Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/395—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
  • A61P1/04—Drugs for disorders of the alimentary tract or the digestive system for ulcers, gastritis or reflux esophagitis, e.g. antacids, inhibitors of acid secretion, mucosal protectants
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2839—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the integrin superfamily
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
  • G01N33/6854—Immunoglobulins
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/505—Medicinal preparations containing antigens or antibodies comprising antibodies
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/54—Medicinal preparations containing antigens or antibodies characterised by the route of administration
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
  • C07K2317/24—Immunoglobulins specific features characterized by taxonomic origin containing regions, domains or residues from different species, e.g. chimeric, humanized or veneered
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/90—Immunoglobulins specific features characterized by (pharmaco)kinetic aspects or by stability of the immunoglobulin
  • C07K2317/94—Stability, e.g. half-life, pH, temperature or enzyme-resistance
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q2600/00—Oligonucleotides characterized by their use
  • C12Q2600/106—Pharmacogenomics, i.e. genetic variability in individual responses to drugs and drug metabolism
• • C—CHEMISTRY; METALLURGY
  • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
  • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
  • C12Q2600/00—Oligonucleotides characterized by their use
  • C12Q2600/158—Expression markers
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
  • G01N2333/435—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans
  • G01N2333/52—Assays involving cytokines
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/52—Predicting or monitoring the response to treatment, e.g. for selection of therapy based on assay results in personalised medicine; Prognosis

Definitions

• IBD Inflammatory bowel disease
• IBD treatments have included anti-inflammatory drugs (such as, corticosteroids and sulfasalazine), immunosuppressive drugs (such as, 6- mercaptopurine, cyclosporine and azathioprine) and surgery (such as, colectomy).
• anti-inflammatory drugs such as, corticosteroids and sulfasalazine
• immunosuppressive drugs such as, 6- mercaptopurine, cyclosporine and azathioprine
• surgery such as, colectomy.
• treatment progresses into regimens that expose patients to progressive risk of side effects and loss of quality of life.
• Integrin receptors are important for regulating both lymphocyte recirculation and recruitment to sites of inflammation (Carlos, T.M. and Harlan, J.M., Blood, 84:2068- 2101 (1994)).
• the human ⁇ 4 ⁇ 7 integrin has several ligands, one of which is the mucosal vascular addressin MAdCAM-1 (Berlin, C, et al, Cell 74: 185-195 (1993); Erie, D.J., et al., J. Immunol.
• the ⁇ 4 ⁇ 7 integrin acts as a homing receptor that mediates lymphocyte migration to intestinal mucosal lymphoid tissue
• Antibodies against human ⁇ 4 ⁇ 7 integrin such as murine monoclonal antibody Act-1 (mAb Act-1), interfere with ⁇ 4 ⁇ 7 integrin binding to mucosal addressin cell adhesion molecule- 1 (MAdCAM-1) present on high endothelial venules in mucosal lymph nodes.
• Act-1 was originally isolated by Lazarovits, A. I., et al., J. Immunol.
• mice immunized with human tetanus toxoid-specific T lymphocytes were reported to be a mouse IgGl/ ⁇ antibody. Subsequent analysis of the antibody by Schweighoffer, T., et al, J. Immunol. 757:717-729 (1993)
• EntyvioTM vedolizumab an anti-a 4 p 7 integrin monoclonal antibody (mAb) with structural features derived from Act-1 , is indicated for treating ulcerative colitis (UC) and Crohn's disease (CD).
• UC ulcerative colitis
• CD Crohn's disease
• Studies reporting the activity of vedolizumab in treating these disorders showed varying levels of success depending on the disorder and nature of prior therapies. As these were lengthy studies and there are a growing number of treatment options available to patients, there is a need to identify patients who can benefit from vedolizumab therapy early in their treatment. Expedient and accurate treatment decisions lead to effective management of the disease.
• the invention relates to the identification of patients who can respond to therapy comprising an anti- 4p7 antibody, such as vedolizumab.
• an anti- 4p7 antibody such as vedolizumab.
• factors measured from the patient or from biological samples of the patient indicate whether a patient is likely to respond to treatment.
• pharmacokinetics or pharmacodynamics factors can indicate whether a patient will respond to treatment with an anti-oc4p7 antibody, such as vedolizumab.
• an anti-oc4p7 antibody such as vedolizumab.
• understanding determinants of mAb clearance may optimize dosing regimens.
• Applicants have identified the problem, and characterized anti-oc4p7 antibody, such as vedolizumab, pharmacokinetic factors in patients with UC and CD, identified clinically relevant determinants of anti-a4p7 antibody, such as antibody clearance, and described the pharmacokinetic-pharmacodynamic relationship using population modeling.
• a pharmacokinetics factor is mean serum trough concentration.
• a pharmacokinetics factor is therapeutic antibody clearance.
• a pharmacodynamic factor is the amount of antibody bound to 4 ⁇ 7 integrin.
• a pharmacodynamic factor is the amount of unbound ⁇ 4 ⁇ 7 integrin.
• a method for treating a patient having inflammatory bowel disease (IBD) with an anti-a4p7 antibody, such as vedolizumab comprises administering two doses of the anti-cc4p7 antibody to a patient suffering from IBD, wherein the second dose is administered about two weeks after the first dose is administered to the patient; waiting a period of time about four weeks; measuring the patient's serum concentration of the anti-a4p7 antibody; and administering one or more further doses of the anti-a4p7 antibody to the patient if the patient's serum concentration, e.g., a trough serum concentration, of the antibody is at least 8 ⁇ g per ml.
• the waiting period is two weeks or about two to five weeks.
• the method comprises administering two doses of vedolizumab to a patient suffering from IBD, wherein the second dose is administered about two weeks after the first dose is administered to the patient; waiting a period of time about four weeks; measuring the patient's serum concentration of vedolizumab; and administering one or more further doses of vedolizumab to the patient if the patient's serum concentration, e.g., a trough serum concentration, of the antibody is at least 8 ⁇ g per ml.
• the patient's serum concentration of the anti-a4p7 antibody, e.g., vedolizumab may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• a patient who is likely to respond to the anti- ⁇ 4 ⁇ 7 antibody, e.g., vedolizumab has a serum concentration, e.g., a trough serum concentration of greater than 17 g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• the patient's serum concentration of anti-a4p7 antibody, e.g., vedolizumab may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 ⁇ g per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• a method for treating a patient having inflammatory bowel disease (IBD) with an anti-a4p7 antibody, such as vedolizumab comprises the steps of administering at least one dose of vedolizumab to the patient suffering from IBD; waiting a period of at least two weeks, measuring the patient's serum concentration of vedolizumab; and administering one or more further doses of vedolizumab to the patient if the patient's serum concentration is at least 8 ⁇ g per ml.
• the waiting period is about two to five weeks.
• clinical measures during early treatment can indicate whether a patient will respond to treatment with an anti-a4 7 antibody, such as vedolizumab.
• the patient can have mucosal healing. In another embodiment, the patient can have deep remission.
• the method for treating a patient can comprise measuring an endoscopic subscore, e.g., from the Mayo score, wherein the anti-oc4p7 antibody, e.g., vedolizumab is continued with an endoscopic score of less than 3.
• the endoscopic score can be less than 2.5, less than 2, between 0 and 2, 1 , or equal to or less than 1 ( ⁇ 1) or less than 1 (( ⁇ 1).
• the method for treating a patient can comprise measuring the Crohn's Disease Activity Index (CDAI).
• the method for treating a patient can comprise measuring the number, size or severity of fistulae.
• the endoscopic score is a simple endoscopic score for Crohn's Disease (SES-CD).
• the SES-CD can be in the range of 0 to 6, ⁇ 6, ⁇ 5 or no more than 4 ( ⁇ 4).
• the SES-CD is decreased by 25%, 35%, 40%, 45%, 50%, 55%, 60% or 65% from baseline.
• the SES-CD is decreased 50% from baseline.
• the method for treating a patient can comprise measuring the amount of ulceration in the digestive tract.
• the method for treating a patient can comprise measuring mucosal healing. In some embodiments of mucosal healing, ulceration is decreased or absent.
• measures of inflammation can indicate whether a patient will respond to treatment with an anti-a4p7 antibody, such as vedolizumab.
• Measures of inflammation include amounts of fecal calprotectin, amounts of C-reactive protein (CRP) and amount of albumin.
• the method comprises measuring the fecal calprotectin concentration.
• Treatment with the antibody, e.g., vedolizumab can be continued with a fecal calprotectin concentration of less than 1500 ⁇ g/g.
• the fecal calprotectin concentration can be less than 1250 g/g, less than 1000 ⁇ g/g, less than 750 ⁇ g/g, less than 500 ⁇ g/g, less than 400 g/g, less than 300 ⁇ g/g, less than 250 ⁇ g/g, between 200-1200 ⁇ g/g, between 350 to 800 ⁇ g g, between 300-1000 g/g, ⁇ 50 ⁇ , ⁇ 100 ⁇ , ⁇ 150 ⁇ , ⁇ 200 ⁇ , ⁇ 250-499 ⁇ , or between 500 to 900 ⁇ .
• treatment with an anti-cc4 7 antibody e.g., vedolizumab can be continued if the fecal calprotectin is reduced to less than 50% of the baseline or concentration before treatment.
• the fecal calprotectin can be reduced to less than 45%, less than 40%, less than 35%, less than 30%, less than 25%, less than 20%, between 10-55%, between 10-30%, between 15-35%, between 15-45%, or between 20-40% of the baseline or concentration before treatment.
• methods described herein comprise measuring albumin concentration.
• An albumin concentration greater than 3.2 g/dL further identifies the patient for continued treatment with an anti-a4p7 antibody, e.g., vedolizumab.
• the albumin concentration can be greater than 3.5 g/dL, greater than 4.0 g/dL, or greater than 4.7 g/dL, in the range of 3.3 to 5.0 g/dL, in the range of 3.5 to 5.0 g/dL, in the range of 3.8 to 5.0 g/dL or in the range of 4.0 to 5.0 g/dL.
• the invention relates to therapeutic methods which further include the step of continuing, stopping, discontinuing or halting a therapy accordingly where factors measured as described herein indicate whether there is continued benefit of the therapy.
• a method of identifying a patient for continued treatment with an anti-cc4p7 antibody comprises the steps of: measuring the concentration of the anti- ⁇ 4 ⁇ 7 antibody in a sample of serum obtained from a patient suffering from
• IBD inflammatory bowel disease
• the patient may have received at least one dose of the anti-a4p7 antibody within the previous month.
• the patient received at least two doses of the anti-a4 7 antibody within the previous four months; and the method identifies the patient for continued treatment with the anti- 4p7 antibody if its serum concentration in the sample is at least 8 ⁇ g per ml four weeks after the second dose, e.g., four weeks after the dose at week 2.
• the patient may have received at least two doses of the anti-a4p7 antibody within the previous three months or the previous two months.
• the patient's serum concentration of the anti-cc4p7 antibody may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• the patient's serum concentration of the anti-a4p7 antibody may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 g per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• a method of identifying a patient for continued treatment with vedolizumab comprises the steps of: measuring the concentration of vedolizumab in a sample of serum obtained from a patient suffering from inflammatory bowel disease (IBD) and who received at least two doses of vedolizumab within the previous four months; and identifying the patient for continued treatment with vedolizumab if the serum concentration in the sample is at least 8 ⁇ g per ml four weeks after the second dose, e.g., four weeks after the dose at week 2.
• the patient may have received at least two doses of vedolizumab within the previous three months or the previous two months.
• the patient's serum concentration of vedolizumab may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• the patient's serum concentration of vedolizumab may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 ⁇ g per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• the invention relates to a method of identifying a patient for continued treatment with vedolizumab, the method comprising the steps of:
• the patient may have received at least one dose of vedolizumab within the previous month.
• the patient's serum concentration of vedolizumab may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• the patient's serum concentration of vedolizumab may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 ⁇ per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• continuing treatment includes maintaining remission of IBD.
• the invention relates to a method for maintaining remission of inflammatory bowel disease (IBD) in a patient, wherein the patient had received at least one dose of an anti-a4p7 antibody in the previous two months, the method comprising: obtaining a serum sample from the patient; measuring the concentration of the anti-a4p7 antibody in the sample; administering the anti-a4p7 antibody thereafter every eight weeks if the concentration is at least 8 ⁇ g per ml.
• the patient's serum concentration of the anti-a4p7 antibody may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• the patient's serum concentration of the anti-a4p7 antibody may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 ⁇ per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• the invention relates to a method for maintaining remission of inflammatory bowel disease (IBD) in a patient, wherein the patient had received at least one dose of vedolizumab in the previous two months, the method comprising: obtaining a serum sample from the patient; measuring the concentration of IBD.
• IBD inflammatory bowel disease
• the patient's serum concentration of vedolizumab may be at least 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml.
