WO2019143761A1 - Compositions and methods for treatment of hunter's syndrome - Google Patents

Abstract

Disclosed are methods and compositions for the treatment of an individual having Hunter's Syndrome. The disclosed methods and compositions include administering an inhibitor of the C5a pathway to an individual in need thereof, in an amount sufficient to delay onset of and/or alleviate one or more symptoms of Hunter's Syndrome in the individual. Inhibitors of the C5a pathway may include C5a Receptor (C5aR) inhibitors, antagonists of C5aRl, C5aR2, or combinations thereof, and C5aRl and C5aR2 inhibitors that are muteins of C5a.

Description

COMPOSITIONS AND METHODS FOR TREATMENT

OF HUNTER’S SYNDROME

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority to and benefit of U.S. Provisional Application Serial No. 62/618,185, to Manoj Pandey, filed on January 17, 2018. The contents of which are incorporated in their entirety for all purposes.

BACKGROUND

[0002] Hunter Syndrome is a lysosomal storage disease (LSD) that affects approximately 1 in 100,000 newborn boys. Hunter Syndrome is caused by mutation in iduronate-2-sulfatase (IDS), resulting in a deficiency of iduronate-2-sulfatase. The defect in IDS, in turn, causes excess storage of glycosaminoglycans (GAGs) such as heparan sulfate (HS) and dermatan sulfate (DS), in almost every cell of the body. Affected individuals exhibit abnormal appearance, mental development, organ function, and physical skills. The mechanism by which GAGs propagate disease in Hunter syndrome is unknown.

[0003] The current therapy for Hunter Syndrome is Elaprase® enzyme replacement therapy. Not only is this treatment currently one of the world’s most expensive treatments, costing $300,000-$400,000 a year, but the treatment is not effective, with death typically occurring in the first or second decade of life despite treatment. Thus, improved methods of treating individuals having Hunter Syndrome are needed in the art. The instant disclosure seeks to address one or more of the aforementioned needs in the art.

BRIEF SUMMARY

[0004] Disclosed are methods and compositions for the treatment of an individual having Hunter’s Syndrome. The disclosed methods and compositions include administering an inhibitor of the C5a pathway to an individual in need thereof, in an amount sufficient to delay onset of and/or alleviate one or more symptoms of Hunter’s Syndrome in the individual. Inhibitors of the C5a pathway may include C5a Receptor (C5aR) inhibitors, antagonists of C5aRl, C5aR2, or combinations thereof, and C5aRl and C5aR2 inhibitors that are muteins of C5a. BRIEF DESCRIPTION OF THE DRAWINGS

[0005] This application file contains at least one drawing executed in color. Copies of this patent or patent application publication with color drawing(s) will be provided by the Office upon request and payment of the necessary fee.

[0006] Those of skill in the art will understand that the drawings, described below, are for illustrative purposes only. The drawings are not intended to limit the scope of the present teachings in any way.

[0007] FIG. 1A-1F. WT mice were injected i.p. with 100 pl of Vehicle (PBS) or dermatan sulfate (DS), i.e., 1, 2, 4, and 8 mg /ml/ day for four weeks (n = 5/group) (1A). Blood was collected and serum level of C5a determined using ELISA (1B) and circulatory level of monocytes were estimated by automated system, i.e., Hemavet 850, Drew Scientific, Oxford, CT (1C). Furthermore, circulatory leukocytes were isolated from indicated vehicle and DS-treated mice strains and characterized for monocytes by performing FACS staining with antibodies to CD115 and CDl lb (1D) and their specific isotypes, i.e., Rat IgG2a and Rat IgG2b (1E). Expression of C5aRl on circulatory CDll5+CDllb+ monocytes from vehicle and DS treated WT mice were detected with uses of C5aRl specific CD88 and their corresponding isotype Rat IgG2b antibodies (1F). In the 1B and 1C, the black column correspond to vehicle (PBS; 0 mg/ml) treated and hatched columns correspond to DS (1, 2, 4, and 8 mg/ml) treated mice. In the histograms, the black and yellow lines correspond to vehicle (PBS)/DS treated cells and their staining with Rat IgG2a isotype antibodies, whereas brown/blue lines correspond to PBS (0 mg/ml) DS (1, 2, 4, and 8 mg/ml) treated cells and their staining with antibodies to mouse C5aRl (CD88).

[0008] FIG. 2. Single cell suspension prepared from spleen of Vehicle (IOOmI; PBS) and DS (IOOmI of 1, 2,4, and 8 mg/ml) treated WT and C5aRT^/_ mice (n = 5/ group) were used to prepare cytospin slide with Diff-Quik staining (Dade Behring, In; Newark, DE). DS treated C5aRl sufficient mouse cells showing classical storage cells (X 20).

[0009] FIG 3A-3E. Single cell suspensions prepared from spleen of Vehicle and DS treated WT and C5aRT^/_ mice (n = 5/group) were used for measurement of inflammatory subsets of monocytes and macrophages. For monocytes/macrophages, cells were gated first on CDl lb and Ly6C (3 A) and their corresponding isotypes, i.e., Rat IgG2a k and Rat IgG2bk (3B) CDl lb and Ly6C gated cells on FSC/SSC compartment were stained for Ly6G, F4/80, and CDl lc markers for detection of CDllb+ Ly6C+ Ly6G+ monocytes (3C) CDl lb-l·- Ly6C+ F4/80+ (3D) and CDl lb+ Ly6C+ CDl lc macrophages (3E). In the histograms, the black line correspond to vehicle (PBS), yellow to 1 mg/ml, blue to 2 mg/ml, purple to 4 mg/ml, and green to 8mg/ml DS- treated WT and C5aRL^/_ mice (n = 5/group). Data are representative of three independent experiments.

[0010] FIG 4A-4D. Single cell suspensions prepared from spleen of Vehicle and DS treated WT and C5aRL^/_ mice (n=5/group) were used for measurement of effector T cells.

For T cells, lymphocyte gated cells (4A) were stained with antibodies to CD3 and CD45R (4B) and their corresponding isotypes (Hamster IgG2ak and Rat IgG2ak (4C). CD3 positive and CD45R negative cells on lymphocyte compartment were stained for CD69 marker for detection of CD3+ CD69+ effector T cells (4D). In the histograms, the black line correspond to vehicle (PBS), yellow to 1 mg/ml, blue to 2 mg/ml, purple to 4 mg/ml, and green to 8mg/ml DS- treated WT and C5aRL^/_ mice (n=5/group). Data are the representative of three independent experiments.

[0011] FIG 5A-5C. Macrophages and CD4+T cells were purified from vehicle (PBS) treated WT and C5aRL^/_ mice as well as DS treated WT and C5aRL^/_ mice strains (n = 5/group). These cells were co-cultured for 24 hrs and macrophages were assessed for CD40, CD80 and CD86 expression (5A) and CD4+ T cells were assessed for CD69 (5B) by FACS. Cytokine production of co-cultured macrophages and CD4+T cells were measured by ELISA (5C). In the bar diagram and histograms, the blue and brown columns/lines correspond to DS- treated WT and C5aRL^/_ cells respectively. The black and the yellow columns/lines correspond to vehicle-treated WT and C5aRL^/_ cells, respectively. Data are representative of three independent experiments (mean ± SD), and group comparisons were done by ANOVA (**, p<0.0l; ***, p<0.00l; ****, p<0.000l).

