout a day.

El33. The method of any one of E75 to El32, wherein the tapering n comprises administering a tapering dose of about 50 IU/kg to about 100 IU/kg of the chimeric protein.

E134. The method of any one of E75 to E133, wherein the tapering dose is administered once a day, once every other day, or three times every week.

E135. The method of any one of E75 to E134, wherein the tapering dose is stered for at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 9 weeks, at least about 10 weeks, at least about 11 weeks, at least about 12 weeks, at least about 13 weeks, at least about 14 weeks, at least about 15 weeks, at least about 16 weeks, at least about 17 weeks, at least about 18 weeks, at least about 19 weeks, at least about 20 weeks, at least about 21 weeks, at least about 22 weeks, at least about 23 weeks, at least about 24 weeks, at least about 25 weeks, at least about 26 weeks, at least about 27 weeks, at least about 28 weeks, at least about 29 weeks, at least about 30 weeks, at least about 31 weeks, or at least about 32 weeks.

E136. The method of any one of E74 to El35, wherein the tapering regimen comprises administering a tapering dose of the ic protein of about 50 IU/kg or about 100 IU/kg.

El37. The method of any one of E75 to E136, wherein the tapering regimen comprises administering a tapering dose of the chimeric protein of about 50 IU/kg once a day from week 1 to week 6 following immune tolerance.

El38. The method of any one of E75 to E136, wherein the ng regimen ses administering a tapering dose of the chimeric protein of about 100 IU/kg once a day from week 1 to week 6 following immune tolerance.

El39. The method of El37 or El38, wherein the tapering n further comprises administering a tapering dose of the chimeric protein of about 50 IU/kg or about 100 IU/kg once every other day from week 6 to week 12 ing immune tolerance. _ 20 _ ] E140. The method of E139, wherein the tapering regimen r comprises administering a tapering dose of the chimeric protein of about 50 IU/kg or about 100 IU/kg once every other day from week 12 to week 16.

E141. The method of any one of E77 to E140, wherein the prophylactic dose comprises about 50 IU/kg to about 100 IU/kg.

E142. The method of any one of E77 to E14l, wherein the prophylactic dose is administered about one time per week, about two times per week, about three times per week, or about three times per week.

E143. The method of any one of E79 to E91 and 94 to E142, wherein the ic protein comprising a clotting factor and an Fc region is administered to the human less than about 1 day, less than about 2 days, less than about 3 days, less than about 4 days, less than about 5 days, less than about 6 days, less than about 7 days, less than about 2 weeks, less than about 3 weeks, less than about 4 weeks, less than about 2 months, less than about 3 months, less than about 4 months, less than about 5 months, less than about 6 months, or less than about 1 year after measuring the level of an tory immune response in the human.

El44. The method of any one of E79 to E91 and 94 to El43, wherein the chimeric protein comprising a ng factor and an Fc region is administered to the human less than about 1 day after measuring the level of an inhibitory immune response in the human.

E145. The method of any one of E79 to E91 and 94 to El44, wherein the chimeric protein comprising a clotting factor and an Fc region is administered to the human less than about 12 hours after measuring the level of an inhibitory immune response in the human.

E146. The method of any one of E1 to E145, wherein the administration of the chimeric protein results in a lower time to tolerance in the human as compared to the time to tolerance in a human following treatment with a ng factor alone.

BRIEF DESCRIPTION OF THE FIGURES is a flow m, outlining the methods used to investigate the effects of rFVIIIFc on FcyR binding, internalization, signaling and cytokine tion, and gene expression changes, as well as subsequent interactions and effects on T cells in vilro. _ 21 _ FIGS. 2A-2C are graphical entations of the relative macrophage and dendritic cell surface expression levels of the Fcy receptors CD16 (), CD32 (), and CD64 () following treatment with horseradish peroxidase immune xes (HRP- IC, positive control), IgGl, recombinant FVIII (rFVIII), or a rFVIII Fc fusion protein (rFVIIIFc). Asterisks (*) indicate degree of significance (n=3, ** = P3001, *** = PS0.005, significance for HRP-IC as compared with the other treatments is not shown).

FIGs. 3A-3C are graphical representations illustrating relative signaling following treatment with rFVIII or rFVIIIFc. shows signaling, as measured by Syk phosphorylation, in THP-l monocytic cell line ("THP-l"), monocytes, peripheral blood monocyte-derived macrophages ("macrophage"), and peripheral blood monocyte-derived dendritic cells treated with HRP-IC, IgGl, rFVIII or rFVIIIFc for 15 minutes. shows relative Syk phosphorylation in macrophages treated with rFVIIIFc ("WT"), mutant rFVIIIFc that is unable to bind to neonatal Fc receptor ("FcRn mutant"), or with mutant rFVIIIFc that is unable to bind to FcyR ("chR mutant"). shows the ve production of the ammatory cytokines interleukin lb (IL-lb), IL-6, IL-8, IL-10, and tumor necrosis factor alpha (TNFa) in macrophages twenty-four hours following treatment with HRP-IC, IgGl, rFVIII or rFVIIIFc. shows the relative phosphorylation status of Src homology region 2 domain- containing phosphatase-l , pSHP2, phosphatidylinositol-3,4,5-trisphosphate 5- phosphatase 1 (SHIPl), and pSHIP2 one minute, five minutes, and thirty minutes after treatment with rFVIII or rFVIIIFc. Asterisks (*) te degree of significance (n=3, >“*PSOOl, SO.OOS).

FIGs. 5A-5M are graphical representations of gene sion ns of genic macrophages following treatment with rFVIII or rFVIIIFc. FIGs. 5A-5B are Venn diagrams, illustrating the distribution of genes that were significantly downregulated () and the distribution of genes that were significantly upregulated () in monocyte-derived macrophages treated with IgGl, rFVIII, or rFVIIIFc for six hours (n=3). FIGs. 5C-5G are graphs showing the ve expressions of various NRF2 and lipid lism pathway genes, such as heme oxygenase l (Hmoxl, ), peroxisome proliferator-activated receptor gamma , ), lipoprotein lipase (LPL, ), early growth response 2 (EGR2, ), and solute carrier organic anion transporter family member 4Al (SLCO4A1, ), CD206 at 6 hours (FIG. SI) and 12 hours (FIG. SJ) post treatment, and _ 22 _ arginase l (ARGl, ) as measured by quantitative PCR, following treatment with rFVIII or rFVIIIFc. Asterisks (*) indicate degree of significance (n=8, *PSOOS, >“"‘PSOOl, >“""“P£O.OOS, FIGs. 5C-5G). FIGs. 5K and 5M are graphs showing the number of cells collected by flow cytometry expressing CD206. In on, rFVIIIFc-educated macrophages were found to exhibit a characteristic M2-like phenotype (FIGs. SI-SM). In ular, macrophages treated with rFVIIIFc had higher relative CD206 (also known as mannose receptor C-type l, MRCl) expression than cells treated with rFVIII after 6 hours (FIG. SI) and after 24 hours (FIG. SJ), and macrophages treated with rFVIIIFc had higher relative ARGl sion than cells treated with rFVIII after 24 hours (). is a flow chart diagraming the methods used to determine the effects of rFVIIIFc treatment on T-cell differentiation. is a graphical representation of the percent of regulatory T cells six days after macrophages or tic cells were treated with IgGl (control), rFVIII, or Fc for 24 hours, and then placed into co-culture with naive CD4 positive T cells. is a graphical representation of the t of regulatory T cells following culture of naive CD4 positive T cells in the conditioned media of macrophages or tic cells pretreated with IgGl, rFVIII, or rFVIIIFc. is an ration of the proposed ism of rFVIIIFc regulatory T-cell differentiation. is an illustration of the proposed effects of rFIXFc on macrophages.

DETAILED DESCRIPTION The present disclosure provides methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human an effective amount of a chimeric protein comprising a ng factor and an Fc region or a composition comprising a clotting factor and an Fc region, wherein the human has developed an inhibitor against the clotting factor and has failed to respond to one or more previous immune tolerance therapy against the clotting factor. In some embodiments, the clotting factor is ed from the group consisting of factor VII (FVII), factor VIIa (FVIIa), FVIII, FIX, factor X (FX), von Willebrand factor (VWF), and any combination thereof. _ 23 _ 1. DEFINITIONS It is to be noted that the term "a" or "an" entity refers to one or more of that entity; for e, "a nucleotide ce," is understood to represent one or more tide ces. As such, the terms "a" (or "an"), "one or more," and "at least one" can be used interchangeably herein.

Furthermore, "and/or" where used herein is to be taken as specific sure of each of the two specified features or components with or without the other. Thus, the term "and/or" as used in a phrase such as "A and/or B" herein is intended to include "A and B," "A or B," "A" (alone), and "B" (alone). Likewise, the term "and/or" as used in a phrase such as "A, B, and/or C" is intended to encompass each of the following aspects: A, B, and C, A, B, or C, A or C, A or B, B or C, A and C, A and B, B and C, A (alone), B (alone), and C (alone).

It is tood that wherever s are described herein with the language "comprising," otherwise analogous aspects described in terms of "consisting of' and/or "consisting essentially of" are also provided.

Unless defined otherwise, all technical and scientific terms used herein have the same g as commonly understood by one of ordinary skill in the art to which this disclosure is related. For example, the Concise Dictionary of Biomedicine and Molecular Biology, Juo, Pei-Show, 2nd ed., 2002, CRC Press, The Dictionary of Cell and Molecular Biology, 3rd ed., 1999, Academic Press, and the Oxford Dictionary Of Biochemistry And Molecular Biology, Revised, 2000, Oxford sity Press, provide one of skill with a general dictionary of many of the terms used in this disclosure.

Units, prefixes, and symbols are denoted in their Systeme International de Unites (SI) ed form. Numeric ranges are inclusive of the numbers defining the range. Unless otherwise indicated, amino acid sequences are written left to right in amino to carboxy orientation. The headings provided herein are not limitations of the various s of the disclosure, which can be had by reference to the specification as a whole. Accordingly, the terms defined immediately below are more fully defined by reference to the specification in its entirety.

The term " is used herein to mean approximately, roughly, around, or in the regions of. When the term "about" is used in conjunction with a numerical range, it modifies that range by extending the boundaries above and below the numerical values set forth. Thus, "about 10-20" means "about 10 to about 20." In general, the term "about" can modify a _ 24 _ numerical value above and below the stated value by a variance of, e. g., 10 percent, up or down r or lower).

"Administering," as used herein, means to give a pharmaceutically acceptable composition, e. g., comprising a chimeric protein, disclosed herein to a subject via a pharmaceutically acceptable route. Routes of administration can be intravenous, e. g., intravenous ion and intravenous infusion. Additional routes of administration include, e. g., subcutaneous, intramuscular, oral, nasal, and pulmonary administration. Chimeric protein and hybrid proteins can be administered as part of a pharmaceutical ition comprising at least one excipient. In some embodiments, the clotting factor and/or Fc, e. g., the chimeric protein, are administered to a human through a gene therapy, e. g., wherein one or more polynucleotides encoding the clotting factor and/or Fc, e.g., the chimeric protein, are administered to the human, and the ng factor and/or Fc, e.g., the chimeric n, is expressed in the human.

"Treat," "treatment," or "treating," as used herein refers to, e.g., the ion in severity of a disease or condition, the reduction in the duration of a ion course, the amelioration or elimination of one or more symptoms associated with a disease or condition, the provision of cial effects to a subject with a disease or condition, without necessarily curing the e or condition. In some ments, the term "treat" or "treating" means reducing or eliminating an inhibitory immune response to a ng factor, e.g., FVIII.

The term "induce immune tolerance," as used herein, means to elicit in a subject a condition by which the subject does not have an immune response when administered a particular stimulus, e.g., administration of a clotting factor (e.g., FVIII). This condition, immune tolerance, can be temporary, such that the subject is tolerant to the us for a definite period of time, or prolonged, such that the subject is tolerant to the stimulus indef1nitely. In certain embodiments, the subject remains tolerant to the stimulus so long as the stimulus is administered to the subject. For example, in some embodiments, the subject s tolerant to the clotting factor so long as the chimeric protein comprising the clotting factor and an Fc region is administered to the subject at a given dosing al. In other embodiments, the subject remains tolerant to the clotting factor even after administration of the chimeric n comprising the clotting factor and an Fc region is terminated.

In some ments, the immune response is an "inhibitory" immune response. An inhibitory immune response is an immune response that blocks or diminishes the effects of _ 25 _ the stimulus, e.g., stration of a clotting factor (e.g., FVIII). In certain embodiments, the inhibitory immune response comprises the production of inhibitory antibodies against the stimulus, e. g., inhibitory anti-FVIII antibodies. The term "inhibitory antibody" or "inhibitory dies," as used , refers to antibodies that block or diminish the on of the antigen recognized by the antibody. For example, an inhibitory antibody against FVIII blocks or diminishes the activity of FVIII. In some embodiments, the inhibitory antibody binds the antigen, e. g., the FVIII, and accelerates the clearance of the antigen from the serum of the human. When the antibody accelerates the clearance of the antigen, the antibody reduces the half-life of the antigen.

Inhibitory immune ses can be determined using laboratory tests such as the Bethesda test or the Nijmegan modification of the Bethesda test. A level of at least 0.6 Bethesda Units (BU) can indicate the presence of an inhibitory immune response. A level of at least 5 BU can indicate the presence of a high titer inhibitor. ements of the in vivo recovery and half-life of bolus clotting factor infusion can also be used. In certain embodiments, immune tolerance is observed when the titer of the tory antibodies in the human is less than about 5 BU, less than about 4 BU, less than about 3 BU, less than about 2 BU, less than about 1 BU, less than about 0.9 BU, less than about 0.8 BU, less than about 0.7 BU, less than about 0.6 BU, less than about 0.5 BU, less than about 0.4 BU, less than about 0.3 BU, less than about 0.2 BU, less than about 0.1 BU, or about 0 BU. In one particular embodiment, immune nce is ed when the titer of the inhibitory antibodies in the human is less than about 0.6 BU.

In other embodiments, the immune response comprises a cell-mediated immune response. In some embodiments, the cell-mediated immune response comprises the release of a ne. In certain embodiments, the nes released as part of a cell-mediated immune response can be selected from the group consisting of IL-12, IL-4, IL-l7, TNF-oc, and any combination thereof.

] In other embodiments, the immune response comprises a clinical symptom selected from the group consisting of: increased bleeding tendency, high clotting factor consumption, lack of response to clotting factor therapy, decreased efficacy of clotting factor therapy, shortened half-life of the clotting factor, and any ation thereof.

In other embodiments, immune tolerance is measured by an increase in the half-life of the ng factor following administration to the human. In some embodiments, immune _ 26 _ tolerance is induced once the half-life of the clotting factor is increased by at least about 10%, at least about 15%, at least about 20%, at least about 25%, at least about 30%, at least about %, at least about 40%, at least about 45%, at least about 50%, at least about 75%, at least about 100%, at least about 150%, at least about 200%, at least about 300%, at least about 400%, at least about 500%, or at least about 1000% as ed to the half-life of the clotting factor administered to the human before immune tolerance induction. In certain embodiments, the half-life of the clotting factor is at least about 3 hours, at least about 4 hours, at least about 5 hours, at least about 6 hours, at least about 7 hours, at least about 8 hours, at least about 9 hours, at least about 10 hours, at least about 11 hours, at least about 12 hours, at least about 13 hours, at least about 14 hours, or at least about 15 hours following immune nce induction.

The term "comparable" as used herein means a compared rate or level ed from using, e. g., the chimeric protein is equal to, ntially equal to, or similar to the reference rate or level. The term "similar" as used herein means a compared rate or level has a difference of no more than 10% or no more than 15% from the reference rate or level (e.g., FXa generation rate by a chimeric protein consisting essentially of or consisting of two Fc portions and processed FVIII, wherein the processed FVIII is fused to one Fc of the two Fc portions). The term "substantially equal" means a compared rate or level has a difference of no more than 0.01%, 0.5% or 1% from the nce rate or level.

Hemostatic disorder, as used herein, means a genetically inherited or acquired condition characterized by a tendency to hemorrhage, either spontaneously or as a result of trauma, due to an impaired y or inability to form a fibrin clot. Examples of such ers include the hemophilias. The three main forms are hemophilia A (Factor VIII deficiency), hemophilia B (Factor IX deficiency or tmas disease") and hemophilia C r XI deficiency, mild bleeding tendency). Other hemostatic disorders include, e.g., Von Willebrand disease, Factor XI deficiency (PTA ncy), Factor XII deficiency, deficiencies or structural abnormalities in fibrinogen, prothrombin, Factor V, Factor VII, Factor X or Factor XIII, Bernard-Soulier syndrome, which is a defect or deficiency in GPIb.

GPIb, the receptor for VWF, can be defective and lead to lack of y clot formation (primary hemostasis) and increased bleeding tendency), and thrombasthenia of Glanzman and Naegeli (Glanzmann thrombasthenia). In liver failure (acute and chronic forms), there is insufficient production of coagulation factors by the liver, this may increase bleeding risk. _ 27 _ ] "Area under the plasma concentration versus time curve (AUC)," as used herein, is the same as the term of art in pharmacology, and is based upon the rate and extent of absorption of FVIII following administration. AUC is determined over a ed time , such as 12, 18, 24, 36, 48, or 72 hours, or for y using extrapolation based on the slope of the curve. Unless otherwise specified herein, AUC is ined for infinity. The determination of AUC can be carried out in a single t, or in a population of subjects for which the average is calculated.

The term agulant activity" is meant the ability of the coagulation factor, e.g., a FVIII, of the invention to participate in the clotting cascade in blood, substituting for the native coagulation factor, e.g., native FVIII. Several assays are available for measuring Factor VIII activity, including the one stage clotting assay (activated partial thromboplastin time, aPTT), thrombin generation time (TGA) and rotational thromboelastometry (ROTEM®).

References made to amino acid numbering of immunoglobulins or globulin fragments, or regions, are all based on Kabat el al. 1991, Sequences of Proteins of Immunological Interest, U. S. Department of Public Health, Bethesda, MD, incorporated herein by reference in its entirety. (The FcRn or has been isolated from several mammalian species including humans. The sequences of the human FcRn, rat FcRn, and mouse FcRn are known (Story el al., J. Exp. Med. 180: 2377 (1994), incorporated herein by reference in its entirety.) An Fc can comprise the CH2 and CH3 domains of an immunoglobulin with or without the hinge region of the immunoglobulin. Exemplary Fc variants are ed in reference in its ty.

"Hybrid" polypeptides and proteins, as used herein, means a combination of a chimeric protein with a second polypeptide. The ic protein and the second polypeptide in a hybrid can be associated with each other via n-protein interactions, such as charge- charge or hydrophobic interactions. The chimeric protein and the second polypeptide in a hybrid can be associated with each other via disulfide or other covalent bond(s). Hybrids are described in by reference in its entirety. See also US. Patent Nos. 7,404,956 and 7,348,004, each of which is incorporated herein by reference in its entirety. The second polypeptide can be a second copy of the same chimeric protein or it can be a non-identical chimeric protein. _ 28 _ As used herein, an "amino acid corresponding to, site corresponding to," or "equivalent amino acid" in a protein sequence is identified by ent to maximize the identity or similarity between a first protein sequence, e.g., a FVIII sequence, and a second protein sequence, e. g., a second FVIII sequence. The number used to identify an equivalent amino acid in a second protein sequence is based on the number used to identify the corresponding amino acid in the first protein sequence.

] As used herein, the term tion site" refers to an amino acid e number in a polypeptide (typically a mature polypeptide, e. g., a mature FVIII polypeptide), or fragment, variant, or derivative thereof, which is immediately upstream of the position at which a heterologous moiety can be ed. An "insertion site" is ied as a number, the number being the number of the amino acid specif1ed protein sequence to which the insertion site corresponds, which is immediately N—terminal to the position of the insertion. For example, the phrase "the FVIII comprises heterologous moiety at an insertion site which corresponds to amino acid 745 of" a given sequence indicates that the heterologous moiety is located between two amino acids corresponding to amino acid 745 and amino acid 746 of the sequence. However, one of skill in the art would readily be able to identify a corresponding position in any variant of the indicated protein, and the present disclosure is not limited to insertions made solely in the variants specif1cally disclosed herein. Rather, the insertions disclosed herein can be made in any d variants or fragments thereof having ty at a position corresponding to a position of the variants disclosed herein.

The phrase "immediately downstream of an amino acid" as used herein refers to position right next to the terminal carboxyl group of the amino acid. Similarly, the phrase "immediately am of an amino acid" refers to the position right next to the terminal amine group of the amino acid. Therefore, the phrase "between two amino acids of an insertion site" as used herein refers to a on in which a heterologous moiety (e.g., a half- life extending moiety) is inserted between two nt amino acids.

The terms "inserted," "is inserted," "inserted into," or grammatically related terms, as used herein refers to the position of a heterologous moiety (e.g., a half-life extending moiety) in a fusion polypeptide relative to the analogous position in specified protein (e. g., a FVIII protein). Those of skill in the field will tand how to fy corresponding insertion positions with respect to other polypeptide sequences, e. g., other FVIII variants. As used herein the terms refer to the characteristics of the inant ptide disclosed herein, _ 29 _ and do not indicate, imply or infer any methods or process by which the fusion polypeptide was made. For e, in reference to a fusion polypeptide provided , the phrase "a heterologous moiety is inserted immediately downstream of residue 745 of the FVIII polypeptide" means that the fusion ptide comprises a heterologous moiety immediately downstream of an amino acid which ponds to amino acid 745 in a particular FVIII variant, e. g., bounded by amino acids corresponding to amino acids 745 and 746 of the FVIII variant.

A "fusion" or ric" protein comprises a first amino acid sequence linked to a second amino acid sequence with which it is not naturally linked in nature. The amino acid sequences which normally exist in separate proteins can be t er in the fusion polypeptide, or the amino acid sequences which ly exist in the same protein can be placed in a new arrangement in the fusion polypeptide, e.g., fusion of a FVIII domain of the invention with an Ig Fc domain. A fusion protein is created, for example, by chemical synthesis, or by creating and translating a polynucleotide in which the peptide s are encoded in the desired relationship. A fusion protein can further comprise a second amino acid sequence associated with the first amino acid sequence by a covalent, non-peptide bond or a non-covalent bond.

The terms "heterologous" and "heterologous moiety" mean that a cleotide, polypeptide, or other moiety is derived from a distinct entity from that of the entity to which it is being compared. For instance, a heterologous polypeptide can be synthetic, or derived from a different species, ent cell type of an individual, or the same or different type of cell of distinct individuals. In one aspect, a logous moiety is a polypeptide fused to another polypeptide to produce a fusion polypeptide or protein. In another aspect, a heterologous moiety is a non-polypeptide such as PEG conjugated to a polypeptide or protein.