• the patient's serum concentration of vedolizumab may be selected from the group consisting of 12-25 ⁇ g per ml, 15-17 ⁇ g per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• evaluation of a patient early in treatment with an anti-a4 7 antibody indicates that the patient is in deep remission.
• the invention relates to a method for treating a patient having
• IBD inflammatory bowel disease
• vedolizumab comprising: providing two doses of vedolizumab, wherein the second dose is about two weeks after the first; waiting about four weeks; and continuing to treat the patient with vedolizumab if the patient is in deep remission, wherein determining deep remission comprises measuring an endoscopic subscore for the patient.
• the patient can be determined to be in deep remission and continue to receive the anti-a4p7 antibody, e.g., vedolizumab, if the endoscopic subscore is 0 to 1.
• the method can further comprise determining a patient-reported outcome score, wherein a determination of deep remission comprises 0 to 1 for both the endoscopic subscore and the patient reported outcome score.
• the patient reported outcome score can comprise a rectal bleeding subscore.
• the patient reported outcome score can comprise a stool frequency subscore.
• the method can further comprise measuring the fecal calprotectin concentration. Treatment with an anti-a4p7 antibody, e.g., vedolizumab, can be continued with a fecal calprotectin concentration of less than 1500 ⁇ g/g.
• the fecal calprotectin concentration can be less than 1250 ⁇ g/g, less than 1000 g/g, less than 750 ⁇ g/g, less than 500 ⁇ g/g, less than 400 ⁇ g/g ) less than 300 ⁇ g/g, less than 250 ⁇ , between 200-1200 ⁇ , between 350 to 800 ⁇ , between 300-1000 ⁇ , ⁇ 50 ⁇ , ⁇ 100 ⁇ , ⁇ 150 ⁇ , ⁇ 200 ⁇ , ⁇ 250-499 ⁇ , or between 500 to 900 ⁇ .
• treatment with the anti-a4p7 antibody can be continued if the fecal calprotectin is reduced to less than 50% of the baseline or concentration before treatment.
• the fecal calprotectin can be reduced to less than 45%, less than 40%, less than 35%, less than 30%, less than 25%, less than 20%, between 10-55%, between 10-30%, between 15-35%, between 15-45%), or between 20-40% of the baseline or concentration before treatment.
• a vedolizumab-treated patient is in deep remission and can continue to be administered vedolizumab if the vedolizumab trough serum
• concentration is at least 25 ⁇ g/ml, at least 27 ⁇ g/ml, at least 30 ⁇ g/ml, at least 32 ⁇ g/ml or at least 34 ⁇ g/m ⁇ .
• the invention relates to a method for identifying a patient for continued treatment with an anti-a4p7 antibody, the method comprising the steps of: measuring the clearance of the anti-a4 7 antibody in a biological sample obtained from a patient suffering from inflammatory bowel disease (IBD) and who was administered at least two doses of the anti-a4p7 antibody within the previous four months; and identifying the patient for continued treatment with the anti-oc4p7 antibody if the clearance in the patient is less than 0.25 L/day.
• IBD inflammatory bowel disease
• the patient was administered at least one dose of the anti-cc4p7 antibody within the previous two months, the patient was administered at least two doses of the anti-oc4p7 antibody within the previous three months or the previous two months, or, the patient was administered at least one dose of the anti-a4 7 antibody within the previous two months or within the previous month.
• the clearance may be less than 0.20 L/day or between 0.1 and 0.2 L/day.
• the invention relates to a method for identifying a patient for continued treatment with vedolizumab, the method comprising the steps of: measuring the clearance of vedolizumab in a biological sample obtained from a patient suffering from inflammatory bowel disease (IBD) and who was administered at least two doses of vedolizumab within the previous four months; and identifying the patient for continued treatment with vedolizumab if the clearance in the patient is less than 0.25 L/day.
• the clearance may be less than 0.20 L/day or between 0.1 and 0.2 L/day.
• the patient was administered at least two doses of vedolizumab within the previous three months or the previous two months.
• the invention relates to a method for identifying a patient for continued treatment with vedolizumab, the method comprising the steps of:
• the clearance may be less than 0.20 L/day or between 0.1 and 0.2 L/day.
• the patient was administered at least one dose of vedolizumab within the previous month.
• the patient was administered at least two doses of vedolizumab within the previous month.
• the invention further relates to assays for use in measuring the factors described herein for identifying a patient who will respond to treatment with an anti-ct4p7 antibody, such as vedolizumab.
• the assay is a pharmacokinetic assay for circulating anti-a4p7 antibody.
• the assay may measure high or sustained positive levels of anti-a4p7 antibody, such as at least 8, 10, 12, 14, 17, 20, 25, 30, 35, or 40 ⁇ g per ml in a serum sample from a patient, e.g., for predicting the ability to respond or maintain a response or remission of the IBD afflicting the patient.
• the serum concentration of the anti-cc4p7 antibody may be measured by a sandwich ELISA assay.
• the serum concentration of the anti-oc4p7 antibody may be measured in an antibody bridging assay.
• the assay for use in measuring the factors described herein for identifying a patient who will respond to treatment with an anti- 4p7 antibody, such as vedolizumab is a pharmacodynamic assay for ⁇ 4 ⁇ 7 integrin, e.g., on circulating lymphocytes.
• low or minimum levels of free ⁇ 4 ⁇ 7 integrin such as less than 10%, less than 7%, less than 5% or less than 3% free ⁇ 4 ⁇ 7 integrin, may predict the effectiveness of the anti-c ⁇ 7 antibody.
• the free ⁇ 4 ⁇ 7 integrin may be measured by the amount of MAdCAM binding to the ⁇ 4 ⁇ 7 integrin.
• the free ⁇ 4 ⁇ 7 integrin may be measured by the amount of 3 ⁇ - ⁇ 4 ⁇ 7 antibody binding to the ⁇ 4 ⁇ 7 integrin.
• the assay measures immune response to the 3 ⁇ - ⁇ 4 ⁇ 7 antibody.
• a low or absent immune response to 3 ⁇ - ⁇ 4 ⁇ 7 antibody may predict the ability to respond or maintain a response or remission of the IBD afflicting the patient.
• the method may further comprise measuring the fecal calprotectin concentration.
• Treatment with the anti-o ⁇ 7 antibody, such as vedolizumab may be continued with a fecal calprotectin concentration of less than 1500 ⁇ g/g.
• the fecal calprotectin concentration may be less than 1250 ⁇ g/g, less than 1000 g/g, less than 750 ⁇ g/g, less than 500 ⁇ g/g, less than 400 ⁇ g/g, less than 300 ⁇ g/g, less than 250 ⁇ g/g, between 200- 1200 ⁇ g/g, between 350 to 800 ⁇ g/g between 300-1000 ⁇ , ⁇ 50 ⁇ , ⁇ 100 ⁇ , ⁇ 150 ⁇ , ⁇ 200 ⁇ g/g, ⁇ 250-499 ⁇ , or between 500 to 900 ⁇ , in a sample from a patient who is likely to respond to the anti-a4p7 antibody, such as vedolizumab.
• treatment with the 3 ⁇ - 4 ⁇ 7 antibody, such as vedolizumab can be continued if the fecal calprotectin is reduced to less than 50% of the baseline or concentration before treatment.
• the fecal calprotectin can be reduced to less than 45%, less than 40%, less than 35%, less than 30%, less than 25%, less than 20%, between 10-55%, between 10-30%, between 15-35%, between 15-45%, or between 20-40% of the baseline or concentration before treatment.
• a method for treating a human patient having inflammatory bowel disease comprises: selecting a human patient having IBD and having a serum concentration of vedolizumab which is at least 8 ⁇ g per ml at a time point that is four weeks after a second dose of vedolizumab, wherein a first dose of vedolizumab was administered to the subject two weeks prior to the second dose of vedolizumab; and administering vedolizumab to the human patient having IBD, thereby treating the human patient having IBD.
• the first dose of vedolizumab comprises 300 mg.
• the second dose of vedolizumab comprises 300 mg.
• the patient received the first and the second dose intravenously.
• the patient had an inadequate response with, lost response to, or was intolerant to a TNF blocker.
• One embodiment provided herein is an in vitro method for determining the responsiveness of a human patient having Inflammatory Bowel Disease (IBD) to treatment with vedolizumab, the method comprising measuring the concentration of vedolizumab in a blood sample from the patient by contacting the blood sample with an anti-vedolizumab antibody, wherein the sample is obtained about four weeks following administration of a second dose of vedolizumab, wherein a first dose of vedolizumab was administered to the subject two weeks prior to the second dose of vedolizumab, and wherein a vedolizumab concentration of at least 8 ⁇ g per ml in the blood sample indicates that the patient is responsive to treatment with vedolizumab, and a concentration of less than 8 ⁇ g per ml in the blood sample indicates that the patient is not responsive to treatment with vedolizumab.
• IBD Inflammatory Bowel Disease
• the method further comprises administering vedolizumab to the patient.
• the first dose of vedolizumab comprises 300 mg.
• the second dose of vedolizumab comprises 300 mg.
• the patient received the first and the second dose intravenously.
• the patient had an inadequate response with, lost response to, or was intolerant to a TNF blocker.
• FIG. 1 shows the median (interquartile range) of observed vedolizumab trough serum concentration versus nominal sampling time in patients with UC (GEMINI 1 ) and patients with CD (GEMINI 2) during maintenance treatment with vedolizumab 300 mg Q4W or Q8W or placebo. All patients (including those in the placebo group) received 2 doses of vedolizumab 300 mg during induction (at weeks 0 and 2).
• FIG. 2 is a diagramatic representation of the population pharmacokinetic model of vedolizumab. Cone, concentration; K m , Michaelis-Menton constant; V max , maximum rate.
• FIG. 3 shows distribution of individual vedolizumab linear clearance (CLL) estimates from the final population pharmacokinetic model in patients with UC and patients with CD.
• CLL linear clearance
• FIG. 4 is a goodness-of-fit plot: observed vedolizumab concentration versus predicted vedolizumab concentration from the final population pharmacokinetic model. Values are indicated by closed circles with a dashed black loss trend line through the data. The line of identity (solid white) is included as reference.
• FIG. 5 shows the effect of covariates on vedolizumab linear clearance (CLL).
• CLL vedolizumab linear clearance
• Each point and line represents the median and 95% credible interval (CDI), respectively, of the Bayesian posterior distribution of normalized samples of vedolizumab CLL adjusted for the covariate.
• the reference individual weighs 70 kg, is 40 years old, has an albumin level of 4 g/dL, fecal calprotectin level of 700 mg/kg, CDAI score of 300 (for patient with CD), partial Mayo score of 6 (for patient with UC), ADA negative, and no concomitant therapy use, and is TNF- antagonist therapy naive.
• Albumin 2.7, 3.2, 3.7, 4.0, 4.2, and 4.7 g/dL represent the 6th, 18th, 50th, 70th, 85th, and 98.5th percentiles, respectively, of baseline albumin levels for patients in GEMINI 1, 2, and 3.
• the vertical black line is drawn at the reference point estimate, and the shaded region is ⁇ 25% of the reference point estimate chosen to represent an uncertainty range of clinical unimportance.
• FIG. 6 shows individual vedolizumab linear clearance (CLL) estimates at the end of induction (week 6) by Mayo clinic endoscopic subscore for patients with UC
• FIG. 7 is a receptor ( ⁇ 4 ⁇ 7 ) saturation plot: observed MAdCAM-1 versus observed vedolizumab concentration in patients with UC (GEMINI 1 ) and patients with CD (GEMINI 2). Baseline data are excluded.
• FIG. 8 shows observed MAdCAM-1 versus time for patients with UC (GEMINI 1) and patients with CD (GEMINI 2).
• FIG. 9 is a goodness-of-fit plot for the vedolizumab final population pharmacokinetic model: CWRESI and residual versus time and population predicted vedolizumab concentration.
• FIG. 10 shows a predictive check for the vedolizumab final population
• FIG. 1 1 shows a predictive check for the vedolizumab final population
• FIG. 12 is a predictive check for the vedolizumab final population pharmacokinetic model: maintenance therapy-every 8 weeks.
• FIG. 13 is a goodness-of-fit model for MAdCAM-1.
• FIG. 14 is Percent of Baseline Calprotectin at Week 6 by Treatment or Response Status.
• FIGS. 15A-15D show clinical, and FIGS. 15E and 15F show HRQoL, outcomes at week 52 in patients in or not in deep remission (definition 1) at week 6.
• FIGS. 16A- 16D show clinical, and FIGS. 16 E and 16F show HRQoL, outcomes at week 52 in patients in or not in deep remission (definition 2) at week 6.
• the invention relates to methods for treating with an anti- 4p7 antibody, e.g., vedolizumab, a patient having inflammatory bowel disease (IBD), methods for identifying a patient for continued treatment with the antibody, such as vedolizumab, and methods for maintaining remission of IBD in a patient.
