US20200299372A1 - Anti-adrenomedullin (adm) antibody or anti-adm antibody fragment or anti-adm non-ig scaffold for use in intervention and therapy of congestion in a patient in need thereof - Google Patents

Anti-adrenomedullin (adm) antibody or anti-adm antibody fragment or anti-adm non-ig scaffold for use in intervention and therapy of congestion in a patient in need thereof Download PDF

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US20200299372A1
US20200299372A1 US16/469,738 US201716469738A US2020299372A1 US 20200299372 A1 US20200299372 A1 US 20200299372A1 US 201716469738 A US201716469738 A US 201716469738A US 2020299372 A1 US2020299372 A1 US 2020299372A1
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adm
antibody
adrenomedullin
congestion
therapy
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Adriaan VOORS
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Adrenomed AG
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    • A61K39/39533—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals
    • A61K39/3955—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals against proteinaceous materials, e.g. enzymes, hormones, lymphokines
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    • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
    • A61P1/16—Drugs for disorders of the alimentary tract or the digestive system for liver or gallbladder disorders, e.g. hepatoprotective agents, cholagogues, litholytics
    • A—HUMAN NECESSITIES
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    • A—HUMAN NECESSITIES
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    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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    • A61P9/00—Drugs for disorders of the cardiovascular system
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
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    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K16/00—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies
    • C07K16/18—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans
    • C07K16/22—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against growth factors ; against growth regulators
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
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    • C07K2317/30—Immunoglobulins specific features characterized by aspects of specificity or valency
    • C07K2317/34—Identification of a linear epitope shorter than 20 amino acid residues or of a conformational epitope defined by amino acid residues
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    • C07K2317/55—Fab or Fab'
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    • C07K2317/00—Immunoglobulins specific features
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    • C07K2317/94—Stability, e.g. half-life, pH, temperature or enzyme-resistance

Definitions

  • Subject matter of the present invention is an anti-Adrenomedullin (ADM) antibody or an anti-Adrenomedullin antibody fragment or an anti-ADM non-Ig scaffold for use in intervention and therapy of congestion in a patient in need thereof.
  • ADM anti-Adrenomedullin
  • the peptide adrenomedullin was described for the first time in 1993 (Kitamura et al., 1993 . Biochem Biophys Res Comm 192 (2): 553-560) as a novel hypotensive peptide comprising 52 amino acids, which had been isolated from a human pheochromocytoma cell line (SEQ ID No.: 20).
  • cDNA coding for a precursor peptide comprising 185 amino acids and the complete amino acid sequence of this precursor peptide were also described.
  • the precursor peptide which comprises, inter alia, a signal sequence of 21 amino acids at the N-terminus, is referred to as “pre-proadrenomedullin” (pre-proADM).
  • the peptide adrenomedullin is a peptide which comprises 52 amino acids (SEQ ID No: 20) and which comprises the amino acids 95 to 146 of pre-proADM, from which it is formed by proteolytic cleavage.
  • ADM physiologically active peptides
  • PAMP physiologically active peptides
  • ADM is an effective vasodilator, and thus it is possible to associate the hypotensive effect with the particular peptide segments in the C-terminal part of ADM. It has furthermore been found that the above-mentioned physiologically active peptide PAMP formed from pre-proADM likewise exhibits a hypotensive effect, even if it appears to have an action mechanism differing from that of ADM (in addition to the above mentioned review articles Eto et al. 2001 and Hinson et al. 2000 see also Kuwasaki et al. 1997 . FEBS Lett 414(1): 105-110; Kuwasaki et al. 1999 . Ann. Clin. Biochem. 36: 622-628; Tsuruda et al.
  • the ADM level in patients with congestive heart failure, myocardial infarction, kidney diseases, hypertensive disorders, diabetes mellitus, in the acute phase of shock and in sepsis and septic shock are significantly increased, although to different extents.
  • the PAMP concentrations are also increased in some of said pathological states, but the plasma levels are lower relative to ADM (Eto 2001 . Peptides 22: 1693-1711). It was reported that unusually high concentrations of ADM are observed in sepsis, and the highest concentrations in septic shock (Eto 2001 . Peptides 22: 1693-1711; Hirata et al. Journal of Clinical Endocrinology and Metabolism 81(4): 1449-1453; Ehlenz et al. 1997 .
  • Plasma concentrations of ADM are elevated in patients with heart failure and correlate with disease severity (Hirayama et al. 1999 . J Endocrinol 160: 297-303; Yu et al. 2001 . Heart 86: 155-160). High plasma ADM is an independent negative prognostic indicator in these subjects (Poyner et al. 2002 . Pharmacol Rev 54: 233-246).
  • MR-proADM SEQ ID No.: 33
  • BACH study Maisel et al. 2010 . J. Am. Coll. Cardiol. 55: 2062-2076
  • MR-proADM was powerfully prognostic for death at 90 days, adding prognostic value beyond natriuretic peptides.
  • Subsequent data from the PRIDE study solidified a potential prognostic role for MR-proADM; among patients MR-proADM had the best area under the curve (AUC) for mortality at 1 year.
  • MR-proADM was investigated during treatment in patients with acute decompensated heart failure (Boyer et al. 2012 . Congest Heart Fail 18 (2): 91-97): patients whose MR-proADM levels tended to increase during acute therapy had findings associated with persistent congestion. In the 12-24 hour time-period after therapy, patients with elevations of MR-proADM had increased peripheral edema. Kaiser et al. measured MR-proADM in patients with univentricular hearts (Kaiser et al. 2014 . Europ J Heart Failure 16: 1082-1088). Levels in patients with a failed Fontan circuit (exhibiting ascites and peripheral edema) were significantly higher as compared to patients without Fontan failure. Moreover, Eisenhut speculated, whether treatments leading to a reduction of adrenomedullin levels can reduce the severity and extent of alveolar edema in pneumonia and septicemia (Eisenhut 2006 . Crit Care 10: 418)
  • the midregional partial peptide of the proadrenomedullin (SEQ ID No. 33), which contains amino acids (45-92) of the entire preproadrenomedullin, is measured in particular with an immunoassay, that works with at least one labeled antibody that specifically recognizes a sequence of the mid-proADM (WO2004/090546).
  • WO2004/097423 describes the use of an antibody against adrenomedullin for diagnosis, prognosis, and treatment of cardiovascular disorders.
  • Treatment of diseases by blocking the ADM receptor are also described in the art, (e.g. WO2006/027147, PCT/EP2005/012844) said diseases may be sepsis, septic shock, cardiovascular diseases, infections, dermatological diseases, endocrinological diseases, metabolic diseases, gastroenterological diseases, cancer, inflammation, hematological diseases, respiratory diseases, muscle skeleton diseases, neurological diseases, urological diseases.
  • ADM For other diseases blocking of ADM may be beneficial to a certain extent. However, it might also be detrimental if ADM is totally neutralized, as a certain amount of ADM may be required for several physiological functions. In many reports it was emphasized, that the administration of ADM may be beneficial in certain diseases. In contrast thereto, in other reports ADM was reported as being life threatening when administered in certain conditions.
  • WO2013/072510 describes a non-neutralizing anti-ADM antibody for use in therapy of a severe chronical or acute disease or acute condition of a patient for the reduction of the mortality risk for said patient.
  • WO2013/072511 describes a non-neutralizing anti-ADM antibody for use in therapy of a chronical or acute disease or acute condition of a patient for prevention or reduction of organ dysfunction or organ failure.
  • WO2013/072512 describes a non-neutralizing anti-ADM antibody that is an ADM stabilizing antibody that enhances the half-life (t 1/2 half retention time) of adrenomedullin in serum, blood, plasma.
  • This ADM stabilizing antibody blocks the bioactivity of ADM to less than 80%.
  • WO2013/072513 describes a non-neutralizing anti-ADM antibody for use in therapy of an acute disease or condition of a patient for stabilizing the circulation.
  • WO2013/072514 describes a non-neutralizing anti-ADM antibody for regulating the fluid balance in a patient having a chronic or acute disease or acute condition.
  • an anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM may be used for the intervention and therapy of congestion of patients in need thereof.
  • antibodies capable to bind ADM, and thus are directed against ADM, and thus can be referred to as “anti-ADM antibodies”, “anti-ADM antibody fragments”, or “anti-ADM non-Ig scaffolds”.
  • the advantage of the administration of an anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM in contrast to the administration of e.g. diuretics is the kidney protecting effect.
  • Said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM is not harming the kidney and therefore, no side effects are expected in this regard.
  • an anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM is preferably a systemic application.
  • said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM may be administered to a patient with vascular barrier dysfunction or endothelial dysfunction that may result in congestion.
  • Vascular barrier dysfunction or endothelial dysfunction is a systemic pathological state of the endothelium (the inner lining of blood vessels) and can be broadly defined as an imbalance between vasodilating and vasoconstricting substances produced by (or acting on) the endothelium (Deanfield et al. 2005 . J Hypertens 23 (1): 7-17).
  • Normal functions of endothelial cells include mediation of coagulation, platelet adhesion, immune function and control of volume and electrolyte content of the intravascular and extravascular spaces.
  • the endothelium is a cellular monolayer that lines the entire cardiovascular system and regulates many processes including vascular tone, thrombosis, angiogenesis, and inflammation.
  • Endothelial cells have been shown to be phenotypically dynamic and, in response to a variety of local and systemic stimuli, are able to transition between quiescent and activated states (Colombo et al. 2015 . Curr Heart Fail Rep. 12(3): 215-222).
  • endothelial dysfunction is a major contributor to cardiovascular disease, including hypertension, atherosclerosis, and congestive heart failure (Gutierrez et al. 2013 . European Heart Journal 34: 3175-3181).
  • the endothelium tightly controls the exchange of fluid from the circulation to the surrounding tissues and dysfunction of this barrier leads to uncontrolled fluid extravasation that may result in congestion and/or edema.
  • a common feature of edema e.g. pulmonary edema
  • Endothelial dysfunction can result from and/or contribute to several disease processes, as occurs in hypertension, hypercholesterolaemia, diabetes or septic shock. Endothelial dysfunction is a major pathophysiological mechanism that leads towards coronary artery disease, and other atherosclerotic diseases.
  • the antibody when administered in a vast molar excess over the endogenous ADM, binds virtually all ADM in the plasma and, as a simple consequence of reaching binding equilibrium, leads to a translocation of ADM from the interstitium to the blood circulation. Interstitially located ADM can bind to vascular smooth muscle cells and induces relaxation resulting in vasodilation. This is reduced by administration of the antibody.