The terms "linked" and " as used herein refers to a first amino acid sequence or nucleotide sequence covalently or non-covalently joined to a second amino acid sequence or nucleotide sequence, respectively. The first amino acid or nucleotide sequence can be directly joined or juxtaposed to the second amino acid or nucleotide sequence or alternatively an intervening sequence can covalently join the first sequence to the second sequence. The term "linked" means not only a fusion of a first amino acid sequence to a second amino acid ce at the C-terminus or the N—terminus, but also includes insertion of the whole first amino acid sequence (or the second amino acid sequence) into any two amino acids in the second amino acid sequence (or the first amino acid sequence, respectively). In one embodiment, the first amino acid ce is linked to a second amino acid sequence by a peptide bond or a linker. The first nucleotide sequence can be linked to a second nucleotide sequence by a phosphodiester bond or a linker. The linker can be a peptide or a polypeptide (for polypeptide chains) or a nucleotide or a nucleotide chain (for nucleotide chains) or any chemical moiety (for both polypeptide and cleotide chains). The term "linked" is also indicated by a hyphen (-).

As used herein the term "associated with" refers to a covalent or non-covalent bond formed between a first amino acid chain and a second amino acid chain. In one embodiment, the term "associated with" means a covalent, non-peptide bond or a non-covalent bond. This association can be ted by a colon, 1'.e., (:). In another embodiment, it means a covalent bond except a peptide bond. For example, the amino acid cysteine comprises a thiol group that can form a disulfide bond or bridge with a thiol group on a second cysteine residue. In most naturally occurring IgG molecules, the CH1 and CL regions are associated by a disulfide bond and the two heavy chains are associated by two de bonds at positions corresponding to 239 and 242 using the Kabat numbering system (position 226 or 229, EU numbering ). Examples of covalent bonds include, but are not limited to, a peptide bond, a metal bond, a hydrogen bond, a disulfide bond, a sigma bond, a pi bond, a delta bond, a glycosidic bond, an ic bond, a bent bond, a dipolar bond, a Pi backbond, a double bond, a triple bond, a ple bond, a quintuple bond, a sextuple bond, conjugation, hyperconjugation, icity, ity, or antibonding. Non-limiting examples of noncovalent bond include an ionic bond (e. g., cation-pi bond or salt bond), a metal bond, an hydrogen bond (e.g., dihydrogen bond, dihydrogen complex, low-barrier hydrogen bond, or symmetric hydrogen bond), van der Walls force, London dispersion force, a mechanical bond, a halogen bond, aurophilicity, intercalation, stacking, entropic force, or chemical polarity.

As used , the term "cleavage site" or "enzymatic cleavage site" refers to a site recognized by an enzyme. Certain enzymatic cleavage sites comprise an intracellular processing site. In one ment, a polypeptide has an enzymatic cleavage site cleaved by an enzyme that is ted during the clotting cascade, such that cleavage of such sites _ 31 _ occurs at the site of clot ion. Exemplary such sites include, e.g., those recognized by thrombin, Factor XIa or Factor Xa. Other enzymatic cleavage sites are known in the art.

] As used , the term "processing site" or "intracellular processing site" refers to a type of enzymatic cleavage site in a polypeptide which is a target for enzymes that function after translation of the polypeptide. In one embodiment, such enzymes function during transport from the Golgi lumen to the trans-Golgi compartment. Intracellular processing enzymes cleave polypeptides prior to secretion of the protein from the cell. Examples of such processing sites include, e. g., those targeted by the PACE/furin (where PACE is an acronym for Paired basic Amino acid Cleaving ) family of endopeptidases. These enzymes are localized to the Golgi membrane and cleave ns on the carboxyterminal side of the sequence motif Arg-[any e]-(Lys or Arg)-Arg. As used herein the "furin" family of enzymes includes, e.g., PCSKl (also known as PCl/PC3), PCSK2 (also known as PC2), PCSK3 (also known as furin or PACE), PCSK4 (also known as PC4), PCSKS (also known as PC5 or PC6), PCSK6 (also known as PACE4), or PCSK7 (also known as PC7/LPC, PC8, or SPC7).

Other processing sites are known in the art.

In constructs that e more than one processing or cleavage site, it will be understood that such sites may be the same or different.

A "processable linker" as used herein refers to a linker comprising at least one intracellular processing site, which is described elsewhere herein.

"Baseline," as used herein, is the lowest ed plasma level of a given analyte, e. g., a clotting factor (e. g., FVIII) or an antibody (e.g., an anti-FVIII antibody), in a subject prior to administering a dose. The plasma levels can be measured at two time points prior to dosing: at a screening visit and immediately prior to dosing.

"Equivalent dose," as used herein, means the same dose of clotting factor ty, e. g., FVIII activity, as expressed in International Units, which is independent of lar weight of the polypeptide in on. For example, one International Unit (IU) of FVIII activity corresponds approximately to the ty of FVIII in one milliliter of normal human plasma. Several assays are available for measuring clotting factor activity, including the European Pharmacopoeia chromogenic substrate assay and a one stage clotting assay.

"Dosing interval," as used herein, means the dose of time that s between multiple doses being administered to a subject. The comparison of dosing interval can be _ 3 2 _ carried out in a single t or in a population of subjects and then the average obtained in the population can be ated. ct," as used herein means a human dual. Subject can be a patient who is currently suffering from a bleeding disorder or is expected to be in need of such a ent.

In some embodiments, the subject has never been previously treated with the clotting factor (i.e., the subject is a previously untreated subject or previously untreated patient). In some embodiments, the subject is a fetus and the methods comprise administering the composition or the chimeric protein to the mother of the fetus and the administration to the subject occurs from the mother across the placenta. In some embodiments, the subject is a child or an adult.

In some embodiments, the subject is a child less than one-year-old, less than two-year-old, less than three-year-old, less than four-year-old, less than f1ve-year-old, less than siX-year- old, less than seven-year-old, less than eight-year-old, less than nine-year-old, less than ten- year-old, less than eleven-year-old, or less than twelve-year-old. In some embodiments, the child is less than one-year old. In some embodiments, the child or adult subject develops a bleeding disorder, wherein the onset of the symptoms of the bleeding disorder is after the one-year-old age. In some embodiments, the administration of the composition or the chimeric protein to the subject is sufficient to prevent, inhibit, or reduce development of an immune response selected from a humoral immune response, a cell-mediated immune response, or both a humoral immune response and a cell-mediated immune response against the clotting factor. In some embodiments, the t is a human, and the subject has previously developed an immune response to a clotting factor. In some embodiments, the human previously failed to d to an immune tolerance therapy. In some embodiments, the previous immune tolerance therapy comprises administration of a high dose of a clotting factor. In other embodiments, the us immune tolerance y comprises administration of one or more immunosuppressant. In one ment, the previous immune tolerance y was a Malmo Regimen. In another embodiment, the previous immune tolerance therapy was a Bonn Protocol.

A "therapeutic dose," "dose," "effective dose," or "dosing amount" as used changeably) herein, means a dose that achieves a therapeutic goal, as described herein.

In some embodiments, a "therapeutic dose" means a dose that s an immune nce in a subject. In certain embodiments, a "therapeutic dose" means a dose that induces an _ 33 _ immune nce in a subject within a specified time to tolerance period, e.g., within 12 weeks of administration of the first dose.

Also included in the present invention are fragments or variants of polypeptides, and any combination f. The term "fragment" or nt" when referring to polypeptides used in the methods of the present disclosure include any polypeptides which retain at least some of the properties (e.g., FcRn binding affinity for an FcRn binding domain or Fc t, or ation activity for a FVIII) of the reference ptide. Fragments of polypeptides include lytic fragments, as well as deletion fragments, in addition to specific dy fragments discussed elsewhere herein, but do not include the lly occurring full-length polypeptide (or mature polypeptide). Variants of polypeptide binding domains or binding molecules used in the methods of the present disclosure include fragments as described above, and also polypeptides with altered amino acid sequences due to amino acid substitutions, deletions, or insertions. Variants can be naturally or turally occurring.

Non-naturally occurring variants can be ed using own mutagenesis techniques.

Variant polypeptides can comprise conservative or non-conservative amino acid substitutions, deletions or additions.

A "conservative amino acid substitution" is one in which the amino acid residue is replaced with an amino acid residue having a similar side chain. Families of amino acid residues having similar side chains have been defined in the art, including basic side chains (e.g., lysine, arginine, histidine), acidic side chains (e. g., aspartic acid, glutamic acid), uncharged polar side chains (e. g., glycine, asparagine, glutamine, , threonine, tyrosine, cysteine), nonpolar side chains (e. g., alanine, valine, leucine, isoleucine, proline, phenylalanine, methionine, tryptophan), beta-branched side chains (e.g., threonine, valine, isoleucine) and aromatic side chains (e.g., tyrosine, phenylalanine, tryptophan, histidine).

Thus, if an amino acid in a polypeptide is replaced with another amino acid from the same side chain family, the substitution is considered to be conservative. In another embodiment, a string of amino acids can be conservatively replaced with a structurally similar string that differs in order and/or composition of side chain family members.

The term "percent sequence identity" n two polynucleotide or polypeptide sequences refers to the number of identical d positions shared by the sequences over a comparison window, taking into account additions or deletions (1'.e., gaps) that must be introduced for optimal ent of the two sequences. A matched position is any position _ 34 _ where an identical nucleotide or amino acid is presented in both the target and reference sequence. Gaps presented in the target sequence are not counted since gaps are not nucleotides or amino acids. Likewise, gaps presented in the reference sequence are not counted since target sequence nucleotides or amino acids are counted, not nucleotides or amino acids from the reference sequence.

The percentage of sequence identity is calculated by determining the number of positions at which the identical acid e or nucleic acid base occurs in both sequences to yield the number of matched positions, dividing the number of matched ons by the total number of positions in the window of ison and multiplying the result by 100 to yield the percentage of sequence identity. The comparison of sequences and determination of t sequence identity between two sequences may be lished using readily available software both for online use and for download. Suitable software programs are available from various sources, and for ent of both protein and nucleotide sequences. One suitable program to determine percent sequence identity is b12seq, part of the BLAST suite of programs available from the US. government's National Center for Biotechnology Information BLAST web site (blast.ncbi.nlm.nih.gov). B12seq performs a comparison between two sequences using either the BLASTN or BLASTP algorithm.

BLASTN is used to e nucleic acid sequences, while BLASTP is used to e amino acid sequences. Other suitable programs are, e.g., , Stretcher, Water, or Matcher, part of the ElVfl30SS suite of bioinformatics programs and also available from the European Bioinformatics ute (EBI) at www.ebi.ac.uk/Tools/psa.

Different regions within a single polynucleotide or ptide target ce that aligns with a polynucleotide or polypeptide reference sequence can each have their own percent sequence identity. It is noted that the percent sequence ty value is rounded to the nearest tenth. For example, 80.11, 80.12, 80.13, and 80.14 are rounded down to 80.1, while 80.15, 80.16, 80.17, 80.18, and 80.19 are rounded up to 80.2. It also is noted that the length value will always be an integer.

One skilled in the art will appreciate that the generation of a sequence alignment for the calculation of a percent sequence identity is not limited to binary sequence-sequence comparisons exclusively driven by primary sequence data. Sequence alignments can be derived from multiple sequence alignments. One suitable program to te multiple ce alignments is ClustalW2, available from www.clustal.org. Another suitable _ 35 _ program is MUSCLE, available from ive5.com/muscle/. ClustalW2 and MUSCLE are alternatively available, e.g., from the EBI.

It will also be appreciated that sequence alignments can be generated by integrating sequence data with data from heterogeneous sources such as structural data (e. g., crystallographic protein structures), functional data (e.g., location of mutations), or phylogenetic data. A suitable m that integrates heterogeneous data to generate a multiple sequence alignment is T-Coffee, available at www.tcoffee.org, and alternatively available, e.g., from the EBI. It will also be appreciated that the final alignment used to calculate percent sequence identity may be curated either automatically or manually.

The polynucleotide variants can contain alterations in the coding regions, non-coding regions, or both. In one ment, the polynucleotide variants contain alterations which produce silent substitutions, additions, or ons, but do not alter the properties or activities of the encoded polypeptide. In another embodiment, tide variants are produced by silent substitutions due to the degeneracy of the genetic code. In other embodiments, variants in which 5-10, 1-5, or 1-2 amino acids are substituted, deleted, or added in any combination.

Polynucleotide variants can be produced for a variety of reasons, e.g., to optimize codon expression for a particular host (change codons in the human mRNA to others, e.g., a bacterial host such as E. coll).

Naturally ing ts are called "allelic variants," and refer to one of several alternate forms of a gene occupying a given locus on a some of an organism (Genes II, Lewin, B., ed., John Wiley & Sons, New York (1985)). These allelic variants can vary at either the polynucleotide and/or polypeptide level and are included in the present disclosure.

Alternatively, non-naturally ing variants can be produced by mutagenesis techniques or by direct synthesis.

Using known methods of n engineering and recombinant DNA logy, variants can be generated to improve or alter the characteristics of the polypeptides. For instance, one or more amino acids can be deleted from the inus or C-terminus of the ed protein t substantial loss of biological function. Ron el al., J. Biol. Chem. 268: 2984-2988 (1993), incorporated herein by reference in its entirety, reported variant KGF proteins having heparin binding activity even after deleting 3, 8, or 27 amino-terminal amino acid es. Similarly, Interferon gamma eXhibited up to ten times higher activity after deleting 8-10 amino acid residues from the carboxy terminus of this protein. i el al, J.

Biotechnology 7: 199-216 (1988), incorporated herein by reference in its entirety.) Moreover, ample evidence demonstrates that variants often retain a biological activity similar to that of the naturally occurring protein. For e, Gayle and coworkers (J. Biol.

Chem 268:22105-22111 (1993), incorporated herein by reference in its entirety) conducted ive mutational analysis of human cytokine IL-1a. They used random mutagenesis to generate over 3,500 individual IL-la mutants that averaged 2.5 amino acid changes per variant over the entire length of the molecule. Multiple mutations were examined at every possible amino acid position. The investigators found that "[m]ost of the molecule could be altered with little effect on either [binding or biological activity]." (See Abstract.) In fact, only 23 unique amino acid sequences, out of more than 3,500 nucleotide sequences examined, produced a protein that significantly differed in activity from wild-type.

] As stated above, polypeptide variants e, e. g., modified polypeptides.

Modif1cations include, e.g., ation, acylation, bosylation, ion, covalent attachment of flavin, covalent attachment of a heme moiety, covalent attachment of a nucleotide or nucleotide derivative, covalent attachment of a lipid or lipid derivative, covalent ment of phosphotidylinositol, cross-linking, cyclization, disulfide bond formation, ylation, formation of covalent cross-links, formation of cysteine, formation of pyroglutamate, formylation, gamma-carboxylation, ylation, GPI anchor formation, hydroxylation, tion, methylation, myristoylation, oxidation, tion (Mei el al, Blood [163270-79 (2010), which is incorporated herein by reference in its entirety), proteolytic sing, phosphorylation, prenylation, racemization, selenoylation, sulfation, transfer-RNA mediated addition of amino acids to proteins such as arginylation, and ubiquitination. In some embodiments, FVIII is d, e. g., pegylated, at any convenient location. In some embodiments, FVIII is pegylated at a surface exposed amino acid of FVIII, e. g., a surface d cysteine, which can be an engineered cysteine. Id. In some embodiments, modified FVIII, e.g., pegylated FVIII, is a chimeric or fusion FVIII.

The term "downstream" refers to a nucleotide ce that is located 3' to a reference nucleotide sequence. "Downstream" can also refer to a peptide sequence that is located C- terminal to a reference peptide sequence.

The term "upstream" refers to a tide sequence that is located 5' to a reference nucleotide sequence. "Upstream" can also refer to a peptide sequence that is located N- terminal to a reference peptide ce.

As used herein, the term "regulatory region" refers to nucleotide sequences located upstream (5' non-coding ces), within, or downstream (3' non-coding sequences) of a coding region, and which influence the transcription, RNA processing, stability, or translation of the associated coding region. tory regions may include promoters, translation leader sequences, introns, polyadenylation recognition ces, RNA processing sites, effector binding sites and stem-loop structures. If a coding region is ed for expression in a eukaryotic cell, a polyadenylation signal and transcription termination ce will usually be located 3' to the coding sequence.

A polynucleotide, which encodes a gene product, e.g., a polypeptide, can include a promoter and/or other transcription or translation control elements operably associated with one or more coding s. Other transcription control elements, besides a promoter, for example enhancers, operators, repressors, and transcription termination signals, can also be operably associated with a coding region to direct gene product expression.

A variety of transcription control regions are known to those skilled in the art. These include, without limitation, transcription control regions, which function in vertebrate cells, such as, but not limited to, promoter and enhancer segments from galoviruses (the immediate early promoter, in conjunction with intron-A), simian virus 40 (the early promoter), and retroviruses (such as Rous sarcoma . Other ription control regions include those derived from vertebrate genes such as actin, heat shock protein, bovine growth hormone and rabbit B-globin, as well as other sequences capable of controlling gene expression in eukaryotic cells. onal suitable ription control regions include tissue-specific promoters and enhancers as well as lymphokine-inducible ers (e.g., promoters ble by interferons or interleukins).

Similarly, a variety of translation control elements are known to those of ordinary skill in the art. These include, but are not limited to ribosome binding sites, translation initiation and termination codons, and elements derived from picomaviruses (particularly an al ribosome entry site, or IRES, also referred to as a CITE sequence).

The term "expression" as used herein refers to a s by which a polynucleotide produces a gene product, for example, an RNA or a polypeptide.

A "vector" refers to any vehicle for the g of and/or transfer of a nucleic acid into a host cell. A vector may be a replicon to which another nucleic acid t may be ed so as to bring about the replication of the attached segment. A "replicon" refers to any genetic element (e.g., plasmid, phage, cosmid, chromosome, virus) that functions as an autonomous unit of replication in vivo, 1'. e., capable of replication under its own control. The tenn"veaoflindudesboflivnalandnonvnalvdndesfixinhodudngthenuden:addinK)a cell in vilro, ex vivo or in vivo. A large number of s are known and used in the art including, for example, plasmids, modified eukaryotic viruses, or modified ial viruses.

Insertion of a cleotide into a suitable vector can be accomplished by ligating the appropriate polynucleotide fragments into a chosen vector that has complementary cohesive termini.

The term "plasmid" refers to an extra-chromosomal element often carrying a gene that is not part of the central metabolism of the cell, and usually in the form of circular double- stranded DNA molecules. Such elements may be autonomously replicating sequences, genome integrating sequences, phage or nucleotide sequences, linear, circular, or supercoiled, of a - or double-stranded DNA or RNA, derived from any source, in which a number of nucleotide sequences have been joined or recombined into a unique construction which is capable of ucing a promoter fragment and DNA sequence for a selected gene product along with appropriate 3' untranslated sequence into a cell.

Eukaryotic viral vectors that can be used include, but are not limited to, adenovirus vectors, retrovirus vectors, associated virus vectors, and poxvirus, e.g., vaccinia virus vectors, baculovirus vectors, or herpesvirus vectors. Non-viral vectors include plasmids, mes, electrically charged lipids (cytofectins), DNA-protein complexes, and ymers.

A "cloning vector" refers to a "replicon," which is a unit length of a nucleic acid that replicates sequentially and which comprises an origin of replication, such as a d, phage or cosmid, to which another nucleic acid segment may be attached so as to bring about the replication of the attached segment. Certain cloning vectors are capable of replication in one cell type, e.g., bacteria and expression in another, e.g., eukaryotic cells. Cloning s typically comprise one or more sequences that can be used for selection of cells sing the vector and/or one or more multiple g sites for insertion of nucleic acid sequences of interest.

] The term "expression vector" refers to a vehicle designed to enable the expression of an inserted nucleic acid sequence following insertion into a host cell. The inserted nucleic acid sequence is placed in operable association with regulatory regions as described above.

Vectors are introduced into host cells by s well known in the art, e. g., transfection, electroporation, microinjection, uction, cell fusion, DEAE dextran, calcium phosphate precipitation, lipofection (lysosome fusion), use of a gene gun, or a DNA vector transporter.

An "isolated" polypeptide or a fragment, variant, or tive thereof refers to a polypeptide that is not in its natural . No particular level of purification is required. For example, an isolated polypeptide can simply be removed from its native or natural environment. Recombinantly produced polypeptides and proteins expressed in host cells are considered isolated for the purpose of the invention, as are native or recombinant polypeptides which have been separated, fractionated, or partially or substantially purified by any suitable technique.

As used herein, the term "host cell" refers to a cell or a tion of cells harboring or capable of harboring a recombinant nucleic acid. Host cells can be a prokaryotic cells (e.g., E. coli), or alternatively, the host cells can be eukaryotic, for example, fungal cells (e.g., yeast cells such as Saccharomyces cerevisiae, Pichia is, or saccharomyces pombe), and various animal cells, such as insect cells (e.g., Sf—9) or mammalian cells (e.g., HEK293F, CHO, COS- 7, NIH-3T3).

"Volume of distribution at steady state (Vss)," as used herein, has the same meaning as the term used in pharmacology, which is the apparent space (volume) into which a drug distributes. Vss = the amount of drug in the body divided by the plasma concentration at steady state. 11. METHODS OF THE INVENTION The t disclosure is based on the ery that a clotting factor fused to an Fc region can be used to induce immune tolerance in a human with hemophilia, wherein the human has ped an inhibitor against a clotting factor and has failed one or more previous immune tolerance ies. Though it was previously believed that treatment with a FVIII-Fc chimeric protein could prevent an immune response to the FVIII treatment, it was surprisingly discovered in the t disclosure that ent with a clotting factor-Fc _ 40 _ chimeric protein can reduce a previously developed immune response in a human that had not responded to previous immune tolerance therapies. Thus, the present disclosure provides methods for inducing immune tolerance in a human, comprising administering to the human an effective amount of a composition comprising a ng factor and an Fc or a chimeric protein comprising a clotting factor and an Fc region or a polynucleotide encoding the same.

