TWI723478B - Use of a pcsk9 inhibitor to treat hyperlipidemia - Google Patents

Abstract

The present invention provides methods for treating hyperlipidemia in patients who are not on statin therapy. The methods of the present invention comprise administering to a patient a pharmaceutical composition comprising a PCSK9 inhibitor. In certain embodiments, the PCSK9 inhibitor is an anti-PCSK9 antibody such as the exemplary antibody referred to herein as mAb316P.

Description

Use of PCSK9 inhibitors for the treatment of hyperlipidemia

The present invention relates to the field of therapeutic treatment of diseases and disorders associated with elevated lipid and lipoprotein levels. More specifically, the present invention relates to the use of PCSK9 inhibitors for the treatment of patients with hyperlipidemia who are not undergoing statin treatment, and include non-response to statin, poor control of treatment with statin, and Patients who are intolerant to statin or have a history of adverse reactions to statin treatment.

Hypercholesterolemia (especially an increase in the amount of low-density lipoprotein (LDL) cholesterol (LDL-C)) is a major risk factor for the development of atherosclerosis and coronary heart disease (CHD) (Sharrett et al., 2001, Circulation 104: 1108-1113). Low-density lipoprotein cholesterol has been confirmed as the main target of cholesterol-lowering therapy and is considered to be an effective alternative treatment evaluation index (endpoint). Many studies have confirmed that reducing the amount of LDL-C will reduce the risk of CHD. Among them, the amount of LDL-C has a strong direct correlation with CHD events; for every 1mmol/L (~40mg/dL) reduction in LDL-C, cardiovascular disease ( CVD) mortality and morbidity decreased by 22%. The greater the reduction in LDL-C, the greater the reduction in events, and the enhanced comparison data relative to standard statin therapy indicates that the lower the amount of LDL-C, the greater the benefit for patients at extremely high cardiovascular (CV) risk .

Existing LDL-C lowering drugs include statins, cholesterol absorption inhibitors (such as ezetimibe [EZE]), fibric acid, nicotine, and cholic acid chelating agents. Although lifestyle adjustments and conventional medications are usually successful in reducing cholesterol levels, not all patients can achieve the recommended target cholesterol levels using these methods. Despite the active use of conventional therapies, several conditions, such as familial hypercholesterolemia (FH), appear to be resistant to lowering the amount of LDL-C. Specifically, the use of statin therapy to lower LDL-C by inhibiting cholesterol synthesis and up-regulating liver LDL receptors may be only somewhat useful for patients whose LDL receptors are absent or defective. In addition, many patients are patients who are unresponsive to statin, poorly controlled with statin therapy, cannot tolerate statin, and/or cannot adhere to their prescribed therapeutic statin regimen due to statin-related side effects. Because hypercholesterolemia is mostly asymptomatic, any undesirable effects of pharmacological drugs used to treat this condition may undermine the patient's willingness to use drugs. In several cohort studies, the reported compliance rate for 1-year statin treatment ranged from 26% to 85%, and a rapid decline in compliance was often observed in the first few months.

Therefore, there is a need in the field of alternative options for reducing LDL-C in patients.

The present invention provides methods for treating hyperlipidemia including, for example, primary hyperlipidemia. Specifically, the method of the present invention can be used to treat patients with hyperlipidemia who are not undergoing statin treatment and include no response to statin, poor control of statin treatment, intolerance to statin, or history Statins treat patients with a history of adverse reactions.

According to one aspect, the method of the present invention administers one or more doses of PCSK9 inhibitor to patients who are not on statin treatment. Patients with hyperlipidemia are not being treated with statin because they have no response to statin, poorly controlled treatment with statin, intolerance to statin, a history of adverse reactions to statin treatment, or because of any other factors.

According to another aspect, the present invention includes a method for treating hyperlipidemia in a patient, which comprises administering one or more doses to a patient whose background statin treatment is discontinued before or at the same time as the first dose of PCSK9 inhibitor. PCSK9 inhibitor.

According to one aspect, patients with hyperlipidemia include patients with non-familial hypercholesterolemia, heterozygous or homozygous familial hypercholesterolemia, or mixed dyslipidemia. In some aspects, patients with hyperlipidemia also have type 2 diabetes.

In some specific cases, PCSK9 inhibitors are administered to patients as monotherapy in the absence of any other lipid-modulating therapies. In some specific cases, PCSK9 inhibitors are administered to patients in combination with other non-statin lipid modulation therapies.

According to one aspect, the method of the present invention comprises administering one or more doses of a PCSK9 inhibitor to patients who are intolerant to statin or have a history of adverse reactions to statin treatment. Examples of adverse reactions to statin treatment include, for example, skeletal muscle pain, discomfort, weakness, and/or cramps. Therefore, according to some specific examples, the present invention provides a method for reducing the amount of serum LCL-C in a patient without causing skeletal muscle pain, discomfort, weakness or cramps, for example, by interrupting the patient’s statin treatment regimen and The patient was administered a PCSK9 inhibitor.

The present invention also provides a method for reducing the amount of serum LCL-C in patients who are intolerant to statin by screening for patients who are intolerant or resistant to statin with moderate, high or very high cardiovascular risk Statins treat patients with a history of adverse reactions and administer one or more doses of PCSK9 inhibitors to the patients.

The present invention also provides a method for the treatment of hyperlipidemia in patients who are intolerant to statin or have a history of adverse reactions to statin treatment by screening for previous patients with moderate, high or very high cardiovascular risk A patient who feels the onset or increase of skeletal muscle-related symptoms during the daily therapeutic statin regimen and is administered one or more doses of PCSK9 inhibitor to the patient. According to some specific cases, based on previous feelings of starting or increasing skeletal muscle phase during at least two individual daily therapeutic statin regimens Patients are screened for symptoms (e.g., where at least one of the daily therapeutic statin regimens is the lowest approved daily dose of statin).

The present invention also provides a pharmaceutical composition comprising a PCSK9 inhibitor, which is used for the treatment of patients with hyperlipidemia who are not undergoing statin treatment.

A specific example provides a method for the treatment of hypercholesterolemia in patients in need, which comprises: (a) screening patients who are intolerant to statin or have a history of adverse reactions to statin treatment; and (b) to The patient is administered one or more doses of PCSK9 inhibitor.

Another specific example provides a method for reducing the amount of serum LDL-C in a patient without causing skeletal muscle pain, discomfort, weakness or cramps, which includes: (a) screening for taking one or more of the approved minimum daily doses Patients who feel the onset or increase of skeletal muscle-related symptoms during statin; and (b) administer one or more doses of PCSK9 inhibitor to the patient; thereby reducing the patient’s serum LDL-C level without causing skeletal muscle pain , Discomfort, weakness or cramps.

Another specific example provides a method for reducing the amount of serum LDL-C in patients with hypercholesterolemia who are intolerant to statin, which includes: (a) screening for those with moderate, high, or very high cardiovascular risk Patients who are intolerant to statin or have a history of adverse reactions to statin treatment; and (b) administer one or more doses of PCSK9 inhibitor to the patient.

Another specific example provides a method for treating hypercholesterolemia in patients who are intolerant to statin or have a history of adverse reactions to statin treatment, which includes: (a) screening with moderate, high or extremely high Cardiovascular risk patients who previously felt the onset or increase of skeletal muscle-related symptoms during the daily therapeutic statin regimen; and (b) administering one or more doses of PCSK9 inhibitor to the patient.

In some specific cases, the patient previously experienced the onset or increase of skeletal muscle-related symptoms during at least two individual daily therapeutic statin regimens. In some specific cases Among them, at least one of the daily therapeutic statin regimens is the lowest approved daily dose of statin. In some specific examples, at least one of the daily therapeutic statin regimens is selected from the group consisting of: 5 mg daily rosuvastatin (rosuvastatin), daily 10 mg atorvastatin (atorvastatin), daily 10 mg simvastatin, 20 mg lovastatin daily, 40 mg pravastatin daily, 40 mg fluvastatin daily, and 2 mg pitavastatin daily. In some specific cases, the PCSK9 inhibitor is administered to the patient in the absence of statin therapy.

A specific example provides a method for eliminating the use of statin in hypercholesterolemia patients who are intolerant to statin while reducing the amount of serum LDL-C in the patient. The method includes: (a) screening is ongoing or previous Patients with daily therapeutic statin regimens who are intolerant to statin or have a history of adverse reactions to statin treatment; (b) interrupt the patient’s daily therapeutic statin regimen; and (c) administer one or Multiple doses of PCSK9 inhibitor.

In some specific cases, the patient exhibited hypercholesterolemia defined as serum low-density lipoprotein cholesterol (LDL-C) levels greater than about 70 mg/dL before or at the same time the PCSK9 inhibitor was administered. In some specific cases, the patient exhibited hypercholesterolemia defined as serum low-density lipoprotein cholesterol (LDL-C) levels greater than about 100 mg/dL before or at the same time as the PCSK9 inhibitor was administered.

In some specific cases, the patient has heterozygous familial hypercholesterolemia (heFH). In some specific cases, the patient has a form of hypercholesterolemia that is not familial hypercholesterolemia (non-FH). In some specific cases, before or at the same time as the PCSK9 inhibitor is administered, the patient has a moderate cardiovascular risk defined as a calculated 10-year mortality risk of cardiovascular disease with SCORE greater than or equal to 1% and less than 5%. In some specific cases, before or at the same time as the PCSK9 inhibitor is administered, the patient has a calculated 10-year mortality risk of cardiovascular disease with SCORE greater than or equal to 5% and one or more of the following High cardiovascular risk of: (i) moderate chronic kidney disease, (ii) type 1 diabetes, no target organ damage; (iii) type 2 diabetes, no target organ damage, and/or (iv) heFH. In some specific cases, the patient has a very high cardiovascular risk defined as one or more of the following before or at the same time the PCSK9 inhibitor is administered: (i) documented coronary heart disease; (ii) ischemic stroke; ( iii) Peripheral stroke; (iv) Peripheral artery disease (PAD); (v) Temporary ischemic stroke (TIA); (vi) Abdominal aortic aneurysm; (vii) Asymptomatic carotid artery occlusion>50%; (viii) Carotid endarterectomy; (ix) Carotid artery stent procedure; (x) Renal artery stenosis; (xi) Renal artery stent procedure; (xii) Type 1 diabetes with target organ damage; and/or ( xiii) Type 2 diabetes, with target organ damage.

In some specific examples, the PCSK9 inhibitor is an antibody or antigen binding protein that specifically binds to PCSK9. In some specific examples, the antibody or antigen-binding fragment thereof comprises a heavy chain CDR and a light chain CDR having an HCVR/LCVR amino acid sequence pair, and the HCVR/LCVR amino acid sequence pair comprises SEQ ID NO: 1/6. In some embodiments, the antibody or antigen-binding fragment thereof comprises the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10. In some specific examples, the antibody or antigen-binding fragment thereof comprises an HCVR having an amino acid sequence of SEQ ID NO:1 and an LCVR having an amino acid sequence of SEQ ID NO:6. In some specific examples, the antibody or antigen-binding fragment thereof is the same as that of the antibody comprising the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10 that bind to PCSK9 Epitope. In some embodiments, the antibody or antigen-binding fragment thereof competes with an antibody comprising the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10 for binding to PCSK9.

In some specific cases, the antibody or antigen binding protein that specifically binds to PCSK9 is administered to the patient at a dose of about 75 mg at a frequency of once every two weeks. In some specific cases, if the patient's LDL-C is measured to be <70 mg/dL after 5 or more doses, the dose of about 75 mg is maintained. In some specific cases, if in 5 or more doses After the patient's LDL-C is measured as ≧70 mg/dL, the dose of about 75 mg is interrupted, and the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is then administered to the patient at a dose of about 150 mg at a frequency of once every two weeks. In some specific cases, the antibody or antigen-binding fragment that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg at a frequency of once every two weeks.

In some specific cases, PCSK9 inhibitors are administered in combination with non-statin lipid modulation therapy. In some specific examples, the non-statin lipid modulation therapy comprises a therapeutic agent selected from the group consisting of ezetimibe, fibric acid, nicotine, omega-3 fatty acids, and cholic acid resin.

In some specific examples, the method improves the serum level of one or more lipid components selected from the group consisting of: (a) lowering the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) Reduce the patient's lipoprotein B (ApoB) by at least 25%; (c) reduce the patient's non-high-density lipoprotein cholesterol (non-HDL-C) by at least 30%; (d) reduce the patient's total cholesterol by at least 20 %; and (e) reduce the patient's lipoprotein a (Lp(a)) by at least 15%.

A specific example provides a method for improving the serum level of one or more lipid components in patients with hypercholesterolemia who are intolerant to statin. The method includes: (a) screening for patients with moderate, high, or very high cardiovascular Patients at risk who are intolerant to statin or have a history of adverse reactions to statin treatment; and (b) administer to the patient at a dose of about 75 to 150 mg/dose and a dosing frequency of about once every two weeks Multi-dose anti-PCSK9 antibody, wherein after about 24 weeks of treatment with anti-PCSK9 antibody, the serum level of one or more lipid components selected from the group consisting of: (a) lowering the patient's low-density lipoprotein cholesterol (LDL-C) to at least 35%; (b) to reduce the patient’s lipo-deficient lipoprotein B (ApoB) to at least 25%; (c) to reduce the patient’s non-high-density lipoprotein cholesterol (non-HDL-C) to at least 30 %; (d) reduce the patient's total cholesterol by at least 20%; and (e) reduce the patient's lipoprotein a (Lp(a)) by at least 15%.

Another embodiment of the present invention provides a method for treating hypercholesterolemia in a patient in need, which comprises administering to the patient a pharmaceutical composition comprising a PCSK9 inhibitor as a monotherapy, wherein the composition is every two weeks Was administered and the patient was not on another lipid-modulating therapy at the same time, thereby treating the patient's hypercholesterolemia.

Another embodiment of the present invention provides a method for lowering low-density lipoprotein cholesterol (LDL-C) in a patient in need, which comprises administering to the patient a pharmaceutical composition comprising a PCSK9 inhibitor as a monotherapy, wherein The composition is administered every two weeks and the patient is not on another lipid-modulating therapy at the same time, thereby reducing the patient's LDL-C.

Another embodiment of the present invention provides a method for maintaining a stable amount of low-density lipoprotein cholesterol (LDL-C) in a patient, which comprises administering to the patient a pharmaceutical composition as a monotherapy, the pharmaceutical composition comprising the initial A PCSK9 inhibitor at a dose of about 75 mg, wherein the composition is administered every two weeks, and wherein the patient is not on another lipid-lowering therapy at the same time, so as to maintain the patient's stable LDL-C amount. In some specific cases, the PCSK9 inhibitor is administered to the patient for at least 24 weeks, and the patient's LDL-C amount remains stable for 20 weeks.

In some specific cases where PCSK9 inhibitors are administered as monotherapy, the patient is intolerant to statin or has a history of adverse reactions to statin treatment. In some specific cases, the patient previously experienced the onset or increase of skeletal muscle-related symptoms during at least two individual daily therapeutic statin regimens. In some specific cases, at least one of the daily therapeutic statin regimens is the lowest approved daily dose of statin. In some specific cases, at least one of the daily therapeutic statin regimens is selected from the group consisting of: 5 mg rosuvastatin daily, 10 mg atorvastatin daily, 10 mg simvastatin daily, daily 20 mg lovastatin, 40 mg pravastatin daily, 40 mg fluvastatin daily, and 2 mg pitavastatin daily.

In some specific cases where PCSK9 inhibitors are administered as monotherapy, Before or at the same time as the PCSK9 inhibitor is administered, the patient exhibits hypercholesterolemia defined as serum low-density lipoprotein cholesterol (LDL-C) levels greater than about 70 mg/dL.

In some specific cases where the administration of PCSK9 inhibitors as monotherapy is provided, before or at the same time as the administration of PCSK9 inhibitors, the patient exhibits high levels defined as serum low-density lipoprotein cholesterol (LDL-C) levels greater than about 100 mg/dL Cholesterolemia.

In some specific cases where the PCSK9 inhibitor is administered as a monotherapy, the patient has heterozygous familial hypercholesterolemia (heFH). In some specific cases where PCSK9 inhibitors are administered as monotherapy, the patient has a form of hypercholesterolemia that is not familial hypercholesterolemia (non-FH). In some specific cases, before or at the same time as the PCSK9 inhibitor is administered, the patient has a moderate cardiovascular risk defined as a calculated 10-year mortality risk of cardiovascular disease with SCORE greater than or equal to 1% and less than 5%. In some specific cases, before or at the same time as the PCSK9 inhibitor is administered, the patient has a high cardiovascular risk defined as a calculated 10-year mortality risk of cardiovascular disease with SCORE greater than or equal to 5% and one or more of the following: (i) Moderate chronic kidney disease, (ii) type 1 diabetes, no target organ damage, (iii) type 2 diabetes, no target organ damage, and/or (iv) heFH. In some specific cases, before or at the same time the PCSK9 inhibitor is administered, the patient has a very high cardiovascular risk defined as one or more of the following: (i) documented coronary heart disease; (ii) ischemic stroke; ( iii) Peripheral stroke; (iv) Peripheral artery disease (PAD); (v) Temporary ischemic stroke (TIA); (vi) Abdominal aortic aneurysm; (vii) Asymptomatic carotid artery occlusion>50%; (viii) Carotid endarterectomy; (ix) Carotid artery stent procedure; (x) Renal artery stenosis; (xi) Renal artery stent procedure; (xii) Type 1 diabetes with target organ damage; and/or ( xiii) Type 2 diabetes, with target organ damage.

In some specific examples where the PCSK9 inhibitor is administered as a monotherapy, the PCSK9 inhibitor is an antibody or antigen binding protein that specifically binds to PCSK9. In some specific examples, the antibody or antigen-binding fragment thereof comprises a heavy chain CDR and a light chain CDR having an HCVR/LCVR amino acid sequence pair, and the HCVR/LCVR amino acid sequence pair Contains SEQ ID NO: 1/6. In some embodiments, the antibody or antigen-binding fragment thereof comprises the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10. In some specific examples, the antibody or antigen-binding fragment thereof comprises an HCVR having an amino acid sequence of SEQ ID NO:1 and an LCVR having an amino acid sequence of SEQ ID NO:6. In some specific examples, the antibody or antigen-binding fragment thereof is the same as that of the antibody comprising the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10 that bind to PCSK9 Epitope. In some embodiments, the antibody or antigen-binding fragment thereof competes with an antibody comprising the heavy chain and light chain CDR amino acid sequences of SEQ ID NO: 2, 3, 4, 7, 8 and 10 for binding to PCSK9.

In some specific examples where the PCSK9 inhibitor is administered as a monotherapy, the antibody or antigen-binding protein that specifically binds to PCSK9 is administered to the patient at a dose of about 75 mg at a frequency of once every two weeks. In some specific cases, if the patient's LDL-C is measured to be <70 mg/dL after five or more doses, then the dose of about 75 mg is maintained. In some specific cases, if the patient’s LDL-C is measured to maintain ≧70 mg/dL after five or more doses, then the dose of about 75 mg is interrupted, and the antibody or antigen-binding fragment thereof that specifically binds to PCSK9 is followed by about A dose of 150 mg is administered to the patient at a frequency of once every two weeks. In some specific cases, the antibody or antigen binding protein that specifically binds to PCSK9 is administered to the patient at a dose of about 150 mg at a frequency of once every two weeks.

In some specific examples that provide the administration of PCSK9 inhibitors as monotherapy, the method improves the serum level of one or more lipid components selected from the group consisting of: (a) lowering the patient's low-density lipoprotein cholesterol (LDL) -C) At least 35%; (b) Reduce the patient's lipoprotein B (ApoB) by at least 25%; (c) Reduce the patient's non-high-density lipoprotein cholesterol (non-HDL-C) by at least 30%; (d) Reduce the patient's total cholesterol by at least 20%; and (e) reduce the patient's lipoprotein a (Lp(a)) by at least 15%.

A specific example provides a method for reducing the amount of free PCSK9 in a patient, which A pharmaceutical composition comprising an anti-PCSK9 antibody or antigen-binding protein at a dose of about 75 mg administered to the patient as a monotherapy, wherein the composition is administered every two weeks, and wherein the patient is not simultaneously undergoing another lipid-lowering Therapy to reduce the amount of free PCSK9 in the patient.

A specific example provides a method for improving the serum amount of one or more lipid components in a patient in need, which comprises administering to the patient at a dosage of about 75 to 150 mg/dose at a dosing frequency of about once every two weeks. With multiple doses of anti-PCSK9 antibody as a monotherapy, where the patient is not on another lipid-modulating therapy at the same time and where after about 24 weeks of treatment with the anti-PCSK9 antibody, one or more lipids selected from the following group are improved Component serum levels: (a) reduce the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) reduce the patient's lipoprotein-deficient B (ApoB) by at least 25%; (c) reduce the patient's LDL-C The non-high-density lipoprotein cholesterol (non-HDL-C) of at least 30%; (d) reduce the patient’s total cholesterol by at least 20%; and (e) reduce the patient’s lipoprotein a (Lp(a)) by at least 15 %.

Other specific examples of the present invention will become clear after referring to the following detailed description.

[Schematic description]

100mg/dL的LDL-C閾值需要上調程序，但在這個研究中以不知情的方式適用

70mg/dL的閾值。圖式下方的箭頭表示評估時間。EOT，治療結束；EZE，依折麥布；LDL-C，低密度脂蛋白膽固醇；NCEPATP III TCP，國家膽固醇教育計劃成人治療第三版；Q2W，每2週；W，週。 Figure 1 shows the study design of the clinical trial described in Example 2. in spite of

The LDL-C threshold of 100 mg/dL requires an upward adjustment procedure, but it was applied in an unknowing manner in this study

The threshold of 70mg/dL. The arrow below the diagram indicates the evaluation time. EOT, the end of treatment; EZE, ezetimibe; LDL-C, low-density lipoprotein cholesterol; NCEPATP III TCP, the third edition of the National Cholesterol Education Program Adult Treatment; Q2W, every 2 weeks; W, weeks.

Figure 2 shows the patient characteristics of the clinical trial described in Example 2. *Life events make it difficult to continue. ITT, intention to treat.

Figure 3 shows the amount of LDL-C (mg/dL) in the clinical trial described in Example 2 Schema of relative study time points (analysis during treatment). Values beyond the 12th week and 24th week data points represent the% change from the baseline LS mean (SE). LDL-C, low-density lipoprotein cholesterol; LS, least squares; SE, standard deviation.

Figure 4 is a set of four graphs, showing the clinical trial described in Example 2, in patients treated with mAb316P (rilozumab) to the 12th week (Figure 4A) and the 24th week (Figure 4B) ), and the distribution of LDL-C percentage changes relative to baseline in patients treated with ezetimibe (maternal under treatment) to Week 12 (Figure 4C) and Week 24 (Figure 4D).

Figure 5 is a set of two graphs, showing that the clinical trial described in Example 2 is based on demographics (Figure 5A) and other baseline characteristics (Figure 5B) (ITT maternal) at week 24 LDL-C relative to baseline The percentage change of the sub-ethnic group analysis.

Figure 6 shows a series of graphs that illustrate the average amount of LDL-C in patients treated with mAb316P (Figure 6A), C _{from beginning to end,} and C _tracking mAb316P ( Rilomab) concentration (Figure 6B), and free PCSK9 amount (Figure 6C). The _{value of C from beginning to end} was obtained 14±6 days after the previous injection; the _tracking value of C was obtained >21 days after the last injection. The triangle represents the upregulation group at week 12. The squares indicate the non-upregulated group at week 21.

Figure 7 is a research flow chart illustrating the clinical trial described in Example 3 herein. "REGN727" is the name of the antibody referred to herein as rilocumab or mAb316P.

Before describing the present invention, it should be understood that the present invention is not limited to the specific methods and experimental conditions, because these methods and conditions may be changed. It should also be understood that the terms used in this article are only used to illustrate specific specific examples, rather than restrictive, because the scope of the present invention will only be limited by the scope of the attached patent application.

definition

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

It should be noted that unless clearly indicated otherwise in the text, the use of the singular form "一 (a, an)" and "the (the)" in the scope of this specification and the accompanying patent application also includes plural referents.

As used herein, the term "about" or "approximately", when used to refer to a specifically quoted value, means that the value can be changed by no more than 1% relative to the quoted value. For example, as used herein, the phrase "about 100" includes 99 and 101, and all values in between (eg, 99.1, 99.2, 99.3, 99.4, etc.).

The term "administer (administer or administration)" means the action of injecting or otherwise physically delivering a substance (such as the formulation of the present invention) that exists outside the body into the patient's body, such as by mucosal, intradermal, intravenous, Subcutaneous, intramuscular delivery, and/or any other physical delivery methods described herein or known in the art. When a disease or one of its symptoms is to be treated, the substance is usually administered after the occurrence of the disease or its symptoms. When a disease or its symptoms is to be prevented, the substance is administered before the disease or its symptoms occur.

The terms "composition" and "formulation" are intended to include products containing specific ingredients (such as anti-PCSK9 antibodies) in specific amounts as appropriate, and any products derived directly or indirectly from combinations of specific ingredients in specific amounts as appropriate .

The term "excipient" means an inert substance that is often used as a diluent, vehicle, preservative, binder, stabilizer, etc. of drugs, and includes, but is not limited to, proteins (such as serum albumin, etc.), amino acids ( For example, aspartic acid, glutamine acid, lysine acid, arginine, glycine, histidine, etc.), fatty acids and phospholipids (e.g. alkyl sulfonate, caprylate, etc.), surfactants (e.g. SDS, polysorbate, nonionic surfactant, etc.), sugars (such as sucrose, maltose, trehalose, etc.) and polyols (such as mannitol, sorbitol, etc.). See also Remington's Pharmaceutical Sciences (1990) Mack Publishing Co., Easton, Pa., which is incorporated as a reference in its entirety.

