RU2795570C2 - Treatment of pathological bone conditions in patients with acid sphingomyelinase deficiency - Google Patents

Abstract

FIELD: medicine; pharmaceuticals.

SUBSTANCE: invention relates to a method for improving the pathological condition of the bone in a patient with acid sphingomyelinase deficiency (ASMD), and the method includes administering multiple doses of olipudase-alpha to the patient, where improvement in the abnormal condition of the bone is indicated by an improvement in the bone condition of the patient after multiple doses of olipudase-alpha.

EFFECT: technical result is alleviating the pathological conditions of the bone by enzyme replacement therapy using ASM in patients with ASMD, including an increase in their bone density and a decrease in their bone marrow "load".

23 cl, 4 dwg, 3 tbl, 1 ex

Description

CROSS-REFERENCE TO RELATED APPLICATION

[0001] This application claims priority over U.S. Provisional Application No. 62/549732, filed August 24, 2017, and European Patent Application No. 17306720.8, filed December 7, 2017. The disclosure of these two priority applications is incorporated herein by reference in its entirety.

Sequence listing

[0002] This application contains a sequence listing that has been filed electronically in ASCII format and is hereby incorporated by reference in its entirety. The ASCII copy of this file created on August 10, 2018 is named 022548_WO047_SL.txt and is 21687 bytes in size.

FIELD OF TECHNOLOGY TO WHICH THE INVENTION RELATES

[0003] This application relates to the use of human acid sphingomyelinase for the treatment of pathological bone conditions in patients with acid sphingomyelinase deficiency (ASMD).

BACKGROUND OF THE INVENTION

[0004] Acid sphingomyelinase deficiency (ASMD) is a rare life-threatening lysosomal storage disease. It is an autosomal recessive genetic disorder that results from mutations in the SMPD1 gene encoding the lysosomal enzyme acid sphingomyelinase (ASM) (Schuchman et al., Mol. Genet. Metab. 120(1-2):27-33 (2017 )). ASMD patients do not metabolize sphingomyelin, which as a result accumulates in lysosomes in many organs, causing disease and neurodegeneration of internal organs in severe cases. Patients with ASMD have elevated levels of cholesterol and other lipids in the spleen, liver, lungs, and bone marrow.

[0005] Pediatric neurovisceral ASMD (formerly known as Niemann-Pick disease type A or NPD A), the most severe disease phenotype, is characterized as an acute neuropathic form with early onset and results in decreased weight gain and stunting, hepatosplenomegaly, and rapidly progressive neurodegeneration. Patients die in early childhood (McGovern et al., Neurology 66(2):228-232 (2006)). In patients with chronic visceral ASMD (NPD B) and chronic neurovisceral ASMD (NPD A/B), disease presentation varies from infancy to adulthood (Wasserstein et al., Pediatrics 114(6):e672-677 (2004); Wasserstein et al ., J. Pediatrics 149(4):554-559 (2006)). NPD B patients are usually diagnosed in childhood, usually after the age of 2 years. Most patients with NPD B survive to adulthood. Patients with NPD A/B are classified as having an intermediate form with childhood neurological symptoms that may develop into a neurodegenerative disease.

[0006] Pathological manifestations due to diseases of the liver, lungs and hematological diseases occur in all patients with chronic ASMD and include hepatosplenomegaly, liver dysfunction, infiltrative lung disease and thrombocytopenia (McGovern et al., Genet. Med. 15(8):618 -623 (2013), McGovern et al., Orphanet J. Rare Dis. 12(1):41 (2017)). Childhood growth retardation and bone damage such as low bone density are also common features of chronic ASMD (Wasserstein et al., J. Pediatr. 142(4):424-428 (2003)). Lung and liver diseases are the leading causes of death in these patients (McGovern et al., Pediatrics 122(2):e341-349 (2008); Cassiman et al., Mol. Genet. Metab. 118(3):206-213 ( 2016)).

[0007] In view of the high rates of morbidity and mortality from ASMD, there remains an urgent need for effective treatment of this genetic disease.

BRIEF DESCRIPTION OF THE INVENTION

[0008] The present invention provides a method of treating a bone condition in a patient with acid sphingomyelinase deficiency (ASMD), comprising the steps of administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient, measuring the bone condition score of the patient, and comparing the bone condition score of the patient with a baseline measure of the patient's bone condition before the administration stage, where the patient's bone condition score improves or does not worsen after multiple doses of rhASM. In some embodiments, the measure of bone health is bone mineral density (BMD), where BMD improves (eg, increases) or does not worsen after multiple doses of rhASM. In some embodiments, an indication of bone health is bone marrow "load" (BMB), where BMB decreases or does not increase after multiple doses of rhASM. In some embodiments, an indicator of bone health is skeletal development (eg, bone maturation and/or linear growth), where skeletal development improves after multiple doses of rhASM. In certain embodiments, the pathological condition of the bone is osteopenia or osteoporosis.

[0009] The present invention also provides a method for reducing bone marrow (BMB) "burden" in an acid sphingomyelinase deficient patient in need thereof, comprising the steps of determining BMB in the patient and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient, by causing the patient's BMB to decrease.

[0010] The present invention also provides a method for improving bone mineral density (BMD) in an acid sphingomyelinase deficient patient in need thereof, comprising the steps of determining the patient's BMD and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient, whereby the patient's BMD is improving.

[0011] The present invention also provides a method of reducing bone marrow "burden" (BMB) in an acid sphingomyelinase deficient patient in need thereof, comprising the steps of selecting an acid sphingomyelinase deficient patient who is not receiving bisphosphonate therapy and administering to the patient multiple doses of recombinant human acid sphingomyelinase (rhASM), which reduces the patient's BMB.

[0012] The present invention also provides a method for improving (e.g. increasing) bone mineral density (BMD) in an acid sphingomyelinase deficient patient in need thereof, comprising the steps of selecting an acid sphingomyelinase deficient patient who is not receiving bisphosphonate therapy and administering to the patient multiple doses of human recombinant acid sphingomyelinase (rhASM), thereby improving the patient's BMD.

[0013] The present invention also provides a method for improving skeletal development (e.g., bone maturation and/or linear growth) in an acid sphingomyelinase deficiency (ASMD) patient in need thereof, comprising the steps of selecting an ASMD patient to improve skeletal development and administering to the patient multiple doses of human recombinant acid sphingomyelinase (rhASM), thereby improving the development of the skeleton in the patient.

[0014] The present invention also provides a method for improving or maintaining quality of life in an acid sphingomyelinase deficiency (ASMD) patient in need thereof, comprising the steps of selecting an ASMD patient to improve quality of life and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient thereby improving or maintaining the patient's quality of life.

[0015] The present invention also provides a method of treating osteopenia in an acid sphingomyelinase deficiency (ASMD) patient in need thereof, comprising the steps of selecting an ASMD patient for osteopenia treatment and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient.

[0016] The present invention also provides a method of treating osteoporosis in an acid sphingomyelinase deficient patient in need thereof, comprising the steps of selecting an ASMD patient for osteoporosis treatment and administering multiple doses of recombinant human acid sphingomyelinase (rhASM) to the patient.

[0017] In any of the treatments described herein, multiple doses may be administered to a patient over a period of six to thirty months. Thus, the mentioned effect of multiple doses of rhASM is achieved in the indicated period.

[0018] In any of the treatments described herein, the patient may have, for example, chronic visceral ASMD (Niemann-Pick disease type B) or chronic neurovisceral ASMD (NPD A/B). The patient may be an adult patient or a pediatric patient.

[0019] In any of the treatments described herein, the first two or more doses of rhASM may be escalating doses and may be administered in sequentially increasing amounts. In some embodiments, the doses administered after the escalation doses are maintenance doses (which may start, for example, with the highest maintenance dose) and may be administered in the same or less amount than the last escalation dose. In certain embodiments, the highest maintenance dose is the highest dose tolerated by the patient. The first dose may be, for example, 0.1 mg/kg for both adult and pediatric patients. The highest maintenance dose may be, for example, 0.3 mg/kg to 3 mg/kg (eg, 1 mg/kg to 3 mg/kg), such as 1 mg/kg, 2 mg/kg, or 3 mg/kg. Maintenance doses may be, for example, 0.1 mg/kg to 3 mg/kg or 0.3 mg/kg to 3 mg/kg, such as 0.1 mg/kg, 0.2 mg/kg , 0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg, 0.7 mg/kg, 0.8 mg/kg, 0.9 mg/kg, 1 mg/kg, 1.5 mg/kg, 2 mg/kg, 2.5 mg/kg or 3 mg/kg. In specific embodiments, increasing doses may be administered in the following order: 0.1 mg/kg, 0.3 mg/kg, 0.3 mg/kg, 0.6 mg/kg, 0.6 mg/kg, 1.0 mg/kg, 2.0 mg/kg and 3.0 mg/kg.

