Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/395—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum
  • A61K39/39533—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals
  • A61K39/39541—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals against normal tissues, cells
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/08—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing oxygen, e.g. ethers, acetals, ketones, quinones, aldehydes, peroxides
  • A61K47/12—Carboxylic acids; Salts or anhydrides thereof
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/16—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing nitrogen, e.g. nitro-, nitroso-, azo-compounds, nitriles, cyanates
  • A61K47/18—Amines; Amides; Ureas; Quaternary ammonium compounds; Amino acids; Oligopeptides having up to five amino acids
  • A61K47/183—Amino acids, e.g. glycine, EDTA or aspartame
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/26—Carbohydrates, e.g. sugar alcohols, amino sugars, nucleic acids, mono-, di- or oligo-saccharides; Derivatives thereof, e.g. polysorbates, sorbitan fatty acid esters or glycyrrhizin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/50—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates
  • A61K47/51—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent
  • A61K47/68—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent the modifying agent being an antibody, an immunoglobulin or a fragment thereof, e.g. an Fc-fragment
  • A61K47/6801—Drug-antibody or immunoglobulin conjugates defined by the pharmacologically or therapeutically active agent
  • A61K47/6803—Drugs conjugated to an antibody or immunoglobulin, e.g. cisplatin-antibody conjugates
  • A61K47/6811—Drugs conjugated to an antibody or immunoglobulin, e.g. cisplatin-antibody conjugates the drug being a protein or peptide, e.g. transferrin or bleomycin
  • A61K47/6817—Toxins
  • A61K47/6819—Plant toxins
  • A61K47/6825—Ribosomal inhibitory proteins, i.e. RIP-I or RIP-II, e.g. Pap, gelonin or dianthin
  • A61K47/6827—Ricin A
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/50—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates
  • A61K47/51—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent
  • A61K47/68—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent the modifying agent being an antibody, an immunoglobulin or a fragment thereof, e.g. an Fc-fragment
  • A61K47/6835—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent the modifying agent being an antibody, an immunoglobulin or a fragment thereof, e.g. an Fc-fragment the modifying agent being an antibody or an immunoglobulin bearing at least one antigen-binding site
  • A61K47/6849—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient the non-active ingredient being chemically bound to the active ingredient, e.g. polymer-drug conjugates the non-active ingredient being a modifying agent the modifying agent being an antibody, an immunoglobulin or a fragment thereof, e.g. an Fc-fragment the modifying agent being an antibody or an immunoglobulin bearing at least one antigen-binding site the antibody targeting a receptor, a cell surface antigen or a cell surface determinant
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/08—Solutions
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/14—Particulate form, e.g. powders, Processes for size reducing of pure drugs or the resulting products, Pure drug nanoparticles
  • A61K9/19—Particulate form, e.g. powders, Processes for size reducing of pure drugs or the resulting products, Pure drug nanoparticles lyophilised, i.e. freeze-dried, solutions or dispersions
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P37/00—Drugs for immunological or allergic disorders
  • A61P37/02—Immunomodulators
  • A61P37/06—Immunosuppressants, e.g. drugs for graft rejection
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2803—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the immunoglobulin superfamily
  • C07K16/2809—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the immunoglobulin superfamily against the T-cell receptor (TcR)-CD3 complex
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2896—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against molecules with a "CD"-designation, not provided for elsewhere
• • 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
  • A61K2039/507—Comprising a combination of two or more separate 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
  • A61K2039/55—Medicinal preparations containing antigens or antibodies characterised by the host/recipient, e.g. newborn with maternal antibodies
• • Y—GENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
  • Y02—TECHNOLOGIES OR APPLICATIONS FOR MITIGATION OR ADAPTATION AGAINST CLIMATE CHANGE
  • Y02A—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE
  • Y02A50/00—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE in human health protection, e.g. against extreme weather
  • Y02A50/30—Against vector-borne diseases, e.g. mosquito-borne, fly-borne, tick-borne or waterborne diseases whose impact is exacerbated by climate change

Definitions

• the present invention relates to the field of therapy, including preventative therapy for chronic Graft versus Host Disease (cGVHD) , antiviral therapy, including prevention of viral reactivation and control of viral reactivation, and prevention of progression of Epstein-Barr virus (EBV) infection to post-transplant
• cGVHD chronic Graft versus Host Disease
• antiviral therapy including prevention of viral reactivation and control of viral reactivation, and prevention of progression of Epstein-Barr virus (EBV) infection to post-transplant
• PTLD lymphoproliferative disorder
• PML Progressive multifocal leukoencephalopathy
• immunomodulatory therapy e.g. immunosuppression
• methods and means for use in such therapy including improved pharmaceutical compositions.
• Immunosuppression is employed in the treatment of certain life- threatening immune conditions, such as transplant-related rejection, Graft versus Host Disease (GVHD), acute solid-organ rejection and several severe autoimmune diseases.
• GVHD Graft versus Host Disease
• EP 0945139 Al, EP 1 066 058 Bl and US 2006/051355 describe an immunotoxin cocktail for treatment of immune related diseases such as GVHD after allogeneic hematopoietic stem cell transplantation (HSCT) .
• the immunotoxin cocktail comprises an anti-CD3 antibody and anti-CD7 antibody, each conjugated to ricin A, which targets mature T cells and natural killer (NK) cells, "resetting" the immune system.
• aGVHD acute GVHD
• WO 98/55150 describes immunotoxins comprising the monoclonal antibody TXU-7 linked to an amount of pokeweed antiviral protein for the treatment of T cell leukemias, lymphomas, acute myeloid
• van Oosterhout et al . Blood, 2000, Vol. 95, No. 12, pp. 3693-3701, describes a pilot study for treatment of acute GVHD using an anti- CD3 and anti-CD7 immunotoxin combination.
• Campath Antibody therapy with Campath (Alemtuzumab) has been employed for immunotherapy of, e.g., B-cell chronic lymphocytic leukemia (B-CLL) .
• B-CLL B-cell chronic lymphocytic leukemia
• Campath has been used in the treatment of acute intestinal GVHD resistant to systemic and topical steroids (Schnitzler et al., Biology of Blood and Marrow Transplantation , 2008, Vol. 15, No. 8, pp. 910-919) .
• a complication of Campath therapy is a significant increase in the risk for opportunistic infections, in particular, reactivation of human cytomegalovirus (CMV) (Schnitzler et al . ibid) .
• CMV human cytomegalovirus
• Antibody therapy with anti-thymocyte globulin (ATG) has been employed for immunotherapy of acute rejection in organ
• ATG has also been employed in treatment of GVHD (Bacigalupo et al . , Blood, 2001, Vol. 98, No. 10, pp. 2942-2947) .
• GVHD Bacillan et al . ibid
• Early treatment with ATG has been reported to improve survival in patients with steroid-resistant aGVHD (MacMillan et al . , Biology of Blood and Marrow Transplantation, 2002, Vol. 8, pp. 40-46) .
• cGVHD chronic GVHD
• reported rates of development of cGVHD among aGVHD-treated survivors are in the range 44%-80% (see: Furlong et al . , Bone Marrow Transplant . , 2009, Vol. 44, No. 11, pp. 739-748; Socie et al . , Blood, 2017, Vol. 129, No. 5, pp. 643-649; MacMillan et al., Biology of Blood and Marrow Transplantation, 2002, Vol. 8, pp. 40-46; and MacMillan et al . , Blood, 2007, Vol. 109, No. 6 , pp . 2657-2662) .
• Post-transplant lymphoproliferative disorder is the name given to a B-cell proliferation due to therapeutic immunosuppression after organ transplantation.
• the disease is an uncontrolled proliferation of B cell lymphocytes latently infected with Epstein- Barr virus (EBV) .
• EBV Epstein- Barr virus
• CLS capillary leak syndrome
• compositions for storage and delivery of combination immunotoxins have been found to exhibit a number of shortcomings in relation to longer term stability, particularly at higher temperatures.
• appearance of insoluble aggregates may impact the shelf-life of such pharmaceutical compositions and/or require prolonged cold storage.
• the present invention relates to methods and means for treating (including prophylactic treatment) viral infection or viral reactivation in subjects who are undergoing immunomodulatory treatment, particularly T-cell directed immunosuppression and/or the suppression of inflammatory cytokines.
• subjects such as human post-transplant patients, treated with the T-Guard (RTM) combination therapy (a cocktail of anti-CD3 and anti-CD7 immunotoxins ) , exhibit reduced incidence of viral infection and/or viral reactivation, e.g. with human cytomegalovirus (CMV) and/or Epstein-Barr virus (EBV) , when compared with patients treated with a standard immunosuppressive control.
• RTM T-Guard
• CMV human cytomegalovirus
• EBV Epstein-Barr virus
• the present invention provides a composition comprising a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, for use in a method of treatment, or preventative treatment, of viral infection or viral reactivation or of
• first and second antibody molecules are each provided with a toxic moiety.
