WO2018099968A1 - Treatment of infection by respiratory syncytial virus (rsv) - Google Patents

Treatment of infection by respiratory syncytial virus (rsv) Download PDF

Info

Publication number
WO2018099968A1
WO2018099968A1 PCT/EP2017/080817 EP2017080817W WO2018099968A1 WO 2018099968 A1 WO2018099968 A1 WO 2018099968A1 EP 2017080817 W EP2017080817 W EP 2017080817W WO 2018099968 A1 WO2018099968 A1 WO 2018099968A1
Authority
WO
WIPO (PCT)
Prior art keywords
polypeptide
daily
rsv
inhalation device
seq
Prior art date
Application number
PCT/EP2017/080817
Other languages
French (fr)
Inventor
Anne BROCHOT
Carmen Fleurinck
Robert ZELDIN
Original Assignee
Ablynx N.V.
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Ablynx N.V. filed Critical Ablynx N.V.
Publication of WO2018099968A1 publication Critical patent/WO2018099968A1/en

Links

Classifications

    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K16/00—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies
    • C07K16/08—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from viruses
    • C07K16/10—Immunoglobulins [IGs], e.g. monoclonal or polyclonal antibodies against material from viruses from RNA viruses
    • C07K16/1027—Paramyxoviridae, e.g. respiratory syncytial virus
    • 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
    • A61K39/12—Viral antigens
    • 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
    • A61K2039/541—Mucosal route
    • A61K2039/544—Mucosal route to the airways
    • 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
    • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
    • C07K2317/22—Immunoglobulins specific features characterized by taxonomic origin from camelids, e.g. camel, llama or dromedary
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/30—Immunoglobulins specific features characterized by aspects of specificity or valency
    • C07K2317/35—Valency
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K2317/00—Immunoglobulins specific features
    • C07K2317/50—Immunoglobulins specific features characterized by immunoglobulin fragments
    • C07K2317/56—Immunoglobulins specific features characterized by immunoglobulin fragments variable (Fv) region, i.e. VH and/or VL
    • C07K2317/569—Single domain, e.g. dAb, sdAb, VHH, VNAR or nanobody®
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12N—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA
    • C12N2760/00—MICROORGANISMS OR ENZYMES; COMPOSITIONS THEREOF; PROPAGATING, PRESERVING, OR MAINTAINING MICROORGANISMS; MUTATION OR GENETIC ENGINEERING; CULTURE MEDIA ssRNA viruses negative-sense
    • C12N2760/00011—Details
    • C12N2760/18011—Paramyxoviridae
    • C12N2760/18511—Pneumovirus, e.g. human respiratory syncytial virus