[0012] FIG 6A-6F. Sera and mononuclear cells were separated from peripheral blood of human patients with Hunter syndrome (n = 5) and control healthy humans (n = 10). Serum level of C5a was determined using ELISA (6A, Hunter Syndrome Patients: right hand bar; Healthy Humans: left hand bar) and circulatory level of monocytes were estimated by uses of

FACS staining with antibodies to CD14 and CDl lb (6B) and their specific isotypes, /._<?., Mouse IgG2bk and mouse IgGlk (6C). Expression of C5aRs on circulatory CDl4+CDllb+ monocytes from Hunter syndrome and control healthy humans were detected with uses of C5aRl and C5aR2 specific antibodies (6D). In an additional experiment, CDl4+CDl lb+ monocytes from Hunter syndrome patients and control healthy Humans were assessed for CD40, CD80 and CD86 expression by FACS (6E). Sera prepared from Hunter syndrome and control healthy Humans were used to measure pro-inflammatory cytokines by ELISA (6F, Hunter Syndrome Patients: right hand bar; Healthy Humans: left hand bar). In the bar diagram and histograms, the blue column/ line correspond Hunter syndrome patients and the green column/lines correspond to healthy humans, respectively. Value shown are mean ± SD and group comparisons were done by student t test ***, p<0.00l; ****, p<0.000l).

DETAILED DESCRIPTION

[0013] DEFINITIONS

[0014] Unless otherwise noted, terms are to be understood according to conventional usage by those of ordinary skill in the relevant art. In case of conflict, the present document, including definitions, will control. Preferred methods and materials are described below, although methods and materials similar or equivalent to those described herein may be used in practice or testing of the present invention. All publications, patent applications, patents and other references mentioned herein are incorporated by reference in their entirety. The materials, methods, and examples disclosed herein are illustrative only and not intended to be limiting.

[0015] As used herein and in the appended claims, the singular forms“a,”“and,” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to“a method” includes a plurality of such methods and reference to“a dose” includes reference to one or more doses and equivalents thereof known to those skilled in the art, and so forth.

[0016] The term“about” or“approximately” means within an acceptable error range for the particular value as determined by one of ordinary skill in the art, which will depend in part on how the value is measured or determined, e.g., the limitations of the measurement

system. For example,“about” may mean within 1 or more than 1 standard deviation, per the practice in the art. Alternatively,“about” may mean a range of up to 20%, or up to 10%, or up to 5%, or up to 1% of a given value. Alternatively, particularly with respect to biological systems or processes, the term may mean within an order of magnitude, preferably within 5- fold, and more preferably within 2-fold, of a value. Where particular values are described in the application and claims, unless otherwise stated the term“about” meaning within an acceptable error range for the particular value should be assumed.

[0017] As used herein, the terms“effective amount” or“amount sufficient to” means the amount of one or more active components that is sufficient to show a desired effect. This includes both therapeutic and prophylactic effects. When applied to an individual active ingredient, administered alone, the term refers to that ingredient alone. When applied to a combination, the term refers to combined amounts of the active ingredients that result in the therapeutic effect, whether administered in combination, serially or simultaneously.

[0018] The terms“individual,”“host,”“subject,” and“patient” are used

interchangeably to refer to an animal that is the object of treatment, observation and/or experiment. Generally, the term refers to a human patient, but the methods and compositions may be equally applicable to non-human subjects such as other mammals. In some embodiments, the terms refer to humans. In further embodiments, the terms may refer to children, such as, for example, an individual under the age of 18 years of age, or a pre- pubescent individual.

[0019] As used herein, an“aptamer” refers to a non-naturally occurring nucleic acid that has a desirable action on a target molecule. A desirable action includes, but is not limited to, binding of the target, catalytically changing the target, reacting with the target in a way that modifies or alters the target or the functional activity of the target, covalently attaching to the target (as in a suicide inhibitor), or facilitating the reaction between the target and another molecule. An aptamer can include any suitable number of nucleotides. Aptamers may be DNA or RNA and may be single stranded, double stranded, or contain double stranded or triple stranded regions.

[0020] To the extent the active agent may form salts, such are also within the scope of the preferred embodiments. Reference to a compound of the active agent herein is understood to include reference to salts thereof, unless otherwise indicated. The term“salt(s)”, as employed herein, denotes acidic and/or basic salts formed with inorganic and/or organic acids and bases. In addition, when an active agent contains both a basic moiety, such as, but not limited to an amine or a pyridine or imidazole ring, and an acidic moiety, such as, but not limited to a carboxylic acid, zwitterions (“inner salts”) may be formed and are included within the term“salt(s)” as used herein. Pharmaceutically acceptable (e.g., non-toxic, physiologically acceptable) salts are preferred, although other salts are also useful, e.g., in isolation or purification steps, which may be employed during preparation. Salts of the compounds of the active agent may be formed, for example, by reacting a compound of the active agent with an amount of acid or base, such as an equivalent amount, in a medium such as one in which the salt precipitates or in an aqueous medium followed by lyophilization. When the compounds are in the forms of salts, they may comprise pharmaceutically acceptable salts. Such salts may include pharmaceutically acceptable acid addition salts, pharmaceutically acceptable base addition salts, pharmaceutically acceptable metal salts, ammonium and alkylated ammonium salts. Acid addition salts include salts of inorganic acids as well as organic acids. Representative examples of suitable inorganic acids include hydrochloric, hydrobromic, hydroiodic, phosphoric, sulfuric, nitric acids and the like.

Representative examples of suitable organic acids include formic, acetic, trichloroacetic, trifluoroacetic, propionic, benzoic, cinnamic, citric, fumaric, glycolic, lactic, maleic, malic, malonic, mandelic, oxalic, picric, pyruvic, salicylic, succinic, methanesulfonic,

ethanesulfonic, tartaric, ascorbic, pamoic, bismethylene salicylic, ethanedisulfonic, gluconic, citraconic, aspartic, stearic, palmitic, EDTA, glycolic, p-aminobenzoic, glutamic, benzenesulfonic, p-toluenesulfonic acids, sulphates, nitrates, phosphates, perchlorates, borates, acetates, benzoates, hydroxynaphthoates, glycerophosphates, ketoglutarates and the like. Examples of metal salts include lithium, sodium, potassium, magnesium salts and the like. Examples of ammonium and alkylated ammonium salts include ammonium, methylammonium, dimethylammonium, trimethylammonium, ethylammonium,

hydroxyethylammonium, diethylammonium, butylammonium, tetramethylammonium salts and the like. Examples of organic bases include lysine, arginine, guanidine, diethanolamine, choline and the like.

[0021]“Sequence identity” as used herein indicates a nucleic acid or amino acid sequence that has the same nucleic acid or amino acid sequence as a reference sequence, or has a specified percentage of nucleotides or amino acids that are the same at the

corresponding location within a reference sequence when the two sequences are optimally aligned. For example a nucleic acid sequence may have at least 50%, 60%, 70%, 75%, 80%, 85%, 90%, 95%, 96%, 97%, 98%, 99%, or 100% identity to the reference sequence. The length of comparison sequences will generally be at least 5 contiguous nucleotides or amino acids, such as at least 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or 25 contiguous nucleotides or amino acids. Sequence identity may be measured using methods and software known in the art.

[0022] Applicant has found that individuals having Hunter’ s syndrome may be treated using an inhibitor of the C5a pathway. In particular, disclosed herein is a method of treating an individual having Hunter’s Syndrome, comprising administering an inhibitor of the C5a pathway to an individual in need thereof. It will be understood that the administration may be in an amount sufficient to delay onset of and/or alleviate one or more symptoms of Hunter’ s Syndrome in the individual administered the compound.