• the first aspect of the present invention also provides a first antibody molecule that specifically recognises CD3 and which first antibody molecule is linked to a toxic moiety for use in a method of treatment, or preventative treatment, of viral infection or viral reactivation or of progression of a viral infection or viral reactivation to PTLD or PML in a mammalian subject undergoing immunomodulatory treatment, wherein said first antibody molecule is for simultaneous, separate or sequential administration with a second antibody molecule that specifically recognises CD7, said second antibody molecule being linked to a toxic moiety.
• the first aspect of the present invention also provides an antibody molecule that specifically recognises CD7 ("second antibody
• first antibody molecule and which antibody molecule is linked to a toxic moiety for use in a method of treatment, or preventative treatment, of viral infection or viral reactivation or of progression of a viral infection or viral reactivation to PTLD or PML in a mammalian subject undergoing immunomodulatory treatment, wherein said second antibody molecule is for simultaneous, separate or sequential administration with a further antibody molecule that specifically recognises CD3 ("first antibody molecule”), said first antibody molecule being linked to a toxic moiety.
• composition may be provided in the form of a mixture or cocktail of the anti-CD3 and the anti-CD7 antibody molecules or may be provided in the form of a kit of parts comprising a first composition comprising the anti-CD3 antibody molecule and a second composition comprising the anti-CD7 antibody molecule, e.g. packaged or
• kit of parts may be for combination prior to administration to the subject or may be for simultaneous, separate or sequential administration, wherein the first and second compositions are each administered to the same subj ect .
• said first and second antibody molecules are provided in the form of a composition (e.g. a mixture or cocktail) and are to be administered to the subject by administering one or more doses of said composition.
• the composition may, for example, be a mixture of the first and second antibody molecules each with their respective toxic moieties, wherein the first and second antibody molecules are in a molar ratio in the range 100:1 to 1:100, typically 10:1 to 1:10 and in certain cases 2:1 to 1:2, such as approximately 1:1.
• the virus of the viral infection or reactivation may be other than HIV.
• the viral infection or viral reactivation may be a virus of the order Herpesvirales .
• the viral infection may be selected from human
• CMV cytomegalovirus
• EBV Epstein-Barr virus
• the viral infection or viral reactivation may be with a JC virus (also known as John Cunningham virus) of the family
• the immunomodulatory treatment is immunosuppressive treatment.
• the immunomodulatory treatment may be T- cell directed immunosuppression.
• the immunomodulatory treatment may be immunosuppressive treatment.
• immunomodulatory treatment comprises treatment of Graft versus Host disease (GvHD) , graft rejection, autoimmune disease, T-cell
• the autoimmune disease may be a disease having aberrant T-cell activity as a component.
• the composition is the same composition used for the immunomodulatory treatment. That is to say one or more doses of the composition (e.g. T-Guard (RTM) ) or its component antibody molecules for simultaneous, separate or sequential administration may be administered, or for administration, to a subject to achieve a double effect or dual purpose.
• the first antibody molecule and/or the second antibody molecule is a murine antibody.
• the first antibody molecule is an IgG2b isotype monoclonal antibody that selectively binds human CD3.
• the first antibody molecule may be the antibody
• the second antibody molecule is an IgG2a isotype monoclonal antibody.
• the second antibody molecule may be the antibody disclosed as "WT1" in in EP 0945139 Al and Tax et al . , Monoclonal antibodies against human thymocytes and T lymphocytes. Protides of the biological fluids, 29 th Colloquium,
• the first antibody and the second antibody are conjugated to a toxic moiety selected from the group consisting of: ricin, deglycosylated ricin A (dgRTA) , and non-glycosylated
• the antibodies may be conjugated to the toxic moiety, e.g. ricin A, using any suitable conjugation or linker chemistry.
• the conjugation may employ N-succinimydyl 3- (2-pyridyldithio) propionate (SPDP; Pharmacia) or 4- succinimidyloxycarbonyl-alpha-methyl- (2-pyridyldithio) toluene (SMPT) .
• the conjugation ratio of toxin (e.g. ricin A) to antibody molecule may be in the range 0.5:1 to 5:1.
• the conjugation ratio of toxin (e.g. ricin A) to antibody molecule may be in the range 0.8:1 to 1.2:1.
• immunotoxins e.g., Fab, scFv or SC mAb linked through cleavable peptide linker to a
• the first and second antibody molecules may be provided as a single bispecific (anti-CD3/anti-CD7 ) antibody, thereby providing a bispecific immunotoxin such as anti-CD3/CD7- rRTA.
• At least one of the following is de-immunised:
• De-immunization strategy may be performed by Epibase (RTM) or Epibase IV (RTM) (Lonza Group AG) or EpiMatrix T cell epitope mapping system (EpiVax, Inc.) .
• the subject has been determined to have, or to be at risk of, viral infection with EBV and/or CMV.
• the subject has been determined to have, or to be at risk of, viral infection with EBV and/or CMV.
• the subject has been determined to have, or to be at risk of, viral infection with EBV and/or CMV.
• the subject has been determined to have, or to be at risk of, viral infection with EBV and/or CMV.
• donor-recipient transplant combinations in which the donor has, or is suspected of having, a history of EBV and/or CMV
• a further example is a recipient of a transplant that has been
• the subject may exhibit an EBV and/or CMV viral titre above 1000 viral DNA copies/ml of blood.
• the subject may exhibit an elevated and/or rising EBV and/or CMV viral titre at any point during the period beginning 7 days prior to the first dose of immunomodulatory therapy and ending with the final dose of
• the subject may present with an elevated EBV and/or CMV plasma viral titre on the day of, or one or more days before, the first dose of the immunomodulatory treatment.
• the subject may exhibit a rising plasma viral titre of EBV and/or CMV (i.e. a higher titre on a second or subsequent measurement as compared with a first
• Subjects including immunocompromised human patients, exhibiting elevated and/or rising EBV and/or CMV viral titre may be particularly suited to treatment with a composition of the invention, such as T-Guard (RTM) .
• RTM T-Guard
• the composition provides a clinical benefit as assessed by a reduction in viral titre (e.g. an EBV and/or CMV viral titre of less than 1000 viral DNA copies/ml of blood) at 180 days after administering the composition of the first aspect of the invention .
• a reduction in viral titre e.g. an EBV and/or CMV viral titre of less than 1000 viral DNA copies/ml of blood
• the composition suppresses and/or kills CD3+ and/or CD7+ T-cells.
• the composition spares CD8+ anti-viral T-cells relative to CD3+ and/or CD7+ T-cells.
• the composition may target CD3+ and CD7+ T-cells, while relatively sparing antiviral T-cells, such as CTLs that target CMV and/or EBV.
• composition may be for use in a method of
• composition may be for use in a method of treatment, including preventative treatment, of Progressive multifocal
• PML leukoencephalopathy
• PML is a rare and usually fatal viral disease characterized by progressive damage or inflammation of the white matter of the brain at multiple locations. It is caused by the JC virus, which is normally present and kept under control by the immune system. JC virus is generally harmless except in cases of weakened immune systems. In general, PML has a mortality rate of 30-50 percent in the first few months and those who survive can be left with varying degrees of neurological disabilities. PML occurs almost exclusively in patients with severe immune deficiency, most commonly among patients with acquired immune deficiency syndrome (AIDS) , but people on chronic immunosuppressive medications including chemotherapy are also at increased risk of PML, such as patients with transplants, Hodgkin ' s Lymphoma, multiple sclerosis, psoriasis and other
• the subject is monitored for viral infection and/or reactivation, e.g. with CMV or EBV, as part of the method of treatment. That is to say, the subject, or more regularly a sample such as a blood or plasma sample obtained from the subject, may be analysed in order to measure viral titre or signs of viral
• the subject may be monitored for indirect signs of viral infection or reactivation, such as symptoms of viral infection.
• Such monitoring may be performed before, during and/or after treatment.
• monitoring may be performed on a periodic basis during the course of treatments, e.g. daily or weekly determinations of viral titre.
• monitoring the subject for viral infection and/or reactivation comprises measuring viral titre at least once before, during and/or after the immunomodulatory treatment.
• monitoring comprises measuring plasma viral titre by real-time quantitative PCR.
• the subject is being or has been treated with prophylactic antiviral medication.
• the subject may have undergone a course of treatment with aciclovir (RTM) .
• RTM aciclovir
• the present invention provides a method of treating a mammalian subject having, or being at risk of, a viral infection or viral reactivation, the method comprising:
• said first and second antibody molecules are provided in the form of a composition (e.g. a mixture or cocktail) and are administered to the subject by administering one or more doses of said composition.
• the composition may, for example, be a mixture o the first and second antibody molecules each with their respective toxic moieties, wherein the first and second antibody molecules are in a molar ratio in the range 100:1 to 1:100, typically 10:1 to 1:1 and in certain cases 2:1 to 1:2, such as approximately 1:1.