• an anti- 4p7 antibody e.g., vedolizumab
• IBD inflammatory bowel disease
• Vedolizumab a humanized monoclonal antibody that binds specifically to the ⁇ 4 ⁇ 7 integrin, is indicated for the treatment of patients with moderately to severely active ulcerative colitis (UC) and Crohn's disease (CD).
• Vedolizumab has a novel gut- selective mechanism of action that differs from that of other currently marketed biologic agents for the treatment for inflammatory bowel disease (IBD), including natalizumab and tumor necrosis factor-a (TNF-a) antagonists.
• IBD inflammatory bowel disease
• TNF-a tumor necrosis factor-a
• MAdCAM-1 expressed on endothelial cells. Consequently, migration of these cells into inflamed intestinal tissue is inhibited.
• vedolizumab serum concentrations fell in a generally biexponential fashion until concentrations reached approximately 1 to 10 ng/mL. Thereafter, concentrations appeared to fall in a nonlinear fashion.
• IV infusions 0.5 and 2 mg/kg in patients with CD and infusion of 2, 6, and 10 mg/kg in patients with UC.
• Vedolizumab pharmacokinetics was generally linear following an IV infusion over the dose range of 2 to 10 mg/kg in patients with UC. After multiple-dose
• vedolizumab induction and maintenance therapy were demonstrated in patients with UC in the GEMINI 1 trial (ClinicalTrials.gov number, NCT00783718) and in patients with CD in the GEMINI 2 (ClinicalTrials.gov number, NCT00783692) and GEMINI 3 (ClinicalTrials.gov number, NCT01224171) trials.
• the exposure-response (efficacy) relationships of vedolizumab in patients with UC and CD for induction and maintenance therapy have been presented elsewhere.
• the "trough" serum concentration of an antibody refers to the concentration just before the next dose.
• "Clinical remission” or “remission” as used herein with reference to ulcerative colitis subjects refers to a complete Mayo score of less than or equal to 2 points and no individual subscore greater than 1 point.
• Crohn's disease “clinical remission” refers to a Crohn's Disease Activity Index (CDAI) score of 150 points or less.
• CDAI Crohn's Disease Activity Index
• HBI Hard-Bradshaw Index
• MREn Magnetic resonance enterography
• Endoscopic remission refers to a condition with a low endoscopic score.
• An example of a method to assess the endoscopic score in ulcerative colitis is flexible sigmoidoscopy.
• the endoscopic score in ulcerative colitis can be the Mayo subscore.
• An example of a method to assess the endoscopic score in Crohn's disease is ileocolonoscopy.
• the endoscopic score in Crohn's disease can be the simple endoscopic score for Crohn's Disease (SES-CD).
• the SES-CD can include measures such as the size of ulcers, the amount of ulcerated surface, the amount of affected surface and whether and to what extent the alimentary canal is narrowed.
• a “clinical response” as used herein with reference to ulcerative colitis subjects refers to a reduction in complete Mayo score of 3 or greater points and 30% from baseline, (or a partial Mayo score of 2 or greater points and 25% or greater from baseline, if the complete Mayo score was not performed at the visit) with an accompanying decrease in rectal bleeding subscore of 1 or greater points (>1) or absolute rectal bleeding score of 1 or less point ( ⁇ 1).
• a “clinical response” as used herein with reference to Crohn's disease subjects refers to a 70 point or greater decrease in CDAI score from baseline (week 0).
• the terms “clinical response” and “response” e.g., alone without any adjective, are used interchangeably herein.
• Endoscopic response refers to a percentage decrease in an endoscopic score from baseline (e.g., at screening or just prior to initial dose). In Crohn's disease, endoscopic response can be assessed by a simple endoscopic score for Crohn's Disease (SES-CD).
• Baseline as used herein describes a value of a parameter which is measured prior to the initial dose of a treatment. It can refer to a measurement of a sample obtained the same day, the day before, during the week before initial treatment, i.e., at a time period before the first dose when little change is expected until after the first dose and values of the measurement obtained after the first dose can be compared to this baseline value to represent the change caused by the dose.
• Mucosal healing refers to a Mayo endoscopic subscore of less than or equal to 1.
• fristula healing results in closure or elimination of fistulae.
• mucosal healing refers to an improvement in the amount or severity of wounding in mucosae, e.g., the digestive tract.
• mucosal healing can refer to a decrease in the amount, size or severity of one or more than one ulcer in the digestive tract.
• mucosal healing refers to a decrease in one or more parameters selected from the group consisting of wall thickness, enhanced bowel wall contrast, mural edema, ulceration and perienteric vascularity.
• Such mucosal healing can be expressed as an SES-CD score, or a Magnetic Resonance Index of Activity (MaRIA) score.
• Complete mucosal healing in Crohn's disease includes absence of ulceration.
• the "MaRIA score” is the sum of the scores, e.g., as measured by magnetic resonance enterography, of various mucosal healing parameters for each segment of colon and the terminal ileum (e.g., ileum, ascending colon, transverse colon, descending colon, sigmoid, and rectum).
• Corticosteroid (CS)-free remission refers to patients using oral corticosteroids at baseline who have discontinued corticosteroid use and are in clinical remission at week 52.
• EQ-5D European Quality of Life-5 Dimension
• VAS visual analogue scale
• a composite EQ-5D score can be calculated from the individual scores to assess overall HRQOL.
• the EQ-5D Visual Analog Scale (VAS) score is a self-assigned rating of overall health using a 20cm visual, vertical scale, with a score of 0 as the worst and 100 as best possible health.
• the EQ-5D and EQ-5D VAS have been shown in many studies to be valid and reliable instruments for measuring HRQOL in patients with GI diseases.
• a decrease of > 0.3 points in the EQ-5D score represents a clinically meaningful improvement in HRQOL for patients.
• An increase of greater than or equal to 7 points in the EQ-5D VAS score represents a clinically meaningful improvement in HRQOL for patients.
• the "Inflammatory Bowel Disease Questionnaire” (IBDQ) questionnaire” (Irvine Journal of Pediatric Gastroenterology & Nutrition 28:S23-27 (1999)) is used to assess quality of life in adult patients with inflammatory bowel disease, ulcerative colitis, or Crohn's Disease and includes 32 questions on four areas of HRQOL: Bowel Systems (10 questions), Emotional Function (12 questions), Social Function (5 questions), and Systemic Function (5 questions). Patients are asked to recall symptoms and quality of life from the last 2 weeks and rate each item on a 7-point Likert scale (higher scores equate to higher quality of life). A total IBDQ score is calculated by summing the scores from each domain; the total IBDQ score ranges from 32 to 224. An IBDQ total score greater than 170 is characteristic of the health related quality of life (HRQoL) of patients in remission.
• HRQoL health related quality of life
• induction therapy is an initial stage of therapy, wherein a patient is administered a relatively intensive dosing regimen of a therapeutic agent.
• the therapeutic agent e.g., antibody
• the therapeutic agent is administered in a way that quickly provides an effective amount of the agent suitable for certain purposes, such as inducing immune tolerance to the agent or for inducing a clinical response and ameliorating disease symptoms (see WO 2012/151247 and WO 2012/151248, incorporated herein by reference).
• maintenance therapy is after induction therapy and is administered in a way that continues the response achieved by induction therapy with a stable level of therapeutic agent, e.g., antibody.
• a maintenance regimen can prevent return of symptoms or relapse of disease, e.g., IBD (see WO 2012/151247 and WO
• a maintenance regimen can provide convenience to the patient, e.g., be a simple dosing regimen or require infrequent trips for treatment.
• ⁇ 4 ⁇ 7 integrin is a heterodimer of an cc chain (CD49D, ITGA4) and a ⁇ 7 chain (ITGB7). Each chain can form a heterodimer with an alternative integrin chain, to form ⁇ 4 ⁇ or ⁇ 7 .
• Human oc and ⁇ 7 genes (GenBank (National Center for Biotechnology Information, Bethesda, MD) RefSeq Accession numbers NM 000885 and NM_000889, respectively) are expressed by B and T lymphocytes, particularly memory CD4+ lymphocytes. Typical of many integrins, ⁇ 4 ⁇ 7 can exist in either a resting or activated state.
• Ligands for ⁇ 4 ⁇ 7 include vascular cell adhesion molecule (VCAM), fibronectin and mucosal addressin (MAdCAM (e.g., MAdCAM- 1)).
• VCAM vascular cell adhesion molecule
• MAdCAM mucosal addressin
• the ⁇ 4 ⁇ 7 integrin mediates lymphocyte trafficking to GI mucosa and gut-associated lymphoid tissue (GALT) through adhesive interaction with mucosal addressin cell adhesion molecule- 1 (MAdCAM- 1), which is expressed on the endothelium of mesenteric lymph nodes and GI mucosa.
• MAdCAM- 1 mucosal addressin cell adhesion molecule- 1
• antibody herein is used in the broadest sense and specifically covers full length monoclonal antibodies, immunoglobulins, polyclonal antibodies, multispecific antibodies (e.g.
• bispecific antibodies formed from at least two full length antibodies, e.g., each to a different antigen or epitope, and individual antigen binding fragments, including dAbs, scFv, Fab, F(ab)' 2 , Fab', including human, humanized and antibodies from non-human species and recombinant antigen binding forms such as monobodies and diabodies.
• the term "monoclonal antibody” as used herein refers to an antibody obtained from a population of substantially homogeneous antibodies, i.e., the individual antibodies comprising the population are identical and/or bind the same epitope, except for possible variants that may arise during production of the monoclonal antibody, such variants generally being present in minor amounts.
• each monoclonal antibody is directed against a single determinant on the antigen.
• the modifier "monoclonal” indicates the character of the antibody as being obtained from a substantially homogeneous population of antibodies, and is not to be construed as requiring production of the antibody by any particular method.
• the monoclonal antibodies to be used in accordance with the present invention may be made by the hybridoma method first described by Kohler et al, Nature, 256:495 (1975), or may be made by recombinant DNA methods (see, e.g., U.S. Pat. No. 4,816,567).
• the "monoclonal antibodies” may also be isolated from phage antibody libraries using the techniques described in Clackson et al., Nature, 352:624-628 (1991) and Marks et al, J. Mol Biol, 222:581-597 (1991), for example.
• Antigen binding fragments of an antibody comprise at least the variable regions of the heavy and/or light chains of an anti-a4 7 antibody.
• an antigen binding fragment of vedolizumab comprises amino acid residues 20-131 of the humanized light chain sequence of SEQ ID NO:2.
• antigen binding fragments include Fab fragments, Fab' fragments, scFv and F(ab') 2 fragments of a humanized antibody known in the art.
• Antigen binding fragments of the humanized antibody of the invention can be produced by enzymatic cleavage or by recombinant techniques. For instance, papain or pepsin cleavage can be used to generate Fab or F(ab') 2 fragments, respectively.
• Antibodies can also be produced in a variety of truncated forms using antibody genes in which one or more stop codons have been introduced upstream of the natural stop site.
• a recombinant construct encoding the heavy chain of an F(ab') 2 fragment can be designed to include DNA sequences encoding the CHi domain and hinge region of the heavy chain.
• antigen binding fragments inhibit binding of ⁇ 4 ⁇ 7 integrin to one or more of its ligands (e.g. the mucosal addressin MAdCAM (e.g.,MAdCAM-l), fibronectin).
• Fc receptor or “FcR” are used to describe a receptor that binds to the Fc region of an antibody.
• the FcR is a native sequence human FcR.
• the FcR is one which binds an IgG antibody (a gamma receptor) and includes receptors of the FcyRI, FcyRII, and FcyRIII subclasses, including allelic variants and alternatively spliced forms of these receptors.
• FcyRII receptors include FcyRIIA (an “activating receptor") and FcyRJIB (an “inhibiting receptor”), which have similar amino acid sequences that differ primarily in the cytoplasmic domains thereof.
• Activating receptor FcyRIIA contains an immunoreceptor tyrosine-based activation motif (ITAM) in its cytoplasmic domain.
• Inhibiting receptor FcyRIIB contains an immunoreceptor tyrosine-based inhibition motif (ITIM) in its cytoplasmic domain.
• ITAM immunoreceptor tyrosine-based activation motif
• ITIM immunoreceptor tyrosine-based inhibition motif
• FcR FcR
• the term also includes the neonatal receptor, FcRn, which is responsible for the transfer of maternal IgGs to the fetus (Guyer et al., J. Immunol. 717:587 (1976) and Kim et al, J. Immunol. 24:249 (1994)) and for regulating the persistence of immunoglobulin G (IgG) and albumin in the serum (reviewed by Rath et al, J. Clin. Immunol 33 Suppl 1 :S9-17 (2013)).
• hypervariable region when used herein refers to the amino acid residues of an antibody which are responsible for antigen binding and are found in the
• the hypervariable region generally comprises amino acid residues from a "complementarity determining region” or "CDR” (e.g. residues 24-34 (LI), 50-56 (L2) and 89-97 (L3) in the light chain variable domain and 31 -35 (HI), 50-65 (H2) and 95-102 (H3) in the heavy chain variable domain; Kabat et al, Sequences of Proteins of Immunological Interest, 5th Ed. Public Health Service, National Institutes of Health, Bethesda, Md. (1991)) and/or those residues from a "hypervariable loop" (e.g.