  • ADM in plasma binds to endothelial cells and thereby stabilizes or even restores vascular integrity. Thus, this function is strengthened, when plasma ADM levels increase as a consequence of administration of the antibody, which is a non-neutralizing antibody. Finally, binding of the antibody to ADM reduces the proteolytic decay of ADM.
  • said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM may be administered to a patient for use in intervention and therapy of congestion with help of a companion diagnostic method. Said companion diagnostic method is described below.
  • Pro-Adrenomedullin or fragments thereof of at least 5 amino acids may be used as an early surrogate marker for congestion and thereby guiding therapy or intervention of congestion comprising:
  • the therapy and intervention as mentioned in the diagnostic method above is the administration of said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM.
  • Severity of congestion is used synonymously throughout this application.
  • Mature ADM, bio-ADM and ADM-NH 2 is used synonymously throughout this application and is a molecule according to SEQ ID No.: 20.
  • Pro-Adrenomedullin or fragments thereof are an early, quantitative and accurate surrogate for congestion in the setting of acute heart failure and heart failure, in particular in a subject having acute heart failure and/or a subject having heart failure presenting with worsening signs and/or a subject with symptoms of heart failure or acute heart failure.
  • Early and accurate surrogate for congestion in the setting of acute heart failure or heart failure means that their concentration and/or level of immune reactivity reflects the extent of congestion.
  • the anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM is administered as therapy or intervention of congestion.
  • said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM is for use in intervention and therapy of congestion in a patient, wherein a sample of bodily fluid taken from said patients exhibits an elevated level of proADM and/or fragments thereof having at least 5 amino acids above a certain threshold.
  • the diagnostic method using said proADM and/or fragments serves as companion diagnostic method.
  • said proADM and/or fragments thereof having at least 5 amino acids is/are selected from the group comprising:
  • proADM 164 amino acids (22-185 of preproADM) SEQ ID No. 31 ARLDVASEF RKKWNKWALS RGKRELRMSS SYPTGLADVK AGPAQTLIRP QDMKGASRSP EDSSPDAARI RVKRYRQSMN NFQGLRSFGC RFGTCTVQKL AHQIYQFTDK DKDNVAPRSK ISPQGYGRRR RRSLPEAGPG RTLVSSKPQA HGAPAPPSGS APHFL
  • SEQ ID No. 32 (Proadrenomedullin N-20 terminal peptide, PAMP): amino acids 22-41 of preproADM
  • SEQ ID No. 35 (C-terminal proAdrenomedullin, CT-proADM): amino acids 148-185 of preproADM
  • said proADM and/or fragments thereof having at least 5 amino acids is/are selected from the group comprising mature ADM-NH 2 (SEQ ID No. 20), ADM 1-52-Gly (SEQ ID No. 34), MR-proADM (SEQ ID No. 33) and CT-proADM (SEQ ID No. 35).
  • the level of mature ADM-NH 2 (SEQ ID No. 20) and/or ADM 1-52-Gly (SEQ ID No. 34), immunoreactivity or the level of MR-proADM (SEQ ID No. 33) immunoreactivity or the level of CT-proADM (SEQ ID No. 35) immunoreactivity is determined and correlated with the need of said patient for therapy or intervention, wherein said patient is identified as having such a need if the level of mature ADM-NH 2 (SEQ ID No. 20) and/or ADM 1-52-Gly (SEQ ID No. 34)—immunoreactivity or the level of MR-proADM (SEQ ID No. 33) immunoreactivity or the level of CT-proADM (SEQ ID No. 35) immunoreactivity in the bodily fluid of said subject is above a threshold.
  • the level of proADM and/or fragments thereof is determined by using at least one binder selected from the group: a binder that binds to a region comprised within the following sequence of mature ADM-NH 2 (SEQ ID No. 20) and/or ADM1-52-Gly (SEQ ID No. 34) and a second binder that binds to a region comprised within the sequence of mature ADM-NH 2 (SEQ ID NO. 20) and/or ADM 1-52-Gly (SEQ ID No. 34).
  • the level of proADM and/or fragments thereof is determined by using at least one binder selected from the group: a binder that binds to a region comprised within the sequence of MR-proADM (SEQ ID No. 33) and a second binder that binds to a region comprised within the sequence of MR-proADM (SEQ ID No. 33).
  • the level of pro-ADM and/or fragments thereof is determined by using at least one binder selected from the group: a binder that binds to a region comprised within the sequence of CT-proADM (SEQ ID No. 35) and a second binder that binds to a region comprised within the sequence of CT-pro-ADM (SEQ ID No. 35).
  • Subject matter in a particular embodiment of the present diagnostic method is a method, according to the present invention wherein said fragment may be selected from MR-proADM according to SEQ ID No.: 33 or mature ADM-NH 2 according to SEQ ID No.: 20.
  • Subject matter of the present diagnostic method is a method according to the diagnostic method invention, wherein the level of Pro-Adrenomedullin or fragments thereof of at least 5 amino acids is determined by using a binder to Pro-Adrenomedullin or fragments thereof of at least 5 amino acids.
  • Subject matter of the present diagnostic method is method, according to the diagnostic method wherein the binder is selected from the group comprising an antibody, an antibody fragment or a non-Ig-Scaffold binding to Pro-Adrenomedullin or fragments thereof of at least 5 amino acids.
  • a bodily fluid according to the present invention is in one particular embodiment a blood sample.
  • a blood sample may be selected from the group comprising whole blood, serum and plasma.
  • said sample is selected from the group comprising human citrate plasma, heparin plasma and EDTA plasma.
  • said anti-ADM antibody or anti-ADM antibody fragment binding to ADM or anti-ADM non-Ig scaffold binding to ADM is for use in intervention and therapy of congestion in a patient according to any embodiment of the invention, wherein said patient is resistant against diuretics or is a non-responder to diuretics therapy.
  • Another specific embodiment of the invention relates to said anti-adrenomedullin antibody or anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold for use in intervention and therapy of congestion in a patient in need thereof, wherein said anti-ADM antibody or anti-ADM fragment or anti-ADM non-Ig scaffold binds to the N-terminal part (aa 1-21) of adrenomedullin:
  • diuretic resistance is defined in general as failure to decrease the extracellular fluid volume despite liberal use of diuretics (Ravnan et al. 2002 . CHF 8:80-85).
  • Epstein et al. defined diuretic resistance as a failure to excrete at least 90 mmol of sodium within 72 hours of a 160-mg oral furosemide dose given twice daily (Epstein et al. 1977 . Curr Ther Res. 21:656-667).
  • Adaptation to diuretic drugs and diuretic resistance may be caused by similar mechanisms.
  • Diuretic adaptations can be classified as those that occur during diuretic action, those that cause sodium retention in the short term (causing ‘post-diuretic NaCl retention’), and those that increase sodium retention chronically (the ‘braking phenomenon’).
  • Ways in which kidneys adapt to chronic diuretic treatment are: First, nephron segments downstream from the site of diuretic action increase NaCl reabsorption during diuretic administration because delivered NaCl load is increased. Second, when diuretic concentrations in the tubule decline, the kidney tubules act to retain Na until the next dose of diuretic is administered.
  • diuretic resistance is thought to occur in one of three patients with congestive HF.
  • Heart failure represents the most common clinical situation in which diuretic resistance is observed.
  • diuretic resistance is not commonly encountered, as long as renal function is preserved.
  • diuretic resistance occurs more frequently and often becomes a clinical problem (Beater 1985 . Drugs 30:427-443; Taylor 2000 Cardiol Rev. 8:104-114).
  • an assay is used for determining the level of proADM and/or fragments thereof having at least 5 amino acids, wherein the assay sensitivity of said assay is able to quantify the mature ADM-NH 2 of healthy subjects and is ⁇ 70 pg/ml, preferably ⁇ 40 pg/ml and more preferably ⁇ 10 pg/ml.
  • concentrations may be used as thresholds for the methods according to the present invention.
  • an assay is used for determining the level of proADM and/or fragments thereof having at least 5 amino acids, wherein the assay sensitivity of said assay is able to quantify MR-proADM of healthy subjects and is ⁇ 0.5 nmol/L, preferably ⁇ 0.4 nmol/L and more preferably ⁇ 0.2 nmol/L.
  • concentrations may be used as thresholds for the methods according to the present invention.
  • an assay is used for determining the level of proADM and/or fragments thereof having at least 5 amino acids, wherein the assay sensitivity of said assay is able to quantify CT-proADM of healthy subjects and is ⁇ 100 ⁇ mol/L, preferably ⁇ 75 ⁇ mol/L and more preferably ⁇ 50 ⁇ mol/L.
  • concentrations may be used as thresholds for the methods according to the present invention.
  • said binder exhibits a binding affinity to proADM and/or fragments thereof of at least 10 7 M ⁇ 1 , preferred 10 8 M ⁇ 1 , preferred affinity is greater than 10 9 M ⁇ 1 , most preferred greater than 10 10 M ⁇ 1 .
  • a person skilled in the art knows that it may be considered to compensate lower affinity by applying a higher dose of compounds and this measure would not lead out-of-the-scope of the invention.
  • the kinetics of binding of Adrenomedullin to immobilized antibody was determined by means of label-free surface plasmon resonance using a Biacore 2000 system (GE Healthcare Europe GmbH, Freiburg, Germany). Reversible immobilization of the antibodies was performed using an anti-mouse Fc antibody covalently coupled in high density to a CMS sensor surface according to the manufacturer's instructions (mouse antibody capture kit; GE Healthcare), (Lorenz et al. 2011 . Antimicrob Agents Chemother. 55 (1): 165-173).
  • said binder is selected from the group comprising an antibody or an antibody fragment or a non-Ig scaffold binding to proADM and/or fragments thereof.
  • an assay is used for determining the level of proADM and/or fragments thereof having at least 5 amino acids, wherein such assay is a sandwich assay, preferably a fully automated assay.
  • it may be a so-called POC-test (point-of-care) that is a test technology, which allows performing the test within less than 1 hour near the patient without the requirement of a fully automated assay system.
  • POC-test point-of-care
  • One example for this technology is the immunochromatographic test technology.
  • such an assay is a sandwich immunoassay using any kind of detection technology including but not restricted to enzyme label, chemiluminescence label, electrochemiluminescence label, preferably a fully automated assay.