[0020] In some embodiments, multiple doses of any of the treatments described herein are administered at 2 week intervals. The introduction of multiple doses can be done, for example, by intravenous injection.

[0021] In any of the treatments described herein, rhASM may be olipudase-alpha (SEQ ID NO:2).

[0022] The present invention also provides the use of recombinant human ASM (e.g., olipudase-alpha) for the manufacture of a medicament for use in any of the treatments described herein, and also provides recombinant human ASM (e.g., olipudase-alpha) for use in any of the treatments described herein.

[0023] The present invention also provides finished products (eg, kits) containing recombinant human ASM (eg, olipudase-alpha) for use in any of the treatments described herein.

BRIEF DESCRIPTION OF GRAPHICS

[0024] FIG. 1A-C are graphs summarizing changes in ceramide (A), lysosphingomyelin (B), and chitotriosidase (C) activity over 30 months of treatment with olipudase-alpha. The norm for the content of ceramide in blood plasma was 1.8-6.5 mg/l. The upper limit of normal for dry blood spot lysosphingomyelin was <69 µg/L, and normal serum chitotriosidase levels were ≤181 nmol/hr/mL (Note: Activity was not adjusted for two patients heterozygous for chitotriosidase null mutation).

[0025] FIG. 2A and 2B are graphs summarizing the effect of olipudase-alpha on liver and spleen volume (A) and lung disease (B). FIG. 2A: Liver and spleen volumes were calculated by integrating transverse magnetic resonance images and expressed as multiples of normal (MN), where normal spleen volume (L) was taken as 0.2% of body weight and normal liver volume (L) was taken as equal to 2.5% of body weight. FIG. 2B: lung disease. Hemoglobin (Hb) adjusted predicted percentage DLco in individual patients at baseline and during treatment was calculated using observed values for male and female patients (Crapo et al., Am. Rev. Respir. Dis. 123(2) :185-189 (1981); Macintyre et al., Eur. Respir. J. 26(4):720-735 (2005)). Severity: 80% = lower limit of normal; >60%-79% = slight decrease; 40%-60% = moderate decrease; <40% = severe decline. HRCT assessment of infiltrative lung disease at baseline and during treatment with olipudase-alpha included assessment of ground-glass haze (GGA), interstitial lung disease (ILD), and reticulonodular induration (RD) assessed on a 4-point scale. , where 0=no interstitial process in the lungs; 1=mild (affects 1-25% of lung volume); 2=moderate (affects 26-50% of lung volume); 3=severe (affects 51-100% of lung volume).

[0026] FIG. 3A and 3B are photographs showing the effect of olipudase-alpha on bone marrow "load". FIG. 3A (femur): Changes in the "load" of the bone marrow in the frontal projection of the femur of patient 2 (female, 32 years old at baseline). Bone marrow hypointensity in the proximal epiphyses at the time of screening on T1-weighted (A) and T2-weighted (B) images is compared with decreased number and slightly hypointense bone marrow in the diaphyses after 30 months of treatment (T1-weighted, C and T2-weighted, D ). Full vertical scale bar, 20 cm FIG. 3B (spine): Bone marrow "load" on a sagittal view of the lumbar spine of patient 2. At the time of screening, there is diffuse bone marrow infiltration with T1-weighted isointensity of unaffected intervertebral discs (A) and T2-weighted signal intensity of presacral fat (B) on level of hyperintensity. After 30 months of treatment, bone marrow infiltration remains unchanged (T1-weighted, C), while pre-sacral fat improved to slightly hyperintense (T2-weighted, D). Complete vertical scale bar, 20 cm.

[0027] FIG. 4A-D are graphs depicting fasting lipid parameters at baseline and during treatment (30 months) with olipudase-alpha. Mean (SD) levels of total cholesterol (A), triglycerides (B), HDL-cholesterol (C) and LDL-cholesterol (D) are shown on an empty stomach before infusion. The norm for the content of total cholesterol: USA <5.18 mmol / l; UK 0-3.9 mmol/l. Norm for the content of HDL-C: US men >0.777; US women >0.9065 mmol/L; UK >1.2 mmol/l. Norm for the content of LDL-C: US <3.3411 mmol / l; Great Britain 0-2 mmol/l. The norm for the content of triglycerides: <1.7 mmol / l.

DETAILED DESCRIPTION OF THE INVENTION

[0028] The present invention is based on the discovery that enzyme replacement therapy (ERT) using ASM alleviates bone pathological conditions in ASMD patients, including increasing their bone density and reducing their bone marrow "burden". Such an improvement can be observed as early as 6-30 months after the start of therapy. This finding was unexpected as it was not clear whether ERT with ASM would be able to reverse all symptoms of ASMD, including low bone density, and if so, how long the therapy would take before symptom resolution was achieved. In other lipid-accumulating disorders, ERT alone improves bone mineral density very slowly. For example, in the case of Gaucher's disease, another genetic disorder with lipid accumulation, the response of patients to treatment with ERT is slower in terms of bone mineral density (BMD) than in terms of the hematological and visceral aspects of GD. Studies have shown that it took eight years of ERT (imiglucerase) to restore patients' BMD to normal levels (Wenstrup et al., J Bone Miner Res. 22(1):119-26 (2007)). The present finding is also significant because ASMD patients cannot take bisphosphonates, the standard of care drug for low BMD, at the same time as ERT with ASM, because bisphosphonates interfere with ASM activity.

[0029] Accordingly, the present invention provides methods for treating a bone condition in an ASMD patient with ERT using ASM. ASMD induces accumulation of sphingomyelin in bone marrow cells, in particular progenitor cells of the mononuclear macrophage lineage. These cells become filled and linger in the bone marrow, which causes bone marrow infiltration and high bone marrow "load" (BMB). ASMD patients also often have chronic inflammation, including in the bones. Bone disease in ASMD adversely affects bone metabolism and structure. Patients suffer from a range of symptoms, including growth retardation, growth retardation, maturation delays, pain, and bone fractures. Indeed, ASMD has been shown to be inversely correlated with lumbar spine bone mineral density (BMD) Z-score (Wasserstein et al. J. Inherit. Metab. Dis. 36(1):123-7 (2013)) and influence to the skeletal system. As used herein, the term "bone pathology or bone disease" refers to any bone problem associated with ASMD and its associated manifestations, such as high bone marrow "load", low bone mineral density, osteopenia, osteoporosis, skeletal developmental delay (eg, delayed bone age (maturation) and linear growth retardation), increasing disability, bone pain, decreased mobility, osteonecrosis, and increased risk of fractures.

[0030] In some embodiments, the bone condition being treated in a patient with ASMD using the methods of the present invention is osteopenia or osteoporosis. In some embodiments, the implementation of the patients are adults (for example, patients aged 18 years or more, including geriatric patients, whose age is 65 years or more). In other embodiments, the patients are pediatric patients (patients who are less than 18 years of age, such as those who are from newborn to 6 years old, who are between 6 and 12 years old, or who are between 12 and 18 years old). In some embodiments, the patient may have Niemann-Pick type A, Niemann-Pick type B, or Niemann-Pick type A/B. In specific embodiments, the methods described herein are used to treat adult patients with chronic visceral ASMD (NPD B). In some embodiments, the methods described herein are used to treat pediatric patients with chronic visceral ASMD (NPD B). In other embodiments, the methods described herein are used to treat adult and pediatric patients with non-neurological manifestations of ASMD.

Assessment of bone condition

[0031] A subject's bone health can be assessed by analyzing bone parameters, collectively referred to herein as "bone health scores", using a variety of methods. Indicators of bone health may include, for example, bone mineral density (BMD), bone marrow "load" (BMB), bone age, linear growth, and the status of certain bone biomarkers. In certain embodiments, pathological conditions of the bone can be assessed using bone imaging, such as radiography and magnetic resonance imaging (MRI). Images of bone scans can be acquired, for example, of the femur and lumbar spine at various time points to assess bone mineral density (BMD) and bone marrow loading (BMB) as indicators of bone health in patients before, during and after treatment with the composition of the present invention. In certain embodiments, images are obtained using DXA (dual energy x-ray absorptiometry) or MRI. In some embodiments, bone scans can be imaged at approximately one week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, six weeks, one month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months , 9 months, 10 months, 11 months, 1 year, 2 years, 3 years, 4 years or 5 years and compared with the original images obtained before the treatment of the present invention. In certain embodiments, images of bone scans can be obtained after approximately 6 months or after a year.