• “Framework Region” or "FR” residues are those variable domain residues other than the hypervariable region residues as herein defined.
• the hypervariable region or the CDRs thereof can be transferred from one antibody chain to another or to another protein to confer antigen binding specificity to the resulting (composite) antibody or binding protein.
• an “isolated” antibody is one which has been identified and separated and/or recovered from a component of its natural environment.
• the antibody will be purified (1) to greater than 95% by weight of protein as determined by the Lowry method, and alternatively, more than 99% by weight, (2) to a degree sufficient to obtain at least 15 residues of N-terminal or internal amino acid sequence by use of a spinning cup sequenator, or (3) to homogeneity by SDS-PAGE under reducing or nonreducing conditions using Coomassie blue or silver stain.
• Isolated antibody includes the antibody in situ within recombinant cells since at least one component of the antibody's natural environment will not be present. Ordinarily, however, isolated antibody will be prepared by at least one purification step.
• Treatment refers to both therapeutic treatment and prophylactic or preventative measures. Those in need of treatment include those already with the disease as well as those in which the disease or its recurrence is to be prevented. Hence, the patient to be treated herein may have been diagnosed as having the disease or may be predisposed or susceptible to the disease. The terms “patient” and “subject” are used interchangeably herein. Treatment of IBP with anti-a4p7 antibodies
• the invention relates to a method of treating IBD in a subject comprising administering to the subject an anti-a4p7 antibody described herein in an amount effective to treat IBD, e.g., in humans.
• the human patient or subject may be an adult (e.g., 18 years or older), an adolescent, or a child.
• a pharmaceutical composition comprising an anti-a4p7 antibody can be used as described herein for treating IBD in a subject suffering therefrom.
• the anti-a4p7 antibody can bind to an epitope on the a4 chain (e.g., humanized MAb 21.6 (Bendig et al., U.S. Pat. No. 5,840,299), on the ⁇ 7 chain (e.g., FIB504 or a humanized derivative (e.g., Fong et al., U.S. Pat. No. 7,528,236)), or to a
• the antibody binds a combinatorial epitope on the ⁇ 4 ⁇ 7 complex, but does not bind an epitope on the a4 chain or the ⁇ 7 chain unless the chains are in association with each other.
• association of a4 integrin with ⁇ 7 integrin can create a combinatorial epitope for example, by bringing into proximity residues present on both chains which together comprise the epitope or by conformationally exposing on one chain, e.g., the a4 integrin chain or the ⁇ 7 integrin chain, an epitopic binding site that is inaccessible to antibody binding in the absence of the proper integrin partner or in the absence of integrin activation.
• the anti-a4p7 antibody binds both the oc4 integrin chain and the ⁇ 7 integrin chain, and thus, is specific for the ⁇ 4 ⁇ 7 integrin complex.
• Such antibodies can bind ⁇ 4 ⁇ 7 but not bind ⁇ 4 ⁇ 1 , and/or not bind ⁇ 7, for example.
• the 3 ⁇ - ⁇ 4 ⁇ 7 antibody binds to the same or substantially the same epitope as the Act-1 antibody (Lazarovits, A. I. et al, J.
• Murine ACT-1 Hybridoma cell line which produces the murine Act-1 monoclonal antibody, was deposited under the provisions of the Budapest Treaty on Aug. 22, 2001 , on behalf of Millennium Pharmaceuticals, Inc., 40 Landsdowne Street, Cambridge, Mass. 02139, U.S.A., at the American Type Culture Collection, 10801 University Boulevard, Manassas, Va. 201 10-2209, U.S.A., under Accession No. PTA-3663.
• the anti-c ⁇ 7 antibody is a human antibody or an ⁇ 4 ⁇ 7 binding protein using the CDRs provided in U.S. Patent Application Publication No.
• the anti-c ⁇ 7 antibody inhibits binding of ⁇ 4 ⁇ 7 to one or more of its ligands (e.g. the mucosal addressin, e.g., MAdCAM (e.g., MAdCAM-1), fibronectin, and/or vascular addressin (VCAM)).
• MAdCAM mucosal addressin
• VCAM vascular addressin
• Primate MAdCAMs are described in the PCT publication WO 96/24673, the entire teachings of which are incorporated herein by this reference.
• the anti-c ⁇ 7 antibody inhibits binding of ⁇ 4 ⁇ 7 to MAdCAM (e.g., MAdCAM- 1) and/or fibronectin without inhibiting the binding of VCAM.
• the 3 ⁇ - ⁇ 4 ⁇ 7 antibodies for use in the treatments are humanized versions of the mouse Act-1 antibody. Suitable methods for preparing humanized antibodies are well-known in the art.
• the humanized anti-a4p7 antibody will contain a heavy chain that contains the 3 heavy chain complementarity determining regions (CDRs, CDR1, SEQ ID NO:4, CDR2, SEQ ID NO:5 and CDR3, SEQ ID NO:6) of the mouse Act-1 antibody and suitable human heavy chain framework regions; and also contain a light chain that contains the 3 light chain CDRs (CDR1 , SEQ ID NO:7, CDR2, SEQ ID NO:8 and CDR3, SEQ ID NO:9) of the mouse Act-1 antibody and suitable human light chain framework regions.
• CDRs 3 heavy chain complementarity determining regions
• the humanized Act-1 antibody can contain any suitable human framework regions, including consensus framework regions, with or without amino acid substitutions.
• one or more of the framework amino acids can be replaced with another amino acid, such as the amino acid at the corresponding position in the mouse Act-1 antibody.
• the human constant region or portion thereof can be derived from the or ⁇ light chains, and/or the ⁇ (e.g., ⁇ , ⁇ 2, ⁇ 3, ⁇ 4), ⁇ , ⁇ (e.g., ⁇ , ⁇ 2), ⁇ or ⁇ heavy chains of human antibodies, including allelic variants.
• a particular constant region (e.g., IgGl), variant or portions thereof can be selected in order to tailor effector function.
• a mutated constant region (variant) can be
• the anti-a4p7 antibody is vedolizumab.
• Vedolizumab also called
• MLN0002, ENTYVIOTM or KYNTELESTM is a humanized immunoglobulin (Ig) Gl mAb directed against the human lymphocyte integrin ⁇ 4 ⁇ 7.
• Vedolizumab binds the ⁇ 4 ⁇ 7 integrin, antagonizes its adherence to MAdCAM-1 and as such, impairs the migration of gut homing leukocytes into GI mucosa.
• Vedolizumab is an integrin receptor antagonist indicated for adult patients with moderately to severely active UC or CD who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids.
• TNF tumor necrosis factor
• vedolizumab is for inducing and maintaining clinical response, inducing and maintaining clinical remission, improving endoscopic appearance of the mucosa, and/or achieving corticosteroid-free remission.
• vedolizumab is for achieving clinical response, achieving clinical remission, and/or achieving corticosteroid-free remission.
• the humanized anti-a4p7 antibody for use in the treatment comprises a heavy chain variable region comprising amino acids 20 to 140 of SEQ ID NO: 1 , and a light chain variable region comprising amino acids 20 to 131 of SEQ ID NO:2 or amino acids 21 to 132 of SEQ ID NO:3.
• a suitable human constant region(s) can be present.
• the humanized anti-a4p7 antibody can comprise a heavy chain that comprises amino acids 20 to 470 of SEQ ID NO: 1 and a light chain comprising amino acids 21 to 239 of SEQ ID NO:3.
• the humanized anti-a4p7 antibody can comprise a heavy chain that comprises amino acids 20 to 470 of SEQ ID NO: l and a light chain comprising amino acids 20 to 238 of SEQ ID NO:2.
• the humanized light chain of vedolizumab e.g., Chemical Abstract Service (CAS, American Chemical Society) Registry number 943609-66-3
• CAS American Chemical Society
• LDP-02 has the somewhat hydrophobic, flexible alanine 1 14 and a hydrophilic site (Aspartate 1 15) that is replaced in vedolizumab with the slightly hydrophilic hydroxyl-containing threonine 1 14 and hydrophobic, potentially inward facing valine 1 15 residue.
• substitutions to the humanized anti-cx4p7 antibody sequence can be, for example, mutations to the heavy and light chain framework regions, such as a mutation of isoleucine to valine on residue 2 of SEQ ID NO: 10; a mutation of methionine to valine on residue 4 of SEQ ID NO: 10; a mutation of alanine to glycine on residue 24 of SEQ ID NO: 1 1 ; a mutation of arginine to lysine at residue 38 of SEQ ID NO: 1 1 ; a mutation of alanine to arginine at residue 40 of SEQ ID NO: 1 1 ; a mutation of methionine to isoleucine on residue 48 of SEQ ID NO: l 1 ; a mutation of isoleucine to leucine on residue 69 of SEQ ID NO: 1 1 ; a mutation of arginine to valine on residue 71 of SEQ ID NO: 1 1 ; a mutation of threonine to isoleucine on residue
• the present invention provides, in a first aspect, a method for treating a patient having inflammatory bowel disease (IBD) with an anti-a4p7 antibody, e.g., vedolizumab.
• the method comprises determining pharmacokinetic factors of the patient.
• the method comprises selecting for treatment a patient who has low clearance of the antibody.
• the method comprises measuring the concentration of the anti-a4p7 antibody in a biological sample from the patient, e.g., blood, serum, plasma, stool, bowel fluid, saliva, inflammatory exudate, at a time, e.g., at least one, two, three, four, five or six weeks, after receiving at least one prior dose of the antibody.
• the measurement provides an indication of clearance, for which "low” is defined by the various methods, and results criteria thereof described herein, of obtaining a clearance indication.
• An indication of clearance may result from the measurement of the concentration of anti-a4p7 antibody in the sample, which may be used alone or used in a calculation, as described herein, of the rate the anti-a4p7 antibody is eliminated from the body, e.g., the blood volume.
• the calculation may be based on knowledge of the amount of anti-a4p7 antibody in the prior dose, the size of the patient or blood volume, the number of days between the day of the prior dose of the anti-a4p7 antibody and the day of obtaining the sample for measurement or from a pharmacokinetics model, e.g., a model as described herein.
• measurement of serum concentration of anti-a4p7 antibody may be an indicator of clearance. Clearance may be affected or further illustrated by other parameters, such as pharmacodynamic factors, clinical factors, inflammation or immune response factors, whose measurement may be used in combination with the measurement of anti-a4p7 antibody.
• An indication of clearance alone or in combination with measurements of one or more other parameters, may be used to predict response to anti-a4p7 antibody treatment, identify a patient who is responding to anti-a4p7 antibody treatment, select a patient for further treatment with anti-a4p7 antibody or monitor the effectiveness of the anti-a4p7 antibody during treatment.
• a method wherein low clearance is indicated, measured or calculated at end of induction comprises further treatment of the patient for maintenance of response or remission, achieving corticosteroid-free remission, improving endoscopic appearance of the mucosa.
• a patient who has low clearance of the antibody may be characterized, a) by a rate of antibody, e.g,.
• vedolizumab clearance that is less than about 0.25 L/day, less than 0.20 L/day, between 0.1 to 0.2 L/day, less than 0.15 L/day or less than 0.1. L/day; and/or b) by a serum concentration of antibody, e.g., vedolizumab, that is at least 8 ⁇ g per ml, 10 ⁇ g per ml, 12 ⁇ g per ml, 14 ⁇ per ml, 17 ⁇ g per ml, 20 ⁇ g per ml, 25 ⁇ g per ml, 30 ⁇ g per ml,' 35 ⁇ g per ml, or 40 ⁇ g per ml or has a range of 12-25 ⁇ g per ml, 15-17 ⁇ g per ml, 17-25 ⁇ g per ml, 12-40 ⁇ g per ml, and 17-40 ⁇ g ml.
• the method for treating a patient having inflammatory bowel disease (IBD) with an anti-a4p7 antibody, e.g., vedolizumab comprises the steps of selecting a human patient having IBD from a group of two or more patients having or suffering from IBD that has, at a time point of four weeks after receiving a second dose of vedolizumab, where the first dose of vedolizumab was administered to the subject two weeks prior to the second dose, a serum concentration of at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 ⁇ g per ml.
• IBD inflammatory bowel disease
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 ⁇ g per ml.
• the patient's serum concentration e.g., a trough serum concentration, may be greater than 17 ⁇ g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• the patient received the prior dose of vedolizumab about two weeks, about three weeks, about four weeks, about five weeks or about six weeks prior to the sampling for serum vedolizumab measurement. Once such a patient is selected from a group of patients, he or she is administered vedolizumab to treat the IBD.
• the present invention provides a method for treating a patient having inflammatory bowel disease (IBD) with an anti-a4p7 antibody, e.g., vedolizumab.