  • such an assay is an enzyme labeled sandwich assay. Examples of automated or fully automated assay comprise assays that may be used for one of the following systems: Roche Elecsys®, Abbott Architect®, Siemens Centauer®, Brahms Kryptor®, BiomerieuxVidas®, Alere Triage®.
  • immunoassays are known and may be used for the assays and methods of the present invention, these include: radioimmunoassays (“RIA”), homogeneous enzyme-multiplied immunoassays (“EMIT”), enzyme linked immunoadsorbent assays (“ELISA”), apoenzyme reactivation immunoassay (“ARIS”), dipstick immunoassays and immuno-chromotography assays.
  • RIA radioimmunoassays
  • EMIT homogeneous enzyme-multiplied immunoassays
  • ELISA enzyme linked immunoadsorbent assays
  • ARIS apoenzyme reactivation immunoassay
  • dipstick immunoassays dipstick immunoassays and immuno-chromotography assays.
  • At least one of said two binders is labeled in order to be detected.
  • Subject matter of the present invention is an anti-adrenomedullin (ADM) antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold for use in intervention and therapy of congestion in a patient wherein said patient has a disease or condition selected from the group comprising: congestive high blood pressure, swelling or water retention (edema), heart failure in particular acute heart failure, kidney or liver disease.
  • ADM anti-adrenomedullin
  • Subject matter of the present invention is an anti-adrenomedullin (ADM) antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold for use in intervention and therapy of congestion in a patient wherein said patient has a disease or condition selected from the group comprising: congestive high blood pressure, swelling or water retention (edema), and heart failure, in particular acute heart failure.
  • ADM anti-adrenomedullin
  • Heart failure is a clinical syndrome characterized by a constellation of symptoms and signs caused by cardiac dysfunction. It is one of the major causes of morbidity and mortality in the developed countries, with a prevalence of 1-2%. Heart failure can be grouped into chronic HF and acute HF. Patients with chronic HF can be grouped into stable chronic HF, worsening signs and symptoms of chronic HF and acute decompensation of chronic HF.
  • Acute heart failure is defined as a rapid onset of signs and symptoms of heart failure resulting in the need for urgent therapy or hospitalization. AHF can present as acute de novo HF (new onset of AHF in a patient without previous cardiac dysfunction) or acute decompensation of chronic HF. AHF is the leading cause of hospitalization in adults older than 65 years of age.
  • Heart failure comprises a wide range of patients, from those with normal left ventricular ejection fraction (LVEF) typically considered as >50%, also known as HF with preserved EF (HFpEF) to those with reduced LVEF, typically considered as ⁇ 40%, also known as HF with reduced EF (HFrEF).
  • LVEF left ventricular ejection fraction
  • HFpEF HF with preserved EF
  • HFrEF HF with reduced EF
  • Patients with an LVEF in the range of 40-49% represent a ‘grey area’, which is defined as HF with mid-range EF (HFmrEF) (Ponikowski et al. 2016 . European Heart Journal 18(8): 891-975).
  • AHF treatment in the in-hospital setting is decongestion (removal of excessive intra- and extracellular fluid simply put) and relief of symptoms and signs of congestion.
  • Diuretics remain the main stay decongestive therapy in AHF and almost all hospitalized patients receive this class of drugs.
  • Other classes of medications that increase cardiac output and reduce filling pressure; like inotropes and vasodilators are given in selected groups of patients. Ultrafiltration might also be considered in some patients, particularly in those who do not adequately respond to diuretic therapy.
  • the subject is a subject having heart failure.
  • the subject is a subject having acute heart failure and/or a subject having heart failure presenting with worsening signs and/or a subject with symptoms of heart failure or acute heart failure.
  • said subject has acute heart failure, that is either new-onset AHF or acute decompensated HF.
  • said subject has acute decompensated chronic HF or worsening signs/symptoms of chronic heart failure.
  • said subject has acute heart failure in particular new-onset AHF.
  • acute is used to mean rapid onset and to describe exacerbated or decompensated heart failure, referring to episodes in which a patient can be characterized as having a change in heart failure signs and symptoms resulting in a need for urgent therapy or hospitalization.
  • chronic refers to long duration. Chronic heart failure is a long-term condition, usually kept stable by the treatment of symptoms (stable chronic HF).
  • Chronic heart failure may also decompensate (termed acute decompensated heart failure or acute decompensated chronic heart failure), which is most commonly the result from an intercurrent illness (such as pneumonia), myocardial infarction, arrhythmias, uncontrolled hypertension or a patient's failure to maintain fluid restriction, diet or medication.
  • patients with acute decompensated chronic HF may return to a stable chronic compensated status (stable chronic HF).
  • Acute HF Chronic HF New-onset Acute decompensated Worsening Stable AHF HF acute signs/symptoms chronic HF decompensated of chronic HF chronic HF
  • HF acute and chronic heart failure
  • RC Renal congestion
  • adequate control of congestion with simultaneous improvement/preservation of renal function has been proposed as a central goal of patient management in HF (Aronson 2012 . Expert Rev Cardiovasc Ther 10: 177-189).
  • Congestion in HF is defined as a high left ventricular diastolic pressure associated with signs and symptoms of HF such as dyspnea, rales, and/or edema. These signs and symptoms related to congestion are the main reasons for HF-related hospitalizations.
  • the extent of congestion may be also expressed as grade severity of congestion and has been determined as described below.
  • the person skilled in the art knows that the extent of congestion may be expressed by other scores or surrogates, such as for instance the score utilized by Ambrosy et al. (Ambrosy et al. 2013 . European Heart Journal 34 (11): 835-843).
  • congestion can be classified in many different ways. The person skilled in the art knows that the extent of congestion may be expressed by other scores or surrogates. Clinical classification can be based on bedside physical examination in order to detect the presence of clinical symptoms/signs of congestion (‘wet’ vs. ‘dry’ if present vs. absent) and/or peripheral hypoperfusion (‘cold’ vs. ‘warm’ if present vs. absent) (for review see Ponikowski et al. 2016 . Eur Heart J . ehw128).
  • the combination of these options identifies four groups: warm and wet (well perfused and congested)—most commonly present; cold and wet (hypoperfused and congested); cold and dry (hypoperfused without congestion); and warm and dry (compensated, well perfused without congestion). This classification may be helpful to guide therapy in the initial phase and carries prognostic information.
  • AHF AHF pulmonary congestion and/or peripheral edema
  • Chest X-ray can be a useful test for the diagnosis of AHF. Pulmonary venous congestion, pleural effusion, interstitial or alveolar edema and cardiomegaly are the most specific findings for AHF, although in up to 20% of patients with AHF, chest X-ray is nearly normal.
  • Symptoms/signs of congestion are defined as orthopnoea, paroxysmal nocturnal dyspnoea, pulmonary rales (bilateral), peripheral edema (bilateral).
  • Symptoms/signs of congestion are defined as jugular venous dilatation, peripheral edema (bilateral), congested hepatomegaly, hepatojugular reflux, ascites, symptoms of gut congestion (for review see table 12.2 in Ponikowski et al. 2016 . Eur Heart J . ehw128).
  • Edema is an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume.
  • the fluid between the interstitial and intravascular spaces is regulated by the capillary hydrostatic pressure gradient and the oncotic pressure gradient across the capillary (Trayes et al. 2013 . Am Fam Physician 88(2):102-110).
  • the accumulation of fluid occurs when local or systemic conditions disrupt this equilibrium, leading to increased capillary hydrostatic pressure, increased plasma volume, decreased plasma oncotic pressure (hypoalbuminemia), increased capillary permeability, or lymphatic obstruction.
  • edema manifests as swelling: the amount of interstitial fluid is determined by the balance of fluid homeostasis, and the increased secretion of fluid into the interstitium, or the impaired removal of the fluid can cause edema.
  • a rise in hydrostatic pressure occurs in cardiac failure.
  • causes of edema which are generalized to the whole body can cause edema in multiple organs and peripherally. For example, severe heart failure can cause pulmonary edema, pleural effusions, ascites and peripheral edema.
  • Pulmonary edema is fluid accumulation in the air spaces and parenchyma of the lungs. It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to adequately remove blood from the pulmonary circulation (“cardiogenic pulmonary edema”), or an injury to the lung parenchyma or vasculature of the lung (“noncardiogenic pulmonary edema”) (Ware and Matthay 2005 . N. Engl. J. Med. 353 (26): 2788-96). Treatment is focused on three aspects: firstly improving respiratory function, secondly, treating the underlying cause, and thirdly avoiding further damage to the lung. Pulmonary edema, especially acute, can lead to fatal respiratory distress or cardiac arrest due to hypoxia. It is a cardinal feature of congestive heart failure.
  • the overwhelming symptom of pulmonary edema is difficulty breathing, but may also include coughing up blood (classically seen as pink, frothy sputum), excessive sweating, anxiety, and pale skin. Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night). These are common presenting symptoms of chronic pulmonary edema due to left ventricular failure.
  • pulmonary edema may be associated with symptoms and signs of “fluid overload”; this is a non-specific term to describe the manifestations of left ventricular failure on the rest of the body and includes peripheral edema (swelling of the legs, in general, of the “pitting” variety, wherein the skin is slow to return to normal when pressed upon), raised jugular venous pressure and hepatomegaly, where the liver is enlarged and may be tender or even pulsatile.
  • Other signs include end-inspiratory crackles (sounds heard at the end of a deep breath) on auscultation and the presence of a third heart sound.
  • Conditions affecting kidney structure and function can be considered acute or chronic, depending on their duration (chronic kidney disease (CKD), acute kidney disease (AKD) or acute kidney injury (AKI)).
  • CKD chronic kidney disease
  • AKD acute kidney disease
  • AKI acute kidney injury
  • AKD is characterized by structural kidney damage for ⁇ 3 months and by functional criteria that are also found in AM, or a GFR of ⁇ 60 ml/min per 1.73 m 2 for ⁇ 3 months, or a decrease in GFR by ⁇ 35%, or an increase in serum creatinine (SCr) by >50% for ⁇ 3 months ( Kidney International Supplements, Vol. 2, Issue 1, March 2012, pp. 19-36).
  • AKI is one of a number of acute kidney diseases and disorders (AKD), and can occur with or without other acute or chronic kidney diseases and disorders.
  • AKI is defined as reduction in kidney function, including decreased GFR and kidney failure.
  • the criteria for the diagnosis of AM and the stage of severity of AKI are based on changes in SCr and urine output. In AKI no structural criteria are required (but may exist), but an increase in serum creatinine (SCr) by 50% within 7 days, or an increase by 0.3 mg/dl (26.5 ⁇ mal), or oliguria is found.