In peptides or polypeptides, the term "fragment" means a peptide or polypeptide that contains less than the full-length amino acid sequence. This fragment can be, for example, truncated at the amino end, at the carboxyl end Caused by truncation and/or internal deletion of residues in the amino acid sequence. Fragments may be due to alternative RNA splicing or protease activity in vivo, for example. In some specific examples, the PCSK9 fragment includes at least 50, at least 100, at least 125 consecutive amino acid residues, and at least 150 consecutive amino acid residues comprising the amino acid sequence of the PCSK9 polypeptide. , A polypeptide with an amino acid sequence of at least 175 consecutive amino acid residues, at least 200 consecutive amino acid residues, or at least 250 consecutive amino acid residues. In a specific embodiment, a fragment of the PCSK9 polypeptide or an antibody that specifically binds to the PCSK9 antigen maintains at least 1, at least 2, or at least 3 functions of the full-length polypeptide or antibody.

The term "pharmaceutically acceptable" refers to those approved by the regulatory agency of the federal or state government or listed in the United States Pharmacopoeia, European Pharmacopoeia or other generally recognized pharmacopoeia for use in animals (more specifically, humans).

The term "prevent (prevent, preventing and prevention)" means the complete or incomplete inhibition of PCSK9-mediated diseases and/or related symptoms due to administration of the therapies or combinations of therapies provided herein (such as combinations of prophylactic or therapeutic agents) The development, recurrence, occurrence or spread of the disease.

The term "PCSK9 antigen" means a portion of a PCSK9 polypeptide that is specifically bound by an antibody. PCSK9 antigen also refers to an analog or derivative of PCSK9 polypeptide or a fragment thereof specifically bound by an antibody. In some specific examples, the PCSK9 antigen is a monomeric PCSK9 antigen or a trimeric PCSK9 antigen. The region of the PCSK9 polypeptide that provides the epitope can be a contiguous amino acid of the polypeptide, or the epitope can be composed of two or more non-contiguous regions of the polypeptide. The epitope may or may not be a three-dimensional surface feature of the antigen. The local area on the surface of the PCSK9 antigen that can cause an immune response is the PCSK9 epitope. The epitope may or may not be a three-dimensional surface feature of the antigen.

The terms "human PCSK9", "hPCSK9" or "hPCSK9 polypeptide" and similar terms mean the polypeptide comprising the amino acid sequence of SEQ ID NO: 198 and related polypeptides ("polypeptide "Peptide", "peptide" and "protein" are used interchangeably herein), including its SNP variants. Related polypeptides include allele variants (such as SNP variants); splice variants; fragments; derivatives; substitutions, deletions, and Insertion variants; fusion polypeptides; and homologs between species, which preferably maintain PCSK9 activity and/or are sufficient to generate an anti-PCSK9 immune response. It also includes a soluble form of PCSK9, which is sufficient to generate an anti-PCSK9 immune response. As known to those skilled in the art, anti-PCSK9 antibodies can bind to PCSK9 polypeptides, polypeptide fragments, antigens and/or epitopes, because epitopes are part of a larger antigen, and larger antigens are part of a larger polypeptide fragment , And the larger polypeptide fragment is part of a larger polypeptide. hPCSK9 can be in trimeric (natural) or monomer (denatured) form.

The terms "PCSK9-mediated diseases", "PCSK9-mediated conditions" and "PCSK9-mediated conditions" are used interchangeably and mean any that is completely or incompletely caused by PCSK9 (e.g., hPCSK9) or caused by PCSK9 (e.g., hPCSK9). A disease. In some specific cases, PCSK9 behaves abnormally (e.g., height). In some specific cases, PCSK9 can be abnormally upregulated. In other specific cases, normal, abnormal or excessive cell signaling is caused by the binding of PCSK9 to PCSK9 ligand. In some specific examples, the PCSK9 ligand is the PCSK9 receptor. In some specific cases, PCSK9-mediated diseases or conditions are selected from the group consisting of: elevated total cholesterol; elevated low-density lipoprotein cholesterol (LDL-C); hyperlipidemia; dyslipidemia; high cholesterol Hypercholesterolemia, especially hypercholesterolemia not controlled by statin, hypercholesterolemia such as familial hypercholesterolemia or non-familial hypercholesterolemia, and hypercholesterolemia not controlled by statin; arterial hypercholesterolemia; Atherosclerosis; and cardiovascular disease.

The terms "individual" and "patient" are used interchangeably. As used herein, the individual is preferably a mammal, such as a non-primate (e.g., cow, pig, horse, cat, dog, rat, etc.) or a primate (e.g., monkey and human), and most preferably a human. In a specific example, the individual is a mammal, preferably a human, who has a PCSK9-mediated disease. In another specific example, the individual is a mammal, preferably a human, who is in the process of developing the PCSK9 medium. The risk of disease.

The term "therapeutic agent" means any agent that can be used to treat, control or alleviate PCSK9-mediated diseases and/or symptoms related thereto. In certain embodiments, the term "therapeutic agent" means the PCSK9 antibody of the present invention. In some other specific examples, "therapeutic agent" means an agent other than the PCSK9 antibody of the present invention. Preferably, the therapeutic agent is an agent that is known to be used, or has been or is currently used to treat, control or alleviate PCSK9-mediated diseases or one or more symptoms related thereto.

The term "therapy" means any procedure, method, and/or agent that can be used to prevent, control, treat, and/or alleviate PCSK9-mediated diseases (such as atherosclerosis or hypercholesterolemia). In some specific cases, the term "therapies and therapy" means biological therapies, supportive therapies, and/or used for prevention, control, treatment, and/or prevention, control, and treatment known to those skilled in the art (such as medical personnel). / Or other therapies to alleviate PCSK9-mediated diseases.

The term "treat (treat, treatment, and treating)" means that the administration of one or more therapies (including, but not limited to, the administration of one or more prophylactic or therapeutic agents) reduces or alleviates the progression or severity of PCSK9-mediated diseases Sex, and/or duration. In certain specific examples, these terms mean to reduce or inhibit the binding of PCSK9 to the PCSK9 ligand.

Although any methods and materials similar or equivalent to those described herein can be used to practice the present invention, preferred methods and materials will now be described. All public documents mentioned in this article are incorporated in their entirety as reference materials.

Patient screening

The present invention includes methods and compositions especially for the treatment of patients with hyperlipidemia who are not undergoing statin treatment, and the patients include non-responsiveness to statin, poor control of statin treatment, and intolerance to statin, Or patients with a history of adverse reactions to statin treatment.

The method of the present invention includes screening patients who have or are at risk of developing PCSK9-mediated diseases or conditions, such as hyperlipidemia or related disorders (such as atherosclerosis); and To these patients, a pharmaceutical composition containing a PCSK9 inhibitor is administered. For example, if a patient is diagnosed with hyperlipidemia or is identified as being at risk of developing hyperlipidemia, the patient can be screened for treatment using the method of the present invention. Hyperlipidemia is, for example, heterozygous familial hypercholesterolemia. (heFH), homozygous familial hypercholesterolemia (hoFH), somatic dominant hypercholesterolemia (ADH, such as ADH related to one or more gain-of-function mutations in the PCSK9 gene), non-familial hypercholesterolemia Disease (non-FH), dyslipidemia, and mixed dyslipidemia. In some aspects, patients to be treated show that LDL blood cell separation is necessary. In some aspects, patients with hyperlipidemia also have type 2 diabetes. In some aspects, the patient to be treated is diagnosed with hypercholesterolemia and is intolerant to statin, does not respond to statin, or cannot control statin. As used herein, hyperlipidemia includes primary hyperlipidemia, secondary hyperlipidemia, and Flexon phenotypes I-V.

As used herein, the phrase "patient in need" means a human or non-human animal that exhibits one or more symptoms or markers of hyperlipidemia, or has been diagnosed with hyperlipidemia, or otherwise benefits from Those who have decreased total serum cholesterol, LDL, triglycerides, VLDL, lipoprotein(a)[Lp(a)], or benefited from increased HDL.

The method of the present invention involves screening patients who are not currently on statin therapy. As used herein, statin therapy is an HMG-CoA reductase inhibitor and includes, but is not limited to, atorvastatin, cerivastatin, fluvastatin, lovastatin, mevastatin, pitavastatin, pravastatin , Rosuvastatin, Simvastatin, etc. In some embodiments, patients whose previous (or "background") statin treatment was discontinued before or at the same time as the first dose of the PCSK9 inhibitor are administered the dose of the PCSK9 inhibitor.

According to some specific cases, according to the risk of moderate, high or very high CV Screen patients. Assess the degree of CV risk and express it as the calculation of 10-year fatal cardiovascular disease (CVD) risk SCORE value, such as by the European Society of Cardiology (ESC) and the European Society of Arteriosclerosis (EAS) in the Management of Dislipidaemias, The European Heart Journal, 2100; 32: 1769-1818 ESC/EAS guide (referred to as "ESC/EAS 2011" in this article) is shown, and its disclosure is incorporated as a reference in its entirety. As used herein, "moderate CV risk" means that the calculated 10-year lethal CVD risk SCORE is greater than or equal to 1% and less than 5%. As used herein, "high CV risk" means a calculated 10-year fatal CVD risk SCORE greater than or equal to 5%, and/or moderate renal disease (CKD), and/or type 1 or type 2 diabetes without target organ damage, And/or heFH. As used herein, "extremely high CV risk" means documented coronary heart disease (CHD), ischemic stroke, peripheral artery disease (PAD), transient ischemic stroke (TIA), abdominal aortic aneurysm, asymptomatic Carotid artery obstruction>50%, carotid endarterectomy or carotid artery stent procedure, renal artery stenosis, renal artery stent procedure, and/or type 1 or type 2 diabetes, with target organ damage.

According to some specific cases, patients are screened based on a history of coronary heart disease (CHD). As used herein, "CHD history" (or "documented CHD history") includes one or more of the following: (i) acute myocardial choking (MI); (ii) silent MI; (iii) unstable angina; (iv) Coronary artery revascularization procedures (such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery [CABG]); and/or (v) clinically obvious CHD, which has undergone invasive or non-invasive tests (such as Coronary angiography, pressure test using treadmill, pressure cardiac ultrasound or magnetic imaging).

According to some specific cases, patients are screened based on one or more other risk factors selected from the group consisting of: age (for example, greater than 40, 45, 50, 55, 60, 65, 70, 75, or 80 years old), Race, ancestry, gender (male or female), exercise habits (e.g. regular exercisers, non-exercisers), other pre-existing medical conditions (e.g. type 2 diabetes, hypertension, etc.), and current medication status (e.g. currently taking Beta blockers, nicotine, Ezetimibe, fibric acid, omega-3 fatty acids and cholic acid resins, etc.).

The method of the invention comprises administering one or more doses of a PCSK9 inhibitor to a patient who is not on statin treatment. Patients with hyperlipidemia may not be receiving statin treatment because they have no response to statin, poor control of statin treatment, intolerance to statin, history of adverse reactions to statin treatment, or any other factors.

Although lifestyle changes and conventional drug treatments usually succeed in lowering cholesterol levels, not all patients can achieve the recommended target cholesterol levels using these methods. Regardless of whether conventional therapies are actively used, several conditions, such as familial hypercholesterolemia (FH), appear to be resistant to lowering the amount of LDL-C. Homozygous and heterozygous familial hypercholesterolemia (hoFH, heFH) is a condition related to early-onset atherosclerotic vascular disease. However, most patients diagnosed with hoFH do not respond to conventional drug therapies and have limited treatment options. Specifically, the use of statin therapy can reduce LDL-C by inhibiting cholesterol synthesis and up-regulating liver LDL receptors, which may have little effect on patients with non-existent or defective LDL receptors. Among patients whose genotype is confirmed to be hoFH and treated with the maximum statin dose, it has been reported that the average LDL-C decrease is only less than about 20%. Adding 10mg/day ezetimibe to this regimen will reduce the total amount of LDL-C to 27%, which is still far from optimal. Similarly, many patients have no response to statin or poorly controlled treatment with statin.

In some aspects, the methods of the invention comprise administering one or more doses of a PCSK9 inhibitor to patients who are "intolerant to statin." As used herein, a patient is considered to be "intolerant to statin" if he feels the onset or increase of one or more adverse reactions during the daily statin treatment regimen and stops when the statin treatment is discontinued. In some specific cases, the adverse reaction is skeletal in nature, such as skeletal muscle pain, pain, weakness or cramps (eg, myalgia, myopathy, rhabdomyolysis, etc.). In some specific cases, the adverse reaction is skeletal muscle pain or pain, which occurs or becomes obvious after exercise or exertion. Adverse reactions related to statin also include liver, gastrointestinal and psychosis Symptoms, which are related to the administration of statin. According to some specific cases, if a patient has a history of skeletal muscle-related symptoms related to at least two different and individual daily statin treatment regimens, the patient is considered "intolerant to statin." According to some specific cases, if a patient exhibits one or more statin-related adverse reactions to one or more approved minimum daily doses of statin, the patient is considered "intolerant to statin." In some specific cases, if a patient cannot tolerate a cumulative weekly dose of statin that is seven times the minimum approved tablet size, the patient is "intolerant to statin." According to other specific examples of the present invention, if a patient can tolerate low-dose statin treatment but develops symptoms when the dose is increased (for example, when the target LDL-C amount is reached), the patient is "intolerant to statin".

According to the present invention, "the history of skeletal muscle-related symptoms related to taking at least two different and individual statins" includes skeletal muscle-related pain, pain, weakness, and skeletal muscle-related pain, pain, weakness, and skeletal muscle that started or increased during statin treatment and stopped when statin treatment was interrupted / Or cramps. In the context of the present invention, exemplary statin treatments related to statin intolerance include a daily therapeutic statin regimen selected from the group consisting of: 5 mg rosuvastatin daily, 10 mg atorvastatin daily , 10 mg simvastatin daily, 20 mg lovastatin daily, 40 mg pravastatin daily, 40 mg fluvastatin daily, and 2 mg pitavastatin daily.

Patients treated using the methods of the present invention can receive one or more other non-statin lipid modulating therapies. Alternatively, they may not receive other lipid-modulating therapies; in this case, the administration of PCSK9 inhibitors can be described as monotherapy. As used herein, the use of a PCSK9 inhibitor as a "monotherapy" means that there is no other concurrent lipid modulation therapy.

Method for treating hyperlipidemia and reducing the amount of serum LDL-C

According to some specific examples, patients who can be treated by the method of the present invention have hyperlipidemia, which includes hypercholesterolemia (sometimes referred to herein as "hypercholesterolemia patients). "Hypercholesterolemia" is, for example, hypercholesterolemia. As used herein, including serum LDL-C concentration greater than or etc. At 70mg/dL, or the serum LDL-C concentration is greater than or equal to 100mg/dL, depending on the patient’s cardiovascular risk ("CV risk"). For example, for a patient with a very high risk (as defined elsewhere herein), if the patient's serum LDL-C concentration is greater than or equal to about 70 mg/dL, the patient is considered to have hypercholesterolemia. For patients with moderate or high CV risk (as defined elsewhere herein), if the patient's serum LDL-C concentration is greater than or equal to about 100 mg/dL, the patient is considered to have hypercholesterolemia.

For the purpose of the present invention, hypercholesterolemia includes heterozygous familial hypercholesterolemia (heFH), homozygous familial hypercholesterolemia (hoFH), somatic dominant hypercholesterolemia (ADH, such as with one or Multiple PCSK9 gene functional gain mutations related to ADH), and the onset of hypercholesterolemia (non-FH) different from familial hypercholesterolemia.

The present invention includes methods for reducing the amount of serum LDL-C in a patient. The patient can be a hypercholesterolemia patient who is intolerant to statin, or any other patient for whom lowering serum LDL-C is considered advantageous or desirable. Likewise, the present invention includes a method for reducing the serum LDL-C level of a patient without causing skeletal muscle pain, discomfort, weakness or cramping. As used herein, "reducing the amount of serum LDL-C" means causing a reduction in the amount of serum LDL-C in a patient by at least 10% (e.g., at least 15%, 20%, 25%, 30%, 35%, 40%, 45% , 50%, 55%, 60%, 65%, 70%, 75% or higher).

Methods used to eliminate or reduce statin use

The present invention includes methods especially for eliminating or reducing statin use in patients with hyperlipidemia, including hypercholesterolemia patients, such as hypercholesterolemia patients who are intolerant to statin. The method according to this aspect of the present invention includes: (a) screening patients who are undergoing or previously on a daily therapeutic statin regimen and who are intolerant to statin or have a history of adverse reactions to statin treatment; (b) discontinue or Reduce the patient’s daily A therapeutic statin regimen; and (c) administering one or more doses of PCSK9 inhibitor to the patient. According to some specific examples of this aspect of the present invention, the patient's daily therapeutic statin regimen is completely discontinued at or before the start of the treatment course, which treatment course includes administering one or more doses of PCSK9 inhibitor to the patient. In other specific cases, the patient's daily therapeutic statin regimen is gradually reduced at or before the start of the treatment course, which includes administering one or more doses of PCSK9 inhibitor to the patient. In this aspect of the present invention, the decrement of the statin regimen may include reducing the amount of statin administered to the patient, and/or reducing the frequency of administration of statin to the patient. According to this aspect of the present invention, the decrement of the statin regimen can completely eliminate the patient's use of statin when the patient receives a PCSK9 inhibitor instead of statin. In this aspect, the adverse effect of statin on patients is reduced or eliminated by reducing or eliminating the patient's use of statin, while still allowing the administration of PCSK9 inhibitors in the patient to adequately treat hypercholesterolemia.

Therapeutic efficacy

The method of the present invention reduces the serum level of one or more lipid components selected from the group consisting of: LDL-C, ApoB 100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, Lp(a) And/or residual cholesterol, and ApoA-1 increased.

According to some specific examples of the present invention, in the absence of any other lipid regulation therapy, the administration of a pharmaceutical composition containing a PCSK9 inhibitor to patients with hypercholesterolemia as a monotherapy will increase the serum low-density lipoprotein cholesterol ( LDL-C) The average percentage decrease from the baseline by at least about 25%, 30%, 40%, 45%, 50%, 60%, or more; the average percentage of ApoB100 from the baseline decreases by at least about 25%, 30%, 40 %, 50%, 60%, or greater; the average percentage of non-HDL-C relative to the baseline decreased by at least about 25%, 30%, 40%, 50%, 60%, or greater; the average percentage of total cholesterol relative to the baseline A decrease of at least about 10%, 15%, 20%, 25%, 30%, 35% or more; and/or an increase in the average percentage of ApoA-1 relative to the baseline by at least about 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or more. The above-mentioned various lipid parameters The percentage decrease may be 1, 2, 3, after the start of a treatment regimen that includes administration of a PCSK9 inhibitor as described herein (e.g., 75 mg or 150 mg mAb316P or other similar administration regimens once every two weeks, see e.g., Example 2 herein) 1, 2, 3, Achieved at 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30 or more weeks.

According to some specific examples, the present invention includes a method for reducing the amount of serum LDL-C in patients with hypercholesterolemia in the absence of any other lipid-modulating therapy. The prescription according to this aspect of the present invention includes: (a) Screening patients with LDL-C between 100mg/dL (2.59mmol/L) and 190mg/dL (4.9mmol/L) who are at moderate cardiovascular risk and have not Are receiving any other lipid-modulating therapy; and (b) administering multiple doses of anti-PCSK9 antibody to the patient in an amount of about 75 to 150 mg/dose and a dosing frequency of about once every two weeks, wherein the anti-PCSK9 antibody After about 24 weeks of antibody treatment, the patient showed improvement in one or more lipid parameters selected from the group consisting of: a decrease of about 47% in the amount of LDL-C from baseline, a decrease of about 41% in the amount of non-HDL-C from baseline, The amount of Apo B decreased by about 37% from baseline, and/or the amount of total cholesterol decreased by about 30% from baseline. The method according to this aspect of the invention may include interrupting the patient's background lipid modulation therapy before or at the same time as the beginning of anti-PCSK9 antibody treatment.

The method of the present invention reduces the serum amount of one or more lipid components selected from the group consisting of: LDL-C, ApoB100, non-HDL-C, total cholesterol, VLDL-C, triglycerides, Lp(a) And/or residual cholesterol. For example, according to some specific examples of the present invention, patients with hypercholesterolemia who are intolerant to statin or have a history of adverse reactions to statin treatment (also referred to herein as "highly intolerant to statin) "Cholesteremia patients") administering a pharmaceutical composition containing a PCSK9 inhibitor will reduce the average percentage of serum low-density lipoprotein cholesterol (LDL-C) relative to baseline by at least about 25%, 30%, 40%, 45%, 50%. %, 60% or more; the average percentage of ApoB100 decreased from baseline by at least about 25%, 30%, 40%, 50%, 60%, or more; the average percentage of non-HDL-C decreased by at least about 25% from baseline , 30%, 40%, 50%, 60%, Or greater; the average percentage of total cholesterol decreased from baseline by at least about 10%, 15%, 20%, 25%, 30%, 35% or greater; the average percentage of VLDL-C decreased from baseline by at least about 5%, 10 %, 15%, 20%, 25%, 30% or greater; the average percentage of triglycerides (such as fasting triglycerides) decreased from baseline by at least about 5%, 10%, 15%, 20%, 25 %, 30%, 35% or greater; and/or the average percentage of Lp(a) decreased from baseline by at least about 5%, 10%, 15%, 20%, 25%, or greater. The above-mentioned various lipid parameter percentage reductions can be after the start of a treatment regimen that includes the administration of PCSK9 inhibitors as described herein (e.g., 75 mg or 150 mg mAb316P or other similar administration regimens once every two weeks, see e.g., Example 3 herein). Achieved at 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30 or more weeks.

According to certain specific examples, the present invention includes a method for reducing the amount of serum LDL-C in patients with hypercholesterolemia who are intolerant to statin. The method according to this aspect of the present invention includes: (a) screening patients with moderate, high or very high cardiovascular risk who are intolerant to statin or have a history of adverse reactions to statin treatment; and (b) to the patient Multiple doses of anti-PCSK9 antibody are administered in an amount of about 75 to 150 mg/dose and a dosing frequency of about once every two weeks, wherein after about 24 weeks of treatment with the anti-PCSK9 antibody, the patient appears to be selected from the following composition Improvement in one or more lipid parameters of the population: the amount of LDL-C decreased by about 45% from the baseline, the amount of non-HDL-C decreased by about 40% from the baseline, the amount of Apo B decreased by about 36% from the baseline, and/or Lp (a) The amount decreased by about 26% from the baseline. The method according to this aspect of the invention may include interrupting the patient's background lipid modulation therapy before or at the same time as the beginning of anti-PCSK9 antibody treatment.

PCSK9 inhibitor

The method of the invention comprises administering to a patient a therapeutic composition comprising a PCSK9 inhibitor. As used herein, "PCSK9 inhibitor" is one that binds to or interacts with human PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo Any kind of medicine. Non-limiting examples of types of PCSK9 inhibitors include small molecule PCSK9 antagonists, peptidyl PCSK9 antagonists (eg, "peptibody" molecules), and antibodies or antigen-binding fragments of antibodies that specifically bind to human PCSK9.

The term "human proprotein convertase subtilisin/Kexin Type 9" or "human PCSK9" or "hPCSK9" as used herein means PCSK9 encoded by the nucleic acid sequence shown in SEQ ID NO: 197, and includes SEQ ID NO: 198 amino acid sequence or biologically active fragments thereof.

The term "antibody" as used herein is intended to mean an immunoglobulin molecule, which contains four polypeptide chains, two heavy (H) chains and two light (L) chains interconnected by disulfide bonds and their aggregates ( For example, IgM). Each heavy chain contains a heavy chain variable region (here abbreviated as HCVR or _VH ) and a heavy chain constant region. The heavy chain constant region comprises three domains, C _H 1, C _H 2 and C _H 3. Each light chain contains a light chain variable region (abbreviated herein as LCVR or V _L) and a light chain constant region. The light chain constant region contains a domain (C _L 1). V _H and V _L regions can be further divided into a super variability region (designated as complementarity determining region (CDR)), interspersed with the more conserved region (designated framework regions (FR)). Each V _H and V _L is composed of three CDR and four FR, to carboxy-terminus in the following order from the amino end: FR1, CDR1, FR2, CDR2 , FR3, CDR3, FR4. In different embodiments of the present invention, the FR of the anti-PCSK9 antibody (or its antigen binding portion) is the same as the human germline sequence, or it can be naturally or artificially modified. The amino acid consensus sequence can be defined by analyzing two or more CDRs in parallel.

The term "antibody" as used herein also includes antigen-binding fragments of complete antibody molecules. The term "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like, as used herein, includes any naturally occurring, enzymatically available, synthetic or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen To form a complex. Antigen-binding fragments of antibodies can use any appropriate standard techniques (such as proteolytic digestion or recombinant genetic engineering techniques involving manipulation and expression of DNA encoding the variable and optionally constant domains of the antibody). Technique) and derived from, for example, complete antibody molecules. Such DNA is known and/or easily obtained from, for example, commercial sources, DNA libraries (including, for example, phage-antibody libraries), or can be synthesized. DNA can be sequenced and manipulated chemically or by using molecular biotechnology, such as arranging one or more variable and/or constant domains into an appropriate configuration, or introducing cysteine residues. Codons, modification, addition or deletion of amino acids, etc.

Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv (scFv) molecules ; (Vi) dAb fragment; and (vii) the smallest identification unit (for example, isolated complementarity determining region (CDR), such as CDR3 peptide), or restriction type consisting of amino acid residues in the hypervariable region of the mimic antibody FR3-CDR3-FR4 peptide. Other engineered molecules (such as domain-specific antibodies, single-domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, tri-antibodies, tetra-antibodies, mini-antibodies, nano-antibodies (e.g. monovalent nano-antibodies) Antibodies, bivalent nano-antibodies, etc.), small regulatory molecule immune drugs (SMIP) and shark variable IgNAR domains) are also included in the term "antigen-binding fragment" as used herein.

Antigen-binding fragments of antibodies typically contain at least one variable domain. Variable domains can be of any size or amino acid composition, and usually contain at least one CDR adjacent to one or more framework sequences or one or more framework sequence window frames. Antigen with a V _H domain and V _L domain of the association - binding fragments, V _H and V _L domains may be in an appropriate position relative to the other of the alignment. For example, the variable region is a dimer and containing _{V H -V H, V H -V} L or V _L -V _L dimer. Alternatively, the antigen - binding fragment may contain monomers V _H or V _L domains.

