WO2005038056A1 - Combination therapy for the treatment of viral diseases - Google Patents

Combination therapy for the treatment of viral diseases Download PDF

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Publication number
WO2005038056A1
WO2005038056A1 PCT/US2004/033965 US2004033965W WO2005038056A1 WO 2005038056 A1 WO2005038056 A1 WO 2005038056A1 US 2004033965 W US2004033965 W US 2004033965W WO 2005038056 A1 WO2005038056 A1 WO 2005038056A1
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antagonist
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PCT/US2004/033965
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French (fr)
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Lawrence M. Blatt
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Intermune, Inc.
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/19—Cytokines; Lymphokines; Interferons
    • A61K38/21—Interferons [IFN]
    • A61K38/212—IFN-alpha
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/177—Receptors; Cell surface antigens; Cell surface determinants
    • A61K38/1793—Receptors; Cell surface antigens; Cell surface determinants for cytokines; for lymphokines; for interferons
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/19—Cytokines; Lymphokines; Interferons
    • A61K38/21—Interferons [IFN]
    • A61K38/217—IFN-gamma
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
    • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07H—SUGARS; DERIVATIVES THEREOF; NUCLEOSIDES; NUCLEOTIDES; NUCLEIC ACIDS
    • C07H21/00—Compounds containing two or more mononucleotide units having separate phosphate or polyphosphate groups linked by saccharide radicals of nucleoside groups, e.g. nucleic acids
    • C07H21/04—Compounds containing two or more mononucleotide units having separate phosphate or polyphosphate groups linked by saccharide radicals of nucleoside groups, e.g. nucleic acids with deoxyribosyl as saccharide radical

Definitions

  • This invention is in the field of viral infection, particularly hepatitis C viral infection.
  • HCV infection is the most common chronic blood borne infection in the United States. Although the numbers of new infections have declined, the burden of chronic infection is substantial, with Centers for Disease Control estimates of 3.9 million (1.8%) infected persons in the United States.
  • Chronic liver disease is the tenth leading cause of death among adults in the United States, and accounts for approximately 25,000 deaths annually, or approximately 1% of all deaths. Studies indicate that 40% of chronic liver disease is HCV-related, resulting in an estimated 8,000-10,000 deaths each year. HCV-associated end- stage liver disease is the most frequent indication for liver transplantation among adults.
  • the present invention provides methods of treating viral infection; methods of treating hepatitis C virus (HCV) infection; methods of reducing the incidence of complications associated with HCV and cirrhosis of the liver; and methods of reducing viral load, or reducing the time to viral clearance, or reducing morbidity or mortality in the clinical outcomes, in patients suffering from viral infection.
  • the methods generally involve administering a therapeutically effective amount of (i) a Type I or Type III interferon receptor agonist, (ii) a Type II interferon receptor agonist, and (iii) a TNF- ⁇ antagonist, for the treatment of viral infection.
  • the invention features a method of treating viral infection, generally involving administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF- ⁇ antagonist concurrently, in an amount effective to ameliorate the clinical course of the disease.
  • the invention also features a method of treating virus infection by administering to an individual (i) a Type I interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF- ⁇ antagonist in a synergistically effective amount to ameliorate the clinical course of the disease.
  • the invention features a method of treating HCV infection, generally involving administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF- ⁇ antagonist concurrently, in an amount effective to achieve a sustained viral response.
  • the invention also features a method of treating HCV infection by administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF- ⁇ antagonist in a synergistically effective amount to achieve a sustained viral response.
  • a Type I or Type III interferon receptor agonist ii) a Type II interferon receptor agonist and (iii) a TNF- ⁇ antagonist are administered to the individual.
  • two or more of the drugs are administered in the same formulation.
  • the Type I or III interferon receptor agonist, the Type II interferon receptor agonist and the T ⁇ F- ⁇ antagonist are administered in two or more separate formulations.
  • a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a T ⁇ F- ⁇ antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another.
  • a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist are administered subcutaneously in multiple doses.
  • the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or T ⁇ F- ⁇ antagonist is/are administered to the individual by a controlled drug delivery device.
  • the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist is/are administered to the individual substantially continuously or continuously by a controlled drug delivery device.
  • the controlled drug delivery device is an implantable infusion pump and the infusion pump delivers the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist to the individual by subcutaneous infusion.
  • ribavirin is co-administered with a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist.
  • ribavirin is co-administered with a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, a T ⁇ F- ⁇ antagonist, and pirfenidone (or a pirfenidone analog).
  • any of the above-described methods involve administering IF ⁇ - ⁇ , IF ⁇ - ⁇ and a TNF- ⁇ antagonist.
  • the methods involve co- administering ribavirin, IFN- ⁇ , IFN- ⁇ , and a TNF- ⁇ antagonist.
  • the methods involve co-administering ribavirin, IFN- ⁇ , IFN- ⁇ , a T ⁇ F- ⁇ antagonist, and pirfenidone or a pirfenidone analog.
  • any of the above-described methods involve administering a Type I interferon receptor agonist that is a PEGylated IF ⁇ - ⁇ conjugate.
  • the PEGylated IF ⁇ - ⁇ conjugate is a monoPEGylated IF ⁇ - ⁇ .
  • the monoPEGylated IFN- ⁇ conjugate is an IFN- ⁇ polypeptide covalently linked to a single PEG moiety via a lysine residue or the N-terminal a ino acid residue of the IFN- ⁇ polypeptide.
  • the monoPEGylated IFN- ⁇ conjugate is an IF ⁇ - ⁇ polypeptide covalently linked to a single PEG moiety via an amide bond between either the epsilon-amino group of a lysine residue or the alpha-amino group of the IF ⁇ - ⁇ polypeptide and an activated carboxyl group of the PEG moiety.
  • the monoPEGylated IFN- ⁇ conjugate is an IFN- ⁇ polypeptide covalently linked to a single, linear PEG moiety.
  • the monoPEGylated IFN- ⁇ conjugate is an IFN- ⁇ polypeptide covalently linked to a single, linear 30 kD PEG moiety ("monoPEG(30 kD, linear)-ylated IFN- ⁇ ")-
  • the monoPEGylated IF ⁇ - ⁇ conjugate is an IF ⁇ - ⁇ polypeptide covalently linked to a single, linear 30 kD PEG moiety via an amide bond between the epsilon- amino group of a lysine residue or the alpha-amino group of the IF ⁇ - ⁇ polypeptide and an activated carboxyl group of the PEG moiety.
  • the monoPEGylated IF ⁇ - ⁇ conjugate is an IFN- ⁇ polypeptide covalently linked to a single, linear 30 kD PEG via an amide bond between the epsilon-amino group of a lysine residue or the alpha-amino group of the IFN- ⁇ polypeptide and an activated propionyl group of the PEG moiety.
  • the monoPEGylated IFN- ⁇ conjugate is an IFN- ⁇ polypeptide covalently linked to a single, linear monomethoxy-PEG (mPEG).
  • the monoPEGylated IFN- ⁇ conjugate is the product of a condensation reaction between an IFN- ⁇ polypeptide and a linear, succinimidyl propionate ester-activated 30 kD mPEG.
  • the IFN- ⁇ polypeptide can be a consensus interferon (CIF ⁇ ) polypeptide.
  • the IFN- ⁇ polypeptide can be a CIFN polypeptide that is interferon alfacon-1.
  • hepatic fibrosis used interchangeably herein with “liver fibrosis,” refers to the growth of scar tissue in the liver that can occur in the context of a chronic hepatitis infection.
  • the tenns "individual,” “host,” “subject,” and “patient” are used interchangeably herein, and refer to a mammal, including, but not limited to, murines, simians, humans, mammalian farm animals, mammalian sport animals, and mammalian pets.
  • liver function refers to a normal function of the liver, including, but not limited to, a synthetic function, including, but not limited to, synthesis of proteins such as serum proteins (e.g., albumin, clotting factors, alkaline phosphatase, aminotransferases (e.g., alanine transaminase, aspartate transaminase), 5'-nucleosidase, ⁇ - glutaminyltranspeptidase, etc.), synthesis of bilirubin, synthesis of cholesterol, and synthesis of bile acids; a liver metabolic function, including, but not limited to, carbohydrate metabolism, amino acid and ammonia metabolism, hormone metabolism, and lipid metabolism; detoxification of exogenous drugs; a hemodynamic function, including splanchnic and portal hemodynamics; and the like.
  • proteins such as serum proteins (e.g., albumin, clotting factors, alkaline phosphatase, aminotransferases (e.g., a
  • sustained viral response refers to the response of an individual to a treatment regimen for HCV infection, in terms of serum HCV titer.
  • a sustained viral response refers to no detectable HCV RNA (e.g., less than about 500, less than about 200, or less than about 100 genome copies per milliliter serum) found in the patient's serum for a period of at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, or at least about six months following cessation of treatment.
  • Treatment failure patients generally refers to HCV-infected patients who failed to respond to previous therapy for HCV (referred to as “non-responders") or who initially responded to previous therapy, but in whom the therapeutic response was not maintained (referred to as “relapsers").
  • the previous therapy generally can include treatment with IFN- ⁇ monotherapy or IFN- ⁇ combination therapy, where the combination therapy may include administration of IFN- ⁇ and an antiviral agent such as ribavirin.
  • treatment refers to obtaining a desired pharmacologic and/or physiologic effect.
  • the effect may be prophylactic in terms of completely or partially preventing a disease or symptom thereof and/or may be therapeutic in terms of a partial or complete cure for a disease and/or adverse affect attributable to the disease.
  • Treatment covers any treatment of a disease in a mammal, particularly in a human, and includes: (a) preventing the disease from occurring in a subject which may be predisposed to the disease but has not yet been diagnosed as having it; (b) inhibiting the disease, i.e., arresting its development; and (c) relieving the disease, i.e., causing regression of the disease.
  • pirfenidone means 5-methyl-l-phenyl-2-(lH)-pyridone.
  • pirfenidone analog means any compound of Formula I, IIA or IIB below.
  • a "specific pirfenidone analog,” and all grammatical variants thereof, refers to, and is limited to, each and every pirfenidone analog shown in Table 1.
  • Type I interferon receptor agonist refers to any naturally occurring or non-naturally occurring ligand of human Type I interferon receptor, which binds to and causes signal transduction via the receptor.
  • Type I interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non-peptide chemical agonists; and the like.
  • Type II interferon receptor agonist refers to any naturally- occurring or non-naturally-occurring ligand of a human Type II interferon receptor which binds to and causes signal transduction via the receptor.
  • Type II interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non-peptide chemical agonists; and the like.
  • a Type III interferon receptor agonist refers to any naturally occurring or non-naturally occurring ligand of humanIL-28 receptor ⁇ ("IL-28R”), the amino acid sequence of which is described by Sheppard, et al., infra., that binds to and causes signal transduction via the receptor.
  • IL-28R humanIL-28 receptor ⁇
  • dosing event refers to administration of an antiviral agent to a patient in need thereof, which event may encompass one or more releases of an antiviral agent from a drug dispensing device.
  • the term "dosing event,” as used herein includes, but is not limited to, installation of a continuous delivery device (e.g., a pump or other controlled release injectible system); and a single subcutaneous injection followed by installation of a continuous delivery system.
  • Continuous delivery as used herein (e.g. , in the context of “continuous delivery of a substance to a tissue”) is meant to refer to movement of drug to a delivery site, e.g., into a tissue in a fashion that provides for delivery of a desired amount of substance into the tissue over a selected period of time, where about the same quantity of drug is received by the patient each minute during the selected period of time.
  • Controlled release as used herein (e.g. , in the context of “controlled drug release”) is meant to encompass release of substance (e.g., a Type I or Type III interferon receptor agonist, e.g., IFN- ⁇ ) at a selected or otherwise controllable rate, interval, and/or amount, which is not substantially influenced by the environment of use.
  • substance e.g., a Type I or Type III interferon receptor agonist, e.g., IFN- ⁇
  • Controlled release thus encompasses, but is not necessarily limited to, substantially continuous delivery, and patterned delivery (e.g., intermittent delivery oVer a period of time that is interrupted by regular or irregular time intervals).
  • “Patterned” or “temporal” as used in the context of drug delivery is meant delivery of drug in a pattern, generally a substantially regular pattern, over a pre-selected period of time (e.g. , other than a period associated with, for example a bolus injection).
  • “Patterned” or “temporal” drug delivery is meant to encompass delivery of drug at an increasing, decreasing, substantially constant, or pulsatile, rate or range of rates (e.g., amount of drug per unit time, or volume of drug formulation for a unit time), and further encompasses delivery that is continuous or substantially continuous, or chronic.
  • controlled drug delivery device is meant to encompass any device wherein the release (e.g., rate, timing of release) of a drug or other desired substance contained therein is controlled by or determined by the device itself and not substantially influenced by the environment of use, or releasing at a rate that is reproducible within the environment of use.
  • substantially continuous as used in, for example, the context of “substantially continuous infusion” or “substantially continuous delivery” is meant to refer to delivery of drug in a manner that is substantially uninterrupted for a pre-selected period of drug delivery, where the quantity of drug received by the patient during any 8 hour interval in the pre-selected period never falls to zero.
  • substantially continuous drug delivery can also encompass delivery of drug at a substantially constant, pre-selected rate or range of rates (e.g., amount of drug per unit time, or volume of drug formulation for a unit time) that is substantially uninterrupted for a pre-selected period of drug delivery.
  • substantially steady state as used in the context of a biological parameter that may vary as a function of time, it is meant that the biological parameter exhibits a substantially constant value over a time course, such that the area under the curve defined by the value of the biological parameter as a function of time for any 8 hour period during the time course ' (AUC 8hr ) is no more than about 20% above or about 20% below, and preferably no more than about 15% above or about 15% below, and more preferably no more than about 10% above or about 10%) below, the average area under the curve of the biological parameter over an 8 hour period during the time course (AUC 8 h r average)- The AUC h.
  • the serum concentration of the drug is maintained at a substantially steady state during a time course when the area under the curve of serum concentration of the drug over time for any 8 hour period during the time course (AUC 8r ⁇ r ) is no more than about 20% above or about 20% below the average area under the curve of serum concentration of the drug over an 8 hour period in the time course (AUC 8 i, r average), i-e., the AUC 8 _ ir is no more than 20% above or 20% below the AUC 8 h r average for the serum concentration of the drug over the time course.
  • any compound or agent described as "effective for the avoidance or amelioration of side effects induced by Type I interferon receptor agonist and/or Type II interferon receptor agonist,” or as “effective for reducing or eliminating the severity or occurrence of side effects induced by Type I interferon receptor agonist and/or Type II interferon receptor agonist,” or any compound or agent described by language with a meaning similar or equivalent to that of either of the foregoing quoted passages, is/are defined as a compound(s) or agent(s) that when co-administered to a patient in an effective amount along with a given dosing regimen of Type I interferon receptor agonist and Type II interferon receptor agonist combination therapy, abates or eliminates the severity or occurrence of side effects experienced by a patient in response to the given dosing regimen of the interferon receptor agonist combination therapy, as compared to the severity or occurrence of side effects that would have been experienced by the patient in response to the same dosing regimen of the interferon receptor
  • the effective amounts of a Type II interferon receptor agonist a Type I or III interferon receptor agonist, and a TNF- ⁇ antagonist are synergistic amounts.
  • a "synergistic combination" or a "synergistic amount" of a Type II interferon receptor agonist, a Type I or III interferon receptor agonist, and a-T ⁇ F- ⁇ antagonist is a combination or amount that is more effective in the therapeutic or prophylactic treatment of a disease than the incremental improvement in treatment outcome that could be predicted or expected from a merely additive combination of (i) the therapeutic or prophylactic benefit of the Type II interferon receptor agonist when administered at that same dosage as a monotherapy (ii) the therapeutic or prophylactic benefit of the Type I or III interferon receptor agonist when administered at the same dosage as a monotherapy and (iii) the therapeutic or prophylactic benefit of the T ⁇ F- ⁇ antagonist when administered at the same dosage as a monotherapy.
  • a selected amount of a Type II interferon receptor agonist, a selected amount of a Type I or III interferon receptor agonist, and a selected amount of a T ⁇ F- ⁇ antagonist are effective when used in triple therapy for a disease, but the selected amount of the Type II interferon receptor agonist, the selected amount of the Type I or III interferon receptor agonist, or the selected amount of the TNF ⁇ - ⁇ antagonist is ineffective when used in monotherapy for the disease, or combination(s) of any two of the foregoing drugs are ineffective when used in double therapy for the disease.
  • the invention encompasses: (1) regimens in which a selected amount of a Type I or III interferon receptor agonist enhances the therapeutic benefit of a selected amount of (i) a Type II interferon receptor agonist and (ii) a T ⁇ F- ⁇ antagonist when used in triple therapy for a disease, where the selected amount of the Type I or III interferon receptor agonist provides no therapeutic benefit when used in monotherapy for the disease; (2) regimens in which a selected amount of a Type II interferon receptor agonist enhances the therapeutic benefit of a selected amount of (i) a Type I or III interferon receptor agonist and (ii) a TNF- ⁇ antagonist when used in triple therapy for a disease, where the selected amount of the Type II interferon receptor agonist provides no therapeutic benefit when used in monotherapy for the disease; (3) regimens in which a selected amount of a TNF- ⁇ antagonist enhances the therapeutic benefit of (i) a selected amount of a Type II interferon receptor agonist and (ii) a Type I
  • a "synergistically effective amount” or “synergistically effective combination” of a Type II interferon receptor agonist, a Type I or III interferon receptor agonist, and a TNF- ⁇ antagonist, and its grammatical equivalents " shall be understood to include any regimen encompassed by any of (l)-(7) above.
  • the present invention provides methods of treating viral infections, including methods of treating HCV infection.
  • the methods generally involve administering an effective amount of a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist, to an individual in need thereof. Of particular interest in many embodiments is treatment of humans.
  • the present invention provides methods for treating viral infection.
  • the methods generally involve administering a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist to an individual in an amount that is effective to ameliorate the clinical course of the disease.
  • Whether a subject method is effective in treating a viral infection can be determined by a reduction in number or length of hospital stays, a reduction in time to viral clearance, a reduction of morbidity or mortality in clinical outcomes, or other indicator of disease response.
  • an effective amount of a Type I or Type III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist is an amount that is effective to (i) reduce the time to viral clearance, (ii) reduce morbidity or mortality in the clinical course of the disease or (iii) reduce viral load in the patient.
  • the present invention provides methods for treating HCV.
  • the methods generally involve administering a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist, to an individual in an amount that is effective to decrease viral load in the individual, and to achieve a sustained viral response.
  • Whether a subject method is effective in treating an HCV infection can be determined by measuring viral load, or by measuring a parameter associated with HCV infection, including, but not limited to, liver fibrosis, elevations in serum transaminase levels, and necroinflammatory activity in the liver. Indicators of liver fibrosis are discussed in detail below.
  • Viral load can be measured by measuring the titer or level of virus in serum. These methods include, but are not limited to, a quantitative polymerase chain reaction (PCR) and a branched DNA (bDNA) test. Quantitative assays for measuring the viral load (titer) of HCV RNA have been developed. Many such assays are available commercially, including a quantitative reverse transcription PCR (RT-PCR) (Amplicor HCV MonitorTM, Roche Molecular Systems, New Jersey); and a branched DNA (deoxyribonucleic acid) signal amplification assay (QuantiplexTM HCV RNA Assay (bDNA), Chiron Corp., Emeryville, California). See, e.g., Gretch et al. (1995) Ann. Intern. Med. 123:321-329.
  • RT-PCR quantitative reverse transcription PCR
  • bDNA branched DNA signal amplification assay
  • an effective amount of a Type I or III interferon receptor agonist, a Type II interferon receptor agonist, and a T ⁇ F- ⁇ antagonist is an amount that is effective to reduce viral load to undetectable levels, e.g., to less than about 5000, less than about 1000, less than about 500, or less than about 200 genome copies/mL serum.
  • an effective amount of a Type I or Type III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist is an amount that is effective to reduce viral load to less than 100 genome copies/mL serum.
  • the methods of the invention achieve a sustained viral response, e.g., the viral load is reduced to undetectable levels for a period of at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, or at least about six months following cessation of treatment.
  • liver fibrosis As noted above, whether a subject method is effective in treating an HCV infection can be determined by measuring a parameter associated with HCV infection, such as liver fibrosis. Methods of determining the extent of liver fibrosis are discussed in detail below. In some embodiments, the level of a serum marker of liver fibrosis indicates the degree of liver fibrosis.
  • ALT levels of serum alanine aminotransferase are measured, using standard assays. In general, an ALT level of less than about 45 international units is considered normal.
  • an effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist is an amount effective to reduce ALT levels to less than about 45 U/ml serum.
  • a therapeutically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist is an amount that is effective to reduce a serum level of a marker of liver fibrosis by at least about 10%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, or at least about 80%, or more, compared to the level of the marker in an untreated individual, or to a placebo-treated individual.
  • Methods of measuring serum markers include immunological-based methods, e.g., enzyme-linked immunosorbent assays (ELISA), radioimmunoassays, and the like, using antibody specific for a given serum marker.
  • ELISA enzyme-linked immunosorbent assays
  • radioimmunoassays radioimmunoassays, and the like, using antibody specific for a given serum marker.
  • Type I interferon receptor agonists include an IFN- ⁇ ; an IFN- ⁇ ; an IFN-tau; an IFN- ⁇ ; antibody agonists specific for a Type I interferon receptor; and any other agonist of Type I interferon receptor, including non-polypeptide agonists.
  • Interferon-Alpha Interferon-Alpha
  • IFN- ⁇ any known IFN- ⁇ can be used in the instant invention.
  • interferon-alpha refers to a family of related polypeptides that inhibit viral replication and cellular proliferation and modulate immune response.
  • IFN- ⁇ includes naturally occurring IFN- ⁇ ; synthetic IFN- ⁇ ; derivatized IFN- ⁇ (e.g., PEGylated IFN- ⁇ , glycosylated IFN- ⁇ , and the like); and analogs of naturally occurring or synthetic IFN- ⁇ ; essentially any IFN- ⁇ that has antiviral properties, as described for naturally occurring IFN- ⁇ .
  • Suitable alpha interferons include, but are not limited to, naturally-occurring IFN- ⁇ (including, but not limited to, naturally occurring IFN- ⁇ 2a, IFN- ⁇ 2b); recombinant interferon alpha-2b such as Intron-A interferon available from Schering Corporation, Kenilworth, N.J.; recombinant interferon alpha-2a such as Roferon interferon available from Hoffmann-La Roche, Nutley, N.
  • interferon alpha-2C such as Berofor alpha 2 interferon available from Boehringer Ingelheim Pharmaceutical, Inc., Ridgefield, Conn.
  • interferon alpha- nl a purified blend of natural alpha interferons such as Sumiferon available from Sumitomo, Japan or as Wellferon interferon alpha-nl (INS) available from the Glaxo-Wellcome Ltd., London, Great Britain
  • interferon alpha-n3 a mixture of natural alpha interferons made by Interferon Sciences and available from the Purdue Frederick Co., ⁇ orwalk, Conn., under the Alferon Tradename.
  • IF ⁇ - ⁇ also encompasses consensus IF ⁇ - ⁇ .
  • Consensus IFN- ⁇ also referred to as “CIFN” and “IFN-con” and “consensus interferon” encompasses but is not limited to the amino acid sequences designated IFN-coni, IFN-con 2 and IFN-con 3 which are disclosed in U.S. Pat. Nos. 4,695,623 and 4,897,471; and consensus interferon as defined by determination of a consensus sequence of naturally occurring interferon alphas (e.g., Infergen®, InterMune, Inc., Brisbane, Calif).
  • IFN-con 1 is the consensus interferon agent in the Infergen® alfacon-1 product.
  • IFN-con The Infergen® consensus interferon product is referred to herein by its brand name (Infergen®) or by its generic name (interferon alfacon-1). DNA sequences encoding IFN-con may be synthesized as described in the aforementioned patents or other standard methods. Use of CIFN is of particular interest.
  • fusion polypeptides comprising an IF ⁇ - ⁇ and a heterologous polypeptide.
  • IFN- ⁇ fusion polypeptides include, but are not limited to, Albuferon-alphaTM (a fusion product of human albumin and IFN- ⁇ ; Human Genome Sciences; see, e.g., Osborn et al. (2002) J Pharmacol. Exp. Therap. 303:540-548).
  • gene-shuffled forms of IFN- ⁇ See., e.g., Masci et al. (2003) Curr. Oncol. Rep. 5:108-113.
  • IFN- ⁇ also encompasses derivatives of IFN- ⁇ that are derivatized (e.g., are chemically modified) to alter certain properties such as serum half-life.
  • IFN-a includes glycosylated IFN- ⁇ ; IFN- ⁇ derivatized with polyethylene glycol ("PEGylated IF ⁇ - ⁇ "); and the like. PEGylated IFN- ⁇ , and methods for making same, is discussed in, e.g., U.S. Patent Nos. 5,382,657; 5,981,709; and 5,951,974.
  • PEGylated IFN- ⁇ encompasses conjugates of PEG and any of the above-described IFN- ⁇ molecules, including, but not limited to, PEG conjugated to interferon alpha-2a (Roferon, Hoffman La-Roche, Nutley, N. J.), interferon alpha 2b (Intron, Schering-Plough, Madison, N. j.), interferon alpha-2c (Berofor Alpha, Boehringer Ingelheim, Ingelheim, Germany); and consensus interferon as defined by determination of a consensus sequence of naturally occurring interferon alphas (Infergen®, InterMune, Inc., Brisbane, Calif).
  • any of the above-mentioned IFN- ⁇ polypeptides can be modified with one or more polyethylene glycol moieties, i.e., PEGylated.
  • the PEG molecule of a PEGylated IFN- ⁇ polypeptide is conjugated to one or more amino acid side chains of the IFN- ⁇ polypeptide.
  • the PEGylated IFN- ⁇ contains a PEG moiety on only one amino acid.
  • the PEGylated IFN- ⁇ contains a PEG moiety on two or more amino acids, e.g., the IFN- ⁇ contains a PEG moiety attached to two, three, four, five, six, seven, eight, nine, or ten different amino acid residues.
  • IFN- ⁇ may be coupled directly to PEG (i.e., without a linking group) through an amino group, a sulfhydryl group, a hydroxyl group, or a carboxyl group.
  • the PEGylated IFN- ⁇ is PEGylated at or near the amino terminus (N-terminus) of the IFN- ⁇ polypeptide, e.g., the PEG moiety is conjugated to the IFN- ⁇ polypeptide at one or more amino acid residues from amino acid 1 through amino acid 4, or from amino acid 5 through about 10.
  • the PEGylated IFN- ⁇ is PEGylated at one or more amino acid residues from about 10 to about 28.
  • the PEGylated IFN- ⁇ is PEGylated at or near the carboxyl terminus (C-terminus) of the IFN- ⁇ polypeptide, e.g., at one or more residues from amino acids 156-166, or from amino acids 150 to 155.
  • the PEGylated IFN- ⁇ is PEGylated at one or more amino acid residues at one or more residues from amino acids 100-114.
  • amino acids at which PEGylation is to be avoided include amino acid residues from amino acid 30 to amino acid 40; and amino acid residues from amino acid 113 to amino acid 149.
  • PEG is attached to IFN- ⁇ via a linking group.
  • the linking group is any biocompatible linking group, where "biocompatible" indicates that the compound or group is non-toxic and may be utilized in vitro or in vivo without causing injury, sickness, disease, or death.
  • PEG can be bonded to the linking group, for example, via an ether bond, an ester bond, a thiol bond or an amide bond.
  • Suitable biocompatible linking groups include, but are not limited to, an ester group, an amide group, an imide group, a carbamate group, a carboxyl group, a hydroxyl group, a carbohydrate, a succinimide group (including, for example, succinimidyl succinate (SS), succinimidyl propionate (SPA), succinimidyl butanoate (SBA), succinimidyl carboxymethylate (SCM), succinimidyl succinamide (SSA) orN-hydroxy succinimide (NHS)), an epoxide group, an oxycarbonylimidazole group (including, for example, carbonyldimidazole (GDI)), a nitro phenyl group (including, for example, nitrophenyl carbonate (NPC) or trichlorophenyl carbonate (TPC)), a trysylate group, an aldehyde group, an isocyanate group, a vinylsulfone group, a
  • succinimidyl propionate (SPA) and succinimidyl butanoate (SBA) ester-activated PEGs are described in U.S. Pat. No. 5,672,662 (Harris, et al.) and WO 97/03106.
  • Pegylated IFN- ⁇ and methods for making same, is discussed in, e.g., U.S. Patent Nos. 5,382,657; 5,981,709; 5,985,265; and 5,951,974.
  • Pegylated IFN- ⁇ encompasses conjugates of PEG and any of the above-described IFN- ⁇ molecules, including, but not limited to, PEG conjugated to interferon alpha-2a (Roferon, Hoffman LaRoche, Nutley, N. J.), where PEGylated Roferon is known as Pegasys (Hoffman LaRoche); interferon alpha 2b (Intron, Schering-Plough, Madison, N.