Definitions

  • the present invention provides methods for the treatment of RSV infections in young children. More specifically, the present invention provides specific dose regimens of immunoglobulin single variable domains that neutralize RSV, for pulmonary administration to young children.
  • Respiratory syncytial virus is a recurrent cause of severe respiratory tract infections in infants and very young children and causes annual epidemics during the winter months.
  • RSV typically causes its primary infection at the point of entry: the ciliated epithelial cells that line the nasal cavity and airways (Black 2003, Respir. Care 48: 209-31; discussion 231-3).
  • Primary infections are usually symptomatic with clinical signs ranging from mild upper respiratory tract illness to more severe lower respiratory tract infections (LRTIs), including bronchopneumonia and bronchiolitis (Aliyu, et al. 2010, Bayero Journal of Pure and Applied Sciences 3: 147-155), which occurs predominantly in infants.
  • the transmembrane glycoproteins F and G are the primary surface antigens of RSV.
  • the attachment protein (G) mediates binding to cell receptors, while the F protein promotes fusion with cell membranes, allowing penetration into the host cell (Lopez et al. 1998, 72: 6922-8).
  • G attachment protein
  • 2 serotypes of RSV have been identified (A and B), along with several subtypes.
  • Glycoprotein F In contrast to the G protein, the F protein is highly conserved between RSV serotypes A and B (89% amino acid identity), and is therefore considered the main target for development of viral entry inhibitors. Glycoprotein F also induces fusion of infected cells with adjacent uninfected cells. This hallmark feature results in the appearance of multinucleate cell formations (epithelial cell syncytia), which allow for cell-to-cell transmission of replicated viral ribonucleic acid (RNA), conferring additional protection against host immune responses (Black 2003).
  • RSV infection imposes a significant burden on health care infrastructure and there remains a high medical need for treatment options, especially since there is no vaccine available to prevent RSV infections.
  • SYNAGIS ® humanized monoclonal antibody
  • the restricted use of SYNAGIS ® is due, at least in part, to the high cost of this product. Since there are no adequate medications available for treatment of RSV infection, the standard of care for hospitalized infants is mostly supportive (e.g., fluid/feed supplementation, observation, and respiratory support as needed). There is clearly a need for improved and/or cheaper prophylactic and/or therapeutic agents for the prevention and/or treatment of infections by hRSV.
  • ALX-0171 of the present disclosure is an immunoglobulin single variable domain directed against the fusion protein of the human respiratory syncytial virus.
  • ALX-0171 consists of 3 anti-hRSV immunoglobulin single variable domains, recombinantly linked by a flexible linker.
  • ALX-0171 was extensively characterized in vitro and in vivo (see for example WO 2010/139808; the contents of which are incorporated by reference in their entirety).
  • the anti-hRSV anti-hRSV
  • the target concentration at which a clinically meaningful reduction of RSV activity is obtained (9 ⁇ g/ml) was estimated to be reached in the alveolar space using a deposited dose of 0.024 mg/kg body weight. Based on this estimated deposited dose, the nominal dose for the pulmonary administration of ALX-0171 to young children was defined as 1.2 mg/kg. Based on this approach, a dose of 1.2 mg/kg was evaluated in the pediatric study described in WO 2016/055656.
  • the present invention provides improved dose regimens for pulmonary administration of ALX-0171 in a pediatric population. More particularly, the present invention provides improved dose regimens for the pulmonary administration of ALX-0171 to young children, such as infants and toddlers.
  • the present invention now provides improved dose regimens for the pulmonary administration, to pediatric subjects, of ALX-0171. These improved dose regimens result in local drug concentrations in the lower respiratory tract at which clinical efficacy is observed.
  • the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration, to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
  • the nominal dose is 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg, such as 3 mg/kg.
  • the present invention relates to a method for the treatment of SV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
  • the nominal dose is 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg, such as 6 mg/kg.
  • the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
  • the nominal dose is 7.5 to 11 mg/kg daily, preferably 7.5 to 10.7 mg/kg, such as 9 mg/kg.
  • the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.5 to 10.7 mg/kg daily, such as 9 mg/kg daily.
  • the invention also relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
  • RSV infection includes RSV infection of the upper respiratory tract, RSV infection of the lower respiratory tract, including bronchiolitis and broncho-pneumonia, as well as diseases and/or disorders associated with RSV infection such as respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
  • the RSV infection is RSV lower respiratory tract infection.
  • the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
  • the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
  • the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
  • the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
  • the invention also relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
  • the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
  • the polypeptide is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, such as e.g. for 3 consecutive days.
  • the young child is aged less than 24 months.
  • the young child is aged 28 days to less than 24 months.
  • the young child is aged 1 month to less than 24 months.
  • the young child is aged less than 36 months.
  • the young child is aged 28 days to less than 36 months.
  • the young child is aged 1 month to less than 36 months. In one aspect, the young child is an infant.
  • the young child is a toddler.
  • the young child is aged less than 24 months, with a gestational age of more than 33 weeks.
  • the young child is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks.
  • the young child is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
  • the young child is aged less than 36 months, with a gestational age of more than 33 weeks.
  • the young child is aged 28 days to less than 36 months, with a gestational age of more than 33 weeks.
  • the young child is aged 1 month to less than 36 months, with a gestational age of more than 33 weeks.
  • the young child is an infant, with a gestational age of more than 33 weeks.
  • the young child is a toddler, with a gestational age of more than 33 weeks.
  • the young child is diagnosed with RSV lower respiratory tract infection.
  • the young child is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
  • the young child is hospitalised for RSV lower respiratory tract infection.
  • the polypeptide (also referred to as "polypeptide of the invention”) comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprises a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61.
  • CDRl has the amino acid sequence of SEQ ID NO: 46
  • CDR2 has the amino acid sequence of SEQ ID NO: 49
  • a CDR3 has the amino acid sequence of SEQ ID NO: 61.
  • Preferred polypeptides of the invention encompass at least one (preferably two, most preferably three) anti-RSV immunoglobulin single variable domain(s) selected from one of the amino acid sequences of SEQ ID NOs: 1-34.
  • the polypeptide of the invention is selected from one of the amino acid sequences of SEQ ID NOs: 65-85, preferably ALX-0171.
  • polypeptide of the invention can be administered as a monotherapy or in combination with another therapeutic agent. In one aspect, the polypeptide of the invention is administered as a monotherapy. In one aspect, polypeptide of the invention is administered as a combination therapy.
  • the invention also provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the other therapeutic agent is a bronchodilator.
  • the bronchodilator preferably belongs to the class of beta2-mimetics or to the class of anticholinergics.
  • the bronchodilator is a long-acting beta2-mimetic such as e.g.
  • the bronchodilator is a short-acting beta2-mimetic such as e.g. salbutamol (e.g. at a dose of 200 micrograms), terbutaline, pirbuterol, fenoterol, tulobuterol, levosabutamol, or a mixture thereof.
  • the bronchodilator is an anticholinergic such as e.g. tiotropium, oxitropium, ipratropium bromide or a mixture thereof.
  • the present invention also relates to an inhalation device (also referred to herein as "inhalation device of the invention") comprising a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.20 mL-2.25 mL or 0.20-1.50 mL.
  • the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.20-0.75 mL, such as e.g. 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, or 0.75 mL.
  • the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.40-1.50 mL, such as e.g. 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, or 1.50 mL.
  • the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.60-2.25 mL, such as e.g. 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, or 2.25 mL.
  • the inhalation device is an aerosol delivery system, such as a nebulizer, preferably a vibrating mesh nebulizer.
  • the nebulizer preferably has a fixed flow of air or oxygen, such as a flow of air or oxygen at 2 L/min.
  • the inhalation device may comprise:
  • the flow channel may be sized and shaped to achieve, at a position immediately upstream of the lateral opening, an average gas velocity of at least 4 m/s at a flow rate of 2 L/min, and/or the flow channel upstream of the lateral opening may be shaped such as to effect a laminar flow when a gas is conducted through the flow channel at a flow rate of 1 to 20 L/min.
  • the polypeptide of the invention present in the 50 mg/mL composition comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61.
  • the anti-RSV immunoglobulin single variable domains comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of SEQ ID NO: 49, and a CDR3 having the amino acid sequence of SEQ ID NO: 61.
  • the anti-RSV immunoglobulin single variable domain is selected from one of the amino acid sequence of SEQ ID NOs: 1-34.
  • polypeptide of the invention present in the inhalation device as described herein is selected from one of the amino acid sequence of SEQ ID NOs: 65-85, preferably ALX-0171.
  • the present invention also relates to such inhalation devices as described above, for use in the methods of the invention. Accordingly, in one aspect, the invention provides the inhalation device as described herein, for use in the treatment of RSV infection in a young child. In one aspect, the invention provides the inhalation device as described herein, for use in the treatment of RSV lower respiratory tract infection in a young child.
  • the young child treated with the inhalation device of the invention is aged less than 24 months.
  • the young child treated with the inhalation device of the invention is aged 28 days to less than 24 months.
  • the young child treated with the inhalation device of the invention is aged 1 month to less than 24 months.
  • the young child treated with the inhalation device of the invention is aged less than 36 months.
  • the young child treated with the inhalation device of the invention is aged 28 days to less than 36 months.
  • the young child treated with the inhalation device of the invention is aged 1 month to less than 36 months.
  • the young child treated with the inhalation device of the invention is an infant.
  • the young child treated with the inhalation device of the invention is a toddler.
  • the young child treated with the inhalation device of the invention is aged less than 24 months, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks. In one aspect, the young child treated with the inhalation device of the invention is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is aged less than 36 months, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is aged 28 days to less than 36 months, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is aged 1 month to less than 36 months, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is an infant, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is a toddler, with a gestational age of more than 33 weeks.
  • the young child treated with the inhalation device of the invention is diagnosed with SV lower respiratory tract infection.
  • the young child treated with the inhalation device of the invention is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
  • the young child treated with the inhalation device of the invention is hospitalised for RSV lower respiratory tract infection.
  • the inhalation device of the invention can be used as a monotherapy or in combination with another therapeutic agent.
  • the inhalation device of the invention is used as a monotherapy.
  • at least one additional therapeutic agent is administered.
  • the additional therapeutic agent can, for example, be a bronchodilator.
  • the inhalation device of the invention is used in combination with a bronchodilator.
  • the bronchodilator used with the inhalation device of the invention preferably may belong to the class of beta2-mimetics or to the class of anticholinergics.
  • the bronchodilator is a long-acting beta2-mimetic such as e.g. formoterol or a solvate thereof, salmeterol or a salt thereof, or a mixture thereof.
  • the bronchodilator is a short-acting beta2-mimetic such as e.g.
  • the bronchodilator is an anticholinergic such as e.g. tiotropium, oxitropium, ipratropium bromide or a mixture thereof.
  • Figure 1 Boxplots of ALX-0171 serum concentrations measured in a phase l/2a study after administration of a (nominal) dose of 1.2 mg/kg of ALX-0171 by inhalation to infants and young children hospitalized for RSV LRTI.
  • Left boxplots shows concentrations from all subjects who had their sample taken.
  • Right boxplot shows concentrations from subjects who had their sample taken at the time defined per protocol (6 hours after the last nebulization).
  • Dashed horizontal lines represent the 90% prediction interval from the PBPK model, full horizontal line represents the median prediction from the PBPK model. Note: Six subjects had concentration below the limit of quantification and were associated to a concentration of 0.5 ng/mL (half the quantification limit) for plotting purpose.
  • Figure 2 Overview of the study design of the clinical study described in Example 2.
  • Figure 3 Overview of the study flow of the clinical study described in Example 2.
  • FIG. 4 Overview of the FOX-Flamingo inhalation system.
  • Figure 5 Cross-sectional side view of a nebulizer.
  • a nucleic acid sequence or amino acid sequence is considered to be "(in) essentially isolated (form)" - for example, compared to the reaction medium or cultivation medium from which it has been obtained - when it has been separated from at least one other component with which it is usually associated in said source or medium, such as another nucleic acid, another
  • nucleic acid sequence or amino acid sequence is considered “essentially isolated” when it has been purified at least 2-fold, in particular at least 10- fold, more in particular at least 100-fold, and up to 1000-fold or more.
  • a nucleic acid sequence or amino acid sequence that is "in essentially isolated form” is preferably essentially homogeneous, as determined using a suitable technique, such as a suitable chromatographical technique, such as polyacrylamide-gel electrophoresis.
  • nucleotide sequence or amino acid sequence is said to "comprise” another nucleotide sequence or amino acid sequence, respectively, or to “essentially consist of” or “consist essentially of” another nucleotide sequence or amino acid sequence, this may mean that the latter nucleotide sequence or amino acid sequence has been incorporated into the first mentioned nucleotide sequence or amino acid sequence, respectively, but more usually this generally means that the first mentioned nucleotide sequence or amino acid sequence comprises within its sequence a stretch of nucleotides or amino acid residues, respectively, that has the same nucleotide sequence or amino acid sequence, respectively, as the latter sequence, irrespective of how the first mentioned sequence has actually been generated or obtained (which may for example be by any suitable method).
  • a polypeptide of the invention when a polypeptide of the invention is said to comprise an immunoglobulin single variable domain, this may mean that said immunoglobulin single variable domain sequence has been incorporated into the sequence of the polypeptide of the invention, but more usually this generally means that the polypeptide of the invention contains within its sequence the sequence of the immunoglobulin single variable domain irrespective of how said polypeptide of the invention has been generated or obtained.
  • the first mentioned nucleic acid or nucleotide sequence is preferably such that, when it is expressed into an expression product (e.g. a
  • the amino acid sequence encoded by the latter nucleotide sequence forms part of said expression product (in other words, that the latter nucleotide sequence is in the same reading frame as the first mentioned, larger nucleic acid or nucleotide sequence).
  • the immunoglobulin single variable domain used in the method of the invention either is exactly the same as the polypeptide of the invention or corresponds to the polypeptide of the invention which has a limited number of amino acid residues, such as 1-20 amino acid residues, for example 1-10 amino acid residues and preferably 1-6 amino acid residues, such as 1, 2, 3, 4, 5 or 6 amino acid residues, added at the amino terminal end, at the carboxy terminal end, or at both the amino terminal end and the carboxy terminal end of the immunoglobulin single variable domain.
  • sequence as used herein (for example in terms like “immunoglobulin sequence”, “variable domain sequence”, “immunoglobulin single variable domain sequence”, “VHH sequence” or “protein sequence), should generally be understood to include both the relevant amino acid sequence as well as nucleic acid sequences or nucleotide sequences encoding the same, unless the context requires a more limited interpretation.
  • amino acid sequence such as an immunoglobulin single variable domain, an antibody, a polypeptide of the invention, or generally an antigen binding protein or polypeptide or a fragment thereof
  • an amino acid sequence that "(specifically) binds", that "can (specifically) bind to”, that "has affinity for” and/or that "has specificity for” a specific antigenic determinant, epitope, antigen or protein (or for at least one part, fragment or epitope thereof) is said to be “against” or “directed against” said antigenic determinant, epitope, antigen or protein.
  • the affinity denotes the strength or stability of a molecular interaction.
  • the affinity is commonly given by the K D , or dissociation constant, which has units of mol/liter (or M).
  • the affinity can also be expressed as an association constant, K A , which equals 1/K D and has units of (mol/liter) "1 (or M "1 ).
  • K A association constant
  • the K D for biological interactions which are considered meaningful are typically in the range of 10 10 M (0.1 nM) to 10 "5 M (10000 nM). The stronger an interaction is, the lower is its K D .
  • the off-rate k 0 ff has units s "1 (where s is the SI unit notation of second).
  • the on-rate k on has units M V 1 .
  • the on-rate may vary between 10 2 I V 1 to about 10 7 I V 1 , approaching the diffusion-limited association rate constant for bimolecular interactions.
  • the off-rate is related to the half-life of a given molecular interaction by the relation .
  • the off-rate may vary between 10 "6 s "1 (near irreversible complex with a ti/ 2 of multiple days) to 1 s "1 s).
  • Specific binding of an antigen-binding protein to an antigen or antigenic determinant can be determined in any suitable manner known per se, including, for example, Scatchard analysis and/or competitive binding assays, such as radio-immunoassays ( IA), enzyme immunoassays (EIA) and sandwich competition assays, and the different variants thereof known per se in the art; as well as the other techniques mentioned herein.
  • Scatchard analysis and/or competitive binding assays such as radio-immunoassays ( IA), enzyme immunoassays (EIA) and sandwich competition assays, and the different variants thereof known per se in the art; as well as the other techniques mentioned herein.
  • K D or K A
  • This can for example be performed using the well-known Biacore instruments (Pharmacia Biosensor AB, Uppsala, Sweden).
  • Kinetic Exclusion Assay (KinExA) (Drake et al. 2004, Analytical Biochemistry 328: 35-43) measures binding events in solution without labeling of the binding partners and is based upon kinetically excluding the dissociation of a complex.
  • the GYROLABTM immunoassay system provides a platform for automated bioanalysis and rapid sample turnaround (Fraley et al. 2013, Bioanalysis 5: 1765-74).
  • the measured K D may correspond to the apparent K D if the measuring process somehow influences the intrinsic binding affinity of the implied molecules for example by artifacts related to the coating on the biosensor of one molecule. Also, an apparent K D may be measured if one molecule contains more than one recognition sites for the other molecule. In such situation the measured affinity may be affected by the avidity of the interaction by the two molecules.
  • K D K D and apparent K D should be treated with equal importance or relevance.
  • infectiousness of a virus refers to the proportion of living subjects that, when exposed to said virus, actually becomes infected by said virus.
  • Neutralization of a virus refers to the modulation and/or reduction and/or prevention and/or inhibition of the infectivity (as defined herein) of a virus by binding of a neutralizing compound to the virion, as measured using a suitable in vitro, cellular or in vivo assay (such as those mentioned further).
  • dosing refers to the administration of the polypeptide of the invention. Unless explicitly indicated different, in the context of the present invention, the term “dosing” refers to the pulmonary administration of the polypeptide of the invention.
  • fill volume refers to the volume of the composition of polypeptide of the invention filled in the nebulizer.
  • dose refers to an amount of polypeptide of the invention that is administered to the subject.
  • the "nominal dose” refers to the dose (e.g. in mg/kg) of polypeptide of the invention that is filled in the nebuliser.
  • the nominal dose is expressed per kilogram (kg) of body weight of the subject.
  • fill dose refers to the actual amount (e.g. in mg) of polypeptide of the invention that is filled in the nebulizer.
  • the “fill dose” can easily be determined based on the fill volume (volume of therapeutic composition filled in the nebulizer) and the concentration of the polypeptide of the invention in the therapeutic composition and will depend on the weight of the subject to be treated.
  • the “delivered dose” refers to the amount of polypeptide of the invention in aerosol particles generated by the vibrating mesh nebuliser and available in the face mask for inhalation.
  • the “inhaled dose” refers to the amount of polypeptide of the invention in aerosol particles available at the upper respiratory tract (i.e., the dose which is inhaled).
  • the inhaled dose can be calculated as a percentage (%) from the nominal dose and will depend on the characteristics of the nebulizer.
  • the "deposited dose” refers to the amount of polypeptide of the invention in aerosol particles deposited in the lower respiratory tract.
  • the deposited dose will depend on the characteristics of the inhaled particles and the breathing pattern of the young child suffering SV infection. Breathing patterns in RSV infected children are e.g. described by Amirav et al. 2002 (J. Nucl. Med. 43: 487-91), Amirav et al. 2012 (Arch. Dis. Child 97: 497-501), Chua et al. 1994 (Eur. Respir. J. 7: 2185-91), Fok et al. 1996 (Pediatr. Pulmonol. 21: 301-9), Wildhaber et al. 1999 (J. Pediatr. 135: 28-33), Totapally et al. 2002 (Crit. Care 6: 160-5), Mundt et al. 2012 (Pediatr. 2012: 721295).
  • the “systemic dose” refers to the amount of polypeptide of the invention absorbed via the alveolar lining fluid of the lower respiratory tract and released into circulation.
  • the systemic dose can easily be determined by measuring the concentration of the polypeptide of the invention in the systemic circulation.
  • the "systemic circulation” as used in the present invention is the part of the cardiovascular system which carries oxygenated blood away from the heart to the body, and returns deoxygenated blood back to the heart.
  • a child is generally a human subject between birth and puberty or in the developmental stage of childhood.
  • a "young child” refers to a child of less than 24 months or less than 36 months (3 years).
  • An “infant” is the very young offspring of a human. The term is usually considered synonymous with baby.
  • the term “infant” is typically applied to young children between the ages of 28 days or 1 month and 12 months.
  • the term “toddler” may be used instead.
  • a “toddler” is a child between the ages of one and three.
  • a “toddler” is a child between the ages of one and less than 24 months or between the ages of one and less than 36 months (3 years).
  • the respiratory system comprises 2 distinct zones: a conducting and a respiratory zone, within which the airway and vascular compartments lie (see e.g. "Pulmonary Drug Delivery”, Edited by Karoline Bechtold-Peters and Henrik Luessen, 2007, ISBN 978-3-87193-322-6 pages 16-28).
  • the conducting zone consists of the nose, pharynx, larynx, trachea, bronchi, and bronchioles. These structures form a continuous passageway for air to move in and out of the lungs.
  • the respiratory zone is found deep inside the lungs and is made up of the respiratory bronchioles, alveolar ducts, and alveoli. These thin-walled structures allow inhaled oxygen to diffuse into lung capillaries in exchange for carbon dioxide.
  • Anatomically, the same structures are often divided into the upper and the lower respiratory tracts.
  • the upper respiratory structures are found in the head and neck and consist of the nose, pharynx, and larynx.
  • the lower respiratory tract structures are located in the thorax or chest and include the trachea, bronchi, and lungs (i.e. bronchioles, alveolar ducts, and alveoli).
  • the lower respiratory tract thus refers to the portions of the airways from the trachea to the lungs.
  • Diagnosed with RSV LRTI may also mean that the subject has a positive RSV diagnostic test.
  • administering means that the polypeptide of the invention is administered to the respiratory tract.
  • the polypeptide of the invention in this delivery method, is present in an aerosol obtained from nebulizing (with a nebulizer) the polypeptide of the invention.
  • An “inhalation device” is a medical device used for delivering medication into the body via the lungs.
  • an "aerosol” as used herein refers to a suspension of liquid in the form of fine particles dispersed in a gas (i.e. a fine mist or spray containing minute particles).
  • a gas i.e. a fine mist or spray containing minute particles.
  • particle refers to liquids, e.g., droplets.
  • polypeptides of the invention to the lungs can be inhaled via the mouth and/or via the nose.
  • the generation of particles smaller than approximately 5 or 6 micrometer is considered necessary to achieve deposition as the fine particle fraction (FPF) (i.e. in the respiratory bronchioles and alveolar region) (O'Callaghan and Barry, 1997, Thorax 52: S31-S44).
  • the particle size in an aerosol can be expressed as mass median diameter (MMD) or volume median diameter (VMD).
  • MMD mass median diameter
  • VMD volume median diameter
  • the "mass median diameter" is defined as the geometric particle diameter of an aerosol, where 50% of the aerosol mass is larger than this value and 50% is smaller than this value.
  • volume median diameter is defined as the geometric particle diameter of an aerosol, where 50% of the aerosol volume is larger than this value and 50% is smaller than this value.
  • density of the aerosol particles is 1 g/cm 3 , the VMD and MMD are equivalent.
  • the "mass median aerodynamic diameter (MMAD)" is defined as the geometric mean aerodynamic diameter, where 50% of the aerosol mass will be smaller than this value and 50% will be larger than this value.
  • the MMAD is determined by the aerodynamic behavior of the particles in an airflow and relates to the size and density of a particle with its behavior in moving air.
  • nebulization refers to the conversion of a liquid into a mist or fine spray by a nebulizer (as further defined herein).
  • an “aerosol generator” is a device or device component capable of generating an aerosol from a liquid formulation; e.g. a pharmaceutical composition for inhalation use.
  • a liquid formulation e.g. a pharmaceutical composition for inhalation use.
  • nebulizer or “nebulising means” may be employed.
  • a "gas” refers to any gas or mixture of gases suitable for inhalation.
  • “Lateral”, or “laterally”, means away from the middle, centre, or centre axis of a device or device component.
  • the "tidal volume" of a subject or patient is the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied.
  • the term “pharmaceutically active amount” refers to the amount of a therapeutic agent (e.g. a polypeptide of the invention), that is sufficient to reduce the severity and/or duration of one or more diseases and/or disorders.
  • polypeptides of the invention may be non-naturally occurring.
  • the polypeptides of the invention may have been designed, manufactured, synthesized, and/or recombined to produce a non-naturally occurring sequence.
  • immunoglobulin sequence whether used herein to refer to a heavy chain antibody or to a conventional 4-chain antibody - is used as a general term to include both the full-size antibody, the individual chains thereof, as well as all parts, domains or fragments thereof (including but not limited to antigen-binding domains or fragments such as V HH domains or V H /V L domains, respectively).
  • sequence as used herein (for example in terms like “immunoglobulin sequence”, “antibody sequence”, “variable domain sequence”, “V HH sequence” or “protein sequence”), should generally be understood to include both the relevant amino acid sequence as well as nucleic acids or nucleotide sequences encoding the same, unless the context requires a more limited interpretation.
  • immunoglobulin single variable domain defines molecules wherein the antigen binding site is present on, and formed by, a single immunoglobulin domain. This sets immunoglobulin single variable domains apart from
  • VH heavy chain variable domain
  • VL light chain variable domain
  • CD s complementarity determining regions
  • the binding site of an immunoglobulin single variable domain is formed by a single V H or V L domain.
  • the antigen binding site of an immunoglobulin single variable domain is formed by no more than three CDRs.
  • immunoglobulin single variable domain and "single variable domain” hence does not comprise conventional immunoglobulins or their fragments which require interaction of at least two variable domains for the formation of an antigen binding site. However, these terms do comprise fragments of conventional immunoglobulins wherein the antigen binding site is formed by a single variable domain.
  • single variable domains will be amino acid sequences that essentially consist of 4 framework regions (FR1 to FR4 respectively) and 3 complementarity determining regions (CDR1 to CDR3 respectively).
  • Such single variable domains and fragments are most preferably such that they comprise an immunoglobulin fold or are capable for forming, under suitable conditions, an immunoglobulin fold.
  • the single variable domain may for example comprise a light chain variable domain sequence (e.g. a V L -sequence) or a suitable fragment thereof; or a heavy chain variable domain sequence (e.g. a V H -sequence or V HH sequence) or a suitable fragment thereof; as long as it is capable of forming a single antigen binding unit (i.e.
  • a functional antigen binding unit that essentially consists of the single variable domain, such that the single antigen binding domain does not need to interact with another variable domain to form a functional antigen binding unit, as is for example the case for the variable domains that are present in for example conventional antibodies and scFv fragments that need to interact with another variable domain - e.g. through a V H /V L interaction - to form a functional antigen binding domain).
  • the immunoglobulin single variable domains can be heavy chain variable domain sequences that are derived from a conventional four-chain antibody or heavy chain variable domain sequences that are derived from a heavy chain antibody.
  • the single variable domain or immunoglobulin single variable domain may be a (single) domain antibody (or an amino acid that is suitable for use as a (single) domain antibody), a "dAb” or dAb (or an amino acid that is suitable for use as a dAb) or a Nanobody (as defined herein, and including but not limited to a V HH ); other single variable domains, or any suitable fragment of any one thereof.
  • variable domains can be derived from certain species of shark (for example, the so- called "IgNA domains", see for example WO 05/18629).
  • the immunoglobulin single variable domain may be a Nanobody ® (as defined herein) or a suitable fragment thereof.
  • Nanobody 9 and Nanobodies 9 are registered trademarks of Ably nx N. V.
  • WO 08/020079 page 16
  • V HH 's and Nanobodies For a further description of V HH 's and Nanobodies, reference is made to the review article by Muyldermans 2001 (Reviews in Molecular Biotechnology 74: 277-302), as well as to the following patent applications, which are mentioned as general background art: WO 94/04678, WO 95/04079 and WO 96/34103 of the Vrije Universiteit Brussel; WO 94/25591, WO 99/37681, WO 00/40968, WO 00/43507, WO 00/65057, WO 01/40310, WO 01/44301, EP 1134231 and WO 02/48193 of Unilever; WO 97/49805, WO 01/21817, WO 03/035694, WO 03/054016 and WO 03/055527 of the Vlaams Instituut voor Biotechnologie (VIB); WO 03/050531 of Algonomics N.V
  • Nanobodies in particular VHH sequences and partially humanized Nanobodies
  • Nanobodies including humanization and/or camelization of Nanobodies, as well as other modifications, parts or fragments, derivatives or "Nanobody fusions", multivalent constructs (including some non-limiting examples of linker sequences) and different modifications to increase the half-life of the Nanobodies and their preparations can be found e.g. in WO 08/101985 and WO 08/142164.
  • the term “immunoglobulin single variable domain” or “single variable domain” comprises polypeptides which are derived from a non-human source, preferably a camelid, preferably a camelid heavy chain antibody. They may be humanized, as previously described. Moreover, the term comprises polypeptides derived from non-camelid sources, e.g. mouse or human, which have been “camelized”, as e.g. described in Davies and Riechmann 1994 (FEBS 339: 285-290), 1995 (Biotechonol. 13: 475-479), 1996 (Prot. Eng. 9: 531-537) and iechmann and Muyldermans 1999 (J. Immunol. Methods 231: 25-38).
  • immunoglobulin single variable domain encompasses immunoglobulin sequences of different origin, comprising mouse, rat, rabbit, donkey, human and camelid immunoglobulin sequences. It also includes fully human, humanized or chimeric immunoglobulin sequences. For example, it comprises camelid immunoglobulin sequences and humanized camelid immunoglobulin sequences, or camelized immunoglobulin single variable domains, e.g. camelized dAbs and camelized VH as described by Ward et al. 1989, WO 94/04678, and Davies and Riechmann 1994, 1995 and 1996).
  • immunoglobulin single variable domains may be derived in any suitable manner and from any suitable source, and may for example be naturally occurring V HH sequences (i.e. from a suitable species of Camelid) or synthetic or semi-synthetic amino acid sequences, including but not limited to partially or fully "humanized” V HH , "camelized” immunoglobulin sequences (and in particular camelized V H ), as well as Nanobodies and/or V HH that have been obtained by techniques such as affinity maturation (for example, starting from synthetic, random or naturally occurring immunoglobulin sequences, such as V HH sequences), CDR grafting, veneering, combining fragments derived from different immunoglobulin sequences, PCR assembly using overlapping primers, and similar techniques for engineering immunoglobulin sequences well known to the skilled person; or any suitable combination of any of the foregoing.
  • affinity maturation for example, starting from synthetic, random or naturally occurring immunoglobulin sequences, such as V HH sequences
  • CDR grafting for example
  • the total number of amino acid residues in an immunoglobulin single variable domain can be in the region of 110-120, is preferably 112-115, and is most preferably 113 (although it will be clear, based on the examples of immunoglobulin single variable domain sequences that are given herein as well as in WO 08/020079, in WO 06/040153 and in the further immunoglobulin single variable domain -related references cited therein, that the precise number of amino acid residues will also depend on the length of the specific CDR's that are present in the immunoglobulin single variable domain).
  • the amino acid sequence and structure of an immunoglobulin single variable domain can be considered - without however being limited thereto - to be comprised of four framework regions or "FR's", which are referred to in the art and herein as “Framework region 1" or “FR1”; as “Framework region 2" or “FR2”; as “Framework region 3" or “FR3”; and as “Framework region 4" or “FR4", respectively; which framework regions are interrupted by three complementary determining regions or "CDR's”, which are referred to in the art as "Complementarity Determining Region 1" or “CDR1”; as “Complementarity Determining Region 2" or “CDR2”; and as “Complementarity Determining Region 3" or “CDR3", respectively.
  • FR1 of an immunoglobulin single variable domain comprises the amino acid residues at positions 1-30
  • CDR1 of an immunoglobulin single variable domain comprises the amino acid residues at positions 31-35
  • FR2 of an immunoglobulin single variable domain comprises the amino acids at positions 36- 49
  • CDR2 of an immunoglobulin single variable domain comprises the amino acid residues at positions 50-65
  • FR3 of an immunoglobulin single variable domain comprises the amino acid residues at positions 66-94
  • CDR3 of an immunoglobulin single variable domain comprises the amino acid residues at positions 95-102
  • FR4 of an immunoglobulin single variable domain comprises the amino acid residues at positions 103-113.
  • the immunoglobulin single variable domain binds F- protein of hRSV and is therefore also referred to as "anti-hRSV immunoglobulin single variable domain” or "anti-hRSV immunoglobulin single variable domain of the invention". More in particular, the anti-hRSV immunoglobulin single variable domain can bind protein F of hRSV with an affinity (suitably measured and/or expressed as a K D -value (actual or apparent), a K A -value (actual or apparent), a k on -rate and/or a k 0ff -rate) preferably such that:
  • K D dissociation constant
  • affinity is determined by Surface Plasmon Resonance, such as by Biacore, or by KinExA (see above).
  • the immunoglobulin single variable domain comprised in the polypeptide of the invention is capable of neutralizing hRSV.
  • Assays to determine the neutralizing capacity of a molecule include e.g. the microneutralization assay described by Anderson et al. (1985, J. Clin. Microbiol. 22: 1050-1052; 1988, J. Virol. 62: 4232-4238), or modifications of this assay such as e.g. described in WO 2010/139808, or a plaque reduction assay as for example described by Johnson et al. (1997, J. Inf. Dis. 176: 1215-1224), and modifications thereof.
  • a microneutralization assay on h SV Long such as e.g. described in WO 2010/139808; page 375, Example 6
  • immunoglobulin single variable domain may have IC50 values between 100 nM and 1000 nM, preferably between 100 nM and 500 nM, or less.
  • the anti-hRSV immunoglobulin single variable domain has a CDR1 which is SEQ ID NO: 46, a CDR2 which is selected from SEQ ID NOs: 49 and 50, and a CDR3 which is SEQ ID NO: 61.
  • CDR1 is SEQ ID NO: 46
  • CDR2 is SEQ ID NO: 49
  • CDR3 is SEQ ID NO: 61.
  • Table A-l also shows preferred combinations of CDR sequences and framework sequences.
  • immunoglobulin single variable domains for use in the polypeptide of the invention are described in WO 2010/139808.
  • the anti-hRSV immunoglobulin single variable domain is selected from any of SEQ ID NOs: 1-34 in Table A-2.
  • the immunoglobulin single variable domains for use in the method of the invention may form part of a polypeptide (referred herein as "polypeptide(s) of the invention"), which may comprise or (essentially) consist of one or more immunoglobulin single variable domains that specifically bind F- protein of hRSV and which may optionally further comprise one or more further amino acid sequences (all optionally linked via one or more suitable linkers).
  • polypeptide(s) of the invention may comprise or (essentially) consist of one or more immunoglobulin single variable domains that specifically bind F- protein of hRSV and which may optionally further comprise one or more further amino acid sequences (all optionally linked via one or more suitable linkers).
  • immunoglobulin single variable domain may also encompass such polypeptide of the invention.
  • the one or more immunoglobulin single variable domains may be used as a binding unit in such a polypeptide, which may optionally contain one or more further amino acid sequences that can serve as a binding unit, so as to provide a monovalent, multivalent or multispecific polypeptide of the invention, respectively (for multivalent and multispecific polypeptides containing one or more VHH domains and their preparation, reference is also made to Conrath et al. 2001 (J. Biol. Chem. 276: 7346-7350), as well as to for example WO 96/34103, WO 99/23221 and WO 2010/115998).
  • the polypeptides of the invention encompass constructs comprising three or more antigen binding units in the form of single variable domains, as outlined above.
  • three or more immunoglobulin single variable domains that bind hRSV also referred to herein as "anti-hRSV immunoglobulin single variable domain(s)" can be linked to form a trivalent or multivalent construct.
  • the polypeptide of the invention consists of three anti-hRSV immunoglobulin single variable domains.
  • the three or more anti-hRSV immunoglobulin single variable domains may be linked directly to each other and/or via one or more suitable linkers or spacers.
  • suitable spacers or linkers for use in multivalent polypeptides will be clear to the skilled person, and may generally be any linker or spacer used in the art to link amino acid sequences.
  • said linker or spacer is suitable for use in constructing proteins or polypeptides that are intended for pharmaceutical use.
  • Some particularly preferred spacers include the spacers and linkers that are used in the art to link antibody fragments or antibody domains. These include the linkers mentioned in the general background art cited above, as well as for example linkers that are used in the art to construct diabodies or ScFv fragments (in this respect, however, it should be noted that, whereas in diabodies and in ScFv fragments, the linker sequence used should have a length, a degree of flexibility and other properties that allow the pertinent V H and V L domains to come together to form the complete antigen-binding site, there is no particular limitation on the length or the flexibility of the linker used in the polypeptide of the invention, since each immunoglobulin single variable domain by itself forms a complete antigen-binding site).
  • a linker may be a suitable amino acid sequence, and in particular amino acid sequences of between 1 and 50, preferably between 1 and 30, such as between 1 and 20 or between 1 and 10 amino acid residues.
  • Widely used peptide linkers comprise Gly-Ser repeats, e.g. (Gly)4-Ser in one, two, three, four, five, six or more repeats, or for example of the type (Gly x Ser y ) z , such as (for example (Gly 4 Ser) 3 or (Gly 3 Ser 2 )3, as described in WO 99/42077, or hinge-like regions such as the hinge regions of naturally occurring heavy chain antibodies or similar sequences (such as described in WO 94/04678).
  • Some other particularly preferred linkers are poly-alanine (such as AAA), as well as the linkers mentioned in Table A-4.
  • linkers generally comprise organic compounds or polymers, in particular those suitable for use in proteins for pharmaceutical use.
  • poly(ethyleneglycol) moieties have been used to link antibody domains, see for example WO 04/081026.
  • the polypeptide of the invention binds F-protein of h SV. More in particular, the polypeptide of the invention can bind protein F of hRSV with an affinity (suitably measured and/or expressed as a K D -value (actual or apparent), a K A -value (actual or apparent), a k on -rate and/or a k 0 fr rate) preferably such that:
  • K D dissociation constant
  • affinity is determined by Surface Plasmon Resonance, such as by Biacore, or by KinExA (see above).
  • the polypeptide of the invention is capable of neutralizing hRSV.
  • Assays to determine the neutralizing capacity of a molecule include e.g. the microneutralization assay described by Anderson et al. (1985, J. Clin. Microbiol. 22: 1050-1052; 1988, J. Virol. 62: 4232-4238), or modifications of this assay such as e.g. described in WO 2010/139808, or a plaque reduction assay as for example described by Johnson et al. (1997, J. Inf. Dis. 176: 1215-1224), and modifications thereof.
  • a microneutralization assay on hRSV Long such as e.g.
  • the polypeptides of the invention may have IC50 values between 10 pM and 1000 pM, preferably between 10 pM and 250 pM, more preferably between 50 pM and 200 pM or less.
  • the polypeptides of the invention may have IC90 values between 1 nM and 100 nM, preferably between 1 nM and 10 nM, more preferably between 1 nM and 5 nM or less such as e.g. 2 nM or less, or 90 ng/mL or less.
  • the polypeptide of the invention binds F-protein of hRSV with an affinity (suitably measured and/or expressed as a K D -value (actual or apparent), as described herein) preferably such that it binds to protein F of hRSV with a dissociation constant (K D ) of 100 nM to 0.1 nM or less, preferably 10 nM to 0.1 nM or less, more preferably 1 nM to 0.1 nM or less, such as e.g.
  • K D dissociation constant
  • the polypeptides of the invention is capable of neutralizing hRSV with IC50 values between 10 pM and 1000 pM, preferably between 10 pM and 250 pM, more preferably between 50 pM and 200 pM or less, or with IC90 values between 1 nM and 100 nM, preferably between 1 nM and 10 nM, more preferably between 1 nM and 5 nM or less such as e.g. 2 nM or less, or 90 ng/mL or less.
  • the polypeptide of the invention binds F-protein of hRSV with an affinity of 5x10 10 M (0.5 nM) or less and neutralizes hRSV with an IC90 value of 90 ng/mL or less.
  • the multivalent (such as trivalent) polypeptide of the invention may comprise or essentially consist of at least three anti-hRSV immunoglobulin single variable domains selected from any of SEQ ID NOs: 1-34 (Table A-2).
  • advantageous polypeptides for use in the method of the invention are described in WO 2010/139808.
  • the polypeptide of the invention is selected from any of SEQ ID NOs: 65-85 (Table A-3), such as e.g. ALX-0171.
  • SEQ ID NOs: 65-85 are a trivalent polypeptides consisting of three anti-h SV immunoglobulin variable domains derived from heavy chain-only llama antibodies. Each of the three anti-hRSV immunoglobulin single variable domains binds to F-protein of hRSV.
  • polypeptides of the invention can be produced by a method comprising the following steps: a) expressing, in a suitable host cell or host organism or in another suitable expression system, a nucleic acid or nucleotide sequence, or a genetic construct encoding the polypeptide of the invention;
  • the method for producing the polypeptide of the invention may comprise the steps of:
  • the polypeptide of the invention is produced in a bacterial cell, in particular a bacterial cell suitable for large scale pharmaceutical production.
  • the polypeptide of the invention is produced in a yeast cell, in particular a yeast cell suitable for large scale pharmaceutical production.
  • the polypeptide of the invention is produced in a mammalian cell, in particular in a human cell or in a cell of a human cell line, and more in particular in a human cell or in a cell of a human cell line that is suitable for large scale pharmaceutical production.
  • preferred heterologous hosts for the (industrial) production of immunoglobulin single variable domains or immunoglobulin single variable domain-containing protein therapeutics include strains of E. coli, Pichia pastoris, S. cerevisiae that are suitable for large scale expression/production/fermentation, and in particular for large scale pharmaceutical expression/production/fermentation. Suitable examples of such strains will be clear to the skilled person. Such strains and production/expression systems are also made available by companies such as Biovitrum (Uppsala, Sweden).
  • mammalian cell lines in particular Chinese hamster ovary (CHO) cells
  • CHO Chinese hamster ovary
  • expression/production systems are also made available by some of the companies mentioned above.
  • the polypeptide of the invention may then be isolated from the host cell/host organism and/or from the medium in which said host cell or host organism was cultivated, using protein isolation and/or purification techniques known per se, such as (preparative) chromatography and/or electrophoresis techniques, differential precipitation techniques, affinity techniques (e.g. using a specific, cleavable amino acid sequence fused with the polypeptide of the invention) and/or preparative immunological techniques (i.e. using antibodies against the amino acid sequence to be isolated).
  • protein isolation and/or purification techniques known per se, such as (preparative) chromatography and/or electrophoresis techniques, differential precipitation techniques, affinity techniques (e.g. using a specific, cleavable amino acid sequence fused with the polypeptide of the invention) and/or preparative
  • the present invention provides methods and dosing schedules for the pulmonary administration of the polypeptides of the invention to young children. As such, these methods and dosing schedules can be used for the treatment (as defined herein) of RSV infection in these young children.
  • RSV infection includes the mild upper respiratory tract illness, as well as the more severe lower respiratory tract infections (LRTIs).
  • RSV lower respiratory tract infection may include bronchiolitis and broncho-pneumonia, possibly showing typical clinical signs and symptoms such as tachypnoea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring.
  • RSV infection may also include diseases and/or disorders associated with RSV infection.
  • diseases and/or disorders associated with hRSV infection will be clear to the skilled person, and for example include the following diseases and/or disorders: respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
  • the present invention also provides methods and dosing schedules for the treatment of respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and/or (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
  • bronchiolitis inflammation of the small airways in the lung
  • pneumonia dyspnea
  • cough recurrent wheezing and/or (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
  • COPD chronic obstructive pulmonary disease
  • the term "treatment" not only comprises treating the disease, but also generally comprises slowing or reversing the progress of disease, slowing the onset of one or more symptoms associated with the disease, reducing and/or alleviating one or more symptoms associated with the disease, reducing the severity and/or the duration of the disease and/or of any symptoms associated therewith and/or preventing a further increase in the severity of the disease and/or of any symptoms associated therewith, preventing, reducing or reversing any physiological damage caused by the disease, and generally any pharmacological action that is beneficial to the patient being treated.
  • the method of the invention provides for the delivery of the polypeptide of the invention to the respiratory tract and, more specifically, to the lower respiratory tract of a subject.
  • the polypeptide of the invention is delivered in an inhalable form. More particularly, the inhalable form is an aerosol obtained by nebulizing (with a nebulizer) the polypeptide of the invention.
  • the subject to be treated is a human, more particularly a young child.
  • the subject to be treated will in particular be a young child suffering from RSV infection.
  • the subject may be a young child suffering from RSV infection, such as RSV lower respiratory tract infection.
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years).
  • the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months).
  • the subject is an infant. In one aspect, the subject is a toddler.
  • the subject has a gestational age of more than 33 weeks. Accordingly, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks.
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with
  • the subject is a young child who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia).
  • the subject is a young child aged 28 days to less 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g.
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g.
  • the subject is an infant who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia).
  • the subject is a toddler who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • the subject is a young child who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g.
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g.