[0023] In one aspect, the inhibitor of the C5a pathway may be an a C5a Receptor (C5aR) inhibitor. The C5aR inhibitor may be one that inhibits C5aRl, C5aR2, or a combination thereof. In one aspect, the inhibitor may be a C5aRl and C5aR2 inhibitor that is a mutein of C5a. For example, the mutein may comprise a sequence selected from SEQ ID NOS: 9-18, or a mutein of C5a having sequence identity to SEQ ID NO. 16 (“A8^{D71 73}”), wherein the sequence identity is 95%, 96%, 97%, 98%, 99% or 100%. SEQ ID NO. 16, or “A8^{D71 73}” is described in US Patent No. 8,524,862 issued on September 13, 2013 to Magnus Otto and Jorg Kohl, and is further described in Pandey et al Nature 2017.

[0024] In one aspect, the inhibitor of the C5a pathway may be selected from an aptamer capable of inhibiting the C5a pathway, an anti-C5 antibody such as Eculizumab® (available from Alexion), coversin (a complement inhibitor that acts on complement

component-C5, preventing release of C5a and formation of C5b-9, available from Akari Therapeutics and described in Hawksworth et al. Mol Immunol 2017, avacopan (“CCX168,” a small molecule C5aRl antagonist, Jayne et al. JASN 2017, having the structure

pharmaceutically acceptable salt thereof; a

C5a C-terminal cyclic peptide PMX 205 (Cyclo (N2-(Oxo-3phenylpropy)-Om-Pro-D- Cha-Trp-Arg, (as described in Kumar et al. Sci Reports 2018, Seow et al Sci Rep 2016, Paczkowski et al Br J Pharmacol 1999, Kohl et al. Curr Opin Mol Therap 2007, available from Tocris) having the structure Cyclo[N2-(l-Oxo-3-phenylpropyl)-Om- Pro-D-Cha-Trp-Arg]), C5aR 1 antagonist, for example, PMX53, available at

Calbiochem, having the structure

pharmaceutically acceptable salt thereof.

[0025] In one aspect, the inhibitor may be an antibody, for example a C5a and C5aRl specific neutralizing monoclonal antibody (Hycultbiotechnology, Quidel, Sigma Aldrich) or a C5a inhibitor antibody (such as eculizumab). In one aspect, the C5aR2 agonist may be a peptide, such as those described in Croker et al Immunol Cell Biol 2016, peptides P32 (Ac- RHYPYWR-OH, SEQ ID NO:20) and P59 (Ac-LIRLWR-OH, SEQ ID NO: 21). P32 and P59 were identified by the authors and although P32 and P59 can bind to both C5aRl and C5aR2, the peptides have neither blocking nor stimulating activity towards C5aRl, with the reasons for this observation currently unresolved. Both agonists, however, have a clear and defined impact on C5aR2 activity: these ligands trigger recruitment of b-arrestin via C5aR2, partially inhibit C5a-mediated ERK1/2 activation, and specifically reduce

lipopoly saccharide-stimulated interleukin 6 (IL-6) production in macrophages. Neither peptide induced C5aRl mediated ERK1/2 activation, demonstrating specificity for C5aR2. These functionally selective ligands for C5aR2 may be used to selectively modulate C5a activity in Hunter syndrome.

[0026] In one aspect, the inhibitor of the C5a pathway may be eculizumab, wherein the eculizumab may be dosed based on the age of the patient. Patients with 18 years of age and older may require i.v. administration of 600 mg weekly for the first 4 weeks, followed by 900 mg for the fifth dose 1 week later, then 900 mg every 2 weeks thereafter.

[0027] In one aspect, the method may further comprise the step of administering to an individual idursulfase (also known as Elaprase®, a purified form of lysosomal enzyme iduronate-2-sulfatase). The idursulfase may be administered via i.v., such as on a weekly dosing schedule. The idursulfase may be administered at a time period selected from before, after, and/or during said administration of an inhibitor of the C5a pathway. For dosing information, see, e.g., http://www.elaprase.com/about/how-is-elaprase-dosed/.

[0028] In one aspect, the inhibitor of the C5a pathway may be administered at a dosage of about 400 to about 500 mg/kg body weight, or from about 100 to about 1000 mg/kg body weight, or from about 200 to about 800 mg/kg of body weight, or from about 300 mg/kg to about 700 mg/kg of body weight. The administration may be at least 1 time per week, or at least 2 times per week, and may be adjusted based on the response of the individual.

[0029] In one aspect, a method of treating an individual having Hunter’s Syndrome is disclosed, wherein the method may comprise the step of administering a composition comprising a mutein of C5a, such as one or a combination of peptides disclosed in SEQ ID NOS: 9-18, or a mutein of C5a having at least 95%, or at least 96%, or at least 97%, or at least 98%, or at least 99%, or 100% sequence identity to SEQ ID NO. 16 (A8^{D71 73}).

[0030] In one aspect, the inhibitor of the C5a pathway may be administered in an amount sufficient to inhibits C5aRl, C5aR2, or a combination thereof, in the individual having Hunter’s Syndrome.

[0031] In one aspect, the disclosed composition may be provided in a unit dose, wherein the unit dose may comprise an amount of mutein of C5a sufficient to obtain a

therapeutic effect in the individual having Hunter’ s Syndrome, wherein the therapeutic effect is a delayed onset of the symptoms of Hunter’s Syndrome, alleviation of one or more symptoms of Hunter’ s Syndrome, or a combination thereof.

[0032] C5a Mutein Component

[0033] In one aspect, the composition used for the treatment of Hunter’s Syndrome may comprise a C5a Mutein component. The mutein used may be derived from the natural C5a sequence of mammal and non-mammal species. It can, for instance be of human, porcine, murine, bovine or rat origin. In one embodiment, the mutein may be a mutant protein of the human C5a protein.

[0034] The mutein used may comprise or have a C-terminal sequence selected from the group consisting of 67-FKRSLLR-73 (SEQ ID NO: 1) (cf. mutein ABB; SEQ ID NO: 9), 67-FKRLLLR-73 (SEQ ID NO: 2) (cf. mutein A8B-Leu-70; SEQ ID NO: 10), 67-FKRSC-71 (SEQ ID NO: 3) (cf. mutein Ab8-Cys7l, SEQ ID NO: 11), 67-FKRSLLC-73 (SEQ ID NO:

4) (cf. mutein Ab8-Cys73, SEQ ID NO: 12), 67-FKRLLLY-73 (SEQ ID NO: 5) (cf. mutein A8B-Leu70-Tyr73, SEQ ID NO: 13), 67-FKKALLR-73 (SEQ ID NO: 6) (cf. mutein A8B- Lys69Ala70; SEQ ID NO: 14), 67-FKRS-70 (SEQ ID NO: 7) (cf. A8B-Del.7l-73, SEQ ID NO: 16) and 67-FKLLLLR-73 (cf. A5a, SEQ ID NO: 18).

[0035] For the sake of clarity, the numbering refers to the amino acid position of C5a, i.e., 67-F means that phenylalanine is present as amino acid at sequence position 67. The mutein can further comprise an Arg residue at sequence position 27, see, for example mutein C5a-(l-66,Cys27Arg)-FKRSLLR (“A8B-Arg27,” SEQ ID NO: 15). Arg at position 27 is found in porcine and bovine C5a. In addition, muteins of human C5a with a Cys27Arg replacement were selected from C5a mutant phage library (Cain, S., et al.“Analysis of receptor/ligand interactions using whole-molecule randomly-mutated ligand libraries,” J. Immunol. Methods. 2000. pp 139-145, 245), incorporated herein by reference. Muteins of C5a with only a Cys27Arg replacement are agonists of the C5a receptor.