• the method using vedolizumab comprises the steps of administering two doses of vedolizumab to a patient suffering from IBD, wherein the second dose is administered about two weeks after the first dose is administered to the patient; waiting a period of time of at least two weeks, at least three weeks, about four weeks or five weeks; measuring the patient's serum concentration of vedolizumab; and administering one or more further doses of vedolizumab to the patient if the patient's serum concentration is at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 ⁇ g per ml.
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 g per ml.
• the patient's serum concentration e.g., a trough serum concentration, may be greater than 17 ⁇ g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• At least one dose of the anti-a4 7 antibody may be administered to a patient suffering from IBD, waiting at least about two weeks, or optionally, a period of two to five weeks, and then measuring the patient's serum concentration of vedolizumab and administering one or more further doses of vedolizumab to the patient if the patient's serum concentration is at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 ⁇ g per ml.
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 ⁇ g per ml.
• the patient's serum concentration, e.g., a trough serum concentration may be greater than 17 ⁇ g ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• the present invention provides a method of identifying a patient (e.g., a patient having mucosal healing) for continued treatment with vedolizumab.
• the method may comprise the steps of measuring the concentration of vedolizumab in a sample of serum obtained from a patient suffering from IBD and who received at least two doses of vedolizumab within the previous four months (e.g, within the previous three months, within the previous two months), and identifying the patient for continued treatment with vedolizumab if the serum concentration in the sample is at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 g per ml.
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 ⁇ g per ml.
• the patient's serum concentration e.g., a trough serum concentration, may be greater than 17 ⁇ g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• the patient received the last prior dose, e.g., the second dose, of vedolizumab about four weeks prior to the sampling for serum vedolizumab measurement. In other embodiments, the patient received the last prior dose 3 to 8 weeks prior to the sampling for serum vedolizumab measurement.
• the method of identifying a patient for continued treatment with an anti- ⁇ 4 ⁇ 7 antibody may comprise the steps of measuring the
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 ⁇ per ml.
• the patient's serum concentration e.g., a trough serum concentration
• the patient's serum concentration may be greater than 17 ⁇ g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• the patient received the prior dose of vedolizumab about two weeks, about three weeks, about four weeks, about five weeks or about six weeks prior to the sampling for serum vedolizumab measurement.
• At least one dose of the anti-a4p7 antibody may be administered to a patient suffering from IBD, waiting at least about two weeks, or optionally, a period of two to five weeks, and then measuring the patient's serum concentration of vedolizumab and administering one or more further doses of vedolizumab to the patient if the patient's serum concentration is at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 ⁇ g per ml.
• the patient's serum concentration may be between about 12-25, about 15- 17, about 17-25, about 12-40, or about 17-40 ⁇ g per ml.
• the patient's serum concentration, e.g., a trough serum concentration may be greater than 17 ⁇ g/ml, greater than 25 ⁇ g/ml, or greater than 35 ⁇ g/ml.
• Vedolizumab may be administered by any suitable method, such as by one or more of intravenous injection, subcutaneous injection, or infusion. In some embodiments, vedolizumab is administered at a dose of 50 mg, 100 mg, 180 mg, 300 mg, or 600 mg. In some embodiments, the vedolizumab is administered, for example subcutaneously, at a dose of 0.5 mg/kg, 1.0 mg/kg, 1.5 mg/kg, 2.0 mg/kg, 2.5 mg/kg, 3.0 mg/kg. 4.0 mg/kg, or 5.0 mg/kg, at a dose of 108 mg, 216 mg, 160 mg or 165 mg. The vedolizumab may be administered once per day, per week, per month, or per year. A vedolizumab dosing regimen may have an initial or induction phase and a
• An induction phase may be one or more than one, e.g., two, three or four doses, of high amounts or without long times, such as only one week, two weeks, three weeks or four weeks between each dose.
• an induction regimen may have two doses, one at day (week) zero and one at week 2 (day 14).
• a maintenance phase e.g., to maintain remission of the IBD, may have lower doses or doses further apart than in the induction phase.
• the induction phase may be one or more than one, e.g., two, three or four doses, of high amounts or without long times, such as only one week, two weeks, three weeks or four weeks between each dose.
• an induction regimen may have two doses, one at day (week) zero and one at week 2 (day 14).
• a maintenance phase e.g., to maintain remission of the IBD, may have lower doses or doses further apart than in the induction phase.
• the IBD may have lower doses or doses further apart than
• vedolizumab is administered at zero, two and six weeks (induction), and then every four weeks or every eight weeks thereafter (maintenance). Patients with IBD refractory to other therapies may need longer induction periods, e.g., 8, 10 or 12 weeks, before beginning maintenance therapy.
• vedolizumab is administered intravenously at zero, two and six weeks, then every eight weeks thereafter.
• vedolizumab is administered one or more times, and then at least one month, at least six months, or at least one year later,
• vedolizumab is again administered one or more times.
• 300 mg vedolizumab may be administered by intravenous infusion at zero, two, and six weeks, and then at four weeks intervals or eight week intervals thereafter.
• 300 mg vedolizumab may be administered by intravenous infusion at zero, two, and six weeks, and then at two-, three- or four-week intervals, 108 mg of vedolizumab may be administered subcutaneously.
• Treatment methods using anti- ⁇ 4 ⁇ 7 integrin antibodies are described in publication nos. U.S. 2005/0095238, WO2012151248 and WO 2012/151247.
• the method of identifying a patient for continued treatment with an anti-a4p7 antibody may comprise a clinical measure.
• a clinical measure may be mucosal healing.
• an endoscopic score of less than 4, less than 3, ⁇ 1 , or between 0 and 2 may help identify a patient for continued treatment.
• a patient with mucosal healing and thus a candidate for continued treatment with an anti-a4p7 antibody, e.g., vedolizumab, may have an assessment selected from the group consisting of endoscopic response, endoscopic remission, improvement in the MaRIA score, decrease in ulceration, and improvement in a mucosal healing parameter, e.g., an MREn parameter.
• endoscopic response is achieved by about a 25% decrease, about a 40% decrease, about a 50% decrease, about a 60% decrease or about a 75% decrease in SES-CD score from baseline. In some embodiments, endoscopic remission is achieved by an SES-CD score of ⁇ 6, ⁇ 5, ⁇ 4 or ⁇ 3.
• mucosal healing is achieved by a MaRIA score of ⁇ 14, ⁇ 13, ⁇ 12, ⁇ 1 1 , ⁇ 10, ⁇ 9, ⁇ 8, ⁇ 7, ⁇ 6, ⁇ 5 or ⁇ 4,
• a decrease in ulceration is selected from the group consisting of a decrease in the size of ulcers, a decrease in the percent of ulcerated surface, a decrease in the percent of affected surface and decrease in the narro wings of the canal.
• the size of ulcers is less than 2 cm in diameter, 0.5 to 2 cm in diameter, 0.1 to 0.5 cm in diameter or ⁇ 0.2 cm diameter.
• the ulcerated surface is less than 30%, 10-30%, less than 10%, or 0.
• the affected surface is less than 75%, 50% - 75%, less than 50%, less than 25% or unaffected.
• the wall thickness is decreased by about 10%, about 15%, about 20%, about 25%, about 30%, about 20% - 40% or more than 45% from baseline.
• the bowel wall contrast (RCE) is decreased about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 20% - 40% or more than 40% from baseline.
• the mural edema is decreased by about 25%, about 40%, about 50%, about 60%, about 70%, more than 75%, or about 70% - 90% from baseline.
• the perienteric vascularity is decreased by about 25%, about 30%, about 40%, about 50%, about 60%, about 50% -70%, about 75% or more than 75% from baseline.
• a Crohn's disease patient who is responsive to vedolizumab has an SES-CD of ⁇ 4 at week 6, 10, 12, 14, 22 or 26 after initiating treatment.
• a Crohn's disease patient who is responsive to vedolizumab has an endoscopic response or >50% reduction of SES-CD at week 6, 10, 12, 14, 22 or 26 after initiating treatment.
• a Crohn's disease patient who is responsive to vedolizumab has a clinical remission or >70 or >100 point reduction of CDAI score at week 6, 10, 12, or 14 after initiating treatment.
• a Crohn's disease patient who is responsive to vedolizumab has a MaRIA score of ⁇ 15, ⁇ 12, ⁇ 10 or ⁇ 7 at week 6, 10, 12, 14, respectively, globally or on a per segment basis, after initiating treatment.
• a Crohn's disease patient who is responsive to vedolizumab has no ulceration at week 14, 22 or 26 after initiating treatment.
• a Crohn's disease patient who is responsive to vedolizumab has no fistulae at week 14, 22, 26 or 30 after initiating treatment.
• a patient who is responsive to vedolizumab may continue to be treated, e.g., may continue a maintenance regimen, with vedolizumab.
• a maintenance regimen comprises a dose of vedolizumab once every 2 weeks.
• a maintenance regimen comprises a dose of vedolizumab once every 4 weeks.
• a maintenance regimen comprises a dose of vedolizumab once every 6 weeks.
• a maintenance regimen comprises a dose of vedolizumab once every 8 weeks.
• the present invention relates to a method for maintaining remission of inflammatory bowel disease in a patient.
• the patient may have received at least one dose of vedolizumab in the previous two months, the previous three months or the previous four months.
• the method may comprise the steps of obtaining a serum sample from the patient, measuring the concentration of vedolizumab in the sample, and administering vedolizumab thereafter every eight weeks if the concentration is at least about 8, about 10, about 12, about 14, about 17, about 20, about 25, about 30, about 35, or about 40 ⁇ g per ml.
• the patient's serum concentration may be between about 12-25, about 15-17, about 17-25, about 12-40, or about 17-40 ⁇ g per ml.
• the patient's serum concentration e.g., a trough serum concentration
• the patient's serum concentration may be greater than 17 ⁇ g/ml, greater than 25 g/ml, or greater than 35 ⁇ g/ml.
• the patient received the prior dose of vedolizumab about two weeks, about three weeks, about four weeks, about five weeks or about six weeks prior to the sampling for serum vedolizumab measurement.
• a method for continuing to treat an IBD patient with vedolizumab comprises the steps of providing two doses of vedolizumab, wherein the second dose is about two weeks after the first; waiting about four weeks; and continuing to treat the patient with vedolizumab if the patient is in deep remission.
• Deep remission may be determined by measuring an endoscopic subscore for the patient and is defined as having an endoscopic subscore of 0 to 1.
• the method may further comprise the step of determining a patient-reported outcome score (e.g., a subscore of 0 to 1).
• the patient-reported outcome may comprise a rectal bleeding subscore (e.g., 0) and/or a stool frequency subscore (e.g., decrease or no change; 0 or 1).
• the invention also relates to a method for identifying a patient for continued treatment with vedolizumab comprising the steps of measuring the clearance of vedolizumab in a biological sample obtained from a patient suffering from IBD and who was administered at least two doses of vedolizumab within the previous four months (e.g., within the previous three months, within the previous two months), and identifying the patient for continued treatment with vedolizumab if the clearance in the patient is less than 0.25 L/day, less than 0.20 L/day, or between 0.1 to 0.2 L/day.
• the biological sample may be any biological sample, for example, serum, plasma, saliva, urine, or feces.
• the method may further comprise measuring anti- ⁇ 4 ⁇ 7 antibody antibodies.
• a low or absent immune response to the anti-a4p7 antibody, e.g., anti-vedolizumab antibody, e.g., a titer of ⁇ 50, ⁇ 125 or ⁇ 575 may further identify the patient for continued treatment with vedolizumab.
• Methods to determine whether a patient will respond to treatment with an anti- ⁇ 4 ⁇ 7 antibody or whether to continue treating a patient with an anti- ⁇ 4 ⁇ 7 antibody may further comprise measuring albumin concentration. In therapeutic antibody therapy, this can be a reflection of clearance activity, such as ability to bind the neonate FcR. In cases of low serum albumin levels, the anti- ⁇ 4 ⁇ 7 antibody can have a high clearance. Consequently, a patient with high serum albumin levels may not respond or may take longer to respond to treatment with anti- ⁇ 4 ⁇ 7 antibody.
• An albumin concentration greater than about 3.0 g/dL, about 3.2 g/dL, about 4.0 g/dL, about 4.7 g/dL, or about 5.0 g/dL, or in the range of 3.3 to 5.0 g/dL, in the range of 3.5 to 5.0 g/dL, in the range of 3.8 to 5.0 g/dL or in the range of 4.0 to 5.0 g/dL may further identify the patient for continued treatment with the anti- ⁇ 4 ⁇ 7 antibody, e.g., vedolizumab.
• the albumin concentration measurement may be accompanied by measurement of patient weight.
• a high weight patient e.g., greater than 90 kg, greater than 100 kg, greater than 1 10 kg, or greater than 120 kg, with low albumin levels, e.g., less than 4.2 g/dL, less than 4.0 g/dL, less than 3.5 g/dL or less than 3.2 g/dL, may have high anti- ⁇ 4 ⁇ 7 antibody clearance and thus may not respond to therapy with the anti- ⁇ 4 ⁇ 7 antibody or may need a higher or more frequent dose of the anti- ⁇ 4 ⁇ 7 antibody for continued treatment.