Another aspect of the present disclosure is directed to a method of inducing immune tolerance in a human with hemophilia, comprising (1) administering to the human an effective amount of a ition comprising a clotting factor and an Fc or a chimeric protein comprising a clotting factor and an Fc region, wherein the effective amount of the composition or chimeric protein induces immune tolerance in the human, and (2) following induction of immune tolerance, administering to the human a tapering regimen of the ition or the chimeric chimeric protein. In certain embodiments, induction of immune tolerance occurs when the titer of the inhibitory antibodies in the human is less than about 0.6 BU. In certain embodiments, ion of immune tolerance occurs when the titer of the tory antibodies in the human is less than about 0.6 BU, and 60% recovery of clotting factor activity as monitored in plasma. In some embodiments of the present disclosure, the method further comprises (3) following the tapering regimen, administering to the human a prophylactic dose of the clotting factor. In certain aspects, the human has not been treated with a previous immune nce therapy against the clotting factor. The composition or the chimeric protein comprising a clotting factor and an Fc region can be stered to the human at any time it has been ined that the human has developed an inhibitor immune response, e.g., after measuring the level of an inhibitory immune response in the human. In other embodiments, the composition or the chimeric protein can be administered to the human who has not yet ped one or more inhibitor immune response to prevent development of an inhibitor immune se. In some embodiments, the composition or the chimeric protein is stered to the human who has a high likelihood (e.g., family history, genetic predisposition, or showing of a ker) of ping an tor immune response. In some embodiments, the method further ses measuring the level of an inhibitory immune response or the likelihood of developing an inhibitor immune response before the administration. In some embodiments, the composition or the chimeric protein comprising a clotting factor and an Fc region is administered to the human less than about 1 day, less than about 2 days, less than about 3 days, less than about 4 days, less than about 5 _ 41 _ days, less than about 6 days, less than about 7 days, less than about 2 weeks, less than about 3 weeks, less than about 4 weeks, less than about 2 months, less than about 3 months, less than about 4 , less than about 5 months, less than about 6 months, less than about 1 year, less than about 2 years, less than about 3 years, less than about 4 years, or less than about 5 years after it has been determined that the human has developed an inhibitor immune response or that the human has a likelihood of developing an inhibitor immune se, e.g., after measuring the level of an inhibitory immune response or the likelihood of developing an inhibitor immune response in the human. In certain embodiments, the composition or the ic protein sing a clotting factor and an Fc region is administered to the human immediately after it has been determined that the human has developed an inhibitor immune response or that the human has a likelihood of developing an inhibitor immune response, e.g., after measuring the level of an inhibitory immune response or the hood of developing an tor immune response in the human. In particular ments, the composition or the chimeric protein comprising a clotting factor and an Fc region is administered to the human less than about 5 minutes, less than about 10 s, less than about 15 minutes, less than about 20 minutes, less than about 30 minutes, less than about 45 minutes, less than about 1 hour, less than about 2 hours, less than about 3 hours, less than about 4 hours, less than about hours, less than about 6 hours, less than about 7 hours, less than about 8 hours, less than about 9 hours, less than about 10 hours, less than about 11 hours, less than about 12 hours, about 18 hours, or less than about 24 hours after it has been ined that the human has developed an inhibitor immune response or that the human has a likelihood of developing an inhibitor immune response, e. g., after measuring the level of an inhibitory immune response or the likelihood of developing an inhibitor immune response in the human. In particular embodiments, the composition or the chimeric protein comprising a clotting factor and an Fc region is administered to the human about 5 minutes, about 10 minutes, about 15 minutes, about 20 minutes, about 30 minutes, about 45 minutes, about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 18 hours, or about 24 hours after it has been determined that the human has developed an inhibitor immune response or that the human has a likelihood of developing an inhibitor immune response, e.g., after measuring the level of an inhibitory immune response or the likelihood of developing an inhibitor immune response in the human. In certain embodiments, the composition or the chimeric _ 42 _ protein comprising a clotting factor and an Fc region is administered to the human less than about 1 day after it has been determined that the human has developed an inhibitor immune response or that the human has a likelihood of developing an inhibitor immune response, e.g., after measuring the level of an tory immune response or the likelihood of developing an inhibitor immune response in the human.

Induction of an immune response can be continued until the level of inhibitor is lower than a certain level or until inhibitors are not detectable. In certain embodiments, the induction period can continue for at least about 24 weeks, at least about 26 weeks, at least about 28 weeks, at least about 30 weeks, at least about 32 weeks, at least about 34 weeks, at least about 36 weeks, at least about 38 weeks, at least about 40 weeks, at least about 42 weeks, at least about 44 weeks, at least about 46 weeks, at least about 48 weeks, at least about 50 weeks, at least about 52 weeks, at least about 54 weeks, at least about 56 weeks, at least about 58 weeks, at least about 60 weeks, at least about 62 weeks, at least about 64 weeks, at least about 66 weeks, at least about 68 weeks, at least about 70 weeks. In a particular embodiment, the induction period is less than 60 weeks.

The inhibitory immune response treated by the methods of the present invention can include any response within the human that negatively impacts one or more effects of a ng factor treatment. In some embodiments, the inhibitory immune se comprises production of inhibitory antibodies against the clotting factor, e. g., inhibitory anti-FVIII antibodies. In n embodiments, the method of the present disclosure further comprises measuring the titer of one or more inhibitory antibodies in the human before (e.g., at ne) and after administering an ive amount of a composition or a chimeric protein comprising a clotting factor and an Fc region or a polynucleotide encoding the same. In some ments, titer of the inhibitory antibodies prior to the administration (e.g., at baseline) is at least about 0.6 Bethesda Units (BU). In certain ments, the titer of the tory antibodies prior to the administration (e.g., at baseline) is at least about 1 BU, at least about 2 BU, at least about 3 BU, at least about 4 BU, at least about 5 BU, at least about 6 BU, at least about 7 BU, at least about 10 BU, at least about 20 BU, at least about 30 BU, at least about 40 BU, at least about 50 BU, at least about 100 BU, at least about 150 BU, or at least about 200 BU. In one particular ment, the titer of the inhibitory antibodies prior to the administration (e.g., at baseline) is at least about 5 BU. _ 43 _ In some embodiments, the methods of the present invention reduce the titer of inhibitory antibodies in a human subject relative to the titer of the inhibitory antibodies prior to the administration. In certain ments, the titer of the inhibitory antibodies after the administration is less than about 0.6 BU. In some embodiments, the titer of the inhibitory antibodies after the administration is less than about 0.5 BU, less than about 0.4 BU, less than about 0.3 BU, less than about 0.2 BU, or less than about 0.1 BU. In one particular embodiment, the titer of the inhibitory antibodies after the administration is 0 BU. In other embodiments, the titer of the inhibitory antibodies after the administration is less than 5 BU, less than 4 BU, less than 3 BU, less than 2 BU, less than 1 BU, less than 0.9 BU, less than 0.8 BU, less than 0.7 BU, or less than 0.6 BU.

In some embodiments, the administration increases the differentiation of hages in the human towards an M2-like phenotype, as compared to macrophage differentiation in untreated controls and humans treated with the ng factor alone. In some ments, the M2-like phenotype comprises upregulation of the NRF2 pathway, the PPAR gamma pathway, or both the NRF2 pathway and the PPAR gamma pathway. In some ments, the M2-like ype comprises upregulation of CD206 (MRCl). In some embodiments, the M2-like phenotype comprises upregulation of ARGl. In some embodiments, the e phenotype comprises upregulation of CD206 (MRCl) and ARGl.

] In some embodiments, the administration results in greater expression of one or more genes in the human, relative to the expression of the one or more genes in an untreated subject or in a subject treated with the clotting factor alone. In some embodiments, the administration results in r expression of one or more genes selected from the group consisting of Hmoxl, PPAR gamma, LPL, EGR2, SLCO4Al, heme oxygenase l (HO-l), oxidative stress induced growth inhibitor 1 (OSGINl), superoxide dismutase l (SODl), glutathione-disulf1de reductase (GSR), glutamate-cysteine ligase catalytic subunit (GCLC), glutamate-cysteine ligase er t (GCLM), NAD(P)H quinone dehydrogenase l (NQOl), fatty acid binding protein 5 (FABPS), B7-H3 (CD276), SLAM family member 3 (SLAMF3, cyte antigen 9, LY9), SLAM family member 7 (SLAMF7), mannose receptor C-type l (MRCl), solute carrier family 12 member 4 (SLCl2A), neuropilin l (NRPl), and any combination thereof. In some embodiments, the administration results in greater sion of one or more genes of the NRF2 pathway. In certain embodiments, the one or more genes of the NRF2 pathway are selected from the group consisting of HO-l, _ 44 _ OSGINl, SODl, GSR, GCLC, GCLM, NQOl, and any combination thereof. In some embodiments, the administration results in greater expression of one or more genes of the PPAR gamma pathway. In some embodiments, the one or more genes of the PPAR gamma pathway are selected from the group ting of PPAR gamma, LPL, FABP5, EGR2, and any combination thereof. In some embodiments, the administration results in greater expression of one or more genes selected from the group consisting of B7-H3 ), SLAMF3, SLAMF7, MRCl, SLC12A, NRPl, and any combination thereof. In particular embodiments, the administration s in greater expression of the one or more genes relative to the expression of the one or more genes in an untreated human or a human administered the clotting factor alone, wherein the expression is at least about 1.5 fold greater, at least about 2 fold greater, at least about 2.5 fold greater, at least about 3 fold greater, at least about 3.5 fold greater, at least about 4 fold greater, at least about 4.5 fold greater, or at least about 5 fold greater.

In some embodiments, the differential expression of the one or more genes is observed less than 6 hours after the administration. In some embodiments, the differential expression is observed less than 12 hours after administration. In some embodiments, the differential sion is observed less than 18 hours after administration. In some embodiments, the ential expression is observed less than 24 hours after administration.

] In some embodiments, the inhibitory immune response comprises a cell-mediated immune response. In certain embodiments, the cell-mediated immune response ses the release of a cytokine. In some embodiments, the ne is any cytokine associated with an increased immune response. In some embodiments, the cytokine selected from the group consisting of IL-1, IL-6, IL-16, IL-12, IL-4, IL-17, tumor necrosis factor 0L (TNF-d), interferon 0t, interferon y and any combination thereof. In one embodiment, the ediated immune response comprises increased serum levels of IL-12. In another embodiment, the cell-mediated immune response comprises increased serum levels of IL-4. In another embodiment, the cell-mediated immune response comprises increased serum levels of IL-17.

In another embodiment, the cell-mediated immune response comprises sed serum levels of TNF- 0L.

Various gene mutations have been linked with an increased risk of developing an inhibitory immune response. For e, the TNF-d -308G>A polymorphism within Hap2, which is associated with increased constitutive and ble transcription levels of TNF has _ 45 _ been linked with an increased risk of developing an inhibitory immune response. See Astermark el al., Blood 108: 3739-3745 (2006), which is herein incorporated by nce in its entirety. Thus, in some embodiments, the human has a genetic polymorphism associated with increased TNF-OL. In some embodiments, the polymorphism is the TNF-d -308G>A polymorphism. In some embodiments, the human has a polymorphism in an IIle gene, e.g. a polymorphism associated with increased secretion of IL10. In some embodiments, Fc is administered to a subject with the allele 134 of the ILlOG microsatellite in the promote region of the IL10 gene. See ark el al. Hemostatis, Thrombosis, and Vascular y 108: 3739-3745 (2006), which is herein incorporated by reference in its entirety.

In some embodiments, the human has a genetic polymorphism associated with decreased CTLA-4 (Cytotoxic T-Lymphocyte Antigen 4) expression. In some ments, the human has a mutation in DRlS (HLA-DRlS) or DQB0602 MHC (Major histocompatibility complex) Class II molecules. Other MHC Class II molecules associated with the development of an inhibitory immune response in subjects with ilia are A3, B7, C7, DQA0102, C2, DQA0103, 3, and DRl3 (see Inhibitors in Patients with Hemophilia, E.C. Rodriguez-Merchan & CA. Lee, Eds, Blackwell Science, Ltd,, 2002).

] In some embodiments, the methods of the present disclosure reduce the level of one or more cytokine in the subject compared to the level of the one or more cytokines in the subject after a previous treatment with a polypeptide consisting of a FVIII polypeptide. In another embodiment, the s of the present disclosure reduce the level of one or more cytokine in the subject compared to the level of the one or more cytokines in the subject prior to the stration. In other embodiments, the expression of one or more tolerogenic molecules is increased after the administration of the methods of the present disclosure relative to the expression level of the one or more tolerogenic molecules prior to the administration. In certain embodiments, the one or more tolerogenic molecules is selected from IL-10, TGF-B, IL-35, IDO-l, and any combination thereof.

In other embodiments, the immune response comprises a clinical symptom ed from the group consisting of: increased ng tendency, high clotting factor ption, lack of response to clotting factor therapy, sed efficacy of clotting factor therapy, shortened ife of the clotting factor, and any combination thereof. In certain embodiments, the immune se comprises a clinical symptom selected from the group consisting of: increased bleeding tendency, high clotting factor consumption, lack of response _ 46 _ to clotting factor therapy, decreased cy of clotting factor therapy, decreased recovery of clotting factor ty as monitored in the plasma, shortened half-life of the clotting factor, and any combination thereof.

In certain ments, the human was previously diagnosed as having an inhibitory immune response. Such a diagnosis can be made using any methods known in the art. For example, a human can be characterized as having an immune response to a ng factor, e. g., a FVIII, if the human has one or more the following: (a) a titer of inhibitory antibodies to the clotting factor greater than or equal to 0.6 BU, (b) increased serum levels of one or more cytokine selected from the group consisting of IL-12, IL-4, IL-17, and TNF-OL, (c) increased bleeding tendency, (d) high clotting factor ption, (e) a lack of response to clotting factor therapy, (f) decreased efficacy of ng factor therapy, (g) shortened ife of the clotting factor, and any combination thereof. In one particular embodiment, the human is characterized as having an immune response to a clotting factor if the human has a titer of inhibitory antibodies to the clotting factor greater than or equal to 0.6 BU.

In some embodiments, the human was previously diagnosed as having developed an inhibitory immune response to the clotting factor at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 , at least about 11 months, at least about 12 months, at least about 13 months, at least about 14 months, at least about 15 months, at least about 16 months, at least about 17 months, at least about 18 months, at least about 19 months, at least about 20 months, at least about 21 months, at least about 22 months, at least about 23 months, at least about 24 , at least about 27 months, at least about 30 months, at least about 33 months, at least about 36 months, at least about 39 months, at least about 42 months, at least about 45 months, at least about 48 years, at least about 51 months, at least about 54 months, at least about 57 months, at least about 60 , at least about 6 years, at least about 7 years, at least about 8 years, at least about 10 years, at least about 15 years, or at least about 20 years prior to the administration. In one embodiment, the human was previously diagnosed as having developed an inhibitory immune response to the clotting factor at least about 5 years prior to the administration.

In some embodiments, the s of the present disclosure provide an improved time to tolerance as compared to standard of care methods of ng immune tolerance. _ 47 _ The term "time to tolerance," as used herein refers to the amount of time between the administration of the first dose of the composition or the chimeric protein comprising a clotting factor and an Fc region and the pment of immune tolerance in the human.

Decreasing the time to tolerance can have significant benefits for the human, including but not limited to reducing the total al burden required to e tolerance. In some embodiments, the time to tolerance is about 1 to about 24 weeks, about 1 to about 23 weeks, about 1 to about 22 weeks, about 1 to about 21 weeks, about 2 to about 20 weeks, about 2 to about 19 weeks, about 2 to about 18 weeks, about 2 to about 17 weeks, about 3 to about 16 weeks, about 3 to about 15 weeks, about 3 to about 14 weeks, about 3 to about 13 weeks, about 4 to about 12 weeks, about 4 to about 11 weeks, about 4 to about 10 weeks, about 4 to about 9 weeks, about 5 to about 8 weeks, about 5 to about 7 weeks, about 5 to about 6 weeks, about 1 to about 12 weeks, about 1 to about 11 weeks, about 1 to about 10 weeks, about 1 to about 9 weeks, about 1 to about 8 weeks, about 1 to about 7 weeks, about 1 to about 6 weeks, about 1 to about 5 weeks, or about 1 to about 4 weeks. In some ments, the time to tolerance is less than about 70 weeks, less than about 65 weeks, less than about 60 weeks, less than about 58 weeks, less than about 56 weeks, less than about 54 weeks, less than about 52 weeks, less than about 50 weeks, less than about 48 weeks, less than about 46 weeks, less than about 44 weeks, less than about 42 weeks, less than about 40 weeks, less than about 38 weeks, less than about 36 weeks, less than about 34 weeks, less than about 32 weeks, less than about 30 weeks, less than about 28 weeks, less than about 26 weeks, less than about 24 weeks, less than about 23 weeks, less than about 22 weeks, less than about 21 weeks, less than about 20 weeks, less than about 19 weeks, less than about 18 weeks, less than about 17 weeks, less than about 16 weeks, less than about 15 weeks, less than about 14 weeks, less than about 13 weeks, less than about 12 weeks, less than about 11 weeks, less than about 10 weeks, less than about 9 weeks, less than about 8 weeks, less than about 7 weeks, less than about 6 weeks, less than about 5 weeks, less than about 4 weeks, less than about 3 weeks, less than about 2 weeks, or less than about 1 week. In certain embodiments, the time to tolerance is about 4 to about 12 weeks. In one embodiment, the time to tolerance is about 4 weeks. In another embodiment, the time to tolerance is about 12 weeks. In some embodiments, the time to tolerance is less than about 10 months. In some embodiments, the time to tolerance is less than about 9 months. In some embodiments, the time to tolerance is less than about 8 months.

In some embodiments, the time to tolerance is less than about 7 months. In some _ 48 _ ments, the time to tolerance is less than about 6 months. In some embodiments, the time to tolerance is less than about 5 months. In some embodiments, the time to tolerance is less than about 4 months. In some embodiments, the methods of the t disclosure result in a shorter time to tolerance in the human following treatment with a composition or the ic protein comprising a clotting factor and an Fc region as compared to the time to tolerance following treatment with the clotting factor alone.

] In some embodiments, development of immune tolerance is characterized by a titer of an inhibitory antibody to the clotting factor of less than about 0.6 BU. In some embodiments, development of immune nce is characterized by a titer of an inhibitory antibody to the clotting factor of than about 0.5 BU. In some embodiments, development of immune tolerance is characterized by a titer of an inhibitory antibody to the clotting factor of less than about 0.4 BU. In some embodiments, development of immune tolerance is characterized by a titer of an inhibitory antibody to the clotting factor of less than about 0.3 BU. In some embodiments, development of immune tolerance is characterized by a titer of an inhibitory antibody to the clotting factor of less than about 0.2 BU. In some embodiments, development of immune tolerance is characterized by a titer of an inhibitory antibody to the clotting factor of less than about 0.1 BU. In some embodiments, pment of immune nce is characterized by a titer of an inhibitory antibody to the clotting factor of 0.0 BU. In n embodiments, the titer of inhibitory immune antibodies is observed at two consecutive measurements, e.g., in two consecutive weeks within a four-week period.

In some embodiments, the development of immune tolerance is characterized by incremental recovery >66% (e.g., incremental ry of about 67%, about 68%, about 69%, about 70%, about 71%, about 72%, about 73%, about 74%, about 75%, about 76%, about 77%, about 78%, about 79%, about 80%, about 81%, about 82%, about 83%, about 84%, about 85%, about 86%, about 87%, about 88%, about 89%, about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 97%, about 98%, about 99%, or about 100%). As used herein, "incremental recovery" refers to peak FVIII levels 15 -30 s after infusion.

After the induction period and tapering period are completed, the subject can then be on lactic treatment of the ic protein. An exemplary prophylactic dosing regimen can be about 50 IU/kg of a chimeric protein every four days or about 25 IU/kg to about 65 IU/kg of a chimeric protein at three to five day intervals. For children less than 6 years of age, _ 49 _ about 50 IU/kg of a chimeric protein twice weekly or about 25 IU/kg to about 65 IU/kg of a chimeric protein at three to five day intervals can be given. See TE® Package Insert available at worldwideweb . eloctate. com/_assets/pdf/ELOCTATE_PI_January2O l 7.pdf.

In some embodiments, the human treated using the methods of the present disclosure is receiving or has recently ed an immunostimulatory therapy. For example, inhibitors have also been reported in HCV positive hemophilia A patients undergoing treatment with interferon as well as in HIV positive ilia A patients having an immune reconstitution inflammatory syndrome associated with anti-retroviral therapy. See Report of Expert Meeting on FVIII Products and Inhibitor Development, European Medicines Agency (February 28, 2006-March 2, 2006). Thus, in some embodiments, the human is receiving interferon therapy.

In some embodiments, the human is receiving anti-viral therapy. In some embodiments, the human is ing an anti-retroviral therapy and having an immune reconstitution inflammatory syndrome.

] In certain embodiments, the human has had less than 150 exposure days (ED) to the clotting factor, 6.g. FVIII. In one embodiment, the human has had less than 50 ED. In another embodiment, the human has had less than 20 ED.

Some aspects of the present disclosure are directed to methods of reducing the severity or occurance of an allergic or anaphylactic reaction to a clotting factor in a subject in need thereof, comprising administering to the subject a ition or a chimeric protein comprising the clotting factor and an Fc region. In some embodiments, the administration of the composition or the chimeric n reduces the severity of an anaphylactoid on to the ng factor. In some embodiments, the administration of the composition or the ic protein reduces the severity of an allergic reaction to the ng factor.

II.A. Chimeric Proteins The methods of inducing immune tolerance disclosed herein are generally applicable to compositions or chimeric proteins comprising a ng factor and an Fc , wherein the clotting factor can be any known clotting factor, fragment thereof, or variant thereof, and wherein the Fc region can be any known Fc region, fragment thereof, or variant thereof. In some embodiments, the ng factor is selected from the group consisting of factor VII (FVII), factor VIIa (FVIIa), factor VIII (FVIII), factor IX (FIX), factor X (FX), von _ 50 _ Willebrand factor (VWF), or any ation thereof. Accordingly, the present disclosures regarding FVIIIFc chimeric proteins, and their uses, are equally applicable to other chimeric proteins comprising a clotting factor portion and an Fc portion. Any clotting factor or any fragment thereof or any t thereof can be used in the methods of the present disclosure.

Similarly, any Fc or any fragment thereof or any variant thereof can be used in the methods of the present disclosure. In some specific examples, the ng factor portion of the chimeric n is FVIII.

In some embodiments, the clotting factor and the Fc are present on separate polypeptide chains. In some embodiments, the clotting factor and the Fc are not linked or associated with each other by a covalent bond.

In other embodiments, the clotting factor can be a clotting factor mimic. Clotting factor mimics can manifest one or more clotting factor activities. For example, an antibody or antibody binding portion f can act like FVIII by binding to both Factor IX and Factor X. Such antibodies or antigen binding portions thereof can be used for the present methods if the antibodies or antigen biding portions thereof ns an Fc . In another ment, the clotting factor is a peptide that has a FVIII activity.

In this respect, the t disclosure provides in general a method of inducing immune tolerance in a human comprising administering to the subject a composition or a chimeric protein comprises a clotting factor portion and an Fc portion.

II.A.1. FACTOR VIII "Factor VIII," abbreviated throughout the instant application as "FVIII," as used herein, means functional FVIII polypeptide in its normal role in coagulation, unless otherwise specified. Thus, the term FVIII es variant polypeptides that are functional. "A FVIII protein" is used interchangeably with FVIII polypeptide (or protein) or FVIII. Examples of the FVIII functions include, but are not limited to, an ability to activate ation, an ability to act as a cofactor for factor IX, or an ability to form a tenase complex with factor IX in the presence of Ca2+ and olipids, which then converts Factor X to the activated form Xa.

The FVIII n can be the human, e, canine, rat, or murine FVIII protein. In addition, comparisons between FVIII from humans and other s have identified conserved residues that are likely to be required for function (Cameron er al., Thromb.

Haemosl. 79:317-22 , US 6,251,632). The full length polypeptide and polynucleotide _ 51 _ sequences are known, as are many functional fragments, mutants and modified versions.

Various FVIII amino acid and nucleotide sequences are disclosed in, e.g., US Publication Nos. 2015/0158929 A1, 2014/0308280 A1, and 2014/0370035 Al and International Publication No. full-length FVIII minus Met at the N—terminus, mature FVIII (minus the signal sequence), mature FVIII with an additional Met at the N—terminus, and/or FVIII with a full or partial deletion of the B domain. FVIII variants include B domain deletions, whether partial or full deletions.