[0036] Exemplary muteins of the human C5a anaphylatoxin having or comprising the amino acid sequence include SEQ ID NO: 9, i.e. C5a-(l-66, Cys27Ala-)A8B; SEQ ID NO:

10, i.e., C5a-(l-66, Cys27Ala)-A8B-Leu 70; SEQ ID NO: 11, i.e., C5a-(l-66, Cys27Ala)- A8B-Cys7l; SEQ ID NO: 12, i.e., C5a-(l-66, Cys27Ala)-A8B-Cys73; SEQ ID NO: 13, i.e., C5a-(l-66, Cys27Ala)-A8B-Leu70-Tyr73); SEQ ID NO: 14, i.e., C5a-(l-66, Cys27Ala)- A8B-Lys69-Ala70); SEQ ID NO: 15; i.e. , C5a-(l-66, Cys27Arg)-A8B; SEQ ID NO: 16, i.e., C5a-(l-66, Cys27Ala)-A8B-Del.7l-73); SEQ ID NO: 17, i.e., C5a-(l-66, Cys-3, Gly-2,- l,Cys27Ala)-A8B; and SEQ ID NO: 18, i.e., C5a-(l-66, Cys27Ala)A5a. In one aspect, the mutein may comprise a terminal sequence selected from SEQ ID NO: 1; SEQ ID NO: 2, SEQ ID NO: 3, SEQ ID NO: 4, SEQ ID NO: 5, SEQ ID NO: 6, SEQ ID NO: 7, and SEQ ID NO:

8. In one aspect, the positively charged amino acid residue at sequence position 69 of the C5a mutein is Arg or Lys. In a further aspect used in the invention, the mutein comprises a hydrophobic amino acid residue at sequence position 67. The aromatic hydrophobic amino acids Trp, Phe and Tyr are particularly preferred as residues at sequence position 67.

Antagonists may include muteins which comprise a hydrophobic amino acid residue at one or more of the sequence positions 70, 71 or 72. Such hydrophobic amino acid residues can be selected independently from each other, they can be identical or different. Preferred hydrophobic residues are Leu, Ile and Ala. Such muteins may comprise, at sequence position 70. an amino acid residue which is selected from Ala or Leu. Other preferred muteins comprise Ser at sequence position 70. One exemplary amino acid at sequence position 71 is Leu. The antagonistic mutein disclosed may comprise a Leu residue at sequence position 72. In one aspect, the mutein comprises Leu at all of the sequence positions 70, 71, and 72. If present, i.e., not deleted, in the C5a mutant, the sequence position 73 may be occupied by a Cys, Tyr, Arg or Ser residue. In some aspects, the mutein has a length of 70, 71, 72 or 73 amino acid residues. Arg, Cys, Tyr or Ser may be C-terminal amino acid residues of a truncated mutein, i.e., a mutein having 70, 71, 72, or 73 amino acid residues.

[0037] Further, muteins are also within the scope of the disclosure in which the positively charged amino acid at position 69 is the C-terminal (last) residue. Accordingly, such muteins can have a length of 69 amino acids. However, it is also possible to introduce deletions, for example, into the N-terminal region of the protein so that an antagonistic protein used herein can comprise fewer than 69 amino acid residues. For clarity reasons it is noted once again that such deletions can, of course, also be present in muteins of the invention in which residues at sequence positions 70 to 74 are not or only partly deleted. [0038] A mutant C5a antagonist cannot only be present as the isolated (recombinant) protein but it can also be modified. In one aspect, a mutein of the invention can be dimerized either with the same or a different mutein to form a homo- or heterodimer. For this purpose the mutein can comprise an N-terminal linker sequence which is capable of dimerizing the C5a mutein. One example of a preferred linker sequence linked to the N-terminus comprises the sequence Cys-Gly-Gly which can be used for spontaneous dimerization of the C5a mutein A8B in the course of the recombinant production of the mutant protein. Another example of such a suitable linker is Cys-(Gly-Gly-Gly-Gly-Ser)2 (SEQ ID NO: 19).

[0039] If the mutein carries a cysteine as C-terminal residue (cf. the muteins A813- Cys7l and A8B-Cys73), the dimerization can also occur by coupling of two muteins via these C-terminal cysteine residues as described by Pellas et al.,“Novel C5a receptor antagonists regulate neutrophil functions in vitro and in vivo,” Journal of Immunology, Jun.

1, 1998, pp 5616-5621, vol. 160, no. 11, incorporated herein by reference. The dimerization can also be achieved by linking a nucleotide sequence encoding a mutein in an appropriate reading frame with the nucleotide sequence coding for a protein which forms a homodimer in its native fold. Subsequent expression of the nucleic acid molecule yields a fusion protein consisting of the dimerization module linked to the C5a mutant polypeptide, which then dimerizes spontaneously. Examples of such proteins which can be used as dimerization modules are alkaline phosphatase, superoxide-dismutase or glutathione-S-transferase. The use these proteins is in particular useful because the respective functional fusion protein can readily be obtained by periplasmic expression in bacterial expression systems such as E. coli. The use of dimerization modules such as alkaline phosphatase or superoxide-dismutase provides the further advantage that such a fusion protein can easily be detected using a chromogenic reaction which is catalyzed, e.g., by alkaline phosphatase. Suitable chromogenic substrates for these enzymes, such as 5-bromo-4-chloro-3-indolylphosphate for alkaline phosphatase, are well known to the person skilled in the art. Those fusion proteins are therefore suitable as diagnostic reagents.

[0040] In accordance with the disclosure of the above paragraph, the mutein of the invention is in a further aspect linked to a protein or a peptide tag, /._<?., in which a fusion protein containing the C5a mutein is also part of the invention. However, the fusion proteins

of the mutein A8B with Jun/Fos alone, and, with Jun/Fos and the minor coat protein (pill) of the filamentous M13 phage fused to the N-terminus of the mutein A8B, which are known from Heller et al,“Selection of a C5a receptor antagonist from phage libraries attenuating the inflammatory response in immune complex disease and ischemia/reperfusion injury,” Journal of Immunology, Jul. 15, 1999, pp 985-994, vol. 163, no. 2, are excluded from the invention. The same applies to the mutein A8B that has a hexahistidine tag directly fused to the N- terminus, because this polypeptide is known from Hennecke, Untersuchung zur C5a-C5a Rezeptor-Interaktion unter Verwendung des Phage-Displays, PhD thesis, 1998, Medical School Hannover, Germany.

[0041] A fusion protein of the invention can comprise any suitable fusion partner, e.g., alkaline phosphatase or the green fluorescent protein (GFP) as long as the fusion partner does not interfere with the antagonistic properties of the mutein disclosed here and converts the mutein into an agonist when given to a patient, for example. A fusion partner appropriate for therapeutic purpose is a protein such as albumin which can enhance the in vivo

(circulation) half-life of a mutein of the invention. The fusion partner can be fused to the N- terminus of the C5a mutein. Likewise, any peptide tag can be fused to the N-terminus of the mutein as long as its antagonistic property is maintained. Examples of suitable affinity tags are the STREP-TAG® which has specific binding affinity for streptavidin or mutants thereof as STREP-TACTIN® (see U.S. Pat. No. 5,506,121, Skerra et ak, issued Apr. 9, 1996, and U.S. Pat. No. 6,022,951, Sano et ak, issued Feb. 8, 2000, both incorporated by reference herein), the Flag-tag or the myc-tag, all of which can be used for purification of the mutein by affinity chromatography.