[0032] For each patient, BMD can be calculated using T- and Z-criteria. The T-score classifies a patient's bone density as compared to that of a healthy person of the same sex. The Z-score classifies a patient's bone density as compared to that of a healthy individual of the same age, sex, weight, and ethnicity.

[0033] BMB can be assessed from serial MRI scans using a BMB scoring system that is based on a bone marrow signal intensity scoring system resulting in a categorical score of a possible eight points each for the lumbar spine and femur - the criteria for femur are averaged for the right and left femur - in the form of a total score of 16 points. A bone marrow signal intensity scoring system is described, for example, in Hangartner et al., Skeletal Radiol. 37(3): 185-188 (2008); Robertson et al., AJM Am J Roentgenol. 188(6): 1521-1528 (2007); and Maas et al., Radiology 229(2): 554-561 (2003), all of which are incorporated herein by reference in their entirety.

[0034] In other embodiments, bone biomarkers will be analyzed to assess bone health in a subject. As used herein, "bone biomarkers" refers to biomarkers associated with bone formation and resorption. For example, bone biomarkers such as serum bone-specific alkaline phosphatase (ALP) and C-telopeptide can be analyzed in patient samples. Bone-specific ALP, a marker of active bone formation, and C-telopeptide, an indicator of bone resorption, can be used as indicators of bone health. For example, in Gaucher disease, another lipid storage disorder, serum levels of C-telopeptide are reduced. In some embodiments, bone biomarkers can be analyzed at approximately 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 months, or at 1, 2, 3, 4, or 5 years and compared to baseline, obtained before the treatment according to the present invention. In certain embodiments, bone biomarkers can be analyzed after 3 or 6 months.

[0035] Most children with ASMD experience stunted growth. Z-scores for height and weight in pediatric ASMD patients are often lower than those in non-ASMD children. In pediatric patients with ASMD, additional indicators of bone health, such as bone age (eg, as determined by hand x-ray) and linear growth, can be analyzed to evaluate bone growth or skeletal development. In an exemplary embodiment, a hand x-ray may be performed to collect images of the patient's hands, fingers, and wrists. The age (maturation) of the bone can be calculated from the radiograph using the atlas Greulich & Pyle (1959). Linear growth, as measured by the Z-score for height, is another measure of bone health to evaluate growth in pediatric patients.

Treatment of pathological bone conditions with ASM

[0036] Patients with pathological conditions of the bone, such as patients with ASMD, can be treated with ERT using ASM. As used herein, "treat", "administer treatment", and "treatment" refer to a method of alleviating, suppressing, or preventing or delaying the manifestation or worsening (i.e., progression) of a biological disorder or condition and/or at least one of its concomitants. symptoms. As used herein, the term "alleviate" a disease, disorder, or condition means to reduce the severity and/or frequency of symptoms of the disease, disorder, or condition.

[0037] In some embodiments, the ASM used in ASM ERT can be a human ASM, such as recombinant human ASM (rhASM). Recombinant ASM can be produced using recombinant technology in prokaryotic or eukaryotic host cells, such as mammalian host cells (eg, Chinese Hamster Ovary (CHO) cells). In certain embodiments, rhASM is olipudase alpha, the alpha glycoform of human ASM (EC-3.1.4.12), produced in CHO cells. Mature olipudase-alpha is a 570 amino acid polypeptide that retains the enzymatic activity and lysosome targeting activity of the native human protein. The amino acid sequence of olipudase-alpha, including its leader sequence (residues 1-57), is shown below, where the leader sequence is in italics and in bold. The sequence of Mature olipudase-alpha (SEQ ID NO:2, which covers residues 58-627 of the following sequence) does not contain a leader sequence.

MARYGASLRQ SCPRSGREQG QDGTAGAPGL LWMGLALALA LALALSDSRV LWAPAEA HPL SPQGHPARLH RIVPRLRDVF GWGNLTCPIC KGLFTAINLG LKKEPNVARV GSVAIKLCNL LKIAPPAVCQ SIVHLFEDDM VEVWRRSVLS PSEACGLLLG STCGHWDIFS SWNISLPTVP KPPPKPPSPP APGAPVSRIL FLTDLHWDHD YLEGTDPDCA DPLCCRRGSG LPPASRPGAG YWGEYSKCDL PLRTLESLLS GLGPAGPFDM VYWTGDIPAH DVWHQTRQDQ LRALTTVTAL VRKFLGPVPV YPAVGNHEST PVNSFPPPFI EGNHSSRWLY EAMAKAWEPW LPAEALRTLR IGGFYALSPY PGLRLISLNM NFCSRENFWL LINSTDPAGQ LQWLVGELQA AEDRGDKVHI IGHIPPGHCL KSWSWNYYRI V ARYENTLAA QFFGHTHVDE FEVFYDEETL SRPLAVAFLA PSATTYIGLN PGYRVYQIDG NYSGSSHVVL DHETYILNLT QANIPGAIPH WQLLYRARET YGLPNTLPTA WHNLVYRMRG DMQLFQTFWF LYHKGHPPSE PCGTPCRLAT LCAQLSARAD SPALCRHLMP DGSLPEAQSL WPRPLFC (SEQ ID NO:1)

[0038] In some embodiments, ASM is 99%, 98%, 97%, 96%, or 95% identical in amino acid sequence to olipudase-alpha. For example, the ASM useful in the present invention has the ASM sequence shown in US Pat. No. 6,541,218, the disclosure of which is incorporated herein in its entirety. This sequence is shown below with the leader in italics and bold, with the mature protein not containing the leader:

MPRYGASLRQ SCPRSGREQG QDGTAGAPGL LWMGLVLALA LALALALSDS RVLWAPAEA H PLSPQGHPAR LHRIVPRLRD VFGWGNLTCP ICKGLFTAIN LGLKKEPNVA RVGSVAIKLC NLLKIAPPAV CQSIVHLFED DMVEVWRRSV LSPSEACGLL LGSTCGHWDI FSSWNISLPT VPKPPPKPPS PPAPGAPVSR ILFLTDLHWD HDYLEGTDPD CADPLCCRRG SGLPPASRPG AGYWGEYSKC DL PLRTLESL LSGLGPAGPF DMVYWTGDIP AHDVWHQTRQ DQLRALTTVT

ALVRKFLGPV PVYPAVGNHE SIPVNSFPPP FIEGNHSSRW LYEAMAKAWE PWLPAEALRT LRIGGFYALS PYPGLRLISL NMNFCSRENF WLLINSTDPA GQLQWLVGEL QAAEDRGDKV HIIGHIPPGH CLKSWSWNYY RIVARYENTL AAQFFGHTHV DEFEVFYDEE TLSRPLAVAF LAPSATTYIG L NPGYRVYQI DGNYSRSSHV VLDHETYILN LTQANIPGAI PHWQLLYRAR ETYGLPNTLP TAWHNLVYRM RGDMQLFQTF WFLYHKGHPP SEPCGTPCRL ATLCAQLSAR

ADSPALCRHL MPDGSLPEAQ SLWPRPLFC (SEQ ID NO:3)

[0039] The ASM useful in the present invention may also be identical in amino acid sequence to the human ASM disclosed in the UNIPROT database as P17405-1 or polymorphic variants thereof. The P17405-1 sequence is shown below with the leader in italics and bold, with the mature protein lacking the leader:

MPRYGASLRQ SCPRSGREQG QDGTAGAPGL LWMGLVLALA LALALALSDS

RVLWAPAEA H PLSPQGHPAR LHRIVPRLRD VFGWGNLTCP ICKGLFTAIN

LGLKKEPNVA RVGSVAIKLC NLLKIAPPAV CQSIVHLFED DMVEVWRRSV

LSPSEACGLL LGSTCGHWDI FSSWNISLPT VPKPPPKPPS PPAPGAPVSR

ILFLTDLHWD HDYLEGTDPD CADPLCCRRG SGLPPASRPG AGYWGEYSKC

DLPLRTLESL LSGLGPAGPF DMVYWTGDIP AHDVWHQTRQ DQLRALTTVT

ALVRKFLGPV PVYPAVGNHE STPVNSFPPP FIEGNHSSRW LYEAMAKAWE

PWLPAEALRT LRIGGFYALS PYPGLRLISL NMNFCSRENF WLLINSTDPA

GQLQWLVGEL QAAEDRGDKV HIIGHIPPGH CLKSWSWNYY RIVARYENTL

AAQFFGHTHV DEFEVFYDEE TLSRPLAVAF LAPSATTYIG LNPGYRVYQI

DGNYSGSSHV VLDHETYILN LTQANIPGAI PHWQLLYRAR ETYGLPNTLP

TAWHNLVYRM RGDMQLFQTF WFLYHKGHPP SEPCGTPCRL ATLCAQLSAR

ADSPALCRHL MPDGSLPEAQ SLWPRPLFC(SEQ ID NO:4)

[0040]A proof of concept for olipudase-alpha therapy was demonstrated in the ASMKO knockout mouse model (ASMKO) (See, for example, Miranda et al.FASEB14(13):1988-95 (2000); Dhami et al.,Lab. investment. 81(7): 987-99 (2001)). These studies showed that repeated intravenous administration of olipudase to mice with ASMKO resulted in a dose-dependent decrease in the content of sphingomyelin in visceral organs. A decrease in sphingomyelin was also observed in the lungs. Studies with ASMKO have also shown that olipudase-alpha can cause toxicity when administered at high doses. However, when ASMKO mice were administered multiple low doses followed by a high dose, olipudase-alpha did not cause the toxicity seen with a single high dose.