] The FVIII portion in the clotting factor or the chimeric protein used herein has FVIII activity. FVIII activity can be measured by any known methods in the art. A number of tests are available to assess the function of the coagulation system: ted partial thromboplastin time (aPTT) test, chromogenic assay, ROTEM assay, ombin time (PT) test (also used to determine INR), f1brinogen testing (often by the Clauss method), platelet count, platelet function testing (often by PFA-lOO), TCT, bleeding time, mixing test (whether an ality corrects if the patient's plasma is mixed with normal ), coagulation factor assays, antiphospholipid antibodies, D-dimer, genetic tests (e. g., factor V Leiden, ombin mutation G20210A), dilute Russell's viper venom time (dRVVT), laneous platelet function tests, thromboelastography (TEG or Sonoclot), thromboelastometry (TEM®, e. g., ROTEM®), or euglobulin lysis time (ELT).

The aPTT test is a performance indicator ing the efficacy of both the "intrinsic" (also referred to the t activation pathway) and the common coagulation pathways. This test is commonly used to measure clotting activity of commercially available recombinant clotting factors, e.g., FVIII. It is used in conjunction with prothrombin time (PT), which measures the extrinsic y.

ROTEM is provides information on the whole kinetics of haemostasis: clotting time, clot formation, clot stability and lysis. The different parameters in thromboelastometry are dependent on the activity of the plasmatic coagulation system, platelet function, f1brinolysis, or many factors which ce these interactions. This assay can provide a complete view of ary haemostasis.

The chromogenic assay mechanism is based on the principles of the blood coagulation cascade, where activated FVIII accelerates the conversion of Factor X into Factor Xa in the presence of activated Factor IX, phospholipids and calcium ions. The Factor Xa activity is _ 52 _ assessed by hydrolysis of a p-nitroanilide (pNA) substrate specific to Factor Xa. The initial rate of release of p-nitroaniline measured at 405 nM is directly proportional to the Factor Xa activity and thus to the FVIII activity in the sample.

] The chromogenic assay is recommended by the FVIII and Factor IX Subcommittee of the Scientific and Standardization Committee (SSC) of the ational Society on Thrombosis and Hemostatsis . Since 1994, the chromogenic assay has also been the nce method of the European Pharmacopoeia for the assignment of FVIII concentrate potency. Thus, in one embodiment, the chimeric protein comprising FVIII has FVIII activity comparable to a chimeric protein comprising mature FVIII or a BDD FVIII (e.g., ADVATE®, REFACTO®, or ELOCTATE®).

In another embodiment, the chimeric protein comprising FVIII of this disclosure has a Factor Xa generation rate comparable to a chimeric protein comprising mature FVIII or a BDD FVIII (e.g., ADVATE®, REFACTO®, or ELOCTATE®).

] In order to activate Factor X to Factor Xa, activated Factor IX (Factor IXa) hydrolyzes one ne-isoleucine bond in Factor X to form Factor Xa in the presence of Ca2+, membrane phospholipids, and a FVIII cofactor. Therefore, the interaction of FVIII with Factor IX is critical in coagulation pathway. In certain embodiments, the chimeric protein comprising FVIII can interact with Factor IXa at a rate comparable to a chimeric protein comprising mature FVIII sequence or a BDD FVIII (e.g., ®, REFACTO®, or ELOCTATE®).

In on, FVIII is bound to von Willebrand Factor while inactive in circulation.

FVIII degrades rapidly when not bound to VWF and is released from VWF by the action of thrombin. In some embodiments, the chimeric protein comprising FVIII binds to von Willebrand Factor at a level comparable to a chimeric protein comprising mature FVIII sequence or a BDD ern (e.g., ADVATE®, O®, or ELOCTATE®).

] FVIII can be inactivated by activated protein C in the presence of m and phospholipids. Activated protein C cleaves FVIII heavy chain after Arginine 336 in the Al domain, which disrupts a Factor X ate ction site, and cleaves after Arginine 562 in the A2 domain, which enhances the dissociation of the A2 domain as well as disrupts an interaction site with the Factor IXa. This cleavage also bisects the A2 domain (43 kDa) and generates A2-N (18 kDa) and A2-C (25 kDa) domains. Thus, ted protein C can catalyze multiple cleavage sites in the heavy chain. In one embodiment, the chimeric protein _ 53 _ comprising FVIII is inactivated by activated Protein C at a level comparable to a chimeric protein comprising mature FVIII sequence or a BDD FVIII (e.g., ADVATE®, REFACTO®, or ELOCTATE®).

In other embodiments, the chimeric protein comprising FVIII has FVIII activity in vivo comparable to a chimeric protein comprising mature FVIII sequence or a BDD FVIII (e.g., ADVATE®, REFACTO®, or ELOCTATE®). In a particular embodiment, the chimeric n comprising FVIII is capable of protecting a HemA mouse at a level comparable to a chimeric protein comprising mature FVIII sequence or a BDD FVIII (e.g., ADVATE®, REFACTO®, or ELOCTATE®) in a HemA mouse tail vein transection model.

A "B domain" of FVIII, as used herein, is the same as the B domain known in the art that is defined by internal amino acid sequence identity and sites of proteolytic cleavage by thrombin, e.g., residues Ser741-Arg1648 of mature human FVIII. The other human FVIII domains are defined by the following amino acid residues, ve to mature human FVIII: A1, residues Alal-Arg372, A2, residues -Arg740, A3, residues Ser1690-Ile2032, C1, residues Arg2033-Asn2172, C2, residues Ser2173-Tyr2332 of mature FVIII. The sequence residue numbers used herein without ing to any SEQ ID Numbers correspond to the FVIII sequence without the signal peptide sequence (19 amino acids) unless otherwise indicated. The A3-C1-C2 sequence, also known as the FVIII heavy chain, includes residues Ser1690-Tyr2332. The remaining ce, residues Glul649-Arg1689, is usually referred to as the FVIII light chain activation peptide. The locations of the ries for all of the domains, including the B domains, for porcine, mouse and canine FVIII are also known in the art. In one ment, the B domain of FVIII is deleted ("B-domain-deleted FVIII" or "BDD FVIII"). An example of a BDD FVIII is REFACTO® (recombinant BDD FVIII). In one particular ment the B domain deleted FVIII variant ses a on of amino acid residues 746 to 1648 of mature FVIII.

A ain-deleted FVIII" may have the full or partial deletions disclosed in US.

Pat. Nos. 6,316,226, 6,346,513, 7,041,635, 5,789,203, 6,060,447, 5,595,886, 6,228,620, ,972,885, 6,048,720, 5,543,502, 5,610,278, 5,171,844, 5,112,950, 112, and 6,458,563 and Int'l Publ. No. WO 2015106052 A1 (). In some embodiments, a B- domain-deleted FVIII sequence used in the methods of the present disclosure comprises any one of the deletions disclosed at col. 4, line 4 to col. 5, line 28 and Examples 1-5 of US. Pat.

No. 6,316,226 (also in US 6,346,513). In r embodiment, a in deleted Factor _ 54 _ VIII is the S743/Q1638 B-domain deleted Factor VIII (SQ BDD FVIII) (e. g., Factor VIII having a deletion from amino acid 744 to amino acid 1637, e.g., Factor VIII having amino acids 1-743 and amino acids 1638-2332 of mature FVIII). In some embodiments, a B- domain-deleted FVIII used in the methods of the present disclosure has a deletion disclosed at col. 2, lines 26-51 and es 5-8 of US. Patent No. 203 (also US 6,060,447, US ,595,886, and US 6,228,620). In some embodiments, a B-domain-deleted Factor VIII has a deletion described in col. 1, lines 25 to col. 2, line 40 of US Patent No. 5,972,885, col. 6, lines 1-22 and example 1 of US. Patent no. 6,048,720, col. 2, lines 17-46 of US. Patent No. 502, col. 4, line 22 to col. 5, line 36 of US. Patent no. 5,171,844, col. 2, lines 55-68, figure 2, and example 1 of US. Patent No. 5,112,950, col. 2, line 2 to col. 19, line 21 and table 2 of US. Patent No. 4,868,112, col. 2, line 1 to col. 3, line 19, col. 3, line 40 to col. 4, line 67, col. 7, line 43 to col. 8, line 26, and col. 11, line 5 to col. 13, line 39 of US. Patent no. 7,041,635, or col. 4, lines 25-53, of US. Patent No. 6,458,563. In some embodiments, a in-deleted FVIII has a deletion of most of the B , but still contains amino- terminal sequences of the B domain that are essential for in vivo proteolytic processing of the y translation product into two polypeptide chain, as disclosed in WO 91/09122. In some embodiments, a B-domain-deleted FVIII is constructed with a deletion of amino acids 747-1638, i.e., virtually a complete deletion of the B . Hoeben R.C., el al. J. Biol.

Chem. 265 (13): 7318-7323 (1990). A B-domain-deleted Factor VIII may also contain a deletion of amino acids 771—1666 or amino acids 868-1562 of FVIII. Meulien B, el al.

Protein Eng. 2(4): 301-6 (1988). onal B domain deletions that are part of the invention include: deletion of amino acids 982 through 1562 or 760 through 1639 (Toole el al., Proc.

Natl. Acad. Sci. USA. (1986) 83, 5939-5942)), 797 through 1562 (Eaton, el al. Biochemistry (1986) 25:8343-8347)), 741 through 1646 (Kaufman (PCT published application No. WO 87/04187)), 747-1560 (Sarver, el al., DNA (1987) 6:553-564)), 741 through 1648 (Pasek (PCT application 00831)), or 816 through 1598 or 741 through 1648 (Lagner (Behring Inst. Mitt. (1988) No 82:16-25, EP 295597)). In one particular embodiment, the B-domain- deleted FVIII ses a deletion of amino acid residues 746 to 1648 of mature FVIII. In another embodiment, the B-domain-deleted FVIII comprises a deletion of amino acid residues 745 to 1648 of mature FVIII.

] In other embodiments, BDD FVIII includes a FVIII polypeptide containing fragments of the B-domain that retain one or more N—linked glycosylation sites, e.g., residues 757, 784, _ 55 _ 828, 900, 963, or optionally 943, which correspond to the amino acid sequence of the full- length FVIII sequence. Examples of the B-domain fragments include 226 amino acids or 163 amino acids of the B-domain as disclosed in Miao, H.Z., er al., Blood : 3412-3419 (2004), Kasuda, A, el al., J. Thromb. t. 6: 1352-1359 , and Pipe, S.W., el al., J.

Thromb. Haemost. 9: 2235-2242 (2011) (i.e., the first 226 amino acids or 163 amino acids of the B domain are retained). In still other embodiments, BDD FVIII further comprises a point mutation at residue 309 (from Phe to Ser) to improve expression of the BDD FVIII protein.

See Miao, H.Z., et al., Blood 103(a): 3412-3419 (2004). In still other ments, the BDD FVIII includes a FVIII polypeptide containing a n of the in, but not containing one or more furin cleavage sites (e.g., Arg1313 and Arg 1648). See Pipe, S.W., el al., J.

Thromb. Haemost. 9: 2235-2242 (2011). In some embodiments, the BDD FVIII comprises single chain FVIII that contains a deletion in amino acids 765 to 1652 corresponding to the mature full length FVIII (also known as rVIII-SingleChain and AFSTYLA®). See US Patent No. 7,041,635. Each of the foregoing deletions may be made in any FVIII sequence.

A great many functional FVIII variants are known, as is discussed above and below.

In addition, hundreds of nonfunctional mutations in FVIII have been identified in hemophilia patients, and it has been determined that the effect of these ons on FVIII function is due more to where they lie within the 3-dimensional structure of FVIII than on the nature of the substitution (Cutler el al., Hum. Mural. -8 (2002)), incorporated herein by reference in its entirety. In addition, comparisons between FVIII from humans and other species have identified conserved residues that are likely to be required for function (Cameron el al., Thromb. Haemost. 79:317-22 , US 6,251,632), incorporated herein by reference in its entirety.

In some embodiments, an effective amount of the chimeric protein comprising a FVIII and an Fc region is equivalent to an effective amount of the FVIII without the Fc region. In certain embodiments, the effective amount is from about 20 IU/Kg to about 400 IU/kg. In certain embodiments, the ive amount is from about 20 IU/Kg to about 300 IU/kg. In some embodiments, the effective amount is from about 50 IU/Kg to about 300 IU/kg. In some embodiments, the effective amount is from about 50 IU/kg to about 200 IU/kg. In some embodiments, the effective amount is about 100 IU/kg to about 300 IU/kg, about 100 IU/kg to about 200 IU/kg, about 100 IU/kg to about 290 IU/kg, about 100 IU/kg to about 280 IU/kg, about 100 IU/kg to about 270 IU/kg, about 100 IU/kg to about 260 IU/kg, WO 02760 _ 56 _ about 100 IU/kg to about 250 IU/kg, about 100 IU/kg to about 240 IU/kg, about 100 IU/kg to about 230 IU/kg, from about 100 IU/kg to about 220 IU/kg, from about 100 IU/kg to about 210 IU/kg, from about 150 IU/kg to about 300 IU/kg, from about 150 IU/kg to about 290 IU/kg, from about 150 IU/kg to about 280 IU/kg, from about 150 IU/kg to about 270 IU/kg, from about 150 IU/kg to about 260 IU/kg, from about 150 IU/kg to about 250 IU/kg, from about 150 IU/kg to about 240 IU/kg, from about 140 IU/kg to about 250 IU/kg, from about 130 IU/kg to about 260 IU/kg, from about 120 IU/kg to about 270 IU/kg, from about 110 IU/kg to about 280 IU/kg. In one particular embodiment, the effective amount is from about 200 IU/kg to about 300 IU/kg. In another ment, the effective amount is from about 200 IU/kg to about 290 IU/kg. In other embodiments, the effective amount is from about 200 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 270 IU/kg, from about 200 IU/kg to about 260 IU/kg, from about 200 IU/kg to about 250 IU/kg, from about 200 IU/kg to about 240 IU/kg, from about 200 IU/kg to about 230 IU/kg, from about 200 IU/kg to about 220 IU/kg, or from about 200 IU/kg to about 210 IU/kg.

In some embodiments, the ive amount is about 50 IU/kg, about 60 IU/kg, about 70 IU/kg, about 80 IU/kg, about 90 IU/kg, about 100 IU/kg, about 105 IU/kg, about 110 IU/kg, about 115 IU/kg, about 120 IU/kg, about 125 IU/kg, about 130 IU/kg, about 135 IU/kg, about 140 IU/kg, about 145 IU/kg, about 150 IU/kg, about 155 IU/kg, about 160 IU/kg, about 165 IU/kg, about 170 IU/kg, about 175 IU/kg, about 180 IU/kg, about 185 IU/kg, about 190 IU/kg, about 195 IU/kg, about 200 IU/kg, about 225 IU/kg, about 250 IU/kg, about 275 IU/kg, or about 300 IU/kg. In one particular embodiment, the effective amount is about 150 IU/kg. In another embodiment, the effective amount is about 200 IU/kg.

In another embodiment, the effective amount is about 250 IU/kg. In another embodiment, the effective amount is about 50 IU/kg. In another ment, the effective amount is about 100 IU/kg.

The dosing interval when administering the chimeric protein comprising FVIII and an Fc region or a fragment thereof can be at least about one and one-half times longer than the dosing interval required for an equivalent dose of the clotting factor t the Fc domain.

The dosing interval can be at least about one and one-half to siX times longer, one and one- half to five times longer, one and one-half to four times longer, one and one-half to three times longer, or one and one-half to two times longer, than the dosing interval required for an equivalent dose of the FVIII without the Fc domain. _ 57 _ In some embodiments, the effective dose of the chimeric protein comprising a FVIII and an Fc region is administered to the human at a dosing interval of about a day, about two days, about three days, about four days, about five days, about siX days, about seven days, about eight days, about nine days, about ten days, about 11 days, about 12 days, about 13 days, about 14 days, about 15 days, about 16 days, about 17 days, about 18 days, about 19 days, about 20 days, about 21 days, about 22 days, about 23 days, or about 24 days. In some embodiments, the effective dose of the chimeric protein comprising a FVIII and an Fc region is administered to the human at a dosing interval of about 25 days, about 26 days, about 27 days, about 28 days, about 29 days, about 30 days, about 45 days, or about 60 days.

In some embodiments, the ition or the chimeric protein comprising a FVIII and an Fc region is administered at a dosing interval of about 1 to about 14 days, about 1 to about 13 days, about 1 to about 12 days, about 1 to about 11 days, about 1 to about 10 days, about 1 to about 9 days, about 1 to about 8 days, about 1 to about 7 days, about 1 to about 6 days, about 1 to about 5 days, about 1 to about 4 days, about 1 to about 3 days, about 1 to about 2 days, about 2 to about 14 days, about 3 to about 14 days, about 4 to about 14 days, about 5 to about 14 days, about 6 to about 14 days, about 7 to about 14 days, about 8 to about 14 days, about 9 to about 14 days, about 10 to about 14 days, about 11 to about 14 days, about 12 to about 14 days, about 13 to about 14 days, or about 5 to about 10 days. In other embodiments, the ition or the chimeric protein comprising a FVIII and an Fc region is administered at a dosing interval of about 1 to about 21 days, about 1 to about 20 days, about 1 to about 19 days, about 1 to about 18 days, about 1 to about 17 days, about 1 to about 16 days, about 1 to about 15 days, about 1 to about 14 days, about 1 to about 13 days, about 1 to about 12 days, about 1 to about 11 days, about 1 to about 10 days, about 1 to about 9 days, about 1 to about 8 days, about 1 to about 7 days, about 1 to about 6 days, about 1 to about 5 days, about 1 to about 4 days, about 1 to about 3 days, about 1 to about 2 days, about 2 to about 21 days, about 3 to about 21 days, about 4 to about 21 days, about 5 to about 21 days, about 6 to about 21 days, about 7 to about 21 days, about 8 to about 21 days, about 9 to about 21 days, about 10 to about 21 days, about 11 to about 21 days, about 12 to about 21 days, about 13 to about 21 days, about 14 to about 21 days, about 15 to about 21 days, about 16 to about 21 days, about 17 to about 21 days, about 18 to about 21 days, about 19 to about 21 days, about 20 to about 21 days, about 5 to about 10 days, about 10 to about 15 days, about to about 20 days. In certain embodiments, the ition or the chimeric protein _ 58 _ comprising a FVIII and an Fc region is stered at a dosing interval of about 2 to about 6 days. In another embodiment, the composition or the chimeric protein comprising a FVIII and an Fc region is administered at a dosing interval of about 3 to about 5 days.

In one embodiment, the effective dose is 25-65 IU/kg (25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 62, 64, or 65 IU/kg) and the dosing interval is once every 3-5, 3-6, 3-7, 3, 4, 5, 6, 7, or 8 or more days, or three times per week, or no more than three times per week.

In another embodiment, the effective dose is 65 IU/kg and the dosing interval is once weekly, or once every 6-7 days. The doses can be administered repeatedly as long as they are necessary (e.g., at least 10, 20, 28, 30, 40, 50, 52, or 57 weeks, at least 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 years). In one particular ment, the effective dose is about 25-65 IU/kg and the dosing interval is once every 3-5 days.

In one embodiment, the effective amount is about 200 IU/kg and the effective amount is administered daily. In r embodiment, the effective amount is about 50 IU/kg, and the effective amount is administered about three times a week.

In certain embodiments, the ive amount or the effective dose is administered as a single dose. In some embodiments, the effective amount or the effective dose is administered in two or more doses throughout a day.

In some embodiments, the composition or the chimeric n comprising a FVIII and an Fc region is administered to the human at a dose of about 200 IU/kg once daily until tolerization is observed. In some embodiments, the tolerization period extends for about 4 weeks to about 36 . In some embodiments, the tolerization period s for about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 11 weeks, about 12 weeks, about 3 months, about 4 months, about 5 months, about 6 months, about 7 months, about 8 months, about 9 months, about 10 months, about 11 months, about 12 months, about 13 months, about 14 months, about 15 months, about 16 , about 17 months, about 18 months, about 19 months, about 20 months, about 21 months, about 22 months, about 23 months, about 24 months, about 25 months, about 26 months, about 27 months, about 28 months, about 29 months, about 30 months, about 31 months, about 32 months, about 33 , about 34 months, about 35 , or about 36 months. _ 59 _ In certain embodiments, once immune nce is achieved, the human will be subjected to a tapering period. As used herein, the terms "tapering period" and ing regimen" are used interchangeably to refer to a dosing regimen wherein one or more tapering dose is administered. In some embodiments, the tapering period comprises administration of from about 20 IU/Kg to about 400 IU/kg. In certain embodiments, the tapering period comprises stration of from about 20 IU/Kg to about 300 IU/kg. In some embodiments, the tapering period comprises administration of from about 50 IU/Kg to about 300 IU/kg. In some embodiments, the tapering period comprises administration of from about 50 IU/Kg to about 100 IU/kg. In some embodiments, the tapering period comprises administration of from about 100 IU/kg to about 300 IU/kg, about 100 IU/kg to about 200 IU/kg, about 100 IU/kg to about 290 IU/kg, about 100 IU/kg to about 280 IU/kg, about 100 IU/kg to about 270 IU/kg, about 100 IU/kg to about 260 IU/kg, about 100 IU/kg to about 250 IU/kg, about 100 IU/kg to about 240 IU/kg, about 100 IU/kg to about 230 IU/kg, from about 100 IU/kg to about 220 IU/kg, from about 100 IU/kg to about 210 IU/kg, from about 150 IU/kg to about 300 IU/kg, from about 150 IU/kg to about 290 IU/kg, from about 150 IU/kg to about 280 IU/kg, from about 150 IU/kg to about 270 IU/kg, from about 150 IU/kg to about 260 IU/kg, from about 150 IU/kg to about 250 IU/kg, from about 150 IU/kg to about 240 IU/kg, from about 140 IU/kg to about 250 IU/kg, from about 130 IU/kg to about 260 IU/kg, from about 120 IU/kg to about 270 IU/kg, from about 110 IU/kg to about 280 IU/kg. In one ular embodiment, the tapering period comprises administration of from about 200 IU/kg to about 300 IU/kg. In another embodiment, the ng period comprises stration of from about 200 IU/kg to about 290 IU/kg. In other embodiments, the tapering period comprises administration of from about 200 IU/kg to about 280 IU/kg, from about 200 IU/kg to about 270 IU/kg, from about 200 IU/kg to about 260 IU/kg, from about 200 IU/kg to about 250 IU/kg, from about 200 IU/kg to about 240 IU/kg, from about 200 IU/kg to about 230 IU/kg, from about 200 IU/kg to about 220 IU/kg, or from about 200 IU/kg to about 210 IU/kg. In another ment, the tapering regimen comprises administering a ng dose of about 50 IU/kg to about 100 IU/kg of the composition or the chimeric protein. In one particular embodiment, the tapering regimen comprises administering a tapering dose of about 50 IU/kg of the composition or, the chimeric protein. In another embodiment, the tapering regimen ses administering a tapering dose of about 150 IU/kg of the composition or the chimeric protein.