• the method of treatment provides a clinical benefit as assessed by a reduction in viral titre (e.g. an EBV and/or CMV viral titre of less than 1000 viral DNA copies/ml of blood) at 180 days after administering said first and second antibodies .
• a reduction in viral titre e.g. an EBV and/or CMV viral titre of less than 1000 viral DNA copies/ml of blood
• compositions, options and other features of the first aspect of the invention apply equally to the second aspect of the invention.
• the present invention provides use of a
• composition comprising a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, in the preparation of a medicament for use in a method of treatment, or preventative treatment, of viral infection or viral reactivation in a mammalian subject undergoing
• the first and second antibodies may be provided as a composition (e.g. a mixture or cocktail) to be administered to the subject by administering one or more doses of said composition.
• the first and second antibodies may be provided in the form of a kit of parts comprising a first composition comprising the anti-CD3 antibody molecule and a second composition comprising the anti-CD7 antibody molecule, e.g. packaged or contained in separate containers.
• the kit of parts may be for combination prior to administration to the subject or may be for simultaneous, separate or sequential administration, wherein the first and second compositions are each administered to the same subject.
• compositions, options and other features of the first aspect of the invention apply equally to the third aspect of the invention.
• the present invention provides a composition comprising a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, for use in a method of treatment, or preventative treatment, of chronic Graft versus Host disease (cGVHD) in a mammalian subject undergoing immunomodulatory treatment, wherein the first and second antibody molecules are each provided with a toxic moiety.
• cGVHD Chronic Graft versus Host disease
• the composition may be for use in preventative treatment of cGVHD to provide clinical benefit as measured by the incidence of cGVHD at 180 days following said immunomodulatory treatment .
• the immunomodulatory treatment comprises treatment of acute Graft versus Host disease (aGVHD) .
• aGVHD acute Graft versus Host disease
• a patient who has received an allogeneic stem cell transplant and has developed aGVHD, especially steroid-refractory aGVHD may be treated with the composition, e.g. T-Guard (RTM) , so as to provide therapeutic benefit for the aGVHD and in order to provide clinical benefit in the form of a reduced likelihood of developing cGVHD (e.g. as measured at 180 days following the treatment with the composition, e.g. T-Guard (RTM) ) .
• T-Guard T-Guard
• the composition is the same composition used for the immunomodulatory treatment, the composition therefor being administered for a dual purpose. Namely, the treatment of aGVHD and the preventative treatment of cGVHD.
• the first and second antibody molecules may be as defined in accordance with the first aspect of the invention.
• the present invention provides a method of treating a mammalian subject having, or being at risk of developing chronic Graft versus Host disease (cGVHD) , the method comprising: administering simultaneously, separately or sequentially a therapeutically effective amount of a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, wherein the first and second antibody molecules are each provided with a toxic moiety, to the subject in need of said treatment,
• cGVHD chronic Graft versus Host disease
• said first and second antibody molecules are provided in the form of a composition (e.g. a mixture or cocktail) and are administered to the subject by administering one or more doses of said composition.
• the composition may, for example, be a mixture of the first and second antibody molecules each with their respective toxic moieties, wherein the first and second antibody molecules are in a molar ratio in the range 100:1 t 1:100, typically 10:1 to 1:10 and in certain cases 2:1 to 1:2, such as approximately 1:1.
• compositions, options and other features of the first aspect of the invention apply equally to the fifth aspect of the invention.
• the immunomodulatory treatment comprises treatment of acute Graft versus Host disease (aGVHD) .
• aGVHD acute Graft versus Host disease
• a patient who has received an allogeneic stem cell transplant and has developed aGVHD, especially steroid-refractory aGVHD may be treated with the composition, e.g. T-Guard (RTM) , so as to provide therapeutic benefit for the aGVHD and in order to provide clinical benefit in the form of a reduced likelihood of developing cGVHD (e.g. as measured at 180 days following the treatment with the composition, e.g. T-Guard (RTM) ) .
• the composition is the same composition used for the immunomodulatory treatment, the composition therefor being administered for a dual purpose. Namely, the treatment of aGVHD and the preventative treatment of cGVHD.
• the present invention provides a pharmaceutical composition comprising:
• composition is in water and has a pH in the range 6 to 7.5, optionally 6.5.
• the antibody molecule that specifically recognises CD3 is a murine IgG2b isotype monoclonal antibody that selectively binds human CD3.
• the antibody may be SPV-T3a.
• the antibody molecule that specifically recognises CD7 is a murine IgG2a isotype monoclonal antibody that selectively binds human CD7.
• the antibody may be WT1.
• both SPV-T3a and WT1 are present in the composition.
• each antibody is conjugated to an average of between 1 and 2 RTA (e.g. deglycosylated RTA (dgRTA) ) molecules per antibody molecule.
• the conjugation is via an 4-succinimidyloxycarbonyl-alpha-methyl-a (2- pyridyldithio) toluene crosslinker.
• the citrate buffer comprises a pharmaceutically acceptable base forming a salt with citric acid, for example, sodium, calcium, potassium, magnesium, or ammonium citrate.
• the citrate buffer comprises sodium citrate.
• the L-arginine salt is L-arginine . HC1.
• the polysorbate is Tween (RTM) 20.
• composition further comprises at least one agent selected from:
• composition may comprise 130 to 150 mM
• the composition comprises:
• composition is in water for injection and has a pH of
• the composition is sterile. In some embodiments, the composition is sterile. In some
• the composition is suitable for injection.
• the present invention provides a lyophilised composition that is a freeze-dried form of the composition of the sixth aspect of the invention.
• the lyophilised composition may be suitable for reconstitution, e.g., with water or an aqueous solution to form the composition of the sixth aspect of the invention.
• the present invention provides the
• composition of the sixth or seventh aspect of the invention for use in the method of treatment of the second aspect of the invention and/or for use in the method of treatment of the fifth aspect of the invention.
• the present invention provides use of a
• composition of the sixth or seventh aspect of the invention in the preparation of a medicament for use in the method of treatment of the second aspect of the invention and/or for use in the method of treatment of the fifth aspect of the invention.
• the present invention provides an article of manufacture comprising:
• the container or housing retains
• sterility e.g., by means of a seal and/or air-tight closure.
• the present invention provides a composition of the sixth or seventh aspect of the invention for use in medicine.
• the present invention provides a composition o the sixth or seventh aspect of the invention for use in a method of treatment of acute Graft versus Host disease (aGVHD) , graft
• aGVHD acute Graft versus Host disease
• the present invention provides a method of treating acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T-cell leukaemia or T-cell lymphoma in a mammalian subject, the method comprising administering a composition of the sixth or seventh aspect of the invention to a subject in need thereof .
• aGVHD acute Graft versus Host disease
• graft rejection graft rejection
• autoimmune disease T-cell leukaemia or T-cell lymphoma
• the present invention provides use of a composition of the sixth or seventh aspect of the invention in the preparation of a medicament for treating acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T-cell leukaemia or T-cell lymphoma in a mammalian subject.
• aGVHD acute Graft versus Host disease
• graft rejection autoimmune disease
• T-cell leukaemia T-cell lymphoma
• the present invention provides an article of manufacture comprising:
• aGVHD graft rejection
• autoimmune disease T-cell leukaemia or T- cell lymphoma in a mammalian subject.
• T-cell leukaemia T-cell leukaemia or T- cell lymphoma in a mammalian subject.
• container or housing retains sterility, e.g., by means of a seal and/or air-tight closure.
• the present invention provides a composition comprising a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, wherein the first and second antibody molecules are each provided with a toxic moiety, for use in a method of treatment of acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T- cell leukaemia or T-cell lymphoma in a human patient, wherein the patient has a serum albumin level of less than 30 g/L as measured prior to administration of said composition.
• aGVHD graft versus Host disease
• the composition the patient has a serum albumin level of between 10 g/L and 30 g/L, optionally between 15 g/L and 25 g/L.
• the composition is for use in a method to provide clinical benefit as measured by the incidence of grade 3 or above capillary leak syndrome (CLS) following administration of said composition.
• the first and second antibody molecules are as defined in connection with the first aspect of the invention.
• the composition is as defined in connection with the sixth aspect of the invention.
• the present invention provides a method for treating acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T-cell leukaemia or T-cell lymphoma in a human patient, the method comprising administering, simultaneously, separately or sequentially, a therapeutically effective amount of a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, wherein the first and second antibody molecules are each provided with a toxic moiety, to the patient in need of said treatment, and wherein the patient has a serum albumin level of less than 30 g/L as measured prior to administration of said composition. In some embodiments, the patient has a serum albumin level of between 10 g/L and 30 g/L, optionally between 15 g/L and 25 g/L. In some
• the method is to provide clinical benefit as measured by the incidence of grade 3 or above capillary leak syndrome (CLS) following said administration.
• CLS capillary leak syndrome
• the first and second antibody molecules are as defined in connection with the first aspect of the invention.