In some embodiments, the antigen-binding fragment of the antibody may contain at least one variable domain covalently linked to at least one constant domain. In the present invention, it may be the antigen - binding non-variable and constant domain of the restriction fragments found in the exemplary configurations _{include: (i) V H -C H} 1; (ii) V H -C H 2; (iii ) V _H -C _H 3; (iv) V _H -C _H 1-C _H 2; (v) V _H -C _H 1-C _H 2-C _H 3; (vi) V _H -C _H 2- _{C H 3; (vii) V} H -C L; (viii) V L -C H 1; (ix) V L -C H 2; (x) V L -C H 3; (xi) V L -C _{H 1-C H 2; (} xii) V L -C H 1-C H 2-C H 3; (xiii) V L -C H 2-C H 3; and (xiv) V _L -C _L. In any configuration of the variable and constant domains (including any of the exemplary configurations listed above), the variable and constant domains can be directly connected to each other or connected by fully or partially hinged or connected subregions. The pivot region is composed of at least 2 (for example, 5, 10, 15, 20, 40, 60 or more) amino acids, which produce elasticity between adjacent variable and/or constant domains in a single polypeptide molecule Or semi-elastic bond. Further, the present invention is the antigen - binding fragment may comprise any of the above variable and constant domains of one configuration and / or with one or more monomers V _H or V _L domains non-covalently associated with each other (e.g. A homodimer or heterodimer (or other aggregates) formed by disulfide bonds (etc.).

In the case of fully antibody molecules, the antigen-binding fragments can be monospecific or multispecific (e.g., bispecific). The multispecific antigen-binding fragment of an antibody typically contains at least two different variable domains, where each variable domain can specifically bind to individual antigens or different epitopes on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody format disclosed herein, can be modified into an antigen-binding fragment suitable for use in the antibody of the present invention using conventional techniques available in the art.

The constant region of an antibody is crucial for the antibody's ability to fix complement and mediate cell-dependent cytotoxicity. Therefore, the isotype of the antibody can be selected according to whether the antibody-mediated cytotoxicity is required.

The term "human antibody", as used herein, is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. The human antibody of the present invention may include amino acid residues that are not encoded by human germline immunoglobulin sequences (for example, mutations introduced by random or sited mutations in vitro or by in vivo mutations), for example, in CDR And especially in CDR3. However, the term "human antibody", as used herein, is not intended to include antibodies derived from the germline CDR sequences of another mammalian species (such as a mouse) that have been grafted onto human framework sequences.

The term "recombinant human antibody", as used herein, is intended to include all human antibodies prepared, expressed, produced or isolated by recombinant methods, such as antibodies expressed using recombinant expression vectors transfected into host cells (further (Described below), antibodies isolated from recombinant, combinatorial human antibody libraries (further described below), antibodies isolated from animals (e.g., mice) transfected with human immunoglobulin genes (see, e.g., Taylor et al. (1992) ) Nucl. Acids Res. 20: 6287-6295), or by any other method involving the splicing of human immunoglobulin gene sequences to other DNA sequences to prepare, express, produce or isolate antibodies. These recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in some specific cases, these recombinant human antibodies are mutagenic in vitro (or somatic mutagenesis in vivo when using animals transfected with human Ig sequences), and therefore the V of these recombinant antibodies amino acid sequences of the _H and V _L region to region may be present in vivo sequences not naturally occurring human antibody germline, although they are derived from a human germline V _H and V _L sequence and associated therewith.

Human antibodies exist in two forms related to hub heterogeneity. In one form, the immunoglobulin molecule contains a stable four-chain construct of about 150-160 kDa, where the dimers are constrained together by inter-chain heavy chain disulfide bonds. In the second form, the dimer is not linked via interchain disulfide bonds, and forms a molecule (half antibody) of approximately 75-80 kDa consisting of covalently coupled light and heavy chains. These forms are very difficult to separate even after affinity purification.

The frequency of occurrence of the second form in various intact IgG isotypes is due to (but not limited to) structural differences related to the pivotal region isotypes of antibodies. In the hub region of the human IgG4 hub, a single amino acid substitution may significantly reduce the appearance of the second form to the extent generally observed with the human IgG1 hub (Angal et al. (1993) Molecular Immunology 30: 105). The present invention encompasses antibodies having one or more hubs in the C _H 2 or C _H 3 region mutations, which may be desired, for example, enhance the yield of the desired antibody form during manufacture.

"Isolated antibody", as used herein, means a Antibody that has been separated and/or recovered from at least one component of the environment. For example, an antibody that has been isolated or removed from at least one component of an organism, or a tissue or cell where the antibody is naturally occurring or naturally produced therein, is a "isolated antibody" for the purpose of the present invention. Isolated antibodies also include antibodies in situ in recombinant cells. An isolated antibody is an antibody that has undergone at least one purification or isolation step. According to some specific examples, the isolated antibody is essentially free of other cellular materials and/or chemicals.

The term "specifically binds" or similar terms means that an antibody or antigen-binding fragment thereof forms a complex with an antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are known in the art, and include, for example, balanced dialysis, surface plasma resonance, and the like. For example, an antibody that "specifically binds" PCSK9 as used in the context of the present invention includes less than about 1000 nM, less than about 500 nM, less than about 300 nM, less than about 200 nM, less than as measured by surface plasmon resonance analysis. About 100nM, less than about 90nM, less than about 80nM, less than about 70nM, less than about 60nM, less than about 50nM, less than about 40nM, less than about 30nM, less than about 20nM, less than about 10nM, less than about 5nM, less than about 4nM, less than about 3nM, less than about 2nM, or less than about less than about 1nM 0.5nM K _D of binding PCSK9 antibody or a portion thereof. However, isolated antibodies that specifically bind to human PCSK9 are cross-reactive with other antigens, such as PCSK9 molecules from other (non-human) species.

Compared with the corresponding germline sequence derived from the antibody, the anti-PCSK9 antibody that can be used in the method of the present invention can contain one or more amino acids in the backbone and/or the CDR regions of the heavy chain and light chain variable domains Replacement, insertion and/or deletion. These mutations can be easily confirmed by comparing the amino acid sequences disclosed herein with germline sequences available, for example, from public antibody sequence databases. The present invention includes methods involving the use of antibodies and antigen-binding fragments thereof, which are derived from any amino acid sequence disclosed herein, wherein one or more amino acids in one or more frameworks and/or CDR regions Mutations into the corresponding residues of the germline sequence from which the antibody is derived, or the corresponding residues of another human germline sequence, or the conserved amino acid substitutions of the corresponding germline residues (such as sequence changes are intended to be used herein) Referred to as "germline mutation"). Those skilled in the art can easily manufacture many antibodies and antigen-binding fragments containing one or more individual germline mutations or combinations thereof starting from the heavy chain and light chain variable region sequences disclosed herein. In some embodiments, V _H and / or V _L domain of all backbone and / or CDR residues are mutated residues reverts to the original antibody derived from the germline sequences found in the. In other specific examples, only certain residues are mutated back to the original germline sequence, for example, only the mutated residues found in the first 8 amino acids of FR1 or the last 8 amino acids of FR4 , Or only the mutated residues found in CDR1, CDR2 or CDR3. In other specific examples, one or more of the skeleton and/or CDR residues are mutated into corresponding residues of different germline sequences (that is, germline sequences that are different from the germline sequence originally derived from the antibody). In addition, the antibody of the present invention may contain a combination of two or more germline mutations in the framework and/or CDR regions, for example, some individual residues are mutated into corresponding residues of a specific germline sequence, which are different from the original Certain other residues of the germline sequence are maintained as they are or mutated to the corresponding residues of a different germline sequence. After being obtained, antibodies and antigen-binding fragments containing one or more germline mutations can be directed against one or more desired properties (such as increased binding specificity, increased binding affinity, antagonistic or agonistic biological properties increased or increased (as the case may be). Set), immunogenicity reduction, etc.) for simple testing. The antibodies and antigen-binding fragments obtained in this general manner are included in the present invention.

The present invention also includes methods involving the use of anti-PCSK9 antibodies, which contain variants of any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein with one or more conservative substitutions. For example, the present invention includes the use of anti-PCSK9 antibodies having HCVR, LCVR, and/or CDR amino acid sequences, which have, for example, 10 relative to any of the HCVR, LCVR, and/or CDR amino acid sequences disclosed herein. Or less, 8 or less, 6 or less, 4 or less, etc. conservative amino acid substitutions.

The term "surface plasmon resonance", as used herein, means an optical phenomenon that allows the analysis of real-time interactions of biomolecules by detecting changes in the protein concentration in the biosensor matrix, for example, using the BLAcore ^TM system (Biacore Life Sciences division of GE Healthcare, Piscataway, NJ).

The term "K _D ", as used herein, is intended to mean the equilibrium dissociation constant of a particular antibody-antigen interaction.

The term "epitope" means an epitope that interacts with a specific antigen-binding site in the variable region of an antibody molecule known as a paratope. A single antigen may have more than one epitope. Therefore, different antibodies can bind to different regions of the antigen and may have different biological effects. The epitope can be conformational or linear. Conformational epitopes can be generated by amino acids that are spatially juxtaposed by segments of different linear polypeptide chains. Linear epitopes are produced by adjacent amino acid residues in the polypeptide chain. In some cases, the epitope may include a carbohydrate, phosphooxy or sulfonyl moiety on the antigen.

According to some specific examples, the anti-PCSK9 antibody used in the method of the present invention is an anti-PCSK9 antibody with pH-dependent binding characteristics. As used herein, the phrase "pH-dependent binding" means that the antibody or antigen-binding fragment thereof exhibits "decreased binding to PCSK9 at acidic pH compared to neutral pH" (for the purpose of this disclosure, the two terms can be Used interchangeably). For example, antibodies with "pH-dependent binding characteristics" include antibodies and antigen-binding fragments thereof that bind to PCSK9 with higher affinity at neutral pH than at acidic pH. In some specific examples, the antibodies and antigen-binding fragments of the present invention are at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55 higher at neutral pH than at acidic pH. , 60, 65, 70, 75, 80, 85, 90, 95, 100 or more times the affinity binds to PCSK9.

According to this aspect of the present invention, the anti-PCSK9 antibody with pH-dependent binding characteristics may have one or more amino acid variations relative to the parent anti-PCSK9 antibody. E.g, An anti-PCSK9 antibody with pH-dependent binding characteristics may contain one or more histidine substitutions or insertions, for example, in one or more CDRs of the parental anti-PCSK9 antibody. Therefore, according to some specific examples of the present invention, there is provided a method of administering an anti-PCSK9 antibody, the anti-PCSK9 antibody comprising CDR amino acid sequences (such as heavy chain and light chain CDR), which is incompatible with the parental anti-PCSK9 antibody The CDR amino acid sequence of the CDR is the same, except that one or more amino acids of one or more CDRs of the parent antibody are replaced with histidine residues. Anti-PCSK9 antibodies with pH-dependent binding characteristics can have, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions, whether in a single CDR of the parent antibody Or distributed in multiple (e.g., 2, 3, 4, 5, or 6) CDRs of the parental anti-PCSK9 antibody. For example, the present invention includes the use of an anti-PCSK9 antibody with pH-dependent binding characteristics, the antibody comprising one or more histidine substitutions in HCDR1 and one or more histidine substitutions in HCDR2 of the parent anti-PCSK9 antibody Histidine substitutions, one or more histidine substitutions in HCDR3, one or more histidine substitutions in LCDR1, one or more histidine substitutions in LCDR2, and/or one or more histidine substitutions in LCDR2 A histidine replacement in LCDR3.

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

Non-limiting examples of anti-PCSK9 antibodies that can be used in the context of the present invention include, for example, alirocumab, evolocumab, bococizumab, or an antigen binding portion thereof.

Preparation of human antibodies

The method used to make human antibodies in genetically transgenic mice is already in the art. Known. Any of these known methods can be used in the context of the present invention to produce human antibodies that specifically bind to human PCSK9.

Using VELOCIMMUNE ^TM (see, for example, US, 6,596,541, Regeneron Pharmaceuticals) technology or any other known method for generating monoclonal antibodies, first isolate the human variable region and mouse constant region with high affinity to PCSK9 Chimeric antibody. The VELOCIMMUNE® technology involves the production of a genetically transgenic mouse with a gene body that includes human heavy chain and light chain variable regions operably linked to endogenous mouse constant region loci, so that the mouse can react to the antigen Stimulate the response to produce antibodies containing human variable regions and mouse constant regions. The DNA encoding the variable regions of the heavy and light chains of the antibody is separated and operably linked to the DNA encoding the constant regions of the human heavy and light chains. Then express the DNA in cells capable of expressing fully human antibodies.

Generally, VELOCIMMUNE® mice are stimulated with the antigen of interest, and lymphocytes (such as B cells) are recovered from the antibody-expressing mice. Lymphocytes and myeloma cell lines are fused to prepare immortal fusion tumor cell lines, and these fusion tumor cell lines are screened and selected to identify fusion tumor cell lines that produce antibodies specific to the antigen of interest. The DNA encoding the variable regions of the heavy and light chains is separated and linked to the constant regions of the same type of the desired heavy and light chains. Such an antibody protein is produced in cells, such as in CHO cells. Alternatively, the DNA encoding the antigen-specific chimeric antibody or the variable domains of the light and heavy chains can be isolated directly from the antigen-specific lymphocytes.

In the beginning, high-affinity chimeric antibodies with human variable regions and mouse constant regions were isolated. Using standard procedures known to those skilled in the art, antibodies are identified and selected for desired properties (including affinity, selectivity, epitopes, etc.). The mouse constant region is replaced with the desired human constant region to generate the fully human antibody of the present invention, such as wild-type or modified IgG1 or IgG4. Although the screened constant region may vary depending on the specific application, there are high-affinity antigen-binding and target specific characteristics in the variable region.

Generally, when measured by binding to an antigen (immobilized on a solid phase or in a liquid phase), the antibodies that can be used in the method of the present invention have high affinity as described above. The mouse constant region is replaced with the desired human constant region to generate the fully human antibody of the present invention. Although the selected constant region can be changed according to the specific application, there are high-affinity antigen-binding and target specific characteristics in the variable region.

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

The sequence identity between the two amino acid sequences is based on the best sequence alignment for the entire length of the reference amino acid sequence (that is, the amino acid sequence identified by SEQ ID NO) and/or the two amino acid sequences The optimal sequence arrangement area is determined by using tools known in the art, such as Align, using standard settings, preferably EMBOSS: needle, matrix: Blosum62, gap opening 10.0, and gap extension 0.5.

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

In some specific examples of the present invention, the anti-PCSK9 antibody or antigen binding protein that can be used in the method of the present invention has an amino acid sequence of HCDR1/HCDR2/HCDR3/LCDR1/LCDR2/LCDR3 selected from the following SEQ ID NO: 2 /3/4/7/8/10 (mAb316P [also known as "REGN727", or "rilozumab"]) and 12/13/14/16/17/18 (mAb300N) (see US Patent Application Publication Case No. 2010/0166768) and 12/13/14/16/17/18, wherein SEQ ID NO: 16 contains histidine substituted leucine (L30H) at amino acid residue 30.

In some specific embodiments of the present invention, the antibody or antigen binding protein comprises selected from The HCVR/LCVR amino acid sequence pairs of the group consisting of the following SEQ ID NO: 1/16 and 11/15. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO:1 and the LCVR amino acid sequence of SEQ ID NO:6. In certain exemplary embodiments, the antibody or antigen binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 11 and the LCVR amino acid sequence of SEQ ID NO: 15. In certain exemplary embodiments, the antibody or antigen-binding protein comprises the HCVR amino acid sequence of SEQ ID NO: 11 and the LCVR amino acid sequence of SEQ ID NO: 15, the LCVR amino acid sequence is in the amino acid sequence. Residue 30 contains histidine replacement leucine (L30H).

Pharmaceutical composition and method of administration

The present invention includes a method comprising administering a PCSK9 inhibitor to a patient, wherein the PCSK9 inhibitor is included in a pharmaceutical composition. The pharmaceutical composition of the present invention is formulated with appropriate carriers, excipients, and other agents that provide proper transportation, delivery, tolerance and similar properties. Many suitable formulations can be found in prescriptions well known to all pharmaceutical chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. Such formulations include, for example, powders, pastes, ointments, gels, waxes, oils, lipids, lipids (cationic or anionic) containing vesicles (such as LIPOFECTIN ^™ ), DNA conjugates, anhydrous absorption pastes , Oil-in-water and water-in-oil emulsions, emulsion carb wax (polyethylene glycol of various molecular weights), semi-solid gels and semi-solid mixtures containing carb wax. See also Powell et al. "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52: 238-311.

Various delivery systems are known and can be used to administer the pharmaceutical composition of the present invention, such as encapsulated in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated pinocytosis (see, for example, Wu et al. al. (1987) J. Biol. Chem. 262: 4429-4432). Administration methods include, but are not limited to intradermal, intramuscular, intraperitoneal, Intravenous, subcutaneous, intranasal, supradural and oral routes. The composition can be administered by any conventional route, such as by infusion or bolus injection, by absorption through the epidermis or mucosal skin lining (such as oral mucosa, rectum and intestinal mucosa, etc.), and can be combined with other biological activities. Administer together with the agent.

The pharmaceutical composition of the present invention can be delivered subcutaneously or intravenously using standard needles and syringes. In addition, with regard to subcutaneous delivery, the pen-type delivery device is suitable for delivering the pharmaceutical composition of the present invention without difficulty. Such pen-type delivery devices can be reused or disposable. Reusable pen-type delivery devices usually use replaceable cartridges containing pharmaceutical compositions. Once all the pharmaceutical compositions in the medicine cassette have been administered and the medicine cassette is empty, the empty medicine cassette can be easily discarded and replaced with a new medicine cassette containing the pharmaceutical composition. Then, the pen-type delivery device can be reused. In the disposable pen-type delivery device, there is no replaceable medicine cartridge. The disposable pen-type delivery device is filled with a pharmaceutical composition contained in a receptacle in the device. Once the reservoir is empty of pharmaceutical composition, the entire device is discarded.

Many reusable pen-type delivery devices and auto-injector delivery devices can be used to deliver the pharmaceutical composition of the present invention subcutaneously. Examples include, but are not limited to, AUTOPEN ^TM (Owen Mumford, Inc., Woodstock, UK), DISETRONIC ^TM pen (Disetronic Medical Systems, Berghdorf, Switzerland), HUMALOG MIX 75/25 ^TM pen, HUMALOG ^TM pen, HUMALIN 70/30 ^TM pen (Eli Lilly and Co., Indianapolis, IN), NOVOPEN ^TM I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR ^TM (Novo Nordisk, Copenhagen, Denmark), BD ^TM pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN ^TM , OPTIPEN PRO ^TM , OPTIPEN STARLET ^TM and OPTICLIK ^TM (sanofi-aventis, Frankfurt, Germany), to name just a few. Disposable pen delivery devices that can be applied to subcutaneously deliver the pharmaceutical composition of the present invention include, but are not limited to SOLOSTAR ^TM pen (sanofi-aventis), FLEXPEN ^TM (Novo Nordisk) and KWIKPEN ^TM (Eli Lilly), SURECLICK ^TM Autoinjector (Amgen , Thousand Oaks, CA), PENLET ^TM (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP), and HUMIRA ^TM Pen (Abbott Labs, Abbott Park IL), just to name a few.

In some cases, the pharmaceutical composition is delivered in a controlled release system. In a specific example, a pump can be used (see Langer, supra; Sefton 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another specific example, polymeric materials can be used; see Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another specific example, the controlled release system is placed adjacent to the composition target, so only a part of the systemic dose is required (see, for example, Goodson, 1984, Medical Applications of Controlled Release, supra, vol. 2, pp.115-138). Other controlled release systems are discussed in the review of Langer, 1990, Science 249: 1527-1533.

Injectable products may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injection, drip infusion, and the like. These injectable products can be prepared according to known methods. For example, injectable products can be prepared, for example, by dissolving, suspending or emulsifying the above-mentioned antibody or its salt in a sterile aqueous or oily medium conventionally used for injection. Regarding the aqueous medium for injection, there are, for example, physiological saline, isotonic solutions containing glucose and other adjuvants, etc., which can be combined with appropriate cosolvents (such as alcohols (ethanol), polyols (such as propylene glycol, polyethylene glycol)) , Non-ionic surfactants [for example, polysorbate 80, HCO-50 (hydrogenated sesame oil polyoxyethylene (50 mol) adduct)], etc. are used in combination. For oily media, for example, sesame oil, soybean oil, etc. are used. It can be used in combination with co-solvents (such as benzyl benzoate, benzyl alcohol, etc.). The injection thus prepared is preferably filled in an appropriate ampoule.

Advantageously, the above-mentioned pharmaceutical composition for oral or parenteral use is prepared in a dosage form of a unit dose suitable for administration of the active ingredient. These unit dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, and the like.

Exemplary pharmaceutical formulations containing anti-PCSK9 antibodies that can be used in the context of the method of the present invention are listed in US 2013/0189277, the disclosure of which is incorporated herein as a reference in its entirety.

dose

According to the method of the present invention, the amount of PCSK9 inhibitor (for example, anti-PCSK9 antibody) administered to the patient is usually a therapeutically effective amount. As used herein, the idiom "therapeutically effective amount" means to cause a detectable decrease in one or more parameters selected from the group consisting of (at least about 5%, 10%, 15%, 20%, 25% relative to the baseline , 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or higher) PCSK9 inhibitor dose: LDL-C, ApoB100, non-HDL-C , Total cholesterol, VLDL-C, triglycerides, Lp(a) and residual cholesterol.

In the case of an anti-PCSK9 antibody, the therapeutically effective amount can be from about 0.05 mg to about 600 mg, for example, about 0.05 mg, about 0.1 mg, about 1.0 mg, about 1.5 mg, about 2.0 mg, about 10 mg, about 20 mg, about 30 mg , About 40mg, about 50mg, about 60mg, about 70mg, about 80mg, about 90mg, about 100mg, about 110mg, about 120mg, about 130mg, about 140mg, about 150mg, about 160mg, about 170mg, about 180mg, about 190mg, about 200mg, about 210mg, about 220mg, about 230mg, about 240mg, about 250mg, about 260mg, about 270mg, about 280mg, about 290mg, about 300mg, about 310mg, about 320mg, about 330mg, about 340mg, about 350mg, about 360mg, About 370mg, about 380mg, about 390mg, about 400mg, about 410mg, about 420mg, about 430mg, about 440mg, about 450mg, about 460mg, about 470mg, about 480mg, about 490mg, about 500mg, about 510mg, about 520mg, about 530mg , About 540 mg, about 550 mg, about 560 mg, about 570 mg, about 580 mg, about 590 mg, or about 600 mg of anti-PCSK9 antibody. In some specific cases, the therapeutically effective amount is 75 mg of anti-PCSK9 antibody. In some specific cases, the therapeutically effective amount is 150 mg of anti-PCSK9 antibody.

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

Combination therapy

According to certain embodiments of the present invention, one or more non-statin lipid modulating therapies can be administered to the patient in combination with a PCSK9 inhibitor. Examples of such non-statin lipid-modulating therapies include, for example, (1) agents that inhibit cholesterol absorption inhibitors (e.g., ezetimibe); (2) agents that increase lipoprotein breakdown (e.g., nicotinic acid, including nicotine and Slow release of nicotine); (3) Fibric acid; (4) Cholic acid chelator and/or (5) LXR transcription factor activator (such as 22-hydroxycholesterol) that plays a role in eliminating cholesterol.

Dosing plan

According to some specific examples of the present invention, multiple doses of PCSK9 inhibitors (for example, pharmaceutical compositions containing PCSK9 inhibitors) can be administered to patients over a limited period of time (instead of the daily therapeutic statin regimen). The method according to this aspect of the invention comprises sequentially administering multiple doses of the PCSK9 inhibitor to the individual. As used herein, "sequential administration" means that each dose of PCSK9 inhibitor is administered to the patient at different time points, such as at different intervals separated by predetermined intervals (eg, hours, days, weeks, or months). day. The present invention includes sequential administration of a single initial dose of PCSK9 inhibitor followed by one or more second doses of PCSK9 inhibitor, and optionally one or more third doses of PCSK9 inhibitor to the patient.

The terms "initial dose", "second dose" and "third dose" mean the time sequence of administering individual doses of the pharmaceutical composition containing the PCSK9 inhibitor. Therefore, the "initial dose" is the dose administered at the beginning of the treatment regimen (also referred to as the "baseline dose"); the "second dose" is the dose administered after the initial dose; and the "third dose" It is the dose administered after the second dose. The initial dose, the second dose, and the third dose can all contain the same amount of PCSK9 inhibitor, but usually differ in the frequency of administration. However, in some In a specific example, the amount of PCSK9 inhibitor contained in the initial dose, the second dose, and/or the third dose will be relatively changed during the course of treatment (for example, adjusted up or down, if necessary). In some specific cases, two or more (eg, 2, 3, 4, or 5) doses are administered as a "loading dose" at the beginning of the treatment regimen, followed by administration on a less frequent basis Subsequent dose (eg "maintenance dose").

According to the exemplary embodiment of the present invention, each second dose and/or third dose is 1 to 26 days immediately after the previous dose (for example, 1, 1½, 2, 2½, 3, 3½, 4, 4½, 5, 5½ , 6, 6½, 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 12½, 13, 13½, 14, 14½, 15, 15½, 16, 16½, 17, 17½, 18 , 18½, 19, 19½, 20, 20½, 21, 21½, 22, 22½, 23, 23½, 24, 24½, 25, 25½, 26, 26½ or longer) were cast. The term "immediately following the previous dose", as used herein, means that in the sequence of multiple administrations, the next dose of the antigen-binding molecule dose in the sequence is administered to the patient without any intervening dose.