[0041] Olipudase-alpha has been used in clinical trials to treat non-neurological manifestations of ASMD. Observations in mice led to the development of a phase 1 study to evaluate the safety and pharmacokinetics of olipudase-alpha treatment, in which single incremental doses of olipudase-alpha (0.03, 0.1, 0.3, 0.6 and 1.0 mg/kg) was evaluated in 11 patients (McGovern et al., Genet. Med. 15(8):618-623 (2013) and WO 2011/025996; the disclosure of which is incorporated herein by reference in its entirety). In this study, patients showed a dose-dependent increase in acute phase reagents, including ceramide, bilirubin, and highly sensitive C-reactive protein (hsCRP). Dose-related adverse events covering constitutional symptoms (pain, fever, nausea and vomiting) have also been reported, consistent with first dose toxicity.

[0042] A phase 1b study to evaluate the safety and tolerability of olipudase-alpha over a 26-week treatment period was performed with 5 adult patients (Wasserstein et al., Mol. Genet. Metab. 116(1-2):88-97 (2015 ), incorporated herein by reference in its entirety). In this study, patients were administered olipudase-alpha in a dose escalation manner with an initial dose of 0.1 mg/kg followed by biweekly increments to reach the target dose of 3.0 mg/kg. The study showed that the dose escalation regimen was well tolerated without serious or severe adverse events and resulted in a gradual decrease in the concentration of sphingomyelin and its catabolites. "Decrease in concentration" refers to the elimination of sphingomyelin that has accumulated in the patient's visceral organs due to ASMD. Improvements observed in patients included a decrease in spleen and liver volumes, a decrease in lung interstitial process scores, an increase in lung function, and a decrease in chitotriosidase, CCL18, serum ACE, and other disease biomarkers. At present, the present inventors have found that when these patients continued to be treated and monitored for 30 months in a long-term evaluation of safety and efficacy, they showed a robust safety profile and continuous improvements in clinically relevant parameters, including spleen and liver volumes, disease score lungs, lipid profiles and ASM biomarkers. The present inventors also unexpectedly found that patients showed a clear improvement in bone mineral density (BMD) and bone marrow loading (BMB). These data demonstrate that ERT using ASM can alleviate or prevent deterioration of a patient's bone pathology such as osteopenia and osteoporosis.

Dosage and route of administration of ASM

[0043] Pharmaceutical compositions containing the ASM described herein will be administered to treat the condition in question (e.g., ASMD-associated bone condition) in a therapeutically effective amount, i.e., at dosages and for periods of time necessary to achieve the desired result. The therapeutically effective amount may vary depending on such factors as the particular condition being treated, the age, sex and weight of the patient, and whether enzyme replacement therapy is administered as a single treatment or in combination with one or more additional treatments. "Therapeutically effective amount" refers to the amount to be administered therapeutic agent, which to some extent will reduce or prevent the worsening of one or more symptoms of the disorder or condition being treated. Compositions based on ASM can be administered by intravenous injection.

[0044] In some embodiments, efficacy may be indicated as an improvement in T-scores for bone mineral density (eg, T-scores for the spine and/or femur). In certain embodiments, the T-score improves by at least 0.5 points. In some embodiments, efficacy may be indicated as an improvement in bone mineral density Z-scores (eg, spine and/or femur Z-scores). In certain embodiments, the implementation of the Z-score improves by at least 0.1 points.

In some embodiments, efficacy may be indicated as improvement, no worsening, or delay in the progression of bone diseases such as osteopenia or osteoporosis. In some embodiments, efficacy may be indicated as improvements in skeletal development, such as linear growth or bone age (maturation). In certain embodiments, improvement in skeletal development can be measured against data collected from a study of pediatric patients (Wasserstein et al ., J Pediatr 142(4):424-428 (2003)). In other embodiments, improvement in skeletal development can be measured against each patient's growth chart prior to ASM therapy.

[0045] In some embodiments, the methods of the present invention provide for a dose escalation protocol in which increasing doses of ASM (e.g., rhASM, such as olipudase-alpha) are administered over an appropriate period to gradually reduce the concentration of previously accumulated sphingomyelin and to minimize toxic side effects caused by sphingomyelin catabolites. For example, treatment may involve administering one or multiple initial, low, non-toxic doses of ASM to a patient to reduce the amount of sphingomyelin that has accumulated in the patient. Each increasing dose may be separated from the previous dose by one, two or three weeks. In specific embodiments, escalating doses are administered at two weekly intervals. As used herein, the term "non-toxic dose(s)" and the like refers to a dosage of ASM administered to patients with ASMD that does not result in one, two, three, or all of the following: (i) moderate or severe associated adverse an event defined by a clinical symptom that interferes with normal daily functioning and requires additional monitoring, intervention, or treatment, or by an abnormal laboratory value or procedure result that causes clinical concern that requires additional monitoring, treatment, or investigation. See, for example, Clinical Data Exchange Standardization Consortium Study Data Classification Model standard terminology v.3.1.1; (ii) a total bilirubin value greater than 1.5 mg/dl, 2 mg/dl, 3 mg/dl, or 4 mg/dl that persists for more than one week, two weeks, or three weeks after a dose of rhASM; (iii) a plasma ceramide concentration greater than 8.2 mcg/dl, 9 mcg/dl, 10 mcg/dl, 15 mcg/dl, 20 mcg/dl, 30 mcg/dl, 40 mcg/dl, 50 mcg/ dl, 60 µg/dl, 70 µg/dl, or 80 µg/dl, 24 hours, 36 hours, 48 hours, or 72 hours after ASM dose; or (iv) response/acute phase response. The "non-toxic dose" of ASM may vary depending on, for example, the stability of the enzyme used, the activity of the enzyme used, and/or the route of administration of the enzyme. For example, the dosage of a modified ASM enzyme with increased activity may be lower than the dosage of unmodified ASM. One of skill in the art will be able to adjust the dose of enzyme administered based on enzyme stability, enzyme activity, and/or route of enzyme administration.

[0046] After a certain period of time, the dose of ASM can be increased until the highest therapeutically effective dosage tolerated by the patient is reached. Once such a dosage has been determined, it can be used as a maintenance dose to treat a patient. Alternatively, the maintenance dose may be reduced from the highest escalating dose once the patient's ASMD has stabilized following the escalation regimen. Maintenance doses can be administered to the patient after 1, 2, 3 or 4 weeks. In certain embodiments, the maintenance dose is administered biweekly.