  • the subject is an infant who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • the subject is a toddler who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • the subject is a young child who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia).
  • the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g.
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to
  • the subject is an infant who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is an infant who is hospitalised for RSV infection (e.g.
  • RSV lower respiratory tract infection such as bronchiolitis or broncho-pneumonia
  • the subject is a toddler who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • the subject is a young child who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to
  • the subject is an infant who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a toddler who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia).
  • the subject is a young child who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia,) but is otherwise healthy.
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than
  • the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g.
  • the subject is an infant who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • RSV infection e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia
  • the subject is a toddler who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
  • the polypeptide of the invention is administered by inhalation to subjects suffering RSV infection, such as RSV lower respiratory tract infection, at the selected dosing schedules such that treatment occurs.
  • the activity of the polypeptide of the invention can be assessed by measuring the reduction in viral load during the treatment.
  • the viral load can, for example, be determined in nose mucus of the young child. Mucus can be removed from the nose e.g. by nasal suction with a nasal aspirator, a rubber bulb syringe or a nasal swab.
  • the viral load is determined in a nasal swab specimen taken from the subject.
  • viral load is determined in samples obtained via nasal swabs collecting a mid-turbinate specimen.
  • the viral load can be determined by any method known in the art, such as e.g. polymerase chain reaction (e.g. q T-PC ) or culturing (e.g. plaque forming unit (PFU) assay). Determination of and LoglO viral copies/mL and LoglO PFU/mL in nasal swabs is preferably performed by validated methods.
  • polymerase chain reaction e.g. q T-PC
  • PFU plaque forming unit
  • the anti-viral effect of ALX-0171 is determined by the time to drop below quantification limit (BQL) in plaque cultures, which is the parameter that best reflects the inhibition of viral replication. More specifically, the time needed for the viral load (as assessed by plaque cultures) to drop below the quantification limit (BQL) is calculated (also referred to herein as "time- to-BQL"). The median time-to-BQL can be compared between each of the ALX 0171 dose groups and placebo using a log-rank test.
  • BQL quantification limit
  • Quantification of viral load can also be assessed by RT-qPCR as it is a more sensitive method than culture assay and has a good dynamic range. This method, however, will also quantify complete viral particles that are unable to replicate, partially assembled virions, and whole and fragmented viral genome in addition to quantifying fully replication-competent virus.
  • KL-6 Kerbs von Lungren 6 antigen
  • KL-6 Kerbs von Lungren 6 antigen
  • Serum levels of KL-6 were shown to indicate disease activity in various interstitial lung diseases and are believed to reflect the presence of alveolar damage (Imai et al. 2002, Pediatric pulmonology 33: 135-141; Kawasaki et al. 2009, J. Med. Virol. 81: 2104-8).
  • High serum KL-6 levels in RSV-infected infants correlate with low Sp02 and need for 02 administration (Kubota and Haruta 2006, J.
  • KL-6 levels in serum can be measured by any method known per se using techniques known to the skilled person, such as e.g. following commercially available assays: the KL-6 Human ELISA (BioVendor; Cat# RSCYK243882R), the Krebs Von den Lungen 6 Immunoassay Kit (BIOTREND Chemikalien GmbH; Cat# E05k0061), or the KL-6 ELISA kit (Biorbyt; Cat# orbl53677).
  • Clinical Activity Outcome Measures heart rate and peripheral capillary 0 2 saturation (Sp0 2 ) levels; feeding (type of feeding support, sufficiency of feeding), with particular attention to hydration and breathing comfort during feeding; respiratory rate (measured over 1-minute interval); wheezing as e.g. assessed during lung auscultation (during expiration/inspiration, lung fields affected);
  • composite scores such as Global Severity Score, Respiratory Distress Assessment Instrument (RDAI) score and Respiratory Assessment Change Score (RACS) can be calculated.
  • RDAI Respiratory Distress Assessment Instrument
  • RACS Respiratory Assessment Change Score
  • the Global Severity Score is based on a recent clinical score that allows categorization of infants with respiratory infections on 7 different parameters: feeding intolerance, medical intervention, respiratory difficulty, respiratory frequency, apnea, general condition and fever (Justicia-Grande et al. 2015, Leipzig: 33rd Annual Meeting of the European Society for Paediatric Infectious Diseases;
  • the respiratory distress assessment instrument (RDAI) score is a 17 point score based on wheezing and retraction as explained in Table B-6.
  • the RDAI score is the sum of the row scores, with total range 0 to 17; higher scores indicate more severe disease.
  • the respiratory assessment change score is the sum of the change in the RDAI score and a standardized score for the change in respiratory rate.
  • the change in respiratory rate is assigned 1 point per each 10% change in respiratory rate.
  • a decrease in the RDAI or in the respiratory rate is recorded as a negative RACS, meaning an improvement.
  • the polypeptide of the invention inhibits an early event in the viral life cycle, preventing extracellular virus from infecting virus-naive cells by inhibiting fusion of the virion to the target cell.
  • the methods and dosing schedules of the invention are used for inhibiting these early events in the viral life cycle and preventing extracellular virus from infecting virus-naive cells by inhibiting fusion of the virion to the target cell.
  • the in vitro concentration of 90 ng/mL was determined as the concentration at which the polypeptide of the invention reaches 90% of its maximal inhibitory antiviral effect (IC 90 ).
  • the resulting value (9 microgram/mL or more) is considered the target concentration of the polypeptide of the invention, i.e. the concentration of polypeptide of the invention that would be required in the lower respiratory tract to result in clinically meaningful reduction of RSV infectivity.
  • This concentration was calculated to be sufficient to completely saturate all target available at peak viral titres in an RSV-infected infant, and is also supported by the local target concentrations that showed efficacy in nonclinical studies in RSV-infected neonatal lambs and cotton rats (Detalle 2014 "Delivery of ALX-0171 by inhalation greatly reduces disease burden in a neonatal lamb RSV infection model" 9 th RSV Symposium, Whybosch - South Africa; WO 2016/055656).
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser in order to reach this target concentration is estimated to be 2 to 11 mg/kg daily (e.g. between 2 and 11 mg/kg daily).
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide of the invention, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 11 mg/kg daily (e.g. between 2 and 11 mg/kg daily), more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily (e.g.
  • the invention also relates to a polypeptide of the invention for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2 to 11 mg/kg daily e.g. between 2 and 11 mg/kg daily), more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily (e.g. between 2.5 and 10.7 mg/kg daily), such as 3 to 9 mg/kg daily (e.g. between 3 and 9 mg/kg daily).
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the polypeptide is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, preferably for 3 consecutive days.
  • the polypeptide of the invention is administered for 3 consecutive days at a nominal dose of 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably at a nominal dose of 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as at a nominal dose of 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the polypeptide is administered for 3 consecutive days at a nominal dose of 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably at a nominal dose of 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as at a nominal dose of 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the polypeptide is administered for 3 consecutive days at a nominal dose of 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably at a nominal dose of 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as at a nominal dose of 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • polypeptide of the invention used in the above methods of the invention is preferably selected from SEQ ID NOs: 65-85, preferably ALX-0171.
  • the present invention relates to a method for the treatment of SV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a target
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a target concentration of 9 microgram/mL (wherein this value is understood to optionally encompass a range of ⁇ 0.5 microgram/mL) or more.
  • the present invention also relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the polypeptide selected from SEQ ID NOs: 65-85 is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, such as e.g. for 3 consecutive days.
  • the present invention also relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
  • RSV infection such as RSV lower respiratory tract infection
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the present invention relates to a method for the treatment of SV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • SV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • RSV infection such as RSV lower respiratory tract infection
  • the invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • composition(s) of the invention or “formulation(s) of the invention”
  • composition(s) of the invention or “formulation(s) of the invention”
  • the polypeptides of the invention may be formulated as a formulation or compositions (also referred to as “pharmaceutical composition(s) of the invention” or “pharmaceutical formulation(s) of the invention”) comprising the polypeptide of the invention at a certain concentration and at least one pharmaceutically acceptable carrier, diluent or excipient and/or adjuvant, and optionally one or more further pharmaceutically active ingredient.
  • the invention also provides a composition comprising the polypeptide of the invention at a certain concentration, and optionally one or more further components of such compositions known per se for use in the method of the invention.
  • the invention also provides a pharmaceutical composition comprising the polypeptide of the invention at a certain concentration and at least one pharmaceutically acceptable carrier, diluent or excipient and/or adjuvant, and optionally one or more further pharmaceutically active ingredient for use in the method of the invention.
  • polypeptide of the invention can be formulated and administered in any suitable manner known per se, for which reference is for example made to standard handbooks, such as Remington and Gennaro 1990 ("Remington's Pharmaceutical Sciences” 18 th Ed., Mack Publishing Company, USA), Remington and Beringer 2006 ("The Science and Practice of Pharmacy", 21 st Ed., Lippincott Williams and Wilkins); or Dubel S. (Ed.) 2007 ("The Handbook of Therapeutic Antibodies” Wiley, Weinheim; see for example pages 252-255).
  • the formulation is preferably in a form suitable for administration by inhalation.
  • the pharmaceutical composition will comprise the polypeptide of the invention and at least one carrier, diluent or excipient suitable for administration to a subject by inhalation, and optionally one or more further active ingredients.
  • the formulation of the polypeptide of the invention is developed as a liquid solution for inhalation, to ensure rapid delivery of the study drug to the site of RSV infection, and to maintain product quality and stability in combination with the nebulization protocol.
  • excipient refers to an inert substance which is commonly used as a diluent, vehicle, preservative, binder or stabilizing agent for drugs which imparts a beneficial physical property to a formulation, such as increased protein stability, increased protein solubility, and/or decreased viscosity.
  • excipients include, but are not limited to, proteins (e.g., serum albumin), amino acids (e.g., aspartic acid, glutamic acid, lysine, arginine, glycine), surfactants (e.g., sodium dodecyl sulfate (SDS), polysorbates such as Tween 20 and Tween 80, poloxamers such as Pluronics, and other nonionic surfactants such as poly(ethylene glycol) (PEG)), saccharides (e.g., glucose, sucrose, maltose and trehalose), polyols (e.g., mannitol and sorbitol), fatty acids and phospholipids (e.g., alkyl sulfonates and caprylate).
  • proteins e.g., serum albumin
  • amino acids e.g., aspartic acid, glutamic acid, lysine, arginine, glycine
  • surfactants e
  • carrier suitable for administration by inhalation means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, or solvent, involved in carrying or transporting the agent (e.g. prophylactic or therapeutic agent) e.g. in the respiratory tract.
  • agent e.g. prophylactic or therapeutic agent
  • carrier must be "acceptable” in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient.
  • the carrier comprised in the composition of the invention preferably is an aqueous carrier such as e.g. distilled water, MilliQ ® water or Water for Injection (WFI).
  • the composition can be buffered by any buffer that is pharmaceutical acceptable.
  • Preferred buffers for use in the composition of the invention include (without being limiting) phosphate buffered saline (PBS), phosphate buffer, TrisHCI, histidine buffer and citrate buffer, such as e.g. histidine pH 6.0-6.5, phosphate buffer pH 7.0, TrisHCI pH 7.5 and citrate buffer/phosphate buffer pH 6.5, in particular phosphate
  • compositions such as lactose, glucose and sucrose
  • glycols such as propylene glycol
  • polyols such as glycerin, sorbitol, mannitol and polyethylene glycol
  • esters such as ethyl oleate and ethyl laurate
  • buffering agents such as magnesium hydroxide and aluminum hydroxide
  • pyrogen-free water isotonic saline
  • Ringer's solution ethyl alcohol
  • phosphate buffer solutions and other nontoxic compatible substances employed in pharmaceutical formulations.
  • concentrations having values around these concentrations therefore also can be used.
  • concentrations of 25, 30, 35, 40, 45, 55, 60, 65, 70, 75 mg/mL can be used. It will be clear to the skilled person that, in view of the specific nominal dose (mg/kg) determined in the present invention, the volume of the
  • composition filled in the nebulizer will depend on the concentration of the polypeptide of the invention in the a pharmaceutical composition.
  • the nominal dose to be filled in the nebuliser to ensure clinically meaningful reduction of RSV infectivity was determined to be 2.0 to 11.0 mg/kg daily, more specifically 2.5 to 10.7 mg/kg daily, such as e.g. 3.0 to 9.0 mg/kg daily.
  • the volume of the pharmaceutical composition at a particular concentration, such as e.g. 50 mg/mL of polypeptide of the invention
  • the fill volume will differ.
  • the administered dose of the polypeptides of the invention (and as such the fill volume of a pharmaceutical composition comprising the polypeptides of the invention at a particular concentration) can be standardised for (narrow) body weight categories (see e.g. Tables B-l, B-2, B-3, and B-4 for a pharmaceutical composition of 50 mg/mL).
  • the present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 for use in the method of the invention.
  • the present invention also relates to a pharmaceutical device suitable for the delivery by inhalation of the polypeptide of the invention and suitable for the delivery by inhalation of a composition comprising the same, also referred to herein as "inhalation device".
  • the present invention accordingly, relates to an inhalation device comprising the polypeptide of the invention at the selected dose.
  • the present invention also relates to an inhalation device comprising the polypeptide of the invention at the selected dose for use in the method of the invention.
  • the device is an inhaler for liquids (e.g. a suspension of fine solid particles or droplets) comprising the polypeptide of the invention.
  • this device is an aerosol delivery system or a nebulizer comprising the polypeptide of the invention.
  • the aerosol delivery system used in the method of the invention may comprise a container comprising the composition of the invention and an aerosol generator connected to it.
  • the aerosol generator is constructed and arranged to generate an aerosol of the composition of the invention.
  • the aerosol delivery system is a nebulizer.
  • Nebulizers produce a mist of drug-containing liquid droplets for inhalation.
  • "Nebulization" means the conversion of a liquid to a fine spray. Nebulizers mix medicine with compressed air to create a fine mist that the patient breathes in through a facemask or mouthpiece.
  • Vibrating mesh type nebulizers are considered the most appropriate technology for nebulization of the polypeptides of the invention, preferably SEQ ID NOs: 65-85, such as ALX-0171.
  • Vibrating-mesh nebulizers are divided into passively and actively vibrating-mesh devices (Newman 2005, J. Appl. Ther. Res. 5: 29-33).
  • Passively vibrating-mesh devices e.g. Omron MICROAIR ® NE-U22 nebulizer
  • a vibrating piezo-electric crystal attached to a transducer horn induces "passive" vibrations in the perforated plate positioned in front of it, resulting in extrusion of fluid through the holes and generation of the aerosol.
  • Actively vibrating-mesh devices e.g. AERONEB ® Pro nebulizer
  • may employ a "micropump" system which comprises an aerosol generator consisting of a plate with up to 1000 dome-shaped apertures and a vibrating element which contracts and expands on application of an electric current. This results in upward and downward movements of the mesh by a few micrometers, extruding the fluid and generating the aerosol.
  • a continuous flow nebuliser is used. Considering that young infants with bronchiolitis may require additional oxygen or air supply, maintaining a continuous oxygen or air supply of 2 L/min through the delivery system is recommended.
  • the nebulizer can be used with or without additional air or 0 2 flow.
  • the nebulizer is used with additional air or 0 2 flow, such as a flow of 2 L/min additional air or 0 2 .
  • the nebulizer may comprise (see Figures 4 and 5):
  • the flow channel may be sized and shaped to achieve, at a position immediately upstream of the lateral opening, an average gas velocity of at least 4 m/s at a flow rate of 2 L/min.
  • the flow channel upstream of the lateral opening is shaped such as to effect a laminar flow when a gas is conducted through the flow channel at a flow rate of 1 to 20 L/min.
  • the gas inlet opening may be shaped as a tube fitting.
  • the flow channel exhibits no further inlet opening for receiving a gas.
  • the aerosol generator may be oriented such as to emit nebulised aerosol into the flow channel at an angle of approx. 90° to the longitudinal axis of the flow channel.
  • the interior volume of the flow channel between the lateral opening and the aerosol inlet opening of the face mask is not more than 30 mL.
  • the inhalation device may comprise a switch for starting and stopping the operation of the aerosol generator, wherein the operation of the aerosol generator comprises the continuous vibration of the vibratable mesh.
  • the face mask of the inhalation device may be configured to allow the exhalation by the patient through the mask. This may be achieved by a valve which exhibits a rather small exhalation resistance.
  • the nominal internal volume of the face mask is not more than about 120 mL.
  • the nominal internal volume is understood as the internal volume enclosed by the casing from the aerosol inlet opening to the patient contacting surface when the patient contacting surface is placed on a flat surface. This volume is slightly larger than the effective internal volume, or so-called dead space, which is the volume enclosed by the mask when placed against the face of a patient, and which therefore depends on the size and shape of the patient's face.
  • the nominal internal volume is preferably not more than about 90 mL, or even not more than about 80 mL, or not more than about 70 mL, or not more than about 60 mL, or not more than about 50 mL, or not more than about 40 mL, respectively, depending on the size of the face of the patient. It is currently preferred to select a mask with a nominal internal volume of not more than about 40 or 50 mL if the patient is a neonate.
  • the nominal internal volume of the face mask is smaller than the tidal volume.
  • the nominal internal face mask volume should be smaller than this.
  • the respective volume may be in the range from about 10 % to about 80 % of the average tidal volume.
  • the nominal internal face mask volume is not more than about 60 %, or even not more than about 50 %, of the patient's average tidal volume.
  • the face mask may have a two-way inhalation- and exhalation valve having a resistance of not more than 3 mbar in either direction, and wherein the nominal internal volume of the face mask is not more than about 50 mL.
  • the face mask may have one or more inhalation valves and one or more exhalation valves, wherein the exhalation valve has a resistance of not more than 3 mbar, and wherein the nominal internal volume of the mask is not more than about 70 mL.
  • the face mask may comprise further inhalation and/or exhalation valves. If so, the effective exhalation pressure of the combined valves should still be in the specified range, i.e.
  • the exhalation pressure may also be selected from about 0.5 mbar to about 3 mbar, such as about 1 mbar or about 2 mbar, respectively.
  • the valve(s) provided in the face mask may have any structure suitable for providing this exhalation resistance; e.g. slit valves, duck bill valves or membrane valves, to mention only a few.
  • the valve may be a one-way valve with a cross-slit and an overlying membrane, such as a silicone membrane. In one direction, from the cross-slit to the membrane, the valve opens, whereas in the opposite direction the membrane will be pressed tightly onto the cross and thus blocks the valve. Depending on which way round the valve is inserted into the face mask, it can serve both as an inhalation or an exhalation valve.
  • the inhalation device may be connected to a gas source that provides a gas at a constant flow rate in the range from 1 to 5 L/min.
  • the gas provided by said gas source may be selected from oxygen, air, oxygen-enriched air, a mixture of oxygen and nitrogen, and a mixture of helium and oxygen.
  • the main components of preferred nebulizers are ( Figure 4) a re-usable base unit (containing the electronics), a single-use disposable inhalation set (including a pediatric face mask (in 2 sizes), a mask adaptor, a vibrating mesh nebulizer with a reservoir).
  • a re-usable base unit containing the electronics
  • a single-use disposable inhalation set including a pediatric face mask (in 2 sizes)
  • a mask adaptor including a vibrating mesh nebulizer with a reservoir.
  • preferred nebulizers adapted for pediatric use are described in WO 2016/055656.
  • Examples of vibrating-mesh nebulizers include the Akita2 Apixneb (Activaero, now Vectura, UK), EFLOW ® (PARI GmbH, Grafelingen, Germany; see also US 5,586,550), AERONEB ® (Aerogen, Inc., Sunnyvale, California; see also US 5,586,550; US 5,938,117; US 6,014,970; US 6,085,740; US 6,205,999), and the FOX-Flamingo vibrating mesh nebulizer (Vectura, UK), all adapted for pediatric use.
  • the FOX- Flamingo inhalation system consists of a battery-operated, hand-held device, intended for single- patient use. The device provides an aerosol with particle size suitable for the intended study population.
  • the nebulizer is always to be used with a flow of 2 L/min additional air or 02.
  • the inhalation device or nebulizer is loaded with the pharmaceutical composition of the invention. Accordingly, the present invention also relates to an inhalation device or nebulizer containing a pharmaceutical composition comprising the polypeptide of the invention.
  • the inhalation device or nebulizer contains a pharmaceutical composition that comprises a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171.
  • the polypeptide of the invention can be present in the nebulizer at any suitable concentration such as 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 mg/mL, preferably at a concentration of 50 mg/mL.
  • the present invention also relates to a pharmaceutical composition
  • a pharmaceutical composition comprising the polypeptide of the invention loaded in an inhalation device or nebulizer for use in the method of the invention.
  • the pharmaceutical composition loaded in the inhalation device or nebulizer comprises a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171.
  • the polypeptide of the invention can be present in the pharmaceutical composition loaded in the inhalation device or nebulizer at any suitable concentration such as 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 mg/mL, preferably at a concentration of 50 mg/mL.
  • the polypeptide of the invention is administered at a nominal dose of 2 to 11 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3 to 9 mg/kg daily.
  • the nominal dose of the polypeptide of the invention that is filled in the nebuliser is 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the volume of pharmaceutical composition at a concentration of 50 mg/mL of polypeptide of the invention
  • the resulting "fill dose” will be as follows (see also Table B-4):
  • Table B-l Nebulizer fill volume of a 50 mg/mL composition of the polypeptide of the invention and corresponding fill dose for each weight category
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of RSV infection, such as e.g. SV lower respiratory tract infection, in a young child.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of RSV infection, such as e.g. SV lower respiratory tract infection, in a young child.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • the present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL), for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL), for use in the method of the invention.
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the volume of pharmaceutical composition (at a concentration of 50 mg/mL of polypeptide of the invention) that should be loaded into the nebulizer also referred to as the "fill volume”
  • the resulting "fill dose" will be as follows (see also Table B-4):
  • Table B-2 Nebulizer fill volume of a 50 mg/mL composition of the polypeptide of the invention and corresponding fill dose for each weight category
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • the present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL), for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL
  • the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ⁇ 0.5 mg/kg).
  • the volume of pharmaceutical composition at a concentration of 50 mg/mL of polypeptide of the invention
  • the resulting "fill dose” will be as follows (see also Table B-4):
  • Table B-3 Nebulizer fill volume of a 50 mg/mL composition of the polypeptides of the invention and corresponding fill dose for each weight category
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child.
  • the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
  • the present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL), for use in the method of the invention.
  • a polypeptide of the invention preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL), for use in the method of the invention.
  • the young child is aged less than 24 months (2 years).
  • the young child is aged 28 days to less than 24 months.
  • the young child is aged 1 month to less than 24 months.
  • the young child is aged less than 36 months (3 years).
  • the young child is aged 28 days to less than 36 months (3 years).
  • the young child is aged 1 month to less than 36 months (3 years).
  • the young child is an infant.
  • the young child is a toddler.
  • the young child is aged less than 24 months (2 years), with a gestational age of more than 33 weeks.
  • the young child is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks.
  • the young child is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
  • the young child is aged less than 36 months (3 years), with a gestational age of more than 33 weeks.
  • the young child is aged 28 days to less than 36 months (3 years), with a gestational age of more than 33 weeks.
  • the young child is aged 1 month to less than 36 months (3 years), with a gestational age of more than 33 weeks.
  • the young child is an infant, with a gestational age of more than 33 weeks.
  • the young child is a toddler, with a gestational age of more than 33 weeks.
  • the young child is diagnosed with RSV lower respiratory tract infection. In one aspect, the young child is diagnosed with SV lower respiratory tract infection but is otherwise healthy.
  • the young child is hospitalised for RSV lower respiratory tract infection.
  • polypeptides of the invention may be administered as a monotherapy or in combination with other pharmaceutically active compounds or principles that are or can be used for the treatment of RSV infection, as a result of which a synergistic effect may or may not be obtained. Examples of such compounds and principles, as well as routes, methods and pharmaceutical formulations or compositions for administering them will be clear to the clinician.
  • two or more substances or principles When two or more substances or principles are to be used as part of a combined treatment regimen, they can be administered via the same route of administration or via different routes of administration, at essentially the same time or at different times (e.g. essentially simultaneously, consecutively, or according to an alternating regime).
  • the substances or principles When the substances or principles are to be administered simultaneously via the same route of administration, they may be administered as different pharmaceutical formulations or compositions or part of a combined pharmaceutical formulation or composition, as will be clear to the skilled person.
  • each of the substances or principles may be administered in the same amount and according to the same regimen as used when the compound or principle is used on its own, and such combined use may or may not lead to a synergistic effect.
  • the present invention also provides methods and dosing schedules for pulmonary administration of a polypeptide of the invention that binds and neutralizes hRSV, wherein the polypeptide is administered in combination with at least one additional therapeutic agent.
  • additional therapeutic agents can be selected from the standard of care during hospitalisation for RSV infections, such as RSV lower respiratory tract infection, including (without being limiting) bronchodilators, antibiotics (e.g. in case of secondary bacterial infection [surinfection] during hospitalisation), apinephrine, anticholinergics, antipyretica and/or nonsteroidal antiinflammatory medication.
  • the polypeptide of the invention is administered in combination with a bronchodilator.
  • the present invention also relates to a method for the treatment of SV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65- 85, such as ALX-0171, wherein the polypeptide is administered to the child by inhalation at the selected dosing schedules in combination with a bronchodilator.
  • a polypeptide of the invention and the bronchodilator are administered to the respiratory tract (i.e. by inhalation) as a combination therapy (kit of parts).
  • the polypeptide of the invention and the bronchodilator are used as part of a combined treatment regimen. More specifically, both parts of this combination therapy are administered to the respiratory tract (i.e. by inhalation) simultaneously, separately or sequentially.
  • bronchodilators i.e. the sympaticomimetics
  • the short- acting and the long-acting beta2-mimetics include the short- acting and the long-acting beta2-mimetics
  • the anticholinergics include (but are not restricted to) salbutamol, terbutaline, fenoterol, pirbuterol and tulobuterol. They can be used as a base or as an acceptable pharmaceutical salt.
  • the long-acting beta2-mimetics include (but are not restricted to) formoterol and salmeterol. They can also be used as a base or as an acceptable pharmaceutical salt.
  • the anticholinergic drugs include (but are not restricted to) ipratropium, oxitropium and tiotropium.
  • additional bronchodilators for use in the method of the invention include Accu Hale, albuterol, bitolterol, ephedrine, epinephrine, isoetharine, isoproterenol, metaproterenol, pirbuterol, racepinephrine, ritodrine, terbutaline, levosabutamol, levabuterol, clenbuterol, amphetamine, methamphetamine, cocaine, theophylline, caffeine, theobromine, THC, and MDPV.
  • the bronchodilator class of molecules with very long duration of action will have to be administered only once a day (e.g. tiotropium).
  • Long acting beta2-mimetics are usually administered twice a day like formoterol and salmeterol.
  • short-acting bronchodilators such as salbutamol, terbutaline, ipratropium or oxitropium which have to be administered 4 to 6 times a day.
  • treatment schedules can be designed in order to take optimal advantage of the combination therapy.
  • the treatment schedules may encompass the simultaneous, separate or sequential administration of the polypeptide of the invention and the bronchodilator.
  • the most common devices for the administration of the combination therapy (kit of parts) are a nebulizer, a metered dose inhaler (MDI), and a combination of these.
  • the polypeptide of the invention and the bronchodilator are administered simultaneously.
  • the polypeptide of the invention and the bronchodilator are administered in admixture in inhalable form.
  • the inhalable form of the polypeptide of the invention and the bronchodilator can be an aerosol obtained from simultaneously nebulizing (e.g. with a nebulizer) the polypeptide of the invention and the bronchodilator, both preferably present in the same composition (of the invention).
  • the polypeptide of the invention and the bronchodilator are administered separately.
  • the polypeptide of the invention and the bronchodilator are administered in separate inhalable form.
  • the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention or the bronchodilator, separately present in a composition (of the invention).
  • the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g.
  • the polypeptide of the invention and a separate aerosol obtained from breakup into droplets (e.g. with a metered dose inhaler (MDI)) of the bronchodilator dissolved or suspended in the volatile propellant, followed by rapid evaporation of these droplets.
  • MDI metered dose inhaler
  • the polypeptide of the invention and the bronchodilator are administered with two different (types of) inhalers, each producing a separate inhalable form.
  • the polypeptide of the invention and the bronchodilator are administered sequentially.
  • the polypeptide of the invention and the bronchodilator are administered separately and sequentially in inhalable form.
  • the inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention or the bronchodilator, separately present in a composition (of the invention).
  • the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g.
  • the polypeptide of the invention and the bronchodilator should be present in two different (separate) compositions of the invention that are separately loaded into the inhaler device, in order that two separate, sequential inhalable forms can be generated.
  • the polypeptide of the invention and the bronchodilator may be administered with two different (types of) inhaler.
  • the use of two different inhalers is not necessarily required as in some devices (such as e.g. in a nebulizer) the separate compositions can be loaded sequentially. Without being limiting, following combinations can be proposed:
  • Preferred intervals for the sequential administration of the polypeptide of the invention and the bronchodilator will depend on the polypeptide of the invention and the bronchodilator used (as is described above) and may include from 5 minutes to 24 hours or more, such as e.g. 5 minutes, 10 minutes, 15 minutes, 20 minutes, 30 minutes, 1 hour, 4 hours, 6 hours, 8 hours, 12 hours, etc.
  • the bronchodilator is a short-acting beta2-agonist, such as e.g. salbutamol.
  • the bronchodilator such as a short-acting beta2-agonist
  • a MDI prior to administration of the polypeptide of the invention with a nebulizer.
  • the bronchodilator, a short-acting beta2-agonist can be administered 10-15 minutes prior to the administration of the polypeptide of the invention.
  • the short-acting beta2-agonist such as salbutamol is administered to the young child at a dose of 200 micrograms (e.g. two puffs of 100 microgram) 15 minutes prior to administration of the polypeptide of the invention.
  • the bronchodilator is administered with a nebulizer prior to administration of the polypeptide of the invention with a nebulizer.
  • the polypeptide of the invention and the bronchodilator can be administered with the same nebulizer (i.e. each of the polypeptide of the invention and the bronchodilator can be present in a separate composition that is sequentially loaded into the nebulizer) or with two different nebulizers.
  • the polypeptide of the invention and the bronchodilator are administered simultaneously with a nebulizer.
  • the polypeptide of the invention and the bronchodilator are preferably present in one single compositions of the invention which is loaded into the nebulizer. Else, the polypeptide of the invention and the bronchodilator are present in two different compositions of the invention that are both loaded into the nebulizer.
  • Serum samples were obtained from 33 ALX-0171 treated subjects, mostly at the defined time point, with the exception of 3 subjects which had their blood sample taken approximately 24 h after the second inhalation.
  • ALX-0171 serum concentrations were quantifiable in 27 out of the 33 ALX- 0171 dosed subjects with available PK sample.
  • the ALX-0171 serum concentrations measured were on average below the levels predicted with the PBPK model described in WO 2016/055656. As ALX-0171 serum concentration is a surrogate for the local lung exposure, the site of action of ALX-0171, low serum concentrations would indicate low local lung exposure.
  • Example 2 Administration of the selected doses of anti-RSV Nanobody ALX-0171 to subjects hospitalized for RSV lower respiratory tract infection
  • a clinical study is conducted to evaluate the anti-viral effect and safety of different doses of inhaled ALX-0171 in subjects hospitalized for RSV LRTI. Also the clinical activity, the PK properties, the pharmacodynamic (PD) effect and the immunogenicity of the different doses of inhaled ALX-0171 are evaluated.
  • PD pharmacodynamic
  • This study is conducted in compliance with the Guidance for Industry ICH E6 GCP (including archiving of essential study documents), the Declaration of Helsinki, the applicable regulations of the country(ies) in which the study is conducted, and with the Commission Directives 2001/20/EC and 2005/28/EC.
  • the Clinical Study Protocol(s) and the ICF(s) is submitted for review and approval by the IEC/I B prior to the eligibility screening/baseline.
  • the composition of the IEC/IRB is in accordance with the recommendations of the World Health Organization, the ICH E6 Guideline for GCP, the European Union Clinical Trial Directive (CTD) (Directive 2001/20/EC) and/or the USA Code of Federal Regulations (CFR) (21 CFR 56), in line with local regulations.
  • CTD European Union Clinical Trial Directive
  • CFR USA Code of Federal Regulations
  • subjects' parent(s), legal guardian(s) or the legally acceptable representative(s) must provide their written informed consent before enrolment of their child in the clinical study, and before any protocol specified procedures are performed. Freely given and written informed consent is obtained according to local requirements after the nature of the study has been fully explained. The consent form that is used is approved by the reviewing IEC/IRB. The informed consent is in accordance with principles that originated in the Declaration of Helsinki, current ICH and GCP guidelines, and applicable regulatory requirements.
  • a randomized, double-blind, placebo-controlled, multicenter dose-ranging study is conducted to assess the administration of the different selected doses of ALX-0171 to infants and young children hospitalized for RSV lower respiratory tract infection.
  • Dose 2 target dose of 6.0 mg/kg
  • the study is planned to enroll approximately 180 male or female infants and young children (aged 28 days to 2 years, with a gestational age of > 33 weeks) who are diagnosed with and hospitalized for RSV LRTI (such as bronchiolitis or broncho-pneumonia), but otherwise healthy.
  • RSV LRTI such as bronchiolitis or broncho-pneumonia
  • the study consists of a sequential part followed by a parallel part ( Figure 2).
  • an Independent Data Monitoring Committee reviews the available cumulative safety data (i.e., all data from prior visits that have been done for all included subjects, including preceding cohorts). After this comprehensive review, the IDMC advises on proceeding to the subsequent cohort (i.e., the higher dose), and which planned dose levels can be taken forward into the parallel part.
  • IDMC Independent Data Monitoring Committee
  • the remaining 144 subjects are randomly assigned in a 1:1:1:1 ratio to one of following treatment groups, yielding an overall randomization ratio of 3:1 active to placebo.
  • ALX-0171 is administered once daily for 3 consecutive days.
  • the 3-day treatment period is expected to bridge the time needed for the body to mount an effective immune response.
  • An overview of the study flow is shown in Figure 3.
  • Subjects are screened as soon as possible after arrival to the hospital/emergency unit. After completion of the screening assessments and confirmation of subject's eligibility, randomization follows as soon as possible but not more than 24 hours after arrival.
  • Study drug administration starts as soon as possible after randomization with a maximum time interval of 3 hours following randomization.
  • Subsequent doses of study drug are administered at 24-hour intervals ( ⁇ 4 hours) relative to the first dose. No premedication is required or recommended per protocol, but an inhaled 2-agonist may be administered at the discretion of the treating Investigator.
  • ALX-0171 or matching placebo is administered via inhalation, using a dedicated vibrating mesh nebulizer, the FOX-Flamingo inhalation system (Vectura GmbH, Germany), as described in WO 2015/055655 (see also Figure 4).
  • This inhalation device consists of a re-usable base unit (containing the electronics), a single-use disposable inhalation set (including a pediatric face mask in 2 sizes, a mask adaptor, a vibrating mesh nebulizer with reservoir). The device provides an aerosol with particle size suitable for the intended study population ( ⁇ 3 ⁇ ).
  • the nebulizer is used with a flow of 2 L/min additional air or 0 2 (to be decided by the Investigator based on oxygen need of the subject).
  • ALX-0171 (and matching placebo) was developed specifically as a liquid solution for inhalation (as described in WO 2011/098552).
  • ALX-0171 is present at 50 mg/ml in the formulation buffer (NaH 2 P0 4 /Na 2 HP0 4 10 mM, NaCI 130 mM, pH 7.0).
  • the formulation buffer without ALX-0171 is used as placebo.
  • the Placebo group serves as comparator group for the 3 ALX-0171 dose groups. To achieve double-blinding across the different groups, each dose is administered as two serial nebulizations (Nebulization 1 and Nebulization 2). In the placebo group, subjects will receive 2 nebulizations of placebo. In the ALX-0171 dose 1 and 2 groups, subjects will receive 1 nebulization of ALX 0171 and 1 nebulization of placebo. In the ALX-0171 dose 3 group, both nebulizations will contain ALX-0171.
  • Per body weight category the total volume (to be administered via the 2 serial nebulizations) will be the same for the 4 treatment groups ensuring blinding across the treatment groups. This approach allows a design with a placebo-controlled group as representative comparison for the 3 dose levels.
  • the drug volume filled into the nebulizer (“fill" volume) is calculated per weight category range.
  • Table B-4 Nebulizer fill volume of ALX-0171 and corresponding fill dose for each nebulization and each weight category
  • Dose 1 target dose of 3.0 mg/kg (depending on the subject's weight category, the actual nominal dose is between 2.5 and 3.6 mg/kg)
  • Dose 2 target dose of 6.0 mg/kg (depending on the subject's weight category, the actual nominal dose is between 5.0 and 7.1 mg/kg)
  • Dose 3 target dose of 9.0 mg/kg (depending on the subject's category, the actual nominal dose is between 7.6 and 10.7 mg/kg)
  • ITT Intent-to-treat
  • Safety Population All subjects who received at least 1 administration of study drug, as treated (i.e., using the treatment that the subject actually received).
  • PK population Subset of the subjects in the safety population for whom the primary PK data are considered to be sufficient and interpretable. For this study, this will correspond to all subjects in the safety population who received at least 1 administration of ALX 0171 and for whom at least one ALX-0171 serum concentration has been determined.
  • Per Protocol (PP) Population Consists of a subset of the ITT population, and excludes those subjects who have had a major protocol deviation.
  • the mITT Population is the primary study population used for the analysis of efficacy data
  • the Safety Population is the primary study population used for the analysis of safety, PD, and
  • the PK population is the primary study population used for analysis of PK data.
  • Example 3 Evaluation of the viral load after administration of selected doses of ALX-0171 to subjects hospitalized for RSV LRTI
  • nasal swabs (mid-turbinate specimen) are collected for analysis of viral load, at specified time points. Quantitative viral titers in the nasal cavity (viral load) are assessed by plaque forming unit (PFU) assay and qRT-PCR.
  • PFU plaque forming unit
  • the anti-viral effect of ALX-0171 is mainly determined by the time for the viral load to drop below the limit of quantification (BQL), also referred to herein as "time-to-BQL".
  • Time-to-BQL is assessed in plaque cultures, which is the parameter that best reflects the inhibition of viral replication.
  • RT-qPCR Quantification of viral load by RT-qPCR is also assessed as it is a more sensitive method than culture assay and has a good dynamic range. However, as the mode of action of ALX-0171 is to inhibit viral entry into the target cell, modest effects of ALX-0171 treatment on viral RNA are expected. After all, complete viral particles that are unable to replicate, partially assembled virions, and whole and fragmented viral genome are also quantified by RT-qPCR, in addition to fully replication-competent virus.
  • time-to-BQL the time needed for the viral load (as assessed by plaque cultures) to drop below the quantification limit (BQL) is calculated (time-to-BQL).
  • the median time-to-BQL is compared between each of the ALX 0171 dose groups and placebo using a log-rank test. The test is performed in a sequential way to preserve the family-wise error rate at 0.05. Specifically, dose 3 of ALX 0171 is first tested against placebo at the 0.05 significance level. Dose 2 of ALX 0171 is only compared to placebo at the 0.05 significance level if the comparison of dose 3 with placebo is significant. Consequently, dose 1 of ALX-0171 is only compared to placebo at the 0.05 significance level if the comparison of dose 2 of ALX-0171 with placebo is significant.
  • viral load will be characterized through parameters including time-to-BQL, AUC, percent of subjects with undetectable RSV (from Day 1 to Day 14) and rate of decline from baseline in viral load.
  • Example 4 Evaluation of the clinical activity of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
  • hearth rate and Sp02 Following clinical symptoms (clinical activity parameters) are evaluated over time: hearth rate and Sp02, feeding, respiratory rate, respiratory rate measured over a 1-minute interval, wheezing (as assessed during lung auscultation), cough (during the night and during the day), respiratory muscle retractions, general appearance (activity, irritation, and responsiveness), and body temperature.
  • Time to Clinical Response is calculated based on the feeding and oxygen saturation data.
  • Stable oxygen saturation on room air defined as Sp02 > 92% over a period of > 4 hours.
  • the level of supplementation is to be considered for reduction at least three times per day.
  • RDAI Respiratory Distress Assessment Instrument
  • the Global Severity Score is based on a recent clinical score that allows categorization of infants with respiratory infections on 7 different parameters: feeding intolerance, medical intervention, respiratory difficulty, respiratory frequency, apnea, general condition and fever (Justicia-Grande et al. 2015, Leipzig: 33rd Annual Meeting of the European Society for Paediatric Infectious Diseases;
  • the RDAI is a scoring system based on the presence and severity of wheezing and respiratory muscle retractions.
  • the RDAI score is the sum of the row scores, with total range 0 to 17 (Table B-6); higher scores indicate more severe disease.
  • the RACS is based on the RDAI and adds a standardized score for the change in respiratory rate.
  • the change in respiratory rate is assigned 1 point per each 10% change in the respiratory rate.
  • a decrease in the RDAI or in the respiratory rate during the study period is recorded as a negative RACS, meaning an improvement.
  • Initiation of invasive or non-invasive ventilation i.e., continuous positive airway pressure [cPAP] or HFOT
  • cPAP continuous positive airway pressure
  • HFOT HFOT
  • Parent(s)/Caregiver(s) assessment of the clinical condition of the subject is done by daily completion of a diary during the hospital stay and up to the EOS (Day 28) visit.
  • the diary is used to measure three respiratory symptoms (cough, [audible] wheeze, and trouble breathing), to score the general health of the subject and asks for use of health care utilization and medication for respiratory symptoms.
  • the three respiratory symptoms are scored from not present over very mild, mild, moderate, and severe up to very severe.
  • VAS Visual Analogue Scale
  • Example 5 Evaluation of the pharmacokinetics of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
  • the systemic concentration of ALX-0171 is evaluated in serum, as a surrogate for evaluating local (lung) concentration.
  • blood samples are taken for analysis of ALX-0171 concentrations in serum.
  • a subset 48 subjects, i.e., 12 subjects per dose group) undergoes more extensive pharmacokinetic (PK) sample analysis (3 blood samples for PK assessment).
  • PK pharmacokinetic
  • Subjects not undergoing the more extensive blood sampling scheme have 1 blood sample taken on Day 2 or 3, at any time between 0.5 hours after completion of the second dose and initiation of the administration of the third dose.
  • Subjects undergoing the more extensive blood sampling scheme have 3 blood samples taken on Days 2-3: 1) pre second dose, 2) at any time between 0.5 hours and 3 hours after completion of the second dose, and 3) at any time between 3 hours and 6 hours after completion of the second dose (and at least 1 hour apart from the previous sampling).
  • Individual PK parameters are derived by means of empirical Bayesian estimation. The following individual PK parameters are provided: apparent clearance (CL/F), area under the curve (AUC) as nominal (filling) dose divided by CL/F and cumulative AUC over 72 hours as an expression of the cumulated exposure during the course of treatment. Individual PK parameters are summarized with sample size, mean, standard deviation and coefficient of variation.
  • Example 6 Evaluation of the pharmacodynamics of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
  • Pharmacodynamic effect evaluates the evolution over time of (i) viral load, and (ii) exploratory biomarker KL-6.
  • Example 7 Evaluation of the immunogenicity of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
  • Determination of ADA is done using a validated screening, confirmation and titration ADA bridging assay, with further characterization of ADA positive samples by a competitive ligand binding neutralizing antibody assay.
  • Subjects are classified for presence of pre-Ab, Treatment-emergent (TE) ADA and neutralizing anti-drug antibodies (NAb).
  • TE Treatment-emergent
  • NAb neutralizing anti-drug antibodies
  • Example 8 Safety assessment after administration of selected doses of ALX-0171 to subjects hospitalized for RSV LRTI
  • Safety is assessed through adverse event (AE) collection (including SAEs, hypertension reactions), measurements of vital signs, lung auscultation, heart rate and peripheral capillary oxygen saturation (Sp02), respiratory rate, body weight, body temperature, physical examination, and clinical laboratory parameters.
  • AE adverse event
  • Sp02 peripheral capillary oxygen saturation
  • Safety lab assessments are planned two times during the study (at screening and at the FU visit).
  • Clinical chemistry alanine aminotransferase, aspartate aminotransferase, creatinine, sodium, potassium, chloride, C-reactive protein, ⁇ glutamyl-transferase, blood urea nitrogen;
  • Hematology hemoglobin, hematocrit, red blood cell count and indices, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, platelet count (or estimate), white blood cell count including differential.
  • a lung auscultation is performed to assess wheezing, crackles/crepitation and other abnormalities in lung auscultation.
  • a physical examination is performed, including heart auscultation, examination of abdomen, skin and ears/nose/throat.
  • Table A-1 Amino acid sequences of anti-hRSV immunoglobulin single variable domains (with FR and CDR sequences indicated)