[0042] It should, however, be noted that in the event of, e.g., inventive C5a muteins conjugated or fused to a partner that confers agonistic properties, the antagonistic muteins can be readily generated/released from its (fusion) partner by treatment such as limited proteolysis or cleavage, for example enzymatic or chemical cleavage, of a (peptide) bond which links the C5a mutein to the (fusion) partner. Accordingly, it is also within the scope of the present invention, to use a fusion partner, for example, for improved purification of the mutein, for example, even if this fusion partner confers an agonistic activity as long as this activity can be eliminated before (and thus the antagonistic activity of the inventive mutein is

generated) the muteins is used, for instance, in a desired therapeutic application. It is also possible to use a mutein the antagonistic activity of which is reduced by the (fusion) partner but not completely abolished. In this case, it is thus not necessary to deliberate the mutein of the invention by cleavage from its (fusion) partner. Rather, the fusion protein or the conjugate as explained in the following can be used in a desired application.

[0043] The mutein used in the present invention can also be conjugated to a protein or a different chemical (macromolecular) moiety via a suitable peptidic or non-pep tidic linker that can be attached to any suitable residue within the primary sequence of the mutein. A protein can, for instance, be conjugated with the C5a mutein using solvent exposed a-amino groups of lysine residues and glutaraldehyde as linker. Another suitable coupling chemistry is amine-amine crosslinking using bis(succinimidylesters) of 5,5'-dithiobis-(2-nitrobenzoic acid) (DTNB) as described in Haugland, R. Handbook of Fluorescent Probes and Research Chemicals, 6th Ed. 1996, Molecular Probes, Eugene, Oreg., on page 96, incorporated herein by reference. Any protein can be coupled to the C5a mutein, depending on the desired application. For example, a conjugate with streptavidin, horseradish peroxidase or green fluorescent protein might be used as a diagnostic reagent or research tool for visualizing a C5a receptor on the surface or within different compartments of a cell.

[0044] PHARMACEUTICAL COMPOSITIONS

[0045] In one aspect, active agents provided herein may be administered in an dosage form selected from intravenous or subcutaneous unit dosage form, oral, parenteral, intravenous, and subcutaneous. In some aspects, active agents provided herein may be formulated into liquid preparations for, e.g., oral administration. Suitable forms include suspensions, syrups, elixirs, and the like. In some aspects, unit dosage forms for oral administration include tablets and capsules. Unit dosage forms configured for administration once a day; however, in certain aspects it may be desirable to configure the unit dosage form for administration twice a day, or more.

[0046] In one aspect, pharmaceutical compositions are isotonic with the blood or other body fluid of the recipient. The isotonicity of the compositions may be attained using sodium tartrate, propylene glycol or other inorganic or organic solutes. An example includes sodium chloride. Buffering agents may be employed, such as acetic acid and salts, citric acid and salts, boric acid and salts, and phosphoric acid and salts. Parenteral vehicles include sodium chloride solution, Ringer’ s dextrose, dextrose and sodium chloride, lactated Ringer’ s or fixed oils. Intravenous vehicles include fluid and nutrient replenishers, electrolyte replenishers (such as those based on Ringer’s dextrose), and the like.

[0047] A pharmaceutically acceptable preservative may be employed to increase the shelf life of the pharmaceutical compositions. Benzyl alcohol may be suitable, although a variety of preservatives including, for example, parabens, thimerosal, chlorobutanol, or benzalkonium chloride may also be employed. A suitable concentration of the preservative is typically from about 0.02% to about 2% based on the total weight of the composition, although larger or smaller amounts may be desirable depending upon the agent selected. Reducing agents, as described above, may be advantageously used to maintain good shelf life of the formulation.

[0048] In one aspect, active agents provided herein may be in admixture with a suitable carrier, diluent, or excipient such as sterile water, physiological saline, glucose, or the like, and may contain auxiliary substances such as wetting or emulsifying agents, pH buffering agents, gelling or viscosity enhancing additives, preservatives, flavoring agents, colors, and the like, depending upon the route of administration and the preparation desired. See, e.g.,“Remington: The Science and Practice of Pharmacy”, Lippincott Williams & Wilkins; 20th edition (June 1, 2003) and“Remington’s Pharmaceutical Sciences,” Mack Pub. Co.; l8th and l9th editions (December 1985, and June 1990, respectively). Such preparations may include complexing agents, metal ions, polymeric compounds such as polyacetic acid, polyglycolic acid, hydrogels, dextran, and the like, liposomes, microemulsions, micelles, unilamellar or multilamellar vesicles, erythrocyte ghosts or spheroblasts. Suitable lipids for liposomal formulation include, without limitation, monoglycerides, diglycerides, sulfatides, lysolecithin, phospholipids, saponin, bile acids, and the like. The presence of such additional components may influence the physical state, solubility, stability, rate of in vivo release, and rate of in vivo clearance, and are thus chosen according to the intended application, such that the characteristics of the carrier are tailored to the selected route of administration. [0049] For oral administration, the pharmaceutical compositions may be provided as a tablet, aqueous or oil suspension, dispersible powder or granule, emulsion, hard or soft capsule, syrup or elixir. Compositions intended for oral use may be prepared according to any method known in the art for the manufacture of pharmaceutical compositions and may include one or more of the following agents: sweeteners, flavoring agents, coloring agents and preservatives. Aqueous suspensions may contain the active ingredient in admixture with excipients suitable for the manufacture of aqueous suspensions.

[0050] Formulations for oral use may also be provided as hard gelatin capsules, wherein the active ingredient(s) are mixed with an inert solid diluent, such as calcium carbonate, calcium phosphate, or kaolin, or as soft gelatin capsules. In soft capsules, the active agents may be dissolved or suspended in suitable liquids, such as water or an oil medium, such as peanut oil, olive oil, fatty oils, liquid paraffin, or liquid polyethylene glycols. Stabilizers and microspheres formulated for oral administration may also be used. Capsules may include push-fit capsules made of gelatin, as well as soft, sealed capsules made of gelatin and a plasticizer, such as glycerol or sorbitol. The push-fit capsules may contain the active ingredient in admixture with fillers such as lactose, binders such as starches, and/or lubricants, such as talc or magnesium stearate and, optionally, stabilizers.

[0051] Tablets may be uncoated or coated by known methods to delay disintegration and absorption in the gastrointestinal tract and thereby provide a sustained action over a longer period of time. For example, a time delay material such as glyceryl monostearate may be used. When administered in solid form, such as tablet form, the solid form typically comprises from about 0.001 wt. % or less to about 50 wt. % or more of active ingredient(s), for example, from about 0.005, 0.01, 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1, 0.2,

0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, or 1 wt. % to about 2, 3, 4, 5, 6, 7, 8, 9, 10, 15, 20, 25, 30, 35,

40, or 45 wt. %.

[0052] Tablets may contain the active ingredients in admixture with non-toxic pharmaceutically acceptable excipients including inert materials. For example, a tablet may be prepared by compression or molding, optionally, with one or more additional ingredients. Compressed tablets may be prepared by compressing in a suitable machine the active ingredients in a free-flowing form such as powder or granules, optionally mixed with a

binder, lubricant, inert diluent, surface active or dispersing agent. Molded tablets may be made by molding, in a suitable machine, a mixture of the powdered active agent moistened with an inert liquid diluent.

[0053] In some embodiments, each tablet or capsule contains from about 1 mg or less to about 1,000 mg or more of a active agent provided herein, for example, from about 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100 mg to about 150, 200, 250, 300, 350, 400, 450, 500, 550, 600, 650, 700, 750, 800, or 900 mg. In some embodiments, tablets or capsules are provided in a range of dosages to permit divided dosages to be administered. A dosage appropriate to the patient and the number of doses to be administered daily may thus be conveniently selected. In certain embodiments two or more of the therapeutic agents may be incorporated to be administered into a single tablet or other dosage form (e.g., in a combination therapy);

however, in other embodiments the therapeutic agents may be provided in separate dosage forms.