[0047] As used herein, the term "maintenance dose" refers to the dosage of ASM described herein that is administered to patients with ASMD to maintain a desired therapeutic effect, e.g., improvement or no worsening of one or more pathological bone conditions, such as those described in this document. In specific embodiments, the maintenance dose(s) maintain one, two, three, four, or more of the following desired therapeutic effects: (i) splenic volume reduction as measured by techniques known in the art, eg, MRI; (ii) reduction in hepatic sphingomyelin levels as measured by techniques known in the art, eg, biochemical analysis and/or histomorphometric analysis of liver samples; (iii) increase in exercise capacity, as measured by techniques known in the art, for example, maximum workload in bicycle ergometry, including predicted percentage of maximum workload, peak oxygen consumption, and carbon dioxide production; (iv) an increase in lung function, as measured by techniques known in the art, such as those described in the American Thoracic Society, Am. Rev. Respir. Dis. 144: 1202-1218 (1991), e.g., diffusing capacity (DLco), predicted forced vital capacity percentage (FVC), measured, for example, using spirometric techniques, expiratory volume in 1 second (FEV1), measured, for example, using spirometric techniques, and total lung capacity; (v) decrease in sphingomyelin content in bronchoalveolar lavage (BAL); (vi) liver volume reduction as assessed by techniques known in the art, e.g. MRI; (vii) improvement in lung appearance as assessed by techniques known in the art, e.g. high resolution computed tomography (CT) or chest X-ray; (viii) a decrease in the concentration of sphingomyelin or lysosphingomyelin in the liver, skin, plasma and dry blood spot (DBS), measured, for example, using tandem mass spectrometry; (ix) reducing or alleviating the severity of ASMD and/or a symptom associated with it; (x) reducing the duration of a symptom associated with ASMD; (xi) preventing recurrence of a symptom associated with ASMD; (xii) reducing the subject's hospitalizations; (vi) reduced length of hospitalization; (xiii) increase the survival of the subject; (xiv) reduction in mortality; (xv) reducing the frequency of hospitalizations; (xvi) reducing the number of symptoms associated with ASMD; (xvii) increase asymptomatic survival in patients with ASMD; (xviii) improvement in neurological function (eg, psychomotor function, social responsiveness, etc.); (xix) improvement in lung clearance as measured, for example, by the number and profile of BAL cells; (xx) decrease in serum levels of chitotriosidase; (xxi) decrease in serum levels of chemokine motif ligand-18 (cc) (CCL18); (xxii) improving the lipid profile (eg, HDL, LDL, cholesterol, triglycerides and total cholesterol:HDL ratios); (xxiii) improvement in bone pathology; and (xxiv) improvement in quality of life (QOL), as measured, for example, by a questionnaire such as the Brief Fatigue Assessment (BFI) (Mendoza et al., Cancer 85(5):1186- 1196 (1999)), the Brief Pain Inventory - Short Form (BPI-SF) (Cleeland C., Acta Paediatr. Suppl. 91(439):43-47 (2002)), or the Pediatric Quality of Life Assessment Questionnaire (PedsQL ) (Varmi et al., Medical Care 39(8):800-812 (2001)), or the PedsQL multivariate fatigue rating scale (Varmi et al., J Rheumatol 31(12):2494-2500 (2004)). In certain embodiments, the highest maintenance dose is the highest or maximum dose tolerated by the patient.

[0048] In some embodiments, the monitoring of a patient receiving a maintenance dose is carried out after 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 months, or once a year or every two years in relation to one or a plurality of the following: (i) associated adverse events; (ii) total/direct/indirect bilirubin concentrations; (iii) plasma ceramide concentration or (iv) acute phase response. In some embodiments, the patient is monitored after 3 months, after 6 months, or once a year. If the patient experiences a moderate-intensity associated adverse event, total bilirubin concentration exceeds the total bilirubin value for a person not suffering from ASMD (for example, a healthy person), the plasma ceramide concentration exceeds the plasma ceramide concentration for a person not suffering from ASMD (for example, a healthy person ), or an acute phase response is observed, the dose administered to the patient may be evaluated by a physician or other healthcare professional to determine if adjustment is necessary.

[0049] In certain embodiments, a method of treating a human patient having ASMD comprises: (a) a dose escalation regimen (e.g., to decrease the patient's accumulated sphingomyelin substrate concentration) comprising: (i) administering an initial dose (e.g., low non-toxic dose, such as 0.1 mg/kg) of ASM (eg, olipudase-alpha) described herein to a human patient; (ii) administering successively higher doses of ASM to a human patient; and (iii) monitoring the patient for one or more side effects after administration of each subsequent dose, as indicated by, for example, elevated total bilirubin, elevated plasma ceramide, lysosphingomyelin , chitotriosidase, production of acute phase reagents, production of inflammatory mediators, or adverse event (eg, as defined in the standard terminology of the Clinical Data Exchange Standardization Consortium Study Data Classification Model v.3.1.1); and (b) a maintenance regimen administering a dose that is equal to or less than the highest patient tolerated dose (eg, equal to or less than 3 mg/kg) as the patient's maintenance dose.

[0050] In certain embodiments, a method of treating a human patient having ASMD comprises: (a) a dose escalation regimen (e.g., to decrease the patient's accumulated sphingomyelin substrate concentration) comprising: (i) administering an initial dose (e.g., low non-toxic dose, such as 0.1 mg/kg) of ASM (eg, olipudase-alpha) described herein to a human patient; (ii) administering successively higher doses of ASM to a human patient unless the patient exhibits one or more of the adverse events indicated by, for example, elevated total bilirubin, elevated plasma ceramide, production of acute phase reagents, lysosphingomyelin, chitotriosidase, inflammatory mediator production, or adverse event (eg, as defined in the standard terminology of the Clinical Data Exchange Standardization Consortium Study Data Classification Model v.3.1.1); and (b) a maintenance regimen comprising repeated administration of a maintenance dose that is equal to or less than the highest dose tolerated by the patient (eg, equal to or less than 3 mg/kg). In some embodiments, the patient is monitored for some period of time after a dose of ASM (e.g., 6 hours, 12 hours, 16 hours, 24 hours, 48 hours, 72 hours, weeks, or until the next dose) for one or more unwanted side effects. In certain embodiments, the maintenance dose that is administered may be adjusted during the course of the patient's treatment. In some embodiments, the highest maintenance dose administered to a patient is the highest dose tolerated by the patient.

[0051] In certain embodiments, the initial dose is in the range of 0.025 to 0.275 mg/kg, e.g., 0.03 to 0.5 mg/kg, 0.01 to 0.5 mg/kg, or 0.1 mg/kg up to 1 mg/kg ASM (eg olipudase-alpha). In specific embodiments, the initial dose is 0.03 mg/kg or 0.1 mg/kg. For example, the initial dose for a pediatric patient may be 0.03 mg/kg; and the initial dose for an adult patient may be 0.1 mg/kg. In some embodiments, the initial dose for a pediatric or adult patient may be 0.1 mg/kg.

[0052] In certain embodiments, patients will be administered the same dose of olipudase-alpha at least twice before increasing to the next higher dose. In some embodiments, successive higher doses are administered one, two, three, or four weeks after the previous dose. In some specific embodiments, each of the successive higher doses is administered two weeks after the previous dose. In specific embodiments, a successive higher dose of 0.05-1.0 mg/kg, 0.1-3.0 mg/kg, or 0.5-2.0 mg/kg is greater than the previous dose, such as about 0 .07 mg/kg, 0.2 mg/kg, 0.3 mg/kg, 0.4 mg/kg, or 1 mg/kg higher than the previous dose.

[0053] In some embodiments, the highest therapeutically effective dose tolerated by the patient is 1 mg/kg to 2.5 mg/kg, 2 mg/kg to 3 mg/kg, 3 mg/kg to 5 mg/kg. kg. In some embodiments, the highest therapeutically effective dose tolerated by the patient is 1 mg/kg, 2 mg/kg, 3 mg/kg, 4 mg/kg, or 5 mg/kg. In certain embodiments, the highest dose tolerated by the patient is 1 mg/kg to 3 mg/kg, such as 1 mg/kg to 2.5 mg/kg. In some embodiments, the highest dose is administered to the human patient as the highest maintenance dose. In certain embodiments, the highest maintenance dose is, for example, 0.3 mg/kg, 0.6 mg/kg, 1 mg/kg, 2 mg/kg, or 3 mg/kg. In specific embodiments, the highest maintenance dose is 3 mg/kg. Subsequent maintenance doses may be administered in the same amount or less than the highest maintenance dose. In some embodiments, maintenance doses are 0.3-3 mg/kg.

[0054] In some embodiments, a dose escalation schedule may include administering ASM in multiple doses in the following order, e.g., 0.1 mg/kg, 0.3 mg/kg, 0.3 mg/kg, 0.6 mg /kg, 0.6 mg/kg, 1.0 mg/kg, 2.0 mg/kg and 3.0 mg/kg (the highest maintenance dose), where each of the consecutive doses is administered two weeks after the previous dose. In other embodiments, a dose escalation schedule may include administering ASM in multiple doses in the following order, e.g., 0.03 mg/kg, 0.1 mg/kg, 0.3 mg/kg, 0.3 mg/kg, 0.6mg/kg, 0.6mg/kg, 1.0mg/kg, 2.0mg/kg and 3.0mg/kg (highest maintenance dose) where each consecutive dose is administered two weeks later after the previous dose.

[0055] In certain embodiments, the dose of ASM described herein is administered to the patient one week later, two weeks later, three weeks later, or four weeks later. In specific embodiments, the doses are administered at two week intervals, for example by intravenous injection.