The method according to this aspect of the invention may comprise administering to the patient any number of second and/or third doses of PCSK9 inhibitor. For example, in some specific cases, only a single second dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, or more) second doses are administered to the patient. Likewise, in some specific cases, only a single third dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, or more) third doses are administered to the patient.

In specific examples involving multiple second doses, each second dose may be administered at the same frequency as the other second doses. For example, each second dose may be administered to the patient 1 to 2, 4, 6, 8 or more weeks immediately after the previous dose. Likewise, in specific examples involving multiple third doses, each third dose may be administered at the same frequency as the other third doses. For example, each third dose may be 1 to 2, immediately after the previous dose It is administered to patients for 4, 6, 8 or more weeks. Alternatively, the frequency of administration of the second dose and/or the third dose to the patient may vary with the course of the treatment plan. The frequency of administration can also be adjusted by the clinician during the course of treatment according to the needs of individual patients following clinical testing.

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

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

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

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

The present invention includes a dosing regimen that includes an up-regulation option (also referred to herein as "dose adjustment"). As used herein, "up-regulation option" means that after receiving a certain number of doses of PCSK9 inhibitor, if the patient does not achieve a clear decline in one or more prescribed treatment parameters, then increase the dose of PCSK9 inhibitor. For example, the treatment regimen includes administering a 75 mg dose of anti-PCSK9 antibody to the patient at a frequency of once every two weeks, if after 8 weeks (e.g., at week 0, week 2 and week 4, week 6 and week 4) 5 doses administered in 8 weeks) the patient’s serum LDL-C concentration does not reach less than 70 mg/dL, then (for example, starting at the 10th week or 12th week or later) is increased to the anti-antibody administered once every two weeks. -PCSK9 antibody dose to, for example, 150 mg.

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

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

In some specific cases, the antibody is administered to the patient at a dose of about 75 mg every two weeks It lasts for 12 weeks, and if the patient's LDL-C value is lower than 100 mg/dL and LDL-C drops by 30% at the 8th week, the dose is maintained at 75 mg every two weeks.

In other specific examples, the antibody is administered to the patient at a dose of about 75 mg every two weeks for 12 weeks, and if the patient’s LDL-C value is greater than or equal to 100 mg/dL at the 8th week, the dose is increased to every two weeks About 150mg.

In some specific cases, the antibody is administered to the patient at a dose of about 75 mg every two weeks for 12 weeks, and if the patient’s LDL-C value is lower than 70 mg/dL at the 8th week and the LDL-C decreases by 30%, then The dose is maintained at 75 mg every two weeks.

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

In another specific example, the antibody is administered to the patient at a dose of about 300 mg every four weeks for a total of three doses, and if the patient does not reach the predetermined treatment goal or the patient's LDL-C does not decrease at least from baseline at the 8th week 30%, change the dose to 150 mg every two weeks for another 36 weeks.

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

In some specific cases, the antibody is administered to the patient at a dose of about 150 mg every four weeks for 12 weeks, and if the patient’s LDL-C value is lower than 100 mg/dl at the 8th week and the LDL-C drops by 30%, the dose Maintain at 150mg every four weeks.

In other specific examples, the antibody is administered to the patient at a dose of about 150 mg every four weeks for 12 weeks, and if the patient's LDL-C value is greater than or equal to 100 mg/dl at the 8th week, the dose is increased to about every two weeks 300mg.

In some specific cases, the antibody is administered to the patient at a dose of about 150 mg every four weeks for 12 weeks, and if the patient’s LDL-C value is lower than 70 mg/dl and the LDL-C drops by 30% at the 8th week, the dose Maintain at 150mg every four weeks.

In another specific example, the patient is administered at a dose of about 300 mg every four weeks Antibody.

In another specific example, the antibody is administered to the patient at a dose of about 300 mg every four weeks for a total of three doses, and if the patient does not reach the predetermined treatment goal or the patient's LDL-C does not decrease at least from baseline at the 8th week 30%, change the dose to 150 mg every two weeks for another 36 weeks.

100mg/dL的LDL-C閾值需要上調程序，但在這個研究中以不知情的方式適用

70mg/dL的閾值。圖式下方的箭頭表示評估時間。EOT，治療結束；EZE，依折麥布；LDL-C，低密度脂蛋白膽固醇；NCEP ATP III TCP，國家膽固醇教育計劃成人治療第三版；Q2W，每2週；W，週。 Figure 1 shows the study design of the clinical trial described in Example 2. in spite of

The LDL-C threshold of 100 mg/dL requires an upward adjustment procedure, but it was applied in an unknowing manner in this study

The threshold of 70mg/dL. The arrow below the diagram indicates the evaluation time. EOT, end of treatment; EZE, ezetimibe; LDL-C, low-density lipoprotein cholesterol; NCEP ATP III TCP, National Cholesterol Education Program Adult Treatment Third Edition; Q2W, every 2 weeks; W, weeks.

Figure 2 shows the patient characteristics of the clinical trial described in Example 2. *Life events make it difficult to continue. ITT, intention to treat.

Figure 3 is a graph showing the amount of LDL-C (mg/dL) in the clinical trial described in Example 2 versus the study time point (analysis during treatment). Values beyond the 12th week and 24th week data points represent the% change from the baseline LS mean (SE). LDL-C, low-density lipoprotein cholesterol; LS, least squares; SE, standard deviation.

Figure 4 is a set of four graphs, showing the clinical trial described in Example 2, in patients treated with mAb316P (rilozumab) to the 12th week (Figure 4A) and the 24th week (Figure 4B) ), and the distribution of LDL-C percentage changes relative to baseline in patients treated with ezetimibe (maternal under treatment) to Week 12 (Figure 4C) and Week 24 (Figure 4D).

Figure 5 is a set of two graphs, showing that the clinical trial described in Example 2 is based on demographics (Figure 5A) and other baseline characteristics (Figure 5B) (ITT maternal) at week 24 LDL-C relative to baseline The percentage change of the sub-ethnic group analysis.

Figure 6 shows a series of graphs that illustrate the average amount of LDL-C in patients treated with mAb316P (Figure 6A), C _{from beginning to end,} and C _tracking mAb316P ( Rilomab) concentration (Figure 6B), and free PCSK9 amount (Figure 6C). The _{value of C from beginning to end} was obtained 14±6 days after the previous injection; the _tracking value of C was obtained >21 days after the last injection. The triangle represents the upregulation group at week 12. The squares indicate the non-upregulated group at week 21.

Figure 7 is a research flow chart illustrating the clinical trial described in Example 3 herein. "REGN727" is the name of the antibody referred to herein as rilocumab or mAb316P.

Instance

The following examples are presented to provide complete disclosure and instructions on how to make and use the methods and compositions of the present invention to those skilled in the art, and do not intend to limit the scope that the inventor regards as his invention. Every effort has been made to ensure the correctness of the numbers used (such as quantity, temperature, etc.), but some experimental errors and deviations may occur. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, and pressure is at or near atmospheric.

Example 1. Generation of human antibodies against human PCSK9

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

Example 2: Anti-PCSK9 antibody ("mAb316P") versus ezetimibe monotherapy in patients with hypercholesterolemia: results of a 24-week, double-blind, randomized phase 3 trial

background

Hypercholesterolemia (especially the increased amount of low-density lipoprotein cholesterol (LDL-C)) is the main risk factor for the development of atherosclerosis and CHD, and is the main cause of death and disability in the Western world. LDL-C has been identified as the main target of cholesterol-lowering therapy and is considered to be an effective surrogate evaluation index. Many studies have confirmed that the use of statin mainly reduces the amount of LDL-C via 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMG CoA) inhibition, which reduces the risk of CHD, among which LDL- There is a strong direct correlation between the amount of C and CHD events; for every 1mmol/L (~40mg/dL) decrease in LDL-C, the mortality and morbidity of cardiovascular disease (CVD) will decrease by 22%.

Three Phase 1 studies have been conducted with mAb316P and evaluated for safety, tolerability, and PK/PD profile. Two single-dose studies were conducted in healthy individuals with LDL-C>100mg/dL that did not require statin treatment (one study was IV administration with a dose of 0.3 mg to 12 mg/kg and the other study was SC administration 50mg to 250mg dose). A third study was conducted in patients with hypercholesterolemia (familial or non-familial), where single or multiple SC administrations of 50 mg, 100 mg, 150 mg, and 200 mg were added as a stable dose of 10 mg to 40 mg/day of atorvastatin Therapy or as a monotherapy.

The results of these phase 1 studies showed that mAb316P administered to healthy individuals and patients by IV or SC administration was generally well tolerated at all doses; adverse events (TEAE) that occurred during treatment did not show a dose correlation. No adverse event (AE) pattern was determined to be drug-related. In all of these Phase 1 studies, the MAb316P guide was administered Cause LDL-C relative to baseline rapid, large and continuous decline to as much as 60%. The magnitude and duration of these declines are positively correlated with the administered dose. It should also be noted that in the third study, the results were similar in patients with familial hypercholesterolemia and patients with non-familial hypercholesterolemia. In these three Phase 1 studies, a total of 109 individuals were exposed to at least one dose of mAb316P.

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

introduction

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

The purpose of this study is to provide an overview of the level of efficacy and safety when the research product mAb316P is used as a monotherapy. Obtaining the single efficacy and safety data of mAb316P is very important for the correct understanding of the data obtained when mAb316P is used as an add-on therapy to statin.

Another purpose of this study is to provide monotherapy data to support the evaluation of mAb316P in patients with statin intolerance. When statins are considered inappropriate or intolerant, existing LDL-C lowering drugs can be used as monotherapy, which include ezetimibe, nicotine, and bile acid chelator. These options that can be used for monotherapy are associated with a decrease in LDL-C of approximately 20%.

The control group selected for this study was ezetimibe 10 mg PO daily. This allows studies to compare mAb316P with the treatment options available in customary clinical practice (ie ezetimibe).

This specific study was conducted to prove mAb316P 75mg and/or 150mg Q2W in patients with moderate CV risk and LDL-C between 100mg/dL (2.59mmol/L) and 190mg/dL (4.9mmol/L) Monotherapy caused a statistically significant and clinically significant decrease in LDL-C compared to ezetimibe.

Research matrix

The study mother for monotherapy studies is patients with LDL-C between 100mg/dL (2.59mmol/L) and 190mg/dL (4.9mmol/L).

This study included patients with moderate CV risk. The moderate CV risk was defined by the 10-year CVD death risk ≧1% and <5% based on the SCORE chart, but there was no definite CHD or CHD risk equivalent event. Risk maps such as SCORE are intended to assist in assessing risk in seemingly healthy individuals with no clinical or preclinical signs of disease. SCORE measures the 10-year risk of death from CV based on total cholesterol, age, gender, smoking and contracted BP. This amount of risk is considered appropriate in monotherapy studies using non-statin active comparators.

During the 24-week double-blind study treatment period, a sample of 100 patients (50 patients in each group) was intended to detect a treatment difference of 20% in the average percentage change in LDL-C from baseline to week 24, of which 0.05 The bilateral significance is assumed to be 25% and 5% non-evaluable primary evaluation indicators.

Dose screening

All patients were initially treated with 75 mg Q2W, and only those patients whose LDL-C levels remained the same or higher than 100 mg/dL after 8 weeks of treatment were increased to 150 mg Q2W from the 12th week.

The choice of dosage, dosing frequency and up-regulation method is based on the LDL-C reduction required to provide the best benefit for CV disease reduction and potential safety considerations of low LDL-C values. Based on the results of the two-dose study, the Q2W dosing regimen is expected to maintain a steady decline in LDL-C during the inter-dose period, with 150 mg Q2W dosing providing maximum efficacy at week 12. However, for many patients, the level of efficacy observed with the 150 mg Q2W dose is not necessary to achieve the target LDL-C goal and can be started with a lower dose. Using a dose-response model, 75mg Q2W was selected to provide an approximately 50% drop in LDL-C from baseline; all patients were initially treated with 75mg Q2W, and only those Patients whose LDL-C amount remained the same or higher than 100 mg/dL after 8 weeks of treatment increased the dose to 150 mg Q2W (at week 12). Using this treatment plan, it is expected that most patients with primary hypercholesterolemia will reach their target LDL-C levels, and a few of them will reach levels below 25 mg/dL.

The preliminary PK data of the Phase 2 study showed that during the 8-week follow-up period after the double-blind treatment period, the exposure to mAb316P declined, in which the total serum concentration of mAb316P could still be detected, but the amount was extremely low. Therefore, to ensure a low enough non-effective serum mAb316P concentration, patients were followed during the 8-week follow-up period (that is, 10 weeks after the last dose). The pharmacokinetic results of this trial are critical, because the absence of a statin background would impair the effectiveness of mAb316P.

Research objectives

The main goal of the monotherapy study is to prove that compared to 10 mg of ezetimibe (EZE) per day, in patients with hypercholesterolemia with moderate cardiovascular (CV) risk, after 24 weeks of treatment, mAb316P every two Week (Q2W) as a monotherapy, low-density lipoprotein cholesterol (LDL-C) decreased.

The secondary goals of monotherapy research are as follows. (1) To evaluate the efficacy of mAb316P 75mg compared to EZE for LDL-C after 12 weeks of treatment. (2) To evaluate the utility of mAb316P on other lipid parameters (ie ApoB, non-HDL-C, total-C, Lp(a), HDL-C, TG amount, and Apo A-1 amount). (3) To evaluate the safety and tolerability of MAb316P. (4) To evaluate the production of anti-MAb316P antibodies. (5) To evaluate the pharmacokinetics (PK) of MAb316P.

Research design

This is a randomized, double-blind, parallel group, double virtual, ezetimibe control, balanced (1:1, mAb316P: ezetimibe), multi-center, multi-country study, for evaluation The efficacy and safety of mAb316P in patients with hypercholesterolemia and a 10-year risk score (SCORE) of 21% and <5%. Randomized stratification based on DM status. After randomization, the patients received double-blind study treatment (mAb316P or placebo) every 2 weeks for a 24-week period, and PO ezetimibe or placebo of ezetimibe every day. The dose increase based on the amount of LDL-C at week 8 can be done for patients randomly assigned to mAb316P at week 12. The patient was followed for 8 weeks after the last visit of the double-blind treatment period (DBTP). The study design is shown in Figure 1.

Procedure description

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

Screening period-including an intermediate visit lasting up to 2 weeks, during which the patient (or another designated person, such as a spouse, relative, etc.) is trained to inject/inject the placebo of mAb316P by itself. An eligibility assessment is performed to allow patients to be randomly assigned to the study. Before randomly assigning visits, the researchers can choose to provide a second training set of mAb316P with placebo for patients who need additional self-injection training. The patient or the researcher can choose to let the patient take the injection at home or at the research site.

Double-blind treatment period (DBTP)-a 24-week randomized, double-blind, double-virtual study treatment period. The first injection during the double-blind period was completed as soon as possible at the study site on the day of random assignment (week 0 [D1]-V3) and after calling IVRS/IWRS for random assignment into the study. Subsequently, the patient (self-injection) or another designated person (such as spouse, relative, etc.) completes the subsequent injection at the patient's preferred location (home, etc.). Patients from random assignment (V3) up to the 12th week (V6) (that is, 0, 2, 4, 6, 8 and 10 weeks) were randomly assigned to mAb316P + placebo. Patients with mAb316P received a dose of 75 mg mAb316P, and placebo Patients receiving ezetimibe for PO daily. At the 12th week visit (V6), these patients were unknowingly: (1) If the 8th week LDL-C <100mg/dL (1.81mmol/L), continue to mAb316P 75mg ( From the 12th week until the last injection in the 22nd week), or (2) If the LDL-C at the 8th week is 2100mg/dL (1.81mmol/L), then Adjust the dose to mAb316P 150mg every 2 weeks (from the 12th week until the last injection in the 22nd week. From the random assignment (V3) up to the 24th week (V8), the patients who were randomly assigned to ezetimibe every 2 weeks Received an injection of mAb316P placebo + 10 mg PO ezetimibe per day.

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

Duration of research participation

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

Patient screening

The target mother of this study is based on the systemic coronary heart disease risk assessment method (SCORE) with hypercholesterolemia, a 10-year risk score of ≧1% and <5% defined as being at moderate cardiovascular (CV) risk and having Patients who have signed written informed consent.

The following exclusion criteria are used to screen patients who meet all the above inclusion criteria, and the exclusion criteria are classified and numbered in accordance with the following 3 subsections:

A. Exclusions related to research methodology

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

2. Medical history with recorded CHD or CHD risk synonyms as defined below: (A) Recorded history of CHD (including one or more of the following): (1) Acute myocardial choking (MI); (2) Silent MI; (3) Unstable angina pectoris; (4) Coronary artery revascularization procedures (such as percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]); (5) Clinically obvious CHD, through invasive or non-invasive Invasive tests (such as coronary angiography, (B) CHD risk synonymous words include clinical signs of non-coronary heart disease in the form of atherosclerotic disease: (1) Symptomatic peripheral arterial disease; 2) Abdominal aortic aneurysm; or (3) Temporary ischemic stroke or ischemic stroke and "clinically significant carotid artery obstruction due to invasive or non-invasive tests (such as angiography or ultrasound)" .

3. Patients with DM related to risk SCORE≧5% or any other risk factors (such as the following): (1) a documented history of ankle brachial index ≦0.90; (2) a documented microalbuminuria or Large albuminuria (30) medical history or test paper urinalysis> 2+ protein at the screening visit (week -2); or (3) a documented history of preproliferative or proliferative retinopathy or retinopathy Radiotherapy.

4. Within 4 weeks of the screening visit (week -2, V1) or between the screening and random assignment visits, use statin, nicotinic acid, bile acid binding chelator, intestinal tract with a dose> 1000 mg per day Cholesterol absorption (ICA) blockers (ie ezetimibe) or omega-3 fatty acids.

5. Use fibric acid within 6 weeks of the screening visit (week -2, V1) or between screening and random assignment visits.

6. Use nutritional supplements or over-the-counter medications that may affect lipids for at least 4 weeks before the screening visit (week -2) or between the screening and random assignment visits, which is not necessarily a fixed dose/quantity.

7. Use red yeast rice products within 4 weeks of the screening visit (week -2) or between the screening and random assignment visits.

8. Plan to receive planned PCI, CABG, carotid artery or peripheral vascular reconstruction during the study period.

9. At screening (week -2, V1) or randomly assigned (week 0), systolic blood pressure (BP)>160mmHg or diastolic BP>100mmHg.

10. The New York Heart Association (NYHA) heart failure in the past 12 months Class III or IV medical history.

11. Known history of hemorrhagic stroke.

12. The age at the screening visit (week -2) is <18 years or the legal age of an adult, whichever is older.

13. Patients who were not instructed to take a cholesterol-lowering diet before the screening visit (week -2).

14. Diabetes that was recently diagnosed (within 3 months before the random assignment visit [week 0]) or poorly controlled (at the screening visit [week -2] HbA1 _c >8.5%).

15. There are any clinically significant poorly controlled endocrine diseases that are known to affect serum lipids or lipoproteins. Note: If the dose has been stable for at least 12 weeks before screening and the amount of TSH at the screening visit falls within the normal range of the central laboratory, patients who are undergoing thyroid replacement therapy can be included.

16. Have a history of bariatric surgery within 12 months prior to the screening visit (week -2).

17. Unstable body weight, as defined by a change of >5 kg in the 2 months prior to the screening visit (week -2).

18. Known homozygous or heterozygous familial hypercholesterolemia history.

19. Known history of PCSK9 loss of function (such as genetic mutation or sequence variation).

20. Use systemic corticosteroids, unless used as a replacement therapy for pituitary/adrenal disease, a stable regimen lasting at least 6 weeks before random assignment visits (week 0). Note: Topical, intra-articular, intranasal, inhalation and ophthalmic steroid therapy are not considered "systemic" and are permitted.

21. Use continuous estrogen or testosterone hormone replacement therapy, unless the regimen has been stable in the past 6 weeks before the screening visit (week -2) and there is no plan to change the regimen during the study period.

22. Cancer history in the past 5 years, except for fully treated basal cell skin cancer, squamous cell skin cancer, or cervical cancer in situ.

23. Known HIV-positive medical history.

24. Patients who have taken any study drug other than the MAb316P training placebo set within 1 month or 5 half-lives, depending on which is longer.

25. Patients who have previously participated in any clinical trial of MAb316P or any other anti-PCSK9 therapy.

26. Patients who withdraw their consent during the screening period (patients who are unwilling to continue or who have not returned).

27. Circumstances/situations such as the following: (1) Any clinically significant abnormality identified at the time of screening, which, in the judgment of the researcher or any agent researcher, will hinder the safe end of the study or limit such as more serious systemic diseases According to the evaluation index, the life expectancy of the patient is short; or (2) the researcher or any agent researcher believes that the research is inappropriate for any reason, for example: (a) it is considered that the specific procedure conditions cannot be met, such as planned Visit; (b) The patient or researcher believes that it is unable to administer or tolerate long-term injections; (c) The researcher or any agent researcher, pharmacist, research coordinator, other researcher or their related personnel directly involved in the implementation of the procedure Etc.; or (d) There are any other circumstances (such as geographic, social) that the researcher believes will actually or expected to restrict or restrict the patient’s participation in the study period.

28. Laboratory research results during the screening period (excluding the random assignment of laboratories in week 0): (1) Hepatitis B surface antigen or hepatitis C antibody test positive (confirmed by reflex test); (2) In Among women who may be pregnant, the serum β-hCG or urine pregnancy test is positive (including the 0th week); (3) Triglycerides>400mg/dL (>4.52mmol/L) (allow the laboratory to repeat once) ; (4) eGFR<60mL/min/1.73 m2, based on the 4-variable MDRD research equation (calculated by the central laboratory); (5) ALT or AST>3 x ULN (allow the laboratory to repeat once); (6) )CPK>3 x ULN (allow the laboratory to repeat once); or (7) TSH<LLN or >ULN.

B. Exclusion elements related to background therapy

29. All contraindications or warnings/earnings (if any) of the active comparator (ezetimibe) displayed on the individual national product label.

C. Exclusion elements related to MAb316P

30. Known allergy to monoclonal antibody therapeutics

31. Women who are pregnant or breastfeeding

32. Women who are likely to become pregnant without effective methods of birth control and/or unwilling or unable to have a pregnancy test

Note: Women who are likely to become pregnant must undergo a negative pregnancy test during screening visits and random assignment visits. They must use effective contraceptive methods throughout the study period and agree to repeat urine pregnancy tests at designated visits. According to the Annotated Guidelines on the conduct of human clinical trials and non-clinical safety studies for the authorization of commercially available drugs, the method of contraception must meet the requirements of highly effective birth control. After menopause, women must have amenorrhea for at least 12 months.

Research treatment

Research medication (IMP) and dosing

Both provide sterile mAb316P drugs at 75 mg/mL and 150 mg/mL in a volume of 1 mL in an auto-injector. A sterile placebo of mAb316P was prepared in the same formulation as mAb316P in a volume of 1 mL in an auto-injector without the addition of protein.

Ezetimibe 10 mg tablets are completely encapsulated. Placebo capsules for ezetimibe.

The mAb316P IMP can be administered by self-injection or by another designated person (such as spouse, relative, etc.). The used auto-injector is discarded into the sharps container provided to the patient.

Ask the patient to store mAb316P IMP in the refrigerator. Before administration, the The IMP is placed in a safe place outside at room temperature for about 30 to 40 minutes. After that, IMP should be invested as soon as possible.

During the double-blind treatment period, mAb316P or mAb316P placebo was administered subcutaneously every two weeks, starting from week 0 and up to the last injection 2 weeks before the end of the double-blind treatment period (week 22).

MAb316P IMP injection is ideally administered subcutaneously every 2 weeks at approximately the same time as the day; however, a window period of ±3 days is acceptable.

Take ezetimibe 10 mg or a placebo of ezetimibe capsules once a day at approximately the same time every day, with or without food.

Research evaluation index

Main effectiveness evaluation indicators

The main efficacy evaluation index is the calculated percentage change of LDL-C from the baseline to the 22nd week, which is defined as: 100x (calculated value of LDL-C at week 24-calculated value of LDL-C at baseline)/LDL-C The calculated value at the baseline.

The baseline calculated value of LDL-C is the last amount of LDL-C obtained before the first double-blind IMP, which is defined as the earliest between the date of the first double-blind injection and the first time the capsule is taken.

The calculated value of LDL-C at Week 24 is the amount of LDL-C obtained in the 24th week time window and during the main effectiveness period. The primary efficacy period is defined as the time from the first double-blind IMP up to 21 days after the last IMP injection or up to the upper limit of the 24th week analysis window, depending on whichever comes first.

According to the above definition, if appropriate, all calculated LDL-C values (planned or non-planned, fasting or non-fasting) can be used to provide the value of the main efficacy evaluation index.

Secondary effectiveness evaluation index

Important and secondary effectiveness evaluation indicators

(1) Percentage change of LDL-C calculated from baseline to week 12: Similar definitions and general rules as above, except that the calculated value of LDL-C at week 12 is within the analysis window of week 12 and is effective at week 12 The amount of LDL-C obtained during the period. The 12-week potency period is defined as the period from the first double-blind IMP up to the sixth visit before providing IVRS contact or up to 21 days after the last double-blind IMP injection, depending on whichever comes first. The blood sample collected on the day of IVRS exposure at the sixth visit was considered pre-titration.

(2) The percentage change of Apo B from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(3) The percentage change of non-HDL-C from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(4) The percentage change of total C from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(5) The percentage change of Apo B from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(6) The percentage change of non-HDL-C from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(7) The percentage change of total C from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(8) The proportion of patients who reached the LDL-C target <100mg/dl (2.59mmol/mL) in the 24th week, with the same definition and general rule as the main evaluation index.

(9) The proportion of patients who reached the LDL-C target <70mg/dl (1.81mmol/mL) in the 24th week has the same definition and general rule as the main evaluation index.

(10) The percentage change of Lp(a) from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(11) The percentage change of HDL-C from baseline to week 24. And the main comment The same definitions and general rules as the evaluation indicators.