[0054] Suitable inert materials include diluents, such as carbohydrates, mannitol, lactose, anhydrous lactose, cellulose, sucrose, modified dextrans, starch, and the like, or inorganic salts such as calcium triphosphate, calcium phosphate, sodium phosphate, calcium carbonate, sodium carbonate, magnesium carbonate, and sodium chloride. Disintegrants or granulating agents may be included in the formulation, for example, starches such as corn starch, alginic acid, sodium starch glycolate, Amberlite, sodium carboxymethylcellulose, ultramylopectin, sodium alginate, gelatin, orange peel, acid carboxymethyl cellulose, natural sponge and bentonite, insoluble cationic exchange resins, powdered gums such as agar, karaya or tragamayth, or alginic acid or salts thereof.

[0055] Binders may be used to form a hard tablet. Binders include materials from natural products such as acacia, tragamayth, starch and gelatin, methyl cellulose, ethyl cellulose, carboxymethyl cellulose, polyvinyl pyrrolidone, hydroxypropylmethyl cellulose, and the like.

[0056] Lubricants, such as stearic acid or magnesium or calcium salts thereof, polytetrafluoroethylene, liquid paraffin, vegetable oils and waxes, sodium lauryl sulfate, magnesium lauryl sulfate, polyethylene glycol, starch, talc, pyrogenic silica, hydrated silicoaluminate, and the like, may be included in tablet formulations.

[0057] Surfactants may also be employed, for example, anionic detergents such as sodium lauryl sulfate, dioctyl sodium sulfosuccinate and dioctyl sodium sulfonate, cationic such as benzalkonium chloride or benzethonium chloride, or nonionic detergents such as polyoxyethylene hydrogenated castor oil, glycerol monostearate, polysorbates, sucrose fatty acid ester, methyl cellulose, or carboxymethyl cellulose.

[0058] Controlled release formulations may be employed wherein the active agent or analog(s) thereof is incorporated into an inert matrix that permits release by either diffusion or leaching mechanisms. Slowly degenerating matrices may also be incorporated into the formulation. Other delivery systems may include timed release, delayed release, or sustained release delivery systems.

[0059] Coatings may be used, for example, nonenteric materials such as methyl cellulose, ethyl cellulose, hydroxyethyl cellulose, methylhydroxy-ethyl cellulose, hydroxypropyl cellulose, hydroxypropyl-methyl cellulose, sodium carboxy-methyl cellulose, providone and the polyethylene glycols, or enteric materials such as phthalic acid esters. Dyestuffs or pigments may be added for identification or to characterize different combinations of active agent doses.

[0060] When administered orally in liquid form, a liquid carrier such as water, petroleum, oils of animal or plant origin such as peanut oil, mineral oil, soybean oil, or sesame oil, or synthetic oils may be added to the active ingredient(s). Physiological saline solution, dextrose, or other saccharide solution, or glycols such as ethylene glycol, propylene glycol, or polyethylene glycol are also suitable liquid carriers. The pharmaceutical compositions may also be in the form of oil-in-water emulsions. The oily phase may be a vegetable oil, such as olive or arachis oil, a mineral oil such as liquid paraffin, or a mixture thereof. Suitable emulsifying agents include naturally-occurring gums such as gum acacia and gum tragamayth, naturally occurring phosphatides, such as soybean lecithin, esters or partial esters derived from fatty acids and hexitol anhydrides, such as sorbitan mono-oleate, and condensation products of these partial esters with ethylene oxide, such as

polyoxyethylene sorbitan mono-oleate. The emulsions may also contain sweetening and flavoring agents.

[0061] Pulmonary delivery of the active agent may also be employed. The active agent may be delivered to the lungs while inhaling and traverses across the lung epithelial lining to the blood stream. A wide range of mechanical devices designed for pulmonary delivery of therapeutic products may be employed, including but not limited to nebulizers, metered dose inhalers, and powder inhalers, all of which are familiar to those skilled in the art. These devices employ formulations suitable for the dispensing of active agent. Typically, each formulation is specific to the type of device employed and may involve the use of an appropriate propellant material, in addition to diluents, adjuvants, and/or carriers useful in therapy.

[0062] The active ingredients may be prepared for pulmonary delivery in particulate form with an average particle size of from 0.1 um or less to 10 um or more, for example, from about 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, or 0.9 pm to about 1.0, 1.5, 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, or 9.5 pm. Pharmaceutically acceptable carriers for pulmonary delivery of active agent include carbohydrates such as trehalose, mannitol, xylitol, sucrose, lactose, and sorbitol. Other ingredients for use in formulations may include DPPC, DOPE, DSPC, and DOPC. Natural or synthetic surfactants may be used, including polyethylene glycol and dextrans, such as cyclodextran. Bile salts and other related enhancers, as well as cellulose and cellulose derivatives, and amino acids may also be used. Liposomes, microcapsules, microspheres, inclusion complexes, and other types of carriers may also be employed.

[0063] Pharmaceutical formulations suitable for use with a nebulizer, either jet or ultrasonic, typically comprise the active agent dissolved or suspended in water at a concentration of about 0.01 or less to 100 mg or more of active agent per mL of solution, for example, from about 0.1, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 mg to about 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, or 90 mg per mL of solution. The formulation may also include a buffer and a simple sugar (e.g., for protein stabilization and regulation of osmotic pressure). The nebulizer formulation may also contain a surfactant, to reduce or prevent surface induced aggregation of the active agent caused by atomization of the solution in forming the aerosol.

[0064] Formulations for use with a metered-dose inhaler device generally comprise a finely divided powder containing the active ingredients suspended in a propellant with the aid of a surfactant. The propellant may include conventional propellants, such as

chlorofluorocarbons, hydrochlorofluorocarbons, hydrofluorocarbons, and hydrocarbons. Example propellants include trichlorofluoromethane, dichlorodifluoromethane,

dichlorotetrafluoroethanol, 1,1,1, 2-tetrafluoroethane, and combinations thereof. Suitable surfactants include sorbitan trioleate, soya lecithin, and oleic acid.

[0065] Formulations for dispensing from a powder inhaler device typically comprise a finely divided dry powder containing active agent, optionally including a bulking agent, such as lactose, sorbitol, sucrose, mannitol, trehalose, or xylitol in an amount that facilitates dispersal of the powder from the device, typically from about 1 wt. % or less to 99 wt. % or more of the formulation, for example, from about 5, 10, 15, 20, 25, 30, 35, 40, 45, or 50 wt.

% to about 55, 60, 65, 70, 75, 80, 85, or 90 wt. % of the formulation.

[0066] In some aspects, an active agent provided herein may be administered by intravenous, parenteral, or other injection, in the form of a pyrogen-free, parenterally acceptable aqueous solution or oleaginous suspension. Suspensions may be formulated according to methods well known in the art using suitable dispersing or wetting agents and suspending agents. The preparation of acceptable aqueous solutions with suitable pH, isotonicity, stability, and the like, is within the skill in the art. In some aspects, a

pharmaceutical composition for injection may include an isotonic vehicle such as 1,3- butanediol, water, isotonic sodium chloride solution, Ringer’ s solution, dextrose solution, dextrose and sodium chloride solution, lactated Ringer’s solution, or other vehicles as are known in the art. In addition, sterile fixed oils may be employed conventionally as a solvent or suspending medium. For this purpose, any bland fixed oil may be employed including synthetic mono or diglycerides. In addition, fatty acids such as oleic acid may likewise be used in the formation of injectable preparations. The pharmaceutical compositions may also contain stabilizers, preservatives, buffers, antioxidants, or other additives known to those of skill in the art.