[0056] In some embodiments, the methods of the present invention provide for the administration of doses of ASM over a period of 6 to 30 months, for example, over a period of no more than 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, 24 months, 25 months, 26 months, 27 months, 28 months, 29 months or 30 months, to improve target bone condition(s). In certain embodiments, the ASM doses are administered over a period of no more than 30 months.

[0057] In additional embodiments, the methods of the present invention provide for the dosage protocols and/or routes of administration described, for example, in WO 2011/025996, the disclosure of which is incorporated herein by reference in its entirety.

[0058] In specific embodiments, a dose escalation regimen used to treat adult or pediatric patients with ASMD, for example, may be as shown in the table below:

Table 1 Dose escalation schedule

Week of treatment Dose of olipudase-alpha (mg/kg) 0 0.1 2 0.3 4 0.3 6 0.6 8 0.6 10 1.0 12 2.0 14 3.0 16 3.0

[0059] In further specific embodiments, a dose escalation regimen used to treat pediatric patients with ASMD, for example, may be as shown in the table below:

Table 2 Dose escalation schedule for pediatric patients

Week of treatment Dose of olipudase-alpha (mg/kg) 0 0.03 2 0.1 4 0.3 6 0.3 8 0.6 10 0.6 12 1.0 14 2.0 16 3.0

[0060] In some embodiments, the pediatric patient populations include an adolescent ASMD cohort (aged 12 to <18 years), a cohort of children with ASMD (aged 6 to <12 years), and an infant/toddler cohort (age from birth). up to <6 years).

Finished products and kits

[0061] The present invention also provides finished products and kits containing the ASM described in this document. In some embodiments, the products and kits are suitable for the treatment of the patient described herein, for example, a patient with ASMD. For example, articles and kits may be suitable for the treatment of the bone condition described herein in a patient with ASMD. In some embodiments, pharmaceutically active ingredients in articles and kits are prepared for administration at the dosages described herein and formulated for administration using the methods described herein.

[0062] Unless otherwise defined herein, scientific and technical terms used in connection with the present invention should have meanings that are commonly understood by those of ordinary skill in the art. Exemplary methods and materials are described herein, although methods and materials similar or equivalent to those described herein may also be used in the practice or testing of the present invention. In the event of conflict, the present description, including definitions, shall prevail. Generally used nomenclature related to cell and tissue culture, molecular biology, immunology, microbiology, genetics, analytical chemistry, synthetic organic chemistry, medicinal and pharmaceutical chemistry, and chemistry and hybridization of proteins and nucleic acids, as well as the corresponding techniques described in this document are well known and widely used in the art. Enzymatic reactions and purification procedures are performed according to the manufacturer's descriptions, as is commonly done in the art or as described herein. All publications and other references mentioned in this document are incorporated by reference in their entirety. Although a number of documents are cited in this document, this citation is not an admission that any of these documents form part of the general knowledge in the art. In addition, unless otherwise required by context, terms in the singular include the plural, and terms in the plural include the singular. Throughout this specification and embodiments, the words "have" and "comprise" or variations thereof such as "has", "having", "comprises", or "comprising" should be understood to mean the inclusion of a specified integer or group of integers, but not the exclusion of any other integer or group of integers.

[0063] For a better understanding of the present invention, the following examples are given. These examples are for illustrative purposes only and should in no way be construed as limiting the scope of the present invention.

EXAMPLE

Example 1 A Long-term Study to Evaluate the Safety and Efficacy of Olipudase-alpha in ASMD Patients

Patients and Study Design

[0064] The aim of the study is to obtain information regarding the safety and efficacy of olipudase-alpha in patients with ASMD after long-term administration. This ongoing, open-label, long-term study (LTS) (NCT02004704; EudraCT number: 2013-000051-40) is following 5 adult patients with chronic ASMD who were previously enrolled in a phase 1b study (Wasserstein et al. Mol Genet Metab 116(1-2 ):88-97 (2015)). Data were analyzed for all patients after 30 months of treatment. The institutional review board or ethics committee at each site approved the protocol, and all patients gave written informed consent. The study was conducted in accordance with good clinical practice and in accordance with the principles of the Declaration of Helsinki.

[0065] Criteria for inclusion in the phase 1b study have been described previously. There . Patients who completed the phase 1b study with an acceptable safety profile met the inclusion criteria for the LTS and continued to take the same dose of lipudase-alpha that they received at the end of the phase 1b study.

Outcome indicators and analyzes

[0066]Safety assessments included standard blood count and blood chemistry, as well as ongoing monitoring of AEs, including infusion-associated reactions (IARs), as previously described in McGovern et al.Genet Med 18(1):34-40 (2015) and Wasserstein et al.Mol. Genet. Metab. 116(1-2):88-97 (2015). The content of sphingomyelin and ceramide catabolite in blood plasma was assessed using liquid chromatography with tandem mass spectrometry (LC/MS/MS). Biomarkers of bone health also included chitotriosidase (serum) and lysosphingomyelin [dry blood spot (DBS)], which were determined by LC/MS/MS. Anti-drug antibody production was assessed as previously described in McGovern et al., 2015, above, and Wasserstein et al.Mol. Genet. Metab. 116(1-2):88-97 (2015).

[0067]Spleen and liver volumes were quantified by abdominal MRI and organ volumes were expressed as multiples of normal (MN). Hemoglobin-adjusted predicted percent carbon monoxide diffusing capacity (DLco) was calculated using standardized formulas (Crapo and MorrisAm Rev Respir Dis 123(2):185-189 (1981), Macintyre et al.Eur Respir J 26(4):720-735 (2005)). Infiltrative lung disease was assessed by high resolution computed tomography (HRCT). HRCT images of lung regions were assessed subjectively for ground glass opacities (GG), interstitial lung disease (ILD), and reticulonodular compaction (RND) ranging from 0 (no disease) to 3 (severe disease) as described previously in McGovern et al. al., 2015 above and Wasserstein et al., 2015, higher.

[0068] Fasting plasma lipid profiles, including values for total cholesterol (TC), low density lipoprotein (LDL-C), high density lipoprotein (HDL-C), and triglycerides, were measured throughout the study. Non-HDL cholesterol levels were calculated post-hoc as the difference between total cholesterol and HDL cholesterol levels (Jacobson et al., J. Clin. Lipidol. 9(2):129-169 (2015)).

[0069] Bone marrow "load" (BMB) was determined from MRI data of the lumbar spine and both femurs, where image quantification indicated the degree of bone marrow infiltration with lipid-loaded cells (Robertson et al, AJR. Am. J. Roentgenol. 188(6):1521-1528 (2007)). Bone mineral density (BMD) was determined from dual-energy x-ray absorptiometry (DXA) images of the lumbar spine and both femurs, as well as T- and Z-scores (WHO JAMA 285(6):785-795 (2001) ). BMD was assessed using guidelines provided by the International Society for Clinical Densitometry (ISCD 2015).

[0070] Patient-reported results using an 11-point scale from 0 (absent) to 10 (worst condition) included a validated BFI (Mendoza et al., Cancer 85 (5): 1186-1196 (1999 )) and the Brief Pain Inventory - Short Form (BPI-SF) to assess interference with daily activities at baseline and periodically throughout treatment (Cleeland C., Acta Paediatr. Suppl. 91(439):43-47 (2002) ).

Statistical Methods

[0071] Descriptive statistics are presented for categorical and continuous variables, change from baseline and percentage change from baseline were calculated for organ volumes and DLco, and differences were determined using paired t-test and Wilcoxon-Mann-Whitney test.

Patients and exposure

[0072] All five adult patients (3 Caucasian males and 2 females) who completed the Phase 1b study continued with LTS. At baseline, all patients had splenomegaly (range 7.4 to 16.1 MN), hepatomegaly (range 1.2 to 2.2 MN), impaired gas exchange (predicted DLco range 43-80%), and proatherogenic lipid profile. Patient characteristics have been previously published (Wasserstein et al. Mol. Genet. Metab. 116(1-2):88-97 (2015)) and are described in Table 3. Most patients (4/5) remained on the target dose of olipudase-alpha 3 mg/kg for all 30 months of treatment. For patient 2, the dose was reduced to 2 mg/kg for 6 months (months 12-18) and then to 1 mg/kg (month 18-present) due to AEs, which are described below.