  • PEGylated Intron is known as PEG-Intron (Schering- Plough); interferon alpha-2c (Berofor Alpha, Boehringer Ingelheim, Ingelheim, Germany); and consensus interferon (CIFN) as defined by determination of a consensus sequence of naturally occurring interferon alphas (Infergen®, InterMune, Inc., Brisbane, Calif), where PEGylated Infergen is referred to as PEG-Infergen.
  • the PEG is a monomethoxyPEG molecule that reacts with primary amine groups on the IFN- ⁇ polypeptide.
  • Methods of modifying polypeptides with monomethoxy PEG via reductive alkylation are known in the art. See, e.g., Chamow et al. (1994) Bzoconj. Chem. 5:133-140.
  • PEG is linked to IFN- ⁇ via an SPA linking group.
  • SPA esters of PEG, and methods for making same, are described in U.S. Patent No. 5,672,662.
  • SPA linkages provide for linkage to free amine groups on the IFN- ⁇ polypeptide.
  • a PEG molecule is covalently attached via a linkage that comprises an amide bond between a propionyl group of the PEG moiety and the epsilon amino group of a surface-exposed lysine residue in the IFN- ⁇ polypeptide.
  • Such a bond can be formed, e.g., by condensation of an ⁇ -methoxy, omega propanoic acid activated ester of PEG (mPEGspa).
  • one monopegylated CIFN conjugate preferred for use herein has a linear PEG moiety of about 30 kD attached via a covalent linkage to the CIFN polypeptide, where the covalent linkage is an amide bond between a propionyl group of the PEG moiety and the epsilon amino group of a surface-exposed lysine residue in the CIFN polypeptide, where the surface-exposed lysine residue is chosen from lys 31 , lys 50 , lys 71 , lys 84 , lys , lys , lys , lys , and lys , and the amide bond is formed by condensation of an ⁇ - methoxy, omega propanoic acid activated ester of PEG.
  • Polyethylene glycol Polyethylene glycol
  • Polyethylene glycol suitable for conjugation to an IFN- ⁇ polypeptide is soluble in water at room temperature, and has the general formula R(O-CH 2 -CH 2 ) n O-R, where R is hydrogen or a protective group such as an alkyl or an alkanol group, and where n is an integer from 1 to 1000. Where R is a protective group, it generally has from 1 to 8 carbons.
  • PEG has at least one hydroxyl group, e.g., a terminal hydroxyl group, which hydroxyl group is modified to generate a functional group that is reactive with an amino group, e.g., an epsilon amino group of a lysine residue, a free amino group at the N- terminus of a polypeptide, or any other amino group such as an amino group of asparagine, glutamine, arginine, or histidine.
  • an amino group e.g., an epsilon amino group of a lysine residue, a free amino group at the N- terminus of a polypeptide, or any other amino group such as an amino group of asparagine, glutamine, arginine, or histidine.
  • PEG is derivatized so that it is reactive with free carboxyl groups in the IFN- ⁇ polypeptide, e.g., the free carboxyl group at the carboxyl terminus of the IF ⁇ - ⁇ polypeptide.
  • Suitable derivatives of PEG that are reactive with the free carboxyl group at the carboxyl-terminus of IF ⁇ - ⁇ include, but are not limited to PEG-amine, and hydrazine derivatives of PEG (e.g., PEG-NH-NH 2 ).
  • PEG is derivatized such that it comprises a terminal thiocarboxylic acid group, -COSH, which selectively reacts with amino groups to generate amide derivatives.
  • -SH a terminal thiocarboxylic acid group
  • selectivity of certain amino groups over others is achieved.
  • -SH exhibits sufficient leaving group ability in reaction with N-terminal amino group at appropriate pH conditions such that the ⁇ -amino groups in lysine residues are protonated and remain non-nucleophilic.
  • reactions under suitable pH conditions may make some of the accessible lysine residues to 'react with selectivity.
  • the PEG comprises a reactive ester such as an N-hydroxy succinimidate at the end of the PEG chain.
  • a reactive ester such as an N-hydroxy succinimidate at the end of the PEG chain.
  • Such an N-hydroxysuccinimidate-containing PEG molecule reacts with select amino groups at particular pH conditions such as neutral 6.5-7.5.
  • the N-terminal amino groups may be selectively modified under neutral pH conditions.
  • accessible-NH 2 groups of lysine may also react.
  • the PEG can be conjugated directly to the IFN- ⁇ polypeptide, or through a linker.
  • a linker is added to the IFN- ⁇ polypeptide, forming a linker-modified IF ⁇ - ⁇ polypeptide.
  • Such linkers provide various functionalities, e.g., reactive groups such sulfhydryl, amino, or carboxyl groups to couple a PEG reagent to the linker-modified IFN- ⁇ polypeptide.
  • the PEG conjugated to the IFN- ⁇ polypeptide is linear. In other embodiments, the PEG conjugated to the IFN- ⁇ polypeptide is branched. Branched PEG derivatives such as those described in U.S. Pat. No. 5,643,575, "star-PEG's” and multi-armed PEG's such as those described in Shearwater Polymers, Inc. catalog "Polyethylene Glycol Derivatives 1997-1998.” Star PEGs are described in the art including, e.g., in U.S. Patent No. 6,046,305.
  • PEG having a molecular weight in a range of from about 2 kDa to about 100 kDa is generally used, where the term "about,” in the context of PEG, indicates that in preparations of polyethylene glycol, some molecules will weigh more, some less, than the stated molecular weight.
  • PEG suitable for conjugation to IFN- ⁇ has a molecular weight of from about 2 kDa to about 5 kDa, from about 5 kDa to about 10 kDa, from about 10 kDa to about 15 kDa, from about 15 kDa to about 20 kDa, from about 20 kDa to about 25 kDa, from about 25 kDa to about 30 kDa, from about 30 kDa to about 40 kDa, from about 40 kDa to about 50 kDa, from about 50 kDa to about 60 kDa, from about 60 kDa to about 70 kDa, from about 70 kDa to about 80 kDa, from about 80 kDa to about 90 kDa, or from about 90 kDa to about 100 kDa.
  • the PEG moiety can be attached, directly or via a linker, to an amino acid residue at or near the N-terminus, internally, or at or near the C-terminus of the IFN- ⁇ polypeptide. Conjugation can be carried out in solution or in the solid phase. N-terminal linkage
  • Methods for attaching a PEG moiety to an amino acid residue at or near the N-terminus of an IF ⁇ - ⁇ polypeptide are known in the art. See, e.g., U.S. Patent No. 5,985,265.
  • known methods for selectively obtaining an N-terminally chemically modified IFN- ⁇ are used. For example, a method of protein modification by reductive alkylation which exploits differential reactivity of different types of primary amino groups (lysine versus the N-terminus) available for derivatization in a particular protein can be used. Under the appropriate reaction conditions, substantially selective derivatization of the protein at the N-terminus with a carbonyl group containing polymer is achieved.
  • the reaction is performed at pH which allows one to take advantage of the pK a differences between the ⁇ - amino groups of the lysine residues and that of the ⁇ -amino group of the N-terminal residue of the protein.
  • pH which allows one to take advantage of the pK a differences between the ⁇ - amino groups of the lysine residues and that of the ⁇ -amino group of the N-terminal residue of the protein.
  • N-terminal-specific coupling procedures such as described in U.S. Patent No. 5,985,265 provide predominantly monoPEGylated products.
  • the purification procedures aimed at removing the excess reagents and minor multiply PEGylated products remove the N-terminal blocked polypeptides.
  • such processes lead to significant increases in manufacturing costs.
  • examination of the structure of the well-characterized Infergen® Alfacon-1 CIFN polypeptide amino acid sequence reveals that the clipping is approximate 5% at the carboxyl terminus and thus there is only one major C- terminal sequence.
  • N-terminally PEGylated IFN- ⁇ is not used; instead, the IFN- ⁇ polypeptide is C-terminally PEGylated.
  • a PEG reagent that is selective for the C-terminal can be prepared with or without spacers.
  • polyethylene glycol modified as methyl ether at one end and having an amino function at the other end may be used as the starting material.
  • Preparing or obtaining a water-soluble carbodiimide as the condensing agent can be carried out.
  • Coupling IFN- ⁇ e.g., Infergen® Alfacon-1 CIFN or consensus interferon
  • a water-soluble carbodiimide as the condensing reagent is generally carried out in aqueous medium with a suitable buffer system at an optimal pH to effect the amide linkage.
  • a high molecular weight PEG can be added to the protein covalently to increase the molecular weight.
  • ED AC ED AC
  • l-ethyl-3- (3-dimethylaminopropyl) carbodiimide a suitable reagent.
  • the water solubility of ED AC allows for direct addition to a reaction without the need for prior organic solvent dissolution.
  • Excess reagent and the isourea formed as the by-product of the cross-linking reaction are both water-soluble and may easily be removed by dialysis or gel filtration.
  • a concentrated solution of ED AC in water is prepared to facilitate the addition of a small molar amount to the reaction. The stock solution is prepared and used immediately in view of the water labile nature of the reagent.
  • the optimal reaction medium to be in pH range between 4.7 and 6.0. However the condensation reactions do proceed without significant losses in yields up to pH 7.5. Water may be used as solvent.
  • the medium will be 2-(N-morpholino)ethane sulfonic acid buffer pre-titrated to pH between 4.7 and 6.0.
  • 0.1M phosphate in the pH 7-7.5 may also be used in view of the fact that the product is in the same buffer.
  • the ratios of PEG amine to the IFN- ⁇ molecule is optimized such that the C- terminal carboxyl residue(s) are selectively PEGylated to yield monoPEGylated derivative(s).
  • PEG amine has been mentioned above by name or structure, such derivatives are meant to be exemplary only, and other groups such as hydrazine derivatives as in PEG-NH-NH 2 which will also condense with the carboxyl group of the IFN- ⁇ protein, can also be used.
  • the reactions can also be conducted on solid phase.
  • Polyethylene glycol can be selected from list of compounds of molecular weight ranging from 300-40000. The choice of the various polyethylene glycols will also be dictated by the coupling efficiency and the biological performance of the purified derivative in vitro scad in vivo i.e., circulation times, ami viral activities etc.
  • suitable spacers can be added to the C-terminal of the protein.
  • the spacers may have reactive groups such as SH, NH 2 or COOH to couple with appropriate PEG reagent to provide the high molecular weight IFN- ⁇ derivatives.
  • a combined solid/solution phase methodology can be devised for the preparation of C-terminal pegylated interferons. For example, the C-terminus of IFN- ⁇ is extended on a solid phase using a Gly-Gly-Cys-NH 2 spacer and then monopegylated in solution using activated dithiopyridyl-PEG reagent of appropriate molecular weights.
  • C-terminal PEGylation Another method of achieving C-terminal PEGylation is as follows. Selectivity of C- terminal PEGylation is achieved with a sterically hindered reagent which excludes reactions at carboxyl residues either buried in the helices or internally in IFN- ⁇ .
  • a sterically hindered reagent which excludes reactions at carboxyl residues either buried in the helices or internally in IFN- ⁇ .
  • one such reagent could be a branched chain PEG ⁇ 40kd in molecular weight and this agent could be synthesized as follows:
  • This reagent can be used in excess to couple the amino group with the free and flexible carboxyl group of IFN-ot to form the peptide bond.
  • PEGylated IFN- ⁇ is separated from unPEGylated IFN- ⁇ using any known method, including, but not limited to, ion exchange chromatography, size exclusion chromatography, and combinations thereof.
  • the products are first separated by ion exchange chromatography to obtain material having a charge characteristic of monoPEGylated material (other multi- PEGylated material having the same apparent charge may be present), and then the monoPEGylated materials are separated using size exclusion chromatography.
  • interferon-beta includes IFN- ⁇ polypeptides that are naturally occurring; non-naturally-occurring IFN- ⁇ polypeptides; and analogs of naturally occurring or non- naturally occurring IFN- ⁇ that retain antiviral activity of a parent naturally-occurring or non- naturally occurring IFN- ⁇ .
  • beta interferons can be administered in a subject method.
  • Suitable beta interferons include, but are not limited to, naturally-occurring IFN- ⁇ ; IFN- ⁇ la, e.g., Avonex® (Biogen, Inc.), and R-ebif® (Serono, SA); IFN- ⁇ lb (Betaseron®; Berlex); and the like.
  • the IFN- ⁇ formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN- ⁇ .
  • IFN- ⁇ polypeptides can be produced by any known method. DNA sequences encoding IFN- ⁇ may be synthesized using standard methods. In many embodiments, IFN- ⁇ polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN- ⁇ is "recombinant IFN- ⁇ .” Where the host cell is a bacterial host cell, the IFN- ⁇ is modified to comprise an N- terminal methionine.
  • IFN- ⁇ as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like.
  • IFN-tau may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like.
  • interferon-tau includes IFN-tau polypeptides that are naturally occurring; non- naturally-occurring IFN-tau polypeptides; and analogs of naturally occurring or non-naturally occurring IFN-tau that retain antiviral activity of a parent naturally-occurring or non-naturally occurring IFN-tau.
  • Suitable tau interferons include, but are not limited to, naturally-occurring IFN-tau; Tauferon® (Pepgen Corp.); and the like.
  • IFN-tau may comprise an amino acid sequence as set forth in any one of GenBank Accession Nos. PI 5696; P56828; P56832; P56829; P56831; Q29429; Q28595; Q28594; S08072; Q08071; QO8070; Q08053; P56830; P28169; P28172; and P28171.
  • the sequence of any known IFN-tau polypeptide may be altered in various ways known in the art to generate targeted changes in sequence.
  • a variant polypeptide will usually be substantially similar to the sequences provided herein, i. e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids.
  • sequence changes may be substitutions, insertions or deletions.
  • Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
  • Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
  • modifications of glycosylation e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps;
  • the IFN-tau formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN-tau.
  • IFN-tau polypeptides can be produced by any known method. DNA sequences encoding IFN-tau may be synthesized using standard methods. In many embodiments, IFN-tau polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN-tau is "recombinant IFN-tau.” Where the host cell is a bacterial host cell, the IFN-tau is modified to comprise an N-terminal methionine.
  • IFN-tau as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like.
  • IFN- ⁇ may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like.
  • interferon-omega includes IFN- ⁇ polypeptides that are naturally occurring; non-naturally-occurring IFN- ⁇ polypeptides; and analogs of naturally occurring or non-naturally occuning IF ⁇ - ⁇ that retain antiviral activity of a parent naturally-occurring or non-naturally occurring IF ⁇ - ⁇ .
  • Any known omega interferon can be administered in a subject method.
  • Suitable IFN- ⁇ include, but are not limited to, naturally-occurring IFN- ⁇ ; recombinant IFN- ⁇ , e.g., Biomed 510 (BioMedicines); and the like.
  • IFN- ⁇ may comprise an amino acid sequence as set forth in GenBank Accession No. NP_002168; or AAA70091.
  • the sequence of any known IFN- ⁇ polypeptide may be altered in various ways known in the art to generate targeted changes in sequence.
  • a variant polypeptide will usually be substantially similar to the sequences provided herein, i.e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids.
  • the sequence changes may be substitutions, insertions or deletions.
  • Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
  • Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
  • modifications of glycosylation e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps;
  • the IFN- ⁇ formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN- ⁇ .
  • IFN- ⁇ polypeptides can be produced by any known method. DNA sequences encoding IFN- ⁇ may be synthesized using standard methods. In many embodiments, IFN- ⁇ polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN- ⁇ is "recombinant IFN- ⁇ .” Where the host cell is a bacterial host cell, the IFN- ⁇ is modified to comprise an N- terminal methionine.
  • IFN- ⁇ as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like.
  • modified amino acid residues e.g., glycosylations, chemical modifications, and the like.
  • the interferon receptor agonist is in some embodiments an agonist of a Type III interferon receptor (e.g., "a Type III interferon agonist").
  • Type III interferon agonists include an IL-28b polypeptide; and IL-28a polypeptide; and IL-29 polypeptide; antibody specific for a Type III interferon receptor; and any other agonist of Type III interferon receptor, including non-polypeptide agonists.
  • IL-28A, IL-28B, and IL-29 (referred to herein collectively as "Type III interferons" or "Type III IFNs") are described in Sheppard et al. (2003) Nature 4:63-68.
  • Each polypeptide binds a heterodimeric receptor consisting of IL-10 receptor ⁇ chain and an IL-28 receptor ⁇ . Sheppard et al. (2003), supra.
  • the amino acid sequences of IL-28A, IL-28B, and IL-29 are found under GenBank Accession Nos. NP_742150, NP_742151, and NP_742152, respectively.
  • the amino acid sequence of a Type III IFN polypeptide may be altered in various ways known in the art to generate targeted changes in sequence.
  • a variant polypeptide will usually be substantially similar to the sequences provided herein, ? ' .e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids.
  • the sequence changes may be substitutions, insertions or deletions. Scanning mutations that systematically introduce alanine, or other residues, may be used to determine key amino acids. Specific amino acid substitutions of interest include conservative and non-conservative changes.
  • Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
  • Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
  • modifications of glycosylation e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps;
  • polypeptides that have been modified using ordinary chemical techniques so as to improve their resistance to proteolytic degradation, to optimize solubility properties, or to render them more suitable as a therapeutic agent.
  • the backbone of the peptide may be cyclized to enhance stability (see Friedler et al. (2000) J. Biol. Chem. 275:23783-23789).
  • Analogs may be used that include residues other than naturally occurring L-amino acids, e.g. D-amino acids or non-naturally occurring synthetic amino acids.
  • the protein may be pegylated to enhance stability.
  • the polypeptides may be fused to albumin.
  • polypeptides may be prepared by in vitro synthesis, using conventional methods as known in the art, by recombinant methods, or may be isolated from cells induced or naturally producing the protein. The particular sequence and the manner of preparation will be determined by convenience, economics, purity required, and the like. If desired, various groups may be introduced into the polypeptide during synthesis or during expression, which allow for linking to other molecules or to a surface. Thus cysteines can be used to make thioethers, histidines for linking to a metal ion complex, carboxyl groups for forming amides or esters, amino groups for forming amides, and the like. TYPE II INTERFERON RECEPTOR AGONISTS
  • Type II interferon receptor agonists suitable for use in a subject method include any naturally occurring or non-naturally-occurring ligand of a human Type II interferon receptor that binds to and causes signal transduction via the receptor.
  • Type II interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non- peptide chemical agonists; and the like.
  • a specific example of a Type II interferon receptor agonist is IFN-gamma and variants thereof. While the present invention exemplifies use of an IFN-gamma polypeptide, it will be readily apparent that any Type II interferon receptor agonist can be used in a subject method.
  • Interferon-Gamma Interferon-Gamma
  • the nucleic acid sequences encoding IFN- ⁇ polypeptides may be accessed from public databases, e.g., Genbank, journal publications, etc. While various mammalian IFN- ⁇ polypeptides are of interest, for the treatment of human disease, generally the human protein will be used. Human IFN- ⁇ coding sequence may be found in Genbank, accession numbers XI 3274; V00543; and NM_000619. The corresponding genomic sequence may be found in Genbank, accession numbers J00219; M37265; and V00536. See, for example. Gray et al. (1982) Nature 295:501 (Genbank XI 3274); and Rinderknecht et al. (1984) J.B.C 259:6790.
  • IFN- ⁇ lb (Actimmune®; human interferon) is a single-chain polypeptide of 140 amino acids. It is made recombinantly in E.coli and is unglycosylated. Rinderknecht et al. (1984) J. Biol. Chem. 259:6790-6797. [00125]
  • the IFN- ⁇ to be used in the methods of the present invention may be any of natural IFN- ⁇ s, recombinant IFN- ⁇ s and the derivatives thereof so far as they have an IFN- ⁇ activity, particularly human IFN- ⁇ activity.
  • Human IFN- ⁇ exhibits the antiviral and anti-proliferative properties characteristic of the interferons, as well as a number of other immunomodulatory activities, as is known in the art.
  • IFN- ⁇ is based on the sequences as provided above, the production of the protein and proteolytic processing can result in processing variants thereof.
  • the unprocessed sequence provided by Gray et al., supra, consists of 166 amino acids (aa).
  • coli was originally believed to be 146 amino acids, (commencing at amino acid 20) it was subsequently found that native human IFN- ⁇ is cleaved after residue 23, to produce a 143 aa protein, or 144 aa if the terminal methionine is present, as required for expression in bacteria.
  • the mature protein can additionally be cleaved at the C terminus after reside 162 (referring to the Gray et al. sequence), resulting in a protein of 139 amino acids, or 140 amino acids if the initial methionine is present, e.g. if required for bacterial expression.
  • the N-terminal methionine is an artifact encoded by the mR ⁇ A translational "start" signal AUG that, in the particular case of E. coli expression is not processed away. In other microbial systems or eukaryotic expression systems, methionine may be removed.
  • IFN- ⁇ peptides for use in the subject methods, any of the native IFN- ⁇ peptides, modifications and variants thereof, or a combination of one or more peptides may be used.
  • IFN- ⁇ peptides of interest include fragments, and can be variously truncated at the carboxyl terminus relative to the full sequence. Such fragments continue to exhibit the characteristic properties of human gamma interferon, so long as amino acids 24 to about 149 (numbering from the residues of the unprocessed polypeptide) are present. Extraneous sequences can.be substituted for the amino acid sequence following amino acid 155 without loss of activity. See, for example, U.S. Patent No. 5,690,925.
  • Native IFN- ⁇ moieties include molecules variously extending from amino acid residues 24-150; 24-151, 24-152; 24- 153, 24-155; and 24-157. Any of these variants, and other variants known in the art and having IFN- ⁇ activity, may be used in the present methods.
  • the sequence of the IFN- ⁇ polypeptide may be altered in various ways known in the art to generate targeted changes in sequence.
  • a variant polypeptide will usually be substantially similar to the sequences provided herein, i.e., will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids.
  • the sequence changes may be substitutions, insertions or deletions. Scanning mutations that systematically introduce alanine, or other residues, may be used to determine key amino acids. Specific amino acid substitutions of interest include conservative and non-conservative changes.
  • Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
  • Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like.
  • the invention contemplates the use of IFN- ⁇ variants with one or more non-naturally occurring glycosylation and/or pegylation sites that are engineered to provide glycosyl- and/or PEG- derivatized polypeptides with reduced serum clearance, such as the IFN- ⁇ polypeptide variants described in International Patent Publication No. WO 01/36001.
  • glycosylation e.g., those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g., by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes.
  • sequences that have phosphorylated amino acid residues e.g., phosphotyrosine, phosphoserine, or phosphothreonine.
  • polypeptides that have been modified using ordinary chemical techniques so as to improve their resistance to proteolytic degradation, to optimize solubility properties, or to render them more suitable as a therapeutic agent.
  • the backbone of the peptide may be cyclized to enhance stability (see Friedler et al. (2000) J Biol. Chem. 275:23783-23789).
  • Analogs may be used that include residues other than naturally occurring L-amino acids, e.g., D-amino acids or non-naturally occurring synthetic amino acids.
  • the protein may be pegylated to enhance stability.
  • the polypeptides may be prepared by in vitro synthesis, using conventional methods as known in the art, by recombinant methods, or may be isolated from cells induced or naturally producing the protein. The particular sequence and the manner of preparation will be determined by convenience, economics, purity required, and the like. If desired, various groups may be introduced into the polypeptide during synthesis or during expression, which allow for linking to other molecules or to a surface. Thus cysteines can be used to make thioethers, histidines for linldng to a metal ion complex, carboxyl groups for forming amides or esters, amino groups for forming amides, and the like.
  • the polypeptides may also be isolated and purified in accordance with conventional methods of recombinant synthesis.
  • a lysate may be prepared of the expression host and the lysate purified using HPLC, exclusion chromatography, gel electrophoresis, affinity chromatography, or other purification technique.
  • the compositions which are used will comprise at least 20% by weight of the desired product, more usually at least about 75% by weight, preferably at least about 95% by weight, and for therapeutic purposes, usually at least about 99.5% by weight, in relation to contaminants related to the method of preparation of the product and its purification. Usually, the percentages will be based upon total protein. TNF ANTAGONISTS
  • Suitable TNF- ⁇ antagonists for use in a subject method include agents that decrease the level of TNF- ⁇ synthesis, agents that block or inhibit the binding of TNF- ⁇ to a T ⁇ F- ⁇ receptor (T ⁇ FR), and agents that block or inhibit TNFR-mediated signal transduction.
  • T ⁇ FR T ⁇ F- ⁇ receptor
  • TNFR-mediated signal transduction agents that block or inhibit TNFR-mediated signal transduction.
  • TNF receptor polypeptide and "T ⁇ FR polypeptide” refer to polypeptides derived from TNFR (from any species) which are capable of binding TNF.
  • T ⁇ FR Two distinct cell-surface TNFRs have described: Type II T ⁇ FR (or p75 T ⁇ FR or T ⁇ FRII) and Type I T ⁇ FR (or p55 T ⁇ FR or T ⁇ FRI).
  • Type II T ⁇ FR or p75 T ⁇ FR or T ⁇ FRII
  • Type I T ⁇ FR or p55 T ⁇ FR or T ⁇ FRI
  • the mature full-length human p75 T ⁇ FR is a glycoprotein having a molecular weight of about 75-80 kilodaltons (kD).
  • the mature full- length human p55 T ⁇ FR is a glycoprotein having a molecular weight of about 55-60 kD.
  • Exemplary TNFR polypeptides are derived from TNFR Type I and/or TNFR type II.
  • Soluble T ⁇ FR includes p75 T ⁇ FR polypeptide; fusions of p75 T ⁇ FR with heterologous fusion partners, e.g., the Fc portion of an immunoglobulin.
  • TNFR polypeptide may be an intact TNFR or a suitable fragment of TNFR.
  • U.S. Pat. No. 5,605,690 provides examples of TNFR polypeptides, including soluble TNFR polypeptides, appropriate for use in the present invention.
  • the TNFR polypeptide comprises an extracellular domain of TNFR.
  • the T ⁇ FR polypeptide is a fusion polypeptide comprising an extracellular domain of TNFR linked to a constant domain of an immunoglobulin molecule.
  • the TNFR polypeptide is a fusion polypeptide comprising an extracellular domain of the p75 TNFR linked to a constant domain of an IgGl molecule.
  • an Ig used for fusion proteins is human, e.g., human IgGl.
  • TNFR polypeptides may be used in the present invention.
  • Multivalent forms of TNFR polypeptides possess more than one TNF binding site.
  • the TNFR is a bivalent, or dimeric, form of T ⁇ FR.
  • a chimeric antibody polypeptide with TNFR extracellular domains substituted for the variable domains of either or both of the immunoglobulin heavy or light chains would provide a T ⁇ FR polypeptide for the present invention.
  • TNFR:Fc chimeric TNFR:antibody polypeptide
  • a subject method involves administration of an effective amount of the soluble T ⁇ FR ENBREL® etanercept.
  • ENBREL® is a dimeric fusion protein consisting of the extracellular ligand-binding portion of the human 75 kilodalton (p75) TNFR linked to the Fc portion of human IgGl.
  • the Fc component of ENBREL® contains the CH2 domain, the CH3 domain and hinge region, but not the CHI domain of IgGl.
  • ENBREL® is produced in a Chinese hamster ovary (CHO) mammalian cell expression system. It consists of 934 amino acids and has an apparent molecular weight of approximately 150 kilodaltons. Smith et al.
  • Monoclonal antibodies that bind TNF- ⁇ .
  • Monoclonal antibodies include "humanized" mouse monoclonal antibodies; chimeric antibodies; monoclonal antibodies that are at least about 80%, at least about 90%, at least about 95%, or 100% human in amino acid sequence; and the like. See, e.g., WO 90/10077; WO 90/04036; and WO 92/02190.
  • Suitable monoclonal antibodies include antibody fragments, such as Fv, F(ab') and Fab; synthetic antibodies; artificial antibodies; phage display antibodies; and the like.
  • REMICADE® is a chimeric monoclonal anti-TNF- ⁇ antibody that includes about 25% mouse amino acid sequence and about 75% human amino acid sequence.
  • REMICADE® comprises a variable region of a mouse monoclonal anti-T ⁇ F- ⁇ antibody fused to the constant region of a human IgGl .
  • SAPK inhibitors are known in the art, and include, but are not limited to 2-alkyl imidazoles disclosed in U.S. Patent No. 6,548,520; 1,4,5-substituted imidazole compounds disclosed in U.S. Patent No.
  • a stress-activated protein kinase is a member of a family of mitogen- activated protein kmases which are activated in response to stress stimuli.
  • SAPK include, but are not limited to, p38 (Lee et al. (1994) Nature 372:739) and c-jun N-terminal kinase (JNK).
  • TNF antagonist activity may be assessed with a cell-based competitive binding assay.