• the composition is as defined in connection with the sixth aspect of the invention.
• the present invention provides use of a composition comprising a first antibody molecule that specifically recognises CD3 and a second antibody molecule that specifically recognises CD7, wherein the first and second antibody molecules are each provided with a toxic moiety, in the preparation of a
• the medicament for treating acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T-cell leukaemia or T-cell lymphoma in a human patient, wherein the patient has a serum albumin level of less than 30 g/L as measured prior to administration of said composition.
• the patient has a serum albumin level of between 10 g/L and 30 g/L, optionally between 15 g/L and 25 g/L.
• the medicament is for treating acute Graft versus Host disease (aGVHD) , graft rejection, autoimmune disease, T-cell leukaemia or T-cell lymphoma in a human patient, wherein the patient has a serum albumin level of less than 30 g/L as measured prior to administration of said composition.
• the patient has a serum albumin level of between 10 g/L and 30 g/L, optionally between 15 g/L and 25 g/L.
• the medicament is for treating acute Graft versus Host
• CLS capillary leak syndrome
• the first and second antibody molecules are as defined in connection with the first aspect of the invention.
• the composition is as defined in connection with the sixth aspect of the invention.
• the present invention includes the combination of the aspects and preferred features described except where such a combination is clearly impermissible or is stated to be expressly avoided.
• Thes and further aspects and embodiments of the invention are describe in further detail below and with reference to the accompanying examples and figures.
• Figure 2 shows a survival curve (survival on the y-axis plotted against time in months post-GvHD on the x-axis) for patients treated with the control (institutional standard of care) .
• An initial phase ⁇ 6 months exhibits a rapid decline in survival associated with refractory GvHD and infections; a later phase >6 months exhibits a slower decline in survival associated with relapse of underlying disease .
• the T-Guard (RTM) -treated patients exhibit higher survival than the control group.
• Figure 4 shows a plot of EBV (circles) and CMV (triangles) titres plotted against time in days after treatment start for a patient treated with T-Guard (RTM) (four infusions given at 48-hour intervals as indicated by the arrows) . It is clear that after T-Guard (RTM) treatment and subsequent wash-out, the EBV titre, which had reached a measured level of 250000 DNA copies/ml, exhibited a significant decline over subsequent days .
• FIG. 5 shows a plot of EBV (circles) and CMV (triangles) titres plotted against time in days after treatment start for a patient (different patent than that treated in Figure 4) treated with T- Guard(RTM) (four infusions given at 48-hour intervals as indicated by the arrows) .
• T-Guard (RTM) the CMV titre declined.
• T-Guard (RTM) treatment and subsequent wash out 14 days after the start of treatment, a significant decline in EBV titre was seen.
• Figure 6 shows an example from one patient of FACS cell sorting results obtained from patients treated with T-Guard (RTM) .
• the left- hand panel shows CD3 cy7 plotted against CD8 FITC.
• the right-hand panel shows CMV PE plotted against CMV APC.
• Analysis of circulating T cells of patient 02-02 with tetramers revealed a large fraction (17.38%) of CMV-reactive cells within the CD8 positive T cell fraction, within 3 weeks after treatment start.
• FIG 7 shows overall clinical response (ORR) at day 28 and overall survival (OS) at 6 months for T-Guard (RTM) -treated patients and patients treated with the historical controls.
• CR Complete Response (lower bar portions in darker shading of bars 1 and 2) .
• PR Partial Response (upper bar portions in lighter shading) .
• the y- axis shows the percentage of the study population.
• the y-axis is OS (%); the x-axis is time (months) follow-up post-second line treatment.
• Six month OS was 60% for T-Guard (RTM) -treated vs. 29% for historical controls.
• Figure 9 shows a flow-chart depiction of the step-by-step process for preparing and purifying the antibody-toxin conjugates to obtain pharmaceutically acceptable product compositions ("Process A") .
• the conjugation and purification steps above the central horizontal line are performed in the 25 mM phosphate buffer at pH 7.5; steps below the horizontal line are performed in the 10 mM citrate buffer at pH 6.5.
• Figure 10 shows a flow-chart depiction of an alternative step-by- step process for preparing and purifying the antibody-toxin
• Process B compositions
• FIG 11 shows that T-Guard(RTM) treatment induces a swift immune reconstitution with a diverse T cell repertoire.
• A The number of unique T cell clones, as measured by the total number of unique CDR3 sequences, are shown for 21 patients before (screening) and at 1 month (Ml), 3 months (M3) and 6 months (M6) after T-Guard (RTM) therapy (Wilcoxon matched-paired signed rank test) .
• Ml 1 month
• M3 3 months
• M6 6 months
• RTM T-Guard
• FIG. 12 shows an illustration depicting the possible mechanistic mode of action of immunotoxin combination of the present invention, as exemplified by T-Guard (RTM) administration. Both toxin-induced apoptosis (anti-CD3 and anti-CD7 directed) and inhibition of alloactivation are believed to be implicated.
• Figure 13 Overview of the response rate at day 28 (top) and overall survival 6 months after treatment with CD3/CD7-IT (bottom) compared to historical controls. The difference between patients who received CD3/CD7-IT and the historical controls was statistically
• FIG. 14 CD3/CD7-IT induces rapid immune reconstitution with a diverse T-cell repertoire.
• A-C Time course of the median T-cell count (A) , median NK- cell count (B) , and median B-cell count (C) for all patients. In each plot, the blue line represents the median value, and the lower and upper gray dotted lines represent the 25 th and 75 th percentiles, respectively.
• D Summary of the absolute number of unique T-cell clones prior to administration of CD3/CD7-IT (Pre) and 1, 3, and 6 months after treatment. The number of unique T-cell clones was measured using the total number of unique CDR3 sequences. The p-values are based on a Wilcoxon matched-paired signed rank test. The significant increase in unique T-cell clones 6 months after CD3/CD7-IT therapy reflects an increase in the
• E-H Representative histograms showing the T-cell repertoires in a single patient pre-therapy (E) and 1 (F) , 3 (G) , and 6 (H) months after CD3/CD7-IT therapy.
• CD3/CD7-IT does not affect the fraction of anti-virus EBV- and CMV-associated T cell clones.
• A&C Summary of the absolute numbers of anti-EBV (A) and anti-CMV (C) T-cells in patients who tested positive for viral infection after treatment. In each patient group, the number of virus- associated T-cells was measured prior and after treatment.
• B&D Plots showing the differential abundance analysis of unique anti-EBV (B) and anti-CMV (D) T-cell clones. Shown are representative graphs of two patients who tested positive for the respective viral infection prior to treatment. Screening samples were compared to samples taken 1 month and 3 months after therapy with CD3/CD7-IT. This pairwise comparison confirms that the majority of the respective CMV- and EBV-associated clones neither expanded nor contracted as a result of therapy. In each plot, the solid gray diagonal line indicates equal numbers of clones in both samples (no change) . Clones positioned between the dotted gray lines and the respective X or Y-axis were not present in other sample, e.g.
• antibody or “antibody molecule” includes any immunoglobulin whether natural or partly or wholly synthetically produced.
• antibody or “antibody molecule” includes monoclonal
• Antibodies may be intact or fragments derived from full antibodies (see below) .
• Antibodies may be human antibodies, humanised antibodies or antibodies of non-human origin.
• “Monoclonal antibodies” are homogeneous, highly specific antibody populations directed against a single antigenic site or "determinant" of the target molecule.
• “Polyclonal antibodies” include heterogeneous antibody populations that are directed against different antigenic determinants of the target molecule.
• antigen or
• antigena refers to blood serum containing antibodies obtained from immunized animals.
• binding fragments are (i) the Fab fragment consisting of V L , V H , CL and CHI domains; (ii) the Fd fragment consisting of the V H and CHI domains;
• antibody molecule and immunotoxin are intended to encompass recombinant antibodies and recombinant immunotoxins , respectively (e.g., Fab, scFv or SC mAb linked through a cleavable peptide linker to a recombinant ribosomal inhibiting protein) .
• the first and second antibody molecules may be provided as a single bispecific (anti-CD3/anti-CD7 ) antibody, thereby providing a bispecific immunotoxin such as anti- CD3/CD7-rRTA.
• the term “selectively binds” may be used herein to refer to the situation in which one member of a specific binding pair will not show any significant binding to molecules other than its specific binding partner (s) .
• the term is also applicable where e.g. an antigen-binding site is specific for a particular epitope that is carried by a number of antigens, in which case the specific binding member carrying the antigen-binding site will be able to bind to the various antigens carrying the epitope.
• the antibody that selectively binds CD3 may in some cases comprise the complementarity determining regions (CDRs) of the antibody SPV- T3a.
• CDRs complementarity determining regions
• the CDRs of SPV-T3a are: CDRH1-H3: SEQ ID NOs: 5-7; CDRL1-L3: SEQ ID NOs : 8-10.