In another embodiment, the tapering regimen comprises administering a tapering dose of _ 6O _ about 125 IU/kg of the ition or the chimeric n. In another ular ment, the tapering regimen comprises administering a tapering dose of about 100 IU/kg of the composition or the chimeric protein. In another ment, the tapering regimen comprises administering a tapering dose of about 90 IU/kg of the composition or the chimeric protein. In another embodiment, the tapering regimen comprises administering a tapering dose of about 80 IU/kg of the composition or the chimeric protein. In another embodiment, the tapering regimen comprises administering a tapering dose of about 75 IU/kg of the composition or the chimeric protein. In another embodiment, the ng regimen ses stering a tapering dose of about 70 IU/kg of the composition or the chimeric protein. In another embodiment, the tapering regimen comprises administering a tapering dose of about 60 IU/kg of the composition or the chimeric n. In another embodiment, the tapering regimen comprises administering a tapering dose of about 40 IU/kg of the composition or the chimeric protein. In another embodiment, the tapering n comprises administering a tapering dose of about 30 IU/kg of the composition or the chimeric protein.

In another embodiment, the ng regimen comprises stering a tapering dose of about 25 IU/kg of the composition or the chimeric protein. In another embodiment, the tapering regimen comprises administering a tapering dose of about 20 IU/kg of the composition or the ic protein. In another embodiment, the tapering regimen comprises administering a tapering dose of about 10 IU/kg of the composition or the chimeric protein.

In some embodiments, the tapering period comprises administration of the composition or the chimeric protein every day. In other embodiments, the tapering period comprises administration of the composition or the chimeric protein once about every two days, once about every three days, once about every four days, once about every five days, once about every siX days, once about every seven days, once about every eight days, once about every nine days, once about every ten days, once about every eleven days, once about every twelve days, once about every thirteen days, or one about every fourteen days.

In certain embodiments, the tapering dose is administered once a day, once every other day, or three times every week. In some embodiments, the tapering dose is administered for at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 9 weeks, at least about 10 weeks, at least about 11 weeks, at least about 12 weeks, at least about 13 weeks, at least about 14 weeks, at least about 15 weeks, at least _ 61 _ about 16 weeks, at least about 17 weeks, at least about 18 weeks, at least about 19 weeks, at least about 20 weeks, at least about 21 weeks, at least about 22 weeks, at least about 23 weeks, at least about 24 weeks, at least about 25 weeks, at least about 26 weeks, at least about 27 weeks, at least about 28 weeks, at least about 29 weeks, at least about 30 weeks, at least about 31 weeks, or at least about 32 weeks. In a particular ment, the tapering dose is administered for about 16 weeks or less.

In certain ments, the dose of the composition or the chimeric protein is gradually reduced during the tapering period and the dosing interval s the same. In other ments, the dosing interval is increased during the tapering period and the dose of the composition or the chimeric protein remains the same. In some embodiments, the dose of the composition or the chimeric protein is gradually reduced during the tapering period and the dosing interval is gradually sed.

In one particular embodiment, the tapering period comprises stration of about 200 IU/kg of the ic clotting factor every other day, followed by further reduction in dosage and dosing interval. In other embodiments, the doses of the chimeric protein required for a day can be divided up into two doses, three doses, or more. For example, about 200 IU/kg of the chimeric protein can be divided up to about 100 IU/kg twice a day, about 70 IU/kg three times a day, or about 50 IU/kg four times a day.

In some embodiments, the tapering period extends from about 1 month to about 6 months. In certain embodiments, the tapering period extends for about 1 month, about 2 months, about 3 months, about 4 months, about 5 months, or about 6 months. In one ular embodiment, the tapering period extends for about 4 months.

In certain embodiments, the tapering regimen comprises administering a tapering dose of the chimeric protein of about 100 IU/kg once a day from week 1 to week 6 following immune nce. In certain embodiments, the tapering regimen further comprises administering a tapering dose of the chimeric protein of about 100 IU/kg once every other day from week 6 to week 12 following immune tolerance. In certain embodiments, the tapering regimen further comprises administering a tapering dose of the chimeric protein of about 50 IU/kg once every other day from week 12 to week 16.

In some embodiments, the tapering period is followed by a follow-up period. In some embodiments, the follow-up period comprises lactic treatment with composition or the chimeric protein . In some embodiments, the follow-up period ses prophylactic _ 62 _ treatment with the clotting factor. The clotting factor used in the follow-up period can be ed from the clotting factor used in the tolerization and tapering periods, with or without the Fc region, and any variants f. The clotting factor can include, but is not limited to, a native clotting factor, any variant described herein (e.g., B domain deleted variants of , and any chimeric clotting factor described herein (e.g., FVIII-Fc, FVIII-albumin, etc.). In certain embodiments, the prophylactic ent comprises administration of the approved prophylactic dose of, e.g., recombinant FVIIIFc. In some embodiments, the prophylactic treatment comprises 25-65 IU/kg (25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60,61, 62,62, 64, or 65 IU/kg) and the dosing interval is once every 3-5, 3-6, 3-7, 3, 4, 5, 6, 7, or 8 or more days, or three times per week, or no more than three times per week. In another embodiment, the prophylactic treatment comprises is 65 IU/kg and the dosing interval is once weekly, or once every 6-7 days. In another ment, the prophylactic treatment comprises administering a dose of the clotting factor of 50 IU/kg. In another ment, the prophylactic treatment comprises administering a dose of the clotting factor of 50 IU/kg and the dosing interval is about three times per week. In one particular embodiment, the prophylactic treatment comprises about 25-65 IU/kg and the dosing interval is once every 3-5 days. In certain embodiments, the -up period s for about 8 months.

In one particular embodiment, the chimeric protein, e.g., FVIIIFc, is administered at about 200 IU/kg/day until immune tolerance is observed, e. g., when the titer of the inhibitory antibodies in the human is less than about 0.6 BU, then, following immune tolerance, a tapering regimen is administered, wherein the tapering regimen comprises administering a tapering dose of the ic protein, e. g., FVIIIFc, of about 100 IU/kg once a day from week 1 to week 6 following immune tolerance, administering a tapering dose of the chimeric protein, e. g., FVIIIFc, of about 100 IU/kg once every other day from week 6 to week 12 following immune tolerance, and administering a tapering dose of the chimeric protein, e.g., FVIIIFc, of about 50 IU/kg once every other day from week 12 to week 16, and then, following the tapering regimen, a prophylactic dose of the clotting factor of about 50 IU/kg is administered about three times per week.

The composition or the ic protein comprising a FVIII and an Fc region, can be formulated for any riate manner of administration, including, for example, topical (e.g., transdermal or ocular), oral, , nasal, vaginal, rectal or parenteral administration. _ 63 _ The term parenteral as used herein includes subcutaneous, intradermal, intravascular (e.g., intravenous), intramuscular, spinal, intracranial, intrathecal, intraocular, periocular, intraorbital, intrasynovial and intraperitoneal injection, as well as any similar injection or infusion que. The composition can be also for example a suspension, emulsion, sustained release formulation, cream, gel or powder. The composition can be formulated as a suppository, with traditional binders and carriers such as triglycerides.

In one example, the ceutical formulation is a liquid formulation, e.g., a buffered, isotonic, aqueous solution. In another example, the pharmaceutical composition has a pH that is physiologic, or close to physiologic. In other examples, the aqueous formulation has a physiologic or close to physiologic osmolarity and salinity. It can contain sodium chloride and/or sodium acetate.

In some embodiments, the chimeric protein comprising a FVIII and an Fc region used in the s of the present invention is formulated in a pharmaceutical composition comprising : (a) the ic protein, (b) one or more stabilizing agents selected from sucrose, trehalose, raff1nose, arginine, or mixture thereof, (c) sodium chloride (NaCl), (d) L- histidine, (e) calcium de, and (f) polysorbate 20 or polysorbate 80. In certain embodiments, the pharmaceutical composition comprises: (a) 50 IU/ml to 2500 IU/ml of the chimeric protein, (b) 10 mg/ml to 25 mg/ml of sucrose, (c) 8.8 mg/ml to 14.6 mg/ml sodium chloride (NaCl), (d) 0.75 mg/ml to 2.25 mg/ml L-histidine, (e) 0.75 mg/ml to 1.5 mg/ml calcium chloride dihydrate, and (f) 0.08 mg/ml to 0.25 mg/ml rbate 20 or polysorbate 80. In some examples, the pharmaceutical composition used in the methods of the present disclosure is lized.

In some embodiments, the pharmaceutical composition does not comprise an immune cell. In some embodiments, the ceutical composition does not comprise a cell.

In certain ments, the human d using the s of the present sure previously developed a FVIII inhibitory immune response. In some embodiments, the previously developed FVIII inhibitory response developed in response to a recombinant FVIII. In some embodiments, the previously ped FVIII tory response developed in response to a FVIII product selected from the group consisting of ADVATE®, RECOMBINATE®, KOGENATE FS®, HELIXATE FS®, XYNTHA/REFACTO AB®, HEMOFIL-M®, MONARC-M®, ATE-P®, HUMATE—P®, ATE®, KOATE-DVI®, AFSTYLA®, AND HYATE:C®. _ 64 _ In some embodiments, once tolerization is reached according to decreased titers of inhibitory antibodies, the serum level of the clotting factor is ined from about 100 IU/dL to about 200 IU/dL. In some embodiments, the effective amount of the composition or the chimeric protein is reduced prior to the start of the tapering regimen to maintain a serum level of the clotting factor from about 100 IU/dL to about 200 IU/dL. In certain embodiments, the effective amount of the composition or the chimeric n is reduced to about 175 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In certain embodiments, the effective amount of composition or the chimeric protein is reduced to about 150 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In certain embodiments, the effective amount of the composition or the chimeric protein is reduced to about 125 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In certain embodiments, the effective amount of the composition or the ic protein is reduced to about 100 day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In n embodiments, the effective amount of the composition or the chimeric protein is d to about 75 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In certain embodiments, the ive amount of the composition or the chimeric protein is reduced to about 50 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL. In certain embodiments, the effective amount of the composition or the chimeric protein is reduced to about 25 IU/kg/day if the serum level of the clotting factor is greater than or equal to 200 IU/dL.

Certain aspects of the present disclosure are directed to methods of ng immune tolerance in a human with hemophilia, sing administering to the human about 200 IU/kg of a composition or a chimeric protein comprising a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric protein is administered every other day. In other embodiments, the composition or the chimeric protein is stered daily.

In other aspects, the present disclosure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 202 IU/kg of a composition or a chimeric protein comprising a clotting factor and an Fc region. In certain embodiments, the composition or the ic protein is administered daily.

In other aspects, the present sure is directed to methods of inducing immune tolerance in a human with ilia, comprising administering to the human about 150 _ 65 _ IU/kg of a composition or the chimeric protein comprising a clotting factor and an Fc region.

In certain embodiments, the composition or the chimeric protein is stered daily.

] In other aspects, the present disclosure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 130 IU/kg of a composition or a chimeric n comprising a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric protein is administered daily.

In other aspects, the present disclosure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 115 IU/kg of a composition or a chimeric protein sing a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric protein is administered every other ] In other aspects, the present sure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 100 IU/kg of a composition or a chimeric protein comprising a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric n is administered daily. In other embodiments, the composition or the chimeric n is administered three times per week.

In other aspects, the present sure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 102 IU/kg of a composition or a chimeric protein comprising a ng factor and an Fc region. In certain ments, the composition or the chimeric protein is administered every other In other aspects, the present disclosure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 96 IU/kg of a composition or a chimeric protein comprising a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric protein is administered daily.

In other aspects, the present disclosure is directed to methods of inducing immune tolerance in a human with hemophilia, comprising administering to the human about 85 IU/ kg of a composition or a chimeric protein sing a clotting factor and an Fc region. In certain embodiments, the composition or the chimeric protein is stered daily.

In other aspects, the present disclosure is ed to methods of inducing immune tolerance in a human with hemophilia, comprising stering to the human about 50 IU/ kg of a composition or a ic protein comprising a clotting factor and an Fc region. In _ 66 _ certain embodiments, the composition or the chimeric protein is administered three times per week.

Certain aspects of the t disclosure are directed to s of inducing immune tolerance in a human with hemophilia, comprising (1) administering to the human about 200 IU/kg of a composition or a chimeric protein comprising a clotting factor and an Fc region, wherein the ition or the chimeric protein s immune tolerance in the human, and (2) following induction of immune tolerance, administering to the human a tapering regimen of the composition or the chimeric n.

II.A.2 Fc In some embodiments, the compositions, ic proteins, and/or the ng factors of the disclosure include an Fc domain or a portion thereof that binds to an Fc receptor (FcR, e. g., FcRn). In some embodiments, the Fc domain is fused to the clotting factor, e.g., as part of a chimeric protein comprising a ng factor and an Fc region. In other embodiments, the Fc domain is fused to a polypeptide other than the clotting factor, wherein the composition comprises a (l) clotting factor and (2) a chimeric protein comprising an Fc domain and an additional polypeptide. The Fc domain or a portion thereof can improve pharmacokinetic or pharmacodynamic properties of the chimeric n. In certain embodiments, the Fc domain or a portion thereof extends a half-life of a molecule fused to the Fc domain or a portion thereof.

As used herein, the term "Fc domain" of "Fc region" as used herein, means functional FcR (e.g., FcRn) binding partners, unless otherwise specified. The Fc domain is the portion of a ptide which corresponds to the Fc domain of native Ig, i.e., as formed by the dimeric association of the respective Fc domains of its two heavy chains. A native Fc domain forms a homodimer with another Fc domain. In contrast, the term "genetically-fused Fc region" or "single-chain Fc region" (sch ), as used herein, refers to a synthetic dimeric Fc region comprised of Fc domains genetically linked within a single polypeptide chain (1'.e., encoded in a single contiguous genetic ce).

In one embodiment, the "Fc region" refers to the portion of a single Ig heavy chain beginning in the hinge region just upstream of the papain cleavage site (i.e. residue 216 in IgG, taking the first e of heavy chain constant region to be 114) and ending at the C- _ 67 _ terminus of the antibody. Accordingly, a complete Fc domain comprises at least a hinge domain, a CH2 domain, and a CH3 domain.

The Fc region of an Ig constant region, depending on the Ig isotype can include the CH2, CH3, and CH4 domains, as well as the hinge region. Chimeric proteins sing an Fc region of an Ig bestow l desirable properties on a chimeric protein including increased stability, increased serum ife (see Capon el al., 1989, Nature 337 :525) as well as binding to Fc receptors such as the neonatal Fc receptor (FcRn) (US. Pat. Nos. 6,086,875, 6,485,726, 6,030,613, WO 03/077834, US2003-0235536A1), which are incorporated herein by reference in their entireties.

The FcRn receptor has been isolated from several mammalian species including humans. The sequences of the human FcRn, monkey FcRn, rat FcRn, and mouse FcRn are known (Story et al. 1994, J. Exp. Med. 1802377). The FcRn receptor binds IgG (but not other Ig classes such as IgA, IgM, IgD, and IgE) at relatively low pH, actively transports the IgG transcellularly in a luminal to serosal direction, and then releases the IgG at relatively higher pH found in the titial fluids. It is expressed in adult epithelial tissue (US. Pat.

Nos. 6,485,726, 6,030,613, 6,086,875, wo 03/077834, US2003-0235536A1) including lung and intestinal epithelium (Israel et al. 1997, Immunology 92:69) renal proximal tubular epithelium (Kobayashi et al. 2002, Am. J. Physiol. Renal Physiol. 282:F358) as well as nasal epithelium, vaginal surfaces, and biliary tree surfaces.

Fc regions useful in the present invention encompass molecules that can specif1cally bind an FcR, ing whole IgG, the Fc nt of IgG, and other fragments that include the complete g region of an FcR. The region of the Fc portion of IgG that binds to, e.g., the FcRn receptor has been described based on X-ray crystallography (Burmeister et al. 1994, Nature 372379). The major contact area of the Fc with the FcRn is near the junction of the CH2 and CH3 domains. Fc-FcRn ts are all within a single Ig heavy chain. The Fc regions include whole IgG, the Fc fragment of IgG, and other nts of IgG that e the complete binding region of FcRn. The major contact sites include amino acid residues 248, 250—257, 272, 285, 288, 290—291, 308-311, and 314 of the CH2 domain and amino acid residues 7, 428, and 433-436 of the CH3 domain. nces made to amino acid numbering of Igs or Ig fragments, or regions, are all based on Kabat et al. 1991, Sequences of Proteins of Immunological Interest, US. ment of Public Health, Bethesda, Md. _ 68 _ Specifically bound refers to two molecules forming a complex that is relatively stable under physiologic conditions. Specific binding is characterized by a high affinity and a low to moderate capacity as distinguished from nonspecific binding which y has a low affinity with a moderate to high capacity. Typically, binding is considered specific when the y constant KA is higher than 106 M'l, or higher than 108 M'l. If necessary, non-specific binding can be reduced without substantially affecting specific binding by varying the binding conditions. The appropriate binding conditions such as concentration of the molecules, ionic strength of the solution, temperature, time allowed for binding, concentration of a blocking agent (e.g. serum albumin, milk casein), etc., may be optimized by a skilled artisan using routine techniques.

In certain embodiments, a chimeric protein of the invention comprises one or more truncated Fc regions that are eless sufficient to confer FcR binding properties to the Fc region. For example, the portion of an Fc region that binds to FcRn (i.e., the FcRn binding portion) comprises from about amino acids 282-438 of IgG1, EU ing (with the y contact sites being amino acids 248, 250-257, 272, 285, 288, 290-291, 308-311, and 314 of the CH2 domain and amino acid residues 385-387, 428, and 6 of the CH3 domain. Thus, an Fc region of the ion may comprise or consist of an FcRn g portion.

FcR binding portions may be derived from heavy chains of any isotype, ing IgGl, IgG2, IgG3 and IgG4. In one embodiment, an FcR binding n from an antibody of the human isotype IgGl is used. In another embodiment, an FcR binding portion from an antibody of the human e IgG4 is used.

In another embodiment, the "Fc region" includes an amino acid sequence of an Fc domain or derived from an Fc domain. In certain ments, an Fc region comprises at least one of: a hinge (e.g., upper, middle, and/or lower hinge ) domain (about amino acids 216-230 of an antibody Fc region according to EU ing), a CH2 domain (about amino acids 231-340 of an antibody Fc region according to EU numbering), a CH3 domain (about amino acids 341-438 of an antibody Fc region according to EU numbering), a CH4 domain, or a variant, portion, or fragment f. In other embodiments, an Fc region comprises a complete Fc domain (i.e., a hinge domain, a CH2 domain, and a CH3 domain).

In some embodiments, an Fc region comprises, consists essentially of, or consists of a hinge domain (or a portion thereof) fused to a CH3 domain (or a portion thereof), a hinge domain _ 69 _ (or a n thereof) fused to a CH2 domain (or a portion thereof), a CH2 domain (or a portion thereof) fused to a CH3 domain (or a n thereof), a CH2 domain (or a portion thereof) fused to both a hinge domain (or a portion thereof) and a CH3 domain (or a portion thereof). In still other embodiments, an Fc region lacks at least a portion of a CH2 domain (e.g., all or part of a CH2 domain). In a particular embodiment, an Fc region comprises or consists of amino acids corresponding to EU numbers 221 to 447.

The Fc regions d as F, F1, or F2 herein may be obtained from a number of different sources. In one embodiment, an Fc region of the polypeptide is d from a human Ig. It is understood, however, that an Fc region may be derived from an Ig of another mammalian species, including for example, a rodent (e.g. a mouse, rat, rabbit, or guinea pig) or non-human primate (e.g. chimpanzee, macaque) s. Moreover, the polypeptide of the Fc domains or portions thereof may be d from any Ig class, including IgM, IgG, IgD, IgA and IgE, and any Ig isotype, including IgGl, IgG2, IgG3 and IgG4. In another embodiment, the human isotype IgGl is used.

In n ments, the Fc variant confers a change in at least one effector function imparted by an Fc region comprising the wild-type Fc domain (e.g., an improvement or reduction in the y of the Fc region to bind to Fc receptors (e.g., improvement or reduction in binding to FcyRI, FcyRII, or chRIII), complement proteins (e.g. Clq), or other Fc binding partners (e.g. or to trigger antibody-dependent cytotoxicity (ADCC), , DC-SIGN), phagocytosis, or complement-dependent cytotoxicity (CDCC)). In other embodiments, the Fc t provides an engineered cysteine residue.

The Fc regions of the invention may employ art-recognized Fc ts which are known to impart a change (e.g., an enhancement or reduction) in effector function and/or FcR or FcRn g. Specifically, a binding molecule of the invention may include, for example, a change (e.g., a substitution) at one or more of the amino acid positions disclosed in International PCT Publications W088/O7089Al, WO96/l4339Al, WO98/05787Al, WO98/23289Al, WO99/51642Al, WO99/58572Al, WOOO/O956OA2, WOOO/32767Al, WOOO/42072A2, WOO2/44215A2, WOO2/O609l9A2, WOO3/O74569A2, WOO4/Ol6750A2, WOO4/O29207A2, WOO4/O35752A2, WOO4/O633 51A2, WOO4/O74455A2, WOO4/O99249A2, WOOS/O402l7A2, WOO4/O44859, WOOS/O70963Al, WOOS/O77981A2, WOOS/O92925A2, WOOS/l23780A2, WOO6/Ol9447Al, WOO6/O47350A2, and WOO6/085967A2, US Patent Publication Nos. /O23l329, US2007/O23l329, _ 70 _ /0237765, USZOO7/0237766, USZOO7/0237767, USZOO7/0243 l88, USZOO7/0248603, US2007/0286859, US2008/0057056, or US s 5,648,260, 5,739,277, 5,834,250, ,869,046, 6,096,871, 6,121,022, 6,194,551, 6,242,195, 6,277,375, 6,528,624, 6,538,124, 6,737,056, 6,821,505, 6,998,253, 7,083,784, 7,404,956, and 7,317,091. In one embodiment, the specific change (e.g., the specific substitution of one or more amino acids disclosed in the art) may be made at one or more of the disclosed amino acid positions. In another embodiment, a different change at one or more of the disclosed amino acid positions (e.g., the different substitution of one or more amino acid position disclosed in the art) may be made.