Abstract

Polypeptides are described for use in the treatment of RSV infections in young children. The polypeptides bind and neutralize F protein of h RSV and are administered to the lungs of young children at specific dose regimens.

Description

TREATMENT OF INFECTION BY RESPIRATORY SYNCYTIAL VIRUS (RSV)
FIELD OF THE INVENTION
The present invention provides methods for the treatment of RSV infections in young children. More specifically, the present invention provides specific dose regimens of immunoglobulin single variable domains that neutralize RSV, for pulmonary administration to young children.
BACKGROUND ART
Respiratory syncytial virus (RSV) is a recurrent cause of severe respiratory tract infections in infants and very young children and causes annual epidemics during the winter months. RSV typically causes its primary infection at the point of entry: the ciliated epithelial cells that line the nasal cavity and airways (Black 2003, Respir. Care 48: 209-31; discussion 231-3). Primary infections are usually symptomatic with clinical signs ranging from mild upper respiratory tract illness to more severe lower respiratory tract infections (LRTIs), including bronchopneumonia and bronchiolitis (Aliyu, et al. 2010, Bayero Journal of Pure and Applied Sciences 3: 147-155), which occurs predominantly in infants.
The transmembrane glycoproteins F and G are the primary surface antigens of RSV. The attachment protein (G) mediates binding to cell receptors, while the F protein promotes fusion with cell membranes, allowing penetration into the host cell (Lopez et al. 1998, 72: 6922-8). Based on antigenic and genetic variability of the G protein, 2 serotypes of RSV have been identified (A and B), along with several subtypes.
In contrast to the G protein, the F protein is highly conserved between RSV serotypes A and B (89% amino acid identity), and is therefore considered the main target for development of viral entry inhibitors. Glycoprotein F also induces fusion of infected cells with adjacent uninfected cells. This hallmark feature results in the appearance of multinucleate cell formations (epithelial cell syncytia), which allow for cell-to-cell transmission of replicated viral ribonucleic acid (RNA), conferring additional protection against host immune responses (Black 2003).
RSV infection imposes a significant burden on health care infrastructure and there remains a high medical need for treatment options, especially since there is no vaccine available to prevent RSV infections.
The only drug product available in the market is a humanized monoclonal antibody (SYNAGIS® (palivizumab)) directed against the viral glycoprotein F, which is used prophylactically in children that are at a very high risk of suffering a severe hRSV infection. The restricted use of SYNAGIS® is due, at least in part, to the high cost of this product. Since there are no adequate medications available for treatment of RSV infection, the standard of care for hospitalized infants is mostly supportive (e.g., fluid/feed supplementation, observation, and respiratory support as needed). There is clearly a need for improved and/or cheaper prophylactic and/or therapeutic agents for the prevention and/or treatment of infections by hRSV.
ALX-0171 of the present disclosure is an immunoglobulin single variable domain directed against the fusion protein of the human respiratory syncytial virus. ALX-0171 consists of 3 anti-hRSV immunoglobulin single variable domains, recombinantly linked by a flexible linker.
ALX-0171 was extensively characterized in vitro and in vivo (see for example WO 2010/139808; the contents of which are incorporated by reference in their entirety). The anti-hRSV
immunoglobulin single variable domain specifically and potently binds to the respiratory syncytial virus (RSV) F protein. In vitro micro-neutralization studies in HEp2 cells, suggested that ALX-0171 inhibits an early event in the viral life cycle, preventing extracellular virus from infecting virus naive cells. Efficacy of ALX-0171 was confirmed in RSV-infected cotton rats and lambs (Detalle et al. 2014, Delivery of ALX-0171 by inhalation greatly reduces disease burden in neonatal lamb RSV infection model, 9th RSV Symposium, Stellenbosch, South Africa; Detalle et al. 2016, Antimicrobial Agents and Chemotherapy 60: 6-13).
Since ALX-0171 is intended to neutralize and inhibit RSV, direct delivery and deposition in the respiratory tract through an aerosol device is considered the preferred and most suitable route of administration. Formulation of immunoglobulin single variable domains (including ALX-0171) as a nebulizer solution has been described in WO 2011/098552.
The safety, tolerability and pharmacokinetic (PK) parameters of inhalation of ALX-0171 have further been evaluated in three Phase I clinical studies in adult volunteers (Fougerolles 2014 "Using Nanobodies® as novel inhalation therapeutic for the treatment of respiratory infectious diseases" British Pharmacology Society, James Black Meeting, 19 Sept 2014; De Bruyn et al. 2015, RDD Europe 2015, Vol 1: 37-48). These studies showed that inhalation and intravenous (i.v.) infusion of ALX-0171 is generally well-tolerated. There is, however, no possibility for extrapolating efficacy from adults to children, or from older to younger children, as lower respiratory tract disease caused by RSV rarely occurs in these populations.
Safety and tolerability of ALX-0171 was further evaluated in a Phase l/2a study in infants and young children hospitalized for RSV LRTI. For this pediatric study, described in WO 2016/055656, dose determination was based on a modelling approach, complemented by additional experiments that generated data specifically for administration of ALX-0171 with the FOX-Flamingo inhalation system. Physiologically-based PK modelling was considered the best approach to bridge nonclinical, human adult, and human pediatric PK parameters, taking into account growth and developmental processes such as organ maturation, changes in blood flow, body composition, and ontogeny of elimination mechanisms (Barrett et al. 2012 "Physiologically based pharmacokinetic (PBPK) modeling in children" Clinical pharmacology and therapeutics 92: 40-49; Khalil and Laer 2011 "Physiologically Based Pharmacokinetic Modeling: Methodology, Applications, and Limitations with a Focus on Its Role in Pediatric Drug Development" J. of Biomed. and Biotechnol., 2011: article ID 907461, 13 p.).
Based on this modeling approach, the target concentration at which a clinically meaningful reduction of RSV activity is obtained (9 μg/ml) was estimated to be reached in the alveolar space using a deposited dose of 0.024 mg/kg body weight. Based on this estimated deposited dose, the nominal dose for the pulmonary administration of ALX-0171 to young children was defined as 1.2 mg/kg. Based on this approach, a dose of 1.2 mg/kg was evaluated in the pediatric study described in WO 2016/055656.
The results of this pediatric study (described in WO 2016/055656) indicated that this dose was well tolerated in all age groups (1 to 24 months). Reductions in nasal viral load (obtained from nasal swabs) were noted, confirming that ALX-0171 can exert antiviral activity when relevant
concentrations are achieved. With this dose of 1.2 mg/kg, however, the desired level of clinical efficacy was not reached. As further explained in the Example section, further PK analysis of the data of this study showed a serum concentration of ALX-0171 lower than expected, which is indicative of insufficient drug concentrations in the lung, an important site of RSV replication and the driver for clinical effect.
SUMMARY OF THE INVENTION
To address these unexpectedly low drug concentrations in the lung, the present invention provides improved dose regimens for pulmonary administration of ALX-0171 in a pediatric population. More particularly, the present invention provides improved dose regimens for the pulmonary administration of ALX-0171 to young children, such as infants and toddlers.
As indicated above, for RSV neutralizing drugs, there is no possibility for extrapolating efficacy from adults to children, or from older to younger children, as lower respiratory tract disease caused by RSV rarely occurs in these populations. Therefore, dose determination could only be based on a modelling approach. Based on such a modelling approach, the desired concentration of drug in the lung was unexpectedly not reached.
The present invention now provides improved dose regimens for the pulmonary administration, to pediatric subjects, of ALX-0171. These improved dose regimens result in local drug concentrations in the lower respiratory tract at which clinical efficacy is observed.
Accordingly, the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration, to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
In one aspect, the nominal dose is 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg, such as 3 mg/kg. Accordingly, the present invention relates to a method for the treatment of SV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
In another aspect, the nominal dose is 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg, such as 6 mg/kg. Accordingly, the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
In yet another aspect, the nominal dose is 7.5 to 11 mg/kg daily, preferably 7.5 to 10.7 mg/kg, such as 9 mg/kg. Accordingly, the present invention relates to a method for the treatment of RSV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.5 to 10.7 mg/kg daily, such as 9 mg/kg daily.
The invention also relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily. In one aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
In another aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
In yet another aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
RSV infection includes RSV infection of the upper respiratory tract, RSV infection of the lower respiratory tract, including bronchiolitis and broncho-pneumonia, as well as diseases and/or disorders associated with RSV infection such as respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV. In one aspect, the RSV infection is RSV lower respiratory tract infection. Accordingly, the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
In one aspect, the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
In another aspect, the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
In yet another aspect, the present invention relates to a method for the treatment of RSV lower respiratory tract infection in a young child, said method comprising the administration, to the child suffering the RSV lower respiratory tract infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered, to the child suffering RSV infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
The invention also relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
In one aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
In another aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
In yet another aspect, the invention relates to a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV lower respiratory tract infection in a young child, wherein the polypeptide is administered, to the child suffering RSV lower respiratory tract infection, by inhalation at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
In one aspect, the polypeptide is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, such as e.g. for 3 consecutive days.
In one aspect, the young child is aged less than 24 months.
In one aspect, the young child is aged 28 days to less than 24 months.
In one aspect, the young child is aged 1 month to less than 24 months.
In one aspect, the young child is aged less than 36 months.
In one aspect, the young child is aged 28 days to less than 36 months.
In one aspect, the young child is aged 1 month to less than 36 months. In one aspect, the young child is an infant.
In one aspect, the young child is a toddler.
In one aspect, the young child is aged less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 28 days to less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 1 month to less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is an infant, with a gestational age of more than 33 weeks.
In one aspect, the young child is a toddler, with a gestational age of more than 33 weeks.
In one aspect, the young child is diagnosed with RSV lower respiratory tract infection.
In one aspect, the young child is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
In one aspect, the young child is hospitalised for RSV lower respiratory tract infection.
The polypeptide (also referred to as "polypeptide of the invention") comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprises a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61. Preferably, CDRl has the amino acid sequence of SEQ ID NO: 46, CDR2 has the amino acid sequence of SEQ ID NO: 49, and a CDR3 has the amino acid sequence of SEQ ID NO: 61. Preferred polypeptides of the invention encompass at least one (preferably two, most preferably three) anti-RSV immunoglobulin single variable domain(s) selected from one of the amino acid sequences of SEQ ID NOs: 1-34. In one aspect, the polypeptide of the invention is selected from one of the amino acid sequences of SEQ ID NOs: 65-85, preferably ALX-0171.
The polypeptide of the invention can be administered as a monotherapy or in combination with another therapeutic agent. In one aspect, the polypeptide of the invention is administered as a monotherapy. In one aspect, polypeptide of the invention is administered as a combination therapy.
Accordingly, the invention also provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 2 to 11 mg/kg daily, preferably 2.5 to 10.7 mg/kg daily, such as 3 to 9 mg/kg daily.
In one aspect, the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 2 to 4 mg/kg daily, preferably 2.5 to 3.6 mg/kg daily, such as 3 mg/kg daily.
In another aspect, the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 4 to 7.5 mg/kg daily, preferably 5 to 7.1 mg/kg daily, such as 6 mg/kg daily.
In yet another aspect, the invention provides a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the simultaneous, separate or sequential administration by inhalation, to the child suffering the RSV infection, of a polypeptide of the invention and another therapeutic agent such as a bronchodilator, wherein the polypeptide is administered to the child by inhalation at at a nominal dose of 7.5 to 11 mg/kg daily, preferably 7.6 to 10.7 mg/kg daily, such as 9 mg/kg daily.
In one aspect, the other therapeutic agent is a bronchodilator.
The bronchodilator preferably belongs to the class of beta2-mimetics or to the class of anticholinergics. In one aspect, the bronchodilator is a long-acting beta2-mimetic such as e.g.
formoterol or a solvate thereof, salmeterol or a salt thereof, or a mixture thereof. In another aspect, the bronchodilator is a short-acting beta2-mimetic such as e.g. salbutamol (e.g. at a dose of 200 micrograms), terbutaline, pirbuterol, fenoterol, tulobuterol, levosabutamol, or a mixture thereof. In another aspect, the bronchodilator is an anticholinergic such as e.g. tiotropium, oxitropium, ipratropium bromide or a mixture thereof.
The present invention also relates to an inhalation device (also referred to herein as "inhalation device of the invention") comprising a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.20 mL-2.25 mL or 0.20-1.50 mL. In one aspect, the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.20-0.75 mL, such as e.g. 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, or 0.75 mL.
In another aspect, the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.40-1.50 mL, such as e.g. 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, or 1.50 mL.
In yet another aspect, the inhalation device comprises a 50 mg/mL composition of a polypeptide of the invention, wherein the fill volume of said composition in the inhalation device is 0.60-2.25 mL, such as e.g. 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, or 2.25 mL.
In one aspect, the inhalation device is an aerosol delivery system, such as a nebulizer, preferably a vibrating mesh nebulizer.
The nebulizer preferably has a fixed flow of air or oxygen, such as a flow of air or oxygen at 2 L/min.
Accordingly, the inhalation device may comprise:
(a) an aerosol generator with a vibratable mesh;
(b) a reservoir for a liquid to be nebulised, said reservoir being in fluid connection with the vibratable mesh;
(c) a gas inlet opening;
(d) a face mask, having
- a casing,
- an aerosol inlet opening,
- a patient contacting surface, and
- a one-way exhalation valve or a two-way inhalation/exhalation valve in the casing having an exhalation resistance selected in the range from 0.5 to 5 mbar; and
(e) a flow channel extending from the gas inlet opening to the aerosol inlet opening of the face mask, the flow channel having
- a lateral opening through which the aerosol generator is at least partially inserted into the flow channel,
- a constant flow resistance between the gas inlet opening and the aerosol inlet opening of the face mask at a flow rate of 1 to 20 L/min.
The flow channel may be sized and shaped to achieve, at a position immediately upstream of the lateral opening, an average gas velocity of at least 4 m/s at a flow rate of 2 L/min, and/or the flow channel upstream of the lateral opening may be shaped such as to effect a laminar flow when a gas is conducted through the flow channel at a flow rate of 1 to 20 L/min. In this inhalation device as described herein, the polypeptide of the invention present in the 50 mg/mL composition comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61. Preferably, the anti-RSV immunoglobulin single variable domains comprise a CDR1 having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of SEQ ID NO: 49, and a CDR3 having the amino acid sequence of SEQ ID NO: 61. In one aspect, the anti-RSV immunoglobulin single variable domain is selected from one of the amino acid sequence of SEQ ID NOs: 1-34.
In one aspect, the polypeptide of the invention present in the inhalation device as described herein is selected from one of the amino acid sequence of SEQ ID NOs: 65-85, preferably ALX-0171.
The present invention also relates to such inhalation devices as described above, for use in the methods of the invention. Accordingly, in one aspect, the invention provides the inhalation device as described herein, for use in the treatment of RSV infection in a young child. In one aspect, the invention provides the inhalation device as described herein, for use in the treatment of RSV lower respiratory tract infection in a young child.
In one aspect, the young child treated with the inhalation device of the invention is aged less than 24 months.
In one aspect, the young child treated with the inhalation device of the invention is aged 28 days to less than 24 months.
In one aspect, the young child treated with the inhalation device of the invention is aged 1 month to less than 24 months.
In one aspect, the young child treated with the inhalation device of the invention is aged less than 36 months.
In one aspect, the young child treated with the inhalation device of the invention is aged 28 days to less than 36 months.
In one aspect, the young child treated with the inhalation device of the invention is aged 1 month to less than 36 months.
In one aspect, the young child treated with the inhalation device of the invention is an infant.
In one aspect, the young child treated with the inhalation device of the invention is a toddler.
In one aspect, the young child treated with the inhalation device of the invention is aged less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks. In one aspect, the young child treated with the inhalation device of the invention is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is aged less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is aged 28 days to less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is aged 1 month to less than 36 months, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is an infant, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is a toddler, with a gestational age of more than 33 weeks.
In one aspect, the young child treated with the inhalation device of the invention is diagnosed with SV lower respiratory tract infection.
In one aspect, the young child treated with the inhalation device of the invention is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
In one aspect, the young child treated with the inhalation device of the invention is hospitalised for RSV lower respiratory tract infection.
The inhalation device of the invention can be used as a monotherapy or in combination with another therapeutic agent. In one aspect, the inhalation device of the invention is used as a monotherapy. In another aspect, at least one additional therapeutic agent is administered.
The additional therapeutic agent can, for example, be a bronchodilator. Accordingly, in an aspect, the inhalation device of the invention is used in combination with a bronchodilator. The bronchodilator used with the inhalation device of the invention preferably may belong to the class of beta2-mimetics or to the class of anticholinergics. In one aspect, the bronchodilator is a long-acting beta2-mimetic such as e.g. formoterol or a solvate thereof, salmeterol or a salt thereof, or a mixture thereof. In another aspect, the bronchodilator is a short-acting beta2-mimetic such as e.g.
salbutamol (e.g. at a dose of 200 micrograms), terbutaline, pirbuterol, fenoterol, tulobuterol, levosabutamol, or a mixture thereof. In another aspect, the bronchodilator is an anticholinergic such as e.g. tiotropium, oxitropium, ipratropium bromide or a mixture thereof.
FIGURE LEGENDS
Figure 1: Boxplots of ALX-0171 serum concentrations measured in a phase l/2a study after administration of a (nominal) dose of 1.2 mg/kg of ALX-0171 by inhalation to infants and young children hospitalized for RSV LRTI. Left boxplots shows concentrations from all subjects who had their sample taken. Right boxplot shows concentrations from subjects who had their sample taken at the time defined per protocol (6 hours after the last nebulization). Dashed horizontal lines represent the 90% prediction interval from the PBPK model, full horizontal line represents the median prediction from the PBPK model. Note: Six subjects had concentration below the limit of quantification and were associated to a concentration of 0.5 ng/mL (half the quantification limit) for plotting purpose.
Figure 2: Overview of the study design of the clinical study described in Example 2.
Figure 3: Overview of the study flow of the clinical study described in Example 2.
Figure 4: Overview of the FOX-Flamingo inhalation system.
Figure 5: Cross-sectional side view of a nebulizer.
DETAILED DESCRIPTION
Definitions
Unless indicated or defined otherwise, all terms used have their usual meaning in the art, which will be clear to the skilled person. Reference is for example made to the standard handbooks, such as Sambrook et al. "Molecular Cloning: A Laboratory Manual" ( 2nd. Ed.), Vols. 1-3, Cold Spring Harbor Laboratory Press (1989); F. Ausubel et al. eds., "Current protocols in molecular biology", Green Publishing and Wiley Interscience, New York (1987); Lewin "Genes II", John Wiley & Sons, New York, N.Y., (1985); Old et al. "Principles of Gene Manipulation: An Introduction to Genetic Engineering", 2nd edition, University of California Press, Berkeley, CA (1981); Roitt et al. "Immunology" (6th. Ed.), Mosby/Elsevier, Edinburgh (2001); Roitt et al. Roitt's Essential Immunology, 10th Ed. Blackwell Publishing, UK (2001); and Janeway et al. "Immunobiology" (6th Ed.), Garland Science Publishing/ Churchill Livingstone, New York (2005), as well as to the general background art cited herein.
Unless indicated otherwise, all methods, steps, techniques and manipulations that are not specifically described in detail can be performed and have been performed in a manner known per se, as will be clear to the skilled person. Reference is for example again made to the standard handbooks and the general background art mentioned herein and to the further references cited therein; as well as to for example the following reviews: Presta 2006 (Adv. Drug Deliv. Rev. 58 (5-6): 640-56), Levin and Weiss 2006 (Mol. Biosyst. 2(1): 49-57), Irving et al. 2001 (J. Immunol. Methods 248(1-2): 31-45), Schmitz et al. 2000 (Placenta 21 Suppl. A: S106-12), Gonzales et al. 2005 (Tumour Biol. 26(1): 31-43), which describe techniques for protein engineering, such as affinity maturation and other techniques for improving the specificity and other desired properties of proteins such as immunoglobulins.
A nucleic acid sequence or amino acid sequence is considered to be "(in) essentially isolated (form)" - for example, compared to the reaction medium or cultivation medium from which it has been obtained - when it has been separated from at least one other component with which it is usually associated in said source or medium, such as another nucleic acid, another
protein/polypeptide, another biological component or macromolecule or at least one contaminant, impurity or minor component. In particular, a nucleic acid sequence or amino acid sequence is considered "essentially isolated" when it has been purified at least 2-fold, in particular at least 10- fold, more in particular at least 100-fold, and up to 1000-fold or more. A nucleic acid sequence or amino acid sequence that is "in essentially isolated form" is preferably essentially homogeneous, as determined using a suitable technique, such as a suitable chromatographical technique, such as polyacrylamide-gel electrophoresis.
When a nucleotide sequence or amino acid sequence is said to "comprise" another nucleotide sequence or amino acid sequence, respectively, or to "essentially consist of" or "consist essentially of" another nucleotide sequence or amino acid sequence, this may mean that the latter nucleotide sequence or amino acid sequence has been incorporated into the first mentioned nucleotide sequence or amino acid sequence, respectively, but more usually this generally means that the first mentioned nucleotide sequence or amino acid sequence comprises within its sequence a stretch of nucleotides or amino acid residues, respectively, that has the same nucleotide sequence or amino acid sequence, respectively, as the latter sequence, irrespective of how the first mentioned sequence has actually been generated or obtained (which may for example be by any suitable method). By means of a non-limiting example, when a polypeptide of the invention is said to comprise an immunoglobulin single variable domain, this may mean that said immunoglobulin single variable domain sequence has been incorporated into the sequence of the polypeptide of the invention, but more usually this generally means that the polypeptide of the invention contains within its sequence the sequence of the immunoglobulin single variable domain irrespective of how said polypeptide of the invention has been generated or obtained. Also, when a nucleic acid or nucleotide sequence is said to comprise another nucleotide sequence, the first mentioned nucleic acid or nucleotide sequence is preferably such that, when it is expressed into an expression product (e.g. a
polypeptide), the amino acid sequence encoded by the latter nucleotide sequence forms part of said expression product (in other words, that the latter nucleotide sequence is in the same reading frame as the first mentioned, larger nucleic acid or nucleotide sequence).
By "essentially consist(s) of" or "consist(s) essentially of" is meant that the immunoglobulin single variable domain used in the method of the invention either is exactly the same as the polypeptide of the invention or corresponds to the polypeptide of the invention which has a limited number of amino acid residues, such as 1-20 amino acid residues, for example 1-10 amino acid residues and preferably 1-6 amino acid residues, such as 1, 2, 3, 4, 5 or 6 amino acid residues, added at the amino terminal end, at the carboxy terminal end, or at both the amino terminal end and the carboxy terminal end of the immunoglobulin single variable domain.
In addition, the term "sequence" as used herein (for example in terms like "immunoglobulin sequence", "variable domain sequence", "immunoglobulin single variable domain sequence", "VHH sequence" or "protein sequence"), should generally be understood to include both the relevant amino acid sequence as well as nucleic acid sequences or nucleotide sequences encoding the same, unless the context requires a more limited interpretation.
An amino acid sequence (such as an immunoglobulin single variable domain, an antibody, a polypeptide of the invention, or generally an antigen binding protein or polypeptide or a fragment thereof) that "(specifically) binds", that "can (specifically) bind to", that "has affinity for" and/or that "has specificity for" a specific antigenic determinant, epitope, antigen or protein (or for at least one part, fragment or epitope thereof) is said to be "against" or "directed against" said antigenic determinant, epitope, antigen or protein.
The affinity denotes the strength or stability of a molecular interaction. The affinity is commonly given by the KD, or dissociation constant, which has units of mol/liter (or M). The affinity can also be expressed as an association constant, KA, which equals 1/KD and has units of (mol/liter)"1 (or M"1). In the present specification, the stability of the interaction between two molecules (such as immunoglobulin single variable domain or polypeptide of the invention and F-protein of h SV) will mainly be expressed in terms of the KD value of their interaction; it being clear to the skilled person that in view of the relation KA =1/KD, specifying the strength of molecular interaction by its KD value can also be used to calculate the corresponding KA value. The KD-value characterizes the strength of a molecular interaction also in a thermodynamic sense as it is related to the free energy (DG) of binding by the well-known relation DG=RT.In(KD) (equivalently DG=-RT.In(KA)), where R equals the gas constant, T equals the absolute temperature and In denotes the natural logarithm.
The KDfor biological interactions which are considered meaningful (e.g. specific) are typically in the range of 10 10M (0.1 nM) to 10"5M (10000 nM). The stronger an interaction is, the lower is its KD.
The KD can also be expressed as the ratio of the dissociation rate constant of a complex, denoted as k0ff, to the rate of its association, denoted kon (so that KD =k0ff/k0n and KA = kon/k0ff). The off-rate k0ff has units s"1 (where s is the SI unit notation of second). The on-rate kon has units M V1. The on-rate may vary between 102 I V1 to about 107 I V1, approaching the diffusion-limited association rate constant for bimolecular interactions. The off-rate is related to the half-life of a given molecular interaction by the relation
Figure imgf000016_0001
. The off-rate may vary between 10"6 s"1 (near irreversible complex with a ti/2 of multiple days) to 1 s"1 s).
Specific binding of an antigen-binding protein to an antigen or antigenic determinant can be determined in any suitable manner known per se, including, for example, Scatchard analysis and/or competitive binding assays, such as radio-immunoassays ( IA), enzyme immunoassays (EIA) and sandwich competition assays, and the different variants thereof known per se in the art; as well as the other techniques mentioned herein.
The affinity of a molecular interaction between two molecules can be measured via different techniques known per se, such as the well-known surface plasmon resonance (SPR) biosensor technique (see for example Ober et al. 2001, Intern. Immunology 13: 1551-1559) where one molecule is immobilized on the biosensor chip and the other molecule is passed over the
immobilized molecule under flow conditions yielding kon, koff measurements and hence KD (or KA) values. This can for example be performed using the well-known Biacore instruments (Pharmacia Biosensor AB, Uppsala, Sweden). Kinetic Exclusion Assay (KinExA) (Drake et al. 2004, Analytical Biochemistry 328: 35-43) measures binding events in solution without labeling of the binding partners and is based upon kinetically excluding the dissociation of a complex.
The GYROLAB™ immunoassay system provides a platform for automated bioanalysis and rapid sample turnaround (Fraley et al. 2013, Bioanalysis 5: 1765-74).
It will also be clear to the skilled person that the measured KD may correspond to the apparent KD if the measuring process somehow influences the intrinsic binding affinity of the implied molecules for example by artifacts related to the coating on the biosensor of one molecule. Also, an apparent KD may be measured if one molecule contains more than one recognition sites for the other molecule. In such situation the measured affinity may be affected by the avidity of the interaction by the two molecules.
Another approach that may be used to assess affinity is the 2-step ELISA (Enzyme-Linked Immunosorbent Assay) procedure of Friguet et al. 1985 (J. Immunol. Methods 77: 305-19). This method establishes a solution phase binding equilibrium measurement and avoids possible artifacts relating to adsorption of one of the molecules on a support such as plastic.
However, the accurate measurement of KD may be quite labor-intensive and as consequence, often apparent KD values are determined to assess the binding strength of two molecules. It should be noted that as long all measurements are made in a consistent way (e.g. keeping the assay conditions unchanged) apparent KD measurements can be used as an approximation of the true KD and hence in the present document KD and apparent KD should be treated with equal importance or relevance.
The term "infectivity of a virus", as used herein, refers to the proportion of living subjects that, when exposed to said virus, actually becomes infected by said virus.
"Neutralization of a virus", as used herein, refers to the modulation and/or reduction and/or prevention and/or inhibition of the infectivity (as defined herein) of a virus by binding of a neutralizing compound to the virion, as measured using a suitable in vitro, cellular or in vivo assay (such as those mentioned further).
The term "dosing" refers to the administration of the polypeptide of the invention. Unless explicitly indicated different, in the context of the present invention, the term "dosing" refers to the pulmonary administration of the polypeptide of the invention.
The term "fill volume" or "filling volume" refers to the volume of the composition of polypeptide of the invention filled in the nebulizer.
The term "dose" refers to an amount of polypeptide of the invention that is administered to the subject.
The "nominal dose" refers to the dose (e.g. in mg/kg) of polypeptide of the invention that is filled in the nebuliser. The nominal dose is expressed per kilogram (kg) of body weight of the subject.
The term "fill dose" or "filling dose" refers to the actual amount (e.g. in mg) of polypeptide of the invention that is filled in the nebulizer. The "fill dose" can easily be determined based on the fill volume (volume of therapeutic composition filled in the nebulizer) and the concentration of the polypeptide of the invention in the therapeutic composition and will depend on the weight of the subject to be treated.
The "delivered dose" refers to the amount of polypeptide of the invention in aerosol particles generated by the vibrating mesh nebuliser and available in the face mask for inhalation.
The "inhaled dose" refers to the amount of polypeptide of the invention in aerosol particles available at the upper respiratory tract (i.e., the dose which is inhaled). The inhaled dose can be calculated as a percentage (%) from the nominal dose and will depend on the characteristics of the nebulizer.
The "deposited dose" refers to the amount of polypeptide of the invention in aerosol particles deposited in the lower respiratory tract. The deposited dose will depend on the characteristics of the inhaled particles and the breathing pattern of the young child suffering SV infection. Breathing patterns in RSV infected children are e.g. described by Amirav et al. 2002 (J. Nucl. Med. 43: 487-91), Amirav et al. 2012 (Arch. Dis. Child 97: 497-501), Chua et al. 1994 (Eur. Respir. J. 7: 2185-91), Fok et al. 1996 (Pediatr. Pulmonol. 21: 301-9), Wildhaber et al. 1999 (J. Pediatr. 135: 28-33), Totapally et al. 2002 (Crit. Care 6: 160-5), Mundt et al. 2012 (Pediatr. 2012: 721295).
The "systemic dose" refers to the amount of polypeptide of the invention absorbed via the alveolar lining fluid of the lower respiratory tract and released into circulation. The systemic dose can easily be determined by measuring the concentration of the polypeptide of the invention in the systemic circulation. The "systemic circulation" as used in the present invention, is the part of the cardiovascular system which carries oxygenated blood away from the heart to the body, and returns deoxygenated blood back to the heart.
A child is generally a human subject between birth and puberty or in the developmental stage of childhood. In the context of the present invention, a "young child" refers to a child of less than 24 months or less than 36 months (3 years). An "infant" is the very young offspring of a human. The term is usually considered synonymous with baby. The term "infant" is typically applied to young children between the ages of 28 days or 1 month and 12 months. When a human child learns to walk, the term "toddler" may be used instead. A "toddler" is a child between the ages of one and three. In the context of the present invention, a "toddler" is a child between the ages of one and less than 24 months or between the ages of one and less than 36 months (3 years).
"Pediatrics" is the branch of medicine that deals with the medical care of infants and children.
"Respiratory tract" is for the purposes of this invention equivalent with "respiratory system", "airway tissue" or "airways". The respiratory system comprises 2 distinct zones: a conducting and a respiratory zone, within which the airway and vascular compartments lie (see e.g. "Pulmonary Drug Delivery", Edited by Karoline Bechtold-Peters and Henrik Luessen, 2007, ISBN 978-3-87193-322-6 pages 16-28). The conducting zone consists of the nose, pharynx, larynx, trachea, bronchi, and bronchioles. These structures form a continuous passageway for air to move in and out of the lungs. The respiratory zone is found deep inside the lungs and is made up of the respiratory bronchioles, alveolar ducts, and alveoli. These thin-walled structures allow inhaled oxygen to diffuse into lung capillaries in exchange for carbon dioxide. Anatomically, the same structures are often divided into the upper and the lower respiratory tracts. The upper respiratory structures are found in the head and neck and consist of the nose, pharynx, and larynx. The lower respiratory tract structures are located in the thorax or chest and include the trachea, bronchi, and lungs (i.e. bronchioles, alveolar ducts, and alveoli). The lower respiratory tract thus refers to the portions of the airways from the trachea to the lungs.
"(Clinically) diagnosed with RSV LRTI", "(clinically) diagnosed with bronchiolitis" or "(clinically) diagnosed with broncho-pneumonia" as used in the present invention means that the patient shows typical clinical signs and symptoms of RSV LRTI, bronchiolitis or bronchopneumonia, such as tachypnea, wheezing, cough, crackles, use of accessory muscles and/or nasal flaring.
"Diagnosed with RSV LRTI" may also mean that the subject has a positive RSV diagnostic test.
"Administration by inhalation", "pulmonary administration", "delivery by inhalation", and "pulmonary delivery" as used in the present invention means that the polypeptide of the invention is administered to the respiratory tract. In the present invention, in this delivery method, the polypeptide of the invention is present in an aerosol obtained from nebulizing (with a nebulizer) the polypeptide of the invention.
An "inhalation device" is a medical device used for delivering medication into the body via the lungs.
An "aerosol" as used herein refers to a suspension of liquid in the form of fine particles dispersed in a gas (i.e. a fine mist or spray containing minute particles). As used herein, the term "particle" refers to liquids, e.g., droplets. Pharmaceutical aerosols for the delivery of the
polypeptides of the invention to the lungs can be inhaled via the mouth and/or via the nose. In pulmonary delivery, the generation of particles smaller than approximately 5 or 6 micrometer is considered necessary to achieve deposition as the fine particle fraction (FPF) (i.e. in the respiratory bronchioles and alveolar region) (O'Callaghan and Barry, 1997, Thorax 52: S31-S44). The particle size in an aerosol can be expressed as mass median diameter (MMD) or volume median diameter (VMD). The "mass median diameter" is defined as the geometric particle diameter of an aerosol, where 50% of the aerosol mass is larger than this value and 50% is smaller than this value. The "volume median diameter" is defined as the geometric particle diameter of an aerosol, where 50% of the aerosol volume is larger than this value and 50% is smaller than this value. When the density of the aerosol particles is 1 g/cm3, the VMD and MMD are equivalent.
The "mass median aerodynamic diameter (MMAD)" is defined as the geometric mean aerodynamic diameter, where 50% of the aerosol mass will be smaller than this value and 50% will be larger than this value. The MMAD is determined by the aerodynamic behavior of the particles in an airflow and relates to the size and density of a particle with its behavior in moving air.
The term "nebulization" as used in the present invention refers to the conversion of a liquid into a mist or fine spray by a nebulizer (as further defined herein).
An "aerosol generator" is a device or device component capable of generating an aerosol from a liquid formulation; e.g. a pharmaceutical composition for inhalation use. Synonymously, the terms "nebulizer" or "nebulising means" may be employed.
Unless specified otherwise, a "gas" refers to any gas or mixture of gases suitable for inhalation.
"Lateral", or "laterally", means away from the middle, centre, or centre axis of a device or device component.
The "tidal volume" of a subject or patient is the lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied.
The terms "subject" and "patient" are used interchangeably. As used herein, the terms "subject" and "subjects" refer to a human. The phrase "pharmaceutically acceptable" as used herein means approved by a regulatory agency of the Federal or a state government, or listed in the U.S. Pharmacopeia, European
Pharmacopoeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans. In this sense, it should be compatible with the other ingredients of the formulation and not eliciting an unacceptable deleterious effect in the subject. It refers to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.
As used herein, the term "pharmaceutically active amount" refers to the amount of a therapeutic agent (e.g. a polypeptide of the invention), that is sufficient to reduce the severity and/or duration of one or more diseases and/or disorders.
Polypeptide of the invention
The polypeptides of the invention may be non-naturally occurring. Thus, the polypeptides of the invention may have been designed, manufactured, synthesized, and/or recombined to produce a non-naturally occurring sequence.
Immunoglobulin single variable domain
Unless indicated otherwise, the term "immunoglobulin sequence" - whether used herein to refer to a heavy chain antibody or to a conventional 4-chain antibody - is used as a general term to include both the full-size antibody, the individual chains thereof, as well as all parts, domains or fragments thereof (including but not limited to antigen-binding domains or fragments such as VHH domains or VH/VL domains, respectively). In addition, the term "sequence" as used herein (for example in terms like "immunoglobulin sequence", "antibody sequence", "variable domain sequence", "VHH sequence" or "protein sequence"), should generally be understood to include both the relevant amino acid sequence as well as nucleic acids or nucleotide sequences encoding the same, unless the context requires a more limited interpretation.
The term "immunoglobulin single variable domain", interchangeably used with "single variable domain", defines molecules wherein the antigen binding site is present on, and formed by, a single immunoglobulin domain. This sets immunoglobulin single variable domains apart from
"conventional" immunoglobulins or their fragments, wherein two immunoglobulin domains, in particular two variable domains, interact to form an antigen binding site. Typically, in conventional immunoglobulins, a heavy chain variable domain (VH) and a light chain variable domain (VL) interact to form an antigen binding site. In this case, the complementarity determining regions (CD s) of both VH and VL will contribute to the antigen binding site, i.e. a total of 6 CD s will be involved in antigen binding site formation.
In contrast, the binding site of an immunoglobulin single variable domain is formed by a single VH or VL domain. Hence, the antigen binding site of an immunoglobulin single variable domain is formed by no more than three CDRs.
The term "immunoglobulin single variable domain" and "single variable domain" hence does not comprise conventional immunoglobulins or their fragments which require interaction of at least two variable domains for the formation of an antigen binding site. However, these terms do comprise fragments of conventional immunoglobulins wherein the antigen binding site is formed by a single variable domain.
Generally, single variable domains will be amino acid sequences that essentially consist of 4 framework regions (FR1 to FR4 respectively) and 3 complementarity determining regions (CDR1 to CDR3 respectively). Such single variable domains and fragments are most preferably such that they comprise an immunoglobulin fold or are capable for forming, under suitable conditions, an immunoglobulin fold. As such, the single variable domain may for example comprise a light chain variable domain sequence (e.g. a VL-sequence) or a suitable fragment thereof; or a heavy chain variable domain sequence (e.g. a VH-sequence or VHH sequence) or a suitable fragment thereof; as long as it is capable of forming a single antigen binding unit (i.e. a functional antigen binding unit that essentially consists of the single variable domain, such that the single antigen binding domain does not need to interact with another variable domain to form a functional antigen binding unit, as is for example the case for the variable domains that are present in for example conventional antibodies and scFv fragments that need to interact with another variable domain - e.g. through a VH/VL interaction - to form a functional antigen binding domain).
In the present invention, the immunoglobulin single variable domains can be heavy chain variable domain sequences that are derived from a conventional four-chain antibody or heavy chain variable domain sequences that are derived from a heavy chain antibody.
For example, the single variable domain or immunoglobulin single variable domain (or an amino acid that is suitable for use as an immunoglobulin single variable domain) may be a (single) domain antibody (or an amino acid that is suitable for use as a (single) domain antibody), a "dAb" or dAb (or an amino acid that is suitable for use as a dAb) or a Nanobody (as defined herein, and including but not limited to a VHH); other single variable domains, or any suitable fragment of any one thereof.
For a general description of (single) domain antibodies, reference is also made to the prior art cited herein, as well as to EP 0368684. For the term "dAb's", reference is for example made to Ward et al. 1989 (Nature 341: 544-546), to Holt et al.2003 (Trends Biotechnol. 21: 484-490); as well as to for example WO 04/068820, WO 06/030220, WO 06/003388, WO 06/059108, WO 07/049017, WO 07/085815 and other published patent applications of Domantis Ltd. It should also be noted that, although less preferred in the context of the present invention because they are not of mammalian origin, single variable domains can be derived from certain species of shark (for example, the so- called "IgNA domains", see for example WO 05/18629).
In particular, the immunoglobulin single variable domain may be a Nanobody® (as defined herein) or a suitable fragment thereof. [Note: Nanobody9 and Nanobodies9 are registered trademarks of Ably nx N. V.] For a general description of Nanobodies, reference is made to the further description below, as well as to the prior art cited herein, such as e.g. described in WO 08/020079 (page 16).
For a further description of VHH's and Nanobodies, reference is made to the review article by Muyldermans 2001 (Reviews in Molecular Biotechnology 74: 277-302), as well as to the following patent applications, which are mentioned as general background art: WO 94/04678, WO 95/04079 and WO 96/34103 of the Vrije Universiteit Brussel; WO 94/25591, WO 99/37681, WO 00/40968, WO 00/43507, WO 00/65057, WO 01/40310, WO 01/44301, EP 1134231 and WO 02/48193 of Unilever; WO 97/49805, WO 01/21817, WO 03/035694, WO 03/054016 and WO 03/055527 of the Vlaams Instituut voor Biotechnologie (VIB); WO 03/050531 of Algonomics N.V. and Ablynx N.V.; WO
01/90190 by the National Research Council of Canada; WO 03/025020 (= EP 1433793) by the Institute of Antibodies; as well as WO 04/041867, WO 04/041862, WO 04/041865, WO 04/041863, WO 04/062551, WO 05/044858, WO 06/40153, WO 06/079372, WO 06/122786, WO 06/122787 and WO 06/122825, by Ablynx N.V. and the further published patent applications by Ablynx N.V.
