WO2020147950A1 - Methods of treating fibromyalgia - Google Patents

Abstract

The present invention relates to anti-LPS immunoglobulin compositions for use in treating patients suffering from fibromyalgia with certain comorbidities. In particular, oral administration of IgY composition comprising a combination of polyclonal avian immunoglobulin IgY specific for Escherichia bacteria and polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, showed significant efficacy in reducing pain in patients suffering from fibromyalgia with migraine as comorbidity.

Description

METHODS OF TREATING FIBROMYALGIA

The present invention relates to anti-LPS immunoglobulin compositions for use in treating patients suffering from fibromyalgia with certain comorbidities. In particular, oral administration of IgY composition comprising a combination of polyclonal avian immunoglobulin IgY specific for Escherichia bacteria and polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, showed significant efficacy in reducing pain in patients suffering from fibromyalgia with migraine as comorbidity.

BACKGROUND

Fibromyalgia syndrome is a chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbance, impaired cognition, anxiety, and other somatic symptoms. Common comorbidities are migraine and irritable bowel syndrome. The etiology of fibromyalgia (FM) is still not fully understood. Abnormalities in pain processing at various levels (peripheral and central), dysregulation of the hypothalamo-pituitary-adrenal axis, and abnormalities of the autonomic nervous system have been identified as contributing factors (Kia and Choy, 2017).

An increase in serum IL-6 and IL-8 has been reported in FM patients, the concentrations of which were positively correlated to duration of disease (Wallace, 2001 ). Also other research groups found increases in different cytokines and chemokines, suggesting a constant state of systemic inflammation (Totsch and Sorge, 2017). The common comorbidity with intestinal disorders, the finding of small intestine bacterial overgrowth (SI BO) and increased intestinal permeability in FM patients suggests the involvement of the microbiota-gut-brain axis in the development of the disease.

WO2012/136522 and WO2012/136534 patent publications reports sample preparations of hyperimmune egg yolk products for treating patients suffering from complex pain syndromes. WO2016/166246 patent publication further relates to the use of predictive biomarker to select responder patients of anti-LPS immunoglobulin treatment.

Worldwide prevalence of fibromyalgia is 2% to 4% and 6.4% in the US population, and headache is reported by 60% - 75% of fibromyalgia patients (Clin Rheumatol 2005, 24:595- 601 ), prevalence of comorbidity migraine is about 50%. In US, three pharmaceutical drugs are currently approved for the treatment of fibromyalgia: Lyrica^® (pregabalin), Savella^® (milnacipran) and Cymbalta^® (duloxetine). For a review of treatment of fibromyalgia, see Kia and Choy 2017, Biomedicine 5, 20.

Since current treatment options are not satisfying, tailored approaches for specific patients subgroups need to be considered (Hauser et al., 2018).

The inventors have now shown significant pain reduction with an anti-LPS immunoglobulin treatment in certain subgroup of fibromyalgia patients, especially with certain comorbidities including migraine.

SUMMARY OF PREFERRED EMBODIMENTS Accordingly, one object of the present disclosure is to provide an anti-LPS immunoglobulin composition for use in the treatment of a patient suffering from (i) fibromyalgia and (ii) at least one comorbidity selected among the following diseases: migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders. In a particular embodiment, said patient is suffering from fibromyalgia and migraine. In another specific embodiment, said patient is suffering from fibromyalgia and irritable bowel syndrome.

The disclosure further includes a method of treating a patient that has or is suspected to have fibromyalgia and at least one comorbidity selected among the following diseases: migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders, in particular with comorbidity selected among migraine, irritable bowel syndrome and joint disease, said method comprising administering a therapeutically efficient amount of an anti-LPS immunoglobulin or IgY composition to said patient.

In specific embodiments, said anti-LPS immunoglobulin treatment is an IgY composition, preferably an IgY composition for oral administration. For example, said IgY composition comprises a combination of polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria, and polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria.

More specifically, said IgY composition may be obtained by mixing i. a first egg yolk product obtained from avians immunized with a vaccine against Escherichia bacteria, e.g. of inactivated strains of E. coli bacteria,

ii. a second egg yolk product obtained from avians immunized with a vaccine against Salmonella bacteria, e.g. of inactivated strains of S. typhimurium bacteria.

In a sub-embodiment of the latter embodiment, said IgY composition essentially consists of said first and second egg yolk products, and, the first egg yolk product represent between 30% and 70% (weight percent) of the IgY composition.

In specific embodiments, said first and second egg yolk products are egg yolk powders, optionally partially delipidated. For example, said first egg yolk product contains at least 60% (titer based percent) of IgY specific for Escherichia, e.g. for E. coli, and said second egg yolk product contains at least 40% (titer based percent) of IgY specific for Salmonella, e.g. for S. typhimurium.