• the antibody that selectively binds CD3 may comprise the V H of SPV-T3a (SEQ ID NO: 3) and/or the V L of SPV-T3a (SEQ ID NO: 4) .
• the antibody that selectively binds CD3 may be the SPV- T3a antibody having the heavy chain of SEQ ID NO: 1 and light chain of SEQ ID NO: 2.
• the antibody that selectively binds CD7 may in some cases comprise the complementarity determining regions (CDRs) of the antibody WTl.
• CDRs complementarity determining regions
• the CDRs of WTl are: CDRH1-H3: SEQ ID NOs: 15- 17; CDRL1-L3: SEQ ID NOs: 18-20.
• the antibody that selectively binds CD7 may comprise the V H of WTl (SEQ ID NO: 13) and/or the V L of WTl (SEQ ID NO: 14) .
• the antibody that selectively binds CD7 may be the WTl antibody having the heavy chain of SEQ ID NO: 11 and light chain of SEQ ID NO: 12.
• SPV-T3a is a murine IgG2b monoclonal antibody that selectively binds human CD3, a T cell surface glycoprotein composed of a CD3y chain (UniProt: P09693), a CD35 chain (UniProt: P04234), and two CD3s chains (UniProt: P07766) .
• the production and characterization of SPV-T3a is described in Spits et al., Hybridoma, 1983, Vol. 2, pp. 423-437, the entire content of which is expressly incorporated herein by reference.
• the SVP-T3a antibody may be conjugated to ricin toxin A (RTA) , for example deglycosylated ricin toxin A, using the 4-succinimidyloxocarbonyl- - methyl- - (2- pyridyldithio) toluene ("SMPT") crosslinker.
• RTA ricin toxin A
• SMPT 4-succinimidyloxocarbonyl- - methyl- - (2- pyridyldithio) toluene
• This antibody conjugate may be referred to herein as SPV-T3a-RTA.
• Conjugation and purification may be carried out by the process depicted in Figure 9 or the process depicted in Figure 10.
• the amino acid sequence of the SPV-T3a light chain and heavy chain were determined by extracting mRNA from hybridoma cell pellets, RT- PCR was performed and DNA sequenced on an ABl3130x
• CDRs complementarity determining regions
• VH domain is underlined; CDRH1-H3 are shown in bold and curved underlined .
• VL domain is underlined; CDRL1-L3 are shown in bold and curved underlined .
• SPV-T3a-VH SPV-T3a-VH:
• GYTFTSYT (SEQ ID NO: 5)
• ARGSRYDYYGMDY (SEQ ID NO: 7)
• SPV-T3a-CDRL2 SPV-T3a-CDRL2 :
• SPV-T3a-CDRL3 SPV-T3a-CDRL3 :
• WTl is a murine IgG2a monoclonal antibody that selectively binds human CD7 (UniProt: P09564), a transmembrane protein which is a member of the immunoglobulin superfamily and is found on thymocytes and mature T cells.
• CD7 UniProt: P09564
• the production and characterization of WTl is described in Tax et al . , Hamatol Bluttransfus, 1983, Vol. 28, pp. 139-141 and Tax et al., Clin Exp Immunol, 1984, Vol. 55, pp. 427- 436, the contents of both of which are expressly incorporated herein by reference.
• the WTl antibody may be conjugated to ricin toxin A (RTA) , for example deglycosylated ricin toxin A, using the SMPT crosslinker.
• RTA ricin toxin A
• the average number of deglycosylated ricin toxin A molecules conjugated to each WTl antibody is believed to be approximately 1.5.
• This antibody conjugate may be referred to herein as WT1-RTA.
• Conjugation and purification may be carried out by the process depicted in Figure 9 or the process depicted in Figure 10.
• WTl is commercially
• the anti-CD7 antibody (clone WTl) is sold by Lifespan Biosciences, Inc. under catalogue number: LS-C122885- 1000 ( ⁇ in PBS, 0.1% sodium azide) for research use, e.g., immunofluorescence and immunohistochemistry .
• the amino acid sequence of the WTl light chain and heavy chain were determined by extracting mRNA from hybridoma cell pellets, RT-PCR was performed and DNA sequenced on an ABl3130xl Genetic Analyzer. Amino acid sequences were predicted and were corroborated by Mass Spectrometry analysis. The complementarity determining regions (CDRs) are as determined according to the IMGT numbering system (Lefranc, M.-P. et al . , Nucleic Acids Research, 1999, Vol. 27, pp. 209-212, incorporated herein by reference) .
• VH domain is underlined; CDRH1-H3 are shown in bold and curved underlined .
• VL domain is underlined; CDRL1-L3 are shown in bold and curved underlined .
• WT1-CDRL2 GTN (SEQ ID NO: 19)
• GVHD is a medical complication following the receipt of transplanted tissue from a genetically different person.
• GVHD is commonly associated with stem cell transplant (bone marrow transplant) , but the term also applies to other forms of tissue graft. Immune cells in the donated tissue (the graft) recognize the recipient (the host) as foreign (nonself ) . The transplanted immune cells then attack the host's body cells.
• GVHD that occurred within the first 100 days after transplantation was arbitrarily classified as acute, whereas GVHD that was still present, or developed, at a later stage was referred to as chronic GVHD.
• chronic GVHD is not simply a continuation of acute GVHD (Toubai et al . 2008, Flowers et al . 2011) . While there is significant overlap between the organs involved in acute and chronic GVHD, the
• GVHD chronic GVHD distribution of affected organs in chronic GVHD is much broader, including also the eyes, lungs, salivary glands, and esophagus.
• acute GVHD is dominated by apoptosis and necrosis, whereas chronic GVHD represents an inflammatory and fibrotic process similar to as seen in certain autoimmune disorders (Higman et al . 2004, Filipovich et al . 2005) .
• acute GVHD is highly associated with subsequent chronic GVDH, approximately 20-30% of people with acute GVHD do not develop chronic GVHD later.
• providing a clinical benefit as measured by the incidence of grade 3 or above capillary leak syndrome (CLS) means avoiding development of grade 3 or above capillary leak syndrome or vascular leak syndrome (VLS) in a patient administered the
• composition of the present invention for example as assessed between 1 and 100, e.g. between 1 and 10 days following
• CLS/VLS grading may be as defined in Sausville et al . , Blood, 1995, Vol. 85, No. 12, pp. 3457- 3465, the contents of which are expressly incorporated herein by reference. In particular, the NCI Common Toxicity criteria were used.
• Vascular leak was specifically graded as follows: grade I, minimal ankle pitting edema; grade 2, ankle pitting edema and weight gain, but total weight gain of less than 10 lb; grade 3, peripheral edema with a weight gain of greater than 10 lb or pleural effusion with no pulmonary function deficit documented; grade 4, anasarca, pleural effusion or ascites with pulmonary function deficit or pulmonary edema; and grade 5, respiratory failure requiring
• compositions and administration thereof are provided.
• compositions of the invention may be formulated as
• compositions that may be in the forms of solid or liquid compositions.
• Such compositions will generally comprise a carrier of some sort, for example a solid carrier or a liquid carrier such as water, petroleum, animal or vegetable oils, mineral oil or synthetic oil.
• a carrier of some sort for example a solid carrier or a liquid carrier such as water, petroleum, animal or vegetable oils, mineral oil or synthetic oil.
• Physiological saline solution, or glycols such as ethylene glycol, propylene glycol or polyethylene glycol may be included.
• Such compositions and preparations generally contain at least 0.1 wt% of the compound.
• the active ingredient may be in the form of a parenterally acceptable aqueous solution or liquid which is pyrogen-free and has suitable pH, tonicity and stability.
• a parenterally acceptable aqueous solution or liquid which is pyrogen-free and has suitable pH, tonicity and stability.
• solutions using, for example, solutions of the compounds or a derivative thereof, e.g. in physiological saline, a dispersion prepared with glycerol, liquid polyethylene glycol or oils.
• compositions can comprise one or more of a pharmaceutically acceptable excipient, carrier, buffer, stabiliser, tonicising adjusting agent, preservative or anti-oxidant or other materials well known to those skilled in the art. Such materials should be non-toxic and should not interfere with the efficacy of the active ingredient.
• a pharmaceutically acceptable excipient e.g., carrier, buffer, stabiliser, tonicising adjusting agent, preservative or anti-oxidant or other materials well known to those skilled in the art.
• Such materials should be non-toxic and should not interfere with the efficacy of the active ingredient.
• the precise nature of the carrier or other material may depend on the route of administration, e.g., intravenous injection.
• the pharmaceutically compositions are given to an individual in a prophylactically effective amount or a
• therapeutically effective amount (as the case may be, although prophylaxis may be considered therapy) , this being sufficient to show benefit to the individual. Typically, this will be to cause a therapeutically useful activity providing benefit to the individual.
• amount of the compounds administered, and rate and time- course of administration will depend on the nature and severity of the condition being treated. Prescription of treatment, e.g.