• Clearance e.g., linear clearance, e.g., the volume of blood which is cleared of drug per unit time
• linear clearance e.g., the volume of blood which is cleared of drug per unit time
• clearance may be estimated by population approach or Bayesian methods, e.g., the full Bayesian Markov Chain Monte Carlo (MCMC) method.
• MCMC Bayesian Markov Chain Monte Carlo
• the anti- ⁇ 4 ⁇ 7 antibody exposure metric such as trough serum concentration, e.g., serum concentration of anti- ⁇ 4 ⁇ 7 antibody prior, e.g., 1 day, 2 days, 3 days, 4 days or up to a week prior, to administering a new dose, peak serum concentration, average serum concentration measured at more than one sampling or area under the concentration time curve, is inputted into the model to determine clearance.
• trough serum concentration e.g., serum concentration of anti- ⁇ 4 ⁇ 7 antibody prior, e.g., 1 day, 2 days, 3 days, 4 days or up to a week prior
• the method for identifying a patient for continued treatment with vedolizumab comprising the steps of measuring the clearance of vedolizumab in a biological sample obtained from a patient suffering from IBD can be performed on a patient who was administered at least one dose of vedolizumab within the previous one or two months, and identifying the patient for continued treatment with vedolizumab if the clearance in the patient is less than 0.25 L/day, less than 0.20 L/day, between 0.1 to 0.2 L/day, less than 0.15 L/day or less than 0.1. L/day.
• the biological sample may be any biological sample, for example, serum, plasma, saliva, urine, or feces.
• the method may further comprise measuring an endoscopic subscore.
• Anti- ⁇ 4 ⁇ 7 antibody e.g., vedolizumab treatment may be continued with an endoscopic subscore of less than about 3, less than about 2.5, less than about 2, between about 0-2, or less than or equal to 1.
• a non-diseased subject will have a fecal calprotectin level of less than 50 ⁇ g/g.
• a fecal calprotectin level greater than 50 but less than 150 ⁇ g/g may be a sign of possible mucosal inflammation, whereas fecal calprotectin levels greater than 150 ⁇ g/g is usually a sign of active inflammation.
• the methods described herein may further comprise measuring the fecal calprotectin concentration. Higher levels of fecal calprotectin are associated with a greater risk of relapse.
• Vedolizumab treatment may be continued with a fecal calprotectin concentration of less than 1500 ⁇ g/g, less 1250 ⁇ g/g, less than 1000 ⁇ g/g, less than 750 ⁇ g/g, less than 500 ⁇ g/g, less than 400 ⁇ g/g, less than 300 ⁇ /g, less than 250 ⁇ , between 200-1200 ⁇ , between 350 to 800 ⁇ , between 300-1000 ⁇ g/g, ⁇ 50 ⁇ , ⁇ 100 ⁇ , ⁇ 150 ⁇ glg, ⁇ 200 ⁇ , ⁇ 250-499 ⁇ , or between 500 to 900
• fecal calprotectin may be reduced to less than about 50%, 45%, 40%, 35%, 30%, 25%, 20%, between 10-55%, between 10-30%, between 15-35%, between 15-45% or between 20-40% of the baseline or concentration before treatment.
• Fecal calprotectin in a stool sample can be measured using the PHICAL test kit (Calpro, Lysaker Norway
• the anti- ⁇ 4 ⁇ 7 antibody, e.g., vedolizumab, serum concentration may be measured by any appropriate means known by those skilled in the art.
• the vedolizumab serum concentration is measured by a sandwich enzyme-linked immunosorbent assay (ELISA) assay.
• ELISA sandwich enzyme-linked immunosorbent assay
• inhibition of MAdCAM-l-Fc binding to a 4 p 7 -expressing peripheral blood cells by the anti- ⁇ 4 ⁇ 7 antibody, e.g., vedolizumab in the blood is used as a measure of the extent of ⁇ 4 ⁇ 7 saturation by the anti- ⁇ 4 ⁇ 7 antibody, e.g., vedolizumab.
• the 3 ⁇ - ⁇ 4 ⁇ 7 antibody amount in serum can be measured in a pharmacokinetic assay.
• An immobilized phase such as a microtiter plate, vessel or bead is coated with a reagent which specifically binds to the anti-a4p7 antibody.
• the immobilized reagent is contacted with a patient sample, e.g., serum, which may or may not comprise the anti- ⁇ 4 ⁇ 7 antibody.
• the anti- ⁇ 4 ⁇ 7 antibody complexed to the coating reagent is contacted with a reagent which binds to the captured antibody and may be detected, e.g., using a label such as horseradish peroxidase (HRP).
• HRP horseradish peroxidase
• the binding reagent may be an anti-human antibody, e.g., polyclonal or monoclonal, which binds to the Fc portion of the anti- ⁇ 4 ⁇ 7 antibody.
• Addition of an HRP substrate such as 3,3 ',5,5'- tetramethylbenzidine (TMB)
• TMB 3,3 ',5,5'- tetramethylbenzidine
• the coating reagent is an anti-idiotypic antibody which specifically binds to the anti-ot4p7 antibody, e.g., its variable region or a portion thereof comprising one or more CDRs, such as heavy chain CDR3, SEQ ID NO:6.
• the anti-idiotypic anti-a4p7 antibody for use in the assay can be specific for, and thus bind, the ⁇ 4 ⁇ 7 integrin-binding portion of the anti-a4p7 antibody but is not specific for the Fc portion of the anti- ⁇ 4 ⁇ 7 antibody and thus does not bind the Fc portion of the anti-a4p7 antibody.
• the anti-idiotypic anti-a4p7 antibody for use in the assay can be specific for, and thus bind, a variable region of the heavy and/or light chain of anti- ⁇ 4 ⁇ 7 antibody, e.g., selected from the group consisting of amino acids 20 to 140 of SEQ ID NO: 1 , amino acids 20 to 131 of SEQ ID NO:2 and amino acids 21 to 132 of SEQ ID NO:3.
• the anti-idiotypic anti-ct4p7 antibody for use in the assay can be specific for, and thus bind, an antigen-binding fragment of the anti-a4p7 antibody.
• the anti-idiotypic antibody can be isolated from an immunization process using the anti-a4p7 antibody or an a4p7 integrin-binding portion thereof, such as an antibody fragment comprising one or more CDRs, and used as isolated or produced by a recombinant method.
• the anti-idiotypic anti-a4p7 antibody is raised against an immunogen comprising heavy chain CDR3, SEQ ID NO:6.
• the anti-idiotypic anti-a4p7 antibody is raised against an immunogen comprising a variable region of the heavy and/or light chain of anti-a4p7 antibody, e.g., selected from the group consisting of amino acids 20 to 140 of SEQ ID NO: l , amino acids 20 to 131 of SEQ ID NO:2 and amino acids 21 to 132 of SEQ ID NO:3.
• the anti-idiotypic antibody is a monoclonal antibody.
• an scFv fragment of the anti-idiotypic antibody is used in the assay.
• the intact anti-idiotypic antibody is used in the assay.
• an anti-idiotypic anti-a4p7 antibody can proceed in the following general methods. Immunization of a suitable animal (e.g., mouse, rat, rabbit or sheep) with protein, e.g., anti-a4p7 antibody or an a4p7 integrin binding portion thereof, or fusion protein comprising the portion, can be performed with the immunogen prepared for injection in a manner to induce a response, e.g., with adjuvant, e.g., complete Freund's adjuvant.
• adjuvants include TITERMAX GOLD® adjuvant (CYTRX Corporation, Los Angeles, CA) and alum.
• Small peptide immunogens such as a fragment comprising a CDR, such as CDR3 of the heavy chain can be linked to a larger molecule, such as keyhole limpet hemocyanin.
• Mice can be injected in a number of manners, e.g., subcutaneous, intravenous or intramuscular at a number of sites, e.g., in the peritoneum (i.p.), base of the tail, or foot pad, or a combination of sites, e.g., i.p. and base of tail.
• Booster injections can include the same or a different immunogen and can additionally include adjuvant, e.g., incomplete Freund's adjuvant.
• a hybridoma is produced by fusing a suitable cell from an immortal cell line (e.g., a myeloma cell line such as SP2/0, P3X63Ag8.653 or a heteromyeloma) with antibody-producing cells.
• an immortal cell line e.g., a myeloma cell line such as SP2/0, P3X63Ag8.653 or a heteromyeloma
• Antibody-producing cells can be obtained from the peripheral blood or, preferably the spleen or lymph nodes, of animals immunized with the antigen of interest.
• Cells that produce antibodies can be produced using suitable methods, for example, fusion of a human antibody-producing cell and a heteromyeloma or trioma, or immortalization of an activated human B cell via infection with Epstein Barr virus.
• the fused or immortalized antibody-producing cells can be isolated using selective culture conditions, and cloned by limiting dilution. Cells which produce antibodies with the desired specificity can be identified using a suitable assay ⁇ e.g., ELISA (e.g., with immunogen immobilized on the microtiter well).
• the anti-a4p7 antibody or the anti-idiotypic anti-a4p7 antibody may be produced by expression of nucleic acid sequences encoding each chain in living cells, e.g., cells in culture.
• a variety of host-expression vector systems may be utilized to express the antibody molecules of the invention. Such host-expression systems represent vehicles by which the coding sequences of interest may be produced and subsequently purified, but also represent cells which may, when transformed or transfected with the appropriate nucleotide coding sequences, express an anti-ot4p7 antibody in situ.
• microorganisms such as bacteria (e.g., E. coli, B. subtilis) transformed with recombinant bacteriophage DNA, plasmid DNA or cosmid DNA expression vectors containing antibody coding sequences; yeast (e.g.,
• yeast expression vectors containing antibody coding sequences
• insect cell systems infected with recombinant virus expression vectors e.g., baculovirus
• plant cell systems infected with recombinant virus expression vectors e.g., cauliflower mosaic virus, CaMV; tobacco mosaic virus, TMV
• recombinant plasmid expression vectors e.g., Ti plasmid
• mammalian cell systems e.g., COS, CHO, BHK, 293, 3T3, NS0 cells harboring recombinant expression constructs containing promoters derived from the genome of mammalian cells (e.g., metallothionein promoter) or from mammalian viruses (e.g., the adenovirus late promoter; the vaccinia virus 7.5K promoter).
• mammalian cells such as Chinese
• a number of expression vectors may be advantageously selected depending upon the use intended for the antibody molecule being expressed.
• vectors which direct the expression of high levels of fusion protein products that are readily purified may be desirable.
• Such vectors include, but are not limited to, the E. coli expression vector pUR278 (Ruther et al, EMBO J. 2: 1791 (1983)), in which the antibody coding sequence may be ligated individually into the vector in frame with the lac Z coding region so that a fusion protein is produced; ⁇ vectors (Inouye & Inouye, Nucleic Acids Res.
• pGEX vectors may also be used to express foreign polypeptides as fusion proteins with glutathione S-transferase (GST).
• GST glutathione S-transferase
• fusion proteins are soluble and can easily be purified from lysed cells by adsorption and binding to matrix glutathione-agarose beads followed by elution in the presence of free glutathione.
• the pGEX vectors are designed to include thrombin or factor Xa protease cleavage sites so that the cloned target gene product can be released from the GST moiety.
• Autographa californica nuclear polyhedrosis virus (AcNPV) is used as a vector to express foreign genes.
• the virus grows in Spodoptera frugiperda cells.
• the antibody coding sequence may be cloned individually into nonessential regions (for example the polyhedrin gene) of the virus and placed under control of an AcNPV promoter (for example the polyhedrin promoter).
• the coating reagent is a ligand of the antibody, such as MAdCAM or an ⁇ 4 ⁇ 7 integrin-binding fragment thereof or fusion protein comprising an a4 7-integrin binding fragment of MAdCAM fused with a non-MAdCAM protein, such as an immunoglobulin G constant domain.
• a ligand of the antibody such as MAdCAM or an ⁇ 4 ⁇ 7 integrin-binding fragment thereof or fusion protein comprising an a4 7-integrin binding fragment of MAdCAM fused with a non-MAdCAM protein, such as an immunoglobulin G constant domain.
• the human anti- anti-a4p7 antibody activity can be determined by detecting and/or measuring anti-drug antibodies (ADAs) or antibodies specific to the anti-a4p7 antibody (anti-vedolizumab antibodies).
• ADAs anti-drug antibodies
• anti-vedolizumab antibodies antibodies specific to the anti-a4p7 antibody
• a screening assay can use a bridging ELISA in which the plate is coated with the anti- ⁇ 4 ⁇ 7 antibody.
• the immobilized anti-a4p7 antibody captures the ADA in the test sample which is bound by an anti-a4p7 antibody conjugated to biotin, which is tagged by horseradish peroxidase (HRP)-labeled streptavidin, then detected with an enzymatic substrate, such as TMB.