  • AKD may occur in patients with trauma, stroke, sepsis, SIRS, septic shock, acute myocardial infarction (MI), post-MI, local and systemic bacterial and viral infections, autoimmune diseases, burned patients, surgery patients, cancer, liver diseases, lung diseases, as well as in patients receiving nephrotoxins such as cyclosporine, antibiotics including aminoglycosides and anticancer drugs such as cisplatin.
  • Kidney failure is a stage of AKI and is defined as a GFR ⁇ 15 ml/min per 1.73 m 2 body surface area, or requirement for renal replacement therapy (RRT).
  • RRT renal replacement therapy
  • CKD is characterized by a glomerular filtration rate (GFR) of ⁇ 60 ml/min per 1.73 m 2 for >3 months and by kidney damage for >3 months ( Kidney International Supplements, 2013; Vol. 3: 19-62).
  • GFR glomerular filtration rate
  • ESRD end-stage renal disease
  • Liver disease (also called hepatic disease) is a type of damage to or disease of the liver. Liver disease can occur through several mechanisms.
  • a common form of liver disease is viral infection caused by e.g. hepatitis virus.
  • Liver cirrhosis is the formation of fibrous tissue in the place of liver cells that have died due to a variety of causes, including viral hepatitis, alcohol overconsumption, and other forms of liver toxicity that causes chronic liver failure.
  • Congestive hepatopathy refers to the spectrum of chronic liver injury attributed to passive hepatic congestion arising in the setting of right-sided heart failure or any cause of increased central venous pressure, including severe pulmonary hypertension (Shah and Sass 2015 . Liver Res Open J. 1(1): 1-10). Cardiohepatic dysfunction is frequent in patients presenting with acute decompensated HF and cardiohepatic syndromes share some common pathophysiological mechanisms with cardiorenal syndromes, such as the increase in venous congestion (Nikolaou et al. 2013 . European Heart Journal 34: 742-749). End-stage liver disease results in profound salt and water retention. Although most of this fluid retention manifests in the peritoneal cavity as ascites, peripheral edema may become prominent in later stages, particularly when there is severe hypoalbuminemia (Cho and Atwood 2002 . Am J Med. 113:580-586).
  • the intervention or therapy of congestion in a patient according to the present invention may be combined with state of the art treatments.
  • Therapy or intervention of congestion according to the state of the art may be selected from the group comprising administration of diuretics, administration of inotropes, administration of vasodilators, ultrafiltration, in particular diuretics.
  • an anti-Adrenomedullin (ADM) antibody or an anti-adrenomedullin antibody fragment or an anti-ADM non-Ig scaffold is monospecific.
  • Monospecific anti-adrenomedullin (ADM) antibody or monospecific anti-adrenomedullin antibody fragment or monospecific anti-ADM non-Ig scaffold means that said antibody or antibody fragment or non-Ig scaffold binds to one specific region encompassing at least 5 amino acids within the target ADM.
  • Monospecific anti-Adrenomedullin (ADM) antibody or monospecific anti-adrenomedullin antibody fragment or monospecific anti-ADM non-Ig scaffold are anti-adrenomedullin (ADM) antibodies or anti-adrenomedullin antibody fragments or anti-ADM non-Ig scaffolds that all have affinity for the same antigen.
  • the anti-ADM antibody or the anti-ADM antibody fragment or anti-ADM non-Ig scaffold binding to ADM is a monospecific antibody, antibody fragment or non-Ig scaffold, respectively, whereby monospecific means that said antibody or antibody fragment or non-Ig scaffold binds to one specific region encompassing at least 4 amino acids within the target ADM.
  • Monospecific antibodies or fragments or non-Ig scaffolds according to the invention are antibodies or fragments or non-Ig scaffolds that all have affinity for the same antigen.
  • Monoclonal antibodies are monospecific, but monospecific antibodies may also be produced by other means than producing them from a common germ cell.
  • Said anti-ADM antibody or antibody fragment binding to ADM or non-Ig scaffold binding to ADM may be a non-neutralizing anti-ADM antibody or antibody fragment binding to ADM or non-Ig scaffold binding to ADM.
  • said anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold is a non-neutralizing antibody, fragment or non-Ig scaffold.
  • a neutralizing anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold would block the bioactivity of ADM to nearly 100%, to at least more than 90%, preferably to at least more than 95%.
  • a non-neutralizing anti-ADM antibody, or anti-ADM antibody fragment or anti-ADM non-Ig scaffold blocks the bioactivity of ADM less than 100%, preferably to less than 95%, preferably to less than 90%, more preferred to less than 80% and even more preferred to less than 50%.
  • bioactivity of ADM is reduced to less than 100%, to 95% or less but not more, to 90% or less but not more, to 80% or less but not more, to 50% or less but not more
  • residual bioactivity of ADM bound to the non-neutralizing anti-ADM antibody, or anti-ADM antibody fragment or anti-ADM non-Ig scaffold would be more than 0%, preferably more than 5%, preferably more than 10%, more preferred more than 20%, more preferred more than 50%.
  • molecule(s) being it an antibody, or an antibody fragment or a non-Ig scaffold with “non-neutralizing anti-ADM activity”, collectively termed here for simplicity as “non-neutralizing” anti-ADM antibody, antibody fragment, or non-Ig scaffold, that e.g. blocks the bioactivity of ADM to less than 80%, is defined as
  • An antibody or fragment according to the present invention is a protein including one or more polypeptides substantially encoded by immunoglobulin genes that specifically binds an antigen.
  • the recognized immunoglobulin genes include the kappa, lambda, alpha (IgA), gamma (IgG 1 , IgG 2 , IgG 3 , IgG 4 ), delta (IgD), epsilon (IgE) and mu (IgM) constant region genes, as well as the myriad immunoglobulin variable region genes.
  • Full-length immunoglobulin light chains are generally about 25 Kd or 214 amino acids in length.
  • Full-length immunoglobulin heavy chains are generally about 50 Kd or 446 amino acid in length.
  • Light chains are encoded by a variable region gene at the NH 2 -terminus (about 110 amino acids in length) and a kappa or lambda constant region gene at the COOH-terminus.
  • Heavy chains are similarly encoded by a variable region gene (about 116 amino acids in length) and one of the other constant region genes.
  • the basic structural unit of an antibody is generally a tetramer that consists of two identical pairs of immunoglobulin chains, each pair having one light and one heavy chain. In each pair, the light and heavy chain variable regions bind to an antigen, and the constant regions mediate effector functions.
  • Immunoglobulins also exist in a variety of other forms including, for example, Fv, Fab, and (Fab′) 2 , as well as bifunctional hybrid antibodies and single chains (e.g., Lanzavecchia et al. 1987 . Eur. J. Immunol. 17:105; Huston et al. 1988 . Proc. Natl. Acad. Sci. U.S.A., 85:5879-5883; Bird et al. 1988 .
  • An immunoglobulin light or heavy chain variable region includes a framework region interrupted by three hypervariable regions, also called complementarity determining regions (CDR's) (see, Sequences of Proteins of Immunological Interest , E. Kabat et al. 1983, U.S. Department of Health and Human Services). As noted above, the CDRs are primarily responsible for binding to an epitope of an antigen.
  • An immune complex is an antibody, such as a monoclonal antibody, chimeric antibody, humanized antibody or human antibody, or functional antibody fragment, specifically bound to the antigen.
  • Chimeric antibodies are antibodies whose light and heavy chain genes have been constructed, typically by genetic engineering, from immunoglobulin variable and constant region genes belonging to different species.
  • the variable segments of the genes from a mouse monoclonal antibody can be joined to human constant segments, such as kappa and gamma 1 or gamma 3.
  • a therapeutic chimeric antibody is thus a hybrid protein composed of the variable or antigen-binding domain from a mouse antibody and the constant or effector domain from a human antibody, although other mammalian species can be used, or the variable region can be produced by molecular techniques. Methods of making chimeric antibodies are well known in the art, e.g., see U.S. Pat. No. 5,807,715.
  • a “humanized” immunoglobulin is an immunoglobulin including a human framework region and one or more CDRs from a non-human (such as a mouse, rat, or synthetic) immunoglobulin.
  • the non-human immunoglobulin providing the CDRs is termed a “donor” and the human immunoglobulin providing the framework is termed an “acceptor.”
  • all the CDRs are from the donor immunoglobulin in a humanized immunoglobulin.
  • Constant regions need not be present, but if they are, they must be substantially identical to human immunoglobulin constant regions, i.e., at least about 85-90%, such as about 95% or more identical.
  • humanized antibody is an antibody comprising a humanized light chain and a humanized heavy chain immunoglobulin.
  • a humanized antibody binds to the same antigen as the donor antibody that provides the CDRs.
  • the acceptor framework of a humanized immunoglobulin or antibody may have a limited number of substitutions by amino acids taken from the donor framework.
  • Humanized or other monoclonal antibodies can have additional conservative amino acid substitutions, which have substantially no effect on antigen binding or other immunoglobulin functions. Exemplary conservative substitutions are those such as gly, ala; val, ile, leu; asp, glu; asn, gln; ser, thr; lys, arg; and phe, tyr.
  • Humanized immunoglobulins can be constructed by means of genetic engineering (e.g., see U.S. Pat. No. 5,585,089).
  • a human antibody is an antibody wherein the light and heavy chain genes are of human origin.
  • Human antibodies can be generated using methods known in the art. Human antibodies can be produced by immortalizing a human B cell secreting the antibody of interest Immortalization can be accomplished, for example, by EBV infection or by fusing a human B cell with a myeloma or hybridoma cell to produce a trioma cell. Human antibodies can also be produced by phage display methods (see, e.g. WO91/17271; WO92/001047; WO92/20791), or selected from a human combinatorial monoclonal antibody library (see the Morphosys website). Human antibodies can also be prepared by using transgenic animals carrying a human immunoglobulin gene (for example, see WO93/12227; WO 91/10741).
  • the anti-ADM antibody may have the formats known in the art.
  • Examples are human antibodies, monoclonal antibodies, humanized antibodies, chimeric antibodies, CDR-grafted antibodies.
  • antibodies according to the present invention are recombinantly produced antibodies as e.g. IgG, a typical full-length immunoglobulin, or antibody fragments containing at least the F-variable domain of heavy and/or light chain as e.g. chemically coupled antibodies (fragment antigen binding) including but not limited to Fab-fragments including Fab minibodies, single chain Fab antibody, monovalent Fab antibody with epitope tags, e.g.