  • radiolabeled TNF is mixed with serially diluted TNF antagonist and cells expressing cell membrane bound TNFR. Portions of the suspension are centrifuged to separate free and bound TNF and the amount of radioactivity in the free and bound fractions determined. TNF antagonist activity is assessed by inhibition of T ⁇ F binding to the cells in the presence of the TNF antagonist.
  • T ⁇ F antagonists may be analyzed for the ability to neutralize TNF activity in vitro in a bioassay using cells susceptible to the cytotoxic activity of TNF as target cells.
  • target cells cultured with TNF, are treated with varying amounts of TNF antagonist and subsequently are examined for cytolysis.
  • TNF antagonist activity is assessed by a decrease in T ⁇ F-induced target cell cytolysis in the presence of the T ⁇ F antagonist.
  • Pirfenidone (5 -methyl- l-phenyl-2-(lH)-pyridone) and pirfenidone analogs are used in certain combination therapies of the invention. Pirfenidone
  • Ri carbocyclic (saturated and unsaturated), heterocyclic (saturated or unsaturated), alkyls (saturated and unsaturated). Examples include phenyl, benzyl, pyrimidyl, naphthyl, indolyl, pyrrolyl, furyl, thienyl, imidazolyl, cyclohexyl, piperidyl, pyrrolidyl, mo holinyl, cyclohexenyl, butadienyl, and the like.
  • Ri can further include substitutions on the carbocyclic or heterocyclic moieties with substituents such as halogen, nitro, amino, hydroxyl, alkoxy, carboxyl, cyano, thio, alkyl, aryl, heteroalkyl, heteroaryl and combinations thereof, for example, 4-nitrophenyl, 3-chlorophenyl, 2,5-dinitrophenyl, 4-methoxyphenyl, 5-methyl-pyrrolyl, 2, 5-dichlorocyclohexyl, guanidinyl- cyclohexenyl and the like.
  • substituents such as halogen, nitro, amino, hydroxyl, alkoxy, carboxyl, cyano, thio, alkyl, aryl, heteroalkyl, heteroaryl and combinations thereof, for example, 4-nitrophenyl, 3-chlorophenyl, 2,5-dinitrophenyl, 4-methoxyphenyl, 5-methyl-pyrrolyl, 2, 5-dichloro
  • R 2 alkyl, carbocylic, aryl, heterocyclic. Examples include: methyl, ethyl, propyl, isopropyl, phenyl, 4-nitrophenyl, thienyl and the like.
  • X may be any number (from 1 to 3) of substituents oh the carbocyclic or heterocyclic ring.
  • the substituents can be the same or different.
  • Substituents can include hydrogen, alkyl, heteroalkyl, aryl, heteroaryl, halo, nitro, carboxyl, hydroxyl, cyano, amino, thio, alkylamino, haloaryl and the like.
  • the substituents may be optionally further substituted with 1-3 substituents from the group consisting of alkyl, aryl, nitro, alkoxy, hydroxyl and halo groups. Examples include: methyl, 2,3-dimethyl, phenyl, p-tolyl, 4-chlorophenyl, 4-nitrophenyl, 2,5-dichlorophenyl, furyl, thienyl and the like.
  • Active agents e.g., a Type I or III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF- ⁇ antagonist
  • a pharmaceutically acceptable excipient(s) are known in the art and need not be discussed in detail herein.
  • Pharmaceutically acceptable excipients have been amply described in a variety of publications, including, for example, A. Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20th edition, Lippincott, Williams, & Wilkins; Pharmaceutical Dosage Forms and Drug Delivery Systems (1999) H.C.
  • the pharmaceutically acceptable excipients such as vehicles, adjuvants, carriers or diluents, are readily available to the public.
  • pharmaceutically acceptable auxiliary substances such as pH adjusting and buffering agents, tonicity adjusting agents, stabilizers, wetting agents and the like, are readily available to the public.
  • the active agents may be administered to the host using any convenient means capable of resulting in the desired therapeutic effect.
  • the agents can be incorporated into a variety of formulations for therapeutic administration. More particularly, active agents can be formulated into pharmaceutical compositions by combination with appropriate, pharmaceutically acceptable carriers or diluents, and may be formulated into preparations in solid, semi-solid, liquid or gaseous forms, such as tablets, capsules, powders, granules, ointments, solutions, suppositories, injections, inhalants ' and aerosols.
  • administration of active agents can be achieved in various ways, including oral, buccal, rectal, parenteral, intraperitoneal, intradermal, subcutaneous, intramuscular, transdermal, intratracheal, etc., administration.
  • two different routes of administration are used.
  • IFN- ⁇ and IFN- ⁇ are administered subcutaneously, and a TNF- ⁇ antagonist is administered orally.
  • Subcutaneous administration of an active agent can be accomplished using standard methods and devices, e.g., needle and syringe, a subcutaneous injection port delivery system, and the like. See, e.g., U.S. Patent ⁇ os. 3,547,119; 4,755,173; 4,531,937; 4,311,137; and 6,017,328.
  • a combination of a subcutaneous injection port and a device for administration of an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • a subcutaneous injection port delivery system e.g., a subcutaneous injection port delivery system
  • subcutaneous administration is achieved by a combination of devices, e.g., bolus delivery by needle and syringe, followed by delivery using a continuous delivery system.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • a continuous delivery system e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • continuous delivery system is used interchangeably herein with “controlled delivery system” and encompasses continuous (e.g., controlled) delivery devices (e.g., pumps) in combination with catheters, injection devices, and the like, a wide variety of which are known in the art.
  • controlled delivery devices e.g., pumps
  • Mechanical or electromechanical infusion pumps can also be suitable for use with the present invention.
  • Examples of such devices include those described in, for example, U.S. Pat. Nos. 4,692,147; 4,360,019; 4,487,603; 4,360,019; 4,725,852; 5,820,589; 5,643,207; 6,198,966; and the like.
  • the present treatment methods can be accomplished using any of a variety of refillable, pump systems. Pumps provide consistent, controlled release over time.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • an active agent is in a liquid formulation in a drug-impermeable reservoir, and is delivered in a continuous fashion to the individual.
  • the drug delivery system used in a subject treatment method is an at least partially implantable device.
  • the implantable device can be implanted at any suitable implantation site using methods and devices well known in the art.
  • An implantation site is a site within the body of a subject at which a drug delivery device is introduced and positioned.
  • Implantation sites include, but are not necessarily limited to a subdermal, subcutaneous, intramuscular, or other suitable site within a subject's body. Subcutaneous implantation sites are in some embodiments preferred because of convenience in implantation and removal of the drug delivery device.
  • Drug release devices suitable for use in the invention may be based on any of a variety of modes of operation.
  • the drug release device can be based upon a diffusive system, a convective system, or an erodible system (e.g., an erosion-based system).
  • the drug release device can be an electrochemical pump, osmotic pump, an electroosmotic pump, a vapor pressure pump, or osmotic bursting matrix, e.g., where the drug is incorporated into a polymer and the polymer provides for release of drug formulation concomitant with degradation of a drug-impregnated polymeric material (e.g., a biodegradable, drug-impregnated polymeric material).
  • the drug release device is based upon an electrodiffusion system, an electrolytic pump, an effervescent pump, a piezoelectric pump, a hydrolytic system, etc.
  • Drug release devices based upon a mechanical or electromechanical infusion pump can also be suitable for use with the present invention.
  • Examples of such devices include those described in, for example, U.S. Pat. Nos. 4,692,147; 4,360,019; 4,487,603; 4,360,019; 4,725,852, and the like.
  • the present treatment method can be accomplished using any of a variety of refillable, non-exchangeable pump systems. Pumps and other convective systems are generally preferred due to their generally more consistent, controlled release over time. Osmotic pumps are particularly preferred due to their combined advantages of more consistent controlled release and relatively small size (see, e.g., PCT published application no. WO 97/27840 and U.S. Pat. Nos.
  • Exemplary osmotically-driven devices suitable for use in the invention include, but are not necessarily limited to, those described in U.S. Pat. Nos. 3,760,984; 3,845,770; 3,916,899; 3,923,426; 3,987,790; 3,995,631; 3,916,899; 4,016,880; 4,036,228; 4,111,202; 4,111,203; 4,203,440; 4,203,442; 4,210,139; 4,327,725; 4,627,850; 4,865,845; 5,057,318; 5,059,423; 5,112,614; 5,137,727; 5,234,692; 5,234,693; 5,728,396; and the like.
  • the drug delivery device is an implantable device.
  • the drug delivery device can be implanted at any suitable implantation site using methods and devices well known in the art.
  • an implantation site is a site within the body of a subject at which a drag delivery device is introduced and positioned.
  • Implantation sites include, but are not necessarily limited to a subdermal, subcutaneous, intramuscular, or other suitable site within a subject's body.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or T ⁇ F- ⁇ antagonist
  • an implantable drug delivery system e.g., a system that is programmable to provide for administration of an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist).
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • Exemplary programmable, implantable systems include implantable infusion pumps. Exemplary implantable infusion pumps, or devices useful in connection with such pumps, are described in, for example, U.S. Pat. Nos.
  • a further exemplary device that can be adapted for the present invention is the Synchromed infusion pump (Medtronic).
  • the agents may be administered in the form of their pha ⁇ naceutically acceptable salts, or they may also be used alone or in appropriate association, as well as in combination, with other pharmaceutically active compounds.
  • the following methods and excipients are merely exemplary and are in no way limiting.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or T ⁇ F- ⁇ antagonist
  • an active agent can he used alone or in combination with appropriate additives to make tablets, powders, granules or capsules, for example, with conventional additives, such as lactose, mannitol, corn starch or potato starch; with binders, such as crystalline cellulose, cellulose derivatives, acacia, corn starch or gelatins; with disintegrators, such as corn starch, potato starch or sodium carboxymethylcellulose; with lubricants, such as talc or magnesium stearate; and if desired, with diluents, buffering agents, moistening agents, preservatives and flavoring agents.
  • conventional additives such as lactose, mannitol, corn starch or potato starch
  • binders such as crystalline cellulose, cellulose derivatives, acacia, corn starch or gelatins
  • a active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • an aqueous or nonaqueous solvent such as vegetable or other similar oils, synthetic aliphatic acid glycerides, esters of higher aliphatic acids or propylene glycol; and if desired, with conventional additives such as solubilizers, isotonic agents, suspending agents, emulsifying agents, stabilizers and preservatives.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • a variety of bases such as emulsifying bases or water-soluble bases.
  • An active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • the suppository can include vehicles such as cocoa butter, carbowaxes and polyethylene glycols, which melt at body temperature, yet are solidified at room temperature.
  • Unit dosage forms for oral or rectal administration such as syrups, elixirs, and suspensions may be provided wherein each dosage unit, for example, teaspoonful, tablespoonful, tablet or suppository, contains a predetermined amount of the composition containing one or more active agents.
  • unit dosage forms for injection or intravenous administration may comprise an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist) in a composition as a solution in sterile water, normal saline or another pharmaceutically acceptable carrier.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • unit dosage form refers to physically discrete units suitable as unitary dosages for human and animal subjects, each unit containing a predetermined quantity of an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist) calculated in an amount sufficient to produce the desired effect in association with a pharmaceutically acceptable diluent, carrier or vehicle.
  • an active agent e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist
  • the invention provides embodiments in which the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist is/are administered to the patient by a controlled drug delivery device.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist is/are delivered to the patient substantially continuously or continuously by the controlled drug delivery device.
  • an implantable infusion pump is used to deliver the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist to the patient substantially continuously or continuously by subcutaneous infusion.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or T ⁇ F- ⁇ antagonist is administered to the patient so as to achieve and maintain a desired average daily serum concentration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or T ⁇ F- ⁇ antagonist at a substantially steady state for the duration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or T ⁇ F- ⁇ antagonist therapy.
  • an implantable infusion pump is used to deliver the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or T ⁇ F- ⁇ antagonist to the patient by subcutaneous infusion so as t ⁇ achieve and maintain a desired average daily serum concentration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist at a substantially steady state for the duration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist therapy.
  • the Type II interferon receptor agonist is an IFN- ⁇ .
  • Effective dosages of IFN- ⁇ can range from about 0.5 ⁇ g/m to about 500 ⁇ g/m , usually from about 1.5 ⁇ g/m 2 to 200 ⁇ g/m 2 , depending on the size of the patient. This activity is based on 10 6 international units (U) per 50 ⁇ g of protein. IFN- ⁇ can be administered daily, every other day, three times a week, or substantially continuously or continuously.
  • IFN- ⁇ is administered to an individual in a unit dosage form of from about 25 ⁇ g to about 500 ⁇ g, from about 50 ⁇ g to about 400 ⁇ g, or from about 100 ⁇ g to about 300 ⁇ g.
  • the dose is about 200 ⁇ g IFN- ⁇ .
  • IFN- ⁇ lb is administered.
  • the amount of IFN- ⁇ per body weight (assuming a range of body weights of from about 45 kg to about 135 kg) is in the range of from about 4.4 ⁇ g IFN- ⁇ per kg body weight to about 1.48 ⁇ g IFN- ⁇ per kg body weight.
  • the body surface area of subject individuals generally ranges from about 1.33 m 2 to about 2.50 m 2 .
  • an IFN- ⁇ dosage ranges from about 150 ⁇ g/m 2 to about 20 ⁇ g/m 2 .
  • an IFN- ⁇ dosage ranges from about 20 ⁇ g/m 2 to about 30 ⁇ g/m 2 , from about 30 ⁇ g/m 2 to about 40 ⁇ g/m 2 , from about 40 ⁇ g/m 2 to about 50 ⁇ g/m 2 , from about 50 ⁇ g/m 2 to about 60 ⁇ g/m 2 , from about 60 ⁇ g/m 2 to about 70 ⁇ g/m 2 , from about 70 ⁇ g/m 2 to about 80 ⁇ g/m 2 , from about 80 ⁇ g/m 2 to about 90 ⁇ g/m 2 , from about 90 ⁇ g/m 2 to about 100 ⁇ g/m 2 , from about 100 ⁇ g/m 2 to about 110 ⁇ g/m 2 , from about 110 ⁇ g/m 2 to about 120 ⁇ g/m 2 , from about 120 ⁇ g/m 2 to about 130 ⁇ g/m 2 , from about 130 ⁇ g/m 2 to about 140 ⁇ g/m 2 , or from about 140 ⁇
  • the Type I interferon receptor agonist is an IFN- ⁇ .
  • Effective dosages of an IFN- ⁇ can range from about 1 ⁇ g to about 30 ⁇ g, from about 3 ⁇ g to about 27 ⁇ g, from about 1 MU to about 20 MU, from about 3 MU to about 10 MU, from about 90 ⁇ g to about 180 ⁇ g, or from about 18 ⁇ g to about 90 ⁇ g.
  • Effective dosages of Infergen® consensus IFN- ⁇ include about 3 ⁇ g, about 9 ⁇ g, about 15 ⁇ g, about 18 ⁇ g, or about 27 ⁇ g of drug per dose.
  • Effective dosages of IFN- ⁇ 2a and IFN- ⁇ 2b can range from 3 million Units (MU) to 10 MU per dose.
  • Effective dosages of PEGylated IFN- ⁇ 2a can contain an amount of about 90 ⁇ g to 180 ⁇ g, or about 135 ⁇ g, of drug per dose.
  • Effective dosages of PEGylated IF ⁇ - ⁇ 2b can contain an amount of about 0.5 ⁇ g to 1.5 ⁇ g of drug per kg of body weight per dose.
  • Effective dosages of PEGylated consensus interferon can contain an amount of about 18 ⁇ g to about 90 ⁇ g, or from about 27 ⁇ g to about 60 ⁇ g, or about 45 ⁇ g, of CIFN amino acid weight per dose of PEG-CIFN.
  • IFN- ⁇ can be administered daily, every other day, once a week, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
  • a Type I or III interferon receptor agonist is administered in a first dosing regimen, followed by a second dosing regimen.
  • the first dosing regimen of Type I or III interferon receptor agonist generally involves administration of a higher dosage of the Type I or III interferon receptor agonist.
  • the first dosing regimen comprises administering CIFN at about 9 ⁇ g, about 15 ⁇ g, about 18 ⁇ g, or about 27 ⁇ g.
  • the first dosing regimen can encompass a single dosing event, or at least two or more dosing events.
  • the first dosing regimen of the Type I or III interferon receptor agonist can be administered daily, every other day, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
  • the first dosing regimen of the Type I or III interferon receptor agonist is administered for a first period of time, which time period can be at least about 4 weeks, at least about 8 weeks, or at least about 12 weeks.
  • the second dosing regimen of the Type I or III interferon receptor agonist (also referred to as "the maintenance dose”) generally involves administration of a lower amount of the Type I or III interferon receptor agonist.
  • the second dosing regimen comprises administering CIFN at least about 3 ⁇ g, at least about 9 ⁇ g, at least about 15 ⁇ g, or at least about 18 ⁇ g.
  • the second dosing regimen can encompass a single dosing event, or at least two or more dosing events.
  • the second dosing regimen of the Type I or III interferon receptor agonist can be administered daily, every other day, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
  • a "priming" dose of a Type II interferon receptor agonist is included.
  • Type II interferon receptor agonist can be administered for a period of time from about 1 day to about 14 days, from about 2 days to about 10 days, or from about 3 days to about 7 days, before the beginning of treatment with the Type I or III interferon receptor agonist. This period of time is referred to as the "priming" phase.
  • Type II interferon receptor agonist treatment is continued throughout the entire period of treatment with the Type I or III interferon receptor agonist.
  • Type II interferon receptor agonist treatment is discontinued before the end of treatment with the Type I or III interferon receptor agonist.
  • the total time of treatment with the Type II interferon receptor agonist is from about 2 days to about 30 days, from about 4 days to about 25 days, from about 8 days to about 20 days, from about 10 days to about 18 days, or from about 12 days to about 16 days.
  • the Type I or III interferon receptor agonist is administered in a non-induction (single) dosing regimen.
  • the dose of CIFN is generally in a range of from about 3 ⁇ g to about 15 ⁇ g, or from about 9 ⁇ g to about 15 ⁇ g.
  • the dose of Type I or a Type III interferon receptor agonist is generally administered daily, every other day, three times a week, every other week, three times per month, once monthly, or substantially continuously.
  • the dose of the Type I or III interferon receptor agonist is administered for a period of time, which period can be, for example, from at least about 24 weeks to at least about 48 weeks, or longer.
  • a "priming" dose of Type II interferon receptor agonist is included.
  • a Type II interferon receptor agonist can be administered for a period of time from about 1 day to about 14 days, from about 2 days to about 10 days, or from about 3 days to about 7 days, before the beginning of treatment with the Type I or III interferon receptor agonist. This period of time is referred to as the "priming" phase.
  • Type II interferon receptor agonist treatment is continued throughout the entire period of treatment with the Type I or III interferon receptor agonist.
  • Type II interferon receptor agonist treatment is discontinued before the end of treatment with Type I or III interferon receptor agonist.
  • the total time of treatment with the Type II interferon receptor agonist is from about 2 days to about 30 days, from about 4 days to about 25 days, from about 8 days to about 20 days, from about 10 days to about 18 days, or from about 12 days to about 16 days.
  • Effective dosages of a TNF- ⁇ antagonist range from 0.1 ⁇ g to 40 mg per do se, e.g., from about 0.1 ⁇ g to about 0.5 ⁇ g per dose, from about 0.5 ⁇ g to about 1.0 ⁇ g per dose, from about 1.0 ⁇ g per dose to about 5.0 ⁇ g per dose, from about 5.0 ⁇ g to about 10 ⁇ g per dose, from about 10 ⁇ g to about 20 ⁇ g per dose, from about 20 ⁇ g per dose to about 30 ⁇ .g per dose, from about 30 ⁇ g per dose to about 40 ⁇ g per dose, from about 40 ⁇ g per dose to about 50 ⁇ g per dose, from about 50 ⁇ g per dose to about 60 ⁇ g per dose, from about 60 ⁇ g per dose to about 70 ⁇ g per dose, from about 70 ⁇ g to about 80 ⁇ g per dose, from about 80 ⁇ g per dose to about 100 ⁇ g per dose, from about 100 ⁇ g to about 150 ⁇ g per dose, from about 150
  • the TNF- ⁇ antagonist is ENBREL® etanercept.
  • Effective dosages of etanercept range from about 0.1 ⁇ g to about 40 mg per dose, from about 0.1 ⁇ g to about 1 ⁇ g per dose, from about 1 ⁇ g to about 10 ⁇ g per dose, from about 10 ⁇ g to about 100 ⁇ g per dose, from about 100 ⁇ g to about 1 mg per dose, from about 1 mg to about 5 mg per dose, from about 5 mg to about 10 mg, from about 10 mg to about 15 mg per dose, from about 15 mg to about 20 mg per dose, from about 20 mg to about 25 mg per dose, from about 25 mg to about 30 mg per dose, from about 30 mg to about 35 mg per dose, or from about 35 mg to about 40 mg per dose.
  • effective dosages of a T ⁇ F- ⁇ antagonist are expressed as mg/kg body weight.
  • effective dosages of a T ⁇ F- ⁇ antagonist are from about 0.1 mg/kg body weight to about 10 mg/kg body weight, e.g., from about 0.1 mg/kg body weight to about 0.5 mg/kg body weight, from about 0.5 mg/kg body weight to about 1.0 mg/kg body weight, from about 1.0 mg/kg body weight to about 2.5 mg/kg body weight, from about 2.5 mg/kg body weight to about 5.0 mg/kg body weight, from about 5.0 mg/kg body weight to about 7.5 mg/kg body weight, or from about 7.5 mg/kg body weight to about 10 mg/kg body weight.
  • the TNF- ⁇ antagonist is REMICADE® infliximab.
  • Effective dosages of REMICADE® range from about 0.1 mg/kg to about 10 mg/kg, from about 0.1 mg/kg to about 0.5 mg/kg, from about 0.5 mg/kg to about 1.0 mg/kg, from about 1.0 mg/kg to about 1.5 mg/kg, from about 1.5 mg/kg to about 2.0 mg/kg, from about 2.0 mg/kg to about 2.5 mg/kg, from about 2.5 mg/kg to about 3.0 mg/kg, from about 3.0 mg/kg to about 3.5 mg/kg, from about 3.5 mg/kg to about 4.0 mg/kg, from about 4.0 mg/kg to about 4.5 mg/kg, from about 4.5 mg/kg to about 5.0 mg/kg, from about 5.0 mg/kg to about 7.5 mg/kg, or from about 7.5 mg/kg to about 10 mg/kg per dose.
  • the T ⁇ F- ⁇ antagonist is HUMIRATM adalimumab.
  • Effective dosages of HUMIRATM range from about 0.1 ⁇ g to about 35 mg, from about 0.1 ⁇ g to about 1 ⁇ g, from about 1 ⁇ g to about 10 ⁇ g, from about 10 ⁇ g to about 100 ⁇ g, from about 100 ⁇ g to about 1 mg, from about 1 mg to about 5 mg, from about 5 mg to about 10 mg, from about 10 mg to about 15 mg, from about 15 mg to about 20 mg, from about 20 mg to about 25 mg, from about 25 mg to about 30 mg, from about 30 mg to about 35 mg, or from about 35 mg to about 40 mg per dose.
  • a T ⁇ F- ⁇ antagonist is administered for a period of about 1 day to about 7 days, or about 1 week to about 2 weeks, or about 2 weeks to about 3 weeks, or about 3 weeks to about 4 weeks, or about 1 month to about 2 months, or about 3 months to about 4 months, or about 4 months to about 6 months, or about 6 months to about 8 months, or about 8 months to about 12 months, or at least one year, and may be administered over longer periods of time.
  • the TNF- ⁇ antagonist can be administered tid, bid, qd, qod, biw, tiw, qw, qow, three times per month, once monthly, substantially continuously, or continuously.
  • a T ⁇ F- ⁇ antagonist is administered once per month, twice per month, three times er month, every other week (qow), once per week (qw), twice per week (biw), three times per week (tiw), four times per week, five times per week, six times per week, every other day (qod), daily (qd), twice a day (bid), or three times a day (tid), substantially continuously, or continuously, over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more.
  • dose levels can vary as a function of the specific compounds, the severity of the symptoms and the susceptibility of the subject to side effects.
  • Preferred dosages for a given compound are readily determinable by those of skill in the art by a variety of means.
  • a preferred means is to measure the physiological potency of a given compound.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered in the same formulation, and are administered simultaneously.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist are administered separately, e.g., in separate formulations.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered separately, and are administered simultaneously.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered separately and are administered within about 5 seconds to about 15 seconds, within about 15 seconds to about 30 seconds, within about 30 seconds to about 60 seconds, within about 1 minute to about 5 minutes, within about 5 minutes to about 15 minutes, within about 15 minutes to about 30 minutes, within about 30 minutes to about 60 minutes, within about 1 hour to about 2 hours, within about 2 hours to about 6 hours, within about 6 hours to about 12 hours, within about 12 hours to about 24 hours, or within about 24 hours to about 48 hours of one another.
  • Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist can be administered, e.g., the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF- ⁇ antagonist can be administered once per month, twice per month, three times per month, once per week, twice per week, three times per week, four times per week, five times per week, six times per week, or daily, over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and T ⁇ F- ⁇ antagonist are administered
  • the three drugs are co-formulated in a single liquid formulation that is contained in a single reservoir, for use in a drug delivery device.
  • the present invention provides a pharmaceutical formulation comprising a liquid formulation comprising a single dose of Type I or III interferon receptor agonist, a single dose of Type II interferon receptor agonist, and a single dose of TNF- ⁇ antagonist.
  • the present invention provides a drug reservoir or other container containing Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist co-formulated in a liquid, wherein the three drugs are present in the formulation in an amount suitable for one dose each. Dosage amounts are described herein.
  • the reservoir can be provided in any of a variety of forms, including, but not limited to, a cartridge, a syringe, a reservoir of a continuous delivery device, and the like.
  • the invention further provides a drug delivery device comprising (e.g., pre-loaded with) a reservoir containing a liquid formulation that comprises a single dose of Type I or III interferon receptor agonist, a single dose of Type II interferon receptor agonist, and a single dose of TNF- ⁇ antagonist.
  • a drug delivery device comprising (e.g., pre-loaded with) a reservoir containing a liquid formulation that comprises a single dose of Type I or III interferon receptor agonist, a single dose of Type II interferon receptor agonist, and a single dose of TNF- ⁇ antagonist.
  • exemplary, non-limiting drug delivery devices include injection devices, such as pen injectors, needle/syringe devices, continuous delivery devices, and the like. Any of the dosage amounts, including synergistically effective amounts, described herein can be used in the pharmaceutical formulation, in the reservoir, or in the drug delivery device.
  • each of the three drugs is in a pharmaceutical formulation contained in a separate reservoir in the same drug delivery device.
  • the invention further provides a drug delivery device that is pre-loaded with separate reservoirs, one reservoir containing a liquid formulation comprising a single dose of Type I or III interferon receptor agonist, and a second reservoir containing a liquid formulation comprising a single dose of Type II interferon receptor agonist, and a third reservoir containing a liquid formulation comprising a single dose of TNF- ⁇ antagonist.
  • Any of the dosage amounts, including synergistically effective amounts, described herein can be used in the pharmaceutical formulation, in the reservoir, or in the drug delivery device.
  • the Type I or III interferon receptor agonist is an IFN- ⁇
  • the Type II interferon receptor agonist is an IFN- ⁇
  • the subject method comprises co-administering to the patient an effective amount of IFN- ⁇ for the duration of the IFN- ⁇ therapy.
  • the IFN- ⁇ is administered to the patient by bolus injection.
  • the IFN- ⁇ and IFN- ⁇ are administered to the patient by a drug delivery device.
  • the device is used to deliver the IFN- ⁇ to the patient by substantially continuous or continuous administration and used to deliver the IF ⁇ - ⁇ to the patient by bolus administration tiw, biw, qod, or qd.
  • the device is used to deliver the IFN- ⁇ and IFN- ⁇ to the patient in the same manner and pattern of administration, such as substantially continuous or continuous administration.
  • the IFN- ⁇ and IFN- ⁇ are contained in separate reservoirs in the drug delivery device.
  • the IFN- ⁇ and IFN- ⁇ are co-formulated in a single liquid formulation that is contained in a single reservoir in the drug delivery device. Additional therapeutic agents
  • the method further includes administration of pirfenidone or a pirfenidone analog.
  • Pirfenidone or a pirfenidone analog can be administered once per month, twice per month, three times per month, once per week, twice per week, three times per week, four times per week, five times per week, six times per week, daily, or in divided daily doses ranging from once daily to 5 times daily over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more.
  • Effective dosages of pirfenidone or a specific pirfenidone analog include a weight- based dosage in the range from about 5 mg/kg/day to about 125 mg/kg/day, or a fixed dosage of about 400 mg to about 3600 mg per day, or about 800 mg to about 2400 mg per day, or about 1000 mg to about 1800 mg per day, or about 1200 mg to about 1600 mg per day, administered orally.
  • Other doses and formulations of pirfenidone and specific pirfenidone analogs suitable for use in the treatment of fibrotic diseases are described in U.S. Pat. Nos., 5,310,562; 5,518,729; 5,716,632; and 6,090,822.