[0067] The duration of the injection may be adjusted depending upon various factors, and may comprise a single injection administered over the course of a few seconds or less, to 0.5, 0.1, 0.25, 0.5, 0.75, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21,

22, 23, or 24 hours or more of continuous intravenous administration.

[0068] In some aspects, active agents provided herein may additionally employ adjunct components conventionally found in pharmaceutical compositions in their art- established fashion and at their art-established levels. Thus, for example, the compositions may contain additional compatible pharmaceutically active materials for combination therapy, or may contain materials useful in physically formulating various dosage forms, such as excipients, dyes, thickening agents, stabilizers, preservatives or antioxidants.

[0069] In some aspects, the active agents provided herein may be provided to an administering physician or other health care professional in the form of a kit. The kit is a package which houses a container which contains the active agent(s) in a suitable pharmaceutical composition, and instructions for administering the pharmaceutical composition to a subject. The kit may optionally also contain one or more additional therapeutic agents currently employed for treating the disease states described herein. For example, a kit containing one or more compositions comprising active agents provided herein in combination with one or more additional active agents may be provided, or separate pharmaceutical compositions containing an active agent as provided herein and additional therapeutic agents may be provided. The kit may also contain separate doses of a active agent provided herein for serial or sequential administration. The kit may optionally contain one or more diagnostic tools and instructions for use. The kit may contain suitable delivery devices, e.g., syringes, and the like, along with instructions for administering the active agent(s) and any other therapeutic agent. The kit may optionally contain instructions for storage, reconstitution (if applicable), and administration of any or all therapeutic agents included.

The kits may include a plurality of containers reflecting the number of administrations to be given to a subject.

EXAMPLES

[0070] The following non-limiting examples are provided to further illustrate aspects of the invention disclosed herein. It should be appreciated by those of skill in the art that the techniques disclosed in the examples that follow represent approaches that have been found to function well in the practice of the invention, and thus may be considered to constitute examples of modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes may be made in the specific embodiments that are disclosed and still obtain a like or similar result without departing from the spirit and scope of the invention.

[0071] Applicant directly compared inflammatory responses to glycosaminoglycan (GAG) in different groups of BALB/c mice by injecting (i.p./day for 4 weeks) separately with altered doses of dermatan sulfate (DS), (0, 1, 2, 4, and 8 mg). Complement 5a (C5a) and their receptor (C5aRl) were measured in sera and monocytes of these mice. As compared to vehicle (PBS), DS treated mice sera and monocytes showed dose dependent increases of C5a and C5aRl. Human patients with Hunter syndrome also show elevated serum level of C5a when compared to healthy controls. C5a-C5aR axis has been valued for increased staffing of immune cells and their venomous influence on tissue impairment in LSD and non-LSDs. To explore this risk in Hunter syndrome, both WT and C5aRl deficient mice were injected in the presence or absence of higher dosages of DS, and circulatory subsets of immune cells were measured. As compared to DS treated WT mice, DS treated C5aRL^/_ mice showed marked reduction in circulatory monocytes, eosinophils, and neutrophils, and diminished pro- inflammatory cytokines secretion. To evaluate the translational influence of this work, sera and peripheral blood mononuclear cells of human patients with Hunter syndrome and control healthy humans were used for measurement of the status of C5a, C5aR and pro-inflammatory cytokines. As compared to control humans, blood cells, (e.g., monocytes and T cells) of Hunter Syndrome patients showed elevated level of C5a, C5aRl and increased production of pro-inflammatory cytokines, (e.g., TNF a and PPb). Applicant’s data show that DS-induced C5a-C5aR activation sparks immune inflammation, which is fatal in Hunter syndrome. Accordingly, the data demonstrate targeting of the C5a/C5aR axis as an alternative therapy for Hunter syndrome.

[0072] METHODS

[0073] The following reagents were from BD Biosciences (San Jose, CA) or eBiosciences (San Diego, CA): Monoclonal antibodies (mAh) to mouse CD115- FITC, CDllb-BV42l (Ml/70), Ly6C-APC, Ly6G-FITC (RB6-8C5), F480-PECF594, CD40 PE, CD80PE, CD86 PE, CD88 PE, CD3-pacific blue, CD4 FITC, B220-BV650, CD69PE and their corresponding isotypes antibodies (rat IgG2a FITC, rat IgG2b BV421, rat IgG2a APC, Rat IgG2b-FITC rat IgG2a- PECF594, rat IgG2a PE, Hamster IgG2-PE, rat IgG2bPE, rat IgG2a FITC, rat IgG2a- BV650, Hamster IgGl PE), mAh to human CDllb- pacific blue, CD14- PerCpCy5.5, CD40-PE, CD80-PE, CD86-PE CD88-PE and their corresponding isotypes, (e.g., mouse IgGl-pacific blue, mouse IgG2b-Perc5Cy5.5,mouse IgGl-PE), and Fc blocking antibodies. Mouse and human ELISA kits for C5a and cytokines (TNFa and IEIb) were from was from R&D System (Minneapolis, MN) and Bio legend (San Diego, CA), Liberase Cl was from Roche (Indianapolis, IN). DNase, were from Sigma (St. Louis, MO). Mouse/human Anti-CD 1 lb, and mouse anti-CD4 microbeads were from Miltenyi Biotec (Auburn, CA). Dermatan sulfate was from AMS Biotechnology (Cambridge, MA),

[0074] Animals.

[0075] C5aRl deficient (C5aRl ^/_) and background matched wild type (WT) controls were on the mixed FVB/C57BL 6J/l29SvEvBrd (50:25:25) backgrounds. Male mice were used at~l2 weeks of age. Mice were maintained under pathogen-free conditions. Animal care was provided in accordance with National Institute of Health guidelines and was approved by Cincinnati Children’s Hospital Medical Center IACUC.

[0076] Hunter syndrome patients and healthy human controls. Frozen sera and cryopreserved blood cells were from human patients with untreated Hunter syndrome (n=5) and healthy volunteers (h=10) were de-identified. Human patients with Hunter syndrome were diagnosed at Cincinnati Children’s Hospital Medical Center (CCHMC).

[0077] Preparation of tissue cells. Spleen and lung were harvested aseptically. Single cell suspensions from lung were obtained from minced pieces that were treated with Liberase Cl (0.5mg/mL) and DNase (0.5mg/mL) in RPMI (45min, 370C). Single cell suspensions from spleen were obtained by grinding and then filtration through a 70-micron cell strainer. For blood cells, blood was directly, followed by RBC lysis (155 mM NH4C1, 10 mM NaHC03, 0.1 mM EDTA), passage through a strainer. Cells were then pelleted by centrifugation at 350 x g. Viable cells were counted using a Neubauer chamber and trypan blue exclusion. M(j>s, and CD4+ T lymphocytes were purified from single cell suspensions of spleen and lung using CDl lb and CD4 (L3T4) microbeads according to the manufacturer’s protocol. The purity of the cells was ~90%-95%.

[0078] In vivo induction of circulatory monocytes.

[0079] Mouse cardiac blood was collected in EDTA containing tubes. Monocyte numbers in the circulation were determined using an automated hematology system

(Hemavet 850, Drew Scientific, and Oxford, CT).