In another specific embodiment, the anti-LPS immunoglobulin composition is obtained by immunizing avians with a vaccine against Escherichia bacteria comprising an immunogenic amount of inactivated Escherichia bacteria, preferably inactivated strains of Escherichia coli, and, optionally, one or more adjuvant and excipients.

In another specific embodiment, the anti-LPS immunoglobulin composition is obtained by immunizing avians with a vaccine against Salmonella bacteria comprising an immunogenic amount of inactivated Salmonella bacteria, preferably inactivated strains of Salmonella typhimurium, and, optionally, one or more adjuvant and excipients.

For example, said patient may receive a daily dose of said anti-LPS immunoglobulin composition of 1 to 10 g/day, 2 to 8 g/day, for example 4 g/day, typically 2 g administered twice daily.

The treatment may typically be carried out by a daily administration for at least 6 weeks.

The disclosure further relates to an IgY composition for use as a drug in patients, obtained by mixing i. a first egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for £. coli bacteria,

ii. a second egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria, wherein said IgY composition essentially consists of said first and second egg yolk product, and, wherein the first egg yolk product represent between between 30% and 70% (weight percent) of the IgY composition.

In a specific embodiment, said first and second egg yolk products are dried egg yolk powder, optionally formulated as a drink or capsule for oral administration.

DETAILED DESCRIPTION

The patient in need of anti-LPS immunoglobulin treatment

The term “patient” and “subject” which are used herein interchangeably refer to any member of the animal kingdom, preferably a mammal, and more preferably a human being. In one embodiment, the present disclosure relates to anti-LPS immunoglobulin composition or IgY composition for use in treating a patient suffering from fibromyalgia.

In another embodiment, the present disclosure relates to anti-LPS immunoglobulin composition or IgY composition for use in treating a patient suffering from migraine.

In another embodiment, the present disclosure relates to anti-LPS immunoglobulin composition or IgY composition for use in treating a patient suffering from irritable bowel syndrome.

In a preferred embodiment, said patient has or is suspected to have fibromyalgia and at least one comorbidity selected among the following diseases: migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders, in particular with comorbidity selected among migraine, irritable bowel syndrome and joint diseases.

Anti-LPS immunoglobulin treatments as described hereafter have indeed been shown to be particularly effective to reduce pain in such sub-groups of patients.

As used herein, the wording “fibromyalgia” preferably refers to a health condition characterized by chronic widespread pain present for at least three months in combination with other symptoms affecting quality of life like impaired sleep, mood, and/or cognitive function. In a preferred embodiment, said anti-LPS immunoglobulin or IgY composition is used for treating a patient selected among the sub-group of patients suffering from fibromyalgia and migraine.

In another specific embodiment, said anti-LPS immunoglobulin or IgY composition is used for treating a patient selected among the sub-group of patients suffering from fibromyalgia and irritable bowel syndrome.

As used herein, the wording“irritable bowel syndrome” or“IBS” preferably refers to a chronic functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits in the absence of a specific and unique organic pathology.

In a specific embodiment, the anti-LPS immunoglobulin or IgY composition is preferably used in treating a patient selected from the sub-group of patients with a high Baseline Overall Pain.

Overall Pain may be measured by the patient according to a pain diary as pain perceived during the last 24 hours (1 1 -point numeric rating scale [NRS], 0 =“no pain” and 10 =“worst possible pain”). The Baseline Overall Pain value may be calculated as the mean Overall Pain of the last seven-day time preceding the first day of the treatment. In a specific embodiment, a high Baseline Overall Pain value is superior or equal to 5, for example, superior or equal to 7.

Typically, in certain preferred embodiments, the patient population selected for the anti- LPS immunoglobulin treatment exhibit a statistically significant reduction of Overall Pain after treatment, even when compared to a Placebo.

Anti-LPS immunoglobulin composition

As used throughout the present text and unless otherwise stated, an “anti-LPS immunoglobulin composition” relates to a composition for use in a therapeutic treatment, said composition comprising, as the active principle, a substance or composition made of immunoglobulins or their antigen-binding portions, directed against lipopolysaccharide (LPS) or against micro-organism producing such lipopolysaccharide or their LPS-containing portions.

As used herein, and as well understood in the art,“treatment” is an approach for obtaining beneficial or desired results, including clinical results. Beneficial or desired results can include but not limited to, alleviation or amelioration of one or more symptoms or conditions, diminishment of extent of disease, stabilized (i.e. not worsening) state of disease, preventing spread of disease, delay or slowing of disease progression, reversal of disease, amelioration or palliation of the disease state, and remission (whether partial or total). In specific embodiments, the treatment includes a significant reduction of pain, typically Overall Pain, beyond the pain reduction observed with a Placebo.

In one specific embodiment, such anti-LPS immunoglobulin composition comprises polyclonal antibodies or monoclonal antibodies raised against LPS-expressing microorganism or their LPS-containing portions, more preferably against gram-negative bacteria (in particular, killed bacteria or live attenuated bacteria) or their LPS-containing portions.