• HRP horseradish peroxidase
• TMB horseradish peroxidase
• the assay cut point e.g., in biotin-avidin-HRP based bridging assay, can be determined by using normal human serum samples as negative controls. The mean absorbance values of the 10 negative control serums can be added to 1.65 times the standard deviation of the negative controls to determine the cut point. Thus, the cut point can allow for approximately a 5% false positive rate. In the presence of 1 ⁇ g/mL vedolizumab, low titer responses are interfered with such that they may become undetectable, although high levels of immunogenicity are detectable at vedolizumab concentrations greater than 1 ⁇ g/mL.
• the standard assay sensitivity can be 0.44 ng/ml
• the sensitivity of the assay can be 180 ng/ml.
• serum samples can be taken greater than 4 weeks, greater than 8 weeks, greater than 12 weeks or greater than 16 weeks after the final dose of anti- ⁇ 4 ⁇ 7 antibody. With a longer time period between the prior dose and the sampling, serum drug levels typically can be below the interference level.
• Another assay method uses streptavidin coated plates, biotin-labeled anti-a4p7 antibody anchored to streptavidin coated vessels, beads or microtiter plates for the immobilized side of the bridge and heavy metal, such as ruthenium, osmium or rhenium -labeled (e.g., via a sulfo tag) anti-a4p7 antibody for the other side of the bridge.
• the bridged complex can be built on the plate by stepwise additions and washes between or in solution, with both sides of the bridge contacting diluted serum sample, then transferred to the plate.
• An example of an assay using this method has a sensitivity of 3.90 ng/ml anti- anti-a4p7 antibody. Detection of the heavy metal labeled bridge complex, e.g., a ruthenium-labeled complex, by
• ECL electrochemiluminescence
• pretreatment of the serum sample with acid e.g., acetic acid or low pH glycine, to release the anti-a4p7 antibody from the patient-derived anti- anti-a4p7 antibodies prior to contacting with the bridging anti-a4p7 antibodies can reduce the interference from the drug in the serum.
• an assay to detect anti-vedolizumab antibodies in a sample of serum from a patient comprises diluting serum by a standard dilution factor, such as 1 :5, 1 :25, 1 :50, and/or 1 : 125; treating with acetic acid; combining the acid treated diluted sample with an assay composition comprising a high pH reagent, such as high concentration TRIS buffer for neutralizing the acid, a biotin-labeled vedolizumab and a ruthenium-labeled vedolizumab for a time sufficient to form a bridge with serum- derived anti-vedolizumab antibodies between the two tagged versions of a standard dilution factor, such as 1 :5, 1 :25, 1 :50, and/or 1 : 125; treating with acetic acid; combining the acid treated diluted sample with an assay composition comprising a high pH reagent, such as high concentration TRIS buffer for neutralizing the acid, a biotin
• vedolizumab transferring the complexes to a streptavidin-coated plate; washing the plate so only ruthenium complexed by the antibody bridge is present. Detection of the bound ruthenium-labeled complex and measuring the sample by
• electrochemiluminescence in the microplate reader can be achieved by adding a read solution such as tripropylamine and applying voltage to stimulate the ruthenium label complexed to the plate via the antibody bridge.
• samples can be further tested in a confirmatory assay that uses excess unlabeled anti-a4p7 antibody to demonstrate specificity. Confirmed positive samples can be further assessed for the ability of the HAHA to neutralize the binding of the anti-ci4p7 antibody, e.g., vedolizumab to cells.
• a competitive flow cytometr -based assay was designed to determine the ability of the immune serum to inhibit the binding of labeled vedolizumab to an 4 ⁇ 7 integrin-expressing cell line, RPMI8866, and detection by flow cytometry.
• the results can indicate categories of immunogenicity status: Negative: no positive HAHA sample; Positive: at least 1 positive HAHA sample; Transiently positive: at least 1 positive HAHA sample and no consecutive positive HAHA samples; and Persistently positive: at least 2 or more consecutive positive HAHA samples.
• Negative patients are likely to respond to anti-a4p7 antibody and can continue being treated with the antibody.
• Persistently positive patients are likely to have high clearance of anti-a4p7 antibody and may not respond to anti-a4p7 antibody treatment.
• Positive patients may have high clearance of anti-ct4p7 antibody and may not respond to anti-a4p7 antibody.
• Positive patients can have an additional serum sample 2, 3, 4, 5 or 6 weeks after another dose of anti-a4p7 antibody to determine if they are persistently positive or transiently positive.
• Transiently positive patients are likely to respond to anti-a4p7 antibody treatment and treatment of these patients can be continued.
• Titers of immunogenicity levels also may be determined. Titer categories include > 5 (low), >50, > 125, > 625 and > 3125 (high). A patient with a high titer in a positive sample may have high clearance of anti-a4p7 antibody and may not respond to anti- a4p7 antibody treatment. A patient with a low titer in a positive sample may respond to anti-a4p7 antibody treatment.
• ADA Day 1 , 15, 29, and 85 (predose) and Days 57, 1 13, 141 , 169, 197, 225, and 253
• Table SI Clinical studies included in vedolizumab population pharmacokinetic/pharmacodynamic analyses
• Placebo 126 (predose); Week 52. intolerance of 1 of 44 weeks ' ):
• Placebo P 654 Samples were collected predose, if applicable.
• Non-ITT ADA: Weeks 0, 6, 14, loss of response to, or VDZ
• VDZ Q4W 26, 38, 52 (or Early intolerance of 1 of 300 mg IV
• Vedolizumab serum concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), with a lower limit of detection of 0.00125 ⁇ g/mL at a 1 : 100 dilution.
• the accuracy of the assay was 10.1% coefficient of variation (CV), intra-sample precision ranged from 1.8% to 3.0% CV, and inter-sample precision ranged from 4.0% to 16.0% CV.
• MAdCAM-l-Fc binding interference flow cytometry assay was developed.
• inhibition of MAdCAM-l-Fc binding to a 4 7 -expressing peripheral blood cells by vedolizumab in the blood is used as a measure of the extent of ⁇ 4 ⁇ 7 saturation by vedolizumab [1].
• the assay which was developed by
• ADAs anti-drug antibodies
• anti-vedolizumab antibodies antibodies specific to the anti-a4p7 antibody
• the plate is coated with the anti-a4p7 antibody.
• the immobilized anti-a4p7 antibody captures the ADA in the test sample.
• the bound complex captures an anti-a4p7 antibody conjugated to biotin, which after another wash, captures HRP-labeled streptavidin.
• HRP-labeled streptavidin When incubated with TMB substrate, a positive color development indicates the presence of ADAs in the sample. All samples that screened positive were further diluted to determine the final ADA titer using standard techniques. If both screening dilutions were negative, the sample was considered negative. Patients were classified as positive for ADAs if antibodies were detected at any visit;
• Vedolizumab serum concentration measurements that were missing, or any values with unknown or missing associated observation times, dose times, dose amounts, or dosing intervals, were excluded from the analysis.
• Covariates present in the population pharmacokinetic dataset were serum C-reactive protein (CRP), serum albumin, fecal calprotectin, body weight, disease activity (Crohn's Disease Activity Index [CDAI], complete Mayo score, partial Mayo score), Mayo endoscopic subscore, age, sex, ADA status (positive or negative), prior TNF-a antagonist therapy status (na ' ive or failed), body mass index (BMI), serum globulin, diagnosis (CD or UC), lymphocyte count, and concomitant therapy use (methotrexate, azathioprine, mercaptopurine, or aminosalicylates).
• the start date and end date of concomitant therapy was populated in the dataset to evaluate the time-dependent effects of concomitant treatments.
• Covariates with missing data were imputed using different imputation methods, based on the remaining available data (e.g. median of the remaining values). No covariates present in the population pharmacokinetic dataset were missing more than 10% of values.
• the population pharmacokinetic analysis for repeated measures was conducted using a nonlinear mixed effects modeling approach (NONMEM 7, Version 7.2; ICON Development Solutions, Ellicott City, MD, USA) [13].
• the base population pharmacokinetic model was developed using the first-order conditional estimation with the ⁇ - ⁇ interaction (FOCEI) method and extensively sampled phase 1 and 2 data. Results from the base model were subsequently used as prior information to selectively inform a subset of population pharmacokinetic model parameters in the full covariate model, which was fit to sparse phase 3 data from GEMINI 1, 2, and 3.
• the full covariate model was fit to the phase 3 data using the full Bayesian Markov Chain Monte Carlo (MCMC) method. All parameter estimates were reported with Bayesian 95% credible intervals (CDIs) as a measure of estimation uncertainly.
• CDIs Bayesian 95% credible intervals
• predefined covariate parameter relationships were identified based on exploratory graphics, scientific interest, and mechanistic plausibility.
• a full covariate model was constructed with care to avoid correlation or collinearity in predictors; covariates with correlation coefficients greater than ⁇ 0.35 were not simultaneously included as potential predictors. Construction of the full model was also guided by evaluating the adequacy of the study design and covariate data to support quantification of the covariate effects of interest.
• the population pharmacokinetic-pharmacodynamic analysis for repeated measures was conducted using the nonlinear mixed effects modeling approach (NONMEM, Version 7.2).
• the pharmacokinetic-pharmacodynamic data were modeled using a sequential approach, where individual predicted vedolizumab serum concentrations from the population pharmacokinetic model were used to drive the pharmacodynamic response.
• the pharmacodynamic evaluations were based on percentage of MAdCAM- 1 binding by lymphocytes expressing high levels of ⁇ 4 ⁇ 7 integrin (CD4 + CD45RO hlgh ).
• a direct effect sigmoid Emax model was selected to characterize the exposure-response relationship for the effect of vedolizumab on MAdCAM-1 binding to ⁇ 4 ⁇ 7 . No formal covariate modeling or model evaluation was conducted.
• the study population consisted of 2554 individuals who contributed 18427 evaluable vedolizumab serum samples, including 87 healthy volunteers from the phase 1 study, 46 patients from the phase 2 study (UC), and 891 , 1 1 15, and 415 patients from the phase 3 GEMINI 1 (UC), GEMINI 2 (CD), and GEMINI 3 (CD) studies, respectively.
• Demographics and other characteristics of the pharmacokinetic analysis population are summarized in Table 1.
• the analysis population consisted of 1290 men and 1264 women with ages ranging from 18 to 78 years and baseline body weights ranging from 28 to 170 kg. A total of 1530 individuals had CD and 937 had UC; 87 were healthy volunteers.
• ADA anti-drug antibody
• CDAI Crohn's Disease Activity Index
• TNF-a tumor necrosis factor-a.
• Vedolizumab pharmacokinetics was described by a 2-compartment model with parallel linear and nonlinear elimination.
• a 2-compartment model resulted in a significant improvement in goodness-of-fit criteria over a 1 -compartment model, as did a parallel linear and nonlinear elimination model over a linear model.
• the population pharmacokinetic model of vedolizumab is represented diagrammatically in FIG. 2.
• Body weight was chosen to represent changes in vedolizumab pharmacokinetics as a function of body size and was described using an allometric model with a reference weight of 70 kg.
• the other continuous covariates of albumin, fecal calprotectin, partial Mayo score, age, and CDA1 score entered the model as power functions normalized by a reference value (typically near the observed median value of the data).
• the categorical covariates of prior TNF-a antagonist therapy status, ADA status, concomitant therapy use, and IBD diagnosis entered the model as power functions, with a separate dichotomous (0, 1) covariate serving as an on-off switch for each effect.
• Time-dependent covariates were body weight, albumin, fecal calprotectin, and concomitant therapy use.
• the effect of IBD diagnosis on linear clearance (CLL) was investigated by modeling separate CLL parameters for patients with UC and those with CD, while the effect of IBD diagnosis on central compartment volume of distribution (V c ) was evaluated by including IBD as a predictor of V c in the covariate model.
• V max 0.265 mg day (0.219, 0.318)
• CDI credible interval
• CL L clearance of linear elimination pathway
• CV coefficient of variation.
• ⁇ Parameter estimate and 95% credible interval were derived from the median, 2.5th and 97.5th quantiles of the Bayesian posterior probability distributions from 4 MCMC chains. Separate typical values of CL L were modeled for patients with UC and those with CD with a shared inter-individual variance term and shared covariate effects except for partial Mayo score and CDAI score.
• the reference individual weighs 70 kg, is 40 years old, has an albumin level of 4 g/dL, fecal calprotectin level of 700 mg/kg, CDAI score of 300 (for patient with CD), partial Mayo score of 6 (for patient with UC), ADA negative, a diagnosis of UC (for Vc parameter), and no concomitant therapy use, and is TNF-a antagonist therapy naive.
• the variance parameter estimates were indicative of moderate to large unexplained interindividual variability.
• the typical values of CLL were 0.159L/day for patients with UC and 0.1 55 L/day for patients with CD.
• the individual estimates of CLL for patients with UC and CD were distributed over a wide range as represented in FIG. 3.
• the proportional residual variance estimate (unexplained random residual variability in the model) was relatively small.