(12) The percentage change of HDL-C from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(13) The percentage change of Lp(a) from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(14) The percentage change of fasting TG from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(15) The percentage change of fasting TG from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

(16) The percentage change of Apo A-1 from baseline to week 24. The same definitions and general rules as the main evaluation indicators.

(17) The percentage change of Apo A-1 from baseline to week 12. The same definition and general rule as the percentage change of the calculated value of LDL-C from baseline to week 12.

Other secondary effectiveness evaluation indicators

(18) The proportion of patients with LDL-C<100mg/dL (2.59mmol/L) in the 12th week.

(19) The proportion of patients with LDL-C<70mg/dL (1.81mmol/L) in the 12th week.

(20) The absolute change of LDL-C (mg/dL and mmol/L) from baseline to Week 12 and Week 24.

(21) The change in the ratio of Apo B/Apo A-1 from baseline to week 12 to week 24.

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

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

(24) Have LDL-C<70mg/dL (1.81mmol/L) and/or LDL-C decreased at the 12th and 24th weeks? 50% (if LDL-C? 70mg/dL[1.81mmol/L]) the proportion of patients.

Effectiveness evaluation method

Lipid parameters

Direct measurement of total-C, HDL-C, TG, Apo B, Apo A-1, and Lp(a). The Friedewald formula was used to calculate LDL-C at all visits (except week -1 and follow-up visits). If the TG value exceeds 400mg/dL (4.52mmol/L), the central laboratory will measure (via Beta quantification) LDL-C instead of calculating LDL-C. Calculate non-HDL-C by subtracting HDL-C from total-C. Calculate the ratio of Apo B/Apo A-1.

Safety Evaluation Index-Observation Period

The observation results of the safety data are as follows:

Pre-treatment period: The pre-treatment observation period is defined as the first administration of double-blind IMP starting from the signing of the consent form.

TEAE period: The TEAE observation period is defined as the time from the first dose of double-blind IMP to the last dose of double-blind IMP injection + 70 days (10 weeks), because MAb316P is expected until 10 weeks after the double-blind IMP injection is stopped There is residual utility.

Post-treatment period: The post-treatment observation period is defined as the time from the day after the end of the TEAE period up to the end of the study.

Safety Evaluation Index-Safety Laboratory

Clinical laboratory data is composed of urinalysis and blood analysis, hematology (RBC count, red blood cell volume distribution width (RDW), reticulocyte count, hemoglobin, hematocrit ratio, platelets, WBC count with blood cell classification), standard Chemistry (glucose, sodium, potassium, chlorine, bicarbonate, calcium, phosphorous, urea nitrogen, creatinine, uric acid, total protein, LDH, albumin, gamma glutamine aminotransferase [γGT]), hepatitis C Antibody, liver function Can check (ALT, AST, ALP, and total bilirubin), and CPK.

Safety evaluation index-vital signs measurement: vital signs include: HR, systolic blood pressure and diastolic blood pressure in a standing position.

Other evaluation indicators Anti-MAb316P antibody evaluation: Anti-mAb316P antibody includes antibody status (positive/negative) and antibody titer.

Sampling time: Regularly obtain serum samples for the determination of anti-mAb316P antibodies during the entire study period. Before IMP injection (before dosing), the first planned sample was obtained during random assignment visits.

Patients with an anti-mAb316P antibody titer of 240 or less at the follow-up visit should obtain additional antibody samples at 6 to 12 months after the last dose and approximately every 3 to 6 months thereafter until the effect The price has returned to below 240. In order to maintain the blindness of the study, the post-study anti-mAb316P antibody sample collection requirement is for patients whose titer is less than 240 at the time of follow-up visit.

Sampling procedure: Five (5) ml blood volume is collected for each anti-mAb316P antibody sample.

Biological analysis method: analyze all anti-mAb316P antibody (ADA; anti-drug antibody) samples.

Use effective non-quantitative, titer-based bridging immunoassay to analyze anti-mAb316P antibody samples. It involves initial screening, confirmation analysis based on drug specificity, and measuring the titer of anti-MAb316P antibody in the sample. The lower limit of detection is about 1.5ng/mL.

For neutralizing antibodies, a valid non-quantitative, competitive ligand binding assay was used to evaluate samples that were positive in the ADA analysis. Based on the single strain positive control neutralizing antibody, the detection limit is 390ng/mL.

hs-CRP: The percentage change of hs-CRP from baseline to Week 12 and Week 24.

HbA1C: The absolute change (%) of HbA1C from baseline to Week 12 and Week 24.

EQ-5D Patient Questionnaire Survey: EQ-5D is a standardized measurement of health status developed by the EuroQol group. It is convenient to provide a simple and universal measurement method for clinically and economically estimating health. As a measure of health-related quality of life, EQ-5D defines health in five dimensions: mobility, self-care, daily life, pain/discomfort, anxiety/depression. For each aspect, you can check one of the three responses (3 sequential degrees of severity): "No problem" (1), "Some problems" (2), and "Serious problems" (3). The overall health status is defined as a 5-digit number. The health status defined by the five-oriented classification can be converted into a corresponding index score that quantifies the health status, where 0 means "death" and 1 means "complete health". If one or more responsive responses are missing, the indicator score will not be obtained.

EQ-5D variables include responses to each EQ-5D project, indicator scores, and changes in indicator scores from the baseline.

Pharmacokinetics: The pharmacokinetic variables include total serum mAb316P concentration. If necessary, the total PCSK9 concentration and free PCSK9 concentration can be measured from the same PK sample.

Sampling time: Serum samples for total mAb316P concentration were collected at IMP (pre-dose) at week 0 (random assignment visit) and then at several visits until the end of the follow-up period. To collect information on the absorption period, optional PK samples were collected 5 days (±2) after IMP injection at week 22 or 5 days (±2) after any subsequent IMP injection while the patient was being treated.

Sampling procedure: Five (5) ml blood volume is collected for each PK sample.

Biological analysis method: Use effective enzyme linked immunosorbent assay (ELISA) to analyze all PK samples to determine the total mAb316P concentration (ie free mAb316P and mAb316P present in the PCSK9: mAb316P complex). Under the quantification of this analysis The limit (LLQ) is 0.078μg/mL.

If necessary, a valid ELISA can be used to analyze PK samples for the determination of total PCSK9 and free PCSK9. The LLQ for total PCSK9 analysis was 0.156 μg/mL, while the LLQ for free PCSK9 analysis was 0.0312 μg/mL.

Research procedure

Regarding all visits after the 1st day/week 0 (randomly assigned visits), a timeframe of a certain number of days is allowed. The window period for visits in the 12th and 24th weeks is ±3 days, and all other site visits during the double-blind treatment period and the follow-up period are regarded as ±7 days. Random assignment visits (day 1/week 0) and screening visits for injection training (week -1) allow a window period of +3 days.

Blood sampling: For all site visits during the entire study period, regarding the determination of lipid parameters (ie total-C, LDL-C, HDL-C, TG, non-HDL-C, Apo B, Apo A-1, Apo B) /Apo A-1 ratio, Lp[a]) blood sampling should be done in the morning on an empty stomach (that is, overnight, at least 10 to 12 hours on an empty stomach and smoking ban). Drinking alcohol is not allowed within 48 hours before blood sampling and vigorous exercise is not allowed within 24 hours before blood sampling.

Laboratory test: Collect laboratory data and transfer it to the central laboratory. Laboratory data includes hematology; chemistry; liver function tests (when the total bilirubin value is higher than the normal range, it will be automatically divided into conjugated bilirubin and Unconjugated bilirubin); creatine phosphokinase (CPK); hepatitis B surface antigen; hepatitis C antibody (using a reflex test to confirm a positive result); and a serum pregnancy test.

Urine sampling: urinalysis-test paper in the central laboratory and assess the presence of pH, specific gravity, blood, protein, glucose, ketones, nitrates, leukocyte esterase, urobilinogen and bilirubin. If the test strip is abnormal, perform standard microscopy.

Other evaluation index evaluation methods: measured by the central laboratory during the research period Other blood parameters. Drinking alcohol is not allowed within 48 hours before blood sampling and vigorous exercise is not allowed within 24 hours before blood sampling. During the entire study period, the central laboratory regularly measured blood glucose parameters ((HbA1c and blood glucose). Regarding blood sampling for inflammatory parameters, hs-CRP was collected regularly throughout the study period.

Pharmacokinetic samples: Serum samples were taken regularly throughout the study period for assessment of mAb316P concentration.

Physical examination: A general physical examination should be performed.

Blood pressure (BP)/heart rate: measure BP in a sitting posture under standardized conditions using the same device on the same arm at approximately the same time of the day (after the patient rests comfortably in a sitting posture for at least 5 minutes). The values were recorded in e-CFR; both systolic BP and diastolic BP were recorded. At the first screening visit, the BP of both arms should be recorded. At this visit, the arm with the highest diastolic blood pressure was determined, and BP was measured on this arm during the entire study period. Record the highest value with e-CRF. Measure heart rate while measuring BP.

Electrocardiogram: The 12-pole ECG should be performed in the supine position after resting for at least 10 minutes.

Weight and height: The weight is obtained with the patient wearing underwear or very light clothing without shoes and emptying the bladder.

Statistical Analysis

The sample size was calculated for each group of 45 patients treated, based on the previous mAb316P trial (McKenney et al., “Safety and efficacy of a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 serine protease, SAR236553/REGN727, in patients with primary hypercholesterolemia receiving ongoing stable atorvastatin therapy”, J Am Coll Cardiol , vol.59,pp.2344-2353(2012)) and an expected exclusion rate of 5%, using a 2-sided t test at 5% significance, assuming common criteria The difference (SD) is 25% to obtain 95% verification power to detect the average difference between the percentage change of mAb316P and ezetimibe in LDL-C from baseline to week 24 is 20%.

The main evaluation indicators are evaluated in an intention-to-treat (ITT) mother, which includes all randomly assigned patients with at least one calculated value of LDL-C at baseline and at one of the predetermined time points from 4 to 24 weeks. On-treatment analysis (corresponding to adjusted ITT or mITT) is also performed, which includes all randomly assigned and treated patients who have at least one at baseline and at one of the predetermined time points from 4 to 24 weeks of treatment The calculated value of LDL-C is defined as the period between the first administration of the study treatment and up to 21 days after the last injection or 3 days after the last capsule administration (whichever comes first).

By the mixed utility model repeated measures (MMRM) method (Siddiqui et al., MMRM vs. LOCF: a comprehensive comparison based on simulation study and 25 NDA datasets", J Biopharm Stat , vol. 19, pp. 227-246 (2009); National Research Council, "The Prevention and Treatment of Missing Data in Clinical Trials" Panel on Handling Missing Data in Clinical Trials. Committee on National Statistics, Division of Behavioral and Social Sciences and Education. 2010. Washington, DC: The National Academies Press; Andersen et al., "On the practical application of mixed effects models for repeated measures to clinical trial data", Pharm Stat. , vol. 12, pp. 7-16 (2013)) produced missing data. In ITT analysis, regardless of whether the status is under treatment or not under treatment, all variables measured from the 4th week to the 24th week predetermined time points (representing the 4th, 8th, 12th, 16th and 24th weeks) are used in the MMRM. The MMRM model is used in LDL-C to provide the least-squares average estimated value and comparison results of the treatment group between the 24th week and the 12th week. More detailed explanations about the model are provided below. Regarding the analysis during treatment, from the 4th week to the 24th week All available on-treatment measurements at a predetermined time point of the week (ie up to 21 days after the last injection/3 days after the last capsule ingestion, whichever comes first) is used in the MMRM model. The ITT analysis is based on In the same way, a model is used to provide estimates and comparison results between the 24th week and the 12th week used in the treatment analysis. Analyze Lp(a) and continuous importance other than triglycerides in a similar manner to the main evaluation indicators The secondary evaluation indicators and the descriptions of the statistical methodology of the secondary evaluation indicators and sub-ethnic analysis are provided below.

The safety analysis included all patients who were randomly assigned and treated. Analyze safety data by narrating statistics. All statistical analysis is performed using SAS ^® version 9.2 or higher (SAS Institute Inc., Cary, NC).

Mixed Utility Model of Repeated Measurements (MMRM)

MMRM includes treatment group (mAb316P vs. ezetimibe), fixed absolute utility of the interaction between time points (4th, 8, 12, 16 and 24 weeks) and treatment over time, and baseline low-density lipoprotein cholesterol value A continuous fixed covariate that interacts with the baseline value over time. For the treatment group, the output data of the model is the baseline-adjusted least square (LS) average estimate and its corresponding standard error (SE) at week 24. Use an appropriate contrast statement to verify the difference in these estimates with a 2-sided 5% alpha level. To estimate the reliability of the main analysis and compare the on-treatment results between groups, the MMRM model was also applied to the LDL-C values collected during the treatment.

Sub-ethnic analysis

130或

160mg/dL)；基線高密度脂蛋白膽固醇(HDL-C)<40mg/dL；基線空腹三酸甘油酯≧150mg/dL；基線脂蛋白(a)[Lp(a)]≧30mg/dL；以及基線游離前蛋白轉化酶枯草桿菌素/克新第9型(PCSK9)量(低於/高於中間值)。 In order to evaluate the uniformity of treatment utility among different sub-groups, treatment-by-ethnic factors, time-point-by-ethnic factors, and treatment-time-by-ethnic factors interaction factors and sub-ethnic factors were added to the main MMRM model. Interested sub-ethnic groups include body mass index (BMI) ≧30kg/m ² ; gender; region (North America, Western Europe); age ≧65 years; baseline LDL-C(

130 or

160mg/dL); Baseline high-density lipoprotein cholesterol (HDL-C)<40mg/dL; Baseline fasting triglycerides≧150mg/dL; Baseline lipoprotein(a)[Lp(a)]≧30mg/dL; and Baseline free proprotein convertase subtilisin/gram new type 9 (PCSK9) amount (lower/higher than the median value).

Statistical analysis of important and secondary evaluation indicators

To analyze important and secondary evaluation indicators, hierarchical procedures are used to control Type I errors and deal with multiplicity. In the intention-to-treat mothers, the secondary efficacy evaluation indicators were tested in order using the order given above. Except for Lp(a) and triglycerides, use the same MMRM model as the main evaluation index of the fixed absolute utility of the treatment group (the interaction between the planned time point up to the 24th week and the treatment time point), and the corresponding baseline The interaction between the continuous fixed covariate of the value and the baseline value over time is used to analyze the continuous important secondary evaluation indicators (including the secondary evaluation indicators in the 12th week). Multiple imputation methods were used to analyze Lp(a) and triglycerides (which have a non-Gaussian distribution) and paired evaluation indicators (proportion of patients with LDL-C<100mg/dL and <70mg/dL) to deal with missing values. For Lp(a) and triglycerides, after multiple imputation, it is a robust regression model that uses the treatment group and the corresponding baseline value as the effect. For the paired evaluation index, multiple imputation is connected to use the treatment group as the utility and the corresponding baseline value as the logistic regression of the covariate. Use the same statistical method as described above to use the value in the treatment to use the sensitivity analysis of the important and secondary evaluation indicators.

result

Among the 204 patients screened, 103 met the eligibility requirements of the study and were randomly assigned (52 in the mAb316P group and 51 in the ezetimibe group; Figure 2). The baseline characteristics and lipid parameters were evenly distributed between the two study groups (Table 1). A total of 4 patients were identified as having diabetes at the time of screening (1 in the mAb316P group and 1 in the ezetimibe group). The average baseline LDL-C amount was 141.1 mg/dL (3.65 mmol/L) in the mAb316P group and 138.3 mg/dL (3.58 mmol/L) in the ezetimibe group (Table 1).

70mg/dL；這些患者中只有一名的LDL-C>100mg/dL。上調至mAb316P 150 mg Q2W之患者的平均基線LDL-C值為153.2mg/dL(3.96mmol/L)，而沒有上調的患者為134.7mg/dL(3.48mmol/L)。根據患者被上調與否，其他脂質數值基線值顯示於表2中。 In the 12th week, 14 patients in the mAb316P group were unknowingly up-regulated to the 150mg Q2W dosing regimen because of their 8LDL-C in the 8th week.

70mg/dL; only one of these patients had LDL-C>100mg/dL. Patients who were up-regulated to mAb316P 150 mg Q2W had an average baseline LDL-C value of 153.2 mg/dL (3.96 mmol/L), while patients without up-regulation had 134.7 mg/dL (3.48 mmol/L). Depending on whether the patient is upregulated or not, the baseline values of other lipid values are shown in Table 2.

Overall, 44/52 (85%) patients in the mAb316P group and 44/51 (86%) patients in the ezetimibe group completed the 24-week treatment period (Figure 2). The main reason for study treatment interruption was TEAE in the treatment group (Figure 2). Among the 15 patients who discontinued treatment early, 3 (6%) patients in the mAb316P group and 5 (10%) patients in the ezetimibe group had no calculated LDL-C values at week 24.

Forty-eight patients in each group injected all injections by themselves (94% in the ezetimibe group and 92% in the mAb316P group). Three patients in the ezetimibe group and 4 patients in mAb316P self-injected some injections and asked the other to inject other injections. No patient asks another person to perform all of their injections.

All randomly assigned patients received at least one dose of the drug assigned to them and were included in the intention-to-treat (ITT) and safety matrices (Figure 2). One patient in each treatment group withdrew from treatment before LDL-C measurement after any randomization and was therefore excluded from the treatment analysis. However, they continued the study and completed the LDL-C measurement before the end of the 24 week study despite being untreated, and were therefore included in the ITT analysis.

Effect result

In terms of the main efficacy analysis (ITT analysis), the least square (LS) mean (SE) percentage of LDL-C to the 24th week relative to the baseline was 47(3)% in the mAb316P group, compared to the ezetimibe group It was 16(3)%, and the statistically significant LS mean (SE) difference between the groups was -32(4)% ( P <0.0001) (Table 3). The results from the on-treatment analysis are similar to those from the ITT analysts: the average (SE) LDL-C reduction from baseline LS by week 24 was 54(2)% for mAb316P and 17(2) for ezetimibe, respectively %( P <0.0001) (Table 3).

At week 12, all patients in the mAb316P group received 75mg Q2W, and the amount of LDL-C decreased by 48(3)% (mAb316P) versus 20(3)% (ezetimibe) in the ITT analysis, with LS between groups The average (SE) difference is -28(4)% ( P <0.0001). In the on-treatment analysis, the corresponding LDL-C drop at week 12 was mAb316P 53(2)% relative to ezetimibe 20(2)%, and the LS mean (SE) difference between the groups was -33(3) %.

Figure 3 shows the time-course changes in the amount of LDL-C during the entire study period for patients treated with mAb316P and ezetimibe. The value in the treatment is shown here, because the purpose of understanding the durability of the drug's effect is not subject to any deviation due to interference factors. Patients receiving mAb316P had a sharp decline in LDL-C from baseline to week 4, where a steady decline in LDL-C was maintained from week 4 to the end of the treatment period at week 24. In the MMRM model, the statistical analysis of the interaction between treatment and time point is not significant, suggesting that the LDL-lowering effect of mAb316P is relative to the stability of ezetimibe over time (as shown in Figure 3).

50%之患者的估算比例在mAb316P組為58%，相較於依折麥布組(ITT)的患者為3%。治療中分析的對應值於mAb316P組為65%而在依折麥布組為2%。所有患者在暴露於治療時對mAb316P有反應(治療中母體)(第4圖)。 Before the up-regulation, LDL-C decreased at the 12th week

The estimated proportion of 50% of patients was 58% in the mAb316P group, compared to 3% in the ezetimibe group (ITT). The corresponding value analyzed during treatment was 65% in the mAb316P group and 2% in the ezetimibe group. All patients responded to mAb316P when exposed to treatment (mother under treatment) (Figure 4).

70mg/dL取代

100mg/dL的上調對於主要效力參數的影響，進行一個額外的分析，其排除儘管LDL-C值<100mg/dL卻仍上調之13名患者的上調後LDL-C值；該分析得到與整體ITT分析相似的結果(表4)。 In order to estimate based on LDL-C

70mg/dL substitution

An additional analysis of the effect of the up-regulation of 100 mg/dL on the main efficacy parameters was carried out, which excluded the up-regulated LDL-C value of 13 patients who were still up-regulated despite the LDL-C value <100 mg/dL; this analysis obtained the same result as the overall ITT Analyze similar results (Table 4).

Regarding mAb316P, the percentage decrease in Apo B, total cholesterol, and non-HDL-C relative to baseline at week 24 was significantly greater compared to ezetimibe and similar to those in the ITT and on-treatment analysis (Table 5). Lp(a), TG were observed after study treatment There was no significant difference between the mAb316P group and the ezetimibe group (Table 5).

Sub-population analysis indicated that there is no significant difference in the potency of mAb316P relative to ezetimibe for various parameters in the ITT parent (Figure 5).

†Displays the combined estimated value of the adjusted average (SE) percentage change of Lp(a) and TG.

‡Because the Lp(a) difference between mAb316P and ezetimibe at week 24 was not significant, no further significance test was performed in accordance with the fixed class method. The P -values of TG, HDL-C and ApoA-1 are shown for descriptive purposes only.

§ P -values are shown for descriptive purposes only.

Apo, lipoprotein deficiency; CI, confidence interval; HDL-C, high-density lipoprotein cholesterol; ITT, intention-to-treat; Lp(a), lipoprotein (a); LS, least squares; Q2W, every 2 weeks; SE , Mean error; TG, triglyceride.

Safety results

The overall percentage of patients who experienced at least one TEAE was 69% in the mAb316P group and 78% in the ezetimibe group (Table 6). There is no death. Two SAEs were reported during the TEAE period: a patient who received Ab316P 75mg Q2W for 3 months and had a history of atrial fibrillation and chronic obstructive pulmonary disease felt pulmonary embolism; the study treatment was interrupted and the patient was hospitalized, and he recovered in the hospital . A patient in the ezetimibe group with a medical history of arthritis felt erosion of the shoulder socket and was hospitalized for surgery (shoulder arthroplasty). The patient recovers in the hospital and completes the study. No SAE was considered by the researchers to be relevant to the study treatment. The TEAEs that occurred in 5% or more of patients in any treatment group are shown in Table 6.

After one or more TEAEs, nine patients discontinued study treatment early (5 [10%] patients in the mAb316P group and 4 [8%] patients in the ezetimibe group). In the ezetimibe group, the TEAE that caused the interruption was 1 patient with gout, 1 patient with fatigue, back pain, and frequent urination, 1 patient with abdominal cramps and injection site reactions, and 1 patient with vivid dreams. In the mAb316P group, the TEAE that caused the interruption was 1 patient with pulmonary embolism, 1 patient with nausea, fatigue, headache, and flushing, 1 patient with arthralgia (general pain), 1 patient with injection site reaction, and 1 other patient with diarrhea .

The most common type of TEAE is infection (42.3% mAb316P vs. 39.2% ezetimibe), mostly respiratory. Muscle-related TEAEs occurred in 2 (4%) mAb316P patients and 2 (4%) ezetimibe patients. In 1 ezetimibe group Of patients reported that the amount of creatine kinase increased more than 10 times the upper limit of normal (Table 6). Three patients felt a local injection site reaction (1 [2%] patients in the mAb316P group and 2 [4%] patients in the ezetimibe group). These events were mild. Patients in the mAb316P group felt 3 local injection site reactions after continuous injections. Three patients treated with mAb316P 75mg Q2W experienced at least one LDL-C value <25mg/dL; it was observed that these three patients had no specific safety issues associated with low LDL-C levels.

126mg/dL(7mmol/L)(6名患者對1名患者；表6)。mAb316P組中於治療期期間經歷高血糖的6名患者在篩選或基線時有異常空腹葡萄糖且從篩選至第24週沒有觀察到血糖或HbA1c有任何變化形態(表7)。 Several (2 or less) patients in the ezetimibe group and no patients in the mAb316P group showed abnormalities in vital signs (blood pressure, heart rate). In addition, alanine aminotransferase or aspartate aminotransferase did not increase more than 3 times the upper limit of normal (Table 6). There were more blood glucose in the mAb316P group than in the ezetimibe group

126 mg/dL (7mmol/L) (6 patients vs. 1 patient; Table 6). The 6 patients in the mAb316P group who experienced hyperglycemia during the treatment period had abnormal fasting glucose at screening or at baseline and no changes in blood glucose or HbA1c were observed from screening to week 24 (Table 7).

240)且未偵測到可能會影響mAb316P藥物動力學、LDL-C效用或安全性的中和抗-藥物抗體。 Treatment-emergent anti-drug antibodies were found in 6 (12%) patients of mAb316P but were not observed in patients in the ezetimibe group. For all patients with positive anti-drug antibodies, the titer is low (in the analysis used

240) and no neutralizing anti-drug antibodies that may affect the pharmacokinetics, LDL-C efficacy or safety of mAb316P were detected.

This is the first phase 3 study of mAb316P, the first monotherapy study of mAb316P, and the first study using a 75mg Q2W dosing regimen. Compared to ezetimibe, MAb316P proved to be superior as a monotherapy throughout the 24 weeks of treatment. In the ITT analysis, in patients receiving mAb316P 75mg Q2, a 48% decrease in LDL-C was observed at week 12 (before upregulation), compared to 20% of ezetimibe 10 mg per day. The corresponding decrease in patients during treatment was 53% for mAb316P 75mg Q2W and 20% for ezetimibe.

The efficacy of MAb316P was consistent with baseline parameters including the amount of LDL-C and PCSK9 and demographics. In fact, all patients treated with mAb316P in the treatment analysis responded to 75 mg Q2W on monotherapy. MAb316P monotherapy showed the effect of continuously lowering LDL from 4 to 24 weeks.

Consistent with the significant decrease in LDL-C, mAb316P also provided a robust decrease in total cholesterol, Apo B, and non-HDL-C. MAb316P caused an 18% drop in Lp(a) in this study, compared to 12% in the ezetimibe group.

MAb316P proved tolerability and safety comparable to ezetimibe. Muscle-related AEs occurred at the same frequency in both treatment groups (4% for mAb316P patients and 4% for ezetimibe patients). In addition, the anti-drug antibodies produced in patients treated with mAb316P are low.