  • pirfenidone or a pirfenidone analog is administered throughout the entire course of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment. In other embodiments, pirfenidone or a pirfenidone analog is administered less than the entire course of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, e.g., only during the first phase of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, only during the second phase of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, or some other portion of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment regimen.
  • the method further includes administration of ribavirin.
  • Ribavirin, l- ⁇ -D-ribofuranosyl-lH-l,2,4-triazole-3-carboxamide available from ICN Pharmaceuticals, Inc., Costa Mesa, Calif, is described in the Merck Index, compound No. 8199, Eleventh Edition. Its manufacture and formulation is described in U.S. Pat. No. 4,211,771. The invention also contemplates use of derivatives of ribavirin (see, e.g., U.S. Pat. No. 6,277,830).
  • the ribavirin may be administered orally in capsule or tablet form, or in the same or different administration form and in the same or different route as the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist.
  • Other types of administration of both medicaments, as they become available are contemplated, such as by nasal spray, transdermally, intravenously, by suppository, by sustained release dosage form, etc. Any form of administration will work so long as the proper dosages are delivered without destroying the active ingredient.
  • Ribavirin is generally administered in an amount ranging from about 30 mg to about 60 mg, from about 60 mg to about 125 mg, from about 125 mg to about 200 mg, from about 200 mg to about 300 gm, from about 300 mg to about 400 mg, from about 400 mg to about 1200 mg, from about 600 mg to about 1000 mg, or from about 700 to about 900 mg per day, or about 10 mg/kg body weight per day.
  • ribavirin is administered throughout the entire course of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ ⁇ antagonist treatment. In other embodiments, ribavirin is administered less than the entire course of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, e.g., only during the first phase of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, only during the second phase of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment, or some other portion of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist treatment regimen.
  • the present invention provides methods of treating viral infection by administering a therapeutically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist to an individual in need thereof.
  • Individuals who are to be treated according to the methods of the invention include individuals who have been clinically diagnosed with a viral infection, as well as individuals who exhibit one or more of the signs and the symptoms of clinical infection but have not yet been diagnosed with an viral infection.
  • a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered to the individual.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and T ⁇ F- ⁇ antagonist are administered in the same formulation.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered in separate formulations.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and T ⁇ F- ⁇ antagonist are administered subcutaneously in multiple doses.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF- ⁇ antagonist is administered for a period of about 1 day to about 7 days, or about 1 week to about 2 weeks, or about 2 weeks to about 3 weeks, or about 3 weeks to about 4 weeks, or about 1 month to about 2 months, or about 3 months to about 4 months, or about 4 months to about 6 months, or about 6 months to about 8 months, or about 8 months to about 12 months, or at least one year, and may be administered over longer periods of time.
  • Dosage regimens can include tid, bid, qd, qod, biw, tiw, qw, qow, three times per month, or monthly administrations.
  • the invention provides methods using a synergistically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist in the treatment of viral infection in a patient.
  • the invention provides methods using a synergistically effective amount of an IFN- ⁇ , IFN- ⁇ , and a T ⁇ F- ⁇ antagonist selected from the group consisting of ENBREL®, REMICADE® and HUMIRATM, in the treatment of viral infection in a patient.
  • the invention provides a method using a synergistically effective amount of a consensus IFN- ⁇ , IFN- ⁇ , and a TNF- ⁇ antagonist selected from the group consisting of ENBREL®, REMICADE® and HUMIRATM, in the treatment of viral infection in a patient.
  • an effective amount of a consensus interferon (CIFN) and IFN- ⁇ suitable for use in the methods of the invention is provided by a dosage ratio of 1 ⁇ g CIFN : 10 ⁇ g IFN- ⁇ , where both CIFN and IFN- ⁇ are unPEGylated and unglycosylated species.
  • the invention provides a method using an effective amount of INFERGEN® consensus IFN- ⁇ , IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 ⁇ g to about 30 ⁇ g of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IF ⁇ - ⁇ containing an amount of about 10 ⁇ g to about 300 ⁇ g of drug per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii
  • the invention provides a method using an effective amount of INFERGEN®consensus IFN- ⁇ , IFN- ⁇ and T ⁇ F- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 ⁇ g to about 9 ⁇ g of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 10 ⁇ g to about 100 ⁇ g of drug per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously bi
  • the invention provides a method using an effective amount of INFERGEN® consensus IFN- ⁇ , IFN- ⁇ and T ⁇ F- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 ⁇ g of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IF ⁇ - ⁇ containing an amount of about 10 ⁇ g to about 50 ⁇ g of drug per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a T ⁇ F- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE
  • the invention provides a method using an effective amount of INFERGEN® consensus IFN- ⁇ , IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient comprising administering to the patient a dosage of INFERGEN® containing an amount of about 9 ⁇ g of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 90 ⁇ g to about 100 ⁇ g of drug per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a T ⁇ F- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an
  • the invention provides a method using an effective amount of INFERGEN®consensus IFN- ⁇ , IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 30 ⁇ g of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 200 ⁇ g to about 300 ⁇ g of drag per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE
  • the invention provides a method using an effective amount of PEGylated consensus IFN- ⁇ , IF ⁇ - ⁇ and T ⁇ F- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGylated consensus IF ⁇ - ⁇ (PEG-CIF ⁇ ) containing an amount of about 4 ⁇ g to about 60 ⁇ g of CIFN amino acid weight per dose of PEG-CIFN subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN- ⁇ containing an amount of about 30 ⁇ g to about 1,000 ⁇ g of drag per week in divided doses administered subcutaneously qd, qod, tiw, biw, or substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10
  • the invention provides a method using an effective amount of PEGylated consensus IFN- ⁇ , IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGylated consensus IFN- ⁇ (PEG-CIFN) containing an amount of about 18 ⁇ g to about 24 ⁇ g of CIFN amino acid weight per dose of PEG-CIFN subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN- ⁇ containing an amount of about 100 ⁇ g to about 300 ⁇ g of drug per week in divided doses administered subcutaneously qd, qod, tiw, biw, or substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug
  • an effective amount of IFN- ⁇ 2a or 2b or 2c and IFN- ⁇ suitable for use in the methods of the invention is provided by a dosage ratio of 1 million Units (MU) IFN- ⁇ 2a or 2b or 2c : 30 ⁇ g IFN- ⁇ , where both IFN- ⁇ 2a or 2b or 2c and IFN- ⁇ are unPEGylated and unglycosylated species.
  • MU 1 million Units
  • the invention provides a method using an effective amount of IFN- ⁇ 2a or 2b or 2c, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IFN- ⁇ 2a containing an amount of about 1 MU to about 20 MU of drag per dose of IFN- ⁇ 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 30 ⁇ g to about 600 ⁇ g of drag per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug
  • the invention provides a method using an effective amount of IFN- ⁇ 2a or 2b or 2c, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IF ⁇ - ⁇ 2a containing an amount of about 3 MU of drug per dose of IFN- ⁇ 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 100 ⁇ g of drug per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drag subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, q
  • the invention provides a method using an effective amount of IFN- ⁇ 2a or 2b or 2c, IFN- ⁇ and T ⁇ F- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IF ⁇ - ⁇ 2a, 2b or 2c containing an amount of about 10 MU of drug per dose of IFN- ⁇ 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN- ⁇ containing an amount of about 300 ⁇ g of drag per dose of IFN- ⁇ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intraven
  • the invention provides a method using an effective amount of PEGASYS®PEGylated IF ⁇ - ⁇ 2a, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGASYS® containing an amount of about 90 ⁇ g to about 360 ⁇ g of drug per dose of PEGASYS® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN- ⁇ containing an amount of about 30 ⁇ g to about 1,000 ⁇ g of drug per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow
  • the invention provides a method using an effective amount of PEGASYS®PEGylated IFN- ⁇ 2a, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGASYS® containing an amount of about 180 ⁇ g of drag per dose of PEGASYS® subcutaneously qw, .
  • a total weekly dosage of IFN- ⁇ containing an amount of about 100 ⁇ g to about 300 ⁇ g of drag per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRATM in an amount of about 40 mg of drag subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
  • a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) RE
  • the invention provides a method using an effective amount of PEG-INTRON®PEGylated IFN- ⁇ 2b, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEG-INTRON® containing an amount of about 0.75 ⁇ g to about 3.0 ⁇ g of drug per kilogram of body weight per dose of PEG-INTRON® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN- ⁇ containing an amount of about 30 ⁇ g to about 1,000 ⁇ g of drug per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drag subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg
  • the invention provides a method using an effective amount of PEG-INTRON®PEGylated IF ⁇ - ⁇ 2b, IFN- ⁇ and TNF- ⁇ antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEG-INTRON® containing an amount of about 1.5 ⁇ g of drug per kilogram of body weight per dose of PEG- INTRON® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN- ⁇ containing an amount of about 100 ⁇ g to about 300 ⁇ g of drag per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF- ⁇ antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously q
  • the invention also provides methods for the treatment of viral infection in which ribavirin therapy is added to any of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist combination therapies described above.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist combination therapy is modified to include a ribavirin regimen of 800 mg to 1200 mg ribavirin orally qd for the specified duration of therapy.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist combination therapy is modified to include a ribavirin regimen of 1000 mg ribavirin orally qd for the specified duration of therapy.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist combination therapy is modified to include a ribavirin regimen of about 10 mg of ribavirin/kg body weight orally qd for the specified duration of therapy.
  • the daily ribavirin dosage can be administered in one dose per day or in divided doses, including one, two, three or four doses, per day.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of T ⁇ F- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 ⁇ g INFERGEN® consensus IF ⁇ - ⁇ administered subcutaneously qd or tiw; 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; and a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; and a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 25 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd, for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 200 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 25 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; and a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 ⁇ g INFERGEN® consensus IFN- ⁇ administered subcutaneously qd or tiw; 200 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; and a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUM
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUM
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 ⁇ g monoPEG(30 kD, linear)-ylated consensus IF ⁇ - ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of T ⁇ F- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 ⁇ g monoPEG(30 kD, linear) -ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having an viral infection a regimen of 200 ⁇ g monoPEG(30 kD, linear)-ylated consensus IF ⁇ - ⁇ administered subcutaneously every 10 days or qw; 100 ⁇ g Actimmune® human IF ⁇ - ⁇ lb administered subcutaneously tiw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy.
  • ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 50 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUM
  • the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 ⁇ g monoPEG(30 kD, linear)-ylated consensus IFN- ⁇ administered subcutaneously every 10 days or qw; a dosage of TNF- ⁇ antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRATM subcutaneously qw or qow; and 100 ⁇ g Actimmune® human IFN- ⁇ lb administered subcutaneously tiw; for the desired duration of therapy.
  • the present invention provides methods of treating HCV infection by administering a combination of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist in a therapeutically effective amount to an individual in need thereof.
  • Individuals who are to be treated according to the methods of the invention include individuals who have been clinically diagnosed as infected with HCV.
  • Individuals who are infected with HCV are identified as having HCV RNA in their blood, and/or having anti-HCV antibody in their serum.
  • Treatment failure patients include non- responders (e.g., individuals in whom the HCV titer was not significantly or sufficiently reduced by a previous treatment for HCV); and relapsers (e.g., individuals who were previously treated for HCV, whose HCV titer decreased, and subsequently increased).
  • individuals have an HCV titer of at least about 10 5 , at least about 5 x 10 5 , or at least about 10 6 , or at least about 2 x 10 6 , genome copies of HCV per milliliter of serum.
  • the patient may be infected with any HCV genotype (genotype 1, including la and lb, 2, 3, 4, 6, etc. and subtypes (e.g., 2a, 2b, 3a, etc.)), particularly a difficult to treat genotype such as HCV genotype 1 and particular HCV subtypes and quasispecies.
  • HCV-positive individuals are HCV-positive individuals (as described above) who exhibit severe fibrosis or early cirrhosis (non-decompensated, Child's-Pugh class A or less), or more advanced cirrhosis (decompensated, Child's-Pugh class B or C) due to chronic HCV infection and who are viremic despite prior anti- viral treatment with IFN- ⁇ -based therapies or who cannot tolerate IFN- ⁇ -based therapies, or who have a contraindication to such therapies.
  • HCV-positive individuals with stage 3 or 4 liver fibrosis according to the METAVIR scoring system are suitable for treatment with the methods of the present invention.
  • individuals suitable for treatment with the methods of the instant invention are patients with decompensated cirrhosis with clinical manifestations, including patients with far-advanced liver cirrhosis, including those awaiting liver transplantation.
  • individuals suitable for treatment with, the methods of the instant invention include patients with milder degrees of fibrosis including those with early fibrosis (stages 1 and 2 in the METAVIR, Ludwig, and Scheuer scoring systems; or stages 1, 2, or 3 in the Ishak scoring system.).
  • a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF- ⁇ antagonist are administered to the individual.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist are administered in the same formulation.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and T ⁇ F- ⁇ antagonist are administered in separate formulations.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another.
  • the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF- ⁇ antagonist are administered subcutaneously in multiple doses.
  • the specific regimen of drug therapy used in treatment of the HCV patient is selected according to certain disease parameters exhibited by the patient, such as the initial viral load, genotype of the HCV infection in the patient, liver histology and/or stage of liver fibrosis in the patient.
  • the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1 ) identifying a patient having advanced or severe stage liver fibrosis as measured by a Knodell score of 3 or 4 and then (2) administering to the patient the drag therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
  • the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having advanced or severe stage liver fibrosis as measured by a Knodell score of 3 or 4 and then (2) administering to the patient the drag therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
  • the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
  • the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drag therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and no or early stage liver fibrosis as measured by a Knodell score of 0, 1, or 2 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and no or early stage liver fibrosis as measured by a Knodell score of 0, 1 , or 2 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks, or about 24 weeks to about 48 weeks, or about 30 weeks to about 40 weeks, or up to about 20 weeks, or up to about 24 weeks, or up to about 30 weeks, or up to about 36 weeks, or up to about 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 24 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drag therapy of the subject method for a time period of about 24 weeks to about 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 3O weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks, or about 24 weeks to about 48 weeks, or about 30 weeks to about 40 weeks, or up to about 20 weeks, or up to about 24 weeks, or up to about 30 weeks, or up to about 36 weeks, or up to about 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 24 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of at least about 24 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 or 4 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV infection characterized by any of HCV genotypes 5, 6, 7, 8 and 9 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV infection characterized by any of HCV genotypes 5, 6, 7, 8 and 9 and then (2) administering to the patient the drug therapy of the subject method for a time period of at least about 24 weeks and up to about 48 weeks.
  • any of the above-described methods of treating a viral infection can be used for the treatment of individuals who have an HCV infection and who have failed previous treatment for HCV infection ("treatment failure patients," including non-responders and relapsers).
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a treatment failure patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks.
  • the present invention provides methods of treating an HCV infection in a treatment failure patient, the method comprising administering an effective amount of an IFN- ⁇ , an effective amount of a TNF- ⁇ antagonist, and an effective amount of an IFN- ⁇ , for 48 weeks.
  • the invention provides methods for treating an HCV infection in a treatment failure patient, the method comprising administering an effective amount of IFN- ⁇ , an effective amount of a TNF- ⁇ antagonist, an effective amount of IFN- ⁇ , and an effective amount of ribavirin, for 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection in a non-responder patient, and where the drag therapy of the subject method is administered to the patient for 48 weeks.
  • the present invention provides methods of treating an HCV infection in a non-responder patient, the method comprising administering an effective amount of an IFN- ⁇ , an effective amount of a T ⁇ F- ⁇ antagonist, and an effective amount of an IFN- ⁇ , for 48 weeks.
  • the invention provides methods for treating an HCV infection in a non-responder patient, the method comprising administering an effective amount of IFN- ⁇ , an effective amount of IFN- ⁇ , an effective amount of a TNF- ⁇ antagonist, and an effective amount of ribavirin, for 48 weeks.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection in a relapser patient, and where the drag therapy of the subject method is administered to the patient for 48 weeks.
  • the invention provides methods for treating an HCV infection in a relapser patient, the method comprising administering an effective amount of an IF ⁇ - ⁇ , an effective amount of an IFN- ⁇ , and an effective amount of a TNF- ⁇ antagonist, for 48 weeks.
  • the invention provides methods for treating an HCV infection in a relapser patient, the method comprising administering an effective amount of IFN- ⁇ , an effective amount of IFN- ⁇ , and an effective amount of a TNF- ⁇ antagonist, and an effective amount of ribavirin, for 48 weeks.
  • any of the above-described methods of treating a viral infection can be used in the treatment of na ⁇ ve patients infected with HCV genotype 1.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a na ⁇ ve patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks.
  • the present invention provides methods of treating an HCV infection in a na ⁇ ve patient having an infection with HCV genotype 1, the method comprising administering an effective amount of an IFN- ⁇ , an effective amount of an IFN- ⁇ , and an effective amount of a TNF- ⁇ antagonist, for 48 weeks.
  • the invention provides methods for treating an HCV infection in a na ' ⁇ ve patient having an infection with HCV genotype 1, the method comprising administering an effective amount of IFN- ⁇ , an effective amount of IFN- ⁇ , an effective amount of a TNF- ⁇ antagonist, and an effective amount of ribavirin, for 48 weeks.
  • any of the above-described treatment regimens can be administered to na ⁇ ve patients infected with HCV genotype 4.
  • the invention provides any of the above- described methods of treating a viral infection, where the viral infection is an HCV genotype 4 infection in a na ⁇ ve patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks.
  • the present invention provides methods of treating an HCV infection in a na ⁇ ve patient having an infection with HCV genotype 4, the method comprising administering an effective amount of an IFN- ⁇ , an effective amount of an IF ⁇ - ⁇ , and an effective amount of a TNF- ⁇ antagonist, for 48 weeks.
  • the invention provides methods for treating an HCV infection in a na ⁇ ve patient having an infection with HCV genotype 4, the method comprising administering an effective amount of IF ⁇ - ⁇ , effective amount of IFN- ⁇ , an effective amount of a TNF- ⁇ antagonist, and an effective amount of ribavirin, for 48 weeks.
  • any of the above-described treatment regimens can be administered to na ⁇ ve patients infected with HCV genotype 1, which patients have a high viral load (HVL), where "HVL” refers to an HCV viral load of greater than 2 x 10 6 HCV genome copies per mL serum.
  • HVL refers to an HCV viral load of greater than 2 x 10 6 HCV genome copies per mL serum.
  • the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a na ⁇ ve patient who has a viral load of greater than 2 x 10 6 HCV genome copies per mL serum, and where the drug therapy of the subject method is administered to the patient for 48 weeks.
  • the present invention provides methods of treating an HCV infection in a na ⁇ ve patient having an infection with HCV genotype 1 and having a high viral load, the method comprising administering an effective amount of an IFN- ⁇ , an effective amount of an IFN- ⁇ , and an effective amount of a TNF- ⁇ antagonist, for 48 weeks.
  • the invention provides methods for treating an HCV infection in a na ⁇ ve patient having an infection with HCV genotype 1 and having a high viral load, the method comprising administering an effective amount of IFN- ⁇ , an effective amount of IFN- ⁇ , an effective amount of a T ⁇ F- ⁇ antagonist, and an effective amount of ribavirin, for 48 weeks.

Abstract

The present invention provides methods of treating virus infection; methods of treating hepatitis C virus (HCV) infection; and methods of reducing viral load, or reducing the time to viral clearance, or reducing morbidity or mortality in the clinical outcomes, in patients suffering from viral infection. The methods generally involve administering a therapeutically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist for the treatment of viral infection, such as HCV infection.

Description

COMBINATION THERAPY FOR THE TREATMENT OF VIRAL DISEASES
FIELD OF THE INVENTION [0001] This invention is in the field of viral infection, particularly hepatitis C viral infection.
BACKGROUND OF THE INVENTION
[0002] Hepatitis C virus (HCV) infection is the most common chronic blood borne infection in the United States. Although the numbers of new infections have declined, the burden of chronic infection is substantial, with Centers for Disease Control estimates of 3.9 million (1.8%) infected persons in the United States. Chronic liver disease is the tenth leading cause of death among adults in the United States, and accounts for approximately 25,000 deaths annually, or approximately 1% of all deaths. Studies indicate that 40% of chronic liver disease is HCV-related, resulting in an estimated 8,000-10,000 deaths each year. HCV-associated end- stage liver disease is the most frequent indication for liver transplantation among adults.
[0003] Antiviral therapy of chronic hepatitis C has evolved rapidly over the last decade, with significant improvements seen in the efficacy of treatment. Nevertheless, even with combination therapy using pegylated IFN-α plus ribavirin, 40% tp 50% of patients fail therapy, i.e., are nonresponders or relapsers. These patients currently have no effective therapeutic alternative. In particular, patients who have advanced fibrosis or cirrhosis on liver biopsy are at significant risk of developing complications of advanced liver disease, including ascites, jaundice, variceal bleeding, encephalopathy, and progressive liver failure, as well as a markedly increased risk of hepatocellular carcinoma.
[0004] The high prevalence of chronic HCV infection has important public health implications for the future burden of chronic liver disease in the United States. Data derived from the National Health and Nutrition Examination Survey (ΝHANES III) indicate that a large increase in the rate of new HCV infections occurred from the late 1960s to the early 1980s, particularly among persons between 20 to 40 years of age. It is estimated that the number of persons with long-standing HCV infection of 20 years or longer could more than quadruple from 1990 to 2015, from 750,000 to over 3 million. The proportional increase in persons infected for 30 or 40 years would be even greater. Since the risk of HCV-related chronic liver disease is related to the duration of infection, with the risk of cirrhosis progressively increasing for persons infected for longer than 20 years, this will result in a substantial increase in cirrhosis-related morbidity and mortality among patients infected between the years of 1965- [0005] There is a need in the art for improved methods for treating viral infections, e.g. hepatitis C viral infection. The present invention addresses this need. Literature
[0006] METAVIR (1994) Hepatology 20:15-20; Brunt (2000) Hepatol. 31:241-246; Alpini (1997 J Hepatol 27:371-380; Baroni et al. (1996) Hepatol. 23:1189-1199; Czaja et al. (1989) Hepatol. 10:795-800; Grossman et al. (1998) J Gastroenterol Hepatol. 13:1058-1060; Rockey and Chxmg (1994) J Invest. Med. 42:660-670; Sakaida et al. (1998) J Hepatol. 28:471-479; Shi et al. (1997) Proc. Natl Acad. Sci. USA 94:10663-10668; Baroni et al. (1999) Ztver 19:212-219; Lortat-Jacob et al. (1997) J Hepatol. 26:894-903; Llorent et al. (1996) J Hepatol. 24:555-563; U.S. Patent No. 5,082,659; European Patent Application EP 294,160; U.S. Patent No. 4,806,347; Balish et al. (1992) J Infect. Diseases 166:1401-1403; Katayama et al. (2001) J Viral Hepatitis 8:180-185; U.S. Patent No. 5,082,659; U.S. PatentNo. 5,190,751; U.S. PatentNo. 4,806,347; Wandl et al. (1992) Br. J. Haematol 81:516-519; European Patent Application No. 294,160; Canadian Patent No. 1,321,348; European Patent Application No. 276,120; Wandl et al. (1992) Sem. Oncol 19:88-94; Balish et al. (1992) J Infectious Diseases 166:1401-1403; Van Dijk et al. (1994) Int. J. Cancer 56:262-268; Sundmacher et al. (1987) Current Eye Res. 6:273-276; U.S. Patent Nos. 6,172,046; 6,245,740; 5,824,784; 5,372,808; 5,980,884; published international patent applications WO 96/21468; WO 96/11953; Torre et al. (2001) J Med. Virol. 64:455-459; Bekkering et al. (2001) J Hepatol. 34:435-440; Zeuzem et al. (2001) Gastroenterol. 120:1438-1447; Zeuzem (1999) J Hepatol. 31:61-64; Keeffe and Hollinger (1997) Hepatol. 26:101S-107S; Wills (1990) Clin. Pharmacokinet. 19:390-399; Heathcote et al. (2000) New Engl. J. Med. 343:1673-1680; Husa and Husova (2001) Bratisl Let Listy 102:248-252; Glue et al. (2000) Clin. Pharmacol. 68:556-567; Bailon et al. (2001) Bioconj. Chem. 12:195-202; and Neumann et al. (2001) Science 282:103; Zalipsky (1995) Adv. Drug Delivery Reviews S. 16, 157-182; Mann et al. (2001) Lancet 358:958-965; Zeuzem et al. (2000) New Engl. J. Med. 343:1666-1672; U.S. Patent Nos. 5,985,265; 5,908,121; 6,177,074; 5,985,263; 5,711,944; 5,382,657; and 5,908,121; Osborn et al. (2002) J Pharmacol. Exp. Therap. 303:540-548; Sheppard et al. (2003) Nat. Immunol. 4:63-68; Chang et al. (1999) Nat. Biotechnol 17:793-797; Adolf (1995) Multiple Sclerosis 1 Suppl. 1:S44-S47.
SUMMARY OF THE INVENTION
[0007] The present invention provides methods of treating viral infection; methods of treating hepatitis C virus (HCV) infection; methods of reducing the incidence of complications associated with HCV and cirrhosis of the liver; and methods of reducing viral load, or reducing the time to viral clearance, or reducing morbidity or mortality in the clinical outcomes, in patients suffering from viral infection. The methods generally involve administering a therapeutically effective amount of (i) a Type I or Type III interferon receptor agonist, (ii) a Type II interferon receptor agonist, and (iii) a TNF-α antagonist, for the treatment of viral infection.
FEATURES OF THE INVENTION [0008] The invention features a method of treating viral infection, generally involving administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF-α antagonist concurrently, in an amount effective to ameliorate the clinical course of the disease. The invention also features a method of treating virus infection by administering to an individual (i) a Type I interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF-α antagonist in a synergistically effective amount to ameliorate the clinical course of the disease. [0009] The invention features a method of treating HCV infection, generally involving administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF-α antagonist concurrently, in an amount effective to achieve a sustained viral response. The invention also features a method of treating HCV infection by administering to an individual (i) a Type II interferon receptor agonist (ii) a Type I or Type III interferon receptor agonist and (iii) a TNF-α antagonist in a synergistically effective amount to achieve a sustained viral response. [0010] In carrying out the methods of combination therapy for viral infection, e.g. hepatitis C viral infection, in an individual as described above, (i) a Type I or Type III interferon receptor agonist (ii) a Type II interferon receptor agonist and (iii) a TNF-α antagonist are administered to the individual. In some embodiments, two or more of the drugs are administered in the same formulation. In other embodiments, the Type I or III interferon receptor agonist, the Type II interferon receptor agonist and the TΝF-α antagonist are administered in two or more separate formulations. When administered in separate formulations, a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TΝF-α antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another. In many embodiments, a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist are administered subcutaneously in multiple doses. Optionally, the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or TΝF-α antagonist is/are administered to the individual by a controlled drug delivery device. Optionally, the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist is/are administered to the individual substantially continuously or continuously by a controlled drug delivery device. Optionally, the controlled drug delivery device is an implantable infusion pump and the infusion pump delivers the Type I or Type III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist to the individual by subcutaneous infusion.
[0011] In carrying out some methods of combination therapy for viral infection, e.g. hepatitis C viral infection, ribavirin is co-administered with a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist. In still other embodiments, ribavirin is co-administered with a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, a TΝF-α antagonist, and pirfenidone (or a pirfenidone analog).
[0012] In many embodiments, any of the above-described methods involve administering IFΝ- α, IFΝ-γ and a TNF-α antagonist. In some of these embodiments, the methods involve co- administering ribavirin, IFN-α, IFN-γ, and a TNF-α antagonist. In other embodiments, the methods involve co-administering ribavirin, IFN-α, IFN-γ, a TΝF-α antagonist, and pirfenidone or a pirfenidone analog.
[0013] In many embodiments, any of the above-described methods involve administering a Type I interferon receptor agonist that is a PEGylated IFΝ-α conjugate. In some embodiments, the PEGylated IFΝ-α conjugate is a monoPEGylated IFΝ-α. In other embodiments, the monoPEGylated IFN-α conjugate is an IFN-α polypeptide covalently linked to a single PEG moiety via a lysine residue or the N-terminal a ino acid residue of the IFN-α polypeptide. In other embodiments, the monoPEGylated IFN-α conjugate is an IFΝ-α polypeptide covalently linked to a single PEG moiety via an amide bond between either the epsilon-amino group of a lysine residue or the alpha-amino group of the IFΝ-α polypeptide and an activated carboxyl group of the PEG moiety. In other embodiments, the monoPEGylated IFN-α conjugate is an IFN-α polypeptide covalently linked to a single, linear PEG moiety.