Table 3. Patient demographics and baseline characteristics (Wasserstein et al., 2015)

Безопасность

Safety

[0073] During the 30 months of treatment, there were no deaths, serious or severe events, or early termination of treatment. All patients experienced at least 1 AE, and almost all (826/838, 98.5%) had mild intensity. Among 443 AEs identified as treatment related, 96 (21.7%) were recognized as IARs (including headache, nausea, abdominal pain, arthralgia, musculoskeletal pain, and myalgia). Six moderate-intensity AEs recognized by the IAR were observed during the phase 1b study (first 6 months) and have been previously reported (Wasserstein et al . Mol. Genet. Metab. 116(1-2):88-97 (2015)). Regarding 6-30 months in LTS, the 5 moderate-intensity AEs recognized as IARs included abdominal pain, liver pain, nausea, muscle spasm, and sensory impairment in Patient 2. There were no hypersensitivity reactions, acute phase reactions, or cytokine release syndrome. None of the patients developed IgG antibodies to olipudase-alpha. There were no clinically significant adverse changes in vital signs, hematological parameters, or cardiac safety parameters.

[0074] Levels of inflammatory markers, IL-6, IL-8, and hsCRP, stable at the end of the phase 1b study (Wasserstein et al. Mol. Genet. Metab. 116(1-2):88-97 (2015)), remained stable in all patients with the exception of patient 2, who experienced fluctuations in hsCRP levels (1.10-33.3 mg/mL; norm 0-5) from month 6 to month 30. Plasma ceramide levels in all patients (FIG .1A) remained within the normal range (1.8-6.5 µg/ml).

[0075] The levels of liver function enzymes remained within the normal range in all patients until month 30, when patient 4 noted transient increases in ALT (1.4 times normal) and AST (2.9 times normal), without corresponding AE and followed by a return to normal levels. Total bilirubin and GGT levels remained the same or below baseline in all patients. Iron levels changed over time but remained within or near normal.

[0076] During dose escalation in phase 1b, patient 2 experienced IAR, which led to a repeat dose of 2 mg/kg (Wasserstein et al . Mol. Genet. Metab. 116(1-2):88-97 (2015)). Subsequently, the patient received the target dose of 3 mg/kg throughout the Phase 1b trial and during the first 6 months of LTS, during which time the patient reported mild AE 7-10 days after most infusions, including nausea, headache, fatigue, pain, intermittent abdominal pain and intermittent fever (38.3 to 40.0°C). The episodes lasted ~3 days and completely resolved before the next infusion. The dose of olipudase-alpha was reduced (2 mg/kg for 6 months, then to the current dose of 1 mg/kg). Dose reduction did not change the timing, frequency, or types of events reported.

Efficiency

Volumes of the spleen and liver

[0077] The volumes of the spleen and liver decreased in all patients relative to baseline (FIG. 2A). Mean spleen volumes decreased from 12.8 times normal (MN) at baseline to 6.7 MN at 30 months, with a decrease from baseline of 47.3% (p<0.0001). Mean liver volumes decreased from 1.7 MN at baseline to 1.07 MN at 30 months, with a decrease from baseline of 35.6% (p=0.006).

Infiltrative lung disease

[0078] The predicted percentage of DLco increased in all patients from baseline (FIG. 2B) and improved from a mean of 53.2% (moderate impairment) at baseline to 67.1% at 30 months (mild impairment). The greatest changes were seen in the three patients with the lowest predicted % DLco at baseline (<40%, in the range of severe impairment). FIG. 2B also shows the score for infiltrative lung disease with component mean scores at baseline, 6 months, 18 months, and 30 months. The data shows a progressive decline in all parameters, in particular GG and RND shading, which have almost completely disappeared.

Fasting lipid metabolism parameters

[0079] Fasting lipid profiles are shown in FIG. 4A-4D. For 30 months, the content of triglycerides decreased by 42.99% (p=0.02), the content of total cholesterol by 12.7% (p=0.04), the content of LDL-C by 22.8% (p=0.007), and the content of HDL-C increased by 137.6% (p=0.01). Non-HDL-cholesterol (total cholesterol minus HDL-C) was >3.37 mmol/L (>130 mg/dL) in 4/5 patients at baseline (mean 3.91 mmol/L) and was <3 .37 mmol/l in all patients at 30 months (mean 2.66 mmol/l).

Biomarker assessment

[0080] Mean levels of lysosphingomyelin in DBS were 5 times the upper limit of normal (ULN=69 μg/l) at baseline and decreased to near normal levels that remained stable from 6 to 30 months (FIG. 1B).

[0081] Pre-infusion serum chitotriosidase levels steadily decreased by 72.3% from 735 nmol/h/mL at baseline to 221 nmol/h/mL at 30 months (p=0.0007), approaching the upper limit of normal range of chitotriosidase content (≤181 nmol/h/mL) (FIG. 1C). Data were not adjusted to account for two patients heterozygous for a common 24 bp duplication that reduces serum chitotriosidase activity.

Hematological research

[0082] In most patients, the platelet count remained slightly below normal or within the low range of normal. In patient 1, the values (57-102x10 ⁹ /l) were below the low values of the norm (150x10 ⁹ /l) throughout the study. Mean changes in platelet count from baseline (increases) fluctuated over time [5.9% (month 27) to 25.7% (month 9)] and was 20.6% at 30 months. Hemoglobin levels remained similar to baseline (mean change from baseline ranged from -6.1% at week 12 to 6.9% at month 24) and were within normal levels in all patients (data not shown).

bone density

[0083] At baseline, mean spine T-scores were in the osteopenia range (-1.0 to -2.5) of -1.48±1.14, while Z-scores were indicative of normal BMD (-1.36±1.26) within -1 standard deviation of the lower BMD threshold (-2.0). Both T-score and Z-score improved after 30 months (-0.94±1.03 and -0.78±1.11, respectively). Patient 2 (female, 32 years of age at baseline) had a baseline T-score for the spine (-3.06) in the osteoporosis range and improved at 18 (-2.48) and 30 months (-2.65 ) to values on the border of osteopenia/osteoporosis. Two patients with T-scores in the range of osteopenia at baseline (Patient 1, 31-year-old male at baseline, -1.31; and Patient 4, 28-year-old male at baseline, -2.14) at 30 months criteria were normal (-0.76 and -0.82, respectively). Results for individual Z-tests were similar over time.

[0084] Mean T- and Z-scores for the femur were normal at baseline (-0.38±1.35 and -0.27±1.46, respectively) and at 30 months (-0.28±1 .27 and -0.13±1.4, respectively). Patient 2 had a baseline T-score for the femur in the osteopenia range (-2.23) and a Z-score indicating low BMD (-2.18); both improved marginally (-1.89 and -1.82, respectively) after 30 months.

"Load" of the bone marrow

[0085] Mean categorical BMB scores were similar at baseline (6.2 ± 2.5) and at 30 months (5.6 ± 1.1). Patient 2 had the highest overall BMB score at baseline of 10, which improved by 3 points (score was 7) at 18 and 30 months. T1- and T2-weighted images of the femur and spine for patient 2 at baseline and after 30 months of treatment with olipudase-alpha are shown in FIG. 3A and 3B. Bone marrow hypointensity in the proximal epiphyses observed at baseline decreased after 30 months of treatment. In the spine, diffuse bone marrow infiltration and hyperintensity presacral fat signal intensity observed at baseline did not change and improved accordingly after 30 months of treatment.

Patient Reported Results

[0086] Mean BFI±SD fatigue scores were 3.04±2.29 at baseline and 2.44±3.44 at 30 months. Mean BPI±SD pain scores were 3.45±2.77 at baseline and 2.90±2.70 at 30 months, and mean BPI±SD pain interference scores were 2.03±1.58 at baseline and 3.29±3.51 after 30 months. Most individual BFI and BPI pain scores at all time points were in the mild (0-3) or moderate (4-6) intensity categories. The exception was patient 5, whose BPI pain was severe (7-10) both at baseline (6.8) and at 30 months (7). BPI pain interference scores increased in patients 2 (2 at baseline, 8.1 at 30 months) and 3 (1.9 at baseline, 5.3 at 30 months). The fatigue reported by patient 2 was moderate (5.8) at baseline and severe (8.3) at 30 months.

[0087] This study demonstrates that treatment for 30 months with olipudase-alpha, the first etiology-specific ASMD treatment in development, was well tolerated and was associated with sustained life-changing improvements in relevant clinical disease outcomes. The safety profile at 30 months was similar to that in the phase 1b study (Wasserstein et al., Mol. Genet. Metab. 116(1-2):88-97 (2015)). There were no hypersensitivity reactions and no antibodies to the drug were found. To date, cytokine release syndrome has not been observed in any patient exposed to olipudase-alpha. Because IARs were not immunological responses, they appear to be associated with the release of biologically active metabolites of sphingomyelin, primarily ceramide, which is a signaling mediator in cytokine release, inflammation, and apoptosis (Spiegel et al., Curr. Opin. Cell Biol 8 (2):159-167 (1996); Gulbins et al., J. Mol. Med. 82(6):357-363 (2004)). During the first six months of treatment, doses of olipudase-alpha caused transient increases in plasma ceramide levels, which typically peaked 48 hours after infusion (Wasserstein et al. Mol. Genet. Metab. 116(1-2):88-97 ( 2015)). Both pre- and post-infusion ceramide levels steadily decreased with each subsequent olipudase-alpha infusion, reaching a plateau after 3 months of treatment and remaining stable up to 30 months.