In summary, this is the first 6-month duration, phase 3, blind evaluation of PCSK9 inhibitors. In the monotherapy mothers, it was observed that the mAb316P 75mg Q2W group had a ~50% decrease in LDL-C at week 12, which was significantly greater than that observed in the ezetimibe group (20%). This study is an extension of the safety observations in the Phase 2 trial, and there is no evidence of safety signals that appear to limit use and tolerability. This is also the first randomized, controlled trial of the injectable monoclonal antibody of PCSK9 using a disposable auto-injector. The use of a disposable auto-injector caused some injection-related AEs (mAb316P patients <2% and ezetimibe patients <4 %).

Pharmacokinetic results

In patients receiving mAb316P monotherapy, the correlation between mAb316P, free PCSK9, and LDL-C concentration was assessed. The changes in free PCSK9 and LDL-C were also evaluated in the ezetimibe group.

An effective enzyme-linked immunosorbent assay was used to determine the amount of serum mAb316P and free PCSK9.

Pharmacokinetic analysis was performed on 46 patients in the mAb316P treatment group who were not discontinued before the 12th week (Table 8). Among 46 patients treated with mAb316P, 32 patients achieved LDL-C<70mg/dL at week 8 and maintained mAb316P 75mg Q2W while 14 patients were upregulated to mAb316P 150mg Q2W.

Compared with patients with unupregulated mAb316P, patients with upregulated mAb316P had a greater amount of baseline LDL-C ( P = 0.044) (Table 9). In the non-upregulated group, the decrease in LDL-C observed at Week 4 continued until Week 24 (Panel 6A). In the up-regulated group, the amount of LDL-C also decreased in the 4th week, but to a relatively smaller extent than the non-up-regulated group (Figure 6A). The decrease in LDL-C with mAb316P was similar between week 12 and week 24, regardless of whether the mAb316P dose was increased at week 12 (Figure 6A), and was consistently greater than with ezetimibe (Table 9).

In the first 12 weeks of the study where all patients received the 75 mg dose, the serum levels of mAb316P in the up-regulated and non-up-regulated groups were similar, and the patients up-regulated at week 12 were approximately doubled (Figure 6B, Table 9).

Compared with the unupregulated group and the ezetimibe group, the baseline free PCSK9 amount and total PCSK9 amount in the upregulated group were slightly larger (Table 9). The amount of free PCSK9 in the non-up-regulated group reached its lowest point in the 4th week; in the up-regulated group the amount of free PCSK9 also decreased in the 4-12 weeks, but it was higher than the non-up-regulated group 2- 3 times (Figure 6C; Table 9). Up-regulation to mAb316P 150mg Q2W at week 12 was associated with additional inhibition of free PCSK9; the decrease was maintained until week 24 (Figure 6C; Table 9). In the ezetimibe group, the amount of free PCSK9 relative to baseline remained constant until week 12, but decreased at week 24 (Table 9). The total amount of PCSK9 increased after treatment with mAb316P instead of ezetimibe (Table 9), probably because the antibody:PCSK9 complex has a longer half-life than free PCSK9.

In patients who maintained mAb316P 75mg Q2W monotherapy until week 24, the amount of free PCSK9 decreased the most in week 4; the effect of lowering LDL-C was maintained from week 4 to week 24. In patients who were upregulated to mAb316P 150mg Q2W at week 12, the serum concentration of mAb316P increased as expected and there was an additional decrease in the amount of free PCSK9, but it had a little effect on LDL-C. The results showed that the monotherapy with mAb316P 75mg Q2W was sufficient to block free PCSK9 and maintain the LDL-C reduction effect for more than 24 weeks in most patients who did not receive statin or other lipid regulating therapies. Because the clearance of the target medium of mAb316P is accelerated by its binding to free PCSK9, higher doses of mAb316P may be required under clinical conditions where patients receive statins or other lipid modifiers to increase free PCSK9.

The scope of the present invention is not limited by the specific examples described herein. In fact, various modifications of the present invention other than those described herein will become apparent to those skilled in the art from the foregoing description and drawings. These modifications fall within the scope of the attached patent application.

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

introduction

The purpose of this study is to evaluate the in vivo phase of anti-PCSK9 antibody ("mAb316P", also known as REGN727 or rilobomab) in patients with primary hypercholesterolemia (heFH and non-FH) who are intolerant to statin. The ability to reduce LDL-C compared to ezetimibe (EZE).

Among the muscle-related symptoms in clinical trials, a group of highly selected patients with high treatment compliance and statin tolerance may not be able to reflect the true incidence of myalgia clinically, as shown by the results of observational studies. prove. The difference in the incidence of muscle-related adverse events (AE) may be secondary to some patients who experience multiple-drug AEs, and this may not represent true intolerance to statins. Therefore, considering that patients who may have AEs for multiple drugs, not just for statin, select a sufficient number of patients and recruit them into the single-blind placebo trial period of this study to ensure that the sample size for the double-blind treatment period is 250 patients (100:100:50; mAb316P: EZE: Atorvastatin).

The sample size of 250 patients (100:100:50; mAb316P: EZE: Atorvastatin), the duration of the 24-week double-blind study treatment, is to obtain information about efficacy and obtain general safety events, all bones A narrative experience of withdrawal related to muscle-related events, and especially skeletal muscle events. In this study, patients with moderate, high, or very high CV risk who are intolerant to statin were included as a mother who would be more difficult to achieve the LDL-C goal when only non-statin alternatives were used. The definition of CV risk is based on existing guidelines (see, for example, the European Society of Cardiology [ESC] and the European Society of Arteriosclerosis [EAS] Dyslipidemia Management Task Force, ESC/EAS Dyslipidemia Management Guidelines. European Heart Journal 2011; 32: 1769-1818); European Heart Journal 2011; 32: 1769-1818); Expert Panel on Detection, Evaluation,and Treatment of High Blood Cholesterol in Adults.Executive summary of the Third Report of the National Cholesterol Education Program[NCEP]Expert Panel on Detection,Evaluation,and Treatment of High Blood Cholesterol in Adults[Adult Treatment Panel III],JAMA 2001 ; 285: 2486-2497).

A 2-week cleanup period was used to ensure that the background therapy had no residual effect on the comparison group.

A 4-week placebo trial period was used to eliminate patients who had muscle-related symptoms on other drugs (including placebo).

The preliminary pharmacokinetic data of the Phase 2 study of mAb316P showed that exposure to mAb316P decreased during the 8-week follow-up period after the double-blind treatment period, where the total serum concentration of mAb316P was still detectable, but at very low levels. Therefore, to ensure a sufficiently low, non-effective serum mAb316P concentration, patients were followed during the 8-week follow-up period (ie, 10 weeks after the last dose).

Ezetimibe is used as an active comparator, because ezetimibe is the current standard care for patients who cannot tolerate statin, and the main purpose of the study is to evaluate LDL-C compared to EZE after 24 weeks of mAb316P. decline. Atorvastatin was also included as a comparison to determine that the mother selected in the study was a mother who was truly intolerant to statin. This was done through the incidence and frequency of interruptions due to skeletal muscle related AEs Evaluation (Fung and Crook, Cardiovasc. Ther. 2012 Oct, 30(5): e212-218).

Two doses of mAb316P were used in this study: 75 mg and 150 mg administered subcutaneously every other week (Q2W). The choice of dose is based on the data planned from the first and second phases. The choice of dosage, dosing frequency, and up-regulation method is also based on the LDL-C reduction required to provide the best benefit in terms of CVD reduction and potential safety considerations regarding low LDL-C values.

70mg/dL的患者以及有中度CV風險和LDL-C

100mg/dl的患者在8週治療後於第12週上調劑量至150mg Q2W。 The Q2W dosing regimen is expected to maintain a stable decrease in LDL-C throughout the inter-dosing interval, with the 150 mg Q2W dose providing maximum efficacy at week 12. However, for many patients, the level of efficacy observed with the 150 mg Q2W dose is not necessary to achieve the LDL-C goal, and treatment can be started with a lower dose. Therefore, in this study, all patients were initially treated with 75mg Q2W, only those with high and very high risk of CV and LDL-C

70mg/dL patients and moderate risk of CV and LDL-C

Patients with 100mg/dl will increase the dose to 150mg Q2W in the 12th week after 8 weeks of treatment.

Based on the clinical data at the beginning of this study, in the mothers of patients with non-familial hypercholesterolemia or heterozygous familial hypercholesterolemia, treatment with mAb316P has shown significant LDL-C lowering effect and usually has a good effect. Tolerance. The effectiveness of LDL-C reduction is related to the consistent results of total-C, ApoB, non-HDL-C and ApoB/ApoA-1 ratios and the positive trends of HDL-C, TG and Lp(a). There is no evidence that mAb316P has an adverse effect on other cardiovascular (CV) risk factors (eg, weight, blood pressure, glucose, or C-reactive protein).

Research objectives

The main goal of the study is to prove that the use of mAb316P in patients with primary hypercholesterolemia (heFH and non-FH) who are intolerant to statin can prove that the use of mAb316P after 24 weeks compared to 10 mg once a day (PO QD) The LDL-C decreased.

The secondary goals of the study are: (1) To evaluate the efficacy of mAb316P 75mg compared with EZE for LDL-C after 12 weeks of treatment; (2) To evaluate the effects of mAb316P on other lipid parameters (e.g., ApoB, non-HDL-C, total- C, Lp(a), HDL-C, TG amount and ApoA-1 amount); (3) To evaluate the safety and tolerability of mAb316P, including the characteristics of the incidence of skeletal muscle-related AEs and the rate of withdrawal from treatment Identification; and (4) Evaluation of the production of anti-mAb316P antibodies.

Research design

This study is a randomized, double-blind, double-dummy, active agent-controlled, parallel group, multi-country, multi-center study, in which patients who are intolerant to statin have primary hypercholesterolemia and moderate and high Or extremely high CV risk. The study design is shown in Figure 7.

Statin intolerance is defined as the inability to tolerate at least 2 previous statins in the approved minimum daily dose due to skeletal muscle-related symptoms, and skeletal muscle-related symptoms are those other than sprains or trauma, such as pain, pain, weakness or cramps , Which started or increased during statin treatment and stopped when statin treatment was discontinued.

The study consisted of 5 periods: screening; clarification; single-blind placebo trial; double-blind treatment; and follow-up.

(1) Screening:

The screening lasts for about 1 week (week-7). From the beginning of the screening to the end of the treatment visit, patients were required to maintain the same stable diet as the National Cholesterol Education Program Adult Treatment Third Edition (NCEP-ATP III) Therapeutic Lifestyle Change (TLC) diet for the entire duration of the study.

(2) Clarification:

Patients who meet all the screening criteria for inclusion and exclusion enter a 2-week (-6th to-4th week) clearance period of EZE, statin (for patients taking non-approved doses or regimens), and red yeast rice.

(3) Single-blind placebo trial:

After clearance, the patient entered a 4-week (-4th to 0th week), single-blind (only the patient was blind to the treatment) placebo trial period, which was determined by the use of placebo (for mAb316P Q2W) (total 2 doses) ) 4 weeks of treatment plus placebo (for EZE/atorvastatin capsule PO QD (28 doses)).

Only during the single-blind placebo trial period did not experience skeletal muscle-related AEs (due to Patients other than sprains or trauma) are eligible to enter the following double-blind treatment period.

Inform patients who experience skeletal muscle-related AEs (because of other than sprain or trauma) during the 4-week single-blind placebo trial period to stop therapy and withdraw from the study.

At the first planned visit in the single-blind placebo trial period (week -4), the patient (or his caregiver) was told to use a single-blind auto-injector containing a placebo (for mAb316P) to administer the study drug and Self-administer the first dose in the clinic (in week -4). The second study drug dose during the single-blind placebo trial period (in week -2) was administered by the patient or caregiver at home using the second single-blind auto-injector of placebo (for mAb316P). The patient took placebo capsules of EZE/atorvastatin QD for 4 weeks during the placebo trial period.

(4) Double-blind treatment:

Patients who met all the inclusion criteria and did not meet the exclusion criteria (including those who felt skeletal muscle related AEs, those due to sprains or trauma) were randomly assigned to receive during the 4-week single-blind placebo trial period: (A) mAb316P 75mg SC Q2W + placebo (for EZE/atorvastatin PO QD); or (B) EZE 10 mg PO QD + placebo (for mAb316P SC Q2W); or (C) atorvastatin 20 mg PO QD + placebo (for mAb316P SC Q2W) ).

Ezetimibe 10 mg and atorvastatin 20 mg were completely encapsulated in capsules to cooperate with the placebo of EZE/atorvastatin to ensure double blindness. Ezetimibe 10mg, atorvastatin 20mg and placebo are indistinguishable from each other.

Randomization stratification was performed based on a documented history of myocardial infarction (MI) or ischemic stroke (with/without).

During the double-blind treatment period, on the day of random assignment (Week 0 [Day 1]-Visit 4) at the site and called to the Interactive Voice Response System (IVRS)/Interactive Internet Response System (IWRS) and The first injection is administered as soon as possible after random assignment to the study. Subsequent injections are given by the patient (self-injection) or designated caregivers (spouse, relatives, etc.) in the patient's preference Place (such as home or work) to invest. Patients are allowed to choose to return to site Q2W and the research staff will administer injections. Patients who were randomly assigned to mAb316P received 75 mg of study drug from random assignment to week 12 (weeks 0, 2, 4, 6, 8 and 10).

After the 12th week visit, based on his LDL-C at the 8th week and baseline CV risk (defined elsewhere in this document), the patient continued to receive mAb316P 75mg Q2W or increased dose as follows:

70mg/dL(1.81mmol/L)，則從第12週直到第22週最後一次注射接受上調至mAb316P 150mg Q2W的劑量。 (A) Patients with extremely high risk of CV, unknowingly: (i) If their LDL-C is less than 70mg/dL (1.81mmol/L) in the 8th week, from the 12th week until the last injection in the 22nd week Continue to receive mAb316P 75mg Q2W; or (ii) if it is LDL-C at week 8

70mg/dL (1.81mmol/L), from the 12th week to the 22nd week, the last injection received the up-regulated dose of mAb316P 150mg Q2W.

100mg/dL(2.59mmol/L)，則從第12週直到第22週最後一次注射接受上調至mAb316P 150mg Q2W的劑量。 (B) Patients with high or moderate risk of CV, unknowingly: (i) If their LDL-C in the 8th week is less than 100mg/dL (2.59mmol/L), from the 12th week to the end of the 22nd week One injection continues to receive mAb316P 75mg Q2W; or (ii) if it is LDL-C in the 8th week

100mg/dL (2.59mmol/L), from the 12th week until the 22nd week, the last injection received the up-regulated dose of mAb316P 150mg Q2W.

(5) Tracking:

After the end of the double-blind treatment period, or after the study treatment was discontinued early, the patients were followed for an 8-week period.

Throughout the study period:

Inform patients to continue taking their background lipid modulation therapy (LMT) (except EZE, statin, red yeast rice, and fibric acid [except fenofibrate]) throughout the study period.

From screening to the end of the treatment visit, the permitted LMT (if applicable) is stable (including dose), except for consideration of overturning approved changes (including, but not limited to, TG warnings reported by the central laboratory) Exceptions are based on the judgment of the researcher.

The longest study duration per patient is up to approximately 39 weeks (9 months): Screened to 1 week more; 2 weeks of clearance; 4 weeks of single-blind placebo trial; 24 weeks of double-blind treatment; and 8 weeks of follow-up. The end of the study is defined as the patient's last visit to the site, as planned for each procedure.

Patient screening

A sufficient number of patients were screened and recruited to the single-blind placebo trial period to ensure that at least 250 patients were eligible to be randomly assigned to the double-blind treatment period (100:100:50; mAb316P: EZE: Atorvastatin).

Study mother: The study mother consists of patients with hypercholesterolemia (heFH or non-FH) and moderate, high, or very high risk of CV who are intolerant to statin. Moderate CV risk is defined as the calculated 10-year fatal CVD risk SCORE ≥ 1% and <5% (ESC/EAS 2011). High CV risk is defined as the calculated 10-year fatal CVD risk SCORE ≧5% (ESC/EAS 2011), moderate chronic kidney disease (CKD), type 1 or type 2 diabetes but no target organ damage, or heFH. Extremely high CV risk is defined as documented CHD, ischemic stroke, peripheral arterial disease (PAD), transient ischemic stroke (TIA), abdominal aortic aneurysm, asymptomatic carotid artery occlusion>50%, carotid artery Endarterectomy or carotid artery stent procedure, renal artery stenosis, renal artery stent procedure, history of type 1 or type 2 diabetes with target organ damage.

A documented history of CHO is defined as one or more of the following: (i) acute MI; (ii) silent MI; (iii) unstable angina; (iv) coronary artery revascularization procedures (such as percutaneous coronary intervention) [PCI] or coronary artery bypass graft surgery [CABG]); and/or (v) clinically obvious CHD, through invasive or non-invasive tests (such as coronary angiography, treadmill stress test, stress heart Ultrasound or nuclear magnetic imaging).

Inclusion criteria: In order to be eligible for this study, patients must have primary hypercholesterolemia (heFH or non-FH), with moderate, high, or very high cardiovascular risk And history of statin intolerance.

Diagnose heFH by genotype or by clinical criteria. For patients who have not been genotyped, the clinical diagnosis must be a clear/exact diagnosis and based on Simon Broome requirements or WHO/Dutch Lipid Network requirements. Moderate, high and extremely high CV risks are as defined above.

Definition of statin intolerance: because of skeletal muscle-related symptoms (because of people other than sprains or trauma, such as pain, pain, weakness, or cramps, which started or increased during statin treatment and stopped when statin treatment was interrupted) Unable to tolerate at least two previous statins at the approved minimum daily dose.

Exclusion criteria: Exclude prospective patients who do not meet the following criteria (sub-categorized according to items A, B and C) from the study:

A. Exclusions related to research methodology:

1. Calculate serum LDL-C<70mg/dL (1.81mmol/L) and extremely high CV risk (as defined elsewhere in this article) during the screening visit (week-7);

2. Calculate serum LDL-C<100mg/dL (2.59mmol/L) and high or moderate CV risk (as defined elsewhere in this article) during the screening visit (week-7);

3. At the time of the screening visit (week -7), the 10-year lethal CVD risk SCORE<1%;

4. Use of statin at or above the approved minimum daily dose within 4 weeks before the screening visit (week -7):

5. During the 4-week single-blind placebo trial, they felt their skeletal muscle-related adverse events (AE) other than sprains or trauma;

6. At the screening visit (week -7), the start of the single-blind placebo trial period (week-4), or day 1/week 0, I felt that they had AEs related to skeletal muscle other than sprains or trauma ；

7. Before the screening visit (week -7) or from screening to random assignment (if appropriate), No fixed-dose lipid modulation therapy (LMT) for at least 4 weeks and/or fenofibrate for at least 6 weeks;

8. Use fibric acid other than fenofibrate within 6 weeks of the screening visit (week -7);

9. Before the screening visit (week-7) or between the screening and random assignment visits, use nutritional products or over-the-counter medications that are known to affect lipids for at least 4 weeks, which is not necessarily a fixed dose/quantity;

10. Use red yeast rice products from the screening visit (week -7) to the end of the research visit (week 32);

11. From the screening visit to the end of the study visit (the 32nd week), the dose is not planned to be a stable analgesic;

12. Diagnosed as fibromyalgia;

13. History of severe neuropathic pain;

14. A history of rheumatic disease (such as rheumatoid arthritis) related to symptoms that may confuse symptoms of statin intolerance;

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

16. A history of known convulsions;

17. Previous medical history of transplantation;

18. Use drugs that need to be administered intramuscularly during the study period, or planned to be injected intramuscularly;

19. Known history of myopathy other than statin-related myopathy;

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

21. There are any clinically significant uncontrolled endocrine diseases that are known to affect serum lipids or lipoproteins. [Note: If the dose of thyroxine is stable before screening For at least 12 weeks and the amount of thyroid stimulating hormone (TSH) is within the normal range of the central laboratory at the time of the screening visit (week -7), patients who are undergoing thyroid replacement therapy are allowed to be included];

22. Have a history of bariatric surgery within 12 months before the screening visit (week -7);

23. Unstable weight (change> 5kg) in the 2 months before the screening visit (week -7);

24. A known medical history of PCSK9 loss of function (such as genetic mutation or sequence variation);

25. Known homozygous FH history;

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

27. Use systemic corticosteroids, unless used as a replacement therapy for pituitary/adrenal disease, a stable regimen that lasts at least 6 weeks before randomization. Note: topical, intra-articular, intranasal, inhalation and ophthalmic steroid therapy are not considered "systemic" and are permitted;

28. Use estrogen or testosterone therapy, unless the program has been stable in the 6 weeks prior to the screening visit (week -7) and there is no plan to change the program during the study period;

29. Medical history of plasmapheresis treatment within 2 months prior to the screening visit (week -7), or plans to undergo plasmapheresis during the study period;

30. Systolic blood pressure> 160mm Hg or diastolic blood pressure> 100mm Hg at the screening visit (week -7) or random assignment (week 0/day 1);

31. Myocardial infarction (MI), unstable angina causing hospitalization, coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI) within 3 months before the screening visit (week -7) ), poorly controlled arrhythmia, carotid artery surgery or stent surgery, stroke, temporary ischemic stroke, carotid artery revascularization, peripheral vascular disease History of intravascular procedures or surgical intervention;

32. Patients currently participating in rehabilitation or exercise courses

33. New York Heart Association heart failure category III or IV medical history in the past 12 months;

34. The age at the screening visit (week-7) is <18 years old or the legal age of an adult, whichever is older;

35. Patients who were not instructed to take a cholesterol-lowering diet before the screening visit (week-7);

36. Known history of hemorrhagic stroke;

37. Cancer history in the past 5 years, except for properly treated basal cell skin cancer, squamous cell skin cancer or cervical cancer in situ;

38. Known HIV-positive medical history;

39. In addition to taking any active study drug within 1 month or 5 half-lives, whichever is longer;

40. Participate in any clinical trials of mAb316P (rilobomab) or any other anti-PCSK9 monoclonal antibody;

41. Circumstances/situations such as the following: (A) Any clinically significant abnormality identified during screening, which, under the judgment of the researcher or any agent researcher, will hinder the safe completion of the research or limit such as serious systemic diseases The patient’s life expectancy is short; (B) the researcher or any acting researcher believes that the research is inappropriate for any reason, for example: (i) is deemed unable to meet certain procedural conditions, such as planned visits (Ii) According to the patient or researcher who is deemed unable to administer or tolerate long-term injections; (iii) the researcher or any agent researcher, pharmacist, research coordinator, other research staff or others who are directly involved in the implementation of the procedure Relevant persons, etc.; (iv) There are any other circumstances (such as geographic, social), actual or expected, that the researcher believes will restrict or restrict the patient's participation in the research period;

42. Laboratory research results during the screening period (excluding randomly assigned laboratories): (A) Hepatitis B surface antigen and/or hepatitis C antibody test was positive; (B) In women who might become pregnant, serum β- hCG or urine pregnancy test is positive; (C) TG>400mg/dL (>3.95mmol/L) (allow the laboratory to repeat once); (D) eGFR<30mL/min/1.73 m2, based on 4-variable MDRD Research equation (calculated by the central laboratory); (E) alanine aminotransferase (ALT) or aspartate aminotransferase (AST)>3 x upper limit of normal (ULN) (allowing the laboratory to repeat 1 Times); (F)CPK>2 x ULN; (G)TSH<lower limit of normal (LLN) of the central laboratory or>ULN; (H) vitamin D3<20ng/mL[50nmol/L];

B: Exclusions related to active comparators or other investigational drugs:

43. All contraindications or warnings/earnings (if any) of other investigational drugs (atorvastatin and EZE) displayed on individual national product labels;

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

44. Known allergy to monoclonal antibody therapeutics;

45. Women who are pregnant or breastfeeding;

46. Women who are likely to become pregnant without effective methods of birth control and/or unwilling or unable to have a pregnancy test.

Patients who discontinue the study prematurely will not be replaced.

Research treatment

The study treatment was a single subcutaneous (SC) injection of mAb316P or placebo at a dose of 75 mg or 150 mg in 1 mL in an auto-injector, administered to the outer area of the abdomen, thigh, or upper arm. During the double-blind treatment period (weeks 0-24), eligible patients were randomly assigned to receive: (1) once every two weeks (Q2W) mAb316P 75mg SC + once a day (PO QD) ezetimibe (EZE) )/Placebo of atorvastatin; or (2) placebo SC Q2W of EZE 10mg PO QD+mAb316P; or (3) atorvastat Placebo SC Q2W with 20mg PO QD+mAb316P.

Ezetimibe 10 mg and atorvastatin 20 mg are completely encapsulated in capsules to match the placebo of EZE/atorvastatin to ensure double blindness. Ezetimibe 10mg, atorvastatin 20mg and placebo are indistinguishable from each other. The study drug was administered by SC injection Q2W, starting at week 0 and continuing up to the last injection (week 22), 2 weeks before the end of the double-blind treatment period.

After the patients were randomly assigned to the study, the first double-blind study drug injection was administered at the clinic site as soon as possible. The patient was observed at the clinic site for 30 minutes after the first injection. The patient/caregiver administers follow-up injections outside the clinic according to the dosing schedule. On the same day as the clinical study visit and dosing, the dose of the study drug is administered after all study evaluations have been performed and all laboratory samples have been collected.

Ideally, study drug Q2W SC should be administered at approximately the same time of the day; however, a window period of ±3 days is considered acceptable. The time of day is based on the patient's preference.

In the event that an injection is delayed for more than 7 days or is completely missed, the patient is instructed to return the original schedule of study drug administration without administering additional injections. If the delay is less than or equal to 7 days relative to the missing date, the patient is instructed to administer the delayed injection and then continue the original dosing schedule. Allow the patient to choose to have the research site staff administer the injection and return to site Q2W for their injection. Take placebo of EZE/atorvastatin, EZE 10mg or atorvastatin 20mg capsules once a day. Detailed guidelines on transportation, storage, preparation, and administration of study drugs will be provided to patients/caregivers at the site.