[0014] In other embodiments, the monoPEGylated IFN-α conjugate is an IFN-α polypeptide covalently linked to a single, linear 30 kD PEG moiety ("monoPEG(30 kD, linear)-ylated IFN- α")- In other embodiments, the monoPEGylated IFΝ-α conjugate is an IFΝ-α polypeptide covalently linked to a single, linear 30 kD PEG moiety via an amide bond between the epsilon- amino group of a lysine residue or the alpha-amino group of the IFΝ-α polypeptide and an activated carboxyl group of the PEG moiety. In other embodiments, the monoPEGylated IFΝ- α conjugate is an IFN-α polypeptide covalently linked to a single, linear 30 kD PEG via an amide bond between the epsilon-amino group of a lysine residue or the alpha-amino group of the IFN-α polypeptide and an activated propionyl group of the PEG moiety. In other embodiments, the monoPEGylated IFN-α conjugate is an IFN-α polypeptide covalently linked to a single, linear monomethoxy-PEG (mPEG). In other embodiments, the monoPEGylated IFN-α conjugate is the product of a condensation reaction between an IFN-α polypeptide and a linear, succinimidyl propionate ester-activated 30 kD mPEG. any of the foregoing methods using a PEGylated IFN-α conjugate, the IFN-α polypeptide can be a consensus interferon (CIFΝ) polypeptide. In any of the foregoing methods using a PEGylated IFN-α conjugate, the IFN-α polypeptide can be a CIFN polypeptide that is interferon alfacon-1.
DEFINITIONS
[0015] As used herein, the term "hepatic fibrosis," used interchangeably herein with "liver fibrosis," refers to the growth of scar tissue in the liver that can occur in the context of a chronic hepatitis infection.
[0016] The tenns "individual," "host," "subject," and "patient" are used interchangeably herein, and refer to a mammal, including, but not limited to, murines, simians, humans, mammalian farm animals, mammalian sport animals, and mammalian pets.
[0017] As used herein, the term "liver function" refers to a normal function of the liver, including, but not limited to, a synthetic function, including, but not limited to, synthesis of proteins such as serum proteins (e.g., albumin, clotting factors, alkaline phosphatase, aminotransferases (e.g., alanine transaminase, aspartate transaminase), 5'-nucleosidase, γ- glutaminyltranspeptidase, etc.), synthesis of bilirubin, synthesis of cholesterol, and synthesis of bile acids; a liver metabolic function, including, but not limited to, carbohydrate metabolism, amino acid and ammonia metabolism, hormone metabolism, and lipid metabolism; detoxification of exogenous drugs; a hemodynamic function, including splanchnic and portal hemodynamics; and the like.
[0018] The term "sustained viral response" (SVR; also referred to as a "sustained response" or a "durable response"), as used herein, refers to the response of an individual to a treatment regimen for HCV infection, in terms of serum HCV titer. Generally, a "sustained viral response" refers to no detectable HCV RNA (e.g., less than about 500, less than about 200, or less than about 100 genome copies per milliliter serum) found in the patient's serum for a period of at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, or at least about six months following cessation of treatment. [0019] "Treatment failure patients" as used herein generally refers to HCV-infected patients who failed to respond to previous therapy for HCV (referred to as "non-responders") or who initially responded to previous therapy, but in whom the therapeutic response was not maintained (referred to as "relapsers"). The previous therapy generally can include treatment with IFN-α monotherapy or IFN-α combination therapy, where the combination therapy may include administration of IFN-α and an antiviral agent such as ribavirin.
[0020] As used herein, the terms "treatment," "treating," and the like, refer to obtaining a desired pharmacologic and/or physiologic effect. The effect may be prophylactic in terms of completely or partially preventing a disease or symptom thereof and/or may be therapeutic in terms of a partial or complete cure for a disease and/or adverse affect attributable to the disease. "Treatment," as used herein, covers any treatment of a disease in a mammal, particularly in a human, and includes: (a) preventing the disease from occurring in a subject which may be predisposed to the disease but has not yet been diagnosed as having it; (b) inhibiting the disease, i.e., arresting its development; and (c) relieving the disease, i.e., causing regression of the disease.
[0021] As used herein, the term "pirfenidone" means 5-methyl-l-phenyl-2-(lH)-pyridone. As used herein, the term "pirfenidone analog" means any compound of Formula I, IIA or IIB below. A "specific pirfenidone analog," and all grammatical variants thereof, refers to, and is limited to, each and every pirfenidone analog shown in Table 1.
[0022] As used herein, the term "a Type I interferon receptor agonist" refers to any naturally occurring or non-naturally occurring ligand of human Type I interferon receptor, which binds to and causes signal transduction via the receptor. Type I interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non-peptide chemical agonists; and the like.
[0023] As used herein, the term "a Type II interferon receptor agonist" refers to any naturally- occurring or non-naturally-occurring ligand of a human Type II interferon receptor which binds to and causes signal transduction via the receptor. Type II interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non-peptide chemical agonists; and the like. [0024] As used herein, the term "a Type III interferon receptor agonist" refers to any naturally occurring or non-naturally occurring ligand of humanIL-28 receptor α ("IL-28R"), the amino acid sequence of which is described by Sheppard, et al., infra., that binds to and causes signal transduction via the receptor.
[0025] The term "dosing event" as used herein refers to administration of an antiviral agent to a patient in need thereof, which event may encompass one or more releases of an antiviral agent from a drug dispensing device. Thus, the term "dosing event," as used herein, includes, but is not limited to, installation of a continuous delivery device (e.g., a pump or other controlled release injectible system); and a single subcutaneous injection followed by installation of a continuous delivery system.
[0026] "Continuous delivery" as used herein (e.g. , in the context of "continuous delivery of a substance to a tissue") is meant to refer to movement of drug to a delivery site, e.g., into a tissue in a fashion that provides for delivery of a desired amount of substance into the tissue over a selected period of time, where about the same quantity of drug is received by the patient each minute during the selected period of time.
[0027] "Controlled release" as used herein (e.g. , in the context of "controlled drug release") is meant to encompass release of substance (e.g., a Type I or Type III interferon receptor agonist, e.g., IFN-α) at a selected or otherwise controllable rate, interval, and/or amount, which is not substantially influenced by the environment of use. "Controlled release" thus encompasses, but is not necessarily limited to, substantially continuous delivery, and patterned delivery (e.g., intermittent delivery oVer a period of time that is interrupted by regular or irregular time intervals).
[0028] "Patterned" or "temporal" as used in the context of drug delivery is meant delivery of drug in a pattern, generally a substantially regular pattern, over a pre-selected period of time (e.g. , other than a period associated with, for example a bolus injection). "Patterned" or "temporal" drug delivery is meant to encompass delivery of drug at an increasing, decreasing, substantially constant, or pulsatile, rate or range of rates (e.g., amount of drug per unit time, or volume of drug formulation for a unit time), and further encompasses delivery that is continuous or substantially continuous, or chronic.
[0029] The term "controlled drug delivery device" is meant to encompass any device wherein the release (e.g., rate, timing of release) of a drug or other desired substance contained therein is controlled by or determined by the device itself and not substantially influenced by the environment of use, or releasing at a rate that is reproducible within the environment of use. [0030] By "substantially continuous" as used in, for example, the context of "substantially continuous infusion" or "substantially continuous delivery" is meant to refer to delivery of drug in a manner that is substantially uninterrupted for a pre-selected period of drug delivery, where the quantity of drug received by the patient during any 8 hour interval in the pre-selected period never falls to zero. Furthermore, "substantially continuous" drug delivery can also encompass delivery of drug at a substantially constant, pre-selected rate or range of rates (e.g., amount of drug per unit time, or volume of drug formulation for a unit time) that is substantially uninterrupted for a pre-selected period of drug delivery.
[0031] By "substantially steady state" as used in the context of a biological parameter that may vary as a function of time, it is meant that the biological parameter exhibits a substantially constant value over a time course, such that the area under the curve defined by the value of the biological parameter as a function of time for any 8 hour period during the time course ' (AUC8hr) is no more than about 20% above or about 20% below, and preferably no more than about 15% above or about 15% below, and more preferably no more than about 10% above or about 10%) below, the average area under the curve of the biological parameter over an 8 hour period during the time course (AUC8hr average)- The AUC h. average is defined as the quotient (q) of the area under the curve of the biological parameter over the entirety of the time course (AUCtotai) divided by the number of 8 hour intervals in the time course (tt0taiι/3days). i.e., q = (AUCtotai)/ (ttotaiι/3days)- For example, in the context of a serum concentration of a drug, the serum concentration of the drug is maintained at a substantially steady state during a time course when the area under the curve of serum concentration of the drug over time for any 8 hour period during the time course (AUC8rιr) is no more than about 20% above or about 20% below the average area under the curve of serum concentration of the drug over an 8 hour period in the time course (AUC8i,r average), i-e., the AUC8_ir is no more than 20% above or 20% below the AUC8hr average for the serum concentration of the drug over the time course.
[0032] As used herein, any compound or agent described as "effective for the avoidance or amelioration of side effects induced by Type I interferon receptor agonist and/or Type II interferon receptor agonist," or as "effective for reducing or eliminating the severity or occurrence of side effects induced by Type I interferon receptor agonist and/or Type II interferon receptor agonist," or any compound or agent described by language with a meaning similar or equivalent to that of either of the foregoing quoted passages, is/are defined as a compound(s) or agent(s) that when co-administered to a patient in an effective amount along with a given dosing regimen of Type I interferon receptor agonist and Type II interferon receptor agonist combination therapy, abates or eliminates the severity or occurrence of side effects experienced by a patient in response to the given dosing regimen of the interferon receptor agonist combination therapy, as compared to the severity or occurrence of side effects that would have been experienced by the patient in response to the same dosing regimen of the interferon receptor agonist combination therapy without co-administration of the agent.
[0033] In many embodiments, the effective amounts of a Type II interferon receptor agonist a Type I or III interferon receptor agonist, and a TNF-α antagonist, are synergistic amounts. As used herein, a "synergistic combination" or a "synergistic amount" of a Type II interferon receptor agonist, a Type I or III interferon receptor agonist, and a-TΝF-α antagonist, is a combination or amount that is more effective in the therapeutic or prophylactic treatment of a disease than the incremental improvement in treatment outcome that could be predicted or expected from a merely additive combination of (i) the therapeutic or prophylactic benefit of the Type II interferon receptor agonist when administered at that same dosage as a monotherapy (ii) the therapeutic or prophylactic benefit of the Type I or III interferon receptor agonist when administered at the same dosage as a monotherapy and (iii) the therapeutic or prophylactic benefit of the TΝF-α antagonist when administered at the same dosage as a monotherapy.
[0034] In some embodiments of the invention, a selected amount of a Type II interferon receptor agonist, a selected amount of a Type I or III interferon receptor agonist, and a selected amount of a TΝF-α antagonist are effective when used in triple therapy for a disease, but the selected amount of the Type II interferon receptor agonist, the selected amount of the Type I or III interferon receptor agonist, or the selected amount of the TNFτ-α antagonist is ineffective when used in monotherapy for the disease, or combination(s) of any two of the foregoing drugs are ineffective when used in double therapy for the disease.
[0035] Thus, the invention encompasses: (1) regimens in which a selected amount of a Type I or III interferon receptor agonist enhances the therapeutic benefit of a selected amount of (i) a Type II interferon receptor agonist and (ii) a TΝF-α antagonist when used in triple therapy for a disease, where the selected amount of the Type I or III interferon receptor agonist provides no therapeutic benefit when used in monotherapy for the disease; (2) regimens in which a selected amount of a Type II interferon receptor agonist enhances the therapeutic benefit of a selected amount of (i) a Type I or III interferon receptor agonist and (ii) a TNF-α antagonist when used in triple therapy for a disease, where the selected amount of the Type II interferon receptor agonist provides no therapeutic benefit when used in monotherapy for the disease; (3) regimens in which a selected amount of a TNF-α antagonist enhances the therapeutic benefit of (i) a selected amount of a Type II interferon receptor agonist and (ii) a Type I or III interferon receptor agonist when used in triple therapy for a disease, where the selected amount of the TNF-α antagonist provides no therapeutic benefit when used in monotherapy for the disease; (4) regimens in which a selected amount of (i) a Type II interferon receptor agonist and (ii) a TNF-α antagonist enhances the therapeutic benefit of a selected amount of a Type I or III interferon receptor agonist when used in triple therapy for a disease, where the selected amount of the Type II interferon receptor agonist and TΝF-α antagonist provides no therapeutic benefit when used in double therapy for the disease; (5) regimens in which a selected amount of (i) a Type I or III interferon receptor agonist and (ii) a TNF-α antagonist enhances the therapeutic benefit of a selected amount of a Type II interferon receptor agonist when used in triple therapy for a disease, where the selected amount of the Type I or III interferon receptor agonist and TΝF-α antagonist provides no therapeutic benefit when used in double therapy for the disease; (6) regimens in which a selected amount of (i) a Type II interferon receptor agonist and (ii) a Type I or III interferon receptor agonist enhances the therapeutic benefit of a selected amount of a TΝF-α antagonist when used in triple therapy for a disease, where the selected amount of the Type II interferon receptor agonist and Type I or III interferon receptor agonist provides no therapeutic benefit when used in double therapy for the disease; and (7) regimens in which a selected amount of a Type I or III interferon receptor agonist, a selected amount of a Type II interferon receptor agonist, and a selected amount of a TNF-α antagonist provide a therapeutic benefit when used in triple therapy for a disease, where each of the selected amounts of the Type II interferon receptor agonist, the Type I or III interferon receptor agonist, and the TNF-α antagonist, respectively, provides no therapeutic benefit when used in monotherapy for the disease.
[0036] As used herein, a "synergistically effective amount" or "synergistically effective combination" of a Type II interferon receptor agonist, a Type I or III interferon receptor agonist, and a TNF-α antagonist, and its grammatical equivalents" shall be understood to include any regimen encompassed by any of (l)-(7) above.
[0037] Before the present invention is further described, it is to be understood that this invention is not limited to particular embodiments described, as such may, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the present invention will be limited only by the appended claims.
[0038] Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges is also encompassed within the invention, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either both of those included limits are also included in the invention.
[0O39] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although any methods and materials similar or equivalent to those described herein can also be used in the practice or testing of the present invention, the preferred methods and materials are now described. All publications mentioned herein are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited.
[0O40] It must be noted that as used herein and in the appended claims, the singular forms "a," "and," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a method" includes a plurality of such methods and reference to "a dose" includes reference to one or more doses and equivalents thereof known to those skilled in the art, and so forth.
[0O41] The publications discussed herein are provided solely for their disclosure prior to the filing date of the present application. Nothing herein is to be construed as an admission that the present invention is not entitled to antedate such publication by virtue of prior invention. Further, the dates of publication provided may be different from the actual publication dates which may need to be independently confirmed.
DETAILED DESCRIPTION OF THE INVENTION [0O42] The present invention provides methods of treating viral infections, including methods of treating HCV infection. The methods generally involve administering an effective amount of a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist, to an individual in need thereof. Of particular interest in many embodiments is treatment of humans. [0O43] The present invention provides methods for treating viral infection. The methods generally involve administering a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist to an individual in an amount that is effective to ameliorate the clinical course of the disease. [O044] Whether a subject method is effective in treating a viral infection can be determined by a reduction in number or length of hospital stays, a reduction in time to viral clearance, a reduction of morbidity or mortality in clinical outcomes, or other indicator of disease response.
[O045] In general, an effective amount of a Type I or Type III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist is an amount that is effective to (i) reduce the time to viral clearance, (ii) reduce morbidity or mortality in the clinical course of the disease or (iii) reduce viral load in the patient.
[O046] The present invention provides methods for treating HCV. The methods generally involve administering a Type I or Type III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist, to an individual in an amount that is effective to decrease viral load in the individual, and to achieve a sustained viral response.
[O047] Whether a subject method is effective in treating an HCV infection can be determined by measuring viral load, or by measuring a parameter associated with HCV infection, including, but not limited to, liver fibrosis, elevations in serum transaminase levels, and necroinflammatory activity in the liver. Indicators of liver fibrosis are discussed in detail below.
[O048] Viral load can be measured by measuring the titer or level of virus in serum. These methods include, but are not limited to, a quantitative polymerase chain reaction (PCR) and a branched DNA (bDNA) test. Quantitative assays for measuring the viral load (titer) of HCV RNA have been developed. Many such assays are available commercially, including a quantitative reverse transcription PCR (RT-PCR) (Amplicor HCV Monitor™, Roche Molecular Systems, New Jersey); and a branched DNA (deoxyribonucleic acid) signal amplification assay (Quantiplex™ HCV RNA Assay (bDNA), Chiron Corp., Emeryville, California). See, e.g., Gretch et al. (1995) Ann. Intern. Med. 123:321-329.
[O049] In general, an effective amount of a Type I or III interferon receptor agonist, a Type II interferon receptor agonist, and a TΝF-α antagonist, is an amount that is effective to reduce viral load to undetectable levels, e.g., to less than about 5000, less than about 1000, less than about 500, or less than about 200 genome copies/mL serum. In some embodiments, an effective amount of a Type I or Type III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist is an amount that is effective to reduce viral load to less than 100 genome copies/mL serum. In many embodiments, the methods of the invention achieve a sustained viral response, e.g., the viral load is reduced to undetectable levels for a period of at least about one month, at least about two months, at least about three months, at least about four months, at least about five months, or at least about six months following cessation of treatment.
[0O50] As noted above, whether a subject method is effective in treating an HCV infection can be determined by measuring a parameter associated with HCV infection, such as liver fibrosis. Methods of determining the extent of liver fibrosis are discussed in detail below. In some embodiments, the level of a serum marker of liver fibrosis indicates the degree of liver fibrosis.
[0O51] As one non-limiting example, levels of serum alanine aminotransferase (ALT) are measured, using standard assays. In general, an ALT level of less than about 45 international units is considered normal. In some embodiments, an effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist is an amount effective to reduce ALT levels to less than about 45 U/ml serum.
[00)52] A therapeutically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist is an amount that is effective to reduce a serum level of a marker of liver fibrosis by at least about 10%, at least about 20%, at least about 25%, at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, or at least about 80%, or more, compared to the level of the marker in an untreated individual, or to a placebo-treated individual. Methods of measuring serum markers include immunological-based methods, e.g., enzyme-linked immunosorbent assays (ELISA), radioimmunoassays, and the like, using antibody specific for a given serum marker. TYPE I INTERFERON RECEPTOR AGONISTS
[0053] In any of the above-described methods, in some embodiments a Type I interferon receptor agonist is administered. Type I interferon receptor agonists include an IFN-α; an IFN- β; an IFN-tau; an IFN-ω; antibody agonists specific for a Type I interferon receptor; and any other agonist of Type I interferon receptor, including non-polypeptide agonists. Interferon-Alpha
[0054] Any known IFN-α can be used in the instant invention. The term "interferon-alpha" as used herein refers to a family of related polypeptides that inhibit viral replication and cellular proliferation and modulate immune response. The term "IFN-α" includes naturally occurring IFN-α; synthetic IFN-α; derivatized IFN-α (e.g., PEGylated IFN-α, glycosylated IFN-α, and the like); and analogs of naturally occurring or synthetic IFN-α; essentially any IFN-α that has antiviral properties, as described for naturally occurring IFN-α.
[0055] Suitable alpha interferons include, but are not limited to, naturally-occurring IFN-α (including, but not limited to, naturally occurring IFN-α2a, IFN-α2b); recombinant interferon alpha-2b such as Intron-A interferon available from Schering Corporation, Kenilworth, N.J.; recombinant interferon alpha-2a such as Roferon interferon available from Hoffmann-La Roche, Nutley, N. J.; recombinant interferon alpha-2C such as Berofor alpha 2 interferon available from Boehringer Ingelheim Pharmaceutical, Inc., Ridgefield, Conn.; interferon alpha- nl, a purified blend of natural alpha interferons such as Sumiferon available from Sumitomo, Japan or as Wellferon interferon alpha-nl (INS) available from the Glaxo-Wellcome Ltd., London, Great Britain; and interferon alpha-n3 a mixture of natural alpha interferons made by Interferon Sciences and available from the Purdue Frederick Co., Νorwalk, Conn., under the Alferon Tradename.
[0056] The term "IFΝ-α" also encompasses consensus IFΝ-α. Consensus IFN-α (also referred to as "CIFN" and "IFN-con" and "consensus interferon") encompasses but is not limited to the amino acid sequences designated IFN-coni, IFN-con2 and IFN-con3 which are disclosed in U.S. Pat. Nos. 4,695,623 and 4,897,471; and consensus interferon as defined by determination of a consensus sequence of naturally occurring interferon alphas (e.g., Infergen®, InterMune, Inc., Brisbane, Calif). IFN-con1 is the consensus interferon agent in the Infergen® alfacon-1 product. The Infergen® consensus interferon product is referred to herein by its brand name (Infergen®) or by its generic name (interferon alfacon-1). DNA sequences encoding IFN-con may be synthesized as described in the aforementioned patents or other standard methods. Use of CIFN is of particular interest.
[0057] Also suitable for use in the present invention are fusion polypeptides comprising an IFΝ-α and a heterologous polypeptide. Suitable IFN-α fusion polypeptides include, but are not limited to, Albuferon-alpha™ (a fusion product of human albumin and IFN-α; Human Genome Sciences; see, e.g., Osborn et al. (2002) J Pharmacol. Exp. Therap. 303:540-548). Also suitable for use in the present invention are gene-shuffled forms of IFN-α. See., e.g., Masci et al. (2003) Curr. Oncol. Rep. 5:108-113. PEGylated Interferon- Alpha
[0058] The term "IFN-α" also encompasses derivatives of IFN-α that are derivatized (e.g., are chemically modified) to alter certain properties such as serum half-life. As such, the term "IFN-a" includes glycosylated IFN-α; IFN-α derivatized with polyethylene glycol ("PEGylated IFΝ-α"); and the like. PEGylated IFN-α, and methods for making same, is discussed in, e.g., U.S. Patent Nos. 5,382,657; 5,981,709; and 5,951,974. PEGylated IFN-α encompasses conjugates of PEG and any of the above-described IFN-α molecules, including, but not limited to, PEG conjugated to interferon alpha-2a (Roferon, Hoffman La-Roche, Nutley, N. J.), interferon alpha 2b (Intron, Schering-Plough, Madison, N. j.), interferon alpha-2c (Berofor Alpha, Boehringer Ingelheim, Ingelheim, Germany); and consensus interferon as defined by determination of a consensus sequence of naturally occurring interferon alphas (Infergen®, InterMune, Inc., Brisbane, Calif).
[0059] Any of the above-mentioned IFN-α polypeptides can be modified with one or more polyethylene glycol moieties, i.e., PEGylated. The PEG molecule of a PEGylated IFN-α polypeptide is conjugated to one or more amino acid side chains of the IFN-α polypeptide. In some embodiments, the PEGylated IFN-α contains a PEG moiety on only one amino acid. In other embodiments, the PEGylated IFN-α contains a PEG moiety on two or more amino acids, e.g., the IFN-α contains a PEG moiety attached to two, three, four, five, six, seven, eight, nine, or ten different amino acid residues.
[0060] IFN-α may be coupled directly to PEG (i.e., without a linking group) through an amino group, a sulfhydryl group, a hydroxyl group, or a carboxyl group.
[0061] In some embodiments, the PEGylated IFN-α is PEGylated at or near the amino terminus (N-terminus) of the IFN-α polypeptide, e.g., the PEG moiety is conjugated to the IFN-α polypeptide at one or more amino acid residues from amino acid 1 through amino acid 4, or from amino acid 5 through about 10.
[0062] In other embodiments, the PEGylated IFN-α is PEGylated at one or more amino acid residues from about 10 to about 28.
[0063] In other embodiments, the PEGylated IFN-α is PEGylated at or near the carboxyl terminus (C-terminus) of the IFN-α polypeptide, e.g., at one or more residues from amino acids 156-166, or from amino acids 150 to 155.
[0064] In other embodiments, the PEGylated IFN-α is PEGylated at one or more amino acid residues at one or more residues from amino acids 100-114.
[0065] The polyethylene glycol derivatization of amino acid residues at or near the receptor- binding and/or active site domains of the IFN-α protein can disrupt the functioning of these domains. In certain embodiments of the invention, amino acids at which PEGylation is to be avoided include amino acid residues from amino acid 30 to amino acid 40; and amino acid residues from amino acid 113 to amino acid 149.
[0066] In some embodiments, PEG is attached to IFN-α via a linking group. The linking group is any biocompatible linking group, where "biocompatible" indicates that the compound or group is non-toxic and may be utilized in vitro or in vivo without causing injury, sickness, disease, or death. PEG can be bonded to the linking group, for example, via an ether bond, an ester bond, a thiol bond or an amide bond. Suitable biocompatible linking groups include, but are not limited to, an ester group, an amide group, an imide group, a carbamate group, a carboxyl group, a hydroxyl group, a carbohydrate, a succinimide group (including, for example, succinimidyl succinate (SS), succinimidyl propionate (SPA), succinimidyl butanoate (SBA), succinimidyl carboxymethylate (SCM), succinimidyl succinamide (SSA) orN-hydroxy succinimide (NHS)), an epoxide group, an oxycarbonylimidazole group (including, for example, carbonyldimidazole (GDI)), a nitro phenyl group (including, for example, nitrophenyl carbonate (NPC) or trichlorophenyl carbonate (TPC)), a trysylate group, an aldehyde group, an isocyanate group, a vinylsulfone group, a tyrosine group, a cysteine group, a histidine group or a primary amine.
[0067] Methods for making succinimidyl propionate (SPA) and succinimidyl butanoate (SBA) ester-activated PEGs are described in U.S. Pat. No. 5,672,662 (Harris, et al.) and WO 97/03106.
[0068] Methods for attaching a PEG to an IFN-α polypeptide are known in the art, and any known method can be used. See, for example, by Park et al, Anticancer Res., 1 :373-376 (1981); Zaplipsky and Lee, Polyethylene Glycol Chemistry: Biotechnical and Biomedical Applications, J. M. Harris, ed., Plenum Press, NY, Chapter 21 (1992); U.S. PatentNo. 5,985,265; U.S. Pat. No. 5,672,662 (Harris, et al.) and WO 97/03106.
[0069] Pegylated IFN-α, and methods for making same, is discussed in, e.g., U.S. Patent Nos. 5,382,657; 5,981,709; 5,985,265; and 5,951,974. Pegylated IFN-α encompasses conjugates of PEG and any of the above-described IFN-α molecules, including, but not limited to, PEG conjugated to interferon alpha-2a (Roferon, Hoffman LaRoche, Nutley, N. J.), where PEGylated Roferon is known as Pegasys (Hoffman LaRoche); interferon alpha 2b (Intron, Schering-Plough, Madison, N. J.), where PEGylated Intron is known as PEG-Intron (Schering- Plough); interferon alpha-2c (Berofor Alpha, Boehringer Ingelheim, Ingelheim, Germany); and consensus interferon (CIFN) as defined by determination of a consensus sequence of naturally occurring interferon alphas (Infergen®, InterMune, Inc., Brisbane, Calif), where PEGylated Infergen is referred to as PEG-Infergen.
[0070] In many embodiments, the PEG is a monomethoxyPEG molecule that reacts with primary amine groups on the IFN-α polypeptide. Methods of modifying polypeptides with monomethoxy PEG via reductive alkylation are known in the art. See, e.g., Chamow et al. (1994) Bzoconj. Chem. 5:133-140.
[0071] In one non-limiting example, PEG is linked to IFN-α via an SPA linking group. SPA esters of PEG, and methods for making same, are described in U.S. Patent No. 5,672,662. SPA linkages provide for linkage to free amine groups on the IFN-α polypeptide. [0072] For example, a PEG molecule is covalently attached via a linkage that comprises an amide bond between a propionyl group of the PEG moiety and the epsilon amino group of a surface-exposed lysine residue in the IFN-α polypeptide. Such a bond can be formed, e.g., by condensation of an α-methoxy, omega propanoic acid activated ester of PEG (mPEGspa).
[0073] As one non-limiting example, one monopegylated CIFN conjugate preferred for use herein has a linear PEG moiety of about 30 kD attached via a covalent linkage to the CIFN polypeptide, where the covalent linkage is an amide bond between a propionyl group of the PEG moiety and the epsilon amino group of a surface-exposed lysine residue in the CIFN polypeptide, where the surface-exposed lysine residue is chosen from lys31, lys50, lys71, lys84, lys , lys , lys , lys , and lys , and the amide bond is formed by condensation of an α- methoxy, omega propanoic acid activated ester of PEG. Polyethylene glycol
[0074] Polyethylene glycol suitable for conjugation to an IFN-α polypeptide is soluble in water at room temperature, and has the general formula R(O-CH2-CH2)nO-R, where R is hydrogen or a protective group such as an alkyl or an alkanol group, and where n is an integer from 1 to 1000. Where R is a protective group, it generally has from 1 to 8 carbons.
[0075] In many embodiments, PEG has at least one hydroxyl group, e.g., a terminal hydroxyl group, which hydroxyl group is modified to generate a functional group that is reactive with an amino group, e.g., an epsilon amino group of a lysine residue, a free amino group at the N- terminus of a polypeptide, or any other amino group such as an amino group of asparagine, glutamine, arginine, or histidine.