The Fc region can be modified according to well recognized procedures such as site directed mutagenesis and the like to yield modified Fc fragments or portions thereof that will be bound by B and/or DC-SIGN. Such modifications include modifications remote from the FcyRIIB and/or DC-SIGN contact sites as well as modifications within the contact sites that preserve or even enhance binding to the FcyRIIB and/or DC-SIGN. For example, the following single amino acid residues in human IgG1 Fc (Fc yl) can be tuted without significant loss of Fc g affinity for B and/or DC-SIGN: P23 8A, S239A, K246A, K248A, D249A, M252A, T256A, E258A, T26OA, D265A, s267A, H268A, E269A, D27OA, E272A, L274A, N276A, Y278A, D280A, V282A, E283A, H285A, N286A, T289A, K29OA, R292A, E293A, E294A, Q295A, Y296F, N297A, s298A, Y3OOF, R301A, V303A, V305A, T307A, L309A, Q311A, D312A, N315A, K317A, E318A, K320A, K322A, S324A, K326A, A327Q, P329A, A33OQ, P331A, E333A, K334A, T335A, S337A, K338A, K34OA, Q342A, R344A, E345A, Q347A, R355A, E356A, M358A, T359A, K36OA, N361A, Q362A, Y373A, S375A, D376A, A378Q, E380A, E382A, S383A, N384A, Q386A, E388A, N389A, N39OA, Y391F, K392A, L398A, S4OOA, D401A, D413A, K414A, R416A, Q418A, Q419A, N421A, V422A, S424A, E43OA, N434A, T437A, Q438A, K439A, S44OA, S444A, and K447A, where for example P238A represents wild type e substituted by alanine at position number 238. As an example, a c embodiment incorporates the N297A mutation, removing a highly ved N—glycosylation site. In addition to alanine other amino acids may be substituted for the wild type amino acids at the positions specified above. Mutations may be uced singly into Fc giving rise to more than one hundred Fc regions distinct from the native Fc. Additionally, ations of two, three, or more of these individual mutations may be introduced together, giving rise to hundreds more Fc regions. Moreover, _ 71 _ one of the Fc region of a construct of the invention may be d and the other Fc region of the uct not mutated at all, or they both may be mutated but with different mutations.

Certain of the above mutations may confer new functionality upon the Fc region or FcRn binding partner. For e, one embodiment orates N297A, removing a highly conserved N—glycosylation site. The effect of this mutation is to reduce immunogenicity, thereby enhancing circulating ife of the Fc region, and to render the Fc region incapable of binding to FcyRI, FcyRIIA, FcyRIIB, and FcyRIIIA, without compromising affinity for FcRn (Routledge et al. 1995, Transplantation 60:847, Friend et al. 1999, lantation 68:1632, Shields et al. 1995, J. Biol. Chem. 276:6591). As a further example of new functionality arising from mutations described above affinity for FcRn may be increased beyond that of wild type in some instances. This increased affinity may reflect an increased "on" rate, a decreased "off" rate or both an increased "on" rate and a decreased "off' rate. Examples of mutations ed to impart an increased affinity for FcRn e, but not limited to, T256A, T307A, E380A, and N434A (Shields et al. 2001, J. Biol. Chem. 276:6591).

Additionally, at least three human Fc gamma receptors appear to recognize a binding site on IgG within the lower hinge region, generally amino acids 234-237. Therefore, r example of new functionality and potential decreased immunogenicity may arise from mutations of this region, as for example by replacing amino acids 233-236 of human IgG1 "ELLG" to the ponding sequence from IgG2 "PVA" (with one amino acid deletion). It has been shown that FcyRI, FcyRII, and FcyRIII, which mediate various or functions, will not bind to IgGl when such mutations have been introduced. Ward and Ghetie 1995, Therapeutic Immunology 2:77 and Armour et al. 1999, Eur. J. Immunol. 29:2613.

In one embodiment, the Fc domain or a portion thereof is a polypeptide including SEQ ID NO: 3 of US. Pat. No. 5,739,277 and optionally further including a sequence selected from SEQ ID NOs: 11, 1, 2, and 31 of US. Pat. No. 5,739,277.

In certain ments, the Fc domain or a portion thereof is hemi-glycosylated. For example, the chimeric protein comprising two Fc s may contain a first, glycosylated, Fc region (e. g., a glycosylated CH2 region) and a second, aglycosylated, Fc region (e. g., an aglycosylated CH2 region). In one embodiment, a linker may be interposed between the glycosylated and aglycosylated Fc regions. In another embodiment, the Fc region is fully _ 72 _ glycosylated, i.e., all of the Fc s are ylated. In other embodiments, the Fc region may be aglycosylated, i.e., none of the Fc moieties are glycosylated.

In n embodiments, a chimeric protein of the invention comprises an amino acid substitution to an Fc domain or a n thereof (e.g., Fc variants), which alters the antigen- ndent or functions of PC domain, in particular the circulating half-life of the protein.

Such proteins exhibit either increased or decreased binding to FcR when compared to proteins lacking these substitutions and, therefore, have an sed or decreased half-life in serum, respectively. Fc variants with improved affinity for FcR are anticipated to have longer serum half-lives, and such molecules have useful applications in methods of ng mammals where long half-life of the administered polypeptide is desired, e.g., to treat a chronic disease or disorder (see, e.g., US Patents 7,348,004, 7,404,956, and 7,862,820). In contrast, Fc variants with decreased FcR binding affinity are expected to have shorter half- lives, and such molecules are also useful, for example, for stration to a mammal where a shortened circulation time may be advantageous, e. g. for in vivo diagnostic g or in situations where the starting polypeptide has toxic side s when present in the circulation for prolonged s. Fc variants with decreased FcRn binding affinity are also less likely to cross the placenta and, thus, are also useful in the treatment of diseases or disorders in pregnant women. In addition, other applications in which reduced FcRn binding affinity may be desired include those applications in which localization the brain, kidney, and/or liver is desired. In one exemplary embodiment, the chimeric protein of the invention exhibit reduced transport across the epithelium of kidney glomeruli from the vasculature. In another ment, the chimeric protein of the invention exhibits reduced transport across the blood brain r (BBB) from the brain, into the vascular space. In one embodiment, a protein with altered FcR binding comprises at least one Fc region (e.g., one or two Fc regions) having one or more amino acid substitutions within the "FcR binding loop" of an Ig constant region. The FcR g loop is, in one embodiment, comprised of amino acid residues 280- 299 ding to EU numbering) of a wild-type, full-length, Fc region. In other embodiments, an Ig constant region or a portion thereof in a chimeric protein of the invention having altered FcR binding affinity comprises at least one Fc region having one or more amino acid substitutions within the 15 A FcR "contact zone." As used herein, the term 15 A FcRn "contact zone" includes residues at the following ons of a wild-type, full-length _ 73 _ Fc moiety: 243-261, 275-280, 282-293, 302—319, 336- 348, 367, 369, 372-389, 391, 393, 408, 424, 425-440 (EU numbering). In other embodiments, an Fc domain or a portion thereof of the invention having altered FcR binding affinity comprises at least one Fc region having one or more amino acid substitutions at an amino acid position corresponding to any one of the following EU positions: 256, 277-281, 283-288, 303—309, 313, 338, 342, 376, 381, 384, 385, 387, 434 (e.g., N434A or , and 438. Exemplary amino acid substitutions which altered FcR binding activity are disclosed in International PCT ation No.

WOO5/O47327 which is incorporated by reference herein.

An Fc region used in the invention may also se an art recognized amino acid substitution which alters the glycosylation of the chimeric n. For example, the Fc region of the chimeric protein linked to a FVIII protein may comprise an Fc region having a mutation leading to reduced glycosylation (e.g., N— or O-linked glycosylation) or may comprise an altered glycoform of the wild-type Fc moiety (e.g., a low fucose or fucose-free glycan).

] In one embodiment, an unprocessed chimeric protein of the invention may comprise a genetically fused Fc region (1'.e., sch region) having two or more of its constituent Ig constant region or a n thereof independently selected from the Ig nt region or a portion thereof described herein. In one embodiment, the Fc regions of a dimeric Fc region are the same. In another embodiment, at least two of the Fc regions are different. For example, the Fc regions of the proteins of the invention comprise the same number of amino acid es or they may differ in length by one or more amino acid residues (e.g., by about amino acid residues (e.g., l, 2, 3, 4, or 5 amino acid residues), about 10 residues, about 15 es, about 20 residues, about 30 residues, about 40 residues, or about 50 residues). In yet other embodiments, the Fc regions of the protein of the invention may differ in ce at one or more amino acid positions. For example, at least two of the Fc regions may differ at about 5 amino acid positions (e. g., l, 2, 3, 4, or 5 amino acid ons), about 10 positions, about 15 positions, about 20 ons, about 30 positions, about 40 positions, or about 50 positions).

In some embodiments, a chimeric protein used in the methods of the present disclosure comprises more than one polypeptide chain. In some embodiments, the chimeric protein comprises two polypeptide chains. In certain embodiments, the first polypeptide chain ses a ng factor and a first Fc region, and the second polypeptide chain comprises _ 74 _ a second Fc region. In certain embodiments, the first Fc region and the second Fc region are ated by a covalent bond. In one embodiment, the first Fc region and the second Fc region are associated by a peptide bond. In another embodiment, the first Fc region and the second Fc region are associated by a disulfide bond.

] In one particular embodiment, the chimeric protein comprises a factor VIII portion and a von Willebrand factor (VWF) portion, wherein the FVIII portion comprises a FVIII polypeptide or a fragment thereof, wherein the VWF portion comprises a VWF polypeptide or a nt thereof, wherein the FVIII portion is linked to a first Fc region, n the VWF n is linked to a second Fc region, and wherein the first Fc region and the second Fc region are associated with each other. In certain ments, the VWF portion comprises the D' and D3 domains of VWF. In one embodiment, the first polypeptide, the second polypeptide, or both the first polypeptide and the second polypeptide further comprise one or more half-life extending moieties.

An Fc region or a portion thereof for producing a chimeric protein used in the methods of the present disclosure may be obtained from a number of different s. In some embodiments, an Fc region or a portion thereof is derived from a human Ig. It is understood, however, that the Fc region or a portion thereof may be derived from an Ig of another mammalian species, including for example, a rodent (e.g. a mouse, rat, rabbit, guinea pig) or non-human primate (e. g. chimpanzee, macaque) species. Moreover, the Fc region or a portion thereof may be derived from any Ig class, including IgM, IgG, IgD, IgA, and IgE, and any Ig e, ing IgGl, IgG2, IgG3, and IgG4. In one embodiment, the human isotype IgGl is used.

A variety of the Fc region gene sequences (e.g., human Fc gene sequences) are available in the form of ly accessible deposits. Fc sequences can be selected having a ular effector function (or lacking a particular effector on) or with a particular modification to reduce immunogenicity. Many sequences of antibodies and antibodyencoding genes have been published and le Fc region sequences can be derived from these sequences using art recognized techniques. The genetic material obtained using any of the foregoing methods may then be altered or sized to obtain chimeric proteins used in the methods of the present disclosure. It will further be appreciated that the scope of this invention encompasses alleles, variants and ons of constant region DNA sequences. _ 75 _ The sequences of the Fc or a portion thereof can be cloned, e.g., using the polymerase chain reaction and primers which are selected to amplify the domain of interest. To clone a sequence of the Fc region or a n thereof from an antibody, mRNA can be isolated from hybridoma, , or lymph cells, reverse transcribed into DNA, and dy genes amplified by PCR. PCR amplification methods are described in detail in US. Pat. Nos. 4,683,195, 4,683,202, 4,800,159, 4,965,188, and in, e. g., "PCR Protocols: A Guide to Methods and Applications" Innis et al. eds., Academic Press, San Diego, CA (1990), Ho et al. 1989. Gene 77:51, Horton et al. 1993. Methods Enzymol. 217:270). PCR may be initiated by consensus constant region primers or by more specific primers based on the published heavy and light chain DNA and amino acid sequences. As sed above, PCR also may be used to e DNA clones encoding the antibody light and heavy chains. In this case the libraries may be screened by consensus primers or larger homologous probes, such as mouse constant region probes. Numerous primer sets suitable for amplification of antibody genes are known in the art (e.g., 5' primers based on the N-terminal sequence of purified antibodies (Benhar and Pastan. 1994. Protein ering 7:1509), rapid amplification of cDNA ends (Ruberti, F. et al. 1994. J. Immunol. Methods 173:33), antibody leader sequences (Larrick et al. 1989 Biochem. Biophys. Res. Commun. 160:1250). The cloning of antibody sequences is further described in Newman et al., US. Pat. No. 570, filed January 25, 1995, which is incorporated by reference herein.

II.B. HalflLifé ing Moieties In some embodiments, a chimeric protein used in the methods of the t disclosure r comprises one or more half-life extending moieties. Half-life of a clotting factor can be determined by any method known to those of skill in the art, e.g., FVIII activity assays (chromogenic assay or one stage clotting aPTT assay) to detect plasma FVIII ty levels or FVIII ELISA to detect plasma FVIII antigen level. In a particular ment, half-life of the clotting activity of a clotting factor is determined by one stage clotting assay.

In a more particular ment, half-life of the clotting activity of a clotting factor is determined in mice, either HemA mice or FVIII and von Willebrand Factor double knockout (DKO) mice.

In certain aspects, a heterologous moiety which increases half-life of the clotting factor of the invention comprises, without limitation, a heterologous polypeptide such as n, an immunoglobulin Fc region, an XTEN sequence, the C-terminal peptide (CTP) of _ 76 _ the [3 subunit of human chorionic gonadotropin, a PAS sequence, a HAP sequence, a transferrin, albumin-binding moieties, or any fragments, derivatives, variants, or combinations of these polypeptides. In other related aspects a half-life extending moiety can include an attachment site for a non-polypeptide moiety such as polyethylene glycol (PEG), hydroxyethyl starch (HES), polysialic acid, or any derivatives, variants, or combinations of these moieties. In certain embodiments, the half-life extending moiety comprises albumin or a fragment thereof, an albumin binding moiety, a PAS sequence, a HAP sequence, errin or a fragment thereof, polyethylene glycol (PEG), polysialic acid, hydroxyethyl starch (HES), a tive thereof, or any combination f. In some ments, the half-life extending moiety does not comprise an XTEN. In other embodiments, the half-life extending moiety comprises an XTEN.

In other embodiments, a chimeric n of the invention is conjugated to one or more polymers. The polymer can be water-soluble or non-water-soluble. The polymer can be covalently or non-covalently attached to the clotting factor, the PC, or to other moieties ated to either the clotting factor or the Fc. Non-limiting es of the polymer can be poly(alkylene oxide), poly(vinyl pyrrolidone), poly(vinyl l), polyoxazoline, or cryloylmorpholine). Additional types of, e. g., polymer-conjugated FVIII are disclosed in US. Patent No. 7,199,223, which is disclosed by reference in its entirety.

In n aspects, a chimeric protein of the invention can comprise one, two, three or more half-life extending moieties, which can each be the same or different molecules.

In some embodiments, the half-life extending moiety is fused to the N—terminus or the C-terminus of the chimeric protein. In some embodiments, the half-life extending moiety is fused to the N—terminus or the C-terminus of the clotting factor. In some embodiments, the half-life extending moiety is fused to the N—terminus or the C-terminus of the Fc. In certain embodiments, the half-life extending moiety is inserted within the clotting factor of the chimeric protein.

In some ments, the ic protein comprises FVIII or a n thereof, and the ife extending moiety is inserted within the FVIII at one or more positions disclosed in US. Patent Publ. No. 2015-0158929 Al and/or Int'l Publication No. WO 2015106052 A1, which are incorporated by reference herein in their entirety. In one ular embodiment, the half-life extending moiety is inserted with in the B domain (or a fragment f) of the FVIII. In one particular embodiment, the half-life extending moiety WO 02760 _ 77 _ is inserted within the FVIII immediately downstream of amino acid residue 745 of mature FVIII.

II.B.I. Albumins In n aspects, a ic protein used in the methods of the present disclosure comprises at least one albumin ptide or fragment, variant, or derivative thereof.

Human serum albumin (HSA, or HA), a protein of 609 amino acids in its full-length form, is sible for a significant proportion of the osmotic pressure of serum and also functions as a carrier of endogenous and exogenous ligands. The term "albumin" as used herein includes full-length n or a functional fragment, variant, derivative, or analog thereof. Examples of albumin or the fragments or variants thereof are disclosed in US Pat. Publ. Nos. 2008/0194481Al, 2008/0004206 Al, 2008/0161243 Al, 2008/0261877 Al, or 2008/0153751 Al or PCT Appl. Publ. Nos. 2008/033413 A2, 2009/058322 Al, or 2007/021494 A2, which are incorporated herein by nce in their entireties.

The albumin-binding polypeptides (ABPs) can compromise, without limitation, bacterial albumin-binding domains, albumin-binding peptides, or albumin-binding antibody fragments that can bind to albumin. Domain 3 from streptococcal protein G, as disclosed by Kraulis el al., FEBS Lett. 378:190-194 (1996) and Linhult el al., Protein Sci. 11:206-213 (2002) is an example of a ial albumin-binding domain. Examples of albumin-binding peptides are disclosed in Dennis et al., J. Biol. Chem. 2002, 277: 35043 (2002).

Examples of albumin-binding antibody fragments are disclosed in Muller and Kontermann, Curr. Opin. Mol. Ther. 9:319-326 (2007), Roovers el al., Cancer Immunol. Immunother. 56:303-317 (2007), and Holt el al., Prot. Eng. Design Sci., 21:283-288 (2008), which are incorporated herein by reference in their ties.

In certain s, a chimeric protein used in the methods of the present disclosure comprises at least one attachment site for a non-polypeptide small molecule, variant, or derivative that can bind to albumin thereof. For example, the chimeric protein can include one or more organic n-binding es. An example of such albumin-binding moieties is 2-(3-maleimidopropanamido)(4-(4-iodophenyl)butanamido)hexanoate ("Albu" tag) as disclosed by Trussel el al., Bioconjugate Chem. 20:2286-2292 (2009). _ 78 _ 11.3.2. XTENs In certain aspects, a chimeric protein used in the methods of the present disclosure comprises at least one XTEN polypeptide or fragment, variant, or derivative thereof. As used here "XTEN sequence" refers to extended length polypeptides with non-naturally ing, substantially non-repetitive sequences that are composed mainly of small hydrophilic amino acids, with the sequence having a low degree or no secondary or tertiary structure under logic ions. As a chimeric protein r, XTENs can serve as a carrier, conferring certain desirable pharmacokinetic, physicochemical and pharmaceutical properties, e.g., when fused with or inserted into the clotting factor of the chimeric protein.

Such desirable properties include but are not limited to ed cokinetic parameters and solubility characteristics.

An XTEN sequence fused with or inserted into the clotting factor of the chimeric n used in the methods of the present disclosure can confer to the chimeric protein one or more of the following advantageous properties: conformational flexibility, enhanced aqueous solubility, high degree of protease resistance, low immunogenicity, low binding to mammalian ors, or increased hydrodynamic (or Stokes) radii. In n aspects, an XTEN sequence can increase cokinetic properties such as longer half-life (e.g., in vivo half-life) or increased area under the curve (AUC), so that the chimeric protein stays in vivo and has gulant activity for an increased period of time compared to the chimeric protein without the XTEN.

Examples of XTEN sequences that can be inserted into recombinant FVIII proteins of the invention are disclosed, e. g., in US. Patent Publication Nos. 239554 A1, 2010/0323956 A1, 2011/0046060 A1, 2011/0046061 A1, 2011/0077199 A1, or 2011/0172146 A1, or International Patent Publication Nos. WO 2010091122 A1, WO 2010144502 A2, WO 2010144508 A1, WO 2011028228 A1, WO 2011028229 A1, WO 2011028344 A2, or WO 2015106052 A1, each of which is incorporated by reference herein in its entirety. 11.3.3. VWFor a Fmgmcut Thereof In certain aspects, a ic n used in the methods of the present sure comprises at least one VWF polypeptide or fragment, variant, or derivative thereof. VWF (also known as F8VWF) is a large, multimeric glycoprotein present in blood plasma and _ 79 _ produced constitutively in endothelium (in the Weibel-Palade bodies), megakaryocytes (0L- granules of platelets), and subendothelian connective tissue. The basic VWF monomer is a 2813 amino acid protein. Every monomer contains a number of specific domains with a specific function, the D'/D3 domain (which binds to Factor VIII), the Al domain (which binds to et GPIb-receptor, n, and/or possibly collagen), the A3 domain (which binds to collagen), the Cl domain (in which the RGD domain binds to platelet integrin dIIbB3 when this is activated), and the "cysteine knot" domain at the C-terminal end of the protein (which VWF shares with platelet-derived growth factor (PDGF), transforming growth factor-B (TGFB) and B-human chorionic gonadotropin (BHCG)).

In one embodiment, the VWF polypeptide is a VWF fragment. The term "a VWF fragment" as used herein includes, but is not d to, functional VWF fragments comprising a D' domain and a D3 domain, which are capable of inhibiting binding of endogenous VWF to FVIII. In one embodiment, the chimeric protein used in the methods of the present disclosure ses a clotting , an Fc region, and a VWF fragment, wherein the clotting factor comprises FVIII, and n the VWF fragment binds to the FVIII protein. In another embodiment, the VWF nt blocks the VWF binding site on the FVIII protein, thereby inhibiting interaction of the FVIII n with endogenous VWF.

The VWF fragments include derivatives, variants, mutants, or analogues that retain these ties of VWF. In n embodiments, the VWF fragment ses the D' domain and D3 domain of VWF.

The 2813 monomer amino acid ce for human VWF is reported as Accession Number _NP_000543.2_ in Genbank. The nucleotide sequence encoding the human VWF is reported as Accession Number _NM_000552.3_ in Genbank.

In certain embodiments, the VWF protein useful herein can be further modified to improve its interaction with FVIII, e.g., to improve binding y to FVIII. In other embodiments, The VWF proteins useful for the invention can have other modifications, e.g., the protein can be pegylated, glycosylated, ted, or polysialylated. Example VWF sequences useful in the methods of the present disclosure are provided, e.g., in US.

Publication Nos. US 2015/0023959 A1, US 2015/0266943 A1, and US 2015/0158929. In certain embodiments, the VWF protein or a nt thereof is fused to or co-administered with an FcRn binding partner. In some embodiments, the VWF protein or a fragment thereof is fused to an Fc or co-administered with an Fc or a polypeptide comprising an PC. In some WO 02760 _ 80 _ embodiments, the VWF protein or a fragment f is fused to an albumin or co- administered with an albumin or a polypeptide comprising an albumin. 11.3.4. CTP In n aspects, a ic protein used in the methods of the present disclosure ses at least one C-terminal peptide (CTP) of the [3 subunit of human chorionic gonadotropin or fragment, t, or derivative thereof. CTP peptides are known to increase the half-life of that protein. See, e.g., US. Patent No. 5,712,122, incorporated by reference herein in its entirety. Non-limiting exemplary CTP peptides are disclosed in US. Patent Application Publication No. US 2009/0087411 A1, orated by reference. 11.3.5. PAS In certain aspects, a chimeric protein used in the methods of the present disclosure comprises at least one PAS peptide or fragment, variant, or derivative thereof. A PAS peptide or PAS sequence, as used herein, means an amino acid sequence sing mainly alanine and serine residues or comprising mainly e, serine, and proline residues, the amino acid sequence forming random coil conformation under physiological conditions.