Dose adjustment ("up adjustment option")

At the 12th week visit, based on the patient's LDL-C and baseline CV risk (defined elsewhere in this article) at the 8th week of the patient, continue to receive mAb316P 75mg Q2W or increase the dose as follows:

70mg/dL(1.81mmol/L)，則自第12週直到第22週最後一次注射接受上調至mAb316P 150mg Q2W的劑量。 (A) Patients with a very high risk of CV without knowing it: (1) If their LDL-C in the 8th week is <70mg/dL (1.81mmol/L), then from the 12th week to the end of the 22nd week One injection continues to receive mAb316P 75mg Q2W; or (2) If its LDL-C in the 8th week is

70mg/dL (1.81mmol/L), from the 12th week until the 22nd week the last injection received the dose up-regulated to mAb316P 150mg Q2W.

100mg/dL(2.59mmol/L)，則第12週直到第22週最後一次注射接受上調至mAb316P 150mg Q2W的劑量。 (B) Patients with high or moderate risk of CV without knowing it: (1) If their LDL-C in the 8th week is <100mg/dL (2.59mmol/L), from the 12th week to the 22nd week Continue to receive mAb316P 75mg Q2W at the last injection of the week; or (2) If the LDL-C at week 8 is

100mg/dL (2.59mmol/L), the 12th week until the last injection of the 22nd week will receive an up-regulated dose of mAb316P 150mg Q2W.

Injection training

During the first planned visit of the single-blind placebo trial period (in week -4), the patient was instructed to administer the study drug using a placebo-containing single-blind auto-injector containing mAb316P and self-administer the first at the clinic Doses. During the single-blind placebo trial period, the patient or caregiver used a second single-blind auto-injector containing mAb316P at home to administer the second dose of the study drug.

The first injection during the double-blind treatment period is on the day of random assignment (Week 0 [Day 1]-Visit 4) and as soon as possible after being randomly assigned to the study, using the automatic set that was randomly assigned to the patient The syringe is administered at the site. The subsequent injections are administered by the patient (self-injection) or by the designated caregiver, or the patient chooses to return to the site Q2W for the research staff to administer the injection. The research staff trains all patients and caregivers who are scheduled to inject the study drug before administering the injection.

Research treatment

The sterile mAb316P drug is supplied at a concentration of 75 mg/mL or 150 mg/mL in histidine, pH 6.0, polysorbate 20 and sucrose in an auto-injector. In the same formulation as mAb316P, but without adding protein to the auto-injector, a placebo matched to mAb316P is provided. Ezetimibe 10mg and atorvastatin 20mg are completely encapsulated in capsules to match the placebo of EZE/atorvastatin to ensure Double blind. Ezetimibe 10mg, atorvastatin 20mg and placebo are indistinguishable from each other.

Background treatment

The patient needs stable LMT for at least 4 weeks (fenofibrate for 6 weeks) before the screening visit (week-7). Instruct patients to continue taking their background LMT (except EZE, statin, red yeast rice and fibric acid [except fenofibrate]) throughout the study. The lipid profile value of the sample obtained after random assignment is unaware. The patient's background LMT did not change from the screening visit (week -7) to the end of the study visit (week 32). During this period of time, no dose adjustment, interruption or start of other LMT (including prohibited LMT), except for the consideration of overturning such approved changes, is based on the judgment of the researcher.

In summary, the background LMT has not been adjusted from screening to follow-up visits. Other background treatments allowed in the study include: bile acid-binding chelating agents (such as cholestyramine, colestipol, colesevelam); niacin; fenofibrate; and omega-3 fatty acids (≧1000 mg per day ).

Random dispatch

Using block arrangement randomization, patients were randomly assigned at a ratio of 2:2:1 to receive mAb316P, EZE, or atorvastatin during the double-blind study treatment period. Random assignment is stratified based on a documented history of MI or ischemic stroke [with/without].

Blindness

Single-blind placebo trial. Regarding the single-blind placebo trial and based on the single-blind design, only study patients remain ignorant of the treatment; the researchers are not ignorant of the study treatment. A placebo of mAb316P was provided in the autoinjector. The oral placebo of EZE/atorvastatin is provided in capsules to maintain blindness.

Double-blind treatment period. Regarding the double-blind treatment period, a placebo of mAb316P and mAb316P was provided with a matching auto-injector with the same packaging and label to maintain blindness. Ezetimibe and atorvastatin are completely encapsulated in capsules to interact with EXE/atorvastatin. The placebo of the statin matches to ensure double blindness. Ezetimibe 10mg, atorvastatin 20mg and placebo are indistinguishable from each other.

Each double-blind treatment kit is marked with a number, which is generated by a computer program. The treatment kit number is obtained by the researcher during the random assignment of patients planned by the central treatment distribution system and subsequent patient visits. It is 24 hours a day, seven days a week.

According to the double-blind design, except for certain circumstances, study patients, researchers, and study site staff remain unaware of the study treatment and cannot obtain random assignment (treatment code).

The lipid parameter values of blood samples obtained after random assignment visits were analyzed by the central laboratory, and they were not transmitted by the site so that they could not infer the treatment group of their patients based on the amount of LDL-C obtained. The event team of the organizer cannot obtain lipid parameters after random assignment and until the final data is locked. In the case that the patient meets the requirements for the increase, the site and the organizer's event team are unaware of the increase in the dose from 75mg to 150mg. Use a blind study drug kit coded by a drug numbering system. In order to maintain blindness, individuals participating in the study cannot obtain a list linking these codes to product batch numbers.

Anti-drug antibody (ADA) results will not be transmitted to the site and the organizer's event team cannot obtain results related to patient identification until the final database is locked. Patients with an anti-mAb316 antibody titer of 240 or more at the follow-up visit should obtain additional antibody samples 6 to 12 months after the last dose, and then approximately every 3 to 6 months until the titer returns below 240. In order to maintain research blindness, patients with titer less than 240 are required to collect post-study anti-mAb316P antibody samples during follow-up visits.

Concomitant medications

If it is deemed necessary for the welfare of the patient and unlikely to interfere with the study drug, concomitant medications (other than those who are prohibited during the study period) are allowed under the consideration of the researcher It is given at a stable dose (if possible). If appropriate, allow and record any other concomitant medications (etc.).

Only when nutritional products or over-the-counter medications that may affect lipids are used at a stable dose for at least 4 weeks before the screening visit (week -7) and maintained from the screening visit until the end of the study (week 32) Use them. Examples of such nutraceuticals or over-the-counter medications include: omega-3 fatty acids, plant sterols (such as those found in benzofuranol, linseed oil, and psyllium seeds) at a dose of <1000 mg.

Combination medications prohibited from the initial screening visit to the follow-up visit include the following: statin; fibric acid, other than fenofibrate; EZE; and red yeast rice products.

Research evaluation index

Baseline characteristics include standard demographics (such as age, race, weight, height, etc.), disease characteristics include medical history, and medication history of each patient. Collect historical information about statin diagnosed as "intolerance to statin", dosage, and actual skeletal muscle-related events as part of the medical/surgical history.

Main efficacy evaluation index: The main efficacy evaluation index is to calculate the percentage change of LDL-C from the baseline to the 24th week, which is defined as: 100x (calculated LDL-C value at the 24th week-calculated LDL-C value at the baseline )/Calculated LDL-C value at baseline. The baseline LDL-C value is necessary for each patient, because the baseline calculated LDL-C value is the last LDL-C amount obtained before the first double-blind study drug injection.

The LDL-C calculated at week 24 is the amount of LDL-C obtained in the analysis window at week 24 and during the main efficacy period. The main efficacy period is defined as the time from the first double-blind study drug injection to at most 21 days after the last double-blind study drug injection or up to the upper limit of the analysis window at week 24 (whichever comes first).

According to the above definition, if appropriate, all calculated LDL-C values (planned or unplanned, fasting or non-fasting) are used to provide the value of the main efficacy evaluation index. Used to The analysis window that assigns time points to the measurement is defined in the statistical analysis plan (SAP).

Secondary effectiveness evaluation indicators: The secondary evaluation indicators of this study include the following:

(1) Calculate the percentage change of LDL-C from baseline to week 12: The calculated LDL-C at week 12 is the amount of LDL-C obtained within the analysis window of week 12 and during the 12-week potency period. The 12-week potency period is defined as the time from the first double-blind study drug injection to the sixth visit contact or the last double-blind study drug injection up to 21 days, whichever comes first.

(2) The percentage change of ApoB from baseline to week 24.

(3) The percentage change of non-HDL-C from baseline to week 24.

(4) The percentage change of total -C from baseline to week 24.

(5) The percentage change of ApoB from baseline to week 12.

(6) The percentage change of non-HDL-C from baseline to week 12.

(7) The percentage change of total -C from baseline to week 12.

(8) The proportion of patients who reached the LDL-C target at week 24; for example, the risk of extremely high CV is LDL-C<70mg/dL (1.81mmol/L), or the risk of moderate or high CV is LDL-C< 100mg/dL (2.59mmol/L), defined as: (the number of patients whose calculated LDL-C value reached the LDL-C target at week 24/the number of patients in the modified intention-to-treat [mITT] mother)* 100. Use the definitions and regulations used in the main evaluation indicators.

(9) The proportion of patients with LDL-C<70mg/dL (1.81mmol/L) in the 24th week.

(10) The percentage change of Lp(a) from baseline to week 24.

(11) The percentage change of HDL-C from baseline to week 24.

(12) The percentage change of HDL-C from baseline to week 12.

(13) The percentage change of Lp(a) from baseline to week 12.

(14) The percentage change of fasting TG from baseline to week 24.

(15) The percentage change of fasting TG from baseline to week 12.

(16) The percentage change of ApoA-1 from baseline to week 24.

(17) The percentage change of ApoA-1 from baseline to week 12.

(18) The proportion of patients who reached the LDL-C target in the 12th week; for example, the risk of extremely high CV is LDL-C<70mg/dL (1.81mmol/L), and the risk of moderate or high CV is LDL-C<100mg/ dL (2.59mmol/L), defined as: (the number of patients whose calculated LDL-C value reached the LDL-C target at the 12th week/the number of patients in the modified mITT mother)*100.

(19) The proportion of patients with LDL-C<100mg/dL (2.59mmol/L) in the 24th week.

(20) The proportion of patients with LDL-C<100mg/dL (2.59mmol/L) in the 12th week.

(21) The proportion of patients with LDL-C<70mg/dL (1.81mmol/L) in the 12th week.

(22) Calculated absolute change of LDL-C (mg/dL and mmol/L) from baseline to week 12 and week 24.

(23) Changes in the ratio of ApoB/ApoA-1 from baseline to week 12 and week 24.

(24) The proportion of patients with ApoB<80mg/dL (0.8mmol/L) in the 12th and 24th weeks.

(25) The proportion of patients with non-HDL-C<100mg/dL in the 12th and 24th weeks.

(26) Calculate LDL-C<70mg/dL(1.81mmol/L) and/or calculate LDL-C decrease ≧50% in the 12th and 24th weeks (if calculating LDL-C≧70mg/dL[1.81mmol/ L]) the proportion of patients.

Other evaluation indicators: (1) Anti-mAb316P anti-drug-antibody status (positive/negative) and titer evaluated throughout the study; (2) High sensitivity C-reactive protein (hs-CRP) relative to the baseline to the first Percentage change at 24 weeks; (3) HbA1c relative to baseline to the first Absolute change in 24 weeks (%).

Research procedure

Collect all laboratory samples before administering the dose of study drug. In the morning on an empty stomach (eg overnight, fasting for at least 10 hours with no smoking), blood samples for the lipid group were collected for all clinical visits. Drinking alcohol is prohibited within 48 hours before blood sampling and strenuous exercise is prohibited within 24 hours before blood sampling. Note: If the patient is not on an empty stomach, no blood samples will be collected and a new appointment one day after the plan (or as close as possible to this date) reminds that blood samples must be taken on an empty stomach (at least 10 hours).

The central laboratory directly measures total-C, HDL-C, TG, ApoB, ApoA-1 and Lp(a) in accordance with a predetermined schedule. The Friedewald formula was used to calculate LDL cholesterol at all visits (except week-15 and follow-up visits). If the TG value exceeds 400mg/dL (4.52mmol/L), the central laboratory (via Beta quantification) measures instead of calculating LDL-C. Calculate non-HDL-C by subtracting HDL-C from total-C. Calculate the ratio of ApoB/ApoA-1.

Lipid group (fasting): Collect blood samples of the lipid group (total-C, TG, HDL-C, and calculated LDL-C) at a predetermined time point after an empty stomach for at least 10 hours.

Characteristic lipid group (fasting): Collect blood samples of characteristic lipid group (ApoB, ApoA-1, ApoB/ApoA-1 ratio, and Lp[a]) at a predetermined time point after an empty stomach for at least 10 hours.

Blood pressure and heart rate: Evaluate blood pressure and heart rate at a predetermined time point. About the same time of the day, use the same device on the same arm to measure blood pressure in a sitting position under standardized conditions (after the patient rests comfortably in a sitting position for at least 5 minutes). At the first screening visit, the BP of both arms should be recorded. At this visit, the arm with the highest diastolic blood pressure was determined, and blood pressure was measured on this arm during the entire study period. Record the highest value in the electronic medical record report form (e-CRF). Measure heart rate while measuring blood pressure.

Physical examination: Perform a thorough and complete physical examination during the screening visit (Visit 1), including height and weight. A physical examination together with body weight is performed at a predetermined time point.

Weight and height: The weight is obtained with the patient wearing underwear or very light clothing without shoes and emptying the bladder. It is better to use the same scale throughout the study. If possible, it is recommended to use a calibrated balance scale.

Electrocardiogram: During a visit that requires blood draw, an electrocardiogram is taken before blood draw. A standard 12-pole conduction ECG was performed at a predetermined time point. The 12-pole ECG is performed in the supine position after resting for at least 10 minutes. Throughout the study, the electrodes were positioned in the same place as much as possible for each ECG recording. The ECG is interpreted on-site by researchers. Compare and filter the record traces to analyze each trace.

Laboratory testing: Collect all laboratory samples before the administration of the study drug. The laboratory test samples are collected at predetermined time points and analyzed by the central laboratory during the research period.

result

Individual traits

This study screened a total of 519 patients, of which 361 (69.6%) patients completed the screening and entered the single-blind placebo trial period. Of those patients who entered the single-blind placebo trial period, 47 (13%) patients discontinued placebo treatment early, and 29 (8%) patients discontinued due to skeletal muscle-related adverse events (that is, meeting the specified exclusion criteria). Therefore, 314 patients (87%) completed the trial period and were eligible to be randomly assigned to the double-blind period.

A total of 314 patients were randomly assigned (63 to the atorvastatin group, 125 to the ezetimibe group, and 126 to the mAb316P group), of which a single patient in the ezetimibe group was randomly assigned but because Did not receive research treatment for "other" reasons (due to the consideration of procedural visits required for the plan). Therefore, the safe mother contains 313 patients. This patient did not come back for any evaluation afterwards, and was therefore not included in the ITT mother. this In addition, 3 patients were excluded from the ITT mother, 1 (Ezetimibe group) lacked baseline LDL-C values and the other 2 (1 in the atorvastatin group and 1 in the ezetimibe group) ) Because of the lack of post-baseline evaluation. Finally, another 9 patients (2 in the atorvastatin group, 4 in the ezetimibe group, and 3 in the mAb316P group) were excluded from the mITT mother because of the lack of on-treatment post-baseline assessment.

As the data cut-off value for the first stage, the patient status during the study period is as follows:

220 (70.1%) patients completed the 24-week double-blind treatment period: 42 (66.7%) in the atorvastatin group, 82 (65.6%) in the ezetimibe group, and 96 (76.2%) in the mAb316P group.

Ninety-three (29.6%) patients discontinued study treatment early before completing the double-blind treatment period: 21 (33.3%) in the atorvastatin group, 42 (33.6%) in the ezetimibe group, and 30 (23.8) in the mAb316P group %). Seventy (22.3%) patients discontinued the study treatment early due to adverse events: 16 (25.4%) in the atorvastatin group, 31 (24.8%) in the ezetimibe group, and 23 (18.3%) in the mAb316P group. Two patients (3.2%) terminated the study treatment early due to poor protocol compliance, and both patients were in the atorvastatin group. Twenty-one (6.7%) patients discontinued study treatment early due to various other reasons: 3 (4.8%) in the atorvastatin group, 11 (8.8%) in the ezetimibe group, and 7 (5.6%) in the mAb316P group .

281 (89.5%) patients were administered at least one open mAb316P treatment and were therefore included in the OLE mother.

Nine (3.2%) patients discontinued study treatment during the OLE phase as the cut-off value of this KRM data, and 8 of these patients (2.8%) discontinued due to adverse events.

The remaining 272 (96.8%) patients from the OLE mother were continued and received study treatment during the OLE phase.

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

Table 10. Baseline characteristics

The baseline lipid parameters are summarized in Table 11.

Effect result

87.0% (314/361) patients completed the placebo trial. In general, demographic characteristics, baseline disease characteristics, statin intolerance questionnaires, baseline efficacy lipid parameters, LMT history, and background LMT use were comparable in each of the three study treatment groups randomly assigned. Fifteen percent of patients have heterozygous FH. The average baseline LDL-C was 187.3 mg/dL in the atorvastatin group, 194.2 mg/dL in the ezetimibe group, and 191.1 mg/dL in the mAb316P group. A total of 89.5% of randomly assigned patients entered the open extension period.

According to the statistics specified in the above procedure (where the multi-test control is 0.05 significant level) Table 12 lists the analysis results of the double-blind period effectiveness evaluation indicators that count the level of test magnitude. Primary and important secondary efficacy analyses were performed to compare patients treated with mAb316P and patients treated with ezetimibe. For the sake of clarity, ITT analysis is to define and include all the evaluation index estimates in the analysis window for the patients in the ITT mother, and has nothing to do with the study treatment administration status (that is, including post-treatment estimates). The on-treatment analysis is defined for the patients of the mITT mother and includes the first double-blind study drug (capsule or injection, whichever comes first) up to 21 days after the last double-blind study drug injection, or after the last capsule administration 3 All evaluation index estimates for days (see whichever comes first) (that is, including estimates during the effective treatment period). Note: If the p value is less than or equal to 0.05, the result is statistically significant on the level of the class test.

For patients treated with mAb316P, the LS average LDL-C value at week 24 was 108.5 mg/dL, which means that the amount of LDL-C changed from baseline to -84 mg/dL (that is, -45.0%). In contrast, patients treated with EZE had an LS average LDL-C value of 159.9 mg/dL at week 24, which means that the amount of LDL-C changed from baseline to -33 mg/dL (that is, -14.6%). For patients treated with mAb316P and patients treated with ezetimibe, the average% difference in LS at week 24 of LDL-C was -30.4% (SE=3.1, p<0.0001).

Fifty-two mAb316P patients (41.9%) reached the LDL-C target at week 24, while only 5 EZE patients (4.4%) reached the LDL-C target at week 24 (p value <0.0001). For the purpose of this analysis, the LDL-C target is defined as less than 70 mg/dL for extremely high-risk patients and less than 100 mg/dL for intermediate and high-risk patients. In addition, 54/109 mAb316P patients (49.5%) increased from 75mg Q2W to 150mg Q2W at week 12 (based on LDL-volume at week 8).

A summary of the decrease in selected secondary lipid parameters (non-HDL-C, ApoB, and Lp(a)) at week 24 is shown in Table 13.

According to the class test procedure, the primary efficacy evaluation index and more than two-thirds of the important and secondary efficacy evaluation indexes achieve statistically significant benefits in favor of patients treated with mAb316P.

Safety results

A total of 313 patients were randomly assigned and received at least one incomplete dose of double-blind study treatment (safe maternal), and 281 patients received OLE study treatment (OLE Maternal). Treatment SAEs occurred in a total of 29 patients. Specifically, 7 (11.1%) patients were in the atorvastatin treatment group, 10 (8.1%) patients were in the ezetimibe treatment group, and 12 ( 9.5%) patients were in the mAb316P treatment group. In any case, no event in each of the three treatment groups had more than 1 report. With the exception of a single exception, 4 (3.2%) patients in the ezetimibe group reported non-cardiac chest pain.

A total of 70 (22.4%) patients discontinued the study treatment early due to TEAE. Specifically, 16 (25.4%) patients in the atorvastatin treatment group, 31 (25.0%) patients in the ezetimibe treatment group, and 23 (18.3%) patients in the mAb316P treatment group terminated the study treatment early. The most common events leading to premature termination included skeletal muscle and connective tissue disorders SOC (14 patients in the atorvastatin group [22.2%], 26 patients in the ezetimibe group [21.0%], and 20 patients in the mAb316P group [15.9%] ] Patients), of which myalgia is most often reported.

No patient deaths were reported during the transition analysis.

5%的患者中所發生的TEAE為-鼻咽炎(阿托伐他汀/依折麥布/mAb316P分別為3.2%/8.1%/6.3%)；上呼吸道感染(阿托伐他汀/依折麥布/mAb316P分別為3.2%/4.0%/5.6%)；頭痛(阿托伐他汀/依折麥布/mAb316P分別為6.3%/4.8%/4.8%)；感覺異常(阿托伐他汀/依折麥布/mAb316P分別為6.3%/0/3.2%)；關節痛(阿托伐他汀/依折麥布/mAb316P分別為7.9%/7.3%/5.6%)；背痛(阿托伐他汀/依折麥布/mAb316P分別為7.9%/5.6%/4.0%)；肌肉痙攣(阿托伐他汀/依折麥布/mAb316P分別為11.1%/7.3%/4.0%)；肌肉虛弱(阿托伐他汀/依折麥布/mAb316P分別為6.3%/1.6%/0.8%)；肌痛(阿托伐他汀/依折麥布/mAb316P分別為27%/23.4%/24.6%)；以及疲倦(阿托伐他汀/依折麥布/mAb316P分 別為7.9%/3.2%/4.8%)。 54 (85.7%) patients in the atorvastatin treatment group, 100 (80.6%) patients in the ezetimibe treatment group, and 104 (82.5%) patients in the mAb316P treatment group had TEAEs. In any treatment group

The TEAE that occurred in 5% of patients was nasopharyngitis (3.2%/8.1%/6.3% for atorvastatin/ezetimibe/mAb316P, respectively); upper respiratory tract infection (atorvastatin/ezetimibe /mAb316P were 3.2%/4.0%/5.6%); headache (atorvastatin/ezetimibe/mAb316P were 6.3%/4.8%/4.8%, respectively); paresthesia (atorvastatin/ezetimibe) Cloth/mAb316P are 6.3%/0/3.2% respectively); arthralgia (atorvastatin/ezetimibe/mAb316P are 7.9%/7.3%/5.6% respectively); back pain (atorvastatin/ezet Maibu/mAb316P were 7.9%/5.6%/4.0%); muscle cramps (atorvastatin/ezetimibe/mAb316P were 11.1%/7.3%/4.0%, respectively); muscle weakness (atorvastatin/ Ezetimibe/mAb316P is 6.3%/1.6%/0.8%, respectively); myalgia (atorvastatin/Ezetimibe/mAb316P is 27%/23.4%/24.6%, respectively); and tiredness (atorva Statins/Ezetimibe/mAb316P were 7.9%/3.2%/4.8% respectively).

5%，且當相比於阿托伐他汀治療組與EZE治療組時在mAb316P組中頻率更高：”精神病症”在mAb316P治療組為9名(7.1%)患者，相對在阿托伐他汀組為2名(3.2%)患者而在EZE治療組為5名(4.0%)患者。最常見的事件為：報導為失眠，發生在mAb316P治療組中為5件(4.0%)，相對於在阿托伐他汀治療組為1件(1.6%)相對在依折麥布治療組為2件(1.6%)。”耳與迷路病症”在mAb316P治療組為8名(6.3%)患者，相對在阿托伐他汀治療組為1名(1.6%)，在EZE治療組為4名(3.2%)患者。最常見事件為暈眩，在mAb316P治療組報導6件(4.8%)，相對在阿托伐他汀治療組為1件(1.6%)，此在依折麥布治療組為2件(1.6%)。”心臟病症”發生在mAb316P治療組為10名(7.9%)患者，相對在阿托伐他汀治療組為2名(3.2%)患者而在EZE治療組為6名(4.8%)患者。最常見事件為心悸，在mAb316P治療組報導4件(3.2%)，相對在阿托伐他汀治療組為0，相對在依折麥布治療組為2件(1.6%)報導。”調查”發生在mAb316P治療組中為9名(7.1%)患者，相對在阿托伐他汀治療組為3名(4.8%)患者而在EZE治療組為7名(5.6%)患者。在阿托伐他汀治療組與EZE治療組中，比mAb316P治療組頻率更高的單一SOC為骨骼肌與結締組織病症。 The frequency of SOC patients in the mAb316P group is

5%, and when compared to the atorvastatin treatment group and the EZE treatment group, the frequency was higher in the mAb316P group: "psychiatric disorders" were 9 (7.1%) patients in the mAb316P treatment group, compared to atorvastatin There were 2 (3.2%) patients in the EZE group and 5 (4.0%) patients in the EZE treatment group. The most common events were reported as insomnia, which occurred in 5 cases (4.0%) in the mAb316P treatment group, compared to 1 case (1.6%) in the atorvastatin treatment group, and 2 cases in the ezetimibe treatment group Pieces (1.6%). "Ear and labyrinth disorders" were 8 (6.3%) patients in the mAb316P treatment group, compared to 1 (1.6%) in the atorvastatin treatment group, and 4 (3.2%) patients in the EZE treatment group. The most common event was dizziness. 6 cases (4.8%) were reported in the mAb316P treatment group, compared with 1 case (1.6%) in the atorvastatin treatment group, and 2 cases (1.6%) in the ezetimibe treatment group. . "Cardiac disorders" occurred in 10 (7.9%) patients in the mAb316P treatment group, compared to 2 (3.2%) patients in the atorvastatin treatment group and 6 (4.8%) patients in the EZE treatment group. The most common event was palpitations, with 4 cases (3.2%) reported in the mAb316P treatment group, 0 cases in the atorvastatin treatment group, and 2 cases (1.6%) reported in the ezetimibe treatment group. The "survey" occurred in 9 (7.1%) patients in the mAb316P treatment group, compared to 3 (4.8%) patients in the atorvastatin treatment group and 7 (5.6%) patients in the EZE treatment group. In the atorvastatin treatment group and the EZE treatment group, the single SOC that was more frequent than the mAb316P treatment group was skeletal muscle and connective tissue disorders.