• compositions are preferably administered to patients in dosages of between about 0.01 and 100 mg of active compound per kg of body weight, and more preferably between about 0.5 and lOmg/kg of body weight .
• compositions of the present invention may be administered, or for administration, at a dose of approximately 4 mg/m 2 Body Surface Area (BSA) .
• BSA Body Surface Area
• the pharmaceutical compositions of the present invention may advantageously be
• Example 1 Prolonged survival of Graft vs. Host Disease patients following treatment with T-Guard(RTM) immunotoxin cocktail.
• T- Guard(RTM) T- Guard(RTM)
• BSA Body Surface Area
• Leucotac, anti-CD25) and etanercept (trade name Enbrel, anti-TNF) , 2 patients developed a probable invasive mould disease, 2 patients developed a CMV infection (one progressing to CMV colitis), 2 patients developed an adenovirus infection, and 3 patients developed an EBV infection.
• day 28 response rate and 6- month survival were both superior in the T-Guard (RTM) -treated group compared with control .
• Figure 2 shows a survival curve for patients treated with Institutional SoC. A marked early mortality phase ( ⁇ 6 months) is evident. This early mortality period is associated with both refractory GvHD and with viral infection or reactivation (see also van Groningen et al . , Biol.
• Figure 3 shows survival curves for T-Guard (RTM) - treated patients versus Institutional SoC, up to the 6-month time point. It is clear that cumulative survival is higher among the T- Guard (RTM) -treated patients.
• Example 2 Spontaneous resolution of viral reactivation among Graft vs. Host Disease patients treated with T-Guard(RTM) immunotoxin cocktail .
• CMV titre was measured by real-time quantitative PCR, essentially as described in Kalpoe et al., J. Clin. Microbiol., 2004, Vol. 42, No. 4, pp. 1498-1504, the entire contents of which are expressly incorporated herein by reference.
• EBV titre was measured by real-time quantitative PCR, essentially as described in Niesters et al., J. Clin. Microbiol., 2000, Vol. 38, pp. 712-715, the entire contents of which are expressly incorporated herein by reference.
• Tetramer analysis of the Day 21-blood sample of the second patient showed that his CD8 positive cells included 17% that were CMV- directed T-cells (see Figure 6) .
• the present inventors believe that the anti-CMV T-cells, relatively spared by T-Guard (RTM) treatment, are able to keep the patient's CMV titre low. It is further contemplated that staining with HLA-matching EBV tetramers will be performed. The resolution of EBV reactivation in the second week after treatment start clearly suggests that there must be EBV-directed T-cells present as well (see Figure 5) .
• the present example demonstrates patients recovering from steroid- resistant acute GvHD and successfully fighting (pre-existing) infections within 2-3 weeks after receiving T-Guard (RTM) treatment.
• T-Guard RTM
• both these patients are ⁇ stable' GvHD responders
• T-Guard RTM
• RTM lymphopenia-induced homeostatic proliferation after T-Guard (RTM) has been washed away (within 1-2 days after last infusion) . Further support for this conclusion comes from the expanded T cell repertoire shown in Figure 11.
• Example 3 a phase I/II study on the anti-CD3/CD7 immunotoxin combination (T-Guard (RTM) ) for the treatment of steroid-refractory acute GVHD
• SR-aGVHD steroid-refractory acute graft-versus- host disease
• T-Guard is therefore a composition in accordance with the various aspects of the present invention.
• T-Guard was given as 4- hour intravenous infusions every 48 hours for a total of 4 doses of each 4 mg/m2.
• the primary efficacy endpoint was defined as overall clinical response (ORR) on day 28.
• the main secondary endpoints were the 6-month OS and the safety and tolerability .
• Baseline albumin levels were median 23 gr/L (range : 16-34 ; N 35-50 gr/L) and based on the 2-biomarker model
• CR Complete Responder
• PR Partial Responder
• A Alive
• D Death .
• T-Guard a composition in accordance with the various aspects of the present invention, was able to preventatively treat cGVHD as assessed by incidence of cGVHD at 180 days after second-line treatment (i.e. T- Guard(RTM) administration) for SR-aGVHD.
• CLS capillary leak syndrome
• Vitetta described for comparable immunotoxins that serum concentrations at or above 1 g/ml (-0.5 x 10-8 M) were typically associated with the occurrence of serious RTA-associated side effects, predominantly consisting of CLS (Amlot et al. 1993, Sausville et al . 1995, Stone et al . 1996) . Moreover, based upon a retrospective analysis of patients in five clinical trials, Schindler et al . concluded that the toxicity of RTA-based immunotoxins is exacerbated by prior radiotherapy (Schindler et al . 2001) . Stone et al., 2001 and Sausville et al. 1995 reported that immunotoxin Cmax is positively correlated with CLS/VLS severity (see, e.g., Fig. 2 of Sausville et al . , 1995) .
• T-Guard (RTM) treatment did not induce any severe CLS or myalgia in any of the patients treated so far. Not in the Phase 1/2 trial, nor in the investigator-initiated dose escalation study, while all respective patients had received prior chemo- and radiotherapy, and Cmax values at or above 1 g/ml were obtained in all patients. Although eight of the patients in the Phase 2 study were diagnosed to have some limited symptoms
• T-Guard (RTM) ' s favorable safety profile might be the partitioning of the RTA toxin over SPV-T3a and WT1 (half a dose each) , which mAbs might have different systemic distribution profiles (and, thereby, causing a dilution of nonspecific toxicities) due to differences in isoelectric point.
• RTM T-Guard
• CLS vascular leak syndrome
• T-Guard (RTM) Phase 1/2 study had median serum albumin levels of 23 g/L (range 16-34 g/L) at treatment start (i.e. 2.3 g/dL (range 1.6-3.4 g/dL)) .
• T-Guard (RTM) despite being and immunotoxin-based therapy, appears to be suitable for use in a patient subgroup having serum albumin levels below that considered safe for another immunotoxin-based therapy (Ontak(RTM)) .
• Ontak(RTM) immunotak
• T-guard(RTM) is being developed for the treatment of GVHD.
• T- Guard(RTM) is a combination product which consists of two antibodies (SPV-T3a and WT1) .
• the monoclonal antibody SPV-T3a is targeted against CD-3 whereas WT-1 targets CD-7 protein. Both are
• RTA Ricin Toxin A chain
• ADCs Conjugates
• concentrates SPV-T3a-RTA and WT1-RTA to be mixed just before administration.
• 4 mL of each formulation (1/1 ratio) may be diluted together in 1 vial up to 100 mL with diluent.
• Both antibodies show physical stability problems in the formulation buffer (13 mM sodium phosphate buffer pH 7.5, 140 mM NaCl and 0.05 % (v/v) Tween-20) .
• This formulation buffer 13 mM sodium phosphate buffer pH 7.5, 140 mM NaCl and 0.05 % (v/v) Tween-20
• SPV-T3a-RTA is stable for 2.5 years at 2-8°C in that formulation buffer, but shows aggregate formation upon freeze/thaw stress.
• WT1-RTA is not stable at 5-8°C in that formulation buffer and is kept stable at -20°C for 2.5 years. After 3 years of storage the product does not meet the specifications concerning biological activity and particle formation, as detected with DLS .
• the present inventors wished to ob ain a formulation which would increase the physical stability of both monoclonal antibodies (MAbs) for a longer shelf life.
• a common application of spectrophotometry is the measurement of light absorption in the UV region of the spectrum, in order to quantify the protein concentration in a sample.
• the absorption of a protein solution depends on the content of the amino acid sequence and the protein concentration.
• ⁇ mass extinction coefficient of a protein
• concentration in a solution can be calculated from its absorbance (A), according to Lambert-Beer's law:
• the spectrophotometer should always be blanked with the formulation buffer.
• the formulation buffer should also be used for the dilution of the sample (s) . Measurements are performed on a UV- 1800 Spectrophotometer (Shimadzu) using disposable cuvettes.
• SDS-PAGE separates proteins in a polyacrylamide matrix according to their electrophoretic mobility. Binding of SDS masks the intrinsic charge of proteins and results in an even distribution of charge to mass units. During gel electrophoresis, SDS-treated proteins will therefore migrate as a function of their approximate size. In addition, existing non covalent aggregates will dissociate in the presence of SDS.
• samples can either be run under non- reducing or reducing conditions.
• Addition of a reducing agent e.g dithiothreitol (DTT)
• DTT dithiothreitol
• SE-UPLC allows determination of the molecular size distribution and the relative amounts of intact, monomeric antibody and potential (protein-related) impurities and variants.
• the primary goal of SE-UPLC is to detect irreversible soluble protein oligomerization and aggregation as well as smaller protein fragments generated by protein hydrolysis.
• a column and mobile phase are selected which give minimal interaction of the protein with the solid phase to prevent "sticking" of the protein or its multimeric forms to the column while at the same time giving a good recovery.