  • bivalent Fab-V5Sx2 bivalent Fab (mini-antibody) dimerized with the CH3 domain
  • bivalent Fab or multivalent Fab e.g. formed via multimerization with the aid of a heterologous domain, e.g. via dimerization of dHLX domains, e.g. Fab-dHLX-FSx2; F(ab′) 2 -fragments, scFv-fragments, multimerized multivalent or/and multispecific scFv-fragments, bivalent and/or bispecific diabodies, BITE® (bispecific T-cell engager), trifunctional antibodies, polyvalent antibodies, e.g. from a different class than G; single-domain antibodies, e.g. nanobodies derived from camelid or fish immunoglobulines and numerous others.
  • biopolymer scaffolds are well known in the art to complex a target molecule and have been used for the generation of highly target specific biopolymers. Examples are aptamers, spiegelmers, anticalins and conotoxins. For illustration of antibody formats please see FIGS. 1 a , 1 b and 1 c.
  • the anti-ADM antibody format is selected from the group comprising Fv fragment, scFv fragment, Fab fragment, scFab fragment, F(ab) 2 fragment and scFv-Fc Fusion protein.
  • the antibody format is selected from the group comprising scFab fragment, Fab fragment, scFv fragment and bioavailability optimized conjugates thereof, such as PEGylated fragments.
  • One of the most preferred formats is the scFab format.
  • Non-Ig scaffolds may be protein scaffolds and may be used as antibody mimics as they are capable to bind to ligands or antigens.
  • Non-Ig scaffolds may be selected from the group comprising tetranectin-based non-Ig scaffolds (e.g. described in US 2010/0028995), fibronectin scaffolds (e.g. described in EP 1 266 025; lipocalin-based scaffolds (e.g. described in WO 2011/154420); ubiquitin scaffolds (e.g. described in WO 2011/073214), transferrin scaffolds (e.g. described in US 2004/0023334), protein A scaffolds (e.g.
  • ankyrin repeat based scaffolds e.g. described in WO 2010/060748
  • microproteins preferably microproteins forming a cysteine knot e.g. described in EP 2314308
  • Fyn SH3 domain based scaffolds e.g. described in WO 2011/023685
  • EGFR-A-domain based scaffolds e.g. described in WO 2005/040229
  • Kunitz domain based scaffolds e.g. described in EP 1 941 867.
  • anti-ADM antibodies according to the present invention may be produced as outlined in Example 1 by synthesizing fragments of ADM as antigens. Thereafter, binder to said fragments are identified using the below described methods or other methods as known in the art.
  • Humanization of murine antibodies may be conducted according to the following procedure: For humanization of an antibody of murine origin the antibody sequence is analyzed for the structural interaction of framework regions (FR) with the complementary determining regions (CDR) and the antigen. Based on structural modeling an appropriate FR of human origin is selected and the murine CDR sequences are transplanted into the human FR. Variations in the amino acid sequence of the CDRs or FRs may be introduced to regain structural interactions, which were abolished by the species switch for the FR sequences. This recovery of structural interactions may be achieved by random approach using phage display libraries or via directed approach guided by molecular modeling (Almagro and Fransson 2008 . Humanization of antibodies. Front Biosci. 2008 Jan. 1; 13:1619-33).
  • the ADM antibody format is selected from the group comprising Fv fragment, scFv fragment, Fab fragment, scFab fragment, F(ab)2 fragment and scFv-Fc Fusion protein.
  • the antibody format is selected from the group comprising scFab fragment, Fab fragment, scFv fragment and bioavailability optimized conjugates thereof, such as PEGylated fragments.
  • One of the most preferred formats is scFab format.
  • the anti-ADM antibody, anti-ADM antibody fragment, or anti-ADM non-Ig scaffold is a full length antibody, antibody fragment, or non-Ig scaffold.
  • the anti-adrenomedullin antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold is directed to and can bind to an epitope of at least 5 amino acids in length contained in ADM.
  • the anti-adrenomedullin antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold is directed to and can bind to an epitope of at least 4 amino acids in length contained in ADM.
  • the anti-adrenomedullin (ADM) antibody or anti-ADM antibody fragment binding to adrenomedullin or anti-ADM non-Ig scaffold binding to adrenomedullin is provided for use in therapy or prevention of an acute disease or acute condition of a patient wherein said antibody or fragment or scaffold is not ADM-binding-Protein-1 (complement factor H).
  • the anti-Adrenomedullin (ADM) antibody or anti-ADM antibody fragment binding to adrenomedullin or anti-ADM non-Ig scaffold binding to adrenomedullin is provided for use in therapy or prevention of an acute disease or acute condition of a patient wherein said antibody or antibody fragment or non-Ig scaffold binds to a region of preferably at least 4, or at least 5 amino acids within the sequence of aa 1-42 of mature human ADM:
  • the anti-Adrenomedullin (ADM) antibody or anti-ADM antibody fragment binding to adrenomedullin or anti-ADM non-Ig scaffold binding to adrenomedullin is provided for use in therapy or prevention of an acute disease or acute condition of a patient wherein said antibody or fragment or scaffold binds to a region of preferably at least 4, or at least 5 amino acids within the sequence of aa 1-21 of mature human ADM:
  • said anti-ADM antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold binds to a region or epitope of ADM that is located in the N-terminal part (aa 1-21) of adrenomedullin.
  • said anti-ADM-antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold recognizes and binds to a region or epitope within amino acids 1-14 (SEQ ID No.: 25) of adrenomedullin; that means to the N-terminal part (aa 1-14) of adrenomedullin.
  • said anti-ADM-antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold recognizes and binds to a region or epitope within amino acids 1-10 of adrenomedullin (SEQ ID No.: 26); that means to the N-terminal part (aa 1-10) of adrenomedullin.
  • said anti-ADM antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold recognizes and binds to a region or epitope within amino acids 1-6 of adrenomedullin (SEQ ID No.: 27); that means to the N-terminal part (aa 1-6) of adrenomedullin.
  • said region or epitope comprises preferably at least 4 or at least 5 amino acids in length.
  • said anti-ADM antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold recognizes and binds to the N-terminal end (aa1) of adrenomedullin.
  • N-terminal end means that the amino acid 1, that is “Y” of SEQ ID No. 20, 22 or 23; is mandatory for antibody binding.
  • the antibody or fragment or scaffold would neither bind N-terminal extended nor N-terminal modified Adrenomedullin nor N-terminal degraded adrenomedullin.
  • said anti-ADM-antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold binds only to a region within the sequence of mature ADM if the N-terminal end of ADM is free.
  • the anti-ADM antibody or anti-adrenomedullin antibody fragment or non-Ig scaffold would not bind to a region within the sequence of mature ADM if said sequence is e.g. comprised within pro-ADM.
  • N-terminal part (aa 1-21) is understood by a person skilled in the art that the N-terminal part of ADM consists of amino acids 1-21 of the mature ADM sequence.
  • anti-ADM antibody or anti-ADM antibody fragment or anti-ADM non-Ig scaffold does not bind to the C-terminal portion of ADM, i.e. the aa 43-52 of ADM
  • an anti-ADM antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold according to the present invention, wherein said anti-adrenomedullin antibody or said anti-adrenomedullin antibody fragment or non-Ig scaffold leads to an increase of the ADM level or ADM immunoreactivity in serum, blood, plasma of at least 10%, preferably at least 50%, more preferably >50%, most preferably >100%.
  • an anti-ADM antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold according to the present invention, wherein said anti-adrenomedullin antibody or said anti-adrenomedullin antibody fragment or non-Ig scaffold is an ADM stabilizing antibody or an adrenomedullin stabilizing antibody fragment or an adrenomedullin stabilizing non-Ig scaffold that enhances the half-life (t 1/2 ; half retention time) of adrenomedullin in serum, blood, plasma at least 10%, preferably at least 50%, more preferably >50%, most preferably >100%.
  • the half-life (half retention time) of ADM may be determined in human serum, blood or plasma in absence and presence of an ADM stabilizing antibody or an adrenomedullin stabilizing antibody fragment or an adrenomedullin stabilizing non-Ig scaffold, respectively, using an immunoassay for the quantification of ADM.
  • a two-fold increase of the half-life of ADM is an enhancement of half-life of 100%.
  • Half-life is defined as the period over which the concentration of a specified chemical or drug takes to fall to half its baseline concentration in the specified fluid or blood.
  • Example 3 An assay that may be used for the determination of the half-life (half retention time) of adrenomedullin in serum, blood, plasma is described in Example 3.
  • said anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold is a non-neutralizing antibody, fragment or scaffold.
  • a neutralizing anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold would block the bioactivity of ADM to nearly 100%, to at least more than 90%, preferably to at least more than 95%.
  • said non-neutralizing anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold blocks the bioactivity of ADM to less than 100%, preferably less than 95% preferably less than 90%.
  • non-neutralizing anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold blocks the bioactivity of ADM to less than 95% an anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold that would block the bioactivity of ADM to more than 95% would be outside of the scope of said embodiment.
  • the bioactivity is reduced to 95% or less but not more, preferably to 90% or less, more preferably to 80% or less, more preferably to 50% or less but not more.
  • the non-neutralizing antibody is an antibody binding to a region of at least 5 amino acids within the sequence of aa 1-42 of mature human ADM (SEQ ID No.: 23), preferably within the sequence aa 1-32 of mature human ADM (SEQ ID No.: 28), or an antibody binding to a region of at least 5 amino acids within the sequence of aa 1-40 of mature murine ADM (SEQ ID No.: 29), preferably within the sequence aa 1-31 of mature murine ADM (SEQ ID No.: 30).
  • the non-neutralizing antibody is an antibody binding to a region of at least 4 amino acids within the sequence of aa 1-42 of mature human ADM (SEQ ID No.: 23), preferably within the sequence aa 1-32 of mature human ADM (SEQ ID No.: 28), or an antibody binding to a region of at least 4 amino acids within the sequence of aa 1-40 of mature murine ADM (SEQ ID No.: 29), preferably within the sequence aa 1-31 of mature murine ADM (SEQ ID No.: 30).
  • an non-neutralizing anti-ADM antibody or an anti-adrenomedullin antibody fragment or ADM non-Ig scaffold is used, wherein said anti-ADM antibody or an anti-adrenomedullin antibody fragment blocks the bioactivity of ADM to less than 80%, preferably less than 50% (of baseline values).