• the estimates of interindividual variances and correlations are presented in Table S2, and the standard deviations and shrinkage estimates of interindividual random effects are presented in Table S3.
• CL L clearance of linear elimination pathway
• corr correlation coefficient
• CV coefficient of variation
• m concentration at half-maximum elimination rate
• Q intercompartmental clearance
• V c central compartment volume of distribution
• V max maximum elimination rate
• V p peripheral compartment volume of distribution
• co 2 interindividual variance
• G0 estimate was derived from the median of the Bayesian posterior probability distributions from 4 MCMC chains.
• FIGS. 4 and 9 Goodness-of-fit plots from the final population pharmacokinetic model are presented in FIGS. 4 and 9. Diagnostic plots indicated that the full covariate pharmacokinetic model was consistent with the observed data and no systematic bias was evident.
• the relative changes in CLL for a reference individual with various covariate values are illustrated in FIG. 5.
• the point estimates and 95% CDIs for the effects of covariates on CLL are presented in Table S4.
• Table S4 Covariate parameter estimates from the vedolizumab final population pharmacokinetic model
• ⁇ aminosalicylate concomitant therapy
• AZA azathioprine concomitant therapy
• CD Crohn's Disease
• CDAI Crohn's disease activity index
• CL L clearance of linear elimination pathway
• ADA anti-drug antibody
• MP 6-mercaptopurine concomitant therapy
• MTX methotrexate concomitant therapy
• Q intercompartmental clearance
• TNF-a tumor necrosis factor-a
• UC ulcerative colitis
• V c central compartment volume of distribution
• V max maximum elimination rate
• V p peripheral compartment volume of distribution.
• the reference individual weighs 70 kg, is 40 years old, has an albumin level of 4 g/dL, fecal calprotectin level of 700 mg kg, CDAI score of 300 (for patient with CD), partial Mayo score of 6 (for patient with UC), ADA negative, a diagnosis of UC (for Vc parameter), and no concomitant therapy use, and is TNF-a antagonist therapy naive
• CDAI score 300 (for patient with CD)
• partial Mayo score of 6 for patient with UC
• ADA negative for patient with UC
• diagnosis of UC for Vc parameter
• no concomitant therapy use and is TNF-a antagonist therapy naive
• the 95% CDIs were narrow indicating that the effect of each covariate on vedolizumab CLL was well defined. Only the effects of albumin and body weight had potential to be clinically meaningful (effect sizes greater than 25%) at extremes values of a representative range.
• the typical CLL values for patients with albumin levels of 4.7 and 3.2 g/dL were approximately 0.8 and 1.3 times, respectively, that of the reference patient (albumin, 4g/dL) (FIG. 5).
• the typical CLL value for a patient of 40 kg was approximately 0.8 times that of the reference patient (weight, 70 kg).
• a patient of 120 kg had 1.2 times higher CLL than the reference patient (FIG. 5).
• a patient of 120 kg with a serum albumin concentration of 4.0 g/dL had a 19% probability of having clearance greater than the pre-specified criterion for clinical significance.
• the final population pharmacokinetic model was rerun with all covariates and pharmacokinetic parameters fixed to estimates from the final model (interindividual variances were re-estimated), and any remaining effects of sex on CLL and V c were quantified.
• the results of this analysis suggest that, after adjusting for other predictors of vedolizumab pharmacokinetics, the typical CLL value and V e are approximately 10% lower and 6% lower, respectively, for a female patient compared with a male patient. However, these effects were not considered clinically relevant since the covariate effect sizes were less than ⁇ 25% from the typical reference values (male patient). Addition of the sex effect explained approximately 4.2% and 6.0% of the unexplained interindividual variability in CLL and V c , respectively.
• the final population pharmacokinetic model and parameter estimates were evaluated with a predictive check method and Bayesian 95% CDIs derived from the posterior probability distributions.
• the basic premise of a predictive check is that a model and parameters derived from an observed dataset should produce simulated data that are similar to the original observed data.
• the predictive check plots demonstrated overall good agreement between the observed and simulated data (FIGS. 10, 1 1, and 12).
• the precision of the parameters estimates was assessed by evaluating the Bayesian 95% CDIs (Tables 2, S2, and S4). Overall, the structural pharmacokinetic model parameters, covariates effects, and variance parameters were estimated with good precision.
• the vedolizumab population pharmacokinetic-pharmacodynamic dataset was composed of 593 individuals contributing a total of 2442 evaluable MAdCAM-1 observations.
• the analysis population consisted of 297 patients with UC and 296 patients with CD (from the phase 2 study and GEMINI 1 and 2).
• Eo is the baseline MAdCAM-1 percent binding
• Emax is the maximum effect
• Cone is the vedolizumab serum concentration
• EC50 is the vedolizumab serum concentration at half-maximum effect
• ⁇ is the Hill-coefficient or slope factor.
• the model was parameterized in terms of baseline MAdCAM-1 inhibition (E 0 ), maximum effect (E ma x), vedolizumab serum concentration at half-maximum effect (EC50), and Hill-coefficient or slope factor ( ⁇ ).
• E 0 baseline MAdCAM-1 inhibition
• E ma x maximum effect
• EC50 vedolizumab serum concentration at half-maximum effect
• ⁇ Hill-coefficient or slope factor
• the base model provided a reasonable description of the data as judged by visual inspection of diagnostic plots (FIG. 13) but some deficiencies in the model were noted. Variance parameter estimates were indicative of moderate to large unexplained interindividual and residual variability, with estimates of 41.8 %CV for E 0j 0.551 (SD logistic distribution) for E max , and 78.3 %CV for the exponential residual error variance (o 2 exp ) (Table 3).
• vedolizumab following IV administration to healthy volunteers and patients with UC and CD using data collected in clinical trials with identical designs and sampling schedules. These design features allowed the direct comparison of the disposition and the pharmacokinetic variability of vedolizumab in patients with UC and those in patients with CD.
• the estimated half-life of vedolizumab was not different between the 2 diseases and was 25.5 days (range 14.6-36.0 days [5 th and 95 th percentiles]), which is typical of human IgGi (25 days) and typical of monoclonal antibodies of the IgGi type A2. This half- life is substantially longer than values for current biologic treatments for IBD.
• a 2-compartment pharmacokinetic model consisting of parallel clearance via the nonlinear pathway (CLNL) and the linear pathway (CLL) from the central compartment was selected as the base model.
• the nonlinear elimination was best described by Michaelis-Menten elimination.
• the nonlinear pathway is thought to be due to clearance by saturable, target-mediated mechanisms such as receptor-mediated endocytosis.
• the linear pathway represents components that are nonsaturable at therapeutic concentrations, such as Fc-mediated elimination.
• Parallel elimination is typical of monoclonal antibodies with disposition that is affected by binding to the target, in this case the ⁇ 4 ⁇ 7 integrin on circulating T lymphocytes.
• TNF-a antagonists Similar effects have been reported for efalizumab, tocilizumab, and cetuximab. In contrast, the elimination of TNF-a antagonists is best described by a linear
• TNF-a exists in both soluble and membrane-bound forms and is present in abnormally high concentrations in serum and gut mucosa in patients with IBD.
• the localization of TNF-a in inflammatory tissues may make it difficult to rapidly achieve target saturation because of slow redistribution of the drug from plasma to the target sites. Accordingly, it may be difficult to achieve target saturation at therapeutic concentrations.
• vedolizumab CLL The estimated vedolizumab CLL values are consistent with those of other monoclonal antibodies that are administered intravenously. Although some authors have reported that the clearance of antibodies could be affected by IBD type, no apparent differences were observed in the pharmacokinetics of vedolizumab in patients with UC and those with CD. Results from the final pharmacokinetic model showed that vedolizumab CLL for a 40-year-old, 70-kg patient with a serum albumin concentration of 4 g/dL was 0.159 L/day for a patient with UC and 0.155 L/day for a patient with CD.
• albumin concentrations decreased and weight increased.
• Albumin concentrations below 3.2 g/dL were associated with increased clearance of vedolizumab that was greater than the pre- specified criterion for clinical significance.
• Similar association of low albumin concentrations with the clearance of other monoclonal antibodies have been reported in population pharmacokinetics analyses.
• FcRn Fc receptor
• Vedolizumab concentrations in feces were not measured during the GEMINI trials precluding us from evaluating this hypothesis.
• the second important covariate identified was body weight, which was positively correlated with the clearance of vedolizumab.
• a patient of 120 kg with a serum albumin concentration of 4.0 g/dL had a 19% probability of having clearance greater than the pre-specified criterion for clinical significance.
• Measures of body size are the most commonly identified covariates influencing the pharmacokinetics of therapeutic monoclonal antibodies.
• AD As has been reported to increase infliximab clearance.
• the presence of AD As was estimated to increase vedolizumab clearance by only 12%.
• the small impact may be a result of the low incidence of ADAs observed in the GEMINI trials.
• vedolizumab trough concentrations were below the limit of quantification.
• vedolizumab is not unique in this regard.
• the current population pharmacokinetic analysis showed no clinically meaningful impact of the following covariates on the pharmacokinetics of vedolizumab: disease activity, prior TNF-a antagonist therapy status, age (from 18 to 78 years old), and concomitant medication use.
• the lack of association between prior TNF-a antagonist therapy use was associated with a higher probability of clinical remission or response in vedolizumab-treated patients with UC and those with CD.
• these observations suggest that the impact of prior TNF-a antagonist therapy use on vedolizumab efficacy is not related to any effect on vedolizumab CLL.
• thiopurines and methotrexate are known to down-regulate Fey receptors on monocytes and other Fc-receptor subtypes.
• ⁇ 4 ⁇ 7 receptor saturation was maintained at vedolizumab concentrations considered subtherapeutic, raising the question as to whether receptor saturation is necessary but not sufficient for clinical efficacy.
• the EC 50 estimate from population pharmacokinetic-pharmacodynamic model was 0.093 ⁇ g/mL, suggesting that full saturation is reached at vedolizumab serum concentration of approximately 1 ⁇ g/mL.
• the exposure-efficacy results indicated that vedolizumab concentrations below 17 and 15 ⁇ g/mL at induction were associated with efficacy similar to placebo in patients with UC and CD, respectively.
• MAdCAM-1 assay measures ⁇ 4 ⁇ 7 saturation in circulating T-cells or may be due to a slow onset of action of the drug.
• the MAdCAM-1 assay is insensitive to dose and should not be used for dose selection. Further studies to evaluate the relative pharmacodynamic contributions of ⁇ 4 ⁇ 7 receptor blockade in peripheral blood in distinction to effects on cell-cell interactions in the tissue compartment are a research priority.
• Example 2 Fecal Calprotectin assessment Fecal levels of calprotectin, a neutrophil cytostolic protein, correlate with endoscopic severity of inflammation in inflammatory bowel disease: ⁇ 50 ⁇ g/g: Typical of non- diseased population; >50 to ⁇ 150 ⁇ g/g: Possible mucosal inflammation; >150 ⁇ g/g: Active inflammation; Higher levels associated with greater risk of relapse. The aim is to determine if induction treatment with VDZ reduces fecal calprotectin levels in patients with moderately to severely active UC.
• the Percent of Baseline Calprotectin at Week 6 by Treatment or Response Status is shown in FIG. 14.
• Table 4 Clinical Response and Remission at Week 6 by Baseline Starting fCal Category
• mean fCAL levels were 2370 and 2552 ⁇ g/g in PBO and VDZ-treated patients, respectively.
• VDZ induction therapy for UC reduced fCal levels at week 6, a marker of mucosal inflammation, significantly more than PBO. Response and remission rates were higher with VDZ regardless of baseline fCal concentration.
• Example 3 Deep Remission at week 6 as predictor of clinical outcome in ulcerative colitis
• Deep remission a combination of endoscopic and patient-reported outcomes, is an emerging treatment goal for patients with ulcerative colitis (UC).
• UC ulcerative colitis
• Statistically significant and clinically meaningful improvement in deep remission endpoints at weeks 6 and 52 were previously reported in the GEMINI 1 population using varying combinations of Mayo subscores of endoscopic and patient-reported outcomes.
• HRQoL health-related quality of life
• Corticosteroid (CS)-free remission patients using oral CS at baseline who have discontinued CS and are in clinical remission at week 52
• IBDQ Inflammatory Bowel Disease Questionnaire
• Definition 1 is considered more stringent than definition 2.
• VDZ-treated patients in deep remission had improved IBDQ and EQ-5D VAS. Even among patients not in deep remission at week 6, maintenance treatment with VDZ resulted in more patients with improved clinical and HRQoL outcomes than those re-randomised to PBO.
• a greater percentage of VDZ-treated patients were in deep remission at week 52 using either definition compared with PBO-treated patients; use of the less stringent definition 2 resulted in more patients classified as having achieved deep remission. Using either definition, a greater percentage of patients in deep remission at week 6 met most clinical and HRQoL endpoints at week 52 compared to those not in deep remission.

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