Accordingly, the PAS sequence is a building block, an amino acid polymer, or a sequence cassette comprising, consisting essentially of, or consisting of alanine, serine, and proline which can be used as a part of the heterologous moiety in the chimeric protein. An amino acid polymer also can form random coil conformation when es other than alanine, serine, and proline are added as a minor constituent in the PAS ce. By "minor constituent" is meant that that amino acids other than alanine, serine, and proline can be added in the PAS sequence to a certain degree, e.g., up to about 12%, i.e., about 12 of 100 amino acids of the PAS sequence, up to about 10%, up to about 9%, up to about 8%, about 6%, about 5%, about 4%, about 3%, i.e. about 2%, or about 1%, of the amino acids. The amino acids different from alanine, serine and proline cab be selected from the group consisting of Arg, Asn, Asp, Cys, Gln, Glu, Gly, His, Ile, Leu, Lys, Met, Phe, Thr, Trp, Tyr, and Val. Under logical conditions, a PAS peptide forms a random coil conformation and thereby can mediate an increased in vivo and/or in vitro stability to a inant protein of the invention, and has procoagulant activity. _ 81 _ Non-limiting examples of the PAS peptides are disclosed in, e.g., US Pat. Publ. No. 2010/0292130 A1, PCT Appl. Publ. No.

EP2173890. 11.3.6. HAP In n aspects, a chimeric protein used in the methods of the present sure comprises at least one homo-amino acid polymer (HAP) peptide or fragment, variant, or derivative thereof. A HAP peptide can comprise a tive sequence of glycine, which has at least 50 amino acids, at least 100 amino acids, 120 amino acids, 140 amino acids, 160 amino acids, 180 amino acids, 200 amino acids, 250 amino acids, 300 amino acids, 350 amino acids, 400 amino acids, 450 amino acids, or 500 amino acids in length. A HAP sequence is capable of extending half-life of a moiety fused to or linked to the HAP sequence. Non-limiting examples of the HAP sequence includes, but are not limited to (Gly)n, er)n or Ser)n, wherein n is 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20. In one embodiment, n is 20, 21, 22, 23, 24, 25, 26, 26, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40. In r embodiment, n is 50, 60, 70, 80, 90, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, or 200. See, e.g., schy M el al., Protein Eng.

Design Selection, 20: 273-284 (2007). 11.3. 7. Transferrin In certain aspects, a ic protein used in the methods of the t disclosure comprises at least one transferrin peptide or fragment, variant, or derivative thereof. Any transferrin can fused with the chimeric protein used in the methods of the present disclosure.

As an example, wild-type human Tf (Tf) is a 679 amino acid protein, of approximately 75 kDa (not accounting for glycosylation), with two main domains, N (about 330 amino acids) and C (about 340 amino acids), which appear to originate from a gene duplication. See GenBank accession numbers NM001063, )flVIOO2793, M12530, )flVIO39845, )flVI 039847 and S95936 (www.ncbi.nlm.nih.gov), all of which are herein incorporated by reference in their entirety.

Transferrin transports iron through transferrin receptor (TfR)—mediated endocytosis.

After the iron is released into an endosomal compartment and Tf—TfR complex is recycled to cell surface, the Tf is released back extracellular space for next cycle of iron transporting. Tf possesses a long half-life that is in excess of 14-17 days (Li el al., Trends Pharmacol. Sci. _ 82 _ 23:206-209 (2002)).Transferrin fusion proteins have been studied for half-life extension, targeted deliver for cancer therapies, oral delivery and ned tion of proinsulin (Brandsma el al., hnol. Adv., 29: 230-238 (2011), Bai el al., Proc. Natl. Acad. Sci.

USA 102:7292—7296 (2005), Kim el al., J. Pharmacol. Exp. Ther., 2-692 (2010), Wang el al., J. Controlled e 155:386-392 (2011)). 11.3.8. PEG In certain aspects, a chimeric protein used in the methods of the present disclosure comprises at least one attachment site for a non-polypeptide heterologous moiety or fragment, variant, or derivative thereof. For e, a ic protein used in the methods of the present disclosure can include one or more polyethylene glycol (PEG) moieties attached to one or more amino acid residues in the clotting factor and/or the Fc region.

PEGylation of a protein can refer to a conjugate formed between the protein and at least one polyethylene glycol (PEG) molecule. PEG is commercially ble in a large variety of molecular weights and average molecular weight ranges. Typical examples of PEG average molecular weight ranges include, but are not limited to, about 200, about 300, about 400, about 600, about 1000, about 1300-1600, about 1450, about 2000, about 3000, about 3000-3750, about 3350, about 000, about 3500-4500, about 5000-7000, about 7000- 9000, about 8000, about 10000, about 8500-11500, about 16000-24000, about 35000, about 40000, about 60000, and about 80000 Daltons. These e molecular weights are provided merely as examples and are not meant to be ng in any way.

A chimeric protein used in the methods of the present disclosure can be ted to include mono- or poly-(e.g., 2-4) PEG moieties. tion can be d out by any of the PEGylation reactions known in the art. Methods for preparing a PEGylated protein product will generally include (i) reacting a polypeptide with polyethylene glycol (such as a reactive ester or aldehyde derivative of PEG) under conditions whereby the peptide of the invention becomes attached to one or more PEG groups, and (ii) obtaining the on product(s). In general, the optimal reaction conditions for the reactions will be determined case by case based on known parameters and the desired result.

There are a number of PEG attachment methods available to those skilled in the art, for example Malik F el 61]., Exp. Hematol. 8-35 (1992), Francis, Focus on Growth Factors 3(2):4-10 (1992), European Pat. Pub. Nos. EP0401384, EP0154316, and EP0401384, and International Pat. Appl. Pub. Nos. WO92/16221 and WO95/34326. As a non-limiting _ 83 _ example, FVIII variants can n cysteine substitutions, and the cysteines can be further conjugated to PEG r. See Mei el al., Blood 116:270-279 (2010) and US. Patent No. 7,632,921, which are incorporated herein by reference in their ties. 11.3.9. HES In certain aspects, a chimeric protein used in the methods of the t disclosure comprises at least one hydroxyethyl starch (HES) polymer. HES is a derivative of naturally occurring amylopectin and is degraded by alpha-amylase in the body. HES exhibits advantageous biological properties and is used as a blood volume replacement agent and in hemodilution therapy in the clinics. See, e. g., Sommermeyer el al., Krankenhauspharmazie 8:271-278 (1987), and Weidler el al., Arzneim.-Forschung/Drug Res. 41: 494-498 (1991).

HES is mainly characterized by the molecular weight distribution and the degree of substitution. HES has a mean lar weight (weight mean) of from 1 to 300 kD, from 2 to 200kD, from 3 to 100 kD, or from 4 to 70kD. Hydroxyethyl starch can further exhibit a molar degree of substitution of from 0.1 to 3, from 0.1 to 2, from 0.1 to 0.9, or from 0.1 to 0.8, and a ratio between C2:C6 substitution in the range of from 2 to 20 with respect to the hydroxyethyl groups. HES with a mean molecular weight of about 130 kD is VOLUVEN® from ius. N® is an ial colloid, employed, e. g., for volume replacement used in the therapeutic indication for y and prophylaxis of hypovolaemia. There are a number of HES attachment methods available to those skilled in the art, e.g., the same PEG attachment methods described above. 11.3.10. PSA In certain aspects, a ic protein used in the methods of the present disclosure comprises at least one polysialic acid (PSA) polymer. PSAs are naturally occurring unbranched polymers of sialic acid produced by certain bacterial s and in mammals in certain cells. See, e. g., Roth J. el al. (1993) in Polysialic Acid: From Microbes to Man, eds.

Roth J., Rutishauser U., Troy F. A. (BirkhauserVerlag, Basel, Switzerland), pp. 335—348.

PSAs can be produced in various degrees of polymerization from n=about 80 or more sialic acid residues down to n=2 by limited acid hydrolysis or by digestion with neuraminidases, or by fractionation of the natural, bacterially derived forms of the polymer. There are a number of PSA attachment s available to those skilled in the art, e. g., the same PEG attachment methods described above. In certain aspects, an activated PSA can also be WO 02760 _ 84 _ attached to a cysteine amino acid residue within the clotting , e. g., on FVIII, or within the Fc region. See, e.g., US. Patent No. 5846951. 1. Clearance Receptors In certain aspects, the ife of a chimeric protein used in the methods of the present sure can be extended where the clotting factor of the chimeric protein comprises FVIII and at least one fragment of a FVIII clearance receptor or FVIII-binding nt, variant, or derivative thereof. Insertion of soluble forms of clearance receptors, such as the low density lipoprotein-related protein receptor LRPl, or fragments thereof, can block g of FVIII to clearance receptors and thereby extend its half-life, e. g., in vivo half-life. LRP1 is a 600 kDa integral membrane protein that is implicated in the receptor- mediate clearance of a variety of proteins, including FVIII. See, e.g., Lenting er al., Haemophilia 16:6-16 (2010). Other suitable FVIII clearance receptors are, e.g., LDLR (low- y lipoprotein receptor), VLDLR (very low-density lipoprotein receptor), and megalin (LRP-2), or fragments thereof. See, e.g., Bovenschen el al., Blood 106:906-912 (2005), Bovenschen, Blood 116:5439-5440 (2010), Martinelli el al., Blood 116:5688-5697 (2010).

III. POLYNUCLEOTIDES, VECTORS, AND HOST CELLS ] In some aspects, the present disclosure provides a method of immune tolerance in a human, comprising administering to the human an effective amount of a cleotide or a set of polynucleotides encoding a clotting factor and/or a Fc region, e.g., encoding a chimeric protein comprising a clotting factor and an Fc region, wherein the human failed to respond to one or more previous immune tolerance therapy. In some embodiments, the polynucleotide or the set of polynucleotides is within an expression vector or a set of sion vectors. In certain ments, the sion vector or the set of expression vectors is within one or more host cells.

The polynucleotide encoding a clotting factor and/or a Fc region, e. g., encoding a chimeric protein comprising a clotting factor and an Fc region, used in the methods of the present disclosure can be a single nucleotide sequence, two nucleotide sequences, three nucleotide sequences, or more. In one embodiment, a single nucleotide sequence encodes a chimeric protein comprising a clotting factor (e.g., a FVIII ptide) and an Fc region. In another embodiment, the polynucleotide comprises two nucleotide sequences, the first nucleotide ce encoding a ng factor (e.g., a FVIII) and the second nucleotide _ 85 _ sequence encoding an Fc region. In another embodiment, the polynucleotide comprises two nucleotide sequences, the first nucleotide ce encoding a ng factor (e.g., a FVIII) and an Fc region and the second nucleotide sequence encoding a second Fc region. In certain embodiments, the encoded Fc domains form a covalent bond after expression.

In some embodiments, the polynucleotide is codon-optimized.

As used herein, an sion vector refers to any nucleic acid construct which contains the necessary elements for the transcription and translation of an inserted coding sequence, or in the case of an RNA viral , the necessary ts for replication and translation, when introduced into an appropriate host cell. Expression vectors can include plasmids, phagemids, viruses, and derivatives thereof.

A gene expression control sequence as used herein is any regulatory nucleotide sequence, such as a promoter sequence or promoter-enhancer combination, which facilitates the efficient transcription and translation of the coding nucleic acid to which it is operably linked. The gene expression control sequence may, for example, be a mammalian or viral promoter, such as a constitutive or inducible promoter. Constitutive mammalian ers include, but are not limited to, the promoters for the following genes: hypoxanthine phosphoribosyl transferase (HPRT), adenosine deaminase, pyruvate kinase, beta-actin promoter, and other constitutive promoters. Exemplary viral promoters which function constitutively in otic cells include, for e, promoters from the cytomegalovirus (CMV), simian virus (e.g., SV40), papilloma virus, adenovirus, human immunodeficiency virus (HIV), Rous sarcoma virus, cytomegalovirus, the long terminal repeats (LTR) of Moloney ia virus, and other retroviruses, and the thymidine kinase promoter of herpes simplex virus. Other constitutive promoters are known to those of ordinary skill in the art.

The promoters useful as gene expression sequences of the invention also include ble promoters. Inducible promoters are expressed in the presence of an inducing agent. For example, the metallothionein promoter is induced to promote transcription and translation in the presence of certain metal ions. Other inducible promoters are known to those of ordinary skill in the art.

For the purposes of this invention, numerous expression vector s can be employed. These expression vectors are typically replicable in the host organisms either as episomes or as an integral part of the host chromosomal DNA. Expression vectors can include expression l ces including, but not limited to, ers (e.g., naturally- WO 02760 _ 86 _ associated or heterologous promoters), enhancers, signal sequences, splice signals, enhancer elements, and transcription termination sequences. Preferably, the expression control ces are eukaryotic promoter systems in vectors capable of transforming or transfecting eukaryotic host cells. Expression vectors can also utilize DNA elements which are derived from animal viruses such as bovine papilloma virus, polyoma virus, adenovirus, vaccinia virus, virus, retroviruses (RSV, MlVlTV or MOMLV), galovirus (CMV), or SV40 virus. Others involve the use of polycistronic systems with internal ribosome g sites.

Commonly, expression vectors contain selection markers (e. g., ampicillin-resistance, hygromycin-resistance, tetracycline resistance or neomycin resistance) to permit detection of those cells transformed with the desired DNA sequences (see, e. g., a er al., US Patent No. 4,704,362). Cells which have integrated the DNA into their somes can be selected by introducing one or more markers which allow selection of transfected host cells. The marker can provide for prototrophy to an auxotrophic host, biocide resistance (e.g., antibiotics) or ance to heavy metals such as copper. The selectable marker gene can either be directly linked to the DNA sequences to be expressed, or introduced into the same cell by cotransformation.

An example of a vector useful for optimized expression of the chimeric proteins used in the methods of the t disclosure is A (US. Patent No. 6,159,730). This vector contains the cytomegalovirus promoter/enhancer, the mouse beta globin major er, the SV40 origin of replication, the bovine growth hormone polyadenylation sequence, neomycin phosphotransferase exon 1 and exon 2, the dihydrofolate reductase gene and leader sequence. This vector has been found to result in very high level expression of antibodies upon incorporation of variable and constant region genes, transfection in cells, ed by selection in G418 containing medium and methotrexate amplif1cation. Vector systems are also taught in US Patent Nos. 5,736,137 and 5,658,570, each of which is incorporated by reference in its entirety herein. This system provides for high expression levels, e.g., > 30 pg/cell/day. Other ary vector systems are disclosed e.g., in US Patent No. 6,413,777.

In other embodiments the polypeptides of the instant invention are expressed using polycistronic constructs. In these expression systems, le gene products of interest such as multiple polypeptides of multimer g protein can be produced from a single _ 87 _ polycistronic construct. These systems advantageously use an internal ribosome entry site (IRES) to provide relatively high levels of polypeptides in eukaryotic host cells. Compatible IRES sequences are disclosed in US Patent No. 6,193,980 which is also incorporated herein.

] More generally, once the vector or DNA sequence encoding a polypeptide has been prepared, the expression vector can be introduced into an appropriate host cell. That is, the host cells can be transformed. Introduction of the plasmid into the host cell can be accomplished by various techniques well known to those of skill in the art, as discussed above. The transformed cells are grown under conditions appropriate for the production of the chimeric protein, and assayed for chimeric protein synthesis. Exemplary assay techniques include enzyme-linked immunosorbent assay (ELISA), radioimmunoassay (RIA), or flourescence-activated cell sorter analysis (FACS), immunohistochemistry, and the like.

] Having now described the present invention in detail, the same will be more clearly understood by reference to the following examples, which are included herewith for purposes of illustration only and are not intended to be limiting of the invention.

EXAlVIPLES EXAMPLE 1 Hemophilia A (“factor VIII [FVIII] deficiency”) is a rare bleeding disorder and the most common type of ilia. The most serious treatment complication for patients with ilia A is the development of inhibitory IgG antibodies to FVIII. tors result in rapid clearance of infused FVIII and marked ion or absence of efficacy. FVIII inhibitor bypassing agents are used to treat acute bleeding in patients with tors, but inhibitor eradication is the goal of erm management.

Immune Tolerance Induction (“ITI”) y using frequent administration of high doses of FVIII is the only strategy that has been shown to achieve antigen-specif1c tolerance.

ITI is usually attempted to ate high-responding FVIII inhibitors (ZSBU titer). Several studies have investigated the y of different FVIII products in achieving successful ITI with different doses and injection frequencies and ational sus recommendations have been issued to support ITI approaches in the clinical practice. In an International ITI Study, patients in the High Dose arm (“HD”) (200 IU/Kg/day) ed a negative titer and a normal recovery significantly more rapidly than patients in the Low Dose arm (“LD”). Hay and DiMichele, Blood 119(6):l335-44 (2012). HD patients also experienced significantly less _ 88 _ bleeds than LD patients, and for this reason, the data safety ring board (“DSMB”) recommended study termination because they identified bleeding as a safety issue. The high dose of 200 IU/Kg/day is the recommended dose in the “high-risk” patients (defined as those with peak historical titer >200BU, pre ITI titer >10 BU and/or >5 years since inhibitor diagnosis). There is increasing interest in the investigation of the use of the ed Half- Life (“EHL”) rFVIIIFc in ITI. rFVIIIFc has been ed in the USA in 2014 with the name ofELOCTATE® and in Europe in 2015 with the name ofELOCTA® rFVIIIFc is produced in a human cell line (“HEK293”) as a recombinant B-domain deleted (“BDD”) factor VIII fused to the Fc domain of human IgG. HEK-produced proteins have similar post-translational ations as native human proteins, in contrast to proteins produced in cell lines from other species, such as hamsters (e. g., CHO cells). In such proteins, non-human glycans (such as N—glycolylneuraminic acid, NGNA and galactose- alpha-1,3-galactose, allpha-Gal) resulting from the post-translational modifications can be potentially immunogenic. Neither NGNA, nor alpha-Gal is found in rFVIIIFc. Mice models have also shown that rFVIIIFc induces regulatory T cell responses to FVIII (See Batsuli Hemophilia (2016), 22 (Suppl. 5), 31—35), suggesting to some investigators that rFVIIIFc could provide more effective ITI, cally shortening ITI, than rFVIII.

Objectives The primary objective of the present study is to describe the time to tolerance with Fc in patients after ITI treatment. The study also aims to describe the outcome of ITI treatment, to describe the relapse rate over a period of time after successful ITI performed with rFVIIIFc, to describe the intercurrent bleeding during ITI and during the period after successful ITI performed with Fc, to describe safety and tolerability of rFVIIIFc when used for ITI, to describe specific quality of life (QoL) questions, and to demonstrate rFVIIIFc consumption.

EXAMPLE 2 The present study aims to describe the use of rFVIIIFc for ITI in ts with severe heamophilia A with inhibitors who have failed previous ITI ies. Specifically, primary objective of this study is to be the outcome of ITI ent performed with rFVIIIFc in patients who failed us attempts of tolerization, including use of immunosuppressants, after ITI treatment. Secondary objectives and their endpoints include: (1) to describe time to _ 89 _ tolerization of ITI performed with rFVIIIFc in patients who failed previous attempts of tolerization; including use of immunosuppressants; with an endpoint of time to ITI success; (2) to describe the relapse rate after successful ITI performed with rFVIIIFc; with an endpoint of ence of e; (3) to be the urrent bleeding during ITI and during the period after successful ITI performed with rFVIIIFc; with an endpoint of ng rate; (4) to describe safety and tolerability of rFVIIIFc when used for ITI; with endpoints of adverse events and/or injection site reactions; and (5) to be the consumption of rFVIIIFc in ITI performed with ELOCTA®; with an endpoint of rFVIIIFc.

EXAMPLE 3 In this study; male ts of all ages with severe hemophilia A and high titer inhibitors (historical peak 25 Bethesda Unit [BU]/mL) will receive recombinant coagulation factor VIII Fc fusion protein (rFVIIIFc) for undergoing first time immune tolerance induction (ITI) therapy; for eradicating and neutralizing anti-coagulation factor VIII (FVIII) alloantibodies.

Participants will receive rFVIIIFc at a dose of 200 international units (IU)/kilogram (kg) as once daily injections or divided on several injections per day at the discretion of the Investigator; starting at baseline visit up to maXimum of 48 Weeks in ITI Period. Participants who meet the criteria for immune tolerance induction (ITI) success will enter the tapering period and will receive rFVIIIFc (as powder for injection administered Intravenously) at a dose adjusted according to Investigator judgment (50 or 100 IU/kg) once a day from Week 1 to 6 and every other day thereafter through Week 16.

The primary outcome measure of this study is to describe the time to tolerization with rFVIIIFc during a time frame of up to 12 months. Tolerization is defined as inhibitor titer /ml; FVIII recovery > 66%; and tug of Z 7hrs.

] A ary outcome measurement is the number of participants with immune tolerance induction (ITI) success. ITI Success will be d as: ve titer for inhibitor less than (<) 0.6 BU/mL by the Nijmegen-modif1ed Bethesda assay; FVIII incremental recovery (IR) >l.3 international units per ter (IU/dL) per IU/kg in 2 consecutive determinations representing 66% of the ed IR 2 IU/dL per IU/kg; half-life (ll/2) 37 hours. ITI success will be monitored over a time frame of up to 48 weeks.

Another secondary outcome measurement is the number of participants who experience relapse. The percentage of participants with ITI success that reach the criteria for _ 90 _ relapse (defined as inhibitor titer > 0.6 BU/mL or al recovery after tolerance is achieved) will be evaluated. Relapse will be monitored over a time frame of up to 48 weeks.

Another secondary outcome measurement is the number of bleeding episodes. A bleeding episode started form the first sign of a bleed and ended no more than 72 hours after the last treatment for the bleed, within which any symptoms of bleeding at the same location or ions less than or equal to 72 hours apart, was considered the same bleeding episode.

Bleeding episodes will be monitored over a time frame of up to week 104.

Another secondary outcome measurement is the number of participants with treatment-emergent adverse events (ABS) and treatment-emergent s adverse events (SAEs). An AB is any untoward medical occurrence that does not necessarily have a causal onship with this treatment. An SAE is any untoward l occurrence that at any dose: results in death; in the view of the Investigator, places the participant at immediate risk of death (a life-threatening event), requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, results in a ital anomaly/birth defect, any other medically important event that, in the opinion of the Investigator, may dize the participant or may require intervention to prevent one of the other outcomes listed in the definition. ABS and SAEs will be measured for a time frame of about 2 years. r secondary outcome measurement is the number of days away from work or school. Number of days missed from school or work will be summarized descriptively, over a time frame of up to week 104. r secondary outcome measurement is the number of hospitalization days. The number of hospitalization days will be summarized ptively and monitored over a time frame of up to week 104.

Another secondary outcome measurement is the adherence to ent regimen, which is defined as percentage of stered doses versus planned doses, and which is monitored over a time frame of up to week 104. r secondary outcome measurement is consumption of rFVIIIFc. Consumption will be assessed based on amount of administered study treatment, and consumption will be monitored over a time frame of up to week 104.

The present study will be directed to male participants of any age diagnosed with severe hemophilia A (as confirmed from the medical record). Subject will have been _ 91 _ diagnosed with high titer inhibitors (historical peak r than or equal to (3) 5 ical units per milliliter (BU/mL); according to l records), and ts will have been previously treated with any plasma-derived or recombinant conventional or Extended Half- Life FVIII. Exclusion criteria includes subjects that have any other coagulation disorder(s) in addition to hemophilia A; any previous ITI therapy; a history of hypersensitivity or anaphylaXis associated with any recombinant coagulation factor VIII Fc (rFVIIIFc) administration; any abnormal renal function (serum creatinine greater than 2.0 milligrams per deciliter [mg/dL]) as assessed by local laboratory; and/or serum alanine aminotransferase or aspartate aminotransferase > 5 X upper limit of normal (ULN) as ed by local laboratory.