  • said limited blocking of the bioactivity (meaning reduction of the bioactivity) of ADM occurs even at excess concentration of the antibody, fragment or scaffold, meaning an excess of the antibody, fragment or scaffold in relation to ADM.
  • Said limited blocking is an intrinsic property of the ADM binder itself in said specific embodiment. This means that said antibody, fragment or scaffold has a maximal inhibition of 80% or 50% respectively.
  • said anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold would block the bioactivity/reduce the bioactivity of anti-ADM to at least 5%.
  • the stated above means that approximately 20% or 50% or even 95% residual ADM bioactivity remains present, respectively.
  • the provided anti-ADM antibodies, anti-ADM antibody fragments, and anti-ADM non-Ig scaffolds do not neutralize the respective ADM bioactivity.
  • bioactivity is defined as the effect that a substance takes on a living organism or tissue or organ or functional unit in vivo or in vitro (e. g. in an assay) after its interaction.
  • ADM bioactivity this may be the effect of ADM in a human recombinant Adrenomedullin receptor cAMP functional assay.
  • bioactivity is defined via an
  • Adrenomedullin receptor cAMP functional assay The following steps may be performed in order to determine the bioactivity of ADM in such an assay:
  • a maximal inhibition in said ADM bioassay of 50% means that said anti-ADM antibody or said anti-adrenomedullin antibody fragment or said anti-adrenomedullin non-Ig scaffold, respectively, blocks the bioactivity of ADM to 50% of baseline values.
  • a maximal inhibition in said ADM bioassay of 80% means that said anti-ADM antibody or said anti-adrenomedullin antibody fragment or said anti-adrenomedullin non-Ig scaffold, respectively, blocks the bioactivity of ADM to 80%. This is in the sense of blocking the ADM bioactivity to not more than 80%. This means approximately 20% residual ADM bioactivity remains present.
  • the expression “blocks the bioactivity of ADM” in relation to the herein disclosed anti-ADM antibodies, anti-ADM antibody fragments, and anti-ADM non-Ig scaffolds should be understood as mere decreasing the bioactivity of ADM from 100% to 20% remaining ADM bioactivity at maximum, preferably decreasing the ADM bioactivity from 100% to 50% remaining ADM bioactivity; but in any case there is ADM bioactivity remaining that can be determined as detailed above.
  • the bioactivity of ADM may be determined in a human recombinant Adrenomedullin receptor cAMP functional assay (Adrenomedullin Bioassay) according to Example 2.
  • a modulating antibody or a modulating anti-adrenomedullin antibody fragment or a modulating anti-adrenomedullin non-Ig scaffold is used in therapy or prevention of a chronic or acute disease or acute condition of a patient for stabilizing the circulation, in particular stabilizing the systemic circulation.
  • a “modulating” anti-ADM antibody or a modulating anti-adrenomedullin antibody fragment or a modulating anti-adrenomedullin non-Ig scaffold is an antibody or an anti-adrenomedullin antibody fragment or non-Ig scaffold that enhances the half-life (t 1/2 half retention time) of adrenomedullin in serum, blood, plasma at least 10%, preferably at least, 50%, more preferably >50%, most preferably >100% and blocks the bioactivity of ADM to less than 80%, preferably less than 50% and said anti-ADM antibody, anti-ADM antibody fragment or anti-ADM non-Ig scaffold would block the bioactivity of ADM to at least 5%.
  • These values related to half-life and blocking of bioactivity have to be understood in relation to the before-mentioned assays in order to determine these values. This is in the sense of blocking the ADM bioactivity of not more than 80% or not more than 50%, respectively.
  • Such a modulating anti-ADM antibody or a modulating anti-adrenomedullin antibody fragment or a modulating anti-adrenomedullin non-Ig scaffold offers the advantage that the dosing of the administration is facilitated.
  • Adrenomedullin bioactivity and increase of the in vivo half-life leads to beneficial simplicity of anti-adrenomedullin antibody or an anti-adrenomedullin antibody fragment or anti-adrenomedullin non-Ig scaffold dosing.
  • the activity lowering effect is the major impact of the antibody or fragment or scaffold, limiting the (negative) effect of Adrenomedullin.
  • the biological effect of anti-adrenomedullin antibody or an anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold is a combination of lowering (by partially blocking) and increase by increasing the Adrenomedullin half-life.
  • the non-neutralizing and modulating anti-adrenomedullin antibody or anti-adrenomedullin antibody fragment or anti-adrenomedullin non-Ig scaffold acts like an ADM bioactivity buffer in order to keep the bioactivity of ADM within a certain physiological range.
  • the antibody is a monoclonal antibody or a fragment thereof.
  • the anti-ADM antibody or the anti-ADM antibody fragment is a human or humanized antibody or derived therefrom.
  • one or more (murine) CDR's are grafted into a human antibody or antibody fragment.
  • Subject matter of the present invention in one aspect is a human CDR-grafted antibody or antibody fragment thereof that binds to ADM, wherein the human CDR-grafted antibody or antibody fragment thereof comprises an antibody heavy chain (H chain) comprising:
  • L chain comprising:
  • the light chain comprises at least one CDR selected from the group comprising:
  • the anti-ADM antibody has a sequence selected from the group comprising: SEQ ID No. 6, 7, 8, 9, 10, 11, 12, and 13.
  • the anti-ADM antibody or anti-adrenomedullin antibody fragment or anti-ADM non-Ig scaffold according to the present invention exhibits an affinity towards human ADM in such that affinity constant is greater than 10 ⁇ 7 M, preferred 10 ⁇ 8 M, preferred affinity is greater than 10 0.9 M, most preferred higher than 10′ 9 M.
  • affinity constants may be determined according to the method as described in Example 1.
  • Subject matter of the present invention is a human monoclonal antibody or fragment that binds to ADM or an antibody fragment thereof for use in intervention and therapy of congestion in a patient according to the present invention, wherein said antibody or fragment comprises a sequence selected from the group comprising:
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient comprising an antibody or fragment or scaffold according to the present invention.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient comprising an antibody or fragment or scaffold according to the present invention wherein said patient has a disease or condition selected from the group comprising: congestive high blood pressure, swelling or water retention (edema), heart failure in particular acute heart failure, kidney or liver disease.
  • a disease or condition selected from the group comprising: congestive high blood pressure, swelling or water retention (edema), heart failure in particular acute heart failure, kidney or liver disease.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention wherein said pharmaceutical formulation is a solution, preferably a ready-to-use solution.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention wherein said pharmaceutical formulation is in a freeze-dried state.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention, wherein said pharmaceutical formulation is administered intra-muscular.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention, wherein said pharmaceutical formulation is administered intra-vascular.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention, wherein said pharmaceutical formulation is administered via infusion.
  • Subject matter of the present invention is a pharmaceutical formulation for use in intervention and therapy of congestion in a patient according to the present invention, wherein said pharmaceutical formulation is to be administered systemically.
  • the antibodies, antibody fragments and non-Ig scaffolds of the example portion in accordance with the invention are binding to ADM, and thus should be considered as anti-ADM antibodies/antibody fragments/non-Ig scaffolds.
  • Peptides for immunization were synthesized, see Table 1, (JPT Technologies, Berlin, Germany) with an additional N-terminal Cystein (if no Cystein is present within the selected ADM-sequence) residue for conjugation of the peptides to Bovine Serum Albumin (BSA).
  • BSA Bovine Serum Albumin
  • the peptides were covalently linked to BSA by using Sulfolink-coupling gel (Perbio-science, Bonn, Germany). The coupling procedure was performed according to the manual of Perbio.
  • the murine antibodies were generated according to the following method:
  • a Balb/c mouse was immunized with 100 ⁇ g Peptide-BSA-Conjugate at day 0 and 14 (emulsified in 100 ⁇ l complete Freund's adjuvant) and 50 ⁇ g at day 21 and 28 (in 100 ⁇ l incomplete Freund's adjuvant).
  • the animal received 50 ⁇ g of the conjugate dissolved in 100 ⁇ l saline, given as one intraperitoneal and one intra-venous injection.
  • Splenocytes from the immunized mouse and cells of the myeloma cell line SP2/0 were fused with 1 ml 50% polyethylene glycol for 30 s at 37° C. After washing, the cells were seeded in 96-well cell culture plates. Hybrid clones were selected by growing in HAT medium [RPMI 1640 culture medium supplemented with 20% fetal calf serum and HAT-Supplement]. After two weeks the HAT medium is replaced with HT Medium for three passages followed by returning to the normal cell culture medium.
  • the cell culture supernatants were primary screened for antigen specific IgG antibodies three weeks after fusion.
  • the positive tested microcultures were transferred into 24-well plates for propagation. After retesting, the selected cultures were cloned and recloned using the limiting-dilution technique and the isotypes were determined (see also Lane, R. D. 1985 . J. Immunol. Meth. 81: 223-228; Ziegler et al. 1996 . Horm. Metab. Res. 28: 11-15).
  • Antibodies were produced via standard antibody production methods (Marx et al, 1997 . Monoclonal Antibody Production, ATLA 25, 121) and purified via Protein A. The antibody purities were >95% based on SDS gel electrophoresis analysis.
  • Human Antibodies were produced by means of phage display according to the following procedure:
  • the human naive antibody gene libraries HALT/8 were used for the isolation of recombinant single chain F-Variable domains (scFv) against adrenomedullin peptide.
  • the antibody gene libraries were screened with a panning strategy comprising the use of peptides containing a biotin tag linked via two different spacers to the adrenomedullin peptide sequence.
  • a mix of panning rounds using non-specifically bound antigen and streptavidin bound antigen were used to minimize background of non-specific binders.
  • the eluted phages from the third round of panning have been used for the generation of monoclonal scFv expressing E. coli strains.
  • Positive clones have been selected based on positive ELISA signal for antigen and negative for streptavidin coated micro titer plates.
  • the scFv open reading frame has been cloned into the expression plasmid pOPE107 (Hust et al., J. Biotechn. 2011), captured from the culture supernatant via immobilised metal ion affinity chromatography and purified by a size exclusion chromatography.
  • the kinetics of binding of Adrenomedullin to immobilized antibody was determined by means of label-free surface plasmon resonance using a Biacore 2000 system (GE Healthcare Europe GmbH, Freiburg, Germany). Reversible immobilization of the antibodies was performed using an anti-mouse Fc antibody covalently coupled in high density to a CMS sensor surface according to the manufacturer's instructions (mouse antibody capture kit; GE Healthcare). (Lorenz et al. 2011 . Antimicrob Agents Chemother. 55(1): 165-173).