Regarding TEAEs of special interest (AESI), the results are indicated by priority grouping according to the previously defined SMQ or CMQ: The injection site reaction (ISR) of the treatment occurred in 1 (1.6%) patient in the atorvastatin treatment group. There were 6 (4.8%) patients in the ezetimibe treatment group, and 6 (4.8%) patients in the mAb316P treatment group. General allergic TEAE, as defined by the "allergic" MedDRA SMQ, occurred in 4 (6.3%) patients in the atorvastatin treatment group and 9 (7.3%) patients in the ezetimibe treatment group. In the mAb316P treatment group, there were 12 (9.5%) patients. Healing the God of Emergence According to the study AE, there were 8 (12.7%) patients in the atorvastatin treatment group, 4 (3.2%) patients in the ezetimibe treatment group, and 11 (8.7%) patients in the mAb316P treatment group . The most common are paresthesias (6.3%/0/3.2% for atorvastatin/ezetimibe/mAb316P, respectively), and muscle weakness (6.3%/1.6% for atorvastatin/ezetimibe/mAb316P, respectively %/0.8%). Neurocognitive disorders that occurred during treatment occurred in 0 patients in the atorvastatin treatment group, 2 (1.6%) patients in the ezetimibe treatment group, and 3 (2.4%) patients in the mAb316P treatment group patient.

Regarding the patients identified as cardiovascular events, one (0.8%) patient was definitely determined to be non-fatal MI, and this patient was in the mAb316P treatment group.

Regarding the frequency of 2 consecutive LDL-C measurements of less than 25 mg/dL, none of the patients in the three treatment groups occurred.

This study defined skeletal muscle-related TEAE twice, especially for those CRFs related to skeletal muscle and the events collected by CMQ (as defined in the program appendix). A total of 99 (31.6%) patients reported CMQ priority, specifically 25 (39.7%) patients in the atorvastatin treatment group, 40 (32.3%) patients in the ezetimibe treatment group, and There were 34 (27.0%) patients in the mAb316P treatment group. The most common CMQ-defined priorities that cause skeletal muscle-related events are myalgia (27%/23.4%/24.6% for atorvastatin/ezetimibe/mAb316P, respectively), muscle cramps (atorvastatin/ezetimibe/mAb316P, respectively). Zetimibe/mAb316P are 11.1%/7.3%/4.0%), and muscle weakness (atorvastatin/ezetimibe/mAb316P are 6.3%/1.6%/0.8%, respectively), all of which are incorporated into skeletal muscle and Connective tissue disorders SOC.

Reported in 55 (17.6%) patients the skeletal muscle-related events that led to the discontinuation of early treatment, specifically 13 (20.6%) patients in the atorvastatin treatment group and in the ezetimibe treatment group In the mAb316P treatment group, there were 23 (18.5%) patients and 19 (15.1%) patients in the mAb316P treatment group. No serious skeletal muscle-related events were reported in any treatment group. No reports of TEAE related to skeletal muscle in any treatment group The patient of the incident died.

in conclusion

This study evaluated patients with a history of intolerance to at least two different statins (including one at the lowest dose) due to muscle-related symptoms. Patients were randomly assigned to receive mAb316P, ezetimibe, or atorvastatin 20 mg (correction group). In this study, the treated patients had extremely high levels of LDL-C (average between 187-193.5 mg/dL) when they first entered the trial. In clinical practice, 10-25% of patients report intolerance to statin.

This study achieved the main efficacy evaluation indicators in the ITT maternal population. Compared with patients treated with ezetimibe (LS mean =-14.6%), in patients treated with mAb316P, the percentage of LDL-C relative to baseline was calculated There was a statistically significant decrease in the change (LS mean = -45.0%), and the mean LS difference between the treatment groups was -30.4%. Regarding more than two-thirds of important secondary efficacy evaluation indicators, this study achieved statistically significant benefits in patients treated with mAb316P compared to patients treated with ezetimibe. Based on the data available from this study, in patients with primary hypercholesterolemia (heFH and non-FH) who are intolerant to statin, subcutaneous administration of mAb316P is generally safe and well tolerated. The proportion of skeletal muscle-related AEs in patients treated with mAb316P was lower than in the control group, and this difference was judged to be statistically significant in patients treated with 20 mg atorvastatin (as per the first skeletal muscle Estimated by the time of AE, p=0.042). In addition, the dropout rate of skeletal muscle-related AEs in patients treated with mAb316P was lower than that of the two control groups. Similar AE rates were observed between all treatment groups in this study (mAb316 82.5%, ezetimibe 81%, atorvastatin 86%). The most common AEs are myalgia ((25% mAb316, 23% ezetimibe, 27% atorvastatin), nasopharyngitis (6% mAb316, 8% ezetimibe, 3% atorvastatin), Joint pain (6% mAb316, 7% ezetimibe, 8% atorvastatin), and upper respiratory tract infection (6% mAb316, 4% ezetimibe, 3% atorvastat).

The scope of the present invention is not limited by the specific examples described herein. In fact, various modifications of the present invention other than those described herein will become apparent to those skilled in the art from the foregoing description and drawings. These modifications fall within the scope of the attached patent application.

<110> Sanofi Company Regeneron Pharmaceutical Company

<120> Use of PCSK9 inhibitor for the treatment of hyperlipidemia

<140> 103135495

<141> 2014/10/13

<150> US 61/890,154, US 61/923,103, US 61/955,514, US 62/004,620, EP 14306221.4, US 62/025,104, US 62/054,571 and EP 14306584.5

<151> 2013/10/11, 2014/01/02, 2014/03/19, 2014/05/29, 2014/07/31, 2014/07/16, 2014/09/24 and 2014/10/09

<160> 198

<170> PatentIn Version 3.5

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<400> 21

<210> 22

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 22

<210> 23

<211> 3

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 23

<210> 24

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 24

<210> 25

<211> 8

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 25

<210> 26

<211> 8

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 26

<210> 27

<211> 20

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 27

<210> 28

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 28

<210> 29

<211> 3

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 29

<210> 30

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 30

<210> 31

<211> 8

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 31

<210> 32

<211> 8

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 32

<210> 33

<211> 20

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 33

<210> 34

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 34

<210> 35

<211> 3

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 35

<210> 36

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 36

<210> 37

<211> 131

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic VH; m2CX1D05 polypeptide

<400> 37

<210> 38

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR1; m2CX1D05 peptide

<400> 38

<210> 39

<211> 20

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR2; m2CX1D05 peptide

<400> 39

<210> 40

<211> 22

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR3; m2CX1D05 peptide

<400> 40

<210> 41

<211> 213

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic LC; m2CX1D05 polypeptide

<400> 41

<210> 42

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR 1; m2CX1D05 peptide

<400> 42

<210> 43

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR2; m2CX1D05 peptide

<400> 43

<210> 44

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR3; m2CX1D05 peptide

<400> 44

<210> 45

<211> 119

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic VH; 1B20 polypeptide

<400> 45

<210> 46

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR1; 1B20 peptide

<400> 46

<210> 47

<211> 20

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR2; 1B20 peptide

<400> 47

<210> 48

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VH CDR3; 1B20 peptide

<400> 48

<210> 49

<211> 220

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic LC; 1B20 polypeptide

<400> 49

<210> 50

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR1; 1B20 peptide

<400> 50

<210> 51

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR2; 1B20 peptide

<400> 51

<210> 52

<211> 8

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of VL CDR3; 1B20 peptide

<400> 52

<210> 53

<211> 120

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable species antibody region polypeptide

<400> 53

<210> 54

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX132 heavy chain CDR1 antibody region peptide

<400> 54

<210> 55

<211> 23

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX132 heavy chain CDR2 antibody region peptide

<400> 55

<210> 56

<211> 15

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX132 heavy chain CDR3 antibody peptide

<400> 56

<210> 57

<211> 108

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light antibody region polypeptide

<400> 57

<210> 58

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 and AX132 light chain CDR1 antibody peptides

<400> 58

<210> 59

<211> 13

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 and AX132 light chain CDR2 antibody peptides

<400> 59

<210> 60

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX132 & AX213 light chain CDR3 antibody peptide

<400> 60

<210> 61

<211> 120

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic variable heavy antibody region peptide

<400> 61

<210> 62

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 heavy chain CDR1 antibody region peptide

<400> 62

<210> 63

<211> 23

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 heavy chain CDR2 antibody region peptide

<400> 63

<210> 64

<211> 15

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 heavy chain CDR3 antibody region peptide

<400> 64

<210> 65

<211> 108

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light antibody region polypeptide

<400> 65

<210> 66

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 and AX132 light chain CDR1 antibody peptides

<400> 66

<210> 67

<211> 13

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX213 and AX132 light chain CDR2 antibody peptides

<400> 67

<210> 68

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX132 & AX213 light chain CDR3 antibody peptide

<400> 68

<210> 69

<211> 119

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX1 VH antibody sequence peptide

<400> 69

<210> 70

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 VH CDR1 antibody sequence peptide

<400> 70

<210> 71

<211> 23

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 VH CDR2 antibody sequence peptide

<400> 71

<210> 72

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 VH CDR3 antibody sequence peptide

<400> 72

<210> 73

<211> 109

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX1 VL antibody sequence peptide

<400> 73

<210> 74

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 VL CDR1 antibody sequence peptide

<400> 74

<210> 75

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 AX9 AX189 VL CDR2 antibody sequence peptide

<400> 75

<210> 76

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 VL CDR3 antibody sequence peptide

<400> 76

<210> 77

<211> 121

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX9 AX189 VH antibody sequence peptide

<400> 77

<210> 78

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX9 AX189 VH CDR1 antibody sequence peptide

<400> 78

<210> 79

<211> 23

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX9 AX189 VH CDR2 antibody sequence peptide

<400> 79

<210> 80

<211> 18

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX9 AX189 VH CDR3 antibody sequence peptide

<400> 80

<210> 81

<211> 109

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of AX189 VL antibody sequence peptide

<400> 81

<210> 82

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX189 VL CDR1 antibody sequence peptide

<400> 82

<210> 83

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX1 AX9 AX189 VL CDR2 antibody sequence peptide

<400> 83

<210> 84

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize AX189 VL CDR3 antibody sequence peptide

<400> 84

<210> 85

<211> 115

<212> PRT

<213> Wisdom

<400> 85

<210> 86

<211> 5

<212> PRT

<213> Wisdom

<400> 86

<210> 87

<211> 17

<212> PRT

<213> Wisdom

<400> 87

<210> 88

<211> 6

<212> PRT

<213> Wisdom

<400> 88

<210> 89

<211> 109

<212> PRT

<213> Wisdom

<400> 89

<210> 90

<211> 14

<212> PRT

<213> Wisdom

<400> 90

<210> 91

<211> 7

<212> PRT

<213> Wisdom

<400> 91

<210> 92

<211> 9

<212> PRT

<213> Wisdom

<400> 92

<210> 93

<211> 123

<212> PRT

<213> Wisdom

<400> 93

<210> 94

<211> 10

<212> PRT

<213> Wisdom

<400> 94

<210> 95

<211> 17

<212> PRT

<213> Wisdom

<400> 95

<210> 96

<211> 14

<212> PRT

<213> Wisdom

<400> 96

<210> 97

<211> 111

<212> PRT

<213> Wisdom

<400> 97

<210> 98

<211> 14

<212> PRT

<213> Wisdom

<400> 98

<210> 99

<211> 7

<212> PRT

<213> Wisdom

<400> 99

<210> 100

<211> 11

<212> PRT

<213> Wisdom

<400> 100

<210> 101

<211> 114

<212> PRT

<213> Wisdom

<400> 101

<210> 102

<211> 10

<212> PRT

<213> Wisdom

<400> 102

<210> 103

<211> 17

<212> PRT

<213> Wisdom

<400> 103

<210> 104

<211> 5

<212> PRT

<213> Wisdom

<400> 104

<210> 105

<211> 113

<212> PRT

<213> Wisdom

<400> 105

<210> 106

<211> 17

<212> PRT

<213> Wisdom

<400> 106

<210> 107

<211> 7

<212> PRT

<213> Wisdom

<400> 107

<210> 108

<211> 9

<212> PRT

<213> Wisdom

<400> 108

<210> 109

<211> 118

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic anti-PCSK9 monoclonal antibody pJG04 (selective strains LGT-209 and LGT-210) Vh heavy chain variable region (FR1-FR4) polypeptide

<400> 109

<210> 110

<211> 5

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize anti-PCSK9 monoclonal antibody clones LGT-209, LGT-210 and LGT-211 heavy chain CDR1 peptide

<400> 110

<210> 111

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: synthesis of anti-PCSK9 monoclonal antibody clones LGT-209, LGT-210 and LGT-211 heavy chain CDR2 peptides

<400> 111

<210> 112

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic anti-PCSK9 monoclonal antibody pJG04 (transgenic strain LGT-209 and LGT-210) Vh heavy chain complementarity determining region 3 (CDR3) peptide

<400> 112

<210> 113

<211> 106

<212> PRT

<213> Artificial sequence

<220>

<223> Description of the artificial sequence: synthetic anti-PCSK9 monoclonal antibody pJG10 (selective strains LGT-209 and LGT-211) Vk light chain can be Variable region (FR1-FR4) polypeptide

<400> 113

<210> 114

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize anti-PCSK9 monoclonal antibody clones LGT-209, LGT-210 and LGT-211 light chain CDR1 peptide

<400> 114

<210> 115

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: Synthesize anti-PCSK9 monoclonal antibody clones LGT-209, LGT-210 and LGT-211 light chain CDR1 peptide

<400> 115

<210> 116

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of mouse anti-PCSK9 monoclonal antibody LFU720 and anti-PCSK9 monoclonal antibody clones LGT-209, LGT-210 and LGT-211 light chain CDR3 peptides

<400> 116

<210> 117

<211> 118

<212> PRT

<213> Wisdom

<400> 117

<210> 118

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 118

<210> 119

<211> 6

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 119

<210> 120

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable heavy chain CDR peptide

<400> 120

<210> 121

<211> 107

<212> PRT

<213> Wisdom

<400> 121

<210> 122

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light chain CDR peptide

<400> 122

<210> 123

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light chain CDR peptide

<400> 123

<210> 124

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light chain CDR peptide

<400> 124

<210> 125

<211> 118

<212> PRT

<213> Wisdom

<400> 125

<210> 126

<211> 10

<212> PRT

<213> Wisdom

<400> 126

<210> 127

<211> 17

<212> PRT

<213> Wisdom

<400> 127

<210> 128

<211> 9

<212> PRT

<213> Wisdom

<400> 128

<210> 129

<211> 107

<212> PRT

<213> Wisdom

<400> 129

<210> 130

<211> 11

<212> PRT

<213> Wisdom

<400> 130

<210> 131

<211> 7

<212> PRT

<213> Wisdom

<400> 131

<210> 132

<211> 9

<212> PRT

<213> Wisdom

<400> 132

<210> 133

<211> 118

<212> PRT

<213> Wisdom

<400> 133

<210> 134

<211> 10

<212> PRT

<213> Wisdom

<400> 134

<210> 135

<211> 17

<212> PRT

<213> Wisdom

<400> 135

<210> 136

<211> 9

<212> PRT

<213> Wisdom

<400> 136

<210> 137

<211> 107

<212> PRT

<213> Wisdom

<400> 137

<210> 138

<211> 11

<212> PRT

<213> Wisdom

<400> 138

<210> 139

<211> 7

<212> PRT

<213> Wisdom

<400> 139

<210> 140

<211> 9

<212> PRT

<213> Wisdom

<400> 140

<210> 141

<211> 118

<212> PRT

<213> Mouse

<400> 141

<210> 142

<211> 7

<212> PRT

<213> Mouse

<400> 142

<210> 143

<211> 6

<212> PRT

<213> Mouse

<400> 143

<210> 144

<211> 9

<212> PRT

<213> Mouse

<400> 144

<210> 145

<211> 108

<212> PRT

<213> Mouse

<400> 145

<210> 146

<211> 11

<212> PRT

<213> Mouse

<400> 146

<210> 147

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light chain CDR peptide

<400> 147

<210> 148

<211> 9

<212> PRT

<213> Mouse

<400> 148

<210> 149

<211> 115

<212> PRT

<213> Mouse

<400> 149

<210> 150

<211> 7

<212> PRT

<213> Mouse

<400> 150

<210> 151

<211> 6

<212> PRT

<213> Mouse

<400> 151

<210> 152

<211> 6

<212> PRT

<213> Mouse

<400> 152

<210> 153

<211> 108

<212> PRT

<213> Mouse

<400> 153

<210> 154

<211> 11

<212> PRT

<213> Mouse

<400> 154

<210> 155

<211> 7

<212> PRT

<213> Mouse

<400> 155

<210> 156

<211> 9

<212> PRT

<213> Mouse

<400> 156

<210> 157

<211> 123

<212> PRT

<213> Mouse

<400> 157

<210> 158

<211> 7

<212> PRT

<213> Mouse

<400> 158

<210> 159

<211> 6

<212> PRT

<213> Mouse

<400> 159

<210> 160

<211> 14

<212> PRT

<213> Mouse

<400> 160

<210> 161

<211> 107

<212> PRT

<213> Mouse

<400> 161

<210> 162

<211> 11

<212> PRT

<213> Mouse

<400> 162

<210> 163

<211> 7

<212> PRT

<213> Mouse

<400> 163

<210> 164

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 164

<210> 165

<211> 117

<212> PRT

<213> Mouse

<400> 165

<210> 166

<211> 7

<212> PRT

<213> Mouse

<400> 166

<210> 167

<211> 6

<212> PRT

<213> Mouse

<400> 167

<210> 168

<211> 8

<212> PRT

<213> Mouse

<400> 168

<210> 169

<211> 108

<212> PRT

<213> Mouse

<400> 169

<210> 170

<211> 11

<212> PRT

<213> Mouse

<400> 170

<210> 171

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthesis of variable light chain CDR peptide

<400> 171

<210> 172

<211> 9

<212> PRT

<213> Mouse

<400> 172

<210> 173

<211> 121

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 173

<210> 174

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 174

<210> 175

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 175

<210> 176

<211> 12

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 176

<210> 177

<211> 108

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 177

<210> 178

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 178

<210> 179

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 179

<210> 180

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 180

<210> 181

<211> 121

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 181

<210> 182

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 182

<210> 183

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 183

<210> 184

<211> 12

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 184

<210> 185

<211> 108

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 185

<210> 186

<211> 11

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 186

<210> 187

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 187

<210> 188

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 188

<210> 189

<211> 125

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 189

<210> 190

<211> 10

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 190

<210> 191

<211> 17

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 191

<210> 192

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 192

<210> 193

<211> 112

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 193

<210> 194

<211> 16

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 194

<210> 195

<211> 7

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 195

<210> 196

<211> 9

<212> PRT

<213> Artificial sequence

<220>

<223> Description of artificial sequence: synthetic peptide

<400> 196

<210> 197

<211> 2076

<212> DNA

<213> Wisdom

<400> 197

<210> 198

<211> 692

<212> PRT

<213> Wisdom

<400> 198

Claims (17)

An antibody or antigen-binding fragment thereof that specifically binds to human PCSK9 is used to prepare a medicament, wherein the medicament is used to treat hypercholesterolemia or mixed dyslipidemia in patients who cannot use the maximum tolerated dose of statin. Achieve LDL-C goals or intolerance to statin, Wherein the antibody or antigen-binding fragment thereof comprises HCVR with the amino acid sequence of SEQ ID NO: 1 and LCVR with the amino acid sequence of SEQ ID NO: 6, Wherein the antibody or its antigen-binding fragment is administered in the absence of statin therapy, and The antibody or antigen-binding fragment thereof is administered to the patient at a dose of 75 mg or 150 mg at a frequency of once every two weeks. Such as the use of item 1 in the scope of the patent application, wherein the patient previously experienced the onset or increase of skeletal muscle-related symptoms when taking one or more of the approved minimum daily doses of statins. Such as the use of item 1 in the scope of the patent application, wherein the patient previously felt the onset or increase of skeletal muscle-related symptoms during at least two individual daily therapeutic statin regimens. Such as the use of item 3 of the scope of patent application, wherein at least one of the daily therapeutic statin regimens is (a) The lowest approved daily dose of statin; or (b) selected from the group consisting of: 5 mg daily rosuvastatin (rosuvastatin), daily 10 mg atorvastatin (atorvastatin), daily 10 mg simvastatin (simvastatin), daily 20 mg lovastatin (lovastatin) ), pravastatin 40 mg daily, fluvastatin 40 mg daily, and pitavastatin 2 mg daily. The use of an antibody or antigen-binding fragment thereof that specifically binds to human PCSK9 for the preparation of a medicament, wherein the medicament is used for the treatment of a confirmed atherosclerotic cardiovascular disease in a patient, and the patient uses the maximum tolerated dose of statin Unable to reach the LDL-C goal or intolerance to statin, Wherein the antibody or antigen-binding fragment thereof comprises an amino acid sequence having SEQ ID NO:1 HCVR and LCVR with the amino acid sequence of SEQ ID NO: 6, Wherein the antibody or its antigen-binding fragment is administered in the absence of statin therapy, and The antibody or antigen-binding fragment thereof is administered to the patient at a dose of 75 mg or 150 mg at a frequency of once every two weeks. Such as the use of item 5 of the scope of patent application, wherein the patient previously experienced the onset or increase of skeletal muscle-related symptoms when taking one or more of the approved minimum daily doses of statins. Such as the use of item 5 of the scope of patent application, wherein the patient previously felt the onset or increase of skeletal muscle-related symptoms during at least two individual daily therapeutic statin regimens. Such as the use of item 7 of the scope of patent application, wherein at least one of the daily therapeutic statin regimens is (a) The lowest approved daily dose of statin; or (b) It is selected from the group consisting of: 5mg per day rosuvastatin (rosuvastatin), 10mg a day Atorvastatin, 10 mg simvastatin daily, 20 mg lovastatin daily, pravastatin 40 mg daily, fluvastatin 40 mg daily, and fluvastatin daily 2mg pitavastatin (pitavastatin). Such as the use of any one of items 1 to 8 in the scope of the patent application, wherein the patient exhibits a serum low-density lipoprotein cholesterol (LDL-C) level greater than Hypercholesterolemia of 70 mg/dL or greater than 100 mg/dL. Such as the use of any one of items 1 to 8 in the scope of patent application, wherein the patient has heterozygous familial hypercholesterolemia (heFH) or a form of hypercholesterolemia that is not familial hypercholesterolemia (non-FH). Such as the use of any one of items 1 to 8 in the scope of the patent application, wherein the patient has a moderate, high, or very high risk of neovascular disease. Such as the use of item 11 of the scope of patent application, wherein the patient has before or at the same time as the administration of the antibody or antigen-binding fragment thereof (a) Defined as calculating the 10-year risk of fatal cardiovascular disease, SCORE is greater than or equal to 1% and less than 5% Of moderate cardiovascular risk; (b) Defined as calculating the 10-year mortality risk of cardiovascular disease with SCORE greater than or equal to 5% and high cardiovascular risk of one or more of the following: (i) moderate chronic kidney disease, (ii) type 1 diabetes, no target Organ damage; (iii) Type 2 diabetes, no target organ damage, and/or (iv) heFH; or (c) Defined as a very high cardiovascular risk of one or more of the following: (i) documented coronary heart disease; (ii) ischemic stroke; (iii) peripheral stroke; (iv) peripheral arterial disease (PAD) ; (V) Temporary ischemic stroke (TIA); (vi) Abdominal aortic aneurysm; (vii) Asymptomatic carotid artery occlusion>50%; (viii) Carotid endarterectomy; (ix) Carotid artery Stent procedure; (x) renal artery stenosis; (xi) renal artery stent procedure; (xii) type 1 diabetes with target organ damage; and/or (xiii) type 2 diabetes with target organ damage. Such as the use of item 1 or 4 of the scope of patent application, wherein one or more initial doses of the agent containing 75 mg of antibody or antigen-binding fragment thereof are administered every two weeks, and wherein (a) If the patient's LDL-C amount after the initial dose is less than 70 mg/dL, one or more doses of the agent containing 75 mg of the antibody or antigen-binding fragment thereof will be administered every two weeks; or (b) If the patient's LDL-C amount after the initial dose is greater than or equal to 70 mg/dL, one or more doses of the drug containing 150 mg of the antibody or antigen-binding fragment thereof will be administered every two weeks. Such as the use of any one of items 1 to 8 in the scope of the patent application, wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 150 mg at a frequency of once every two weeks. Such as the pharmaceutical composition of any one of items 1 to 8 in the scope of the patent application, wherein the pharmaceutical system is administered to the patient in combination with non-statin lipid modulation therapy. Such as the use of item 15 in the scope of the patent application, wherein the non-statin lipid modulation therapy comprises a therapeutic agent selected from the group consisting of ezetimibe, fibric acid, nicotine, omega-3 fatty acid and cholic acid resin . Such as the use of any one of items 1 to 8 in the scope of the patent application, wherein the agent improves the serum level of one or more lipid components selected from the group consisting of: (a) Reduce the patient's low-density lipoprotein cholesterol (LDL-C) by at least 35%; (b) Reduce the lipoprotein B (ApoB) of patients by at least 25%; (c) Reduce the patient's non-high-density lipoprotein cholesterol (non-HDL-C) by at least 30%; (d) Reduce the patient's total cholesterol by at least 20%; and (e) Reduce the patient's lipoprotein a (Lp(a)) by at least 15%.

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