[0076] In other embodiments, PEG is derivatized so that it is reactive with free carboxyl groups in the IFN-α polypeptide, e.g., the free carboxyl group at the carboxyl terminus of the IFΝ-α polypeptide. Suitable derivatives of PEG that are reactive with the free carboxyl group at the carboxyl-terminus of IFΝ-α include, but are not limited to PEG-amine, and hydrazine derivatives of PEG (e.g., PEG-NH-NH2).
[0077] In other embodiments, PEG is derivatized such that it comprises a terminal thiocarboxylic acid group, -COSH, which selectively reacts with amino groups to generate amide derivatives. Because of the reactive nature of the thio acid, selectivity of certain amino groups over others is achieved. For example, -SH exhibits sufficient leaving group ability in reaction with N-terminal amino group at appropriate pH conditions such that the ε-amino groups in lysine residues are protonated and remain non-nucleophilic. On the other hand, reactions under suitable pH conditions may make some of the accessible lysine residues to 'react with selectivity. [0078] In other embodiments, the PEG comprises a reactive ester such as an N-hydroxy succinimidate at the end of the PEG chain. Such an N-hydroxysuccinimidate-containing PEG molecule reacts with select amino groups at particular pH conditions such as neutral 6.5-7.5. For example, the N-terminal amino groups may be selectively modified under neutral pH conditions. However, if the reactivity of the reagent were extreme, accessible-NH2 groups of lysine may also react.
[0079] The PEG can be conjugated directly to the IFN-α polypeptide, or through a linker. In some embodiments, a linker is added to the IFN-α polypeptide, forming a linker-modified IFΝ- α polypeptide. Such linkers provide various functionalities, e.g., reactive groups such sulfhydryl, amino, or carboxyl groups to couple a PEG reagent to the linker-modified IFN-α polypeptide.
[0080] In some embodiments, the PEG conjugated to the IFN-α polypeptide is linear. In other embodiments, the PEG conjugated to the IFN-α polypeptide is branched. Branched PEG derivatives such as those described in U.S. Pat. No. 5,643,575, "star-PEG's" and multi-armed PEG's such as those described in Shearwater Polymers, Inc. catalog "Polyethylene Glycol Derivatives 1997-1998." Star PEGs are described in the art including, e.g., in U.S. Patent No. 6,046,305.
[0081] PEG having a molecular weight in a range of from about 2 kDa to about 100 kDa, is generally used, where the term "about," in the context of PEG, indicates that in preparations of polyethylene glycol, some molecules will weigh more, some less, than the stated molecular weight. For example, PEG suitable for conjugation to IFN-α has a molecular weight of from about 2 kDa to about 5 kDa, from about 5 kDa to about 10 kDa, from about 10 kDa to about 15 kDa, from about 15 kDa to about 20 kDa, from about 20 kDa to about 25 kDa, from about 25 kDa to about 30 kDa, from about 30 kDa to about 40 kDa, from about 40 kDa to about 50 kDa, from about 50 kDa to about 60 kDa, from about 60 kDa to about 70 kDa, from about 70 kDa to about 80 kDa, from about 80 kDa to about 90 kDa, or from about 90 kDa to about 100 kDa. Preparing PEG-IFN-α conjugates
[0082] As discussed above, the PEG moiety can be attached, directly or via a linker, to an amino acid residue at or near the N-terminus, internally, or at or near the C-terminus of the IFN-α polypeptide. Conjugation can be carried out in solution or in the solid phase. N-terminal linkage
[0083] Methods for attaching a PEG moiety to an amino acid residue at or near the N-terminus of an IFΝ-α polypeptide are known in the art. See, e.g., U.S. Patent No. 5,985,265. [0084] In some embodiments, known methods for selectively obtaining an N-terminally chemically modified IFN-α are used. For example, a method of protein modification by reductive alkylation which exploits differential reactivity of different types of primary amino groups (lysine versus the N-terminus) available for derivatization in a particular protein can be used. Under the appropriate reaction conditions, substantially selective derivatization of the protein at the N-terminus with a carbonyl group containing polymer is achieved. The reaction is performed at pH which allows one to take advantage of the pKa differences between the ε- amino groups of the lysine residues and that of the α-amino group of the N-terminal residue of the protein. By such selective derivatization attachment of a PEG moiety to the IFN-α is controlled: the conjugation with the polymer takes place predominantly at the N-terminus of the IFN-α and no significant modification of other reactive groups, such as the lysine side chain amino groups, occurs. C-terminal linkage
[0085] N-terminal-specific coupling procedures such as described in U.S. Patent No. 5,985,265 provide predominantly monoPEGylated products. However, the purification procedures aimed at removing the excess reagents and minor multiply PEGylated products remove the N-terminal blocked polypeptides. In terms of therapy, such processes lead to significant increases in manufacturing costs. For example, examination of the structure of the well-characterized Infergen® Alfacon-1 CIFN polypeptide amino acid sequence reveals that the clipping is approximate 5% at the carboxyl terminus and thus there is only one major C- terminal sequence. Thus, in some embodiments, N-terminally PEGylated IFN-α is not used; instead, the IFN-α polypeptide is C-terminally PEGylated.
[0086] An effective synthetic as well as therapeutic approach to obtain mono PEGylated Infergen product is therefore envisioned as follows:
[0087] A PEG reagent that is selective for the C-terminal can be prepared with or without spacers. For example, polyethylene glycol modified as methyl ether at one end and having an amino function at the other end may be used as the starting material.
[0088] Preparing or obtaining a water-soluble carbodiimide as the condensing agent can be carried out. Coupling IFN-α (e.g., Infergen® Alfacon-1 CIFN or consensus interferon) with a water-soluble carbodiimide as the condensing reagent is generally carried out in aqueous medium with a suitable buffer system at an optimal pH to effect the amide linkage. A high molecular weight PEG can be added to the protein covalently to increase the molecular weight.
[0089] The reagents selected will depend on process optimization studies. A non-limiting example of a suitable reagent is ED AC or l-ethyl-3- (3-dimethylaminopropyl) carbodiimide. The water solubility of ED AC allows for direct addition to a reaction without the need for prior organic solvent dissolution. Excess reagent and the isourea formed as the by-product of the cross-linking reaction are both water-soluble and may easily be removed by dialysis or gel filtration. A concentrated solution of ED AC in water is prepared to facilitate the addition of a small molar amount to the reaction. The stock solution is prepared and used immediately in view of the water labile nature of the reagent. Most of the synthetic protocols in literature suggest the optimal reaction medium to be in pH range between 4.7 and 6.0. However the condensation reactions do proceed without significant losses in yields up to pH 7.5. Water may be used as solvent. In view of the contemplated use of Infergen, preferably the medium will be 2-(N-morpholino)ethane sulfonic acid buffer pre-titrated to pH between 4.7 and 6.0. However, 0.1M phosphate in the pH 7-7.5 may also be used in view of the fact that the product is in the same buffer. The ratios of PEG amine to the IFN-α molecule is optimized such that the C- terminal carboxyl residue(s) are selectively PEGylated to yield monoPEGylated derivative(s).
[0090] Even though the use of PEG amine has been mentioned above by name or structure, such derivatives are meant to be exemplary only, and other groups such as hydrazine derivatives as in PEG-NH-NH2 which will also condense with the carboxyl group of the IFN-α protein, can also be used. In addition to aqueous phase, the reactions can also be conducted on solid phase. Polyethylene glycol can be selected from list of compounds of molecular weight ranging from 300-40000. The choice of the various polyethylene glycols will also be dictated by the coupling efficiency and the biological performance of the purified derivative in vitro scad in vivo i.e., circulation times, ami viral activities etc.
[0091] Additionally, suitable spacers can be added to the C-terminal of the protein. The spacers may have reactive groups such as SH, NH2 or COOH to couple with appropriate PEG reagent to provide the high molecular weight IFN-α derivatives. A combined solid/solution phase methodology can be devised for the preparation of C-terminal pegylated interferons. For example, the C-terminus of IFN-α is extended on a solid phase using a Gly-Gly-Cys-NH2 spacer and then monopegylated in solution using activated dithiopyridyl-PEG reagent of appropriate molecular weights. Since the coupling at the C-terminus is independent of the blocking at the N-terminus, the envisioned processes and products will be beneficial with respect to cost (a third of the protein is not wasted as in N-terminal PEGylation methods) and contribute to the economy of the therapy to treat chronic hepatitis C infections, liver fibrosis etc.
[0092] There may be a more reactive carboxyl group of amino acid residues elsewhere in the molecule to react with the PEG reagent and lead to monoPEGylation at that site or lead to multiple PEGylations in addition to the -COOH group at the C-terminus of the IFN-α. It is envisioned that these reactions will be minimal at best owing to the steric freedom at the C- terminal end of the molecule and the steric hindrance imposed by the carbodiimides and the PEG reagents such as in branched chain molecules. It is therefore the preferred mode of PEG modification for Infergen and similar such proteins, native or expressed in a host system, which may have blocked N-termini to varying degrees to improve efficiencies and maintain higher in vivo biological activity.
[0093] Another method of achieving C-terminal PEGylation is as follows. Selectivity of C- terminal PEGylation is achieved with a sterically hindered reagent which excludes reactions at carboxyl residues either buried in the helices or internally in IFN-α. For example, one such reagent could be a branched chain PEG ~40kd in molecular weight and this agent could be synthesized as follows:
[0094] 0H3C-(CH2CH2O)n-CH2CH2NH2 + Glutamic Acid i.e., HOCO-CH2CH2CH(ΝH2)- COOH is condensed with a suitable agent e.g., dicyclohexyl carbodiimide or water-soluble EDC to provide the branched chain PEG agent OH3C-(CH2CH2O)n- CH2CH2NHCOCH(NH2)CH2OCH3-(CH2CH2O)„-CH2CH2NHCOCH2. o H3C-0-(CH2CH_0)irCH2CH2NH2+ HO C-CH2CH2CH-C00H
CI-1NH.2 EDΛC
H3C-0-(CH2CH2θ)n-CI-l2CH NH-C0
CHNI--2 (CH_)2 H3C-0-(CΗ2CI-l2θ)n-CH2CH2NH-CO
[0095] This reagent can be used in excess to couple the amino group with the free and flexible carboxyl group of IFN-ot to form the peptide bond.
[0096] If desired, PEGylated IFN-α is separated from unPEGylated IFN-α using any known method, including, but not limited to, ion exchange chromatography, size exclusion chromatography, and combinations thereof. For example, where the PEG-IFN-α conjugate is a monoPEGylated IFΝ-α, the products are first separated by ion exchange chromatography to obtain material having a charge characteristic of monoPEGylated material (other multi- PEGylated material having the same apparent charge may be present), and then the monoPEGylated materials are separated using size exclusion chromatography. IFN-β
[0097] The term interferon-beta ("IFN-β") includes IFN-β polypeptides that are naturally occurring; non-naturally-occurring IFN-β polypeptides; and analogs of naturally occurring or non- naturally occurring IFN-β that retain antiviral activity of a parent naturally-occurring or non- naturally occurring IFN-β.
[0098] Any of a variety of beta interferons can be administered in a subject method. Suitable beta interferons include, but are not limited to, naturally-occurring IFN-β; IFN-β la, e.g., Avonex® (Biogen, Inc.), and R-ebif® (Serono, SA); IFN-βlb (Betaseron®; Berlex); and the like.
[0099] The IFN-β formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN-β.
[00100] IFN-β polypeptides can be produced by any known method. DNA sequences encoding IFN-β may be synthesized using standard methods. In many embodiments, IFN-β polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN-β is "recombinant IFN- β." Where the host cell is a bacterial host cell, the IFN-β is modified to comprise an N- terminal methionine.
[00101] It is to be understood that IFN-β as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like. IFN-tau
[00102] The term interferon-tau includes IFN-tau polypeptides that are naturally occurring; non- naturally-occurring IFN-tau polypeptides; and analogs of naturally occurring or non-naturally occurring IFN-tau that retain antiviral activity of a parent naturally-occurring or non-naturally occurring IFN-tau.
[00103] Suitable tau interferons include, but are not limited to, naturally-occurring IFN-tau; Tauferon® (Pepgen Corp.); and the like.
[00104] IFN-tau may comprise an amino acid sequence as set forth in any one of GenBank Accession Nos. PI 5696; P56828; P56832; P56829; P56831; Q29429; Q28595; Q28594; S08072; Q08071; QO8070; Q08053; P56830; P28169; P28172; and P28171. The sequence of any known IFN-tau polypeptide may be altered in various ways known in the art to generate targeted changes in sequence. A variant polypeptide will usually be substantially similar to the sequences provided herein, i. e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids. The sequence changes may be substitutions, insertions or deletions. Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
[00105] Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
[00106] The IFN-tau formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN-tau.
[00107] IFN-tau polypeptides can be produced by any known method. DNA sequences encoding IFN-tau may be synthesized using standard methods. In many embodiments, IFN-tau polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN-tau is "recombinant IFN-tau." Where the host cell is a bacterial host cell, the IFN-tau is modified to comprise an N-terminal methionine.
[00108] It is to be understood that IFN-tau as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like. IFN-ω
[00109] The term interferon-omega ("IFN-ω") includes IFN-ω polypeptides that are naturally occurring; non-naturally-occurring IFN-ω polypeptides; and analogs of naturally occurring or non-naturally occuning IFΝ-ω that retain antiviral activity of a parent naturally-occurring or non-naturally occurring IFΝ-ω. [00110] Any known omega interferon can be administered in a subject method. Suitable IFN-ω include, but are not limited to, naturally-occurring IFN-ω; recombinant IFN-ω, e.g., Biomed 510 (BioMedicines); and the like.
[00111] IFN-ω may comprise an amino acid sequence as set forth in GenBank Accession No. NP_002168; or AAA70091. The sequence of any known IFN-ω polypeptide may be altered in various ways known in the art to generate targeted changes in sequence. A variant polypeptide will usually be substantially similar to the sequences provided herein, i.e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids. The sequence changes may be substitutions, insertions or deletions. Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
[00112] Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
[00113] The IFN-ω formulation may comprise an N-blocked species, wherein the N-terminal amino acid is acylated with an acyl group, such as a formyl group, an acetyl group, a malonyl group, and the like. Also suitable for use is a consensus IFN-ω.
[00114] IFN-ω polypeptides can be produced by any known method. DNA sequences encoding IFN-ω may be synthesized using standard methods. In many embodiments, IFN-ω polypeptides are the products of expression of manufactured DNA sequences transformed or transfected into bacterial hosts, e.g., E. coli, or in eukaryotic host cells (e.g., yeast; mammalian cells, such as CHO cells; and the like). In these embodiments, the IFN-ω is "recombinant IFN- ω." Where the host cell is a bacterial host cell, the IFN-ω is modified to comprise an N- terminal methionine.
[00115] It is to be understood that IFN-ω as described herein may comprise one or more modified amino acid residues, e.g., glycosylations, chemical modifications, and the like. TYPE III INTERFERON RECEPTOR AGONISTS
[00116] In any of the above-described methods, the interferon receptor agonist is in some embodiments an agonist of a Type III interferon receptor (e.g., "a Type III interferon agonist"). Type III interferon agonists include an IL-28b polypeptide; and IL-28a polypeptide; and IL-29 polypeptide; antibody specific for a Type III interferon receptor; and any other agonist of Type III interferon receptor, including non-polypeptide agonists.IL-28A, IL-28B, and IL-29 (referred to herein collectively as "Type III interferons" or "Type III IFNs") are described in Sheppard et al. (2003) Nature 4:63-68. Each polypeptide binds a heterodimeric receptor consisting of IL-10 receptor β chain and an IL-28 receptor α. Sheppard et al. (2003), supra. The amino acid sequences of IL-28A, IL-28B, and IL-29 are found under GenBank Accession Nos. NP_742150, NP_742151, and NP_742152, respectively.
[00117] The amino acid sequence of a Type III IFN polypeptide may be altered in various ways known in the art to generate targeted changes in sequence. A variant polypeptide will usually be substantially similar to the sequences provided herein, ?'.e. will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids. The sequence changes may be substitutions, insertions or deletions. Scanning mutations that systematically introduce alanine, or other residues, may be used to determine key amino acids. Specific amino acid substitutions of interest include conservative and non-conservative changes. Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
[00118] Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. Also included are modifications of glycosylation, e.g. those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g. by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g. phosphotyrosine, phosphoserine, or phosphothreonine.
[00119] Included for use in a subject method are polypeptides that have been modified using ordinary chemical techniques so as to improve their resistance to proteolytic degradation, to optimize solubility properties, or to render them more suitable as a therapeutic agent. For examples, the backbone of the peptide may be cyclized to enhance stability (see Friedler et al. (2000) J. Biol. Chem. 275:23783-23789). Analogs may be used that include residues other than naturally occurring L-amino acids, e.g. D-amino acids or non-naturally occurring synthetic amino acids. The protein may be pegylated to enhance stability. The polypeptides may be fused to albumin.
[00120] The polypeptides may be prepared by in vitro synthesis, using conventional methods as known in the art, by recombinant methods, or may be isolated from cells induced or naturally producing the protein. The particular sequence and the manner of preparation will be determined by convenience, economics, purity required, and the like. If desired, various groups may be introduced into the polypeptide during synthesis or during expression, which allow for linking to other molecules or to a surface. Thus cysteines can be used to make thioethers, histidines for linking to a metal ion complex, carboxyl groups for forming amides or esters, amino groups for forming amides, and the like. TYPE II INTERFERON RECEPTOR AGONISTS
[00121] Type II interferon receptor agonists suitable for use in a subject method include any naturally occurring or non-naturally-occurring ligand of a human Type II interferon receptor that binds to and causes signal transduction via the receptor. Type II interferon receptor agonists include interferons, including naturally-occurring interferons, modified interferons, synthetic interferons, pegylated interferons, fusion proteins comprising an interferon and a heterologous protein, shuffled interferons; antibody specific for an interferon receptor; non- peptide chemical agonists; and the like.
[00122] A specific example of a Type II interferon receptor agonist is IFN-gamma and variants thereof. While the present invention exemplifies use of an IFN-gamma polypeptide, it will be readily apparent that any Type II interferon receptor agonist can be used in a subject method. Interferon-Gamma
[00123] The nucleic acid sequences encoding IFN-γ polypeptides may be accessed from public databases, e.g., Genbank, journal publications, etc. While various mammalian IFN-γ polypeptides are of interest, for the treatment of human disease, generally the human protein will be used. Human IFN-γ coding sequence may be found in Genbank, accession numbers XI 3274; V00543; and NM_000619. The corresponding genomic sequence may be found in Genbank, accession numbers J00219; M37265; and V00536. See, for example. Gray et al. (1982) Nature 295:501 (Genbank XI 3274); and Rinderknecht et al. (1984) J.B.C 259:6790.
[00124] IFN-γlb (Actimmune®; human interferon) is a single-chain polypeptide of 140 amino acids. It is made recombinantly in E.coli and is unglycosylated. Rinderknecht et al. (1984) J. Biol. Chem. 259:6790-6797. [00125] The IFN-γ to be used in the methods of the present invention may be any of natural IFN-γs, recombinant IFN-γs and the derivatives thereof so far as they have an IFN-γ activity, particularly human IFN-γ activity. Human IFN-γ exhibits the antiviral and anti-proliferative properties characteristic of the interferons, as well as a number of other immunomodulatory activities, as is known in the art. Although IFN-γ is based on the sequences as provided above, the production of the protein and proteolytic processing can result in processing variants thereof. The unprocessed sequence provided by Gray et al., supra, consists of 166 amino acids (aa). Although the recombinant IFN-γ produced in E. coli was originally believed to be 146 amino acids, (commencing at amino acid 20) it was subsequently found that native human IFN-γ is cleaved after residue 23, to produce a 143 aa protein, or 144 aa if the terminal methionine is present, as required for expression in bacteria. During purification, the mature protein can additionally be cleaved at the C terminus after reside 162 (referring to the Gray et al. sequence), resulting in a protein of 139 amino acids, or 140 amino acids if the initial methionine is present, e.g. if required for bacterial expression. The N-terminal methionine is an artifact encoded by the mRΝA translational "start" signal AUG that, in the particular case of E. coli expression is not processed away. In other microbial systems or eukaryotic expression systems, methionine may be removed.
[00126] For use in the subject methods, any of the native IFN-γ peptides, modifications and variants thereof, or a combination of one or more peptides may be used. IFN-γ peptides of interest include fragments, and can be variously truncated at the carboxyl terminus relative to the full sequence. Such fragments continue to exhibit the characteristic properties of human gamma interferon, so long as amino acids 24 to about 149 (numbering from the residues of the unprocessed polypeptide) are present. Extraneous sequences can.be substituted for the amino acid sequence following amino acid 155 without loss of activity. See, for example, U.S. Patent No. 5,690,925. Native IFN-γ moieties include molecules variously extending from amino acid residues 24-150; 24-151, 24-152; 24- 153, 24-155; and 24-157. Any of these variants, and other variants known in the art and having IFN-γ activity, may be used in the present methods.
[00127] The sequence of the IFN-γ polypeptide may be altered in various ways known in the art to generate targeted changes in sequence. A variant polypeptide will usually be substantially similar to the sequences provided herein, i.e., will differ by at least one amino acid, and may differ by at least two but not more than about ten amino acids. The sequence changes may be substitutions, insertions or deletions. Scanning mutations that systematically introduce alanine, or other residues, may be used to determine key amino acids. Specific amino acid substitutions of interest include conservative and non-conservative changes. Conservative amino acid substitutions typically include substitutions within the following groups: (glycine, alanine); (valine, isoleucine, leucine); (aspartic acid, glutamic acid); (asparagine, glutamine); (serine, threonine); (lysine, arginine); or (phenylalanine, tyrosine).
[00128] Modifications of interest that may or may not alter the primary amino acid sequence include chemical derivatization of polypeptides, e.g., acetylation, or carboxylation; changes in amino acid sequence that introduce or remove a glycosylation site; changes in amino acid sequence that make the protein susceptible to PEGylation; and the like. In one embodiment, the invention contemplates the use of IFN-γ variants with one or more non-naturally occurring glycosylation and/or pegylation sites that are engineered to provide glycosyl- and/or PEG- derivatized polypeptides with reduced serum clearance, such as the IFN- γ polypeptide variants described in International Patent Publication No. WO 01/36001. Also included are modifications of glycosylation, e.g., those made by modifying the glycosylation patterns of a polypeptide during its synthesis and processing or in further processing steps; e.g., by exposing the polypeptide to enzymes that affect glycosylation, such as mammalian glycosylating or deglycosylating enzymes. Also embraced are sequences that have phosphorylated amino acid residues, e.g., phosphotyrosine, phosphoserine, or phosphothreonine.
[00129] Included in the subject invention are polypeptides that have been modified using ordinary chemical techniques so as to improve their resistance to proteolytic degradation, to optimize solubility properties, or to render them more suitable as a therapeutic agent. For examples, the backbone of the peptide may be cyclized to enhance stability (see Friedler et al. (2000) J Biol. Chem. 275:23783-23789). Analogs may be used that include residues other than naturally occurring L-amino acids, e.g., D-amino acids or non-naturally occurring synthetic amino acids. The protein may be pegylated to enhance stability.
[00130] The polypeptides may be prepared by in vitro synthesis, using conventional methods as known in the art, by recombinant methods, or may be isolated from cells induced or naturally producing the protein. The particular sequence and the manner of preparation will be determined by convenience, economics, purity required, and the like. If desired, various groups may be introduced into the polypeptide during synthesis or during expression, which allow for linking to other molecules or to a surface. Thus cysteines can be used to make thioethers, histidines for linldng to a metal ion complex, carboxyl groups for forming amides or esters, amino groups for forming amides, and the like.
[00131] The polypeptides may also be isolated and purified in accordance with conventional methods of recombinant synthesis. A lysate may be prepared of the expression host and the lysate purified using HPLC, exclusion chromatography, gel electrophoresis, affinity chromatography, or other purification technique. For the most part, the compositions which are used will comprise at least 20% by weight of the desired product, more usually at least about 75% by weight, preferably at least about 95% by weight, and for therapeutic purposes, usually at least about 99.5% by weight, in relation to contaminants related to the method of preparation of the product and its purification. Usually, the percentages will be based upon total protein. TNF ANTAGONISTS
[00132] Suitable TNF-α antagonists for use in a subject method include agents that decrease the level of TNF-α synthesis, agents that block or inhibit the binding of TNF-α to a TΝF-α receptor (TΝFR), and agents that block or inhibit TNFR-mediated signal transduction. Unless otherwise expressly stated, every reference to a "TNF-α antagonist" or "TΝF antagonist" herein will be understood to mean a TΝF-α antagonist other than pirfenidone or a pirfenidone analog.
[00133] As used herein, the terms "TNF receptor polypeptide" and "TΝFR polypeptide" refer to polypeptides derived from TNFR (from any species) which are capable of binding TNF. Two distinct cell-surface TNFRs have described: Type II TΝFR (or p75 TΝFR or TΝFRII) and Type I TΝFR (or p55 TΝFR or TΝFRI). The mature full-length human p75 TΝFR is a glycoprotein having a molecular weight of about 75-80 kilodaltons (kD). The mature full- length human p55 TΝFR is a glycoprotein having a molecular weight of about 55-60 kD. Exemplary TNFR polypeptides are derived from TNFR Type I and/or TNFR type II. Soluble TΝFR includes p75 TΝFR polypeptide; fusions of p75 TΝFR with heterologous fusion partners, e.g., the Fc portion of an immunoglobulin.
[00134] TNFR polypeptide may be an intact TNFR or a suitable fragment of TNFR. U.S. Pat. No. 5,605,690 provides examples of TNFR polypeptides, including soluble TNFR polypeptides, appropriate for use in the present invention. In many embodiments, the TNFR polypeptide comprises an extracellular domain of TNFR. In some embodiments, the TΝFR polypeptide is a fusion polypeptide comprising an extracellular domain of TNFR linked to a constant domain of an immunoglobulin molecule. In other embodiments, the TNFR polypeptide is a fusion polypeptide comprising an extracellular domain of the p75 TNFR linked to a constant domain of an IgGl molecule. In some embodiments, when administration to humans is contemplated, an Ig used for fusion proteins is human, e.g., human IgGl.
[00135] Monovalent and multivalent forms of TNFR polypeptides may be used in the present invention. Multivalent forms of TNFR polypeptides possess more than one TNF binding site. In some embodiments, the TNFR is a bivalent, or dimeric, form of TΝFR. For example, as described in U.S. Pat. No. 5,605,690 and in Mohler et al., 1993, J. Immunol., 151:1548-1561, a chimeric antibody polypeptide with TNFR extracellular domains substituted for the variable domains of either or both of the immunoglobulin heavy or light chains would provide a TΝFR polypeptide for the present invention. Generally, when such a chimeric TNFR:antibody polypeptide is produced by cells, it forms a bivalent molecule through disulfide linkages between the immunoglobulin domains. Such a chimeric TNFR:antibody polypeptide is referred to as TNFR:Fc.
[00136] In one embodiment, a subject method involves administration of an effective amount of the soluble TΝFR ENBREL® etanercept. ENBREL® is a dimeric fusion protein consisting of the extracellular ligand-binding portion of the human 75 kilodalton (p75) TNFR linked to the Fc portion of human IgGl. The Fc component of ENBREL® contains the CH2 domain, the CH3 domain and hinge region, but not the CHI domain of IgGl. ENBREL® is produced in a Chinese hamster ovary (CHO) mammalian cell expression system. It consists of 934 amino acids and has an apparent molecular weight of approximately 150 kilodaltons. Smith et al. (1990) Science 248:1019-1023; Mohler et al. (1993) J. Immunol. 151:1548-1561; U.S. Pat. No. 5,395,760; and U.S. Pat. No. 5,605,690.
[00137] Also suitable for use are monoclonal antibodies that bind TNF-α. Monoclonal antibodies include "humanized" mouse monoclonal antibodies; chimeric antibodies; monoclonal antibodies that are at least about 80%, at least about 90%, at least about 95%, or 100% human in amino acid sequence; and the like. See, e.g., WO 90/10077; WO 90/04036; and WO 92/02190. Suitable monoclonal antibodies include antibody fragments, such as Fv, F(ab') and Fab; synthetic antibodies; artificial antibodies; phage display antibodies; and the like.