Reference is also made to the further prior art mentioned in these applications, and in particular to the list of references mentioned on pages 41-43 of the International application WO 06/040153, which list and references are incorporated herein by reference. As described in these references, Nanobodies (in particular VHH sequences and partially humanized Nanobodies) can in particular be characterized by the presence of one or more "Hallmark residues" in one or more of the framework sequences. A further description of the Nanobodies, including humanization and/or camelization of Nanobodies, as well as other modifications, parts or fragments, derivatives or "Nanobody fusions", multivalent constructs (including some non-limiting examples of linker sequences) and different modifications to increase the half-life of the Nanobodies and their preparations can be found e.g. in WO 08/101985 and WO 08/142164.
Thus, in the meaning of the present invention, the term "immunoglobulin single variable domain" or "single variable domain" comprises polypeptides which are derived from a non-human source, preferably a camelid, preferably a camelid heavy chain antibody. They may be humanized, as previously described. Moreover, the term comprises polypeptides derived from non-camelid sources, e.g. mouse or human, which have been "camelized", as e.g. described in Davies and Riechmann 1994 (FEBS 339: 285-290), 1995 (Biotechonol. 13: 475-479), 1996 (Prot. Eng. 9: 531-537) and iechmann and Muyldermans 1999 (J. Immunol. Methods 231: 25-38).
The term "immunoglobulin single variable domain" encompasses immunoglobulin sequences of different origin, comprising mouse, rat, rabbit, donkey, human and camelid immunoglobulin sequences. It also includes fully human, humanized or chimeric immunoglobulin sequences. For example, it comprises camelid immunoglobulin sequences and humanized camelid immunoglobulin sequences, or camelized immunoglobulin single variable domains, e.g. camelized dAbs and camelized VH as described by Ward et al. 1989, WO 94/04678, and Davies and Riechmann 1994, 1995 and 1996).
Again, such immunoglobulin single variable domains may be derived in any suitable manner and from any suitable source, and may for example be naturally occurring VHH sequences (i.e. from a suitable species of Camelid) or synthetic or semi-synthetic amino acid sequences, including but not limited to partially or fully "humanized" VHH, "camelized" immunoglobulin sequences (and in particular camelized VH), as well as Nanobodies and/or VHH that have been obtained by techniques such as affinity maturation (for example, starting from synthetic, random or naturally occurring immunoglobulin sequences, such as VHH sequences), CDR grafting, veneering, combining fragments derived from different immunoglobulin sequences, PCR assembly using overlapping primers, and similar techniques for engineering immunoglobulin sequences well known to the skilled person; or any suitable combination of any of the foregoing.
The total number of amino acid residues in an immunoglobulin single variable domain can be in the region of 110-120, is preferably 112-115, and is most preferably 113 (although it will be clear, based on the examples of immunoglobulin single variable domain sequences that are given herein as well as in WO 08/020079, in WO 06/040153 and in the further immunoglobulin single variable domain -related references cited therein, that the precise number of amino acid residues will also depend on the length of the specific CDR's that are present in the immunoglobulin single variable domain).
The amino acid sequence and structure of an immunoglobulin single variable domain can be considered - without however being limited thereto - to be comprised of four framework regions or "FR's", which are referred to in the art and herein as "Framework region 1" or "FR1"; as "Framework region 2" or "FR2"; as "Framework region 3" or "FR3"; and as "Framework region 4" or "FR4", respectively; which framework regions are interrupted by three complementary determining regions or "CDR's", which are referred to in the art as "Complementarity Determining Region 1" or "CDR1"; as "Complementarity Determining Region 2" or "CDR2"; and as "Complementarity Determining Region 3" or "CDR3", respectively. As further described in paragraph q) on pages 58 and 59 of WO 08/020079 (incorporated herein by reference), the amino acid residues of an immunoglobulin single variable domain are numbered according to the general numbering for VH domains given by Kabat et al. ("Sequence of proteins of immunological interest", US Public Health Services, NIH Bethesda, MD, Publication No. 91), as applied to VHH domains from Camelids in the article of Riechmann and Muyldermans 2000 (J.
Immunol. Methods 240: 185-195; see for example Figure 2 of this publication), and accordingly FR1 of an immunoglobulin single variable domain comprises the amino acid residues at positions 1-30, CDR1 of an immunoglobulin single variable domain comprises the amino acid residues at positions 31-35, FR2 of an immunoglobulin single variable domain comprises the amino acids at positions 36- 49, CDR2 of an immunoglobulin single variable domain comprises the amino acid residues at positions 50-65, FR3 of an immunoglobulin single variable domain comprises the amino acid residues at positions 66-94, CDR3 of an immunoglobulin single variable domain comprises the amino acid residues at positions 95-102, and FR4 of an immunoglobulin single variable domain comprises the amino acid residues at positions 103-113.
In the method of the present invention, the immunoglobulin single variable domain binds F- protein of hRSV and is therefore also referred to as "anti-hRSV immunoglobulin single variable domain" or "anti-hRSV immunoglobulin single variable domain of the invention". More in particular, the anti-hRSV immunoglobulin single variable domain can bind protein F of hRSV with an affinity (suitably measured and/or expressed as a KD-value (actual or apparent), a KA-value (actual or apparent), a kon-rate and/or a k0ff-rate) preferably such that:
it binds to protein F of hRSV with a dissociation constant (KD) of 1000 nM to 1 nM or less, preferably 100 nM to 1 nM or less, more preferably 15 nM to 1 nM, or even 10 nM to 1 nM or less; and/or
it binds to protein F of hRSV with a kon-rate of between 104 M'V1 to about 107 M'V1, preferably between 10s M'V1 and 107 M'V1, more preferably about 10s M'V1 or more; and/or it binds to protein F of hRSV with a koff rate between 10"2 s"1 (t1 2=0.69 s) and 10"4 s"1 (providing a near irreversible complex with a ti/2 of multiple days), preferably between 10"3 s"1 and 10"4 s"1, or lower.
In certain aspects, affinity is determined by Surface Plasmon Resonance, such as by Biacore, or by KinExA (see above).
In one aspect, the immunoglobulin single variable domain comprised in the polypeptide of the invention is capable of neutralizing hRSV. Assays to determine the neutralizing capacity of a molecule include e.g. the microneutralization assay described by Anderson et al. (1985, J. Clin. Microbiol. 22: 1050-1052; 1988, J. Virol. 62: 4232-4238), or modifications of this assay such as e.g. described in WO 2010/139808, or a plaque reduction assay as for example described by Johnson et al. (1997, J. Inf. Dis. 176: 1215-1224), and modifications thereof. For example, in a microneutralization assay on h SV Long (such as e.g. described in WO 2010/139808; page 375, Example 6), the anti-hRSV
immunoglobulin single variable domain may have IC50 values between 100 nM and 1000 nM, preferably between 100 nM and 500 nM, or less.
Combinations of CDR1, CDR2, and CDR3 sequences of preferred anti-hRSV immunoglobulin single variable domains are shown in Table A-l. In a preferred aspect, the anti-hRSV immunoglobulin single variable domain has a CDR1 which is SEQ ID NO: 46, a CDR2 which is selected from SEQ ID NOs: 49 and 50, and a CDR3 which is SEQ ID NO: 61. Most preferably CDR1 is SEQ ID NO: 46, CDR2 is SEQ ID NO: 49, and CDR3 is SEQ ID NO: 61. Table A-l also shows preferred combinations of CDR sequences and framework sequences.
Without being limiting, advantageous immunoglobulin single variable domains for use in the polypeptide of the invention are described in WO 2010/139808. Preferably, the anti-hRSV immunoglobulin single variable domain is selected from any of SEQ ID NOs: 1-34 in Table A-2.
Polypeptide of the invention
The immunoglobulin single variable domains for use in the method of the invention may form part of a polypeptide (referred herein as "polypeptide(s) of the invention"), which may comprise or (essentially) consist of one or more immunoglobulin single variable domains that specifically bind F- protein of hRSV and which may optionally further comprise one or more further amino acid sequences (all optionally linked via one or more suitable linkers). The term "immunoglobulin single variable domain" may also encompass such polypeptide of the invention. For example, and without limitation, the one or more immunoglobulin single variable domains may be used as a binding unit in such a polypeptide, which may optionally contain one or more further amino acid sequences that can serve as a binding unit, so as to provide a monovalent, multivalent or multispecific polypeptide of the invention, respectively (for multivalent and multispecific polypeptides containing one or more VHH domains and their preparation, reference is also made to Conrath et al. 2001 (J. Biol. Chem. 276: 7346-7350), as well as to for example WO 96/34103, WO 99/23221 and WO 2010/115998).
Preferably, the polypeptides of the invention encompass constructs comprising three or more antigen binding units in the form of single variable domains, as outlined above. For example, three or more immunoglobulin single variable domains that bind hRSV (also referred to herein as "anti-hRSV immunoglobulin single variable domain(s)") can be linked to form a trivalent or multivalent construct. Preferably the polypeptide of the invention consists of three anti-hRSV immunoglobulin single variable domains.
In the polypeptides described above, the three or more anti-hRSV immunoglobulin single variable domains may be linked directly to each other and/or via one or more suitable linkers or spacers. Suitable spacers or linkers for use in multivalent polypeptides will be clear to the skilled person, and may generally be any linker or spacer used in the art to link amino acid sequences. Preferably, said linker or spacer is suitable for use in constructing proteins or polypeptides that are intended for pharmaceutical use.
Some particularly preferred spacers include the spacers and linkers that are used in the art to link antibody fragments or antibody domains. These include the linkers mentioned in the general background art cited above, as well as for example linkers that are used in the art to construct diabodies or ScFv fragments (in this respect, however, it should be noted that, whereas in diabodies and in ScFv fragments, the linker sequence used should have a length, a degree of flexibility and other properties that allow the pertinent VH and VL domains to come together to form the complete antigen-binding site, there is no particular limitation on the length or the flexibility of the linker used in the polypeptide of the invention, since each immunoglobulin single variable domain by itself forms a complete antigen-binding site).
For example, a linker may be a suitable amino acid sequence, and in particular amino acid sequences of between 1 and 50, preferably between 1 and 30, such as between 1 and 20 or between 1 and 10 amino acid residues. Widely used peptide linkers comprise Gly-Ser repeats, e.g. (Gly)4-Ser in one, two, three, four, five, six or more repeats, or for example of the type (GlyxSery)z, such as (for example (Gly4Ser)3 or (Gly3Ser2)3, as described in WO 99/42077, or hinge-like regions such as the hinge regions of naturally occurring heavy chain antibodies or similar sequences (such as described in WO 94/04678). Some other particularly preferred linkers are poly-alanine (such as AAA), as well as the linkers mentioned in Table A-4.
Other suitable linkers generally comprise organic compounds or polymers, in particular those suitable for use in proteins for pharmaceutical use. For instance, poly(ethyleneglycol) moieties have been used to link antibody domains, see for example WO 04/081026.
In one aspect, the polypeptide of the invention binds F-protein of h SV. More in particular, the polypeptide of the invention can bind protein F of hRSV with an affinity (suitably measured and/or expressed as a KD-value (actual or apparent), a KA-value (actual or apparent), a kon-rate and/or a k0fr rate) preferably such that:
- it binds to protein F of hRSV with a dissociation constant (KD) of 100 nM to 0.1 nM or less, preferably 10 nM to 0.1 nM or less, more preferably 1 nM to 0.1 nM or less, such as e.g. 5x10 10 M (0.5 nM) or less;
- it binds to protein F of hRSV with a kon rate of between 104 M'V1 to about 107 M'V1, preferably between 10s M'V1 and 107 M'V1, more preferably about 10s M'V1 or more; and/or - it binds to protein F of hRSV with a k0ff rate between 10"2 s"1
Figure imgf000028_0001
s) and 10"4 s"1 (providing a near irreversible complex with a ti/2 of multiple days), preferably between 10"3 s"1 and 10"4 s"1, more preferably between 5xl0"3 s"1 and 10"4 s"1, or lower.
In certain aspects, affinity is determined by Surface Plasmon Resonance, such as by Biacore, or by KinExA (see above).
In one aspect, the polypeptide of the invention is capable of neutralizing hRSV. Assays to determine the neutralizing capacity of a molecule include e.g. the microneutralization assay described by Anderson et al. (1985, J. Clin. Microbiol. 22: 1050-1052; 1988, J. Virol. 62: 4232-4238), or modifications of this assay such as e.g. described in WO 2010/139808, or a plaque reduction assay as for example described by Johnson et al. (1997, J. Inf. Dis. 176: 1215-1224), and modifications thereof. For example, in a microneutralization assay on hRSV Long (such as e.g. described in WO 2010/139808, page 375, Example 6) the polypeptides of the invention may have IC50 values between 10 pM and 1000 pM, preferably between 10 pM and 250 pM, more preferably between 50 pM and 200 pM or less. The polypeptides of the invention may have IC90 values between 1 nM and 100 nM, preferably between 1 nM and 10 nM, more preferably between 1 nM and 5 nM or less such as e.g. 2 nM or less, or 90 ng/mL or less.
In a preferred aspect, the polypeptide of the invention binds F-protein of hRSV with an affinity (suitably measured and/or expressed as a KD-value (actual or apparent), as described herein) preferably such that it binds to protein F of hRSV with a dissociation constant (KD) of 100 nM to 0.1 nM or less, preferably 10 nM to 0.1 nM or less, more preferably 1 nM to 0.1 nM or less, such as e.g. 5xl0"10 M (0.5 nM) or less; and in addition, the polypeptides of the invention is capable of neutralizing hRSV with IC50 values between 10 pM and 1000 pM, preferably between 10 pM and 250 pM, more preferably between 50 pM and 200 pM or less, or with IC90 values between 1 nM and 100 nM, preferably between 1 nM and 10 nM, more preferably between 1 nM and 5 nM or less such as e.g. 2 nM or less, or 90 ng/mL or less. In one aspect, the polypeptide of the invention binds F-protein of hRSV with an affinity of 5x10 10 M (0.5 nM) or less and neutralizes hRSV with an IC90 value of 90 ng/mL or less.
In a specific aspect, the multivalent (such as trivalent) polypeptide of the invention may comprise or essentially consist of at least three anti-hRSV immunoglobulin single variable domains selected from any of SEQ ID NOs: 1-34 (Table A-2). Without being limiting, advantageous polypeptides for use in the method of the invention are described in WO 2010/139808. Preferably the polypeptide of the invention is selected from any of SEQ ID NOs: 65-85 (Table A-3), such as e.g. ALX-0171. SEQ ID NOs: 65-85 are a trivalent polypeptides consisting of three anti-h SV immunoglobulin variable domains derived from heavy chain-only llama antibodies. Each of the three anti-hRSV immunoglobulin single variable domains binds to F-protein of hRSV.
The polypeptides of the invention can be produced by a method comprising the following steps: a) expressing, in a suitable host cell or host organism or in another suitable expression system, a nucleic acid or nucleotide sequence, or a genetic construct encoding the polypeptide of the invention;
optionally followed by:
b) isolating and/or purifying the polypeptide of the invention thus obtained.
The method for producing the polypeptide of the invention may comprise the steps of:
a) cultivating and/or maintaining a host or host cell under conditions that are such that said host or host cell expresses and/or produces at least one polypeptide of the invention, optionally followed by:
b) isolating and/or purifying the polypeptide of the invention thus obtained.
According to one preferred, but non-limiting embodiment of the invention, the polypeptide of the invention is produced in a bacterial cell, in particular a bacterial cell suitable for large scale pharmaceutical production.
According to another preferred, but non-limiting embodiment of the invention, the polypeptide of the invention is produced in a yeast cell, in particular a yeast cell suitable for large scale pharmaceutical production.
According to yet another preferred, but non-limiting embodiment of the invention, the polypeptide of the invention is produced in a mammalian cell, in particular in a human cell or in a cell of a human cell line, and more in particular in a human cell or in a cell of a human cell line that is suitable for large scale pharmaceutical production.
For production on industrial scale, preferred heterologous hosts for the (industrial) production of immunoglobulin single variable domains or immunoglobulin single variable domain-containing protein therapeutics include strains of E. coli, Pichia pastoris, S. cerevisiae that are suitable for large scale expression/production/fermentation, and in particular for large scale pharmaceutical expression/production/fermentation. Suitable examples of such strains will be clear to the skilled person. Such strains and production/expression systems are also made available by companies such as Biovitrum (Uppsala, Sweden).
Alternatively, mammalian cell lines, in particular Chinese hamster ovary (CHO) cells, can be used for large scale expression/production/fermentation, and in particular for large scale pharmaceutical expression/production/fermentation. Again, such expression/production systems are also made available by some of the companies mentioned above. Subsequently, the polypeptide of the invention may then be isolated from the host cell/host organism and/or from the medium in which said host cell or host organism was cultivated, using protein isolation and/or purification techniques known per se, such as (preparative) chromatography and/or electrophoresis techniques, differential precipitation techniques, affinity techniques (e.g. using a specific, cleavable amino acid sequence fused with the polypeptide of the invention) and/or preparative immunological techniques (i.e. using antibodies against the amino acid sequence to be isolated).
Method of the invention
The present invention provides methods and dosing schedules for the pulmonary administration of the polypeptides of the invention to young children. As such, these methods and dosing schedules can be used for the treatment (as defined herein) of RSV infection in these young children.
RSV infection includes the mild upper respiratory tract illness, as well as the more severe lower respiratory tract infections (LRTIs). RSV lower respiratory tract infection may include bronchiolitis and broncho-pneumonia, possibly showing typical clinical signs and symptoms such as tachypnoea, wheezing, cough, crackles, use of accessory muscles, and/or nasal flaring.
RSV infection may also include diseases and/or disorders associated with RSV infection.
Examples of such diseases and/or disorders associated with hRSV infection will be clear to the skilled person, and for example include the following diseases and/or disorders: respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
Accordingly, the present invention also provides methods and dosing schedules for the treatment of respiratory illness, upper respiratory tract infection, lower respiratory tract infection, bronchiolitis (inflammation of the small airways in the lung), pneumonia, dyspnea, cough, (recurrent) wheezing and/or (exacerbations of) asthma or COPD (chronic obstructive pulmonary disease) associated with hRSV.
In the context of the present invention, the term "treatment" not only comprises treating the disease, but also generally comprises slowing or reversing the progress of disease, slowing the onset of one or more symptoms associated with the disease, reducing and/or alleviating one or more symptoms associated with the disease, reducing the severity and/or the duration of the disease and/or of any symptoms associated therewith and/or preventing a further increase in the severity of the disease and/or of any symptoms associated therewith, preventing, reducing or reversing any physiological damage caused by the disease, and generally any pharmacological action that is beneficial to the patient being treated. The method of the invention provides for the delivery of the polypeptide of the invention to the respiratory tract and, more specifically, to the lower respiratory tract of a subject. Methods for delivery of pharmaceuticals to the respiratory tract and/or delivery of pharmaceuticals by inhalation are known to the skilled person and are e.g. described in the handbook "Drug Delivery: Principles and Applications" (2005) by Binghe Wang, Teruna Siahaan and Richard Soltero (Eds. Wiley Interscience (John Wiley & Sons)); in "Pharmacology PreTest™ Self-Assessment and Review" (11th Ed.) by Rosenfeld G.C., Loose-Mitchell D.S.; and in "Lippincott Illustrated Reviews: Pharmacology" (6th Edition) by Karen Whalen PharmD BCPS (Eds. Finkel R. and Panavelil T.A.). In the method of the present invention, the polypeptide of the invention is delivered in an inhalable form. More particularly, the inhalable form is an aerosol obtained by nebulizing (with a nebulizer) the polypeptide of the invention.
The subject to be treated is a human, more particularly a young child. As will be clear to the skilled person, the subject to be treated will in particular be a young child suffering from RSV infection. For example, the subject may be a young child suffering from RSV infection, such as RSV lower respiratory tract infection.
In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years). In one aspect, the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months). In one aspect, the subject is an infant. In one aspect, the subject is a toddler.
In one aspect, the subject has a gestational age of more than 33 weeks. Accordingly, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks.
In one aspect, the subject is a young child who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia). In one aspect, the subject is a young child aged 28 days to less 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months), who is diagnosed with SV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks, who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is an infant who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia). In one aspect, the subject is a toddler who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
In one aspect, the subject is a young child who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months), who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks, who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is an infant who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a toddler who is diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
In one aspect, the subject is a young child who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia). In one aspect, the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months), who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to
23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks, who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is an infant who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a toddler who is hospitalised for RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia).
In one aspect, the subject is a young child who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than
24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than 36 months (such as e.g. 1 month to 35 months), who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to
35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks, who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is an infant who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia). In one aspect, the subject is a toddler who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia).
In one aspect, the subject is a young child who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia,) but is otherwise healthy. In one aspect, the subject is a young child aged less than 24 months (2 years) or less than 36 months (3 years) who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a young child aged 28 days to less than 24 months (such as e.g. 28 days to 23 months), aged 1 month to less than 24 months (such as e.g. 1 month to 23 months), aged 28 days to less than 36 months (such as e.g. 28 days to 35 months), aged 1 month to less than
36 months (such as e.g. 1 month to 35 months), who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a young child aged less 24 months (2 years) or less than 36 months (3 years) with a gestational age of more than 33 weeks, aged 28 days to less than 24 months (such as e.g. 28 days to 23 months) with a gestational age of more than 33 weeks, aged 1 month to less than 24 months (such as e.g. 1 month to 23 months) with a gestational age of more than 33 weeks, aged 28 days to less than 36 months (such as e.g. 28 days to 35 months) with a gestational age of more than 33 weeks, aged 1 month to less than 36 months (such as e.g. 1 month to 35 months) with a gestational age of more than 33 weeks, who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or bronchopneumonia), but is otherwise healthy. In one aspect, the subject is an infant who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy. In one aspect, the subject is a toddler who is hospitalised for and diagnosed with RSV infection (e.g. RSV lower respiratory tract infection, such as bronchiolitis or broncho-pneumonia), but is otherwise healthy.
In the method of the present invention the polypeptide of the invention, such as ALX-0171 (SEQ ID NO: 71), is administered by inhalation to subjects suffering RSV infection, such as RSV lower respiratory tract infection, at the selected dosing schedules such that treatment occurs. The activity of the polypeptide of the invention can be assessed by measuring the reduction in viral load during the treatment. The viral load can, for example, be determined in nose mucus of the young child. Mucus can be removed from the nose e.g. by nasal suction with a nasal aspirator, a rubber bulb syringe or a nasal swab. In one aspect, the viral load is determined in a nasal swab specimen taken from the subject. In one aspect, viral load is determined in samples obtained via nasal swabs collecting a mid-turbinate specimen.
The viral load can be determined by any method known in the art, such as e.g. polymerase chain reaction (e.g. q T-PC ) or culturing (e.g. plaque forming unit (PFU) assay). Determination of and LoglO viral copies/mL and LoglO PFU/mL in nasal swabs is preferably performed by validated methods.
In one aspect, the anti-viral effect of ALX-0171 is determined by the time to drop below quantification limit (BQL) in plaque cultures, which is the parameter that best reflects the inhibition of viral replication. More specifically, the time needed for the viral load (as assessed by plaque cultures) to drop below the quantification limit (BQL) is calculated (also referred to herein as "time- to-BQL"). The median time-to-BQL can be compared between each of the ALX 0171 dose groups and placebo using a log-rank test.
Quantification of viral load can also be assessed by RT-qPCR as it is a more sensitive method than culture assay and has a good dynamic range. This method, however, will also quantify complete viral particles that are unable to replicate, partially assembled virions, and whole and fragmented viral genome in addition to quantifying fully replication-competent virus.
The activity of the polypeptide of the invention can also be assessed by measuring certain biomarkers in serum such as e.g. Kerbs von Lungren 6 antigen (KL-6). KL-6 is a high-molecular-weight glycoprotein, expressed on the surface of alveolar type II cells. Serum levels of KL-6 were shown to indicate disease activity in various interstitial lung diseases and are believed to reflect the presence of alveolar damage (Imai et al. 2002, Pediatric pulmonology 33: 135-141; Kawasaki et al. 2009, J. Med. Virol. 81: 2104-8). High serum KL-6 levels in RSV-infected infants correlate with low Sp02 and need for 02 administration (Kubota and Haruta 2006, J. Infection Chemotherapy: official journal of the Japan Society of Chemotherapy 12: 22-24). Serum KL-6 has been associated with the severity of RSV bronchiolitis and it was suggested that it may be a useful biomarker for the severity of RSV bronchiolitis. KL-6 levels in serum can be measured by any method known per se using techniques known to the skilled person, such as e.g. following commercially available assays: the KL-6 Human ELISA (BioVendor; Cat# RSCYK243882R), the Krebs Von den Lungen 6 Immunoassay Kit (BIOTREND Chemikalien GmbH; Cat# E05k0061), or the KL-6 ELISA kit (Biorbyt; Cat# orbl53677).
Following assessments can be performed to evaluate the efficacy of the polypeptide of the invention. The clinical activity of the polypeptide of the invention can be assessed by following Clinical Activity Outcome Measures: heart rate and peripheral capillary 02 saturation (Sp02) levels; feeding (type of feeding support, sufficiency of feeding), with particular attention to hydration and breathing comfort during feeding; respiratory rate (measured over 1-minute interval); wheezing as e.g. assessed during lung auscultation (during expiration/inspiration, lung fields affected);
crackles/crepitations during lung auscultation; daytime coughing; (sleep disturbance from) night-time coughing; (respiratory muscle) retractions (supraclavicular, intercostal, and subcostal); general appearance (activity, irritation, interest in environment, and responsiveness); body temperature; and duration of hospitalization.
Based on these Clinical Activity Outcome Measures, composite scores such as Global Severity Score, Respiratory Distress Assessment Instrument (RDAI) score and Respiratory Assessment Change Score (RACS) can be calculated.
The Global Severity Score is based on a recent clinical score that allows categorization of infants with respiratory infections on 7 different parameters: feeding intolerance, medical intervention, respiratory difficulty, respiratory frequency, apnea, general condition and fever (Justicia-Grande et al. 2015, Leipzig: 33rd Annual Meeting of the European Society for Paediatric Infectious Diseases;
Cebey-Lopez et al. 2016, PLoS ONE 11(2): e0146599). It takes into account all clinically relevant aspects of an RSV infected subject. Each item is scored from 0 to 3, except for body temperature (fever) that is scored from 0 to 2, resulting in a maximum total score of 20 points (Table B-5). Higher score indicates more severe disease.
The respiratory distress assessment instrument (RDAI) score is a 17 point score based on wheezing and retraction as explained in Table B-6. The RDAI score is the sum of the row scores, with total range 0 to 17; higher scores indicate more severe disease.
The respiratory assessment change score (RACS) is the sum of the change in the RDAI score and a standardized score for the change in respiratory rate. The change in respiratory rate is assigned 1 point per each 10% change in respiratory rate. A decrease in the RDAI or in the respiratory rate is recorded as a negative RACS, meaning an improvement.
The polypeptide of the invention inhibits an early event in the viral life cycle, preventing extracellular virus from infecting virus-naive cells by inhibiting fusion of the virion to the target cell. The methods and dosing schedules of the invention are used for inhibiting these early events in the viral life cycle and preventing extracellular virus from infecting virus-naive cells by inhibiting fusion of the virion to the target cell.
In neutralisation assays (in e.g. Hep-2 cell cultures, as further described herein) the in vitro concentration of 90 ng/mL was determined as the concentration at which the polypeptide of the invention reaches 90% of its maximal inhibitory antiviral effect (IC90). Subsequently, the IC90 determined in vitro was multiplied by 100, to account for unknown and difficult to assess variables, since (i) the rate of replication of SV in Hep-2 cell culture may not fully reflect the in vivo situation, (ii) infectivity and replication rate of the wide variety of clinical strains may vary considerably, and (iii) although a number (n=6) of clinical virus strains have been assessed for their sensitivity to the inhibitory action of the polypeptide of the invention, they may not represent the full spectrum of clinical strains.
The resulting value (9 microgram/mL or more) is considered the target concentration of the polypeptide of the invention, i.e. the concentration of polypeptide of the invention that would be required in the lower respiratory tract to result in clinically meaningful reduction of RSV infectivity. This concentration was calculated to be sufficient to completely saturate all target available at peak viral titres in an RSV-infected infant, and is also supported by the local target concentrations that showed efficacy in nonclinical studies in RSV-infected neonatal lambs and cotton rats (Detalle 2014 "Delivery of ALX-0171 by inhalation greatly reduces disease burden in a neonatal lamb RSV infection model" 9th RSV Symposium, Stellenbosch - South Africa; WO 2016/055656).
The nominal dose of the polypeptide of the invention that should be filled in the nebuliser in order to reach this target concentration is estimated to be 2 to 11 mg/kg daily (e.g. between 2 and 11 mg/kg daily). Accordingly, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide of the invention, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 11 mg/kg daily (e.g. between 2 and 11 mg/kg daily), more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily (e.g. between 2.5 and 10.7 mg/kg daily), such 3 to 9 mg/kg daily (e.g. between 3 and 9 mg/kg daily). The invention also relates to a polypeptide of the invention for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2 to 11 mg/kg daily e.g. between 2 and 11 mg/kg daily), more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily (e.g. between 2.5 and 10.7 mg/kg daily), such as 3 to 9 mg/kg daily (e.g. between 3 and 9 mg/kg daily).
In one aspect, the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). In one aspect, the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the polypeptide is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, preferably for 3 consecutive days.
In one aspect, the polypeptide of the invention is administered for 3 consecutive days at a nominal dose of 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably at a nominal dose of 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as at a nominal dose of 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the polypeptide is administered for 3 consecutive days at a nominal dose of 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably at a nominal dose of 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as at a nominal dose of 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the polypeptide is administered for 3 consecutive days at a nominal dose of 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably at a nominal dose of 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as at a nominal dose of 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
The above dose regimens are also referred to herein as the "selected dosing schedules" or "selected dose(s)".
The polypeptide of the invention used in the above methods of the invention is preferably selected from SEQ ID NOs: 65-85, preferably ALX-0171.
Accordingly, the present invention relates to a method for the treatment of SV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a target
concentration of 9 microgram/mL (wherein this value is understood to optionally encompass a range of ±0.5 microgram/mL) or more. The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a target concentration of 9 microgram/mL (wherein this value is understood to optionally encompass a range of ±0.5 microgram/mL) or more.
Accordingly, the present invention also relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily. The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
In one aspect, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, is administered daily for 2 to 5 consecutive days, or more, such as daily for 2 consecutive days, for 3 consecutive days, for 4 consecutive days, for 5 consecutive days, or more, such as e.g. for 3 consecutive days.
Accordingly, the present invention also relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily. The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 2.0 to 11.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3.0 to 9.0 mg/kg daily.
In one aspect, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 2.0 to 4.0 mg/kg daily, more specifically at a nominal dose of 2.5 to 3.6 mg/kg daily, such as at a nominal dose of 3.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the present invention relates to a method for the treatment of SV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 4.0 to 7.5 mg/kg daily, more specifically at a nominal dose of 5.0 to 7.1 mg/kg daily, such as at a nominal dose of 6.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
In one aspect, the present invention relates to a method for the treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, wherein the polypeptide is administered to the child for 3 consecutive days by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). The invention also relates to a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171, for use in treatment of RSV infection, such as RSV lower respiratory tract infection, in a young child, wherein the polypeptide is administered to the child suffering RSV infection for 3 consecutive days by inhalation at a nominal dose of 7.5 to 11.0 mg/kg daily, more specifically at a nominal dose of 7.6 to 10.7 mg/kg daily, such as at a nominal dose of 9.0 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg).
Pharmaceutical composition and formulations
The invention further relates to a composition (also referred to herein as "composition(s) of the invention" or "formulation(s) of the invention") comprising the polypeptide of the invention at a certain concentration, and optionally one or more further components of such compositions known per se. Generally, for pharmaceutical use, the polypeptides of the invention may be formulated as a formulation or compositions (also referred to as "pharmaceutical composition(s) of the invention" or "pharmaceutical formulation(s) of the invention") comprising the polypeptide of the invention at a certain concentration and at least one pharmaceutically acceptable carrier, diluent or excipient and/or adjuvant, and optionally one or more further pharmaceutically active ingredient.
Accordingly, the invention also provides a composition comprising the polypeptide of the invention at a certain concentration, and optionally one or more further components of such compositions known per se for use in the method of the invention. The invention also provides a pharmaceutical composition comprising the polypeptide of the invention at a certain concentration and at least one pharmaceutically acceptable carrier, diluent or excipient and/or adjuvant, and optionally one or more further pharmaceutically active ingredient for use in the method of the invention.
The polypeptide of the invention can be formulated and administered in any suitable manner known per se, for which reference is for example made to standard handbooks, such as Remington and Gennaro 1990 ("Remington's Pharmaceutical Sciences" 18th Ed., Mack Publishing Company, USA), Remington and Beringer 2006 ("The Science and Practice of Pharmacy", 21st Ed., Lippincott Williams and Wilkins); or Dubel S. (Ed.) 2007 ("The Handbook of Therapeutic Antibodies" Wiley, Weinheim; see for example pages 252-255).
As the polypeptide of the invention and/or composition comprising the same is administered by inhalation (i.e. to the respiratory tract), the formulation is preferably in a form suitable for administration by inhalation. In this respect, the pharmaceutical composition will comprise the polypeptide of the invention and at least one carrier, diluent or excipient suitable for administration to a subject by inhalation, and optionally one or more further active ingredients.
Preferably, the formulation of the polypeptide of the invention is developed as a liquid solution for inhalation, to ensure rapid delivery of the study drug to the site of RSV infection, and to maintain product quality and stability in combination with the nebulization protocol.
The term "excipient" as used herein refers to an inert substance which is commonly used as a diluent, vehicle, preservative, binder or stabilizing agent for drugs which imparts a beneficial physical property to a formulation, such as increased protein stability, increased protein solubility, and/or decreased viscosity. Examples of excipients include, but are not limited to, proteins (e.g., serum albumin), amino acids (e.g., aspartic acid, glutamic acid, lysine, arginine, glycine), surfactants (e.g., sodium dodecyl sulfate (SDS), polysorbates such as Tween 20 and Tween 80, poloxamers such as Pluronics, and other nonionic surfactants such as poly(ethylene glycol) (PEG)), saccharides (e.g., glucose, sucrose, maltose and trehalose), polyols (e.g., mannitol and sorbitol), fatty acids and phospholipids (e.g., alkyl sulfonates and caprylate). For additional information regarding excipients, see Remington and Gennaro 1990 ("Remington's Pharmaceutical Sciences" 18th Ed., Mack Publishing Company, USA), which is incorporated herein in its entirety. All excipients should comply with the European Pharmacopoeia and/or the United States Pharmacopeia. The phrase "carrier suitable for administration by inhalation" as used herein means a pharmaceutically acceptable material, composition or vehicle, such as a liquid or solid filler, diluent, excipient, or solvent, involved in carrying or transporting the agent (e.g. prophylactic or therapeutic agent) e.g. in the respiratory tract. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not injurious to the patient.
The carrier comprised in the composition of the invention preferably is an aqueous carrier such as e.g. distilled water, MilliQ® water or Water for Injection (WFI). The composition can be buffered by any buffer that is pharmaceutical acceptable. Preferred buffers for use in the composition of the invention include (without being limiting) phosphate buffered saline (PBS), phosphate buffer, TrisHCI, histidine buffer and citrate buffer, such as e.g. histidine pH 6.0-6.5, phosphate buffer pH 7.0, TrisHCI pH 7.5 and citrate buffer/phosphate buffer pH 6.5, in particular phosphate
Figure imgf000043_0001
buffer pH 7.0. Other pharmaceutically acceptable carriers may also be used in a formulation of the present application. Some examples of materials which can serve as pharmaceutically acceptable carriers include: sugars, such as lactose, glucose and sucrose; glycols, such as propylene glycol;
polyols, such as glycerin, sorbitol, mannitol and polyethylene glycol; esters, such as ethyl oleate and ethyl laurate; buffering agents, such as magnesium hydroxide and aluminum hydroxide; pyrogen-free water; isotonic saline; Ringer's solution; ethyl alcohol; phosphate buffer solutions; and other nontoxic compatible substances employed in pharmaceutical formulations.
As demonstrated in the working examples, concentrations of 50 mg/mL have been used for pulmonary administration of the polypeptide of the invention. It is expected that other
concentrations having values around these concentrations (and also outside these values, i.e., higher or lower than these values) therefore also can be used. For example, concentrations of 25, 30, 35, 40, 45, 55, 60, 65, 70, 75 mg/mL can be used. It will be clear to the skilled person that, in view of the specific nominal dose (mg/kg) determined in the present invention, the volume of the
pharmaceutical composition filled in the nebulizer (fill volume) will depend on the concentration of the polypeptide of the invention in the a pharmaceutical composition.
In the method of the invention, the nominal dose to be filled in the nebuliser to ensure clinically meaningful reduction of RSV infectivity was determined to be 2.0 to 11.0 mg/kg daily, more specifically 2.5 to 10.7 mg/kg daily, such as e.g. 3.0 to 9.0 mg/kg daily. Depending on the weight of the young child, the volume of the pharmaceutical composition (at a particular concentration, such as e.g. 50 mg/mL of polypeptide of the invention) that should be loaded into the nebulizer (also referred to as the "fill volume") will differ. In line with other inhalation products, the administered dose of the polypeptides of the invention (and as such the fill volume of a pharmaceutical composition comprising the polypeptides of the invention at a particular concentration) can be standardised for (narrow) body weight categories (see e.g. Tables B-l, B-2, B-3, and B-4 for a pharmaceutical composition of 50 mg/mL).
In one embodiment, the present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 for use in the method of the invention.
Inhalation device - Nebulizer
The present invention also relates to a pharmaceutical device suitable for the delivery by inhalation of the polypeptide of the invention and suitable for the delivery by inhalation of a composition comprising the same, also referred to herein as "inhalation device". The present invention, accordingly, relates to an inhalation device comprising the polypeptide of the invention at the selected dose. The present invention also relates to an inhalation device comprising the polypeptide of the invention at the selected dose for use in the method of the invention.
Various inhalation systems are e.g. described on pages 129 to 148 in the review by Bechtold- Peters and Luessen (Eds) 2007 ("Pulmonary Drug Delivery" ISBN 978-3-87193-322-6). In the method of the present invention, the device is an inhaler for liquids (e.g. a suspension of fine solid particles or droplets) comprising the polypeptide of the invention. Preferably this device is an aerosol delivery system or a nebulizer comprising the polypeptide of the invention.
The aerosol delivery system used in the method of the invention may comprise a container comprising the composition of the invention and an aerosol generator connected to it. The aerosol generator is constructed and arranged to generate an aerosol of the composition of the invention.
In a preferred aspect, the aerosol delivery system is a nebulizer. Nebulizers produce a mist of drug-containing liquid droplets for inhalation. "Nebulization", as used in the present invention, means the conversion of a liquid to a fine spray. Nebulizers mix medicine with compressed air to create a fine mist that the patient breathes in through a facemask or mouthpiece.
Vibrating mesh type nebulizers are considered the most appropriate technology for nebulization of the polypeptides of the invention, preferably SEQ ID NOs: 65-85, such as ALX-0171. Vibrating-mesh nebulizers are divided into passively and actively vibrating-mesh devices (Newman 2005, J. Appl. Ther. Res. 5: 29-33). Passively vibrating-mesh devices (e.g. Omron MICROAIR® NE-U22 nebulizer) employ a perforated plate having up to 6000 micron sized holes. A vibrating piezo-electric crystal attached to a transducer horn induces "passive" vibrations in the perforated plate positioned in front of it, resulting in extrusion of fluid through the holes and generation of the aerosol. Actively vibrating-mesh devices (e.g. AERONEB® Pro nebulizer) may employ a "micropump" system which comprises an aerosol generator consisting of a plate with up to 1000 dome-shaped apertures and a vibrating element which contracts and expands on application of an electric current. This results in upward and downward movements of the mesh by a few micrometers, extruding the fluid and generating the aerosol.
In a preferred aspect, a continuous flow nebuliser is used. Considering that young infants with bronchiolitis may require additional oxygen or air supply, maintaining a continuous oxygen or air supply of 2 L/min through the delivery system is recommended.
Accordingly, the nebulizer can be used with or without additional air or 02 flow. Preferably, the nebulizer is used with additional air or 02 flow, such as a flow of 2 L/min additional air or 02.
Accordingly, in one aspect the nebulizer may comprise (see Figures 4 and 5):
(a) an aerosol generator (101) with a vibratable mesh (102);
(b) a reservoir (103) for a liquid to be nebulised, said reservoir being in fluid connection with the vibratable mesh;
(c) a gas inlet opening (104);
(d) a face mask (105), having
- a casing (106),
- an aerosol inlet opening (107),
- a patient contacting surface (108), and