• the components should be separated solely by their MW.
• Proteins are detected by UV absorbance at 280 nm and the relative amount of a specific protein impurity (expressed as relative surface area (%) is calculated by dividing the surface area of its peak by the total surface area.
• Experiments are performed on an UPLC H-Class bio instrument (Waters) with a detection at 220 nm or 280 nm.
• the system is equipped with a bio-inert flow path a stainless steel, specifically for
• the particles or droplets scatter some of the light in all directions.
• the intensity of the scattered light is uniform in all directions (Rayleigh scattering) ; for larger particles (above approximately 250 nm diameter) , the intensity is angle dependent (Mie scattering) .
• DLS measurements were performed on a Zetasizer NanoZS (Malvern) in disposable low volume UVCuvettes ( PlastiBrand) . Typical measurements were performed in 70 at 25 °C where the sample was equilibrated to the temperature during 3 minutes prior to the actual measurement. Measurement duration and laser intensity was chosen automatically by the instrument based on the scattering signal of the sample. All measurements were analysed using the Zetasiser Software (version 7.02) .
• a PEG-6000 based screen was used to perform a primary formulation screen. Since it is known that the ADC's are susceptible to
• solubility is one of the major stability parameters.
• the buffer type and pH will influence the solubility and therefore 12 different buffers were prepared to screen for an optimal solubility of the MAb's.
• 50 mM solutions were prepared from each buffer as well as buffer solutions containing 40% (w/v) PEG-6000.
• the latter was made by weighing 12 g PEG-6000 and adding concentrated buffer solutions and MQ water up to 30 mL in order to obtain a 50 mM solution with 40% (w/v) PEG-6000.
• the stock solution was diluted further with buffer or protein to a final concentration of 4-20% (w/v) PEG-6000.
• the original material was concentrated using a concentrator (Amicon ultra 15, 10 kDa MWCO) to approximately concentration of 0.40 mg/mL. Concentrations are determined using UV absorbance measurements. The material was diluted 2-fold in the plate in a total volume of 100 and after 1 day incubation at 5°C the plate was measured. The readout was performed on a Envision (Perkin Elmer) with an OD filter of 405 nm.
• Table 2 overview of the different results for WTl-RTA from the freeze/thaw analysis and short term storage study.
• the different buffers (phosphate and citrate) as well as the excipients are given and results are evaluated as good (++) , intermediate (+) or not preferred (-) .
• the SE-UPLC results are given as HMW and agg (area under the curve) .
• F/T freeze/thaw
• Stab stability
• HMW high molecular weight variants
• Agg aggregates.
• Table 3 overview of the different results for SPV-T3a-RTA from the freeze/thaw analysis and short term storage study.
• the different buffers (phosphate and citrate) as well as the excipients are given and results are evaluated as good (++) , intermediate (+) or not preferred (-) .
• the SE-UPLC results are given as HMW and agg (area under the curve) .
• F/T freeze/thaw
• Sttab stability
• HMW high molecular weight variants
• Agg aggregates.
• the formulation that was selected on the basis of the above results for WT1-RTA and SPV-T3a-RTA was: 10 mM citrate (pH 6.5), 155 mM L-Arginine . HC1 and 0.05% (w/v) Tween-20.
• the recipe for this formulation is as follows:
• the present inventors sought to improve the stability of the T- Guard(RTM) formulation still further.
• T- Guard(RTM) formulation 10 mM citrate (pH 6.5), 155mM L-Arginine . HC1 and 0.05 (w/v) Tween-20
• both SPV-T3a-RTA and WT1-RTA were found to be stable at -60°C, -20°C and 5°C for up to 9 months.
• stability at 25 °C was found to be sub-optimal owing to the formation of aggregates.
• the aim of presently-described study was to develop a more stable formulation based on accelerated stability studies. Heat stress study
• antioxidants amino acids and sugars.
• the target for osmolality of the formulation buffers was between 300 and 450 mOsm/kg.
• excipients formulation buffers with higher concentrations of the excipients and formulation buffers with other sugars.
• trehalose 50 mM glycine 2. 10 mM citrate; 125 mM L-arginine; 0.05% Tween 20; 125 iriM maltose; 50 mM glycine
• Table 10 WTl-RTA protein distribution after 2 days at 40°C in the previous and new formulation buffer
• Table 11 SPV-T3a-RTA protein distribution after 2 days at 40°C in the previous and new formulation buffer
• the inventors aimed to reduce precipitation and resulting product loss. Yield of the Blue Sepharose column step (removal of
• the inventors also aimed to refine loading and elution conditions for Blue Sepharose affinity chromatography to achieve robust, complete separation of mAb and mAb-RTA conjugate.
• the inventors sought to employ the favorable formulation buffer further upstream, up to and including the conjugation step, to prevent precipitation in this earlier phase too.
• Figure 9 shows process A, in which the conjugation and
• FIG. 10 shows process B, which differs from process A in that the change to the 10 mM citrate buffer occurs further upstream at the point shown by the upper horizontal line. Steps below that upper horizontal line are performed in the 10 mM citrate buffer at pH 6.5.
• the antibody conjugation reaction is robust and is compatible with the formulation buffer (lOmM citrate, 125mM L-Arg.HCl, 0.05% (w/v) Tween-20, 140mM Maltose (pH 6.5)) .
• Blue Sepharose binding can be subtly altered by changing L- Arginine concentration. Elution can be achieved by increasing the L-arginine concentration.
• Process B is amenable to optimization to balance yield
• drug-antibody variants could be selectively enriched .
• Example 7 Phase I/II trial of a combination of anti-CD3/CD7 immunotoxins for steroid-refractory acute graft-versus-host disease
• Acute graft-versus-host disease is a major complication that can occur following allogenic hematopoietic stem cell
• HSCT hematoma-derived liver transplantation
• SR-aGvHD severe steroid-refractory aGvHD
• GI gastrointestinal
• liver involvement GI
• SR-aGvHD severe steroid-refractory aGvHD
• GI gastrointestinal
• 1 - 2 At present, no standard second-line therapy is approved for SR-aGvHD, and none of the available treatment options seems to provide convincingly superior results with on average only 30% complete responders.
• 1 ' 3 - 4 Six-month survival approximates 50%, but long-term survival is achieved in 1 out of 5 patients. 2
• a graft-versus-host immune reaction The underlying core of a graft-versus-host immune reaction is the proliferation and differentiation of alloreactive donor T-cells in response to the host's antigen-presenting cells, which induce tissue damage and the propagation of inflammation during the effector phase. 5-7 Therefore, many of the currently used therapies consist of antibodies that cause the depletion of T-cells or either biologicals or small molecule inhibitors designed to suppress T-cell
• combination product consists of a 1:1 mixture of two murine
• CD3/CD7-IT ricin toxin A chain 15
• T- GuardTM ricin toxin A chain 15
• CD3/CD7-IT ricin toxin A chain 15
• 16 - 17 Preclinical studies showed that CD3/CD7-IT induces apoptosis of both T-cells— particularly activated T- and NK-cells by inhibiting protein synthesis, and reduces T-cell activation by blocking and modulation of the TCR/CD3 complex ( Figure 12) .
• 17 In a dose-escalation study, 5 out of seven patients with SR-aGvHD, responded to CD3/CD7-IT as third-line therapy. 17 The promising outcome of that study led to the phase I/II study of CD3/CD7-IT for treatment of SR-aGVHD reported here .
• phase I/II The 4 mg/m 2 T-Guard starting dose of the phase I/II study was selected on basis of the outcome of the dose escalation study. 17 A Bryant-Day 2-stage design was applied 18 , with a pre-scheduled interim analysis after 8 patients, to protect patients from unnecessary exposure to an ineffective or toxic treatment. If after the first 8 patients 2 or fewer ( ⁇ 25%) day 28 responders and/or 4 or more ( ⁇ 50%) dose limiting toxicities (adverse drug reactions of grade 3 or higher) would be observed (phase I), the trial would have been terminated for futility and/or toxicity. Otherwise, the trial should be extended to a total of 20 patients (phase II) (sample size estimation: S2) .
• aGvHD grade was defined according to the criteria established by Harris et al . 20 Diagnosis ⁇ aGvHD was confirmed with a tissue biopsy. SR-aGvHD was defined as aGvHD that progressed after 3 days or did not improve after 7 days on systemic corticosteroids ( ⁇ 2mg/kg/day prednisolone or
• CD3/CD7-IT The treatment schedule of CD3/CD7-IT (S3) consisted of four 4-hour intravenous (i.v.) infusions of 4mg/m 2 administered at 48-hour intervals.
• GvHD prophylaxis which consisted primarily of cyclosporine-A either alone or in combination with mycophenolate mofetil, was continued during therapy with CD3/CD7-IT.
• the primary endpoints were the overall response rate (ORR, defined as the sum of PR and CR rates) on day 28 and the occurrence of possible drug-related AEs up to 6 months following treatment with CD3/CD7-IT.