  • the monoclonal antibodies were raised against the below depicted ADM regions of human and murine ADM, respectively.
  • the following table represents a selection of obtained antibodies used in further experiments. Selection was based on target region:
  • the generation of Fab and F(ab) 2 fragments was done by enzymatic digestion of the murine full length antibody NT-M.
  • Antibody NT-M was digested using a) the pepsin-based F(ab) 2 Preparation Kit (Pierce 44988) and b) the papain-based Fab Preparation Kit (Pierce 44985).
  • the fragmentation procedures were performed according to the instructions provided by the supplier. Digestion was carried out in case of F(ab) 2 -fragmentation for 8 h at 37° C.
  • the Fab-fragmentation digestion was carried out for 16 h, respectively.
  • the immobilized papain was equilibrated by washing the resin with 0.5 ml of Digestion Buffer and centrifuging the column at 5000 ⁇ g for 1 minute. The buffer was discarded afterwards.
  • the desalting column was prepared by removing the storage solution and washing it with digestion buffer, centrifuging it each time afterwards at 1000 ⁇ g for 2 minutes. 0.5 ml of the prepared
  • IgG sample where added to the spin column tube containing the equilibrated Immobilized Papain. Incubation time of the digestion reaction was done for 16 h on a tabletop rocker at 37° C. The column was centrifuged at 5000 ⁇ g for 1 minute to separate digest from the Immobilized Papain. Afterwards the resin was washed with 0.5 ml PBS and centrifuged at 5000 ⁇ g for 1 minute. The wash fraction was added to the digested antibody that the total sample volume was 1.0 ml. The NAb Protein A Column was equilibrated with PBS and IgG Elution Buffer at room temperature.
  • the column was centrifuged for 1 minute to remove storage solution (contains 0.02% sodium azide) and equilibrated by adding 2 ml of PBS, centrifuge again for 1 minute and the flow-through discarded.
  • the sample was applied to the column and resuspended by inversion. Incubation was done at room temperature with end-over-end mixing for 10 minutes.
  • the column was centrifuged for 1 minute, saving the flow-through with the Fab fragments.
  • the immobilized Pepsin was equilibrated by washing the resin with 0.5 ml of Digestion Buffer and centrifuging the column at 5000 ⁇ g for 1 minute. The buffer was discarded afterwards.
  • the desalting column was prepared by removing the storage solution and washing it with digestion buffer, centrifuging it each time afterwards at 1000 ⁇ g for 2 minutes.
  • 0.5 ml of the prepared IgG sample where added to the spin column tube containing the equilibrated Immobilized Pepsin. Incubation time of the digestion reaction was done for 16 h on a tabletop rocker at 37° C. The column was centrifuged at 5000 ⁇ g for 1 minute to separate digest from the Immobilized Papain.
  • the resin was washed with 0.5 mL PBS and centrifuged at 5000 ⁇ g for 1 minute. The wash fraction was added to the digested antibody that the total sample volume was 1.0 ml.
  • the NAb Protein A Column was equilibrated with PBS and IgG Elution Buffer at room temperature. The column was centrifuged for 1 minute to remove storage solution (contains 0.02% sodium azide) and equilibrated by adding 2 mL of PBS, centrifuge again for 1 minute and the flow-through discarded. The sample was applied to the column and resuspended by inversion. Incubation was done at room temperature with end-over-end mixing for 10 minutes.
  • the antibody fragment was humanized by the CDR-grafting method (Jones et al. 1986 . Nature 321, 522-525).
  • Total RNA extraction Total RNA was extracted from NT-H hybridomas using the Qiagen kit.
  • RT-PCR QIAGEN OneStep RT-PCR Kit (Cat No. 210210) was used. RT-PCR was performed with primer sets specific for the heavy and light chains. For each RNA sample, 12 individual heavy chain and 11 light chain RT-PCR reactions were set up using degenerate forward primer mixtures covering the leader sequences of variable regions. Reverse primers are located in the constant regions of heavy and light chains. No restriction sites were engineered into the primers.
  • Annotation for the antibody fragment sequences (SEQ ID No.: 7-14): bold and underline are the CDR 1, 2, 3 in chronologically arranged; italic are constant regions; hinge regions are highlighted with bold letters and the histidine tag with bold and italic letters; framework point mutation have a grey letter-background.
  • A-VH-C SEQ ID No.: 6 QVQLQQSGAELMKPGASVKISCKAT GYTFSRYW IEWVKQRPGHGLEWIGE I LPGSGST NYNEKFKGKATITADTSS NTAYMQLSSLTSEDSAVYYC WGQGTTLTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLV KDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQT YICNVNHKPSNTKVDKRV EPK (AM-VH1) SEQ ID No.: 7 QVQLVQSGAEVKKPGSSVKVSCKAS GYTFSRYW ISWVRQAPGQGLEWMGR I LPGSGST NYAQKFQGRVTITADE STSTAYMELSSLRSEDTAVYYC WGQGTTVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLV KDYFPEPVTVSWNSGALTSGVHTFPAVLQSSG
  • Adrenomedullin Bioassay The effect of selected ADM-antibodies on ADM-bioactivity was tested in a human recombinant Adrenomedullin receptor cAMP functional assay (Adrenomedullin Bioassay).
  • Adrenomedullin (CRLR+RAMP3)
  • CHO-K1 cells expressing human recombinant adrenomedullin receptor (FAST-027C) grown prior to the test in media without antibiotic were detached by gentle flushing with PBS-EDTA (5 mM EDTA), recovered by centrifugation and resuspended in assay buffer (KRH: 5 mM KCl, 1.25 mM MgSO 4 , 124 mM NaCl, 25 mM HEPES, 13.3 mM Glucose, 1.25 mM KH 2 PO 4 , 1.45 mM CaCl 2 , 0.5 g/l BSA).
  • PBS-EDTA 5 mM EDTA
  • Dose response curves were performed in parallel with the reference agonists (hADM or mADM).
  • the anti-h-ADM antibodies (NT-H, MR-H, CT-H) were tested for antagonist activity in human recombinant adrenomedullin receptor (FAST-027C) cAMP functional assay in the presence of 5.63 nM Human ADM 1-52, at the following final antibody concentrations: 100 ⁇ g/ml, 20 ⁇ g/ml, 4 ⁇ g/ml, 0.8 ⁇ g/ml, 0.16 ⁇ g/ml.
  • the anti-m-ADM antibodies (NT-M, MR-M, CT-M) were tested for antagonist activity in human recombinant adrenomedullin receptor (FAST-027C) cAMP functional assay in the presence of 0.67 nM Mouse ADM 1-50, at the following final antibody concentrations: 100 ⁇ g/ml, 20 ⁇ g/ml, 4 ⁇ g/ml, 0.8 ⁇ g/ml, 0.16 ⁇ g/ml. Data were plotted relative inhibition vs. antagonist concentration (see FIGS. 2 a to 2 l ). The maximal inhibition by the individual antibody is given in table 3.
  • the stabilizing effect of human ADM by human ADM antibodies was tested using a hADM immunoassay.
  • the technology used was a sandwich coated tube luminescence immunoassay, based on Acridinium ester labelling.
  • CT-H 100 ⁇ g (100 ⁇ l) CT-H (1 mg/ml in PBS, pH 7.4, AdrenoMed AG Germany) was mixed with 10 ⁇ l Acridinium NHS-ester (1 mg/ml in acetonitrile, InVent GmbH, Germany) (EP 0353971) and incubated for 20 min at room temperature.
  • Labelled CT-H was purified by Gel-filtration HPLC on Bio-Sil® SEC 400-5 (Bio-Rad Laboratories, Inc., USA) The purified CT-H was diluted in (300 mmol/L potassium phosphate, 100 mmol/L NaCl, 10 mmol/L Na-EDTA, 5 g/L Bovine Serum Albumin, pH 7.0). The final concentration was approx.
  • RLU relative light units
  • Polystyrene tubes (Greiner Bio-One International AG, Austria) were coated (18 h at room temperature) with MR-H (AdrenoMed AG, Germany) (1.5 ⁇ g MR-H/0.3 mL 100 mmol/L NaCl, 50 mmol/L TRIS/HCl, pH 7.8). After blocking with 5% bovine serum albumine, the tubes were washed with PBS, pH 7.4 and vacuum dried.
  • the assay was calibrated, using dilutions of hADM (BACHEM AG, Switzerland) in 250 mmol/L NaCl, 2 g/L Triton X-100, 50 g/L Bovine Serum Albumin, 20 tabs/L Protease Inhibitor Cocktail (Roche Diagnostics AG, Switzerland).
  • sample 50 ⁇ l was pipetted into coated tubes, after adding labeled CT-H (2000, the tubes were incubated for 4 h at 4° C. Unbound tracer was removed by washing 5 times (each 1 ml) with washing solution (20 mM PBS, pH 7.4, 0.1% Triton X-100).
  • FIG. 3 shows a typical hADM dose/signal curve. And an hADM dose signal curve in the presence of 100 ⁇ g/mL antibody NT-H. NT-H did not affect the described hADM immunoassay.
  • Human ADM was diluted in human Citrate plasma (final concentration 10 nM) and incubated at 24° C. At selected time points, the degradation of hADM was stopped by freezing at ⁇ 20° C. The incubation was performed in absence and presence of NT-H (100 ⁇ g/ml). The remaining hADM was quantified by using the hADM immunoassay described above.
  • FIG. 4 shows the stability of hADM in human plasma (citrate) in absence and in the presence of NT-H antibody.
  • the half-life of hADM alone was 7.8 h and in the presence of NT-H, the half-life was 18.3 h. (2.3 times higher stability).
  • mice 12-15 week old male C57Bl/6 mice (Charles River Laboratories, Germany) were used for the study. 6 mice were treated with (10 ⁇ l/g bodyweight) dose of NT-M, 0.2 mg/ml. As control, 6 mice were treated with (10 ⁇ l/g body weight) PBS. Survival and physical condition was monitored for 14 days. The mortality was 0 in both groups, there were no differences in physical condition between NT-M and control group.
  • mice were treated with vehicle and compound at different concentrations. Vehicle and compounds were supplied by the sponsor as A, B, C and D labelled tubes as “ready-to-use” solutions.