- a one-way exhalation valve or a two-way inhalation/exhalation valve (109) in the casing having an exhalation resistance selected in the range from 0.5 to 5 mbar; and
(e) a flow channel (110) extending from the gas inlet opening to the aerosol inlet opening of the face mask, the flow channel having
- a lateral opening (111) through which the aerosol generator is at least partially inserted into the flow channel,
- a constant flow resistance between the gas inlet opening and the aerosol inlet opening of the face mask at a flow rate of 1 to 20 L/min.
The flow channel may be sized and shaped to achieve, at a position immediately upstream of the lateral opening, an average gas velocity of at least 4 m/s at a flow rate of 2 L/min. In one aspect, the flow channel upstream of the lateral opening is shaped such as to effect a laminar flow when a gas is conducted through the flow channel at a flow rate of 1 to 20 L/min. The gas inlet opening may be shaped as a tube fitting. In one aspect, the flow channel exhibits no further inlet opening for receiving a gas.
The aerosol generator may be oriented such as to emit nebulised aerosol into the flow channel at an angle of approx. 90° to the longitudinal axis of the flow channel. In one aspect, the interior volume of the flow channel between the lateral opening and the aerosol inlet opening of the face mask is not more than 30 mL. The inhalation device may comprise a switch for starting and stopping the operation of the aerosol generator, wherein the operation of the aerosol generator comprises the continuous vibration of the vibratable mesh.
Since infants up to the age of 18 months are virtually obligate nose-breathers, controlled inhalation through a mouthpiece is not feasible and the interface may require special attention in terms of facemask type and size appropriate for the different ages. The face mask of the inhalation device may be configured to allow the exhalation by the patient through the mask. This may be achieved by a valve which exhibits a rather small exhalation resistance.
Preferably, the nominal internal volume of the face mask is not more than about 120 mL. As used herein, the nominal internal volume is understood as the internal volume enclosed by the casing from the aerosol inlet opening to the patient contacting surface when the patient contacting surface is placed on a flat surface. This volume is slightly larger than the effective internal volume, or so-called dead space, which is the volume enclosed by the mask when placed against the face of a patient, and which therefore depends on the size and shape of the patient's face. If the patient is a school child, the nominal internal volume is preferably not more than about 90 mL, or even not more than about 80 mL, or not more than about 70 mL, or not more than about 60 mL, or not more than about 50 mL, or not more than about 40 mL, respectively, depending on the size of the face of the patient. It is currently preferred to select a mask with a nominal internal volume of not more than about 40 or 50 mL if the patient is a neonate.
It is further preferred to select the nominal internal volume of the face mask with respect to the patient's average tidal volume. Advantageously, the nominal internal mask volume is smaller than the tidal volume. For example, if the patient is a pediatric patient having an average tidal volume during normal breathing of about 80 mL, the nominal internal face mask volume should be smaller than this. In particular, the respective volume may be in the range from about 10 % to about 80 % of the average tidal volume. In further embodiments, the nominal internal face mask volume is not more than about 60 %, or even not more than about 50 %, of the patient's average tidal volume.
In one embodiment, the face mask may have a two-way inhalation- and exhalation valve having a resistance of not more than 3 mbar in either direction, and wherein the nominal internal volume of the face mask is not more than about 50 mL. This embodiment is particularly suitable for small pediatric patients such as neonates, infants, and toddlers. In another embodiment, the face mask may have one or more inhalation valves and one or more exhalation valves, wherein the exhalation valve has a resistance of not more than 3 mbar, and wherein the nominal internal volume of the mask is not more than about 70 mL. This embodiment is particularly suitable for toddlers and children. Optionally, the face mask may comprise further inhalation and/or exhalation valves. If so, the effective exhalation pressure of the combined valves should still be in the specified range, i.e.
between about 0.5 and 5 mbar. Optionally, the exhalation pressure may also be selected from about 0.5 mbar to about 3 mbar, such as about 1 mbar or about 2 mbar, respectively. The valve(s) provided in the face mask may have any structure suitable for providing this exhalation resistance; e.g. slit valves, duck bill valves or membrane valves, to mention only a few. For example, the valve may be a one-way valve with a cross-slit and an overlying membrane, such as a silicone membrane. In one direction, from the cross-slit to the membrane, the valve opens, whereas in the opposite direction the membrane will be pressed tightly onto the cross and thus blocks the valve. Depending on which way round the valve is inserted into the face mask, it can serve both as an inhalation or an exhalation valve.
The inhalation device may be connected to a gas source that provides a gas at a constant flow rate in the range from 1 to 5 L/min. The gas provided by said gas source may be selected from oxygen, air, oxygen-enriched air, a mixture of oxygen and nitrogen, and a mixture of helium and oxygen.
In short, the main components of preferred nebulizers are (Figure 4) a re-usable base unit (containing the electronics), a single-use disposable inhalation set (including a pediatric face mask (in 2 sizes), a mask adaptor, a vibrating mesh nebulizer with a reservoir). Without being limiting, preferred nebulizers adapted for pediatric use are described in WO 2016/055656. Examples of vibrating-mesh nebulizers include the Akita2 Apixneb (Activaero, now Vectura, UK), EFLOW® (PARI GmbH, Grafelingen, Germany; see also US 5,586,550), AERONEB® (Aerogen, Inc., Sunnyvale, California; see also US 5,586,550; US 5,938,117; US 6,014,970; US 6,085,740; US 6,205,999), and the FOX-Flamingo vibrating mesh nebulizer (Vectura, UK), all adapted for pediatric use. The FOX- Flamingo inhalation system consists of a battery-operated, hand-held device, intended for single- patient use. The device provides an aerosol with particle size suitable for the intended study population. The nebulizer is always to be used with a flow of 2 L/min additional air or 02.
The inhalation device or nebulizer is loaded with the pharmaceutical composition of the invention. Accordingly, the present invention also relates to an inhalation device or nebulizer containing a pharmaceutical composition comprising the polypeptide of the invention. In a preferred aspect, the inhalation device or nebulizer contains a pharmaceutical composition that comprises a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171. As indicated above, the polypeptide of the invention can be present in the nebulizer at any suitable concentration such as 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 mg/mL, preferably at a concentration of 50 mg/mL.
The present invention also relates to a pharmaceutical composition comprising the polypeptide of the invention loaded in an inhalation device or nebulizer for use in the method of the invention. In a preferred aspect, the pharmaceutical composition loaded in the inhalation device or nebulizer comprises a polypeptide selected from SEQ ID NOs: 65-85, preferably ALX-0171. As indicated above, the polypeptide of the invention can be present in the pharmaceutical composition loaded in the inhalation device or nebulizer at any suitable concentration such as 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75 mg/mL, preferably at a concentration of 50 mg/mL.
To ensure clinically meaningful reduction of SV as described herein, the polypeptide of the invention is administered at a nominal dose of 2 to 11 mg/kg daily, more specifically at a nominal dose of 2.5 to 10.7 mg/kg daily, such as at a nominal dose of 3 to 9 mg/kg daily.
In one aspect, the nominal dose of the polypeptide of the invention that is filled in the nebuliser is 2 to 4 mg/kg daily (e.g. between 2 and 4 mg/kg daily), preferably 2.5 to 3.6 mg/kg daily (e.g. between 2.5 and 3.6 mg/kg daily), such as 3 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). Depending on the weight of the young child, the volume of pharmaceutical composition (at a concentration of 50 mg/mL of polypeptide of the invention) that should be loaded into the nebulizer (also referred to as the "fill volume") and the resulting "fill dose" will be as follows (see also Table B-4):
Table B-l: Nebulizer fill volume of a 50 mg/mL composition of the polypeptide of the invention and corresponding fill dose for each weight category
Figure imgf000048_0001
The above doses are also referred to herein as the "selected dosing schedules".
Accordingly, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171. More specifically, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of RSV infection, such as e.g. SV lower respiratory tract infection, in a young child. The present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
The present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (such as 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, 0.75 mL), for use in the method of the invention.
In one aspect, the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 4 to 7.5 mg/kg daily (e.g. between 4 and 7.5 mg/kg daily), preferably 5.0 to 7.1 mg/kg daily (e.g. between 5.0 and 7.1 mg/kg daily), such as 6 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). Depending on the weight of the young child, the volume of pharmaceutical composition (at a concentration of 50 mg/mL of polypeptide of the invention) that should be loaded into the nebulizer (also referred to as the "fill volume") and the resulting "fill dose" will be as follows (see also Table B-4):
Table B-2: Nebulizer fill volume of a 50 mg/mL composition of the polypeptide of the invention and corresponding fill dose for each weight category
Figure imgf000049_0001
The above doses are also referred to herein as the "selected dosing schedules".
Accordingly, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171. More specifically, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child. The present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
The present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.20-0.75 mL (a fill volume of) 0.40-1.50 mL (such as 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, 1.50 mL), for use in the method of the invention.
In one aspect, the nominal dose of the polypeptide of the invention that should be filled in the nebuliser is 7.5 to 11 mg/kg daily (e.g. between 7.5 and 11 mg/kg daily), preferably 7.6 to 10.7 mg/kg daily (e.g. between 7.6 and 10.7 mg/kg daily), such as 9 mg/kg daily (wherein this value is understood to optionally encompass a range of ±0.5 mg/kg). Depending on the weight of the young child, the volume of pharmaceutical composition (at a concentration of 50 mg/mL of polypeptide of the invention) that should be loaded into the nebulizer (also referred to as the "fill volume") and the resulting "fill dose" will be as follows (see also Table B-4):
Table B-3: Nebulizer fill volume of a 50 mg/mL composition of the polypeptides of the invention and corresponding fill dose for each weight category
Figure imgf000050_0001
The above doses are also referred to herein as the "selected dosing schedules".
Accordingly, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171. More specifically, the present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the treatment of SV infection, such as e.g. RSV lower respiratory tract infection, in a young child. The present invention relates to an inhalation device or nebulizer comprising (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL) of a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171, for use in the method of the invention.
The present invention relates to a 50 mg/mL composition of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65-85, such as ALX-0171 loaded into an inhalation device or nebulizer at (a fill volume of) 0.60-2.25 mL (such as 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, 2.25 mL), for use in the method of the invention.
In one aspect, the young child is aged less than 24 months (2 years).
In one aspect, the young child is aged 28 days to less than 24 months.
In one aspect, the young child is aged 1 month to less than 24 months.
In one aspect, the young child is aged less than 36 months (3 years).
In one aspect, the young child is aged 28 days to less than 36 months (3 years).
In one aspect, the young child is aged 1 month to less than 36 months (3 years).
In one aspect, the young child is an infant.
In one aspect, the young child is a toddler.
In one aspect, the young child is aged less than 24 months (2 years), with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 28 days to less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 1 month to less than 24 months, with a gestational age of more than 33 weeks.
In one aspect, the young child is aged less than 36 months (3 years), with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 28 days to less than 36 months (3 years), with a gestational age of more than 33 weeks.
In one aspect, the young child is aged 1 month to less than 36 months (3 years), with a gestational age of more than 33 weeks.
In one aspect, the young child is an infant, with a gestational age of more than 33 weeks.
In one aspect, the young child is a toddler, with a gestational age of more than 33 weeks.
In one aspect, the young child is diagnosed with RSV lower respiratory tract infection. In one aspect, the young child is diagnosed with SV lower respiratory tract infection but is otherwise healthy.
In one aspect, the young child is hospitalised for RSV lower respiratory tract infection.
Additional therapeutic agents
The polypeptides of the invention may be administered as a monotherapy or in combination with other pharmaceutically active compounds or principles that are or can be used for the treatment of RSV infection, as a result of which a synergistic effect may or may not be obtained. Examples of such compounds and principles, as well as routes, methods and pharmaceutical formulations or compositions for administering them will be clear to the clinician.
When two or more substances or principles are to be used as part of a combined treatment regimen, they can be administered via the same route of administration or via different routes of administration, at essentially the same time or at different times (e.g. essentially simultaneously, consecutively, or according to an alternating regime). When the substances or principles are to be administered simultaneously via the same route of administration, they may be administered as different pharmaceutical formulations or compositions or part of a combined pharmaceutical formulation or composition, as will be clear to the skilled person.
Also, when two or more active substances or principles are to be used as part of a combined treatment regimen, each of the substances or principles may be administered in the same amount and according to the same regimen as used when the compound or principle is used on its own, and such combined use may or may not lead to a synergistic effect. However, when the combined use of the two or more active substances or principles leads to a synergistic effect, it may also be possible to reduce the amount of one, more or all of the substances or principles to be administered, while still achieving the desired therapeutic action. This may for example be useful for avoiding, limiting or reducing any unwanted side-effects that are associated with the use of one or more of the substances or principles when they are used in their usual amounts, while still obtaining the desired pharmaceutical or therapeutic effect.
As such, the present invention also provides methods and dosing schedules for pulmonary administration of a polypeptide of the invention that binds and neutralizes hRSV, wherein the polypeptide is administered in combination with at least one additional therapeutic agent.
Without being limiting, additional therapeutic agents can be selected from the standard of care during hospitalisation for RSV infections, such as RSV lower respiratory tract infection, including (without being limiting) bronchodilators, antibiotics (e.g. in case of secondary bacterial infection [surinfection] during hospitalisation), apinephrine, anticholinergics, antipyretica and/or nonsteroidal antiinflammatory medication. In one aspect, the polypeptide of the invention is administered in combination with a bronchodilator. Accordingly, the present invention also relates to a method for the treatment of SV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide of the invention, preferably a polypeptide selected from SEQ ID NOs: 65- 85, such as ALX-0171, wherein the polypeptide is administered to the child by inhalation at the selected dosing schedules in combination with a bronchodilator. In the method of the invention, the polypeptide of the invention and the bronchodilator are administered to the respiratory tract (i.e. by inhalation) as a combination therapy (kit of parts). In this method, the polypeptide of the invention and the bronchodilator are used as part of a combined treatment regimen. More specifically, both parts of this combination therapy are administered to the respiratory tract (i.e. by inhalation) simultaneously, separately or sequentially.
There are two main classes of bronchodilators, i.e. the sympaticomimetics, including the short- acting and the long-acting beta2-mimetics, and the anticholinergics. Short-acting mimetics include (but are not restricted to) salbutamol, terbutaline, fenoterol, pirbuterol and tulobuterol. They can be used as a base or as an acceptable pharmaceutical salt. The long-acting beta2-mimetics include (but are not restricted to) formoterol and salmeterol. They can also be used as a base or as an acceptable pharmaceutical salt. The anticholinergic drugs include (but are not restricted to) ipratropium, oxitropium and tiotropium.
Without being limiting, additional bronchodilators for use in the method of the invention include Accu Hale, albuterol, bitolterol, ephedrine, epinephrine, isoetharine, isoproterenol, metaproterenol, pirbuterol, racepinephrine, ritodrine, terbutaline, levosabutamol, levabuterol, clenbuterol, amphetamine, methamphetamine, cocaine, theophylline, caffeine, theobromine, THC, and MDPV.
The bronchodilator class of molecules with very long duration of action will have to be administered only once a day (e.g. tiotropium). Long acting beta2-mimetics are usually administered twice a day like formoterol and salmeterol. Finally, there are short-acting bronchodilators such as salbutamol, terbutaline, ipratropium or oxitropium which have to be administered 4 to 6 times a day. Based on such information, treatment schedules can be designed in order to take optimal advantage of the combination therapy. The treatment schedules may encompass the simultaneous, separate or sequential administration of the polypeptide of the invention and the bronchodilator. The most common devices for the administration of the combination therapy (kit of parts) are a nebulizer, a metered dose inhaler (MDI), and a combination of these.
In one aspect, the polypeptide of the invention and the bronchodilator are administered simultaneously. In this embodiment, the polypeptide of the invention and the bronchodilator are administered in admixture in inhalable form. Without being limiting, the inhalable form of the polypeptide of the invention and the bronchodilator can be an aerosol obtained from simultaneously nebulizing (e.g. with a nebulizer) the polypeptide of the invention and the bronchodilator, both preferably present in the same composition (of the invention).
In another aspect, the polypeptide of the invention and the bronchodilator are administered separately. In this embodiment, the polypeptide of the invention and the bronchodilator are administered in separate inhalable form. Without being limiting, the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention or the bronchodilator, separately present in a composition (of the invention). Alternatively, the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention and a separate aerosol obtained from breakup into droplets (e.g. with a metered dose inhaler (MDI)) of the bronchodilator dissolved or suspended in the volatile propellant, followed by rapid evaporation of these droplets. As such, the polypeptide of the invention and the bronchodilator are administered with two different (types of) inhalers, each producing a separate inhalable form. Without being limiting, following combinations can be proposed:
Inhalation of the bronchodilator with a MDI and inhalation of the polypeptide of the invention with a nebulizer;
Inhalation of the bronchodilator with a nebulizer and inhalation of the polypeptide of the invention with another nebulizer.
In another aspect, the polypeptide of the invention and the bronchodilator are administered sequentially. In this embodiment, the polypeptide of the invention and the bronchodilator are administered separately and sequentially in inhalable form. Without being limiting, the inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention or the bronchodilator, separately present in a composition (of the invention). Alternatively, the separate inhalable form of the polypeptide of the invention and/or of the bronchodilator can be an aerosol obtained from nebulizing (e.g. with a nebulizer) the polypeptide of the invention and a separate aerosol obtained from breakup into droplets (e.g. with a metered dose inhaler (MDI)) of the bronchodilator dissolved or suspended in the volatile propellant, followed by rapid evaporation of these droplets. For this sequential administration of the combination therapy, the polypeptide of the invention and the bronchodilator should be present in two different (separate) compositions of the invention that are separately loaded into the inhaler device, in order that two separate, sequential inhalable forms can be generated. In this embodiment, the polypeptide of the invention and the bronchodilator may be administered with two different (types of) inhaler. However, the use of two different inhalers is not necessarily required as in some devices (such as e.g. in a nebulizer) the separate compositions can be loaded sequentially. Without being limiting, following combinations can be proposed:
Inhalation of the bronchodilator with a MDI followed by inhalation of polypeptide of the invention with a nebulizer;
Inhalation of the bronchodilator with a nebulizer followed by inhalation of polypeptide of the invention with a nebulizer (which can be the same or different);
Inhalation of the polypeptide of the invention with a nebulizer followed by inhalation of the bronchodilator with a MDI;
Inhalation of the polypeptide of the invention with a nebulizer followed by inhalation of bronchodilator with a nebulizer (which can be the same or different).
Preferred intervals for the sequential administration of the polypeptide of the invention and the bronchodilator will depend on the polypeptide of the invention and the bronchodilator used (as is described above) and may include from 5 minutes to 24 hours or more, such as e.g. 5 minutes, 10 minutes, 15 minutes, 20 minutes, 30 minutes, 1 hour, 4 hours, 6 hours, 8 hours, 12 hours, etc.
In a preferred aspect, the bronchodilator is a short-acting beta2-agonist, such as e.g. salbutamol.
In a preferred aspect, the bronchodilator, such as a short-acting beta2-agonist, is administered with a MDI prior to administration of the polypeptide of the invention with a nebulizer. For example, the bronchodilator, a short-acting beta2-agonist, can be administered 10-15 minutes prior to the administration of the polypeptide of the invention. For example, the short-acting beta2-agonist such as salbutamol is administered to the young child at a dose of 200 micrograms (e.g. two puffs of 100 microgram) 15 minutes prior to administration of the polypeptide of the invention.
In another preferred aspect, the bronchodilator is administered with a nebulizer prior to administration of the polypeptide of the invention with a nebulizer. In this preferred aspect, the polypeptide of the invention and the bronchodilator can be administered with the same nebulizer (i.e. each of the polypeptide of the invention and the bronchodilator can be present in a separate composition that is sequentially loaded into the nebulizer) or with two different nebulizers.
In another preferred aspect, the polypeptide of the invention and the bronchodilator are administered simultaneously with a nebulizer. In this preferred aspect, the polypeptide of the invention and the bronchodilator are preferably present in one single compositions of the invention which is loaded into the nebulizer. Else, the polypeptide of the invention and the bronchodilator are present in two different compositions of the invention that are both loaded into the nebulizer.
The invention will now be further described by means of the following non-limiting preferred aspects, examples and figures. The entire contents of all of the references (including literature references, issued patents, published patent applications, and co pending patent applications) cited throughout this application are hereby expressly incorporated by reference, in particular for the teaching that is referenced hereinabove.
EXAMPLES
Example 1: Dose selection
During a phase l/2a study with ALX-0171 in infants (WO 2016/055656), one blood sample was withdrawn from each patient for the determination of the ALX-0171 serum concentration (taken approximately 6 hours after the last nebulization). The concentration of ALX-0171 in serum was evaluated as a surrogate measure for evaluating local lung concentrations.
Serum samples were obtained from 33 ALX-0171 treated subjects, mostly at the defined time point, with the exception of 3 subjects which had their blood sample taken approximately 24 h after the second inhalation. ALX-0171 serum concentrations were quantifiable in 27 out of the 33 ALX- 0171 dosed subjects with available PK sample.
The ALX-0171 serum concentrations measured (depicted in Figure 1) were on average below the levels predicted with the PBPK model described in WO 2016/055656. As ALX-0171 serum concentration is a surrogate for the local lung exposure, the site of action of ALX-0171, low serum concentrations would indicate low local lung exposure.
In order to reach the desired higher serum concentration levels of ALX-0171 and higher local lung exposure, higher doses of ALX-0171 are evaluated. The selected doses are estimated to achieve concentrations at which antiviral and clinical activity can be expected while appropriate safety margins are respected. As such, this dose range is expected to provide a benefit to the subjects, and is selected to allow assessment of reduction in nasal viral shedding and improvement of clinical symptoms.
Example 2: Administration of the selected doses of anti-RSV Nanobody ALX-0171 to subjects hospitalized for RSV lower respiratory tract infection
A clinical study is conducted to evaluate the anti-viral effect and safety of different doses of inhaled ALX-0171 in subjects hospitalized for RSV LRTI. Also the clinical activity, the PK properties, the pharmacodynamic (PD) effect and the immunogenicity of the different doses of inhaled ALX-0171 are evaluated.
This study is conducted in compliance with the Guidance for Industry ICH E6 GCP (including archiving of essential study documents), the Declaration of Helsinki, the applicable regulations of the country(ies) in which the study is conducted, and with the Commission Directives 2001/20/EC and 2005/28/EC. The Clinical Study Protocol(s) and the ICF(s) is submitted for review and approval by the IEC/I B prior to the eligibility screening/baseline. The composition of the IEC/IRB is in accordance with the recommendations of the World Health Organization, the ICH E6 Guideline for GCP, the European Union Clinical Trial Directive (CTD) (Directive 2001/20/EC) and/or the USA Code of Federal Regulations (CFR) (21 CFR 56), in line with local regulations.
As the potential subjects are infants or young children, subjects' parent(s), legal guardian(s) or the legally acceptable representative(s) must provide their written informed consent before enrolment of their child in the clinical study, and before any protocol specified procedures are performed. Freely given and written informed consent is obtained according to local requirements after the nature of the study has been fully explained. The consent form that is used is approved by the reviewing IEC/IRB. The informed consent is in accordance with principles that originated in the Declaration of Helsinki, current ICH and GCP guidelines, and applicable regulatory requirements.
2.1 Study design
A randomized, double-blind, placebo-controlled, multicenter dose-ranging study is conducted to assess the administration of the different selected doses of ALX-0171 to infants and young children hospitalized for RSV lower respiratory tract infection.
Following dose levels are evaluated:
• Dose 1: target dose of 3.0 mg/kg
• Dose 2: target dose of 6.0 mg/kg
• Dose 3: target dose of 9.0 mg/kg
The study is planned to enroll approximately 180 male or female infants and young children (aged 28 days to 2 years, with a gestational age of > 33 weeks) who are diagnosed with and hospitalized for RSV LRTI (such as bronchiolitis or broncho-pneumonia), but otherwise healthy.
The study consists of a sequential part followed by a parallel part (Figure 2).
Sequential Part
In safety Cohorts 1 to 3, sequential dose escalation is used to enable appropriate safety follow- up. Each of the 3 safety cohorts consists of 12 subjects (N=36 in total) that are randomized in a 3:1 ratio to receive either ALX-0171 dose 1 (N=9) or placebo (N=3) (Cohort 1), ALX-0171 dose 2 (N=9) or placebo (N=3) (Cohort 2), or ALX-0171 dose 3 (N=9) or placebo (N=3) (Cohort 3).
After the last subject in a safety cohort has completed treatment, an Independent Data Monitoring Committee (IDMC) reviews the available cumulative safety data (i.e., all data from prior visits that have been done for all included subjects, including preceding cohorts). After this comprehensive review, the IDMC advises on proceeding to the subsequent cohort (i.e., the higher dose), and which planned dose levels can be taken forward into the parallel part.
Parallel Part
If the IDMC issues a positive recommendation after each safety cohort, the remaining 144 subjects (i.e., Cohort 4) are randomly assigned in a 1:1:1:1 ratio to one of following treatment groups, yielding an overall randomization ratio of 3:1 active to placebo.
• ALX-0171 dose 1
• ALX-0171 dose 2
• ALX-0171 dose 3
• Placebo
2.2 Study flow
ALX-0171 is administered once daily for 3 consecutive days. The 3-day treatment period is expected to bridge the time needed for the body to mount an effective immune response. An overview of the study flow is shown in Figure 3.
Subjects are screened as soon as possible after arrival to the hospital/emergency unit. After completion of the screening assessments and confirmation of subject's eligibility, randomization follows as soon as possible but not more than 24 hours after arrival. Study drug administration starts as soon as possible after randomization with a maximum time interval of 3 hours following randomization. Subsequent doses of study drug are administered at 24-hour intervals (± 4 hours) relative to the first dose. No premedication is required or recommended per protocol, but an inhaled 2-agonist may be administered at the discretion of the treating Investigator.
On the first 2 dosing days, inpatient hospital stay is required. Provided that the clinical response criteria have been met (which are based on adequate oral feeding and oxygen saturation), discharge from the hospital can take place per protocol at the Investigator's discretion from dosing Day 2 onwards after all required assessments of the 5 hours (± 1 hour) post-dose time point have been completed. Subjects discharged after the second dose return to the hospital for the third study drug administration (to be administered 48 ± 4 hours after the first dose by the appropriately trained study personnel), and monitored for a 2-hour pre-dose and post-dose period. A Follow-Up (FU) visit is scheduled on Day 14 (± 2 days), and an End of Study (EOS) visit on Day 28 (± 2 days). For subjects prematurely withdrawn from the study, a Withdrawal visit is to be performed on the day of withdrawal.
2.3 Administration of ALX-0171 ALX-0171 or matching placebo is administered via inhalation, using a dedicated vibrating mesh nebulizer, the FOX-Flamingo inhalation system (Vectura GmbH, Germany), as described in WO 2015/055655 (see also Figure 4). This inhalation device consists of a re-usable base unit (containing the electronics), a single-use disposable inhalation set (including a pediatric face mask in 2 sizes, a mask adaptor, a vibrating mesh nebulizer with reservoir). The device provides an aerosol with particle size suitable for the intended study population (~3 μιτι). The nebulizer is used with a flow of 2 L/min additional air or 02 (to be decided by the Investigator based on oxygen need of the subject).
The formulation of ALX-0171 (and matching placebo) was developed specifically as a liquid solution for inhalation (as described in WO 2011/098552). ALX-0171 is present at 50 mg/ml in the formulation buffer (NaH2P04/Na2HP04 10 mM, NaCI 130 mM, pH 7.0). The formulation buffer without ALX-0171 is used as placebo.
The Placebo group serves as comparator group for the 3 ALX-0171 dose groups. To achieve double-blinding across the different groups, each dose is administered as two serial nebulizations (Nebulization 1 and Nebulization 2). In the placebo group, subjects will receive 2 nebulizations of placebo. In the ALX-0171 dose 1 and 2 groups, subjects will receive 1 nebulization of ALX 0171 and 1 nebulization of placebo. In the ALX-0171 dose 3 group, both nebulizations will contain ALX-0171.
Placebo group:
- Nebulization 1 with volume 1 of placebo at each dosing day.
- Nebulization 2 with volume 2 of placebo at each dosing day.
Dose 1 group:
- Nebulization 1 with volume 1 of ALX-0171 at each dosing day.
- Nebulization 2 with volume 2 of placebo at each dosing day.
Dose 2 group:
- Nebulization 1 with volume 1 of placebo at each dosing day.
- Nebulization 2 with volume 2 of ALX-0171 at each dosing day.
Dose 3 group:
- Nebulization 1 with volume 1 of ALX-0171 at each dosing day.
- Nebulization 2 with volume 2 of ALX-0171 at each dosing day.
Per body weight category, the total volume (to be administered via the 2 serial nebulizations) will be the same for the 4 treatment groups ensuring blinding across the treatment groups. This approach allows a design with a placebo-controlled group as representative comparison for the 3 dose levels.
The precise dose that will be administered depends on the subject's weight: the drug volume filled into the nebulizer ("fill" volume) is calculated per weight category range. An overview of the appropriate volume to be filled into the nebulizer (per body weight category and per nebulization), is available in Table B-4.
Table B-4: Nebulizer fill volume of ALX-0171 and corresponding fill dose for each nebulization and each weight category
Figure imgf000060_0001
Dose 1: target dose of 3.0 mg/kg (depending on the subject's weight category, the actual nominal dose is between 2.5 and 3.6 mg/kg)
Dose 2: target dose of 6.0 mg/kg (depending on the subject's weight category, the actual nominal dose is between 5.0 and 7.1 mg/kg)
Dose 3: target dose of 9.0 mg/kg (depending on the subject's category, the actual nominal dose is between 7.6 and 10.7 mg/kg)
2.4 Statistics
The following populations are considered for analysis:
• Intent-to-treat (ITT) Population: All randomized subjects.
• Modified Intent-to-treat (mITT) Population: All subjects who received at least 1
administration of study drug, as randomized (i.e., using the treatment to which the subject was randomized).
• Safety Population: All subjects who received at least 1 administration of study drug, as treated (i.e., using the treatment that the subject actually received).
• PK population: Subset of the subjects in the safety population for whom the primary PK data are considered to be sufficient and interpretable. For this study, this will correspond to all subjects in the safety population who received at least 1 administration of ALX 0171 and for whom at least one ALX-0171 serum concentration has been determined. • Per Protocol (PP) Population: Consists of a subset of the ITT population, and excludes those subjects who have had a major protocol deviation.
The mITT Population is the primary study population used for the analysis of efficacy data, the Safety Population is the primary study population used for the analysis of safety, PD, and
immunogenicity data, and the PK population is the primary study population used for analysis of PK data.
Example 3: Evaluation of the viral load after administration of selected doses of ALX-0171 to subjects hospitalized for RSV LRTI
Throughout the study, nasal swabs (mid-turbinate specimen) are collected for analysis of viral load, at specified time points. Quantitative viral titers in the nasal cavity (viral load) are assessed by plaque forming unit (PFU) assay and qRT-PCR.
3.1 Determination of viral load by plaque cultures
The anti-viral effect of ALX-0171 is mainly determined by the time for the viral load to drop below the limit of quantification (BQL), also referred to herein as "time-to-BQL". Time-to-BQL is assessed in plaque cultures, which is the parameter that best reflects the inhibition of viral replication.
3.2 Quantification of viral load by RT-qPCR
Quantification of viral load by RT-qPCR is also assessed as it is a more sensitive method than culture assay and has a good dynamic range. However, as the mode of action of ALX-0171 is to inhibit viral entry into the target cell, modest effects of ALX-0171 treatment on viral RNA are expected. After all, complete viral particles that are unable to replicate, partially assembled virions, and whole and fragmented viral genome are also quantified by RT-qPCR, in addition to fully replication-competent virus.
3.3 Determination of time-to-BQL
In particular, the time needed for the viral load (as assessed by plaque cultures) to drop below the quantification limit (BQL) is calculated (time-to-BQL). The median time-to-BQL is compared between each of the ALX 0171 dose groups and placebo using a log-rank test. The test is performed in a sequential way to preserve the family-wise error rate at 0.05. Specifically, dose 3 of ALX 0171 is first tested against placebo at the 0.05 significance level. Dose 2 of ALX 0171 is only compared to placebo at the 0.05 significance level if the comparison of dose 3 with placebo is significant. Consequently, dose 1 of ALX-0171 is only compared to placebo at the 0.05 significance level if the comparison of dose 2 of ALX-0171 with placebo is significant.
In addition, viral load will be characterized through parameters including time-to-BQL, AUC, percent of subjects with undetectable RSV (from Day 1 to Day 14) and rate of decline from baseline in viral load.
Example 4: Evaluation of the clinical activity of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
The clinical impact of treatment by ALX-0171 in infants and young children is evaluated by changes in clinical symptoms and subsequent calculation of composite scores, the time needed to enable adequate feeding and oxygen saturation, need for medical interventions, and length of hospital stay.
Following clinical symptoms (clinical activity parameters) are evaluated over time: hearth rate and Sp02, feeding, respiratory rate, respiratory rate measured over a 1-minute interval, wheezing (as assessed during lung auscultation), cough (during the night and during the day), respiratory muscle retractions, general appearance (activity, irritation, and responsiveness), and body temperature.
Given the importance of timing of the administration of this anti-viral compound in the time course of the RSV infection, details on the time elapsed between onset of first clinical symptoms and start of treatment with ALX-0171 is also collected and analyzed.
Clinical Response
Time to Clinical Response is calculated based on the feeding and oxygen saturation data.
Subjects are considered to have met the Clinical Response criteria when both of the following criteria are fulfilled:
• Stable oxygen saturation on room air, defined as Sp02 > 92% over a period of > 4 hours. In case of oxygen supplementation, the level of supplementation is to be considered for reduction at least three times per day. Provided oxygen saturation is stable, attempts to remove the supplementation will be done at least three times a day.
• Adequate oral feeding which is sufficient to maintain sufficient hydration, in the judgment of the Investigator.
Based on these criteria of adequate oxygen saturation and oral feeding, the time to clinical response is determined.
Composite scores Based on the clinical activity parameters measured during the study, composite scores that reflect the clinical status of the subject suffering from RSV are calculated, including the Global Severity Score, Respiratory Distress Assessment Instrument (RDAI) score, and Respiratory
Assessment Change Score (RACS).
The Global Severity Score is based on a recent clinical score that allows categorization of infants with respiratory infections on 7 different parameters: feeding intolerance, medical intervention, respiratory difficulty, respiratory frequency, apnea, general condition and fever (Justicia-Grande et al. 2015, Leipzig: 33rd Annual Meeting of the European Society for Paediatric Infectious Diseases;
Cebey-Lopez et al. 2016, PLoS ONE 11(2): e0146599). It takes into account all clinically relevant aspects of an RSV infected subject. Each item is scored from 0 to 3, except for body temperature (fever) that is scored from 0 to 2, resulting in a maximum total score of 20 points (Table B-5). Higher score indicates more severe disease.
Table B-5: Global Severity Score
Figure imgf000063_0001
a Assessed through activity, irritation and interest in environment (worst of the three items will be used for attributing the points)
The RDAI is a scoring system based on the presence and severity of wheezing and respiratory muscle retractions. The RDAI score is the sum of the row scores, with total range 0 to 17 (Table B-6); higher scores indicate more severe disease.
Table B-6: RDAI scoring system
Figure imgf000064_0001
NA = not applicable
The RACS is based on the RDAI and adds a standardized score for the change in respiratory rate. The change in respiratory rate is assigned 1 point per each 10% change in the respiratory rate.
A decrease in the RDAI or in the respiratory rate during the study period is recorded as a negative RACS, meaning an improvement.
Medical intervention outcome measures
The following data are captured to enable evaluation of the medical interventions outcome measures:
• Length of hospital stay for RSV infection;
• Level, method, and duration of supplemental oxygen therapy;
• Initiation of invasive or non-invasive ventilation (i.e., continuous positive airway pressure [cPAP] or HFOT); • Level, method and duration of invasive or non-invasive ventilation;
• Transfer to ICU and duration of stay in ICU;
These measures also contribute to the calculation of the concerned parameters for the Global Severity Score.
Parent/caregiver outcome measures
Parent(s)/Caregiver(s) assessment of the clinical condition of the subject is done by daily completion of a diary during the hospital stay and up to the EOS (Day 28) visit. The diary is used to measure three respiratory symptoms (cough, [audible] wheeze, and trouble breathing), to score the general health of the subject and asks for use of health care utilization and medication for respiratory symptoms.
The three respiratory symptoms (cough, trouble breathing and wheezing) are scored from not present over very mild, mild, moderate, and severe up to very severe.
The global rating of the child's health by the parent(s)/caregiver(s) is captured by a Visual Analogue Scale (VAS). The parent or caregiver makes a mark between 0 ("very bad") and 100 mm ("perfect") on the scale to indicate the subject's current health. In addition, the parent(s)/caregiver(s) indicates when the child was back to his/her condition as before the SV infection started.
Example 5: Evaluation of the pharmacokinetics of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
The systemic concentration of ALX-0171 is evaluated in serum, as a surrogate for evaluating local (lung) concentration. Throughout the study, blood samples are taken for analysis of ALX-0171 concentrations in serum. A subset (48 subjects, i.e., 12 subjects per dose group) undergoes more extensive pharmacokinetic (PK) sample analysis (3 blood samples for PK assessment).
Subjects not undergoing the more extensive blood sampling scheme have 1 blood sample taken on Day 2 or 3, at any time between 0.5 hours after completion of the second dose and initiation of the administration of the third dose.
Subjects undergoing the more extensive blood sampling scheme have 3 blood samples taken on Days 2-3: 1) pre second dose, 2) at any time between 0.5 hours and 3 hours after completion of the second dose, and 3) at any time between 3 hours and 6 hours after completion of the second dose (and at least 1 hour apart from the previous sampling).
The number of subjects undergoing the more extensive PK sample analysis was determined to obtain sufficient precision on the PK parameters as described by Wang et al. (2012, J. Clin.
Pharmacol. 52: 1601-1606). Determination of ALX-0171 concentrations in serum is done by a validated Ligand Binding Assay (LBA)-based method.
Individual PK parameters are derived by means of empirical Bayesian estimation. The following individual PK parameters are provided: apparent clearance (CL/F), area under the curve (AUC) as nominal (filling) dose divided by CL/F and cumulative AUC over 72 hours as an expression of the cumulated exposure during the course of treatment. Individual PK parameters are summarized with sample size, mean, standard deviation and coefficient of variation.
Example 6: Evaluation of the pharmacodynamics of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
Systemic levels of the serum biomarker Krebs von den Lungen (KL-6) is assessed.
Pharmacodynamic effect evaluates the evolution over time of (i) viral load, and (ii) exploratory biomarker KL-6.
Example 7: Evaluation of the immunogenicity of ALX-0171 after administration of selected doses to subjects hospitalized for RSV LRTI
Potential immunogenicity is also assessed systemically (serum), both pre-dose and post-dose (14 days post initial drug administration) by determining the anti-drug antibodies (ADA). If ADA are present, a further evaluation of their neutralizing capacity is performed.
Determination of ADA is done using a validated screening, confirmation and titration ADA bridging assay, with further characterization of ADA positive samples by a competitive ligand binding neutralizing antibody assay.
Subjects are classified for presence of pre-Ab, Treatment-emergent (TE) ADA and neutralizing anti-drug antibodies (NAb). Prevalence of pre-Ab and incidence of TE ADA or NAb, as well as titer levels of the antibody responses, are reported. Potential correlation between pre-existing antibodies, TE ADA or NAb and safety, pharmacokinetics or efficacy is assessed.
Example 8: Safety assessment after administration of selected doses of ALX-0171 to subjects hospitalized for RSV LRTI
Safety is assessed through adverse event (AE) collection (including SAEs, hypertension reactions), measurements of vital signs, lung auscultation, heart rate and peripheral capillary oxygen saturation (Sp02), respiratory rate, body weight, body temperature, physical examination, and clinical laboratory parameters. Safety lab assessments are planned two times during the study (at screening and at the FU visit). Laboratory assessments
The following tests are included in the clinical laboratory analysis:
• Clinical chemistry: alanine aminotransferase, aspartate aminotransferase, creatinine, sodium, potassium, chloride, C-reactive protein, γ glutamyl-transferase, blood urea nitrogen;
• Hematology: hemoglobin, hematocrit, red blood cell count and indices, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, platelet count (or estimate), white blood cell count including differential.
Lung auscultation
A lung auscultation is performed to assess wheezing, crackles/crepitation and other abnormalities in lung auscultation.
Physical examination
A physical examination is performed, including heart auscultation, examination of abdomen, skin and ears/nose/throat.
TABLES
Table A-1: Amino acid sequences of anti-hRSV immunoglobulin single variable domains (with FR and CDR sequences indicated)
Figure imgf000068_0001
Table A-1: Continued
Figure imgf000069_0001
Table A-2: Amino acid sequences of anti-hRSV immunoglobulin single variable domains
Figure imgf000070_0001
Table A-2: Continued
Figure imgf000071_0001
Table A-3: Amino acid sequences of preferred polypeptides of the invention
Figure imgf000072_0001
Table A-3: Continued
Figure imgf000073_0001
Table A-3: Continued
Figure imgf000074_0001
Table A-3: Continued
Figure imgf000075_0001
Table A-4: Amino acid sequences of linkers
Figure imgf000076_0001