[00138] Examples of suitable monoclonal antibodies include infliximab (REMICADE®, Centocor); and adalimumab (HUMIRA™, Abbott) REMICADE® is a chimeric monoclonal anti-TNF-α antibody that includes about 25% mouse amino acid sequence and about 75% human amino acid sequence. REMICADE®comprises a variable region of a mouse monoclonal anti-TΝF-α antibody fused to the constant region of a human IgGl . Elliott et al. (1993) Arthritis Rheum. 36:1681-1690; Elliott et al. (1994) Lancet 344:1105-1110; Baert et al. (1999) Gastroenterology 116:22-28. HUMIRA™ is a human, full-length IgGl monoclonal antibody that was identified using phage display technology. Piascik (2003) J. Am. Pharm. Assoc. 43:327-328. [00139] Also included in the term "TNF antagonist," and therefore suitable for use in a subject method, are stress-activated protein kinase (SAPK) inhibitors. SAPK inhibitors are known in the art, and include, but are not limited to 2-alkyl imidazoles disclosed in U.S. Patent No. 6,548,520; 1,4,5-substituted imidazole compounds disclosed in U.S. Patent No. 6,489,325; 1,4,5-substituted imidazole compounds disclosed in U.S. PatentNo. 6,569,871; heteroaryl aminophenyl ketone compounds disclosed in Published U.S. Patent Application No. 2003/0073832; pyridyl imidazole compounds disclosed in U.S. Patent No. 6,288,089; and heteroaryl aminobenzophenones disclosed in U.S. Patent No. 6,432,962. Also of interest are compounds disclosed in U.S. Patent Application Publication No. 2003/0149041 ; and U.S. Patent No. 6,214,854. A stress-activated protein kinase is a member of a family of mitogen- activated protein kmases which are activated in response to stress stimuli. SAPK include, but are not limited to, p38 (Lee et al. (1994) Nature 372:739) and c-jun N-terminal kinase (JNK).
[00140] Methods to assess TNF antagonist activity are known in the art and exemplified herein. For example, TNF antagonist activity may be assessed with a cell-based competitive binding assay. In such an assay, radiolabeled TNF is mixed with serially diluted TNF antagonist and cells expressing cell membrane bound TNFR. Portions of the suspension are centrifuged to separate free and bound TNF and the amount of radioactivity in the free and bound fractions determined. TNF antagonist activity is assessed by inhibition of TΝF binding to the cells in the presence of the TNF antagonist.
[00141] As another example, TΝF antagonists may be analyzed for the ability to neutralize TNF activity in vitro in a bioassay using cells susceptible to the cytotoxic activity of TNF as target cells. In such an assay, target cells, cultured with TNF, are treated with varying amounts of TNF antagonist and subsequently are examined for cytolysis. TNF antagonist activity is assessed by a decrease in TΝF-induced target cell cytolysis in the presence of the TΝF antagonist. PIRFENIDONE AND ANALOGS THEREOF
[00142] Pirfenidone (5 -methyl- l-phenyl-2-(lH)-pyridone) and pirfenidone analogs are used in certain combination therapies of the invention. Pirfenidone
Figure imgf000032_0001
Pirfenidone analogs
Figure imgf000033_0001
Descriptions for Substituents Ri, R2, X
[00143] Ri: carbocyclic (saturated and unsaturated), heterocyclic (saturated or unsaturated), alkyls (saturated and unsaturated). Examples include phenyl, benzyl, pyrimidyl, naphthyl, indolyl, pyrrolyl, furyl, thienyl, imidazolyl, cyclohexyl, piperidyl, pyrrolidyl, mo holinyl, cyclohexenyl, butadienyl, and the like.
[00144] Ri can further include substitutions on the carbocyclic or heterocyclic moieties with substituents such as halogen, nitro, amino, hydroxyl, alkoxy, carboxyl, cyano, thio, alkyl, aryl, heteroalkyl, heteroaryl and combinations thereof, for example, 4-nitrophenyl, 3-chlorophenyl, 2,5-dinitrophenyl, 4-methoxyphenyl, 5-methyl-pyrrolyl, 2, 5-dichlorocyclohexyl, guanidinyl- cyclohexenyl and the like.
[00145] R2: alkyl, carbocylic, aryl, heterocyclic. Examples include: methyl, ethyl, propyl, isopropyl, phenyl, 4-nitrophenyl, thienyl and the like.
[00146] X: may be any number (from 1 to 3) of substituents oh the carbocyclic or heterocyclic ring. The substituents can be the same or different. Substituents can include hydrogen, alkyl, heteroalkyl, aryl, heteroaryl, halo, nitro, carboxyl, hydroxyl, cyano, amino, thio, alkylamino, haloaryl and the like.
[00147] The substituents may be optionally further substituted with 1-3 substituents from the group consisting of alkyl, aryl, nitro, alkoxy, hydroxyl and halo groups. Examples include: methyl, 2,3-dimethyl, phenyl, p-tolyl, 4-chlorophenyl, 4-nitrophenyl, 2,5-dichlorophenyl, furyl, thienyl and the like.
[00148] Specific Examples include those shown in Table 1 : Table 1 IA IIB
Figure imgf000034_0001
[00149] U.S. Pat. Nos. 3,974,281; 3,839,346; 4,042,699; 4,052,509; 5,310,562; 5,518,729; 5,716,632; and 6,090,822 describe methods for the synthesis and formulation of pirfenidone and pirfenidone analogs in pharmaceutical compositions suitable for use in the methods of the present invention. DOSAGES, FORMULATIONS, AND ROUTES OF ADMINISTRATION
[00150] Active agents (e.g., a Type I or III interferon receptor agonist, a Type II interferon receptor agonist, and a TNF-α antagonist) are administered to individuals in a formulation with a pharmaceutically acceptable excipient(s). A wide variety of pharmaceutically acceptable excipients are known in the art and need not be discussed in detail herein. Pharmaceutically acceptable excipients have been amply described in a variety of publications, including, for example, A. Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20th edition, Lippincott, Williams, & Wilkins; Pharmaceutical Dosage Forms and Drug Delivery Systems (1999) H.C. Ansel et al, eds., 7th ed., Lippincott, Williams, & Wilkins; and Handbook of Pharmaceutical Excipients (2000) A.H. Kibbe et al., eds., 3rd ed. Amer. Pharmaceutical Assoc.
[00151] The pharmaceutically acceptable excipients, such as vehicles, adjuvants, carriers or diluents, are readily available to the public. Moreover, pharmaceutically acceptable auxiliary substances, such as pH adjusting and buffering agents, tonicity adjusting agents, stabilizers, wetting agents and the like, are readily available to the public.
[00152] In the subject methods, the active agents may be administered to the host using any convenient means capable of resulting in the desired therapeutic effect. Thus, the agents can be incorporated into a variety of formulations for therapeutic administration. More particularly, active agents can be formulated into pharmaceutical compositions by combination with appropriate, pharmaceutically acceptable carriers or diluents, and may be formulated into preparations in solid, semi-solid, liquid or gaseous forms, such as tablets, capsules, powders, granules, ointments, solutions, suppositories, injections, inhalants' and aerosols.
[00153] As such, administration of active agents can be achieved in various ways, including oral, buccal, rectal, parenteral, intraperitoneal, intradermal, subcutaneous, intramuscular, transdermal, intratracheal, etc., administration. In some embodiments, two different routes of administration are used. For example, in some embodiments, IFN-α and IFN-γ are administered subcutaneously, and a TNF-α antagonist is administered orally.
[00154] Subcutaneous administration of an active agent (e.g., a Type I or III interferon receptor agonist, a Type II interferon receptor agonist, or a TNF-α antagonist) can be accomplished using standard methods and devices, e.g., needle and syringe, a subcutaneous injection port delivery system, and the like. See, e.g., U.S. Patent Νos. 3,547,119; 4,755,173; 4,531,937; 4,311,137; and 6,017,328. A combination of a subcutaneous injection port and a device for administration of an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) to a patient through the port is referred to herein as "a subcutaneous injection port delivery system." In some embodiments, subcutaneous administration is achieved by a combination of devices, e.g., bolus delivery by needle and syringe, followed by delivery using a continuous delivery system. [00155] In some embodiments, an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) is delivered by a continuous delivery system. The term "continuous delivery system" is used interchangeably herein with "controlled delivery system" and encompasses continuous (e.g., controlled) delivery devices (e.g., pumps) in combination with catheters, injection devices, and the like, a wide variety of which are known in the art.
[00156] Mechanical or electromechanical infusion pumps can also be suitable for use with the present invention. Examples of such devices include those described in, for example, U.S. Pat. Nos. 4,692,147; 4,360,019; 4,487,603; 4,360,019; 4,725,852; 5,820,589; 5,643,207; 6,198,966; and the like. In general, the present treatment methods can be accomplished using any of a variety of refillable, pump systems. Pumps provide consistent, controlled release over time. Typically, an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) is in a liquid formulation in a drug-impermeable reservoir, and is delivered in a continuous fashion to the individual.
[00157] In one embodiment, the drug delivery system used in a subject treatment method is an at least partially implantable device. The implantable device can be implanted at any suitable implantation site using methods and devices well known in the art. An implantation site is a site within the body of a subject at which a drug delivery device is introduced and positioned. Implantation sites include, but are not necessarily limited to a subdermal, subcutaneous, intramuscular, or other suitable site within a subject's body. Subcutaneous implantation sites are in some embodiments preferred because of convenience in implantation and removal of the drug delivery device.
[00158] Drug release devices suitable for use in the invention may be based on any of a variety of modes of operation. For example, the drug release device can be based upon a diffusive system, a convective system, or an erodible system (e.g., an erosion-based system). For example, the drug release device can be an electrochemical pump, osmotic pump, an electroosmotic pump, a vapor pressure pump, or osmotic bursting matrix, e.g., where the drug is incorporated into a polymer and the polymer provides for release of drug formulation concomitant with degradation of a drug-impregnated polymeric material (e.g., a biodegradable, drug-impregnated polymeric material). In other embodiments, the drug release device is based upon an electrodiffusion system, an electrolytic pump, an effervescent pump, a piezoelectric pump, a hydrolytic system, etc.
[00159] Drug release devices based upon a mechanical or electromechanical infusion pump can also be suitable for use with the present invention. Examples of such devices include those described in, for example, U.S. Pat. Nos. 4,692,147; 4,360,019; 4,487,603; 4,360,019; 4,725,852, and the like. In general, the present treatment method can be accomplished using any of a variety of refillable, non-exchangeable pump systems. Pumps and other convective systems are generally preferred due to their generally more consistent, controlled release over time. Osmotic pumps are particularly preferred due to their combined advantages of more consistent controlled release and relatively small size (see, e.g., PCT published application no. WO 97/27840 and U.S. Pat. Nos. 5,985,305 and 5,728,396)). Exemplary osmotically-driven devices suitable for use in the invention include, but are not necessarily limited to, those described in U.S. Pat. Nos. 3,760,984; 3,845,770; 3,916,899; 3,923,426; 3,987,790; 3,995,631; 3,916,899; 4,016,880; 4,036,228; 4,111,202; 4,111,203; 4,203,440; 4,203,442; 4,210,139; 4,327,725; 4,627,850; 4,865,845; 5,057,318; 5,059,423; 5,112,614; 5,137,727; 5,234,692; 5,234,693; 5,728,396; and the like.
[00160] In some embodiments, the drug delivery device is an implantable device. The drug delivery device can be implanted at any suitable implantation site using methods and devices well known in the art. As noted infra, an implantation site is a site within the body of a subject at which a drag delivery device is introduced and positioned. Implantation sites include, but are not necessarily limited to a subdermal, subcutaneous, intramuscular, or other suitable site within a subject's body.
[00161] In some embodiments, an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TΝF-α antagonist) is delivered using an implantable drug delivery system, e.g., a system that is programmable to provide for administration of an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist). Exemplary programmable, implantable systems include implantable infusion pumps. Exemplary implantable infusion pumps, or devices useful in connection with such pumps, are described in, for example, U.S. Pat. Nos. 4,350,155; 5,443,450; 5,814,019; 5,976,109; 6,017,328; 6,171,276; 6,241,704; 6,464,687; 6,475,180; and 6,512,954. A further exemplary device that can be adapted for the present invention is the Synchromed infusion pump (Medtronic).
[00162] In pharmaceutical dosage forms, the agents may be administered in the form of their phaπnaceutically acceptable salts, or they may also be used alone or in appropriate association, as well as in combination, with other pharmaceutically active compounds. The following methods and excipients are merely exemplary and are in no way limiting.
[00163] For oral preparations, an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TΝF-α antagonist) can he used alone or in combination with appropriate additives to make tablets, powders, granules or capsules, for example, with conventional additives, such as lactose, mannitol, corn starch or potato starch; with binders, such as crystalline cellulose, cellulose derivatives, acacia, corn starch or gelatins; with disintegrators, such as corn starch, potato starch or sodium carboxymethylcellulose; with lubricants, such as talc or magnesium stearate; and if desired, with diluents, buffering agents, moistening agents, preservatives and flavoring agents.
[00164] A active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) can be formulated into preparations for injection by dissolving, suspending or emulsifying them in an aqueous or nonaqueous solvent, such as vegetable or other similar oils, synthetic aliphatic acid glycerides, esters of higher aliphatic acids or propylene glycol; and if desired, with conventional additives such as solubilizers, isotonic agents, suspending agents, emulsifying agents, stabilizers and preservatives.
[00165] Furthermore, an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) can be made into suppositories by mixing with a variety of bases such as emulsifying bases or water-soluble bases. An active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) can be administered rectally via a suppository. The suppository can include vehicles such as cocoa butter, carbowaxes and polyethylene glycols, which melt at body temperature, yet are solidified at room temperature.
[00166] Unit dosage forms for oral or rectal administration such as syrups, elixirs, and suspensions may be provided wherein each dosage unit, for example, teaspoonful, tablespoonful, tablet or suppository, contains a predetermined amount of the composition containing one or more active agents. Similarly, unit dosage forms for injection or intravenous administration may comprise an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) in a composition as a solution in sterile water, normal saline or another pharmaceutically acceptable carrier.
[00167] The term "unit dosage form," as used herein, refers to physically discrete units suitable as unitary dosages for human and animal subjects, each unit containing a predetermined quantity of an active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) calculated in an amount sufficient to produce the desired effect in association with a pharmaceutically acceptable diluent, carrier or vehicle. The specifications for a particular active agent (e.g., a Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist) depend on the particular agent employed and the effect to be achieved, and the pharmacodynamics associated with each agent in the host.
[00168] In connection with each of the methods described herein, the invention provides embodiments in which the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist is/are administered to the patient by a controlled drug delivery device. In some embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist is/are delivered to the patient substantially continuously or continuously by the controlled drug delivery device. Optionally, an implantable infusion pump is used to deliver the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist to the patient substantially continuously or continuously by subcutaneous infusion.
[00169] In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TΝF-α antagonist is administered to the patient so as to achieve and maintain a desired average daily serum concentration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TΝF-α antagonist at a substantially steady state for the duration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TΝF-α antagonist therapy. Optionally, an implantable infusion pump is used to deliver the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TΝF-α antagonist to the patient by subcutaneous infusion so as tσ achieve and maintain a desired average daily serum concentration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist at a substantially steady state for the duration of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist therapy.
[00170] In some embodiments, the Type II interferon receptor agonist is an IFN-γ.
[00171] Effective dosages of IFN-γ can range from about 0.5 μg/m to about 500 μg/m , usually from about 1.5 μg/m2 to 200 μg/m2, depending on the size of the patient. This activity is based on 106 international units (U) per 50 μg of protein. IFN-γ can be administered daily, every other day, three times a week, or substantially continuously or continuously.
[00172] In specific embodiments of interest, IFN-γ is administered to an individual in a unit dosage form of from about 25 μg to about 500 μg, from about 50 μg to about 400 μg, or from about 100 μg to about 300 μg. In particular embodiments of interest, the dose is about 200 μg IFN-γ. In many embodiments of interest, IFN-γ lb is administered. [00173] Where the dosage is 200 μg IFN-γ per dose, the amount of IFN-γ per body weight (assuming a range of body weights of from about 45 kg to about 135 kg) is in the range of from about 4.4 μg IFN-γ per kg body weight to about 1.48 μg IFN-γ per kg body weight.
[00174] The body surface area of subject individuals generally ranges from about 1.33 m2 to about 2.50 m2. Thus, in many embodiments, an IFN-γ dosage ranges from about 150 μg/m2 to about 20 μg/m2. For example, an IFN-γ dosage ranges from about 20 μg/m2 to about 30 μg/m2, from about 30 μg/m2 to about 40 μg/m2, from about 40 μg/m2 to about 50 μg/m2, from about 50 μg/m2 to about 60 μg/m2, from about 60 μg/m2 to about 70 μg/m2, from about 70 μg/m2 to about 80 μg/m2, from about 80 μg/m2 to about 90 μg/m2, from about 90 μg/m2 to about 100 μg/m2, from about 100 μg/m2 to about 110 μg/m2, from about 110 μg/m2 to about 120 μg/m2, from about 120 μg/m2 to about 130 μg/m2, from about 130 μg/m2 to about 140 μg/m2, or from about 140 μg/m2 to about 150 μg/m . In some embodiments, the dosage groups range from about 25 μg/m2 to about 100 μg/m . In other embodiments, the dosage groups range from about 25 μg/m2 to about 50 μg/m2.
[00175] In some embodiments, the Type I interferon receptor agonist is an IFN-α. Effective dosages of an IFN-α can range from about 1 μg to about 30 μg, from about 3 μg to about 27 μg, from about 1 MU to about 20 MU, from about 3 MU to about 10 MU, from about 90 μg to about 180 μg, or from about 18 μg to about 90 μg.
[00176] Effective dosages of Infergen® consensus IFN-α include about 3 μg, about 9 μg, about 15 μg, about 18 μg, or about 27 μg of drug per dose. Effective dosages of IFN-α2a and IFN- α2b can range from 3 million Units (MU) to 10 MU per dose. Effective dosages of PEGylated IFN-α2a can contain an amount of about 90 μg to 180 μg, or about 135 μg, of drug per dose. Effective dosages of PEGylated IFΝ-α2b can contain an amount of about 0.5 μg to 1.5 μg of drug per kg of body weight per dose. Effective dosages of PEGylated consensus interferon (PEG-CIFN) can contain an amount of about 18 μg to about 90 μg, or from about 27 μg to about 60 μg, or about 45 μg, of CIFN amino acid weight per dose of PEG-CIFN. IFN-α can be administered daily, every other day, once a week, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
[00177] In some embodiments, a Type I or III interferon receptor agonist is administered in a first dosing regimen, followed by a second dosing regimen. The first dosing regimen of Type I or III interferon receptor agonist (also referred to as "the induction regimen ") generally involves administration of a higher dosage of the Type I or III interferon receptor agonist. For example, in the case of Infergen® consensus IFΝ-α (CIFN), the first dosing regimen comprises administering CIFN at about 9 μg, about 15 μg, about 18 μg, or about 27 μg. The first dosing regimen can encompass a single dosing event, or at least two or more dosing events. The first dosing regimen of the Type I or III interferon receptor agonist can be administered daily, every other day, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
[00178] The first dosing regimen of the Type I or III interferon receptor agonist is administered for a first period of time, which time period can be at least about 4 weeks, at least about 8 weeks, or at least about 12 weeks.
[00179] The second dosing regimen of the Type I or III interferon receptor agonist (also referred to as "the maintenance dose") generally involves administration of a lower amount of the Type I or III interferon receptor agonist. For example, in the case of CIFN, the second dosing regimen comprises administering CIFN at least about 3 μg, at least about 9 μg, at least about 15 μg, or at least about 18 μg. The second dosing regimen can encompass a single dosing event, or at least two or more dosing events.
[00180] The second dosing regimen of the Type I or III interferon receptor agonist can be administered daily, every other day, three times a week, every other week, three times per month, once monthly, substantially continuously or continuously.
[00181] In some embodiments, where an "induction'V'maintenance" dosing regimen of a Type I or a III interferon receptor agonist is administered, a "priming" dose of a Type II interferon receptor agonist is included. In these embodiments, Type II interferon receptor agonist can be administered for a period of time from about 1 day to about 14 days, from about 2 days to about 10 days, or from about 3 days to about 7 days, before the beginning of treatment with the Type I or III interferon receptor agonist. This period of time is referred to as the "priming" phase. In some of these embodiments, Type II interferon receptor agonist treatment is continued throughout the entire period of treatment with the Type I or III interferon receptor agonist. In other embodiments, Type II interferon receptor agonist treatment is discontinued before the end of treatment with the Type I or III interferon receptor agonist. In some of these embodiments, the total time of treatment with the Type II interferon receptor agonist (including the "priming" phase) is from about 2 days to about 30 days, from about 4 days to about 25 days, from about 8 days to about 20 days, from about 10 days to about 18 days, or from about 12 days to about 16 days.
[00182] In other embodiments, the Type I or III interferon receptor agonist is administered in a non-induction (single) dosing regimen. For example, in the case of CIFΝ, the dose of CIFN is generally in a range of from about 3 μg to about 15 μg, or from about 9 μg to about 15 μg. The dose of Type I or a Type III interferon receptor agonist is generally administered daily, every other day, three times a week, every other week, three times per month, once monthly, or substantially continuously. The dose of the Type I or III interferon receptor agonist is administered for a period of time, which period can be, for example, from at least about 24 weeks to at least about 48 weeks, or longer.
[00183] In some embodiments, where a single dosing regimen of a Type I or III interferon receptor agonist is administered, a "priming" dose of Type II interferon receptor agonist is included. For example, a Type II interferon receptor agonist can be administered for a period of time from about 1 day to about 14 days, from about 2 days to about 10 days, or from about 3 days to about 7 days, before the beginning of treatment with the Type I or III interferon receptor agonist. This period of time is referred to as the "priming" phase. In some of these embodiments, Type II interferon receptor agonist treatment is continued throughout the entire period of treatment with the Type I or III interferon receptor agonist. In other embodiments, Type II interferon receptor agonist treatment is discontinued before the end of treatment with Type I or III interferon receptor agonist. In some of these embodiments, the total time of treatment with the Type II interferon receptor agonist (including the "priming" phase) is from about 2 days to about 30 days, from about 4 days to about 25 days, from about 8 days to about 20 days, from about 10 days to about 18 days, or from about 12 days to about 16 days.
[00184] Effective dosages of a TNF-α antagonist range from 0.1 μg to 40 mg per do se, e.g., from about 0.1 μg to about 0.5 μg per dose, from about 0.5 μg to about 1.0 μg per dose, from about 1.0 μg per dose to about 5.0 μg per dose, from about 5.0 μg to about 10 μg per dose, from about 10 μg to about 20 μg per dose, from about 20 μg per dose to about 30 μ.g per dose, from about 30 μg per dose to about 40 μg per dose, from about 40 μg per dose to about 50 μg per dose, from about 50 μg per dose to about 60 μg per dose, from about 60 μg per dose to about 70 μg per dose, from about 70 μg to about 80 μg per dose, from about 80 μg per dose to about 100 μg per dose, from about 100 μg to about 150 μg per dose, from about 150 μg to about 200 μg per dose, from about 200 μg per dose to about 250 μg per dose, from about 250 μg to about 300 μg per dose, from about 300 μg to about 400 μg per dose, from about 400 μg to about 500 μg per dose, from about 500 μg to about 600 μg per dose, from about 600 μg to about 700 μg per dose, from about 700 μg to about 800 μg per dose, from about 80O μg to about 900 μg per dose, from about 900 μg to about 1000 μg per dose, from about 1 mg to about 10 mg per dose, from about 10 mg to about 15 mg per dose, from about 15 mg to about 20 mg per dose, from about 20 mg to about 25 mg per dose, from about 25 mg to about 3O mg per dose, from about 30 mg to about 35 mg per dose, or from about 35 mg to about 40 mg per dose. [00185] In some embodiments, the TNF-α antagonist is ENBREL® etanercept. Effective dosages of etanercept range from about 0.1 μg to about 40 mg per dose, from about 0.1 μg to about 1 μg per dose, from about 1 μg to about 10 μg per dose, from about 10 μg to about 100 μg per dose, from about 100 μg to about 1 mg per dose, from about 1 mg to about 5 mg per dose, from about 5 mg to about 10 mg, from about 10 mg to about 15 mg per dose, from about 15 mg to about 20 mg per dose, from about 20 mg to about 25 mg per dose, from about 25 mg to about 30 mg per dose, from about 30 mg to about 35 mg per dose, or from about 35 mg to about 40 mg per dose.
[00186] In some embodiments, effective dosages of a TΝF-α antagonist are expressed as mg/kg body weight. In these embodiments, effective dosages of a TΝF-α antagonist are from about 0.1 mg/kg body weight to about 10 mg/kg body weight, e.g., from about 0.1 mg/kg body weight to about 0.5 mg/kg body weight, from about 0.5 mg/kg body weight to about 1.0 mg/kg body weight, from about 1.0 mg/kg body weight to about 2.5 mg/kg body weight, from about 2.5 mg/kg body weight to about 5.0 mg/kg body weight, from about 5.0 mg/kg body weight to about 7.5 mg/kg body weight, or from about 7.5 mg/kg body weight to about 10 mg/kg body weight.
[00187] In some embodiments, the TNF-α antagonist is REMICADE® infliximab. Effective dosages of REMICADE® range from about 0.1 mg/kg to about 10 mg/kg, from about 0.1 mg/kg to about 0.5 mg/kg, from about 0.5 mg/kg to about 1.0 mg/kg, from about 1.0 mg/kg to about 1.5 mg/kg, from about 1.5 mg/kg to about 2.0 mg/kg, from about 2.0 mg/kg to about 2.5 mg/kg, from about 2.5 mg/kg to about 3.0 mg/kg, from about 3.0 mg/kg to about 3.5 mg/kg, from about 3.5 mg/kg to about 4.0 mg/kg, from about 4.0 mg/kg to about 4.5 mg/kg, from about 4.5 mg/kg to about 5.0 mg/kg, from about 5.0 mg/kg to about 7.5 mg/kg, or from about 7.5 mg/kg to about 10 mg/kg per dose.
[00188] In some embodiments the TΝF-α antagonist is HUMIRA™ adalimumab. Effective dosages of HUMIRA™ range from about 0.1 μg to about 35 mg, from about 0.1 μg to about 1 μg, from about 1 μg to about 10 μg, from about 10 μg to about 100 μg, from about 100 μg to about 1 mg, from about 1 mg to about 5 mg, from about 5 mg to about 10 mg, from about 10 mg to about 15 mg, from about 15 mg to about 20 mg, from about 20 mg to about 25 mg, from about 25 mg to about 30 mg, from about 30 mg to about 35 mg, or from about 35 mg to about 40 mg per dose.
[00189] In many embodiments, a TΝF-α antagonist is administered for a period of about 1 day to about 7 days, or about 1 week to about 2 weeks, or about 2 weeks to about 3 weeks, or about 3 weeks to about 4 weeks, or about 1 month to about 2 months, or about 3 months to about 4 months, or about 4 months to about 6 months, or about 6 months to about 8 months, or about 8 months to about 12 months, or at least one year, and may be administered over longer periods of time. The TNF-α antagonist can be administered tid, bid, qd, qod, biw, tiw, qw, qow, three times per month, once monthly, substantially continuously, or continuously.
[00190] In many embodiments, multiple doses of a TΝF-α antagonist are administered. For example, a TΝF-α antagonist is administered once per month, twice per month, three times er month, every other week (qow), once per week (qw), twice per week (biw), three times per week (tiw), four times per week, five times per week, six times per week, every other day (qod), daily (qd), twice a day (bid), or three times a day (tid), substantially continuously, or continuously, over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more.
[00191] Those of skill in the art will readily appreciate that dose levels can vary as a function of the specific compounds, the severity of the symptoms and the susceptibility of the subject to side effects. Preferred dosages for a given compound are readily determinable by those of skill in the art by a variety of means. A preferred means is to measure the physiological potency of a given compound.
[00192] In some embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered in the same formulation, and are administered simultaneously. In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist are administered separately, e.g., in separate formulations. In some of these embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered separately, and are administered simultaneously. In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered separately and are administered within about 5 seconds to about 15 seconds, within about 15 seconds to about 30 seconds, within about 30 seconds to about 60 seconds, within about 1 minute to about 5 minutes, within about 5 minutes to about 15 minutes, within about 15 minutes to about 30 minutes, within about 30 minutes to about 60 minutes, within about 1 hour to about 2 hours, within about 2 hours to about 6 hours, within about 6 hours to about 12 hours, within about 12 hours to about 24 hours, or within about 24 hours to about 48 hours of one another. [00193] Multiple doses of a Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist can be administered, e.g., the Type I or III interferon receptor agonist, Type II interferon receptor agonist and/or TNF-α antagonist can be administered once per month, twice per month, three times per month, once per week, twice per week, three times per week, four times per week, five times per week, six times per week, or daily, over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more. In certain methods for the treatment of HCV infection, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TΝF-α antagonist are administered over a period of about 48 weeks.