EXAMPLE 4 A noninterventional retrospective chart review of ITI with rFVIIIFc in patients with severe haemophilia A and itre inhibitors (HTI; 25 BU) was conducted across 10 sites in the United States and Canada between July 1; 2014; and June 1; 2017. Male patients of all ages with severe haemophilia A with HTI who had initiated treatment with rFVIIIFc for ITI; either as primary or rescue therapy; regardless of response; were included.

After institutional regulatory approval; de-identif1ed clinical information was ted via an electronic survey. Patients treated for the first time with ITI were considered at high risk for ITI failure according to the criteria listed earlier. Negative Bethesda titre was defined as £06 BU. Tolerization was defined as negative Bethesda titre and normal FVIII recovery (266%) and half-life (26 hours). The primary ive of this study was to report the clinical characteristics and outcomes of ITI using Fc. Results are ized using descriptive statistics; no inferential statistical analysis was conducted.

Results Study Population Nineteen patients were identified. Of these; seven were receiving ITI for the first time and 12 were oing rescue ITI (Tables 1 and 2). Median age at initiation of rFVIIIFc ITI was 1.3 years (range: 0.8—4.3 years) for time ITI and 6.4 years (range: 1.6—12.6 years) for rescue ITI patients.

First-time ITI patients had a median peak historical inhibitor (pre-ITI) titre of 151 BU (range: 11—1126 BU); the median inhibitor titre at start of rFVIIIFc ITI was 52 BU (range: 3— 1126 BU). At the start of ITI; siX of seven f1rst-time ITI patients had titres >10 BU; four of _ 92 _ these siX had titres >50 BU. The median time from inhibitor diagnosis to start of Fc ITI was 4.4 weeks (range: 0—41 weeks).

For rescue ITI patients, the mean number of prior ITI courses with other FVIII ts was 2.6 (range: 1—5) and the median time from inhibitor diagnosis to the start of rFVIIIFc ITI was 5.5 years (range: 08—12 years). FVIII genotypes for 18 of the 19 patients are shown in Tables 1 and 2.

Finst-time IT1patient outcomes At the time of data tion, four of seven patients undergoing f1rst-time ITI (Table 1) were tolerized and had transitioned to laxis with rFVIIIFc. Three of these four patients achieved a negative Bethesda titre and normal FVIII recovery and half-life, as such, they met the standard definition of zation at 5, 7, and 9 months. The fourth t was considered tolerized by the treating physician at 14.8 months based on a negative tor titre and having been transitioned to prophylaxis, at the time of data collection that patient was 13 months post completion of rFVIIIFc ITI and he continued to have a negative inhibitor on rFVIIIFc prophylaxis. A normal half-life was also reported at that time.

Table 1: Patients receiving ITI for the first time.

Time to peak rFVIIIFc Current negative Geno- pre— Bethesda Current Patient inhibitor . ITI titer Bethesda type rFVIIIFc t1ter t0 titer . status reglmen (BU/mL) titer ITI start of (BU/mL) (weeks) (BU/mL) rFVIIIFc Proh laxis Frame- rFVIIIFc 150. 9 106. 9 Prophylaxis rFVIIIFc 1 126 1 126 Prophylaxis rFVIIIFc Proh laxis rFVIIIFc :a-:378.7 ITI rFVIIIFc 378.1 rFVIIIFc p—1 [\J [\J BU, Bethesda units, EOD, every other day; I-22, intron 22 inversion; ITI, immune tolerance induction, NR, not ed; N/A, not applicable; rFVIIIFc, recombinant factor VIII Fc fusion n. Time to tolerization based on physician report, resolved Bethesda titer, normal recovery and half-life. Patient 4 did not have recovery and _ 93 _ half-life information ble but was reported as tolerized by physician and switched to rFVIIIFc prophylaxis. aReceived rituXimab.

Among the four ts, the median time to attain a negative Bethesda titre was 27.7 weeks (range: 4.1—64 weeks). The ITI n for three of the four tolerized patients consisted of daily rFVIIIFc (85—200 IU/kg) compared with three-times-per-week dosing (50 IU/kg) for the fourth patient (Table 1). Median time to reported tolerization was 33.9 weeks (7.8 ; range: 21—64 weeks) for all four patients. For the three patients treated with daily rFVIIIFc (85—200 IU/kg), tolerization took 29 weeks (6.7 ; range: 20.6—38 weeks), however the fourth patient treated with 50 IU/kg three times per week tolerized in 64 weeks (14.8 months).

Of the remaining patients (n=3), two had a decrease in Bethesda titre (from 32 to 18 BU and 378 to 23 BU after 18 and 58 weeks of ITI, tively). At the time of this review, one patient had an increase in Bethesda titre (from 3 to 16 BU after 15 weeks of ITI), this patient has been on and off ITI and has had rFVIIIFc interruptions and poor compliance per treating physician report (Table 1). All seven first-time ITI patients continue on rFVIIIFc ITI or prophylaxis.

Rescue 1T1patient outcomes Seven of 12 patients undergoing rescue ITI (Table 2) lly achieved Bethesda vity with rFVIIIFc ITI. Median time to attain a negative titre was 14.1 weeks (range: 3— 67.6 weeks). Three of these seven patients remain Bethesda negative and continue on rFVIIIFc ITI or rFVIIIFc wean to prophylaxis. The other four patients who initially achieved a negative titre later developed a titre >O.6 BU. Of these, two continue on rFVIIIFc ITI and two were transitioned to ITI with other factors (Table 2).

Table 2: ts receiving rescue ITI.

Historical 11121211?“ Time to peak rFVIIIFc Current negative before Current Patient inhibitor ITI titer da rFVIIIFc titerb status titer regimen (BU/mL) (BU/mL) (weeks) BU/mL 202 “mg rFVIIIFc 8 1-22 5 250 9 <06 28 da11 ITI wean Large 200 IU/kg Fc 100 IU/kg rFVIIIFc 12“ 1-22 2 200 1501UA<- OtherITI rFVIIIFc rFVIIIFc rFVIIIFc rFVIIIFc rFVIIIFc Large rFVIIIFc 18 4 1024 237 deletion ITI Non- Bypass 19 4 409 26 sense therapy BU; Bethesda units; EOD; every other day; 1-22; Intron 22 Inversion; ITI; immune tolerance induction; rFVIIIFc; recombinant factor VIII Fc fusion n; wk; week. aReceived rituximab; bTime to negative Bethesda titer represents time from start of rFVIIIFc ITI to first report of negative titer; current titer >0.6 BU/mL may represent recurrence.

] Of the seven patients achieving Bethesda negativity; three also achieved normal FVIII recovery at 3; l4; and 65 weeks and a fourth patient reached normal FVIII half-life at 27 weeks. Recovery and half-life were not available in others (Table 2). Of the remaining five ts; one had a decrease in da titre (from 36 to 22 BU after 10 weeks) and four had the Bethesda titre either remain unchanged or increased while on ITI (Table 2). Of these five patients; four continue on rFVIIIFc ITI and one was removed from ITI and placed on bypass therapy alone.

Dosing outcomes, bypass agent use, and current treatment status The patient population ed in this study received a wide range/timing of doses s 1 and 2). A trend toward rapid negative inhibitor titres was seen with higher doses stered daily. Five of five patients (one first-time ITI and four rescue ITI) who ed a daily rFVIIIFc dose of 2130 IU/kg achieved a negative Bethesda titre at a median of 28 weeks. Eighteen of 19 patients used bypass agents concurrently with rFVIIIFc ITI; fourteen were primarily on laxis (9 with aPCCs and 5 with rFVIIa) and four were treated on demand with rFVIIa.

Overall; 16 of 19 patients remained on rFVIIIFc (prophylaxis or ITI) at the time of data collection (Tables 1 and 2).

Safety No adverse events; including no thromboembolisms; were reported. Six surgeries were performed; all of them without interruption of rFVIIIFc ITI (knee synovectomy; _ 95 _ intracranial neurosurgical evacuation, and four Port-A-Cath replacements). Bypass therapy was used in all. Inhibitor titres during surgeries were not collected for this study.

Conclusions Collectively, these results show that ITI with rFVIIIFc is possible and can result in inhibitor eradication and successful ITI in many (high risk for ITI failure) patients oing first-time ITI and in some patients undergoing rescue ITI. Furthermore, rFVIIIFc ITI demonstrated a rapid decrease in Bethesda titres and rapid time to zation in the majority of patients receiving first-time ITI despite their risk . For rescue ITI, it is more difficult to make conclusions as most of these ts were still undergoing ITI with rFVIIIFc at the time of data collection. However, some patients receiving rescue treatment did appear to derive therapeutic benefit in that they either achieved Bethesda negativity or showed significant drops in inhibitor titres. This was particularly the case when higher rFVIIIFc dosing (2130 IU/kg) was administered daily.

EXAMPLE 5 ] The main complication of replacement therapy with factor in hemophilia A is the formation of inhibitors (neutralizing anti—factor VIII antibodies) in ~30% of patients with severe hemophilia A. Inhibitor development impacts ent efficacy as well as the y of life of affected individuals. Further understanding of how the immune system responds to inant factor 111 I) is an ongoing effort in hemophilia research to effectively eradicate inhibitors. The extended half-life rFVIII Fc fusion protein IFc) is an efficacious and well-tolerated therapy to prevent and control bleeding episodes. The Fc region of this molecule is not only responsible for increasing rFVIII ife but may promote antigen-specific nce, as shown in a preclinical animal model (Krishnamoorthy S, et al., Cell Immunol. 301:30-39 (2016)) and as suggested by immune tolerance induction case reports (Groomes CL, et al., Pedialr Blood Cancer 63(5):922-24 (2016), Malec LM, et al., Haemophilia 22(6):e552-e554 (2016), Ragni MV, et al., Haemophilia 22(5):e462-e464 Methods Peripheral blood-derived human APCs or THP-l monocytic cells were used to investigate the effects of rFVIIIFc on FcyR binding, internalization, signaling and cytokine _ 96 _ production, and gene sion changes, as well as subsequent interactions and effects on T cells in vitro (.

Results Decreased cell surface expression of FcyR indicates internalization upon Fc treatment (FIGs. 2A-2C). te-derived macrophages and dendritic cells were treated with horseradish peroxidase immune complexes (HRP-IC) as positive control, human immunoglobulin Gl (IgGl) as negative control, and with recombinant factor VIII (rFVIII) or rFVIII Fc fusion n (rFVIIIFc) at equimolar concentrations (200 nM) for 24 hours. The cell surface expression of the Fcy receptors (FcyR) CD16 (), CD32 (), and CD64 () was ed by flow cytometry (n=3, >“*PSOOl, >“""“PSO.005, significance for HRP-IC to other treatments not shown). Treatment with rFVIIIFc correlated with decreased cell surface expression of CD16 (), CD32 (), and CD64 (), as compared to surface expression following treatment with rFVIII. rFVIIIFc engages FcyR and induces signaling in monocytes and hages, without subsequent proinflammatory cytokine production (FIGs. 3A-3C). THP-l monocytic cell line, monocytes, peripheral blood monocyte-derived macrophages, and peripheral blood monocyte-derived dendritic cells were treated with HRP-IC, IgGl, rFVIII or rFVIIIFc for 15 minutes (). Syk phosphorylation was measured in cell s using the MSD platform (n=3—7, *PSOOS). Syk phosphorylation was measured after treating macrophages with rFVIIIFc (WT), with mutant rFVIIIFc that is unable to bind to neonatal Fc receptor (FcRn mutant), or with mutant rFVIIIFc that is unable to bind to FcyR (FcyR mutant) (n=4, *PSOOS) (). Proinflammatory cytokine production of the twenty-four-hour treated macrophages were measured by MSD ELISA (n=4, signif1cance not shown) (). rFVIIIFc phosphorylates molecules taking part in regulation, rather than molecules playing role in activation and ammatory cytokine tion (Table 3 and . Phosphorylated proteins in lysates from te-derived macrophages d with rFVIIIFc for n minutes were queried using the Proteome Profller phospho-kinase and phospho-immunoreceptor . A list of phosphorylated molecules in rFVIIIFc-treated macrophages identified by the Proteome Profller assays is shown in Table 3. Phosphorylation of phosphatases responsible for inhibitory signaling were measured using the MSD rm (n=3, **P£0.01, ***P£0.005) (. _ 97 _ Table 3: Phosphorylated molecules in rFVIIIFc-treated macrophages identified by a Proteome Profiler assa s.

Phosphorylated Proteins STATS (U WN K1 O p7056 C ' 3 JNK1/2/3 FAK E esmam RSK1/2/3 rFVIIIFc induces gene expression pattern characteristic of genic macrophages (FIGs. 5A-5G). Exploratory RNA sequencing was performed on monocyte-derived macrophages treated with IgGl, rFVIII, or rFVIIIFc for six hours (n=3) for genes that were significantly downregulated () and for genes that were significantly upregulated (), and a pathway is was run on the rFVIIIFc-upregulated genes to investigate the molecular ys ented selectively in these cells, compared to -treated cells (Table 4). Various genes of the NRF2 and PPAR-gamma pathways were found to be upregulated, as well as various other immunoregulators (). Selected genes of the NRF2 and lipid lism pathways were validated by Q-PCR (n=8, *PSOOS, >“*PSOOI, >“""“P£O.005) (FIGs. 5C-5G). In addition, rFVIIIFc-educated macrophages were found to exhibit a characteristic M2-like phenotype (FIGs. 51-5M). In particular, macrophages treated with Fc had higher ve CD206 expression than cells treated with rFVIII after 6 hours (FIG. SI) and after 24 hours (FIG. SJ), and macrophages treated with rFVIIIFc had higher relative ARGl expression than cells d with rFVIII after 24 hours ().

Table 4: Run pathway analysis on the rFVIIIFc-upregulated genes to investigate the molecular athwa s reoresented selectivel in these cells, com oared to rFVIII-treated cells.

Set Candidates NRF2 athwa 10 7.0% 4.07e-O6 0.000273 Lioororoteinmetabolism a710.3% l.Ole-05 0.000338 L1p1d d1gestlon, moblllzatlon, and 8 (7.3%) 05 0.000684 trans oort Cyste1ne and methlon1ne metabollsm- (11.1%) 0.000137 0.00229 Homo saolen human C-MYB transcrition factor network a 6 7.0% 0.000389 0.00521 Nuclearreceootorsmeta-athwa 113.5% 0.000813 0.00908 _ 98 _ Fc-treated antigen presenting cells influence regulatory T-cell differentiation that requires APC—T cell-cell contact (FIGs. 6A-6C). Peripheral blood monocyte-derived macrophages were d with IgGl, rFVIII, or Fc, then placed into co-culture with naive CD4 positive T cells isolated from peripheral blood from the same donor. After six days in co-culture (), the percent of regulatory T cells (CD4+ CD25+ FoxP3+) was quantified using flow cytometry (n=4) (). The percent of regulatory T cells were also quantified when naive T cells were cultured in the conditioned media of APCs pretreated with IgGl, rFVIII, or rFVIIIFc (n=4) ().

Conclusion rFVIIIFc appears to bind and induce internalization and ing through Fcy receptors on APCs. This signaling does not ate to proinflammatory cytokine production and does not activate the APCs (data not . Immunomodulatory signaling events are initiated upon rFVIIIFc treatment. These events appear to drive hage differentiation towards an M2-like phenotype characterized by the upregulation of NRF2 and PPARy pathways () as well as the upregulation of CD206 and arginase 1 molecules. Various other immunoregulators also showed increased expression, while at least ate cyclase l soluble subunit beta (2GUCYlB2), protoporphyrinogen oxidase (PPOX), and suppressor of cytokine signaling 3 (SOCS3) showed sed expression in rFVIIIFc treated cells (). These macrophages may execute the beneficial immunological effects previously reported, such as regulatory T-cell differentiation, FVIII zation, and anti-FVIII inhibitor reduction (.

EXAMPLE 6 Early preclinical and clinical data indicate that rFVIIIFc may allow a relatively short time to negative inhibitor titre when used for ITI ent, possibly due to immunomodulatory effects attributed to the Fc domain of the molecule. In order to obtain more robust clinical data a standardized protocol was ped. The study design is presented here.

ReITIrate (NCTO3lO3542), a prospective, interventional, multicenter, open label study, aims to enroll 20 severe HA inhibitor patients, all ages, who failed previous ITI attempts. The primary purpose of the study is to describe the e of ITI performed with _ 99 _ rFVIIIFc within a timeframe of 60 weeks. The primary endpoint will be ITI success; and the secondary endpoints assessed during ITI treatment will include time to ITI success, occurrence of relapse, number of bleeds, rFVIIIFc consumption, days of missed school or work, hospitalizations and nce. The ITI treatment will comprise rFVIIIFc 200 IU/kg/day (once daily or divided on two daily doses) for a maximum of 60 weeks. After tolerance has been ed, a tapering period of 16 weeks and a 32 weeks -up with rFVIIIFc given prophylactically follows. Success criteria will include negative inhibitor titre (<O.6 Bethesda Unit), ental recovery >66% of expected, and terminal half-life of 27 hours. shows the proposed effects of rFIXFc on macrophages. rFVIIIFc appears to bind and to induce internalization and signaling through Fcy receptors on APCs. This signaling does not translate to pro-inflammatory cytokine production and does not activate the APCs. Rather, immunomodulatory signaling events are initiated upon rFVIIIFc treatment.

These events appear to drive macrophage differentiation towards an ‘Mox/MZ-like‘ ype characterized by the lation ofNRF2 and PPARy pathways.

The foregoing description of the specific embodiments will so fully reveal the general nature of the invention that others can, by applying knowledge within the skill of the art, y modify and/or adapt for various applications such specific embodiments, without undue experimentation, without departing from the general concept of the present invention.

Therefore, such tions and modifications are intended to be within the meaning and range of lents of the disclosed embodiments, based on the ng and guidance presented herein. It is to be understood that the ology or terminology herein is for the purpose of description and not of tion, such that the terminology or phraseology of the present specification is to be interpreted by the skilled artisan in light of the teachings and Other embodiments of the invention will be apparent to those skilled in the art from consideration of the cation and practice of the invention disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims.

All ations, patents, and patent applications disclosed herein are incorporated by reference to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated by reference. - lOO -

Claims (15)

WHAT IS CLAIMED IS:

1. Use of a chimeric protein comprising a clotting factor and an Fc region in a method for inducing immune tolerance in a human with hemophilia, wherein (1) an effective amount of the ic protein sing a clotting factor and an Fc region is administered to the human for a period sufficient to induce immune tolerance, wherein the effective amount of the chimeric protein comprising a clotting factor and an Fc region induces immune tolerance in the human; and (2) following induction of immune tolerance, a tapering regimen of the chimeric protein comprising a clotting factor and an Fc region is administered to the human.

2. The use of claim 1, wherein the effective amount of the chimeric protein comprising FVIII and an Fc region is about 50 IU/kg to about 300 IU/kg.

3. Use of a chimeric protein comprising a clotting factor and an Fc region in a method for inducing immune tolerance in a human with hemophilia, wherein about 200 IU/kg of the chimeric protein is administered to the human for a period sufficient to induce immune tolerance, and wherein the human has developed an inhibitor against the clotting factor and failed to respond to one or more previous immune tolerance therapy against the clotting factor.

4. The use of claim 3, n following immune tolerance, the human is administered a tapering regimen of the chimeric protein comprising a clotting factor and an Fc region.

5. The use of any one of claims 1 to 4, wherein the chimeric protein sing a clotting factor and an Fc region comprises Factor VIII-Fc (FVIII—Fc) or Factor IX-Fc (FIXFc).

6. The use of any one of claims 1 to 5, wherein the ic protein sing a clotting factor and an Fc region is administered until immune nce is ed, wherein immune tolerance is ed when the titer of the inhibitory antibodies in the human is less than about 0.6 BU.

7. The use of any one of claims 1, 2, and 4 to 6, wherein the tapering regimen comprises stering a ng dose of about 50 IU/kg to about 100 IU/kg of the chimeric protein comprising a ng factor and an Fc .

8. The use of any one of claims 1, 2, and 4 to 7, wherein the tapering dose is administered once a day, once every other day, or three times every week.

9. The use of any one of claims 1, 2, and 4 to 8, wherein the tapering dose is administered for at least about 1 week, at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 5 weeks, at least about 6 weeks, at least about 7 weeks, at least about 8 weeks, at least about 9 weeks, at least about 10 weeks, at least about 11 weeks, at least about 12 weeks, at least about 13 weeks, at least about 14 weeks, at least about 15 weeks, at least about 16 weeks, at least about 17 weeks, at least about 18 weeks, at least about 19 weeks, at least about 20 weeks, at least about 21 weeks, at least about 22 weeks, at least about 23 weeks, at least about 24 weeks, at least about 25 weeks, at least about 26 weeks, at least about 27 weeks, at least about 28 weeks, at least about 29 weeks, at least about 30 weeks, at least about 31 weeks, or at least about 32 weeks.

10. The use of any one of claims 1, 2, and 4 to 9, wherein the tapering regimen comprises administering a tapering dose of the chimeric protein comprising a clotting factor and an Fc region of about 50 IU/kg once a day from week 1 to week 6 following immune tolerance or administering a tapering dose of the chimeric protein of about 100 IU/kg once a day from week 1 to week 6 following immune tolerance.

11. The use of claim 10, wherein the tapering regimen further comprises administering a tapering dose of the ic protein comprising a clotting factor and an Fc region of about 50 IU/kg or about 100 IU/kg once every other day from week 6 to week 12 following immune tolerance, and/or administering a tapering dose of the chimeric protein of about 50 IU/kg or about 100 IU/kg once every other day from week 12 to week l6.

12. The use of any one of claims 1, 2, and 4 to 11, further comprising administering a prophylactic dose of the chimeric protein comprising a clotting factor and an Fc region following the ng regimen.

13. The use of any one of claims 1 to 12, wherein the time to tolerance is less than about 24 weeks, less than about 23 weeks, less than about 22 weeks, less than about 21 weeks, less than about 20 weeks, less than about 19 weeks, less than about 18 weeks, less than about 17 weeks, less than about 16 weeks, less than about 15 weeks, less than about 14 weeks, less than about 13 weeks, less than about 12 weeks, less than about 11 weeks, less than about 10 weeks, less than about 9 weeks, less than about 8 weeks, less than about 7 weeks, less than about 6 weeks, less than about 5 weeks, less than about 4 weeks, less than about 3 weeks, less than about 2 weeks, or less than about 1 week.

14. The use of any one of claims 5 to 13, wherein the FVIII comprises a B domain deleted FVIII.

15. The use of any one of claims 1 to 14, wherein the administration of the chimeric protein comprising a clotting factor and an Fc region results in a lower time to tolerance in the human as compared to the time to tolerance in a human ing treatment with a clotting factor alone.