Claims

1. A method for the treatment of RSV infection in a young child, said method comprising the administration to the child suffering the RSV infection, of a polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the polypeptide is administered to the child by inhalation at a nominal dose of 2 to 11 mg/kg daily.
2. A polypeptide that binds F-protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, for use in the treatment of RSV infection in a young child, wherein the polypeptide is administered to the child suffering RSV infection by inhalation at a nominal dose is 2 to 11 mg/kg daily.
3. The method or polypeptide according to claim 1 or 2, wherein the nominal dose is 2.5 to 10.7 mg/kg daily.
4. The method or polypeptide according to claim 3, wherein the nominal dose is 3 to 9 mg/kg daily.
5. The method or polypeptide according to any one of claims 1 to 2, wherein the nominal dose is 2 to 4 mg/kg daily.
6. The method or polypeptide according to claim 5, wherein the nominal dose is 2.5 to 3.6 mg/kg daily.
7. The method or polypeptide according to claim 6, wherein the nominal dose is about 3 mg/kg daily.
8. The method or polypeptide according to any one of claims 1 to 2, wherein the nominal dose is 4 to 7.5 mg/kg daily.
9. The method or polypeptide according to claim 8, wherein the nominal dose is 5.0 to 7.1 mg/kg daily.
10. The method or polypeptide according to claim 9, wherein the nominal dose is about 6 mg/kg daily.
11. The method or polypeptide according to any one of claims 1 to 2, wherein the nominal dose is 7.5 to 11 mg/kg daily.
12. The method or polypeptide according to claim 11, wherein the nominal dose is 7.6 to 10.7 mg/kg daily.
13 The method or polypeptide according to claim 12, wherein the nominal dose is about 9 mg/kg daily.
14. The method or polypeptide according to any one of claims 1 to 13, wherein the polypeptide is administered daily for 2 to 5 consecutive days.
15. The method or polypeptide according to claim 14, wherein the polypeptide is administered daily for 3 consecutive days.
16. The method or polypeptide according to any one of claims 1 to 15, wherein the SV infection is RSV lower respiratory tract infection.
17. The method or polypeptide according to any one of claims 1 to 16, wherein the young child is aged less than 24 months.
18. The method or polypeptide according to claim 17, wherein the young child is aged 28 days to less than 24 months.
19. The method or polypeptide according to claim 18, wherein the young child is aged 28 days to less than 24 months with gestational age of more than 33 weeks.
20. The method or polypeptide according to any one of claims 1 to 19, wherein the young child is an infant.
21. The method or polypeptide according to any one of claims 1 to 19, wherein the young child is a toddler.
22. The method or polypeptide according to any one of claims 1 to 21, wherein the young child is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
23. The method or polypeptide according to any one of claims 1 to 22, wherein the young child is hospitalised for RSV lower respiratory tract infection.
24. The method or polypeptide according to any one of claims 1 to 23, wherein the anti-RSV immunoglobulin single variable domain comprises a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of SEQ ID NO: 49, and a CDR3 having the amino acid sequence of SEQ ID NO: 61.
25. The method or polypeptide according to any of claims 1 to 24, wherein the anti-RSV immunoglobulin single variable domain is selected from one of the amino acid sequences of SEQ ID NOs: 1-34.
26. The method or polypeptide according to claims 25, wherein the polypeptide is selected from one of the amino acid sequences of SEQ ID NOs: 65-85.
27. The method or polypeptide according to any one of claims 1 to 26, wherein the polypeptide is administered as a monotherapy.
28. The method or polypeptide according to any one of claims 1 to 27, wherein at least one additional therapeutic agent is administered.
29. The method or polypeptide according to claim 28, wherein the additional therapeutic agent is a bronchodilator.
30. The method or polypeptide according to claim 29, wherein the bronchodilator belongs to the class of beta2-mimetics.
31. The method or polypeptide according to claim 30, wherein the bronchodilator belongs to the class of long-acting beta2-mimetics.
32. The method or polypeptide according to claim 31, wherein the bronchodilator is selected from formoterol or a solvate thereof, salmeterol or a salt thereof, and mixtures thereof.
33. The method or polypeptide according to claim 30, wherein the bronchodilator belongs to the class of short-acting beta2-mimetics.
34. The method or polypeptide according to claim 33, wherein the bronchodilator is selected from salbutamol, terbutaline, pirbuterol, fenoterol, tulobuterol, levosabutamol and mixtures thereof.
35. The method or polypeptide according to claim 34, wherein salbutamol is administered at a dose of 200 micrograms.
36. The method or polypeptide according to claim 29, wherein the bronchodilator belongs to the class anticholinergics.
37. The method or polypeptide according to claim 36, wherein the bronchodilator is selected from tiotropium, oxitropium, ipratropium bromide and mixtures thereof.
38. An inhalation device comprising a 50 mg/mL composition of a polypeptide that binds F- protein of hRSV and that comprises, consists essentially of, or consists of three anti-hRSV
immunoglobulin single variable domains that comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of one of SEQ ID NOs: 49-50, and a CDR3 having the amino acid sequence of SEQ ID NO: 61, wherein the fill volume of said composition is 0.20 to 2.25 mL, such as 0.20 to 0.75 mL, 0.40 to 1.50 mL, or 0.60 mL to 2.25 mL.
39. The inhalation device according to claim 38, wherein the fill volume of said composition is selected from the group consisting of 0.20 mL, 0.25 mL, 0.35 mL, 0.50 mL, 0.65 mL, and 0.75 mL.
40. The inhalation device according to claim 38, wherein the fill volume of said composition is selected from the group consisting of 0.40 mL, 0.50 mL, 0.70 mL, 1.00 mL, 1.30 mL, and 1.50 mL.
41. The inhalation device according to claim 38, wherein the fill volume of said composition is selected from the group consisting of 0.60 mL, 0.75 mL, 1.05 mL, 1.50 mL, 1.95 mL, and 2.25 mL.
42. The inhalation device according to any one of claims 38 to 41, which is an aerosol delivery system.
43. The inhalation device according to any one of claims 38 to 42, which is a nebulizer.
44. The inhalation device according to claim 43, which is a vibrating mesh nebulizer.
45. The inhalation device according to any one of claims 38 to 44, which has a fixed flow of air or oxygen.
46. The inhalation device according to claim 45, wherein the flow of air or oxygen is 2 L/min.
47. The inhalation device according to any one of claims 38 to 46 comprising:
(a) an aerosol generator with a vibratable mesh;
(b) a reservoir for a liquid to be nebulised, said reservoir being in fluid connection with the vibratable mesh;
(c) a gas inlet opening;
(d) a face mask, having
- a casing,
- an aerosol inlet opening,
- a patient contacting surface, and - a one-way exhalation valve or a two-way inhalation/exhalation valve in the casing having an exhalation resistance selected in the range from 0.5 to 5 mbar; and
(e) a flow channel extending from the gas inlet opening to the aerosol inlet opening of the face mask, the flow channel having
- a lateral opening through which the aerosol generator is at least partially inserted into the flow channel,
- a constant flow resistance between the gas inlet opening and the aerosol inlet opening of the face mask at a flow rate of 1 to 20 L/min.
48. The inhalation device according to claim 47, wherein the flow channel is sized and shaped to achieve, at a position immediately upstream of the lateral opening, an average gas velocity of at least 4 m/s at a flow rate of 2 L/min, and/or wherein the flow channel upstream of the lateral opening is shaped such as to effect a laminar flow when a gas is conducted through the flow channel at a flow rate of 1 to 20 L/min.
49. The inhalation device according to any of claims 38 to 48, wherein the anti-RSV
immunoglobulin single variable domains comprise a CDRl having the amino acid sequence of SEQ ID NO: 46, a CDR2 having the amino acid sequence of SEQ ID NO: 49, and a CDR3 having the amino acid sequence of SEQ ID NO: 61.
50. The inhalation device according to any of claims 38 to 49, wherein the anti-RSV
immunoglobulin single variable domain is selected from one of the amino acid sequence of SEQ ID NOs: 1-34.
51. The inhalation device according to claim 50, wherein the polypeptide is selected from one of the amino acid sequence of SEQ ID NOs: 65-85.
52. The inhalation device according to any one of claims 38 to 51, for use in the method of any of claims 1 to 37.
53. The inhalation device according to any one of claims 38 to 52, for use in the treatment of RSV infection in a young child.
54. The inhalation device according to claim 53, wherein the SV infection is RSV lower respiratory tract infection.
55. The inhalation device according to any one of claims 53 or 54, wherein the young child is aged less than 24 months.
56. The inhalation device according to claim 55, wherein the young child is aged 28 days to less than 24 months.
57. The inhalation device according to any one of claims 53 to 56, wherein the young child is an infant.
58. The inhalation device according to any one of claims 53 to 56, wherein the young child is a toddler.
59. The inhalation device according to any one of claims 53 to 58, wherein the young child is diagnosed with RSV lower respiratory tract infection but is otherwise healthy.
60. The inhalation device according to any one of claims 53 to 59, wherein the young child is hospitalised for RSV lower respiratory tract infection.
61. The inhalation device according to any one of claims 38 to 60, wherein the polypeptide is administered as a monotherapy.
62. The inhalation device according to any one of claims 38 to 60, wherein at least one additional therapeutic agent is administered.
63. The inhalation device according to claim 62 wherein the additional therapeutic agent is a bronchodilator.
64. The inhalation device according to claim 63, wherein the bronchodilator belongs to the class of beta2-mimetics.
65. The inhalation device according to claim 64, wherein the bronchodilator belongs to the class of long-acting beta2-mimetics.
66. The inhalation device according to claim 65, wherein the bronchodilator is selected from formoterol or a solvate thereof, salmeterol or a salt thereof, and mixtures thereof.
67. The inhalation device according to claim 64, wherein the bronchodilator belongs to the class of short-acting beta2-mimetics.
68. The inhalation device according to claim 67, wherein the bronchodilator is selected from salbutamol, terbutaline, pirbuterol, fenoterol, tulobuterol, levosabutamol and mixtures thereof.
69. The inhalation device according to claim 68, wherein salbutamol is administered at a dose of 200 micrograms.
70. The inhalation device according to claim 63, wherein the bronchodilator belongs to the class anticholinergics.
71. The inhalation device according to claim 70, wherein the bronchodilator is selected from tiotropium, oxitropium, ipratropium bromide and mixtures thereof.
PCT/EP2017/080817 2016-11-29 2017-11-29 Treatment of infection by respiratory syncytial virus (rsv) WO2018099968A1 (en)