[0080] Identification of tissue phagocytes and T cells. Tissue cells were identified by flow cytometry. First, they were suspended in PBS containing 1% BSA. After incubation (15 min, 4°C) with FcyR-blocking antibody 2.4G2, cells were stained (45 min, 4°C) with the following antibodies to identify APCs and T cells: CD3 and CD4 for T cells; CDllb, CD115/Ly6C, and Ly6G for monocytes (MOs), CDllb, Ly6C, and F4/80 for M<j>s; CDl lb, Ly6C, and CDllc for DCs. Cells were also stained with the respective isotype antibodies as controls. MOs differentiated M<j>s were first identified by their typical FSC/SSC pattern,

F4/80 and CDllb expression. MOs differentiated DCs were identified as CDl lc+CDl lb+ cells. Further, CD40, CD80 CD86 and C5aRl expression was determined in tissue

MOs/M(j)s. T cells were first characterized by their FSC/SSC pattern and CD3 staining. CD3+ T cells were further stained for CD69 expression. A total of 106 events were acquired for each cell type isolated from the different organs. Specific surface expression was assessed relative to the expression of the corresponding isotype control antibody. FACS Calibur,

LSRII flow cytometer (BD Biosciences, San Jose, CA), and FCS Express software (DeNovo) was used to analyzed these data.

[0081] Complement 5a (C5a) and cytokines measurement.

[0082] For serum detection of C5a and cytokines, blood from DS-treated and - untreated WT and C5aRT^/_ mice (n=5/group) was obtained by cardiac puncture. Whereas frozen blood was obtained from Hunter syndrome patients and healthy human controls. Sera were isolated after one-hour incubation at RT. Sera were diluted 1:10 with sterile PBS and used for detection of C5a and cytokines by ELISA.

[0083] 2.11. Immune phagocytes and T cell co-culture. [0084] A 1:5 ratio of MOs (CDllb+ CD14+) / MF (CDl lb+ F4/80+) and T cells (CD4+ T cells) purified from DS-treated and -untreated WT and C5aRT^/_ mice (n=5/group) lung and spleen or blood of Hunter syndrome patients and healthy human were co-cultured for 48 hrs in complete medium and the cells used for FACS staining with CDllb, CD14, F4/80, CD3, CD4, CD40, CD80, CD86, and CD69 markers. The respective supernatants were used to determine the concentrations of IL-b and TNFa.

[0085] Identification of storage cells.

[0086] Single cell suspension prepared from spleen of Vehicle (IOOmI; PBS) and DS (IOOmI of 1, 2, 4, and 8 mg/ml) treated WT and C5aRT^/_ mice were used to prepare cytospin slide with Diff-Quik staining (Dade Behring, In; Newark, DE). Stained cells were washed and cover-slipped with Vectashield. Images of storage cells were captured under the light microscope.

[0087] All percentages and ratios are calculated by weight unless otherwise indicated.

[0088] All percentages and ratios are calculated based on the total composition unless otherwise indicated.

[0089] It should be understood that every maximum numerical limitation given throughout this specification includes every lower numerical limitation, as if such lower numerical limitations were expressly written herein. Every minimum numerical limitation given throughout this specification will include every higher numerical limitation, as if such higher numerical limitations were expressly written herein. Every numerical range given throughout this specification will include every narrower numerical range that falls within such broader numerical range, as if such narrower numerical ranges were all expressly written herein.

[0090] The dimensions and values disclosed herein are not to be understood as being strictly limited to the exact numerical values recited. Instead, unless otherwise specified, each such dimension is intended to mean both the recited value and a functionally equivalent range surrounding that value. For example, a dimension disclosed as“20 mm” is intended to mean “about 20 mm.” [0091] Every document cited herein, including any cross referenced or related patent or application, is hereby incorporated herein by reference in its entirety unless expressly excluded or otherwise limited. The citation of any document is not an admission that it is prior art with respect to any invention disclosed or claimed herein or that it alone, or in any combination with any other reference or references, teaches, suggests or discloses any such invention. Further, to the extent that any meaning or definition of a term in this document conflicts with any meaning or definition of the same term in a document incorporated by reference, the meaning or definition assigned to that term in this document shall govern.

[0092] While particular embodiments of the present invention have been illustrated and described, it would be obvious to those skilled in the art that various other changes and modifications may be made without departing from the spirit and scope of the invention. It is therefore intended to cover in the appended claims all such changes and modifications that are within the scope of this invention.

Claims

CLAIMS What is claimed is:

1. A medicament for the treatment of an individual having Hunter’s Syndrome, wherein said medicament comprises an inhibitor of the C5a pathway.

2. The medicament of claim 1, wherein said inhibitor of the C5a pathway is an C5a Receptor (C5aR) inhibitor, wherein said C5aR inhibitor is an antagonist of C5aRl, C5aR2, or a combination thereof, preferably wherein said C5aRl and C5aR2 inhibitor is a mutein of C5a, preferably selected from SEQ ID NOS: 9-18, more preferably a mutein of C5a having at least 95% sequence identity to SEQ ID NO. 16 (A8^{D71 73}).

3. The medicament of claim 1, wherein said inhibitor of the C5a pathway is selected from an aptamer capable of inhibiting the C5a pathway, an anti-C5 antibody, coversin,

avacopan having the structure

pharmaceutically acceptable salt thereof, a C5a C-terminal cyclic peptide PMX 205 (Cyclo (N2-(Oxo-3phenylpropy)-Orn-Pro-D-Cha-Trp-Arg, C5aR 1 antagonist (PMX53, available at Calbiochem) having the structure

or pharmaceutically acceptable salt thereof, a C5aR2 specific agonist, or a combination thereof.

4. The medicament of claim 3, wherein said antibody is selected an antibody selected from a C5a and C5aRl specific neutralizing monoclonal antibody, a C5a inhibitor antibody, or a combination thereof, preferably a C5a inhibitor antibody, more preferably Eculizumab®.

5. The medicament of claim 1, wherein said inhibitor of the C5 pathway is a C5aR2 agonist selected from a peptide selected from P32 (Ac-RHYPYWR-OH, SEQ ID NO: 20) and P59 (Ac-LIRLWR-OH, SEQ ID NO: 21), or a combination thereof.

6. The medicament of any preceding claim, wherein said medicament comprises a

pharmaceutically acceptable carrier.

7. The medicament of any preceding claim, wherein said medicament is a sterile

composition.

8. A method treating Hunter’s Syndrome, in an individual in need thereof, comprising the step of administering a composition of any preceding claim, to an individual in need thereof, in an amount sufficient to delay onset of and/or alleviate one or more symptoms of Hunter’s Syndrome in said individual.

9. The method of claim 8, further comprising the step of administering to said individual idursulfase, preferably wherein said idursulfase is administered intravenously, preferably on a weekly dosing schedule, more preferably wherein said idursulfase is administered at a time period selected from before, after, and/or during said administration of said inhibitor of the C5a pathway.

10. The method of claim 8 or 9, wherein said administration is via intravenous administration to said individual.

11. The method of any of claims 8 through 10, wherein said medicament is administered at a dosage of about 400 mg/kg body weight

12. The method of any of claims 8 through 11, wherein said medicament is administered at least 1 time per week, or at least 2 times per week.

13. A method of treating an individual having Hunter’s Syndrome, comprising

administering a composition comprising a mutein of C5a, preferably selected from SEQ ID NOS: 9-18, more preferably a mutein of C5a having at least 95% sequence

identity to SEQ ID NO: 16 (A8^{D71 73}), more preferably 100% identity to SEQ ID NO: 16 (A8^{D71 73}), to an individual in need thereof.

14. The method of claim 13, wherein said mutein of C5a is administered in an amount sufficient to inhibits C5aRl, C5aR2, or a combination thereof, in said individual.

15. The method of claim 13 or 14, wherein said composition is provided in a unit dose, wherein said unit dose comprises an amount of mutein of C5a sufficient to obtain a therapeutic effect in said individual, wherein said therapeutic effect is a delayed onset of the symptoms of Hunter’s Syndrome, alleviation of one or more symptoms of Hunter’s Syndrome, and combinations thereof.