  • a single intravenous injection was performed 5 minutes prior to CLP in the dose 0.1/2/20 mg/kg body weight at a volume 5 ⁇ l/g body weight by tail vein injection.
  • Vehicle was 20 mM His/HCl, pH 6.0.
  • Terminal bleeding was performed from the survivors after 18 hours. 500 ⁇ l blood drawing at 6 h after CLP were obtained from 3 additional individuals per group by terminal bleeding. EDTA-plasma samples were deep frozen latest 1 h after sampling.
  • VEGF is known to increase endothelial vascular permeability and therefore acts as a supporting biomarker for the status of the kidney barrier function. As depicted in FIG. 7 there is a significant lower VEGF expression in all tested doses without any dose dependency.
  • Angiopoietin1 is known to protect against this VEGF-induced plasma leakage and therefore should be in reciprocal relation to the VEGF expression level. This is shown in FIG. 8 with significance for all tested doses.
  • NT-H significantly improves vascular integrity of the kidney of septic mice compared to the placebo group over all doses tested.
  • NT-H exploits a beneficial effect over a wide range of dosing with a slight trend of less effect at 20 mg/kg.
  • the results of this study indicate the application of the NT-H antibody has a positive effect by decreasing the endothelial vascular permeability and therefore preventing or protecting from vascular fluid extravasation and finally from congestion and/or edema.
  • Bio-ADM was measured from plasma collected during baseline evaluation in 1572 hospitalized AHF patients included in the PROTECT trial (all available baseline samples).
  • PROTECT (stands for “Placebo-controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function”) was a multicenter, randomized, double-blind trial that compared rolofylline against placebo in 2033 patients hospitalized for AHF.
  • Diuretic response was defined as weight loss by day 4 per 40 mg of diuretic dose.
  • Hemoconcentration was coded as 0 (if there is a decline or no change in hemoglobin levels by day 4 compared to baseline) or 1 (if there is an increase in hemoglobin levels by day 4 compared to baseline).
  • bio-ADM is an independent predictor of the severity of congestion and the strongest among all other available variables (table 5).
  • AUC area under the curve
  • bio-ADM is an independent predictor of significant residual congestion by day 7.
  • bio-ADM concentrations were higher the more diuretics were used for therapy (tables 7 and 8).
  • MR-proADM was determined. Baseline characteristics by tertiles of MR-proADM are shown in table 9: Similar to bio-ADM, increasing levels of MR-proADM were associated with increasing extent of edema.
  • BIOSTAT Study BIOlogy Study to TAilored Treatment in Chronic Heart Failure. The study has been described in detail (WWW.BIOSTAT-CHF.EU; Voors et al. 2016 . Eur J Heart Fail . June; 18(6):716-26).
  • the BIOlogy Study to TAilored Treatment in Chronic Heart Failure included 2516 patients with worsening signs and/or symptoms of heart failure from 11 European countries, who were considered to be on suboptimal medical treatment. Another 1738 patients from Scotland were included in a validation cohort. Overall, both patient cohorts were well matched. The majority of patients were hospitalized for acute heart failure, and the remainder presented with worsening signs and/or symptoms of heart failure at outpatient clinics.
  • MR-proADM was determined. Baseline characteristics by tertiles of MR-proADM are shown in table 11: Similar to bio-ADM, increasing levels of MR-proADM were associated with increasing extent of edema.
  • the main inclusion criteria were written informed consent, age 18-35 years, agreement to use a reliable way of contraception and a BMI between 18 and 30 kg/m 2 .
  • the baseline ADM-values in the 4 groups did not differ. Median ADM values were 7.1 pg/mL in the placebo group, 6.8 pg/mL in the first treatment group (0.5 mg/kg), 5.5 pg/mL in second treatment group (2 mg/kg) and 7.1 pg/mL in the third treatment group (8 mg/mL).
  • Controlled pressure mode ventilation was chosen to ventilate the animals with an inspiratory oxygen fraction of 0.5, an inspiratory/expiratory ratio of 1:1.5, PEEP set to 5 cm H 2 O and a tidal volume of 8-10 ml/kg BW.
  • the respiratory rate was set to maintain a PaCO 2 of 3.5-4.5 kPa.
  • the body core temperature was maintained above 37.5° C. with a warming blanket.
  • Two central venous catheter were inserted into the external jugular vein and the femoral vein and an arterial PICCO catheter was inserted into the femoral artery by transcutaneous puncture.
  • Haemorrhagic shock was induced by bleeding the animals via the femoral vein catheter. The animals were bled until half of the baseline MAP was reached. Haemorrhagic shock was maintained for 45 minutes, followed by fluid resuscitation with a balanced crystalloid solution in order to restore baseline mean arterial pressure. 2 hours after haemorrhagic shock the blood collected during haemorrhagic shock was re-transfused. As second hit, sepsis was induced using an E. coli -laden clot placed into the abdominal cavity 6 hours after haemorrhagic shock.
  • EDTA-Plasma and serum samples for several measurements were gained before haemorrhagic shock, before sepsis induction and 1, 2, 3, 4, 6, 8, 10 and 12 hours after sepsis induction, and stored at ⁇ 80° C. until measurement.
  • Haemorrhagic and septic shock were not performed on the animals of the SHAM-groups, but apart from that, they received the same treatment including all intravascular catheter, the median laparotomy and the blinded application of the antibody/vehicle solution, and blood samples were drawn as in septic animals.
  • the time schedule for treatment and drawing of blood samples is shown in FIG. 10 .
  • the ADM plasma concentration started to increase after sepsis induction in both groups. This increase was accelerated by the administration of NT-H antibody together with the sepsis induction. While the vehicle group showed an increase to approximately 30 pg/mL at one hour after sepsis induction, the treatment group showed 265 pg/mL at the same time point. The treatment reached a steady state of approximately 1,100 pg/mL 3 hours after application of NT-H antibody, while the vehicle group showed a constant increase of ADM concentration up to 700 pg/mL at the end of the experiment ( FIG. 11 ). Application of NT-H antibodies also induced an increase of plasma ADM in sham control animals. This is analogous to results seen in healthy humans (Example 8).
  • the heart rate (HR) increased at the point of blood removal for hemorrhagic shock in order to compensate the loss of volume and returned to initial values after volume replacement with crystalloid solution and blood.
  • HR heart rate
  • the heart rate remained constant at 60-65 min ⁇ 1 for the first hour and started afterwards to increase, where the rate of increase was higher in the vehicle group compared to the antibody treatment group with end values of 125 min ⁇ 1 (vehicle) compared to 98 min ⁇ 1 (treatment) ( FIG. 12 ).
  • Cardiac output describes the volume of blood being pumped by the heart, in particular by a left or right ventricle, per unit time. CO values can be represented using many physical units, such as L/min. The cardiac output in this study was significantly lower in the NT-H antibody treated group compared to the vehicle group ( FIG. 13 ).
  • Vascular resistance refers to the resistance to blood flow offered by all of the systemic vasculature, excluding the pulmonary vasculature.
  • Systemic vascular resistance (SVR) is used in calculations of blood pressure, blood flow, and cardiac function. SVR, in units of dyn ⁇ s ⁇ cm ⁇ 5 , was calculated from other measurements using the following formula:
  • SVR 80 ⁇ (MAP ⁇ CVP)/CO. SVR increases to tighten the arterial vascular circuit in an attempt to maintain blood pressure. As shown in FIG. 18 , the systemic vascular resistance in this animal model was higher in the NT-H treated group compared to the vehicle group.
  • the aim of this study was to examine the effect of HAM8101 on vascular permeability in liver and kidney following LPS-induced endotoxemia in rats.
  • the time course of the rADM plasma concentrations for the placebo (NaCl+LPS) group showed an increase over the first 6 hours after LPS application to a peak plasma concentration of 140 pg/mL with a subsequent decrease to 64 pg/mL at 24 hours.
  • Rats were treated with NaCl (healthy, green) or LPS at 5 mg/kg b.w (placebo, red); rats were further treated either with NaCl (placebo, red) or HAM8101 (blue) at different doses with a single i.v. bolus injection 5 minutes prior to LPS application.
  • Levels of rADM were determined 3, 6, and 24 hours after LPS application and are presented as (A) mean values ⁇ SEM or (B) as x-fold induction compared to placebo group at respective time-point
  • Vascular permeability was significantly increased after LPS challenge. There was a clear and significant reduction of vascular permeability upon treatment with HAM8101 at doses of 0.1 to 2.5 mg/kg HAM8101 in kidneys (see FIG.
  • Rats were treated with NaCl (control, green) or LPS at 5 mg/kg b.w (placebo, red); rats were further treated either with NaCl (placebo, red) or HAM8101 (blue) at different doses with a single i.v. bolus injection 5 minutes prior to LPS application.
  • Vascular permeability was measured by determination of Evans Blue concentration in (A) kidney and (B) liver tissue 24 hours after LPS challenge and treatment. Values are given as mean ⁇ SEM; p-values of ⁇ 0.05 were considered statistically significant.
  • FIG. 1 a Illustration of antibody formats—Fv and scFv-Variants.
  • FIG. 1 b Illustration of antibody formats—heterologous fusions and bifunctional antibodies.
  • FIG. 1 c Illustration of antibody formats—bivalental antibodies and bispecific antibodies.
  • FIG. 2
  • i Dose/inhibition curve of MR-M in the presence of 0.67 nM mADM.
  • FIG. 3 This figure shows a typical hADM dose/signal curve. And an hADM dose signal curve in the presence of 100 ⁇ g/mL antibody NT-H.
  • FIG. 4 This figure shows the stability of hADM in human plasma (citrate) in absence and in the presence of NT-H antibody.
  • FIG. 5 Alignment of the Fab with homologous human framework sequences.
  • FIG. 6 Extravascular Albumin accumulation 18 h after CLP and NT-M application on different doses.
  • FIG. 7 VEGF expression 18 h after CLP and NT-M application at different doses.
  • FIG. 8 Angiopoetin-1 expression 18 hours after CLP and NT-M application at different doses.
  • FIG. 9 ADM-concentration in healthy human subjects after NT-H application at different doses up to 60 days.
  • FIG. 10 Time schedule for treatment and drawing of blood samples in the two-hit pig model.
  • FIG. 16 Noradrenalin demand/application of vehicle (squares) and treatment (dots) group (mean values with SEM).
  • FIG. 19 rADM Concentrations in LPS-Induced Endotoxemia Rat Model
  • FIG. 20 Vascular Permeability in an Endotoxemia Rat Model

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