Applications Claiming Priority (2)

Application Number Priority Date Filing Date Title
US201662427418P 2016-11-29 2016-11-29
US62/427,418 2016-11-29

Publications (1)

Publication Number Publication Date
WO2018099968A1 true WO2018099968A1 (en) 2018-06-07

Family

ID=60702648

Family Applications (1)

Application Number Title Priority Date Filing Date
PCT/EP2017/080817 WO2018099968A1 (en) 2016-11-29 2017-11-29 Treatment of infection by respiratory syncytial virus (rsv)

Country Status (1)

Country Link
WO (1) WO2018099968A1 (en)

Cited By (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN117050166A (en) * 2022-08-30 2023-11-14 武汉班科生物技术有限公司 C-type single domain antibody for neutralizing respiratory syncytial virus and application thereof

Citations (53)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0368684A1 (en) 1988-11-11 1990-05-16 Medical Research Council Cloning immunoglobulin variable domain sequences.
WO1994004678A1 (en) 1992-08-21 1994-03-03 Casterman Cecile Immunoglobulins devoid of light chains
WO1994025591A1 (en) 1993-04-29 1994-11-10 Unilever N.V. PRODUCTION OF ANTIBODIES OR (FUNCTIONALIZED) FRAGMENTS THEREOF DERIVED FROM HEAVY CHAIN IMMUNOGLOBULINS OF $i(CAMELIDAE)
WO1995004079A1 (en) 1993-08-02 1995-02-09 Raymond Hamers Recombinant vector containing a lipoprotein gene sequence for expressing nucleotide sequences
WO1996034103A1 (en) 1995-04-25 1996-10-31 Vrije Universiteit Brussel Variable fragments of immunoglobulins - use for therapeutic or veterinary purposes
US5586550A (en) 1995-08-31 1996-12-24 Fluid Propulsion Technologies, Inc. Apparatus and methods for the delivery of therapeutic liquids to the respiratory system
WO1997049805A2 (en) 1996-06-27 1997-12-31 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Recognition molecules interacting specifically with the active site or cleft of a target molecule
WO1999023221A2 (en) 1997-10-27 1999-05-14 Unilever Plc Multivalent antigen-binding proteins
WO1999037681A2 (en) 1998-01-26 1999-07-29 Unilever Plc Method for producing antibody fragments
US5938117A (en) 1991-04-24 1999-08-17 Aerogen, Inc. Methods and apparatus for dispensing liquids as an atomized spray
WO1999042077A2 (en) 1998-02-19 1999-08-26 Xcyte Therapies, Inc. Compositions and methods for regulating lymphocyte activation
US6014970A (en) 1998-06-11 2000-01-18 Aerogen, Inc. Methods and apparatus for storing chemical compounds in a portable inhaler
US6085740A (en) 1996-02-21 2000-07-11 Aerogen, Inc. Liquid dispensing apparatus and methods
WO2000040968A1 (en) 1999-01-05 2000-07-13 Unilever Plc Binding of antibody fragments to solid supports
WO2000043507A1 (en) 1999-01-19 2000-07-27 Unilever Plc Method for producing antibody fragments
WO2000065057A1 (en) 1999-04-22 2000-11-02 Unilever Plc Inhibition of viral infection using monovalent antigen-binding proteins
US6205999B1 (en) 1995-04-05 2001-03-27 Aerogen, Inc. Methods and apparatus for storing chemical compounds in a portable inhaler
WO2001021817A1 (en) 1999-09-24 2001-03-29 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Recombinant phages capable of entering host cells via specific interaction with an artificial receptor
WO2001040310A2 (en) 1999-11-29 2001-06-07 Unilever Plc Immobilisation of proteins using a polypeptide segment
WO2001044301A1 (en) 1999-11-29 2001-06-21 Unilever Plc Immobilized single domain antigen-binding molecules
EP1134231A1 (en) 2000-03-14 2001-09-19 Unilever N.V. Antibody heavy chain variable domains against human dietary enzymes, and their uses
WO2001090190A2 (en) 2000-05-26 2001-11-29 National Research Council Of Canada Single-domain antigen-binding antibody fragments derived from llama antibodies
WO2002048193A2 (en) 2000-12-13 2002-06-20 Unilever N.V. Camelidae antibody arrays
WO2003025020A1 (en) 2001-09-13 2003-03-27 Institute For Antibodies Co., Ltd. Method of constructing camel antibody library
WO2003035694A2 (en) 2001-10-24 2003-05-01 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Functional heavy chain antibodies, fragments thereof, library thereof and methods of production thereof
WO2003050531A2 (en) 2001-12-11 2003-06-19 Algonomics N.V. Method for displaying loops from immunoglobulin domains in different contexts
WO2003054016A2 (en) 2001-12-21 2003-07-03 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Method for cloning of variable domain sequences
WO2003055527A2 (en) 2002-01-03 2003-07-10 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Immunoconjugates useful for treatment of tumours
WO2004041867A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Camelidae antibodies against imminoglobulin e and use thereof for the treatment of allergic disorders
WO2004041863A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Single domain antibodies directed against interferon- gamma and uses therefor
WO2004062551A2 (en) 2003-01-10 2004-07-29 Ablynx N.V. RECOMBINANT VHH SINGLE DOMAIN ANTIBODY FROM CAMELIDAE AGAINST VON WILLEBRAND FACTOR (vWF) OR AGAINST COLLAGEN
WO2004068820A2 (en) 2003-01-23 2004-08-12 Unspam, Llc. Method and apparatus for a non-revealing do-not-contact list system
WO2004081026A2 (en) 2003-06-30 2004-09-23 Domantis Limited Polypeptides
WO2005018629A1 (en) 2003-08-12 2005-03-03 Yarbrough William M Treatment for acne vulgaris and method of use
WO2005044858A1 (en) 2003-11-07 2005-05-19 Ablynx N.V. Camelidae single domain antibodies vhh directed against epidermal growth factor receptor and uses therefor
WO2006003388A2 (en) 2004-06-30 2006-01-12 Domantis Limited Compositions and methods for treating inflammatory disorders
WO2006030220A1 (en) 2004-09-17 2006-03-23 Domantis Limited Compositions monovalent for cd40l binding and methods of use
WO2006040153A2 (en) 2004-10-13 2006-04-20 Ablynx N.V. Single domain camelide anti -amyloid beta antibodies and polypeptides comprising the same for the treatment and diagnosis of degenarative neural diseases such as alzheimer's disease
WO2006059108A2 (en) 2004-12-02 2006-06-08 Domantis Limited ANTI-IL-IRl SINGLE DOMAIN ANTIBODIES AND THERAPEUTIC USES
WO2006079372A1 (en) 2005-01-31 2006-08-03 Ablynx N.V. Method for generating variable domain sequences of heavy chain antibodies
WO2006122786A2 (en) 2005-05-18 2006-11-23 Ablynx Nv Improved nanobodies™ against tumor necrosis factor-alpha
WO2006122825A2 (en) 2005-05-20 2006-11-23 Ablynx Nv Single domain vhh antibodies against von willebrand factor
WO2007049017A2 (en) 2005-10-24 2007-05-03 Domantis Limited Agents that bind a target in pulmonary tissue for treating respiratory diseases
WO2007085815A2 (en) 2006-01-24 2007-08-02 Domantis Limited Ligands that bind il-4 and/or il-13
WO2008020079A1 (en) 2006-08-18 2008-02-21 Ablynx N.V. Amino acid sequences directed against il-6r and polypeptides comprising the same for the treatment of deseases and disorders associated with il-6-mediated signalling
WO2008101985A2 (en) 2007-02-21 2008-08-28 Ablynx N.V. Amino acid sequences directed against vascular endothelial growth factor and polypeptides comprising the same for the treatment of conditions and diseases characterized by excessive and/or pathological angiogenesis or neovascularization
WO2008142164A2 (en) 2007-05-24 2008-11-27 Ablynx N.V. Amino acid sequences directed against rank-l and polypeptides comprising the same for the treatment of bone diseases and disorders
WO2010115998A2 (en) 2009-04-10 2010-10-14 Ablynx Nv Improved amino acid sequences directed against il-6r and polypeptides comprising the same for the treatment of il-6r related diseases and disorders
WO2010139808A2 (en) 2009-06-05 2010-12-09 Ablynx Nv IMPROVED AMINO ACID SEQUENCES DIRECTED AGAINST HUMAN RESPIRATORY SYNCYTIAL VIRUS (hRSV) AND POLYPEPTIDES COMPRISING THE SAME FOR THE PREVENTION AND/OR TREATMENT OF RESPIRATORY TRACT INFECTIONS
WO2011098552A2 (en) 2010-02-11 2011-08-18 Ablynx Nv Methods and compositions for the preparation of aerosols
WO2015055655A1 (en) 2013-10-14 2015-04-23 Narrative AB Method of operating a wearable lifelogging device
WO2016055656A1 (en) 2014-10-10 2016-04-14 Ablynx N.V. Methods of treating rsv infections
WO2016055655A1 (en) * 2014-10-10 2016-04-14 Ablynx N.V. Inhalation device for use in aerosol therapy of respiratory diseases

Patent Citations (57)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
EP0368684A1 (en) 1988-11-11 1990-05-16 Medical Research Council Cloning immunoglobulin variable domain sequences.
US5938117A (en) 1991-04-24 1999-08-17 Aerogen, Inc. Methods and apparatus for dispensing liquids as an atomized spray
WO1994004678A1 (en) 1992-08-21 1994-03-03 Casterman Cecile Immunoglobulins devoid of light chains
WO1994025591A1 (en) 1993-04-29 1994-11-10 Unilever N.V. PRODUCTION OF ANTIBODIES OR (FUNCTIONALIZED) FRAGMENTS THEREOF DERIVED FROM HEAVY CHAIN IMMUNOGLOBULINS OF $i(CAMELIDAE)
WO1995004079A1 (en) 1993-08-02 1995-02-09 Raymond Hamers Recombinant vector containing a lipoprotein gene sequence for expressing nucleotide sequences
US6205999B1 (en) 1995-04-05 2001-03-27 Aerogen, Inc. Methods and apparatus for storing chemical compounds in a portable inhaler
WO1996034103A1 (en) 1995-04-25 1996-10-31 Vrije Universiteit Brussel Variable fragments of immunoglobulins - use for therapeutic or veterinary purposes
US5586550A (en) 1995-08-31 1996-12-24 Fluid Propulsion Technologies, Inc. Apparatus and methods for the delivery of therapeutic liquids to the respiratory system
US6085740A (en) 1996-02-21 2000-07-11 Aerogen, Inc. Liquid dispensing apparatus and methods
WO1997049805A2 (en) 1996-06-27 1997-12-31 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Recognition molecules interacting specifically with the active site or cleft of a target molecule
WO1999023221A2 (en) 1997-10-27 1999-05-14 Unilever Plc Multivalent antigen-binding proteins
WO1999037681A2 (en) 1998-01-26 1999-07-29 Unilever Plc Method for producing antibody fragments
WO1999042077A2 (en) 1998-02-19 1999-08-26 Xcyte Therapies, Inc. Compositions and methods for regulating lymphocyte activation
US6014970A (en) 1998-06-11 2000-01-18 Aerogen, Inc. Methods and apparatus for storing chemical compounds in a portable inhaler
WO2000040968A1 (en) 1999-01-05 2000-07-13 Unilever Plc Binding of antibody fragments to solid supports
WO2000043507A1 (en) 1999-01-19 2000-07-27 Unilever Plc Method for producing antibody fragments
WO2000065057A1 (en) 1999-04-22 2000-11-02 Unilever Plc Inhibition of viral infection using monovalent antigen-binding proteins
WO2001021817A1 (en) 1999-09-24 2001-03-29 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Recombinant phages capable of entering host cells via specific interaction with an artificial receptor
WO2001040310A2 (en) 1999-11-29 2001-06-07 Unilever Plc Immobilisation of proteins using a polypeptide segment
WO2001044301A1 (en) 1999-11-29 2001-06-21 Unilever Plc Immobilized single domain antigen-binding molecules
EP1134231A1 (en) 2000-03-14 2001-09-19 Unilever N.V. Antibody heavy chain variable domains against human dietary enzymes, and their uses
WO2001090190A2 (en) 2000-05-26 2001-11-29 National Research Council Of Canada Single-domain antigen-binding antibody fragments derived from llama antibodies
WO2002048193A2 (en) 2000-12-13 2002-06-20 Unilever N.V. Camelidae antibody arrays
WO2003025020A1 (en) 2001-09-13 2003-03-27 Institute For Antibodies Co., Ltd. Method of constructing camel antibody library
EP1433793A1 (en) 2001-09-13 2004-06-30 Institute for Antibodies Co., Ltd. Method of constructing camel antibody library
WO2003035694A2 (en) 2001-10-24 2003-05-01 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Functional heavy chain antibodies, fragments thereof, library thereof and methods of production thereof
WO2003050531A2 (en) 2001-12-11 2003-06-19 Algonomics N.V. Method for displaying loops from immunoglobulin domains in different contexts
WO2003054016A2 (en) 2001-12-21 2003-07-03 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Method for cloning of variable domain sequences
WO2003055527A2 (en) 2002-01-03 2003-07-10 Vlaams Interuniversitair Instituut Voor Biotechnologie Vzw Immunoconjugates useful for treatment of tumours
WO2004041867A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Camelidae antibodies against imminoglobulin e and use thereof for the treatment of allergic disorders
WO2004041863A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Single domain antibodies directed against interferon- gamma and uses therefor
WO2004041865A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Stabilized single domain antibodies
WO2004041862A2 (en) 2002-11-08 2004-05-21 Ablynx N.V. Single domain antibodies directed against tumour necrosis factor-alpha and uses therefor
WO2004062551A2 (en) 2003-01-10 2004-07-29 Ablynx N.V. RECOMBINANT VHH SINGLE DOMAIN ANTIBODY FROM CAMELIDAE AGAINST VON WILLEBRAND FACTOR (vWF) OR AGAINST COLLAGEN
WO2004068820A2 (en) 2003-01-23 2004-08-12 Unspam, Llc. Method and apparatus for a non-revealing do-not-contact list system
WO2004081026A2 (en) 2003-06-30 2004-09-23 Domantis Limited Polypeptides
WO2005018629A1 (en) 2003-08-12 2005-03-03 Yarbrough William M Treatment for acne vulgaris and method of use
WO2005044858A1 (en) 2003-11-07 2005-05-19 Ablynx N.V. Camelidae single domain antibodies vhh directed against epidermal growth factor receptor and uses therefor
WO2006003388A2 (en) 2004-06-30 2006-01-12 Domantis Limited Compositions and methods for treating inflammatory disorders
WO2006030220A1 (en) 2004-09-17 2006-03-23 Domantis Limited Compositions monovalent for cd40l binding and methods of use
WO2006040153A2 (en) 2004-10-13 2006-04-20 Ablynx N.V. Single domain camelide anti -amyloid beta antibodies and polypeptides comprising the same for the treatment and diagnosis of degenarative neural diseases such as alzheimer's disease
WO2006059108A2 (en) 2004-12-02 2006-06-08 Domantis Limited ANTI-IL-IRl SINGLE DOMAIN ANTIBODIES AND THERAPEUTIC USES
WO2006079372A1 (en) 2005-01-31 2006-08-03 Ablynx N.V. Method for generating variable domain sequences of heavy chain antibodies
WO2006122786A2 (en) 2005-05-18 2006-11-23 Ablynx Nv Improved nanobodies™ against tumor necrosis factor-alpha
WO2006122787A1 (en) 2005-05-18 2006-11-23 Ablynx Nv Serum albumin binding proteins
WO2006122825A2 (en) 2005-05-20 2006-11-23 Ablynx Nv Single domain vhh antibodies against von willebrand factor
WO2007049017A2 (en) 2005-10-24 2007-05-03 Domantis Limited Agents that bind a target in pulmonary tissue for treating respiratory diseases
WO2007085815A2 (en) 2006-01-24 2007-08-02 Domantis Limited Ligands that bind il-4 and/or il-13
WO2008020079A1 (en) 2006-08-18 2008-02-21 Ablynx N.V. Amino acid sequences directed against il-6r and polypeptides comprising the same for the treatment of deseases and disorders associated with il-6-mediated signalling
WO2008101985A2 (en) 2007-02-21 2008-08-28 Ablynx N.V. Amino acid sequences directed against vascular endothelial growth factor and polypeptides comprising the same for the treatment of conditions and diseases characterized by excessive and/or pathological angiogenesis or neovascularization
WO2008142164A2 (en) 2007-05-24 2008-11-27 Ablynx N.V. Amino acid sequences directed against rank-l and polypeptides comprising the same for the treatment of bone diseases and disorders
WO2010115998A2 (en) 2009-04-10 2010-10-14 Ablynx Nv Improved amino acid sequences directed against il-6r and polypeptides comprising the same for the treatment of il-6r related diseases and disorders
WO2010139808A2 (en) 2009-06-05 2010-12-09 Ablynx Nv IMPROVED AMINO ACID SEQUENCES DIRECTED AGAINST HUMAN RESPIRATORY SYNCYTIAL VIRUS (hRSV) AND POLYPEPTIDES COMPRISING THE SAME FOR THE PREVENTION AND/OR TREATMENT OF RESPIRATORY TRACT INFECTIONS
WO2011098552A2 (en) 2010-02-11 2011-08-18 Ablynx Nv Methods and compositions for the preparation of aerosols
WO2015055655A1 (en) 2013-10-14 2015-04-23 Narrative AB Method of operating a wearable lifelogging device
WO2016055656A1 (en) 2014-10-10 2016-04-14 Ablynx N.V. Methods of treating rsv infections
WO2016055655A1 (en) * 2014-10-10 2016-04-14 Ablynx N.V. Inhalation device for use in aerosol therapy of respiratory diseases

Non-Patent Citations (62)

* Cited by examiner, † Cited by third party
Title
"Current protocols in molecular biology", 1987, GREEN PUBLISHING AND WILEY INTERSCIENCE
"Pulmonary Drug Delivery", 2007, pages: 16 - 28
"The Handbook of Therapeutic Antibodies", 2007, WILEY
ALIYU ET AL., BAYERO JOURNAL OF PURE AND APPLIED SCIENCES, vol. 3, 2010, pages 147 - 155
AMIRAV ET AL., ARCH. DIS. CHILD, vol. 97, 2012, pages 497 - 501
AMIRAV ET AL., J. NUCL. MED., vol. 43, 2002, pages 487 - 491
ANDERSON ET AL., J. CLIN. MICROBIOL., vol. 22, 1985, pages 1050 - 1052
BARRETT ET AL.: "Physiologically based pharmacokinetic (PBPK) modeling in children", CLINICAL PHARMACOLOGY AND THERAPEUTICS, vol. 92, 2012, pages 40 - 49
BECHTOLD-. PETERS, K AND LUESSEN, H: "Pulmonary Drug Delivery", 2007, pages: 129 - 148
BINGHE WANG; TERUNA SIAHAAN; RICHARD SOLTERO: "Drug Delivery: Principles and Applications", 2005, JOHN WILEY & SONS
BIOTECHONOL., vol. 13, 1995, pages 475 - 479
BLACK, RESPIR. CARE, vol. 48, 2003, pages 209 - 231
CEBEY-LOPEZ ET AL., PLOS ONE, vol. 11, no. 2, 2016, pages e0146599
CHUA ET AL., EUR. RESPIR. J., vol. 7, 1994, pages 2185 - 2191
CONCEPCIÓN PALOMO ET AL: "Trivalency of a Nanobody Specific for the Human RespiratorySyncytial Virus Fusion Glycoprotein Drastically Enhances VirusNeutralization and Impacts Escape Mutant Selection", ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, vol. 60, no. 11, 22 August 2016 (2016-08-22), pages 6498 - 6509, XP055442923, ISSN: 0066-4804, DOI: 10.1128/AAC.00842-16 *
CONRATH ET AL., J. BIOL. CHEM., vol. 276, 2001, pages 7346 - 7350
DAVIES; RIECHMANN, FEBS, vol. 339, 1994, pages 285 - 290
DE BRUYN ET AL., RDD EUROPE, vol. 1, 2015, pages 37 - 48
DETALLE ET AL., ANTIMICROBIAL AGENTS AND CHEMOTHERAPY, vol. 60, 2016, pages 6 - 13
DRAKE ET AL., ANALYTICAL BIOCHEMISTRY, vol. 328, 2004, pages 35 - 43
ERIK M DEPLA: "Non-clinical and early clinical development of Nanobodies: ALX-0171 example", EUFEMED, 22 May 2015 (2015-05-22), EUFEMED, Brussels,, pages 1 - 24, XP055443548, DOI: //www.eufemed.eu/wp-content/uploads/S_4.3_Depla.pdf *
FOK ET AL., PEDIATR. PULMONOL., vol. 21, 1996, pages 301 - 309
FOUGEROLLES: "James Black Meeting", 19 September 2014, BRITISH PHARMACOLOGY SOCIETY, article "Using Nanobodies® as novel inhalation therapeutic for the treatment of respiratory infectious diseases"
FRALEY ET AL., BIOANALYSIS, vol. 5, 2013, pages 1765 - 1774
FRIGUET ET AL., J. IMMUNOL. METHODS, vol. 77, 1985, pages 305 - 319
GONZALES ET AL., TUMOUR BIOL., vol. 26, no. 1, 2005, pages 31 - 43
HOLT ET AL., TRENDS BIOTECHNOL., vol. 21, 2003, pages 484 - 490
IMAI ET AL., PEDIATRIC PULMONOLOGY, vol. 33, 2002, pages 135 - 141
IRVING ET AL., J. IMMUNOL. METHODS, vol. 248, no. 1-2, 2001, pages 31 - 45
J. VIROL., vol. 62, 1988, pages 4232 - 4238
JANEWAY ET AL.: "Immunobiology", 2005, GARLAND SCIENCE PUBLISHING/ CHURCHILL LIVINGSTONE
JOHNSON ET AL., J. INF. DIS., vol. 176, 1997, pages 1215 - 1224
JUSTICIA-GRANDE ET AL., LEIPZIG: 33RD ANNUAL MEETING OF THE EUROPEAN SOCIETY FOR PAEDIATRIC INFECTIOUS DISEASES, 2015
KABAT ET AL.: "Sequence of proteins of immunological interest", US PUBLIC HEALTH SERVICES, NIH
KAREN WHALEN: "Lippincott Illustrated Reviews: Pharmacology. 6th ed.", 2015
KAWASAKI ET AL., J. MED. VIROL., vol. 81, 2009, pages 2104 - 2108
KHALIL; LAER: "Physiologically Based Pharmacokinetic Modeling: Methodology, Applications, and Limitations with a Focus on Its Role in Pediatric Drug Development", J. OF BIOMED. AND BIOTECHNOL., 2011, pages 13
KUBOTA; HARUTA, J. INFECTION CHEMOTHERAPY: OFFICIAL JOURNAL OF THE JAPAN SOCIETY OF CHEMOTHERAPY, vol. 12, 2006, pages 22 - 24
LAURENT DETALLE: "Delivery of ALX-0171 by inhalation greatly reduces disease burden in a neonatal lamb RSV infection model", 9TH RSV SYMPOSIUM STELLENBOSCH -SOUTH AFRICA, 13 November 2014 (2014-11-13), XP055442918 *
LEVIN; WEISS, MOL. BIOSYST., vol. 2, no. 1, 2006, pages 49 - 57
LEWIN: "Genes II", 1985, JOHN WILEY & SONS
MUNDT ET AL., PEDIATR., 2012, pages 721295
MUYLDERMANS, REVIEWS IN MOLECULAR BIOTECHNOLOGY, vol. 74, 2001, pages 277 - 302
NEWMAN, J. APPL. THER. RES., vol. 5, 2005, pages 29 - 33
OBER ET AL., INTERN. IMMUNOLOGY, vol. 13, 2001, pages 1551 - 1559
O'CALLAGHAN; BARRY, THORAX, vol. 52, 1997, pages S31 - S44
OLD ET AL.: "Principles of Gene Manipulation: An Introduction to Genetic Engineering", 1981, UNIVERSITY OF CALIFORNIA PRESS
PRESTA, ADV. DRUG DELIV. REV., vol. 58, no. 5-6, 2006, pages 640 - 656
PROT. ENG., vol. 9, 1996, pages 531 - 537
REMINGTON; BERINGER: "The Science and Practice of Pharmacy", 2006, LIPPINCOTT WILLIAMS AND WILKINS
REMINGTON; GENNARO: "Remington's Pharmaceutical Sciences", 1990, MACK PUBLISHING COMPANY
RIECHMANN; MUYLDERMANS, J. IMMUNOL. METHODS, vol. 231, 1999, pages 25 - 38
RIECHMANN; MUYLDERMANS, J. IMMUNOL. METHODS, vol. 240, 2000, pages 185 - 195
ROITT ET AL.: "Immunology", 2001, MOSBY/ELSEVIER
ROITT ET AL.: "Roitt's Essential Immunology", 2001, BLACKWELL PUBLISHING
ROSENFELD G.C.; LOOSE-MITCHELL D.S.: "Pharmacology PreTestTM Self-Assessment and Review"
SAMBROOK ET AL.: "Molecular Cloning: A Laboratory Manual", vol. 1-3, 1989, COLD SPRING HARBOR LABORATORY PRESS
SCHMITZ ET AL., PLACENTA, vol. 21, 2000, pages 106 - 112
TOTAPALLY ET AL., CRIT. CARE, vol. 6, 2002, pages 160 - 165
WANG ET AL., J. CLIN. PHARMACOL., vol. 52, 2012, pages 1601 - 1606
WARD ET AL., NATURE, vol. 341, 1989, pages 544 - 546
WILDHABER ET AL., J. PEDIATR., vol. 135, 1999, pages 28 - 33

Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN117050166A (en) * 2022-08-30 2023-11-14 武汉班科生物技术有限公司 C-type single domain antibody for neutralizing respiratory syncytial virus and application thereof
CN117050166B (en) * 2022-08-30 2024-02-27 武汉班科生物技术有限公司 C-type single domain antibody for neutralizing respiratory syncytial virus and application thereof

Similar Documents

Publication Publication Date Title
US10561805B2 (en) Methods of treating RSV infections
Van Heeke et al. Nanobodies® as inhaled biotherapeutics for lung diseases
US10512739B2 (en) Inhalation device for use in aerosol therapy of respiratory diseases
EP2387583B1 (en) Pulmonary administration of immunoglobulin single variable domains and constructs thereof
JP2016135133A (en) Antibodies against respiratory syncytial virus and methods for producing vaccines against the virus
TW201444866A (en) Human antibodies to respiratory syncytial virus F protein and methods of use thereof
US20190127447A1 (en) Treatment of rsv infection
WO2018099968A1 (en) Treatment of infection by respiratory syncytial virus (rsv)
US20220025019A1 (en) Methods and compositions for preventing or treating acute exacerbations with polyclonal immunoglobulin
WO2021005232A1 (en) Intranasal administration of neutralising antiviral antibodies
TW202337497A (en) Intranasal formulations and anti-sars-cov-2-spike protein antibodies
NZ730120B2 (en) Inhalation device for use in aerosol therapy of respiratory diseases

Legal Events

Date Code Title Description
121 Ep: the epo has been informed by wipo that ep was designated in this application

Ref document number: 17816560

Country of ref document: EP

Kind code of ref document: A1

NENP Non-entry into the national phase

Ref country code: DE

122 Ep: pct application non-entry in european phase

Ref document number: 17816560

Country of ref document: EP

Kind code of ref document: A1