[0088] Clinical improvements were maintained throughout the 30 months. Statistically significant improvements in liver and spleen volumes (median percent reduction in liver volume was 31.2% and spleen volume was 39.3%) are comparable to responses to ERT in other lysosomal storage diseases. In Gaucher disease, the therapeutic goal is a 30-50% reduction in spleen volume during the first year of treatment and a 20-30% reduction in liver volume during the first 2 years of treatment (Pastores et al., Semin Hematol 41 (Supple 5 ):4-14 (2004)).

[0089] Patients with chronic visceral or chronic neurovisceral ASMD experience worsening of infiltrative lung disease with age (Wasserstein et al., Pediatrics 114 (6): e672-677 (2004)). During 30 months of treatment, there was a 35% increase in lung diffusivity from baseline with marked changes in the 3 patients with the lowest DLCO at baseline. Improvements in lung disease scores observed during the first 6 months of treatment (Wasserstein et al. Mol. Genet. Metab. 116(1-2):88-97(2015)) continued during the subsequent 2 years of treatment, such that some parameters (for example, dimming by type GG and RND).

[0090] Atherogenic lipid profiles tend to worsen with age in patients with chronic ASMD (Wasserstein et al., Pediatrics 114(6):e672-677(2004)), and lipid abnormalities may be associated with the early onset of ischemic heart disease (McGovern et al., J. Pediatr . 145(1):77-81(2004)). Based on lipid profiles, at baseline, patients were at risk for mild to moderate cardiovascular disease (Wasserstein et al. Mol. Genet. Metab. 116(1-2):88-97(2015)), and profiles improved within 30 months of treatment. The level of non-HDL-cholesterol is considered a good predictor of cardiovascular risk in many patient populations, and its optimal level is <3.37 mmol/L (<130 mg/dL) (Jacobson et al., J. Clin. Lipidol. 9(2):129-169 (2015)). All but one patient had non-HDL levels greater than 3.37 mmol/L before ERT, and at 30 months, total cholesterol and HDL levels improved in all patients, with non-HDL levels below the threshold of 3.37 mmol/L. l.

[0091] Skeletal complications are also prominent features of chronic ASMD. Some patients showed improvement in BMD, particularly in the spine, demonstrating that olipudase-alpha has a positive effect on BMD in adults with ASMD. In other lipid storage disorders characterized by low BMD, such as Gaucher's disease, ERT in combination with antiresorptive therapy can lead to normalization of osteopenia (Wenstrup et al., Blood 104(5):1253-1257 (2004)), although the disease response bone on ERT by itself in adult patients is slow (Wenstrup et al J. Bone Miner. Res. 22(1):119-126 (2007)). However, bisphosphonates may not be suitable for ASMD patients due to inhibition of ASM activity (Arenz Cell Physiol. Biochem. 26(1):1-8 (2010)). None of the patients in the study received bisphosphonate therapy. The results of this study indicate that osteopenia will improve when olipudase-alpha is used alone.

[0092] Other clinical indicators show improvement or stability during ERT. The platelet count and hemoglobin levels remained stable. Moderate BMB levels were measured at baseline and after 30 months of treatment with olipudase-alpha, with some patients showing improvement. At baseline, patients had mild to moderate levels of pain and fatigue, which in most patients remained unchanged after 30 months. The deterioration in patient-reported outcomes in patient 3 was not associated with AE. Patient 2 reported deterioration in fatigue and pain with AE characterized by flu-like symptoms after one year of ERT. This patient had atypical lupus erythematosus, and it is not clear whether this condition is related to fatigue and pain, AE, and fluctuations in inflammatory cytokines. Reducing the dose of olipudase-alpha to 1 mg/kg/week in this patient did not affect the incidence of AE, fatigue, or pain. At this lower dose of lipudase-alpha (12 months of exposure), the patient continues to experience clinical benefits, including reduction in spleen and liver volumes, as well as improved predicted DLco percentage, sustained clearance of infiltrative parameters on HRCT, and stabilization of biomarkers.

[0093] Chitotriosidase, a well-known biomarker for therapeutic monitoring during ERT in Gaucher disease (Guo et al., J. Inherit. Metab. Dis. 18(6):717-722 (1995)) and a marker of chronic inflammatory diseases, decreased steadily during treatment with olipudase-alpha (Boot et al., Clin Chim Acta 411(1-2):31-36 (2010)). Lysosphingomyelin, the deacylated form of sphingomyelin, decreased in DBS, suggesting its applicability as a biomarker for monitoring ERT outcomes, as evidenced by its continued decline as patients experience a decrease in sphingomyelin concentration and then stability during long-term treatment . The content of lysosphingomyelin in DBS in patients with chronic visceral ASMD is increased approximately 5-fold (Chuang Mol. Genet. Metab. 111(2):209-211 (2014)).

[0094] This open-label extension study of olipudase-alpha demonstrates that treatment with olipudase-alpha for 30 months was well tolerated and clinically effective.

--->

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<150> EP 17306720.8

<151> 2017-12-07

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<---

Claims (25)

1. A method for improving bone pathology in a patient with acid sphingomyelinase deficiency (ASMD), the method comprising: administering a plurality of doses of olipudase-alpha to a patient, wherein improvement in abnormal bone condition is indicated by an improvement in the bone condition score of the patient after the plurality of doses of olipudase-alpha. 2. The method of claim 1 wherein the measure of bone health is bone mineral density (BMD), where BMD improves or does not worsen after multiple doses of rhASM. 3. The method of claim 1 wherein the bone health score is bone marrow "load" (BMB), where BMB decreases or does not increase after multiple doses of rhASM. 4. The method of claim 1, wherein the bone health score is bone maturation, and wherein bone maturation improves after multiple doses of rhASM. 5. The method of claim 1, wherein linear growth is an indicator of bone health, and wherein linear growth improves after multiple doses of rhASM. 6. The method according to any one of paragraphs. 1-5, where the pathological condition of the bone is osteopenia or osteoporosis. 7. The method according to any one of paragraphs. 1-6, where the patient with acid sphingomyelinase deficiency is not receiving bisphosphonate therapy. 8. The method of any one of the preceding claims, wherein multiple doses are administered to the patient over a period of six to thirty months. 9. The method of any one of the preceding claims, wherein the patient has Niemann-Pick type B disease. 10. The method according to any one of paragraphs. 1-8, where the patient has Niemann-Pick type A/B disease. 11. The method according to any one of the preceding claims, wherein the patient is an adult patient. 12. The method according to any one of paragraphs. 1-10, where the patient is a pediatric patient. 13. The method according to any one of the preceding claims, wherein the first two or more doses are incremental doses and are administered in successively increasing amounts. 14. The method of claim 13 wherein the doses after the escalating doses are maintenance doses and are administered in the same or less amount than the last escalating dose. 15. The method of claim 13 or 14, wherein the first dose is 0.1 mg/kg and the patient is a pediatric patient. 16. The method of claim 13 or 14, wherein the first dose is 0.1 mg/kg and the patient is an adult. 17. The method according to any one of paragraphs. 14-16 where the highest maintenance dose is 0.3 mg/kg to 3 mg/kg. 18. The method according to any one of paragraphs. 14-16 where the highest maintenance dose is 1 mg/kg. 19. The method according to any one of paragraphs. 14-16 where the highest maintenance dose is 2 mg/kg. 20. The method according to any one of paragraphs. 14-16 where the highest maintenance dose is 3 mg/kg. 21. The method according to any one of paragraphs. 14-16, where the highest maintenance dose is the highest dose tolerated by the patient. 22. The method according to any one of paragraphs. 13-21 where increasing doses are administered in the following order: 0.1 mg/kg, 0.3 mg/kg, 0.3 mg/kg, 0.6 mg/kg, 0.6 mg/kg, 1.0 mg/kg, 2.0 mg/kg and 3.0 mg/kg. 23. The method of any one of the preceding claims, wherein multiple doses are administered at 2 week intervals. 24. The method according to any one of the preceding claims, wherein the plurality of doses are administered by intravenous injection.

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