• the secondary endpoints were the day 28 CR rate, 6-month overall survival (OS) , and the incidence of cGvHD.
• CR was defined as the resolution of all signs and symptoms associated with aGvHD.
• PR was defined as an improvement in GvHD stage in all initial GvHD target organs, without complete resolution or emergence of GvHD in any new organ.
• No response (NR) was defined as either no change, a mixed response, progressive disease, or the need for salvage therapy before day 28. 22
• the 2014 NIH diagnostic criteria were used to assess and score cGvHD. 23
• CCS cytokine release syndrome
• Invasive fungal disease (IFD) EBV- and CMV infection were defined in accordance with established guidelines . 25-27
• CD3/CD7-IT consists of the murine monoclonal antibodies SPV-T3a (anti-CD3) and WT1 (anti-CD7), each of which is conjugated to recombinant RTA. CD3/CD7-IT was manufactured using Good
• the immunotoxins were formulated at a concentration of 0.2mg/ml in an isotonic buffered solution, pH6.5, and stored frozen (at -20°C or below) .
• Peripheral blood samples were collected before and after treatment to analyze predictive GvHD biomarkers, cytokine levels, immune reconstitution, pharmacokinetics, and the development of human antidrug antibodies (ADAs) .
• ADAs human antidrug antibodies
• Serum cytokine levels were measured at Myriad RBM (Austin, TX) using quantitative, multiplexed immunoassays.
• Lymphocytes were analyzed by immunophenotyping using flow cytometry. Lymphocytes were gated on CD45+ and side scatter low cells and enumeration of helper T-cells (CD5+ and CD4+) , cytotoxic T-cells (CD5+ and CD8+) , NK cells (CD56+ and CD5-), and B cells (CD19+) was recorded for each phenotype per microliter of blood. CD5 was used instead of CD3 to identify and quantify T-cells because of potential CD3 modulation by the CD3/CD7-IT treatment. For TCR sequencing, DNA was isolated from whole blood collected in PAXgene tubes. The ⁇ , ⁇ CDR3 region was then amplified and sequenced using ImmunoSEQ
• V and J gene primers were used to amplify the rearranged V(D)J segments for high- throughput sequencing (HTS) analysis at approximately 20x coverage.
• CDR3 segments were annotated using the International ImMunoGeneTics information system, thereby identifying which V, D, and J genes contributed to each rearrangement.
• the absolute numbers of EBV- associated and CMV-associated T-cells were determined by comparing the patients' ⁇ , ⁇ data with ⁇ , ⁇ sequences reported to be specific for EBV and CMV antigens. 32
• the median follow-up period after therapy with CD3/CD7-IT was 292 days (range: 3-889 days) .
• Two patients died due to progressive SR- aGvHD before completing the treatment schedule.
• the remaining 18 patients (90%) received all four scheduled doses at 48-hour
• ORR was 60% (12/20 patients) with a 95% CI of 36-81%; 10 patients (50%; 95% CI:27-73%) achieved a CR ( Figure 13) .
• corticosteroids could be tapered according to protocol.
• ORR was 55% (6/11) in patients with a high-risk biomarker profile.
• 12 patients had survived after response on the CD3/CD7-IT combination,
• the Data and Safety Monitoring Board reviewed the pre-planned interim analysis of the first 8 patients, on basis of which they concluded that no major safety concerns had arisen and that the observed risk-benefit balance warranted continuation of the study.
• CD3/CD7-IT was well tolerated and was found to be safe, with no SUSARs (suspected unexpected serious adverse reactions) or SAEs (serious AEs) related to the study-drug reported.
• SAEs serious AEs
• MCP-1 and MIP- ⁇ activation/recruitment
• hypoalbuminemia was present in all 20 patients at baseline (grade 2 or 3 in 80% of patients) and may have worsened in 8 patients due to treatment with CD3/CD7-IT. These 8 patients developed mild peripheral edema, which in all but one case could easily be managed with diuretics.
• the time course is at least suggestive of a possible relationship with CD3/CD7-IT in nine patients.
• ADAs were detected against SPV-T3a- RTA and/or WT1-RTA in 10 out of 20 patients (50%) ; in four of these 10 patients, the titers were ⁇ 20,000 at any given point.
• ADAs typically form after 9-10 days
• CD3/CD7-IT is currently developed as a one-week treatment option only, and its serum half-life is only 9 hours.
• HTS was performed on the CDR3 region of the TCR- ⁇ genes in PBMCs before and—when possible—1, 3, and 6 months after treatment with CD3/CD7-IT. HTS can determine the total T-cell count, the diversity of the T-cell repertoire, and the sequences of the TCR CDR3 regions in all T-cells in a given sample.
• the T-cell diversity in a sample is characterized by the number of unique T-cell clones present in the sample, which is reflected by the number of unique CDR3
• CD3/CD7-IT affects anti-virus T-cell clones.
• FIG. 15A&C show the four patients who experienced an EBV and/or CMV infection after treatment with CD3/CD7-IT (two patients had EBV or CMV infection only and two patients had both EBV&CMV infections) . All these patients
• the sample size was relatively small and we did not include a randomized comparator arm.
• the study population was heterogeneous with respect to age, conditioning regimen, donor type, and GvHD prophylaxis regimens used. Nonetheless, the study population is representative of patients with SR-aGVHD treated at our institutions and consisted primarily of patients with underlying high-risk features .
• CD3/CD7-IT appeared safe. Despite the presence of the anti-CD3 mAb SPV-T3a, CD3/CD7-IT induced a mild infusion reaction in two patients both of whom had not received pre-infusion clemastine. In addition, we observed no toxicity related to CRS or rhabdomyolysis as can be seen with other RTA-based immunotoxins . 37 - 38 Investigators did consider hypoalbuminemia, microangiopathy, and thrombocytopenia as possibly related to CD3/CD7-IT. However, these events primarily consisted of worsening of pre-existing conditions. Investigators deemed these events more likely related to the underlying SR-GVHD and/or the concomitant use of a calcineurin inhibitor. Nevertheless given the potential toxic effects of immunotoxins , it remains possible that CD3/CD7-IT may have contributed to these events and attention will need to be paid to this possibility in future studies .
• lymphoproliferative disorder or CMV disease occurred in our patients. This may be explained by the fact that virus-specific T- cells were relatively spared by the treatment and by the fact that immune reconstitution occurred within 6 months after starting treatment.
• the T-cell and NK-cell counts began to rise, particularly in patients who achieved remission of their SR-aGvHD; at 3 months, these cell counts were similar to those normally seen following HSCT . 42 This increase in cell numbers was also accompanied by a simultaneous and significant increase in the diversity of T-cell clones.
• therapy with CD3/CD7-IT allows the patient's immune system to recover after remission is achieved, and the immune reconstitution after therapy seems favorable compared to other treatment modalities that rely on ⁇ - ⁇ T-cell depletion (for example anti-thymocyte globulins and alemtuzumab) .
• ⁇ - ⁇ T-cell depletion for example anti-thymocyte globulins and alemtuzumab
• CD3/CD7-IT may offer advantages compared to these prior therapies.
• the combination targets multiple antigens on the same target cell, a strategy that tends to be more efficacious than using single immunotoxins .
• CD3/CD7-IT has a clear preference for recently activated T-cells as well as the NK-cells that may play a role in the efferent phase of aGvHD.
• CD3/CD7-IT has a dual mechanism of action in that the anti-CD3 mAb SPV-T3a provides added immunosuppression by binding to the CD3/TCR complex via a mechanism independent of RTA- induced cell killing ( Figure 12) 17 .
• phase III study is currently being designed in order to examine the potential value of including CD3/CD7-IT in the treatment of SR-aGvHD.
• Table 1 Patients characteristics and HSCT and GvHD features .
• NMA conditioning consisted of Flu-TBI; RIC regimen were Flu-Bus and Flu-Mel based; MAC regimen were Cyclo-TBI, Flu-Mel-TBI or FLAMSA based. b Relative to the initial corticosteroid treatment.
• aGvHD acute graft-versus-host disease
• BM bone marrow
• CyA cyclosporin A
• DLI donor lymphocyte infusion
• Haploid haploidentical related donor
• MAC myeloablative conditioning
• MMF mycophenolate mofetil
• MMUD mismatched unrelated donor
• MRD matched related donor
• MTX methotrexate
• MUD matched unrelated donor
• NA not applicable
• NMA non-myeloablative conditioning
• PhAT Pharmacological Audit Trail
• PBSCs peripheral blood stem cells
• RIC reduced intensity conditioning.
• Table 2 Summary of adverse events potentially related to treatment.
• Microangiopathy (1) Microangiopathy
• van Groningen LF van Groningen LF
• Liefferink AM de Haan AF
• de Haan AF et al .
• hematopoietic stem cell transplantation Sixth European Conference on Infections in Leukemia (ECIL-6) guidelines. Haematologica .

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