[00194] In some embodiments, where Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TΝF-α antagonist are administered in combination therapy, the three drugs are co-formulated in a single liquid formulation that is contained in a single reservoir, for use in a drug delivery device. Thus, the present invention provides a pharmaceutical formulation comprising a liquid formulation comprising a single dose of Type I or III interferon receptor agonist, a single dose of Type II interferon receptor agonist, and a single dose of TNF-α antagonist. Thus, the present invention provides a drug reservoir or other container containing Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist co-formulated in a liquid, wherein the three drugs are present in the formulation in an amount suitable for one dose each. Dosage amounts are described herein. The reservoir can be provided in any of a variety of forms, including, but not limited to, a cartridge, a syringe, a reservoir of a continuous delivery device, and the like. The invention further provides a drug delivery device comprising (e.g., pre-loaded with) a reservoir containing a liquid formulation that comprises a single dose of Type I or III interferon receptor agonist, a single dose of Type II interferon receptor agonist, and a single dose of TNF-α antagonist. Exemplary, non-limiting drug delivery devices include injection devices, such as pen injectors, needle/syringe devices, continuous delivery devices, and the like. Any of the dosage amounts, including synergistically effective amounts, described herein can be used in the pharmaceutical formulation, in the reservoir, or in the drug delivery device.
[00195] In other embodiments, where Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TΝF-α antagonist are administered in combination therapy, each of the three drugs is in a pharmaceutical formulation contained in a separate reservoir in the same drug delivery device. The invention further provides a drug delivery device that is pre-loaded with separate reservoirs, one reservoir containing a liquid formulation comprising a single dose of Type I or III interferon receptor agonist, and a second reservoir containing a liquid formulation comprising a single dose of Type II interferon receptor agonist, and a third reservoir containing a liquid formulation comprising a single dose of TNF-α antagonist. Any of the dosage amounts, including synergistically effective amounts, described herein can be used in the pharmaceutical formulation, in the reservoir, or in the drug delivery device.
[00196] In some embodiments, in a treatment method described herein, the Type I or III interferon receptor agonist is an IFN-α, the Type II interferon receptor agonist is an IFN-γ, and the subject method comprises co-administering to the patient an effective amount of IFN-γ for the duration of the IFN-α therapy. In one embodiment, the IFN-γ is administered to the patient by bolus injection. In another embodiment, the IFN-α and IFN-γ are administered to the patient by a drug delivery device. Optionally, the device is used to deliver the IFN-α to the patient by substantially continuous or continuous administration and used to deliver the IFΝ-γ to the patient by bolus administration tiw, biw, qod, or qd. Optionally, the device is used to deliver the IFN-α and IFN-γ to the patient in the same manner and pattern of administration, such as substantially continuous or continuous administration. Optionally, the IFN-α and IFN- γ are contained in separate reservoirs in the drug delivery device. Optionally, the IFN-α and IFN-γ are co-formulated in a single liquid formulation that is contained in a single reservoir in the drug delivery device. Additional therapeutic agents
[00197] In some embodiments, the method further includes administration of pirfenidone or a pirfenidone analog. Pirfenidone or a pirfenidone analog can be administered once per month, twice per month, three times per month, once per week, twice per week, three times per week, four times per week, five times per week, six times per week, daily, or in divided daily doses ranging from once daily to 5 times daily over a period of time ranging from about one day to about one week, from about two weeks to about four weeks, from about one month to about two months, from about two months to about four months, from about four months to about six months, from about six months to about eight months, from about eight months to about 1 year, from about 1 year to about 2 years, or from about 2 years to about 4 years, or more.
[00198] Effective dosages of pirfenidone or a specific pirfenidone analog include a weight- based dosage in the range from about 5 mg/kg/day to about 125 mg/kg/day, or a fixed dosage of about 400 mg to about 3600 mg per day, or about 800 mg to about 2400 mg per day, or about 1000 mg to about 1800 mg per day, or about 1200 mg to about 1600 mg per day, administered orally. Other doses and formulations of pirfenidone and specific pirfenidone analogs suitable for use in the treatment of fibrotic diseases are described in U.S. Pat. Nos., 5,310,562; 5,518,729; 5,716,632; and 6,090,822.
[00199] In some embodiments, pirfenidone or a pirfenidone analog is administered throughout the entire course of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment. In other embodiments, pirfenidone or a pirfenidone analog is administered less than the entire course of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, e.g., only during the first phase of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, only during the second phase of Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, or some other portion of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment regimen.
[00200] In some embodiments, the method further includes administration of ribavirin. Ribavirin, l-β-D-ribofuranosyl-lH-l,2,4-triazole-3-carboxamide, available from ICN Pharmaceuticals, Inc., Costa Mesa, Calif, is described in the Merck Index, compound No. 8199, Eleventh Edition. Its manufacture and formulation is described in U.S. Pat. No. 4,211,771. The invention also contemplates use of derivatives of ribavirin (see, e.g., U.S. Pat. No. 6,277,830). The ribavirin may be administered orally in capsule or tablet form, or in the same or different administration form and in the same or different route as the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist. Of course, other types of administration of both medicaments, as they become available are contemplated, such as by nasal spray, transdermally, intravenously, by suppository, by sustained release dosage form, etc. Any form of administration will work so long as the proper dosages are delivered without destroying the active ingredient.
[00201] Ribavirin is generally administered in an amount ranging from about 30 mg to about 60 mg, from about 60 mg to about 125 mg, from about 125 mg to about 200 mg, from about 200 mg to about 300 gm, from about 300 mg to about 400 mg, from about 400 mg to about 1200 mg, from about 600 mg to about 1000 mg, or from about 700 to about 900 mg per day, or about 10 mg/kg body weight per day.
[00202] In some embodiments, ribavirin is administered throughout the entire course of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α ■ antagonist treatment. In other embodiments, ribavirin is administered less than the entire course of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, e.g., only during the first phase of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, only during the second phase of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment, or some other portion of the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist treatment regimen. COMBINATION REGIMENS FOR VIRAL INFECTION
[00203] The present invention provides methods of treating viral infection by administering a therapeutically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist to an individual in need thereof. Individuals who are to be treated according to the methods of the invention include individuals who have been clinically diagnosed with a viral infection, as well as individuals who exhibit one or more of the signs and the symptoms of clinical infection but have not yet been diagnosed with an viral infection.
[00204] In carrying out the methods of combination therapy for viral infection in an individual as described above, a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered to the individual. In some embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TΝF-α antagonist are administered in the same formulation. In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered in separate formulations. When administered in separate formulations, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another. In many embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TΝF-α antagonist are administered subcutaneously in multiple doses.
[00205] In many embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist, or TNF-α antagonist is administered for a period of about 1 day to about 7 days, or about 1 week to about 2 weeks, or about 2 weeks to about 3 weeks, or about 3 weeks to about 4 weeks, or about 1 month to about 2 months, or about 3 months to about 4 months, or about 4 months to about 6 months, or about 6 months to about 8 months, or about 8 months to about 12 months, or at least one year, and may be administered over longer periods of time. Dosage regimens can include tid, bid, qd, qod, biw, tiw, qw, qow, three times per month, or monthly administrations. [00206] In some embodiments, the invention provides methods using a synergistically effective amount of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist in the treatment of viral infection in a patient. In some embodiments, the invention provides methods using a synergistically effective amount of an IFN-α, IFN-γ, and a TΝF-α antagonist selected from the group consisting of ENBREL®, REMICADE® and HUMIRA™, in the treatment of viral infection in a patient. In one embodiment, the invention provides a method using a synergistically effective amount of a consensus IFN-α, IFN-γ, and a TNF-α antagonist selected from the group consisting of ENBREL®, REMICADE® and HUMIRA™, in the treatment of viral infection in a patient.
[00207] In general, an effective amount of a consensus interferon (CIFN) and IFN-γ suitable for use in the methods of the invention is provided by a dosage ratio of 1 μg CIFN : 10 μg IFN-γ, where both CIFN and IFN-γ are unPEGylated and unglycosylated species.
[00208] In one embodiment, the invention provides a method using an effective amount of INFERGEN® consensus IFN-α, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 μg to about 30 μg of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFΝ-γ containing an amount of about 10 μg to about 300 μg of drug per dose of IFN-γ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00209] In another embodiment, the invention provides a method using an effective amount of INFERGEN®consensus IFN-α, IFN-γ and TΝF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 μg to about 9 μg of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 10 μg to about 100 μg of drug per dose of IFN-γ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00210] In another embodiment, the invention provides a method using an effective amount of INFERGEN® consensus IFN-α, IFN-γ and TΝF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 1 μg of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFΝ-γ containing an amount of about 10 μg to about 50 μg of drug per dose of IFN-γ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TΝF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00211] In another embodiment, the invention provides a method using an effective amount of INFERGEN® consensus IFN-α, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient comprising administering to the patient a dosage of INFERGEN® containing an amount of about 9 μg of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 90 μg to about 100 μg of drug per dose of IFN-γ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TΝF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration. [00212] In another embodiment, the invention provides a method using an effective amount of INFERGEN®consensus IFN-α, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of INFERGEN® containing an amount of about 30 μg of drug per dose of INFERGEN® subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 200 μg to about 300 μg of drag per dose of IFN-γ subcutaneously qd, qod, tiw, biw, qw, qow, three times per month, once monthly, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00213] In another embodiment, the invention provides a method using an effective amount of PEGylated consensus IFN-α, IFΝ-γ and TΝF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGylated consensus IFΝ-α (PEG-CIFΝ) containing an amount of about 4 μg to about 60 μg of CIFN amino acid weight per dose of PEG-CIFN subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 30 μg to about 1,000 μg of drag per week in divided doses administered subcutaneously qd, qod, tiw, biw, or substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00214] In another embodiment, the invention provides a method using an effective amount of PEGylated consensus IFN-α, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGylated consensus IFN-α (PEG-CIFN) containing an amount of about 18 μg to about 24 μg of CIFN amino acid weight per dose of PEG-CIFN subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 100 μg to about 300 μg of drug per week in divided doses administered subcutaneously qd, qod, tiw, biw, or substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00215] In general, an effective amount of IFN-α 2a or 2b or 2c and IFN-γ suitable for use in the methods of the invention is provided by a dosage ratio of 1 million Units (MU) IFN-α 2a or 2b or 2c : 30 μg IFN-γ, where both IFN-α 2a or 2b or 2c and IFN-γ are unPEGylated and unglycosylated species.
[00216] In another embodiment, the invention provides a method using an effective amount of IFN-α 2a or 2b or 2c, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IFN-α2a containing an amount of about 1 MU to about 20 MU of drag per dose of IFN-α 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 30 μg to about 600 μg of drag per dose of IFN-γ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drag subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00217] In another embodiment, the invention provides a method using an effective amount of IFN-α 2a or 2b or 2c, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IFΝ-ά2a containing an amount of about 3 MU of drug per dose of IFN-α 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 100 μg of drug per dose of IFN-γ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drag subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00218] In another embodiment, the invention provides a method using an effective amount of IFN-α 2a or 2b or 2c, IFN-γ and TΝF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of IFΝ-α 2a, 2b or 2c containing an amount of about 10 MU of drug per dose of IFN-α 2a, 2b or 2c subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, a dosage of IFN-γ containing an amount of about 300 μg of drag per dose of IFN-γ subcutaneously qd, qod, tiw, biw, or per day substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00219] In another embodiment, the invention provides a method using an effective amount of PEGASYS®PEGylated IFΝ-α2a, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGASYS® containing an amount of about 90 μg to about 360 μg of drug per dose of PEGASYS® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 30 μg to about 1,000 μg of drug per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drug intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00220] In another embodiment, the invention provides a method using an effective amount of PEGASYS®PEGylated IFN-α2a, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEGASYS® containing an amount of about 180 μg of drag per dose of PEGASYS® subcutaneously qw, . qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 100 μg to about 300 μg of drag per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drag subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00221] In another embodiment, the invention provides a method using an effective amount of PEG-INTRON®PEGylated IFN-α2b, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEG-INTRON® containing an amount of about 0.75 μg to about 3.0 μg of drug per kilogram of body weight per dose of PEG-INTRON® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 30 μg to about 1,000 μg of drug per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drag subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) HUMIRA™ in an amount of about 40 mg of drag subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00222] In another embodiment, the invention provides a method using an effective amount of PEG-INTRON®PEGylated IFΝ-α2b, IFN-γ and TNF-α antagonist in the treatment of viral infection in a patient, comprising administering to the patient a dosage of PEG-INTRON® containing an amount of about 1.5 μg of drug per kilogram of body weight per dose of PEG- INTRON® subcutaneously qw, qow, three times per month, or monthly, a total weekly dosage of IFN-γ containing an amount of about 100 μg to about 300 μg of drag per week administered in divided doses subcutaneously qd, qod, tiw, or biw, or administered substantially continuously or continuously, and a dosage of a TNF-α antagonist selected from the group consisting of (i) ENBREL® in an amount of about 25 mg of drug subcutaneously biw (ii) REMICADE® in an amount of about 3 mg/kg to about 10 mg/kg of drag intravenously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks or (iii) FTUMIRA™ in an amount of about 40 mg of drug subcutaneously qw, qow, three times per month, once monthly, once every 6 weeks, or once every 8 weeks, for the desired treatment duration.
[00223] The invention also provides methods for the treatment of viral infection in which ribavirin therapy is added to any of the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist combination therapies described above. In some embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist combination therapy is modified to include a ribavirin regimen of 800 mg to 1200 mg ribavirin orally qd for the specified duration of therapy. In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist combination therapy is modified to include a ribavirin regimen of 1000 mg ribavirin orally qd for the specified duration of therapy. In additional embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist combination therapy is modified to include a ribavirin regimen of about 10 mg of ribavirin/kg body weight orally qd for the specified duration of therapy. The daily ribavirin dosage can be administered in one dose per day or in divided doses, including one, two, three or four doses, per day.
[00224] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TΝF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00225] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00226] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 μg INFERGEN® consensus IFΝ-α administered subcutaneously qd or tiw; 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; and a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; for the desired duration of therapy.
[00227] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; and a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; for the desired duration of therapy.
[00228] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 25 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd, for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00229] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 200 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00230] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 25 μg Actimmune® human IFN-γlb administered subcutaneously tiw; and a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; for the desired duration of therapy.
[00231] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection with a regimen of 9 μg INFERGEN® consensus IFN-α administered subcutaneously qd or tiw; 200 μg Actimmune® human IFN-γlb administered subcutaneously tiw; and a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; for the desired duration of therapy.
[00232] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00233] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00234] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy.
[00235] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 100 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy.
[00236] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 μg monoPEG(30 kD, linear)-ylated consensus IFΝ-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00237] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00238] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00239] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy.
[00240] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 150 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TΝF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy. [00241] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00242] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 μg monoPEG(30 kD, linear) -ylated consensus IFN-α administered subcutaneously every 10 days or qw; 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00243] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having an viral infection a regimen of 200 μg monoPEG(30 kD, linear)-ylated consensus IFΝ-α administered subcutaneously every 10 days or qw; 100 μg Actimmune® human IFΝ-γlb administered subcutaneously tiw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and ribavirin administered orally qd; for the desired duration of therapy. In this embodiment, ribavirin is administered in an amount of 1000 mg for individuals weighing less than 75 kg, and 1200 mg for individuals weighing 75 kg or more.
[00244] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 50 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy.
[00245] In one embodiment, the present invention provides for treatment of a viral infection, comprising administering to an individual having a viral infection a regimen of 200 μg monoPEG(30 kD, linear)-ylated consensus IFN-α administered subcutaneously every 10 days or qw; a dosage of TNF-α antagonist selected from the group consisting of (i) 25 mg ENBREL® administered subcutaneously biw (ii) 3 mg REMICADE®/kg patient body weight administered intravenously at weeks 0, 2 and 6, and every 8 weeks thereafter or (iii) 40 mg HUMIRA™ subcutaneously qw or qow; and 100 μg Actimmune® human IFN-γlb administered subcutaneously tiw; for the desired duration of therapy. COMBINATION REGIMENS FOR HEPATITIS C VIRAL INFECTION
[00246] The present invention provides methods of treating HCV infection by administering a combination of a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist in a therapeutically effective amount to an individual in need thereof. Individuals who are to be treated according to the methods of the invention include individuals who have been clinically diagnosed as infected with HCV. Individuals who are infected with HCV are identified as having HCV RNA in their blood, and/or having anti-HCV antibody in their serum.
[00247] Individuals who are clinically diagnosed as infected with HCV include naϊve individuals (e.g., individuals not previously treated for HCV) and individuals who have failed prior treatment for HCV ("treatment failure" patients). Treatment failure patients include non- responders (e.g., individuals in whom the HCV titer was not significantly or sufficiently reduced by a previous treatment for HCV); and relapsers (e.g., individuals who were previously treated for HCV, whose HCV titer decreased, and subsequently increased).
[00248] In particular embodiments of interest, individuals have an HCV titer of at least about 105, at least about 5 x 105, or at least about 106, or at least about 2 x 106, genome copies of HCV per milliliter of serum. The patient may be infected with any HCV genotype (genotype 1, including la and lb, 2, 3, 4, 6, etc. and subtypes (e.g., 2a, 2b, 3a, etc.)), particularly a difficult to treat genotype such as HCV genotype 1 and particular HCV subtypes and quasispecies.
[00249] Also of interest are HCV-positive individuals (as described above) who exhibit severe fibrosis or early cirrhosis (non-decompensated, Child's-Pugh class A or less), or more advanced cirrhosis (decompensated, Child's-Pugh class B or C) due to chronic HCV infection and who are viremic despite prior anti- viral treatment with IFN-α-based therapies or who cannot tolerate IFN-α-based therapies, or who have a contraindication to such therapies. In particular embodiments of interest, HCV-positive individuals with stage 3 or 4 liver fibrosis according to the METAVIR scoring system are suitable for treatment with the methods of the present invention. In other embodiments, individuals suitable for treatment with the methods of the instant invention are patients with decompensated cirrhosis with clinical manifestations, including patients with far-advanced liver cirrhosis, including those awaiting liver transplantation. In still other embodiments, individuals suitable for treatment with, the methods of the instant invention include patients with milder degrees of fibrosis including those with early fibrosis (stages 1 and 2 in the METAVIR, Ludwig, and Scheuer scoring systems; or stages 1, 2, or 3 in the Ishak scoring system.).
[00250] In carrying out the methods of combination therapy for hepatitis C viral infection in an individual as described above, a Type I or III interferon receptor agonist, Type II interferon receptor agonist, and TNF-α antagonist are administered to the individual. In some embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist are administered in the same formulation. In other embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TΝF-α antagonist are administered in separate formulations. When administered in separate formulations, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist can be administered substantially simultaneously, or can be administered within about 24 hours of one another. In many embodiments, the Type I or III interferon receptor agonist, Type II interferon receptor agonist and TNF-α antagonist are administered subcutaneously in multiple doses.
[00251] In certain embodiments, the specific regimen of drug therapy used in treatment of the HCV patient is selected according to certain disease parameters exhibited by the patient, such as the initial viral load, genotype of the HCV infection in the patient, liver histology and/or stage of liver fibrosis in the patient. In one embodiment, the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1 ) identifying a patient having advanced or severe stage liver fibrosis as measured by a Knodell score of 3 or 4 and then (2) administering to the patient the drag therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
[00252] In another embodiment, the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having advanced or severe stage liver fibrosis as measured by a Knodell score of 3 or 4 and then (2) administering to the patient the drag therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
[00253] In another embodiment, the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
[00254] In another embodiment, the invention provides any of the above-described methods for the treatment of viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drag therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
[00255] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and no or early stage liver fibrosis as measured by a Knodell score of 0, 1, or 2 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks. [00256] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of greater than 2 million viral genome copies per ml of patient serum and no or early stage liver fibrosis as measured by a Knodell score of 0, 1 , or 2 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 40 weeks to about 50 weeks, or about 48 weeks.
[00257] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks, or about 24 weeks to about 48 weeks, or about 30 weeks to about 40 weeks, or up to about 20 weeks, or up to about 24 weeks, or up to about 30 weeks, or up to about 36 weeks, or up to about 48 weeks.
[00258] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 24 weeks.
[00259] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 infection and an initial viral load of less than or equal to 2 million viral genome copies per ml of patient serum and then (2) administering to the patient the drag therapy of the subject method for a time period of about 24 weeks to about 48 weeks.
[00260] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 3O weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
[00261] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks, or about 24 weeks to about 48 weeks, or about 30 weeks to about 40 weeks, or up to about 20 weeks, or up to about 24 weeks, or up to about 30 weeks, or up to about 36 weeks, or up to about 48 weeks.
[00262] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 24 weeks.
[00263] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 2 or 3 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of at least about 24 weeks.
[00264] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV genotype 1 or 4 infection and then (2) administering to the patient the drug therapy of the subject method for a time period of about 24 weeks to about 60 weeks, or about 30 weeks to about one year, or about 36 weeks to about 50 weeks, or about 40 weeks to about 48 weeks, or at least about 24 weeks, or at least about 30 weeks, or at least about 36 weeks, or at least about 40 weeks, or at least about 48 weeks, or at least about 60 weeks.
[00265] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV infection characterized by any of HCV genotypes 5, 6, 7, 8 and 9 and then (2) administering to the patient the drug therapy of the subject method for a time period of about 20 weeks to about 50 weeks. [00266] In another embodiment, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection, and where the subject method is modified to include the steps of (1) identifying a patient having an HCV infection characterized by any of HCV genotypes 5, 6, 7, 8 and 9 and then (2) administering to the patient the drug therapy of the subject method for a time period of at least about 24 weeks and up to about 48 weeks.
[00267] Any of the above-described methods of treating a viral infection can be used for the treatment of individuals who have an HCV infection and who have failed previous treatment for HCV infection ("treatment failure patients," including non-responders and relapsers). For example, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a treatment failure patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the present invention provides methods of treating an HCV infection in a treatment failure patient, the method comprising administering an effective amount of an IFN-α, an effective amount of a TNF-α antagonist, and an effective amount of an IFN-γ, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a treatment failure patient, the method comprising administering an effective amount of IFN-α, an effective amount of a TNF-α antagonist, an effective amount of IFN-γ, and an effective amount of ribavirin, for 48 weeks.
[00268] In other embodiments, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection in a non-responder patient, and where the drag therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the present invention provides methods of treating an HCV infection in a non-responder patient, the method comprising administering an effective amount of an IFN-α, an effective amount of a TΝF-α antagonist, and an effective amount of an IFN-γ, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a non-responder patient, the method comprising administering an effective amount of IFN-α, an effective amount of IFN-γ, an effective amount of a TNF-α antagonist, and an effective amount of ribavirin, for 48 weeks.
[00269] In other embodiments, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV infection in a relapser patient, and where the drag therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the invention provides methods for treating an HCV infection in a relapser patient, the method comprising administering an effective amount of an IFΝ-α, an effective amount of an IFN-γ, and an effective amount of a TNF-α antagonist, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a relapser patient, the method comprising administering an effective amount of IFN-α, an effective amount of IFN-γ, and an effective amount of a TNF-α antagonist, and an effective amount of ribavirin, for 48 weeks.
[00270] Any of the above-described methods of treating a viral infection can be used in the treatment of naϊve patients infected with HCV genotype 1. For example, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a naϊve patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the present invention provides methods of treating an HCV infection in a naϊve patient having an infection with HCV genotype 1, the method comprising administering an effective amount of an IFN-α, an effective amount of an IFN-γ, and an effective amount of a TNF-α antagonist, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a na'ϊve patient having an infection with HCV genotype 1, the method comprising administering an effective amount of IFN-α, an effective amount of IFN-γ, an effective amount of a TNF-α antagonist, and an effective amount of ribavirin, for 48 weeks.
[00271] Any of the above-described treatment regimens can be administered to naϊve patients infected with HCV genotype 4. For example, the invention provides any of the above- described methods of treating a viral infection, where the viral infection is an HCV genotype 4 infection in a naϊve patient, and where the drug therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the present invention provides methods of treating an HCV infection in a naϊve patient having an infection with HCV genotype 4, the method comprising administering an effective amount of an IFN-α, an effective amount of an IFΝ-γ, and an effective amount of a TNF-α antagonist, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a naϊve patient having an infection with HCV genotype 4, the method comprising administering an effective amount of IFΝ-α, effective amount of IFN-γ, an effective amount of a TNF-α antagonist, and an effective amount of ribavirin, for 48 weeks.
[00272] Any of the above-described treatment regimens can be administered to naϊve patients infected with HCV genotype 1, which patients have a high viral load (HVL), where "HVL" refers to an HCV viral load of greater than 2 x 106 HCV genome copies per mL serum. For example, the invention provides any of the above-described methods of treating a viral infection, where the viral infection is an HCV genotype 1 infection in a naϊve patient who has a viral load of greater than 2 x 106 HCV genome copies per mL serum, and where the drug therapy of the subject method is administered to the patient for 48 weeks. Thus, in some embodiments, the present invention provides methods of treating an HCV infection in a naϊve patient having an infection with HCV genotype 1 and having a high viral load, the method comprising administering an effective amount of an IFN-α, an effective amount of an IFN-γ, and an effective amount of a TNF-α antagonist, for 48 weeks. In other embodiments, the invention provides methods for treating an HCV infection in a naϊve patient having an infection with HCV genotype 1 and having a high viral load, the method comprising administering an effective amount of IFN-α, an effective amount of IFN-γ, an effective amount of a TΝF-α antagonist, and an effective amount of ribavirin, for 48 weeks. While the present invention has been described with reference to the specific embodiments thereof, it should be understood by those skilled in the art that various changes may be made and equivalents may be substituted without departing from the true spirit and scope of the invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process step or steps, to the objective, spirit and scope of the present invention. All such modifications are intended to be within the scope of the claims appended hereto.

Claims

CLAIMS What is claimed is:
1. A method of treating a virus infection in an individual, comprising administering to the individual an effective amount of IFN-α, IFN-γ and a non-pirfenidone TΝF-α antagonist.
2. A method of treating a hepatitis C virus infection in an individual, comprising administering to the individual IFN-α, IFN-γ and a non-pirfenidone TNF-α antagonist in an amount effective to achieve a sustained viral response.
3. The method of claim 1 or 2, wherein the individual receives a synergistic amount of IFN-α and IFN-γ.
4. The method of claim 1 or 2, wherein the individual receives a synergistic amount of IFN-α, IFN-γ and a non-pirfenidone TNF-α antagonist.
5. The method of any of claims 1 -4, wherein the IFN-α is a consensus interferon.
6. The method of any of claims 1 -4, wherein the IFΝ-α is a PEGylated IFΝ-α.
7. The method of any of claims 1 -6, comprising further co-administering to the individual an effective amount of ribavirin for the duration of the IFΝ-α, IFΝ-γ or non- pirfenidone TNF-α antagonist therapy.
8. The method of any of claims 1-7, further comprising co-administering to the individual an effective amount of pirfenidone or a specific pirfenidone analog for the duration of the IFN-α, IFN-γ or non-pirfenidone TNF-α antagonist therapy.
9. A method of decreasing viral load in an individual suffering from hepatitis C virus, comprising administering IFN-α, IFN-γ and a non-pirfenidone TNF-α antagonist in an amount effective to decrease viral load.
10. A method of treating hepatitis C virus in an individual, comprising the steps of: (a) identifying an individual suffering from a genotype 1 or hepatitis C viral (HCV) infection; and (b) administering to the individual an effective amount of IFN-α, IFN-γ and a non-pirfenidone TNF-α antagonist for a period of about 48 weeks.
11. The method of claim 10, wherein the identification of the individual in step (a) further requires the individual to have no or early stage liver fibrosis as measured by a Knodell score of 0, 1 or 2.
12. A method of treating hepatitis C virus in an individual, comprising the steps of: (a) identifying an individual suffering from a genotype 1 hepatitis C viral (HCV) infection and having an initial viral load of less than or equal to 2 million HCV genome copies per milliliter of serum; and (b) administering to the individual an effective amount of IFN-α, IFN-γ and a non-pirfenidone TNF-α antagonist for a period of about 24 to 48 weeks.
13. A method of treating hepatitis C virus in an individual, comprising the steps of: (a) identifying an individual suffering from a genotype 2 or 3 hepatitis C viral (HCV) infection; and (b) administering to the individual an effective amount of IFN-α, IFN-γ and non-pirfenidone TNF-α antagonist for a period of about 24 to 48 weeks.
14. The method of any of claims 9-13, where the IFN-α is a consensus interferon.
15. The method of any of claims 9-14, further comprising co-administering to the individual an effective amount of ribavirin for the duration of IFN-α, IFN-γ or non- pirfenidone TNF-α antagonist therapy.
16. The method of any of claims 9-15, wherein the individual receives a synergistic amount of IFN-α and IFN-γ.
17. The method of any of claims 9-15, wherein the individual receives a synergistic amount of IFN-α, IFN-γ and non-pirfenidone TNF-α antagonist.
18. The method of any of claims 9-17, wherein the IFN-α is a PEGylated IFN-α.
19. The method of any of claims 9-18, further comprising co-administering to the individual an effective amount of pirfenidone or a specific pirfenidone analog for the duration of the IFN-α, IFN-γ or non-pirfenidone TNF-α antagonist therapy.
20. The method of any of claims 1-19, wherein the non-pirfenidone TNF-α antagonist is selected from the group consisting of etanercept, infliximab, and adalimumab.
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