As used herein the term“antibody” or“immunoglobulins” includes whole antibodies and any antigen binding fragments or derivatives (i.e., "antigen-binding portion") or single chains thereof. In specific embodiment, such antibody or immunoglobulin may include monoclonal or polyclonal antibodies or immunoglobulins, or immunoglobulins obtained from immunized animals or from recombinant cells, and their antigen-binding portions.

“LPS-producing microorganisms” may typically be selected from gram-negative bacteria, most preferably selected from the group consisting of Streptobacillus (St.) moniliformis, St. meningococcus, Chlamydophila, chlamydia, spirochetes, cyanobacteria, species of the Proteobacteria phylum, in particular Enterobacteriaceae ( Escherichia coli, Salmonella, Shigella, Klebsiella, Proteus, Enterobacter), Pseudomonas bacteria, Legionella bacteria, Neisseria bacteria, Rickettsia bacteria, Pasteurella multocida bacteria and species of the Bacteroidetes phylum

Said LPS-containing portions of LPS-producing microorganism may be antigens capable of raising an immunological response against lipopolysaccharides produced by LPS- producing microorganism (also called LPS antigenic determinants).

In a specific embodiment, said anti-LPS immunoglobulin composition comprises or essentially consists of immunoglobulin A, immunoglobulin D, immunoglobulin E, immunoglobulin M, immunoglobulin G and/or immunoglobulin Y, or their antigen-binding portions.

In a specific embodiment, said anti-LPS immunoglobulin composition comprises bovine IgG, more specifically colostrum-derived bovine IgG, or their antigen-binding portions. In a preferred embodiment, an anti-LPS immunoglobulin composition used as anti-LPS immunoglobulin treatment is an IgY composition, preferably an IgY composition for oral administration. The term“IgY composition” for use according to the present disclosure means a composition comprising, as the main active principle, IgY molecules. Embodiments of such IgY composition are described more in details in the next Section.

IgY composition or egg yolk product as used as anti-LPS immunoglobulin treatment

Avian naturally occurring immunoglobulins are like mammals in having light (L) and heavy (H) chains, bridged by disulphide bonds. In the cases of avians, typically hens, a distinction is made between the immunoglobulins M (IgM), Y (IgY) and A (IgA). IgM has the same function as mammalian IgM. Present in all vertebrates, IgM delivers the first response with its high molecular weight.

Results of recent genetic research suggest that the IgY molecule is phylogenetically a progenitor of mammalian IgG and IgE. Structurally there is a clear difference between IgY and mammalian' IgG, as the heavy chain of hens IgY has an additional constant domain instead of the hinge region of mammalian IgG. So the molecular weight of IgY is higher as compared to IgG. IgY, like mammalian IgG, is the immunoglobulin delivering the second response with its high serum-concentration and low molecular weight. In the literature, the terms IgG and IgY are sometimes used as synonyms as regards hens, so on the basis of the newest findings it has been decided within the framework of an international ECVAM workshop that the term IgY should be used throughout (Schade et al 2005). As used herein however, the term IgY also includes any antigen-binding portions of such IgY.

Preferably, such IgY composition as used in the present disclosure as anti-LPS immunoglobulin treatment are natural IgY as obtained by immunizing avians as described below. IgY antibodies may be obtained from any member of the class Aves, or, in other words, avians. Within the class of Aves, domesticated fowls may be preferred, such as turkey, ducks, ostrich and geese.

As shown in the examples, IgY compositions show remarkable and unexpected efficacy in reducing pain, typically Overall Pain, in patients suffering from fibromyalgia with other comorbidities, including migraine, irritable bowel syndrome or joint diseases. In a preferred embodiment, said anti-LPS immunoglobulin for use according to the present disclosure thus consists of an IgY composition, including polyclonal IgY antibodies raised against gram-negative bacteria, or their antigen-binding portions.

In order to obtain IgY from avians (e.g. hens) (or their eggs), avians, typically hens, may advantageously be immunized by LPS-producing microorganisms, such as gram-negative bacteria, for example, killed or live-attenuated gram-negative bacteria.

In a specific embodiment, said IgY composition, includes IgY or their antigen-binding portions, as obtained from egg yolk of avians, typically hens, immunized with gram negative bacteria or their LPS-containing portions, for example, at least two groups of avians immunized with two distinct gram-negative bacterial species, more specifically, two groups and no more than two groups of avians immunized with two distinct gram-negative bacterial species.

In more specific embodiments, said IgY composition comprises a combination of polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria, and polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, for example for Salmonella typhimurium.

Typically, each species specific IgY composition is obtained from distinct groups of avians immunized with the respective gram-negative bacterial species.

For example, said IgY composition may be obtained by mixing a first egg yolk product obtained from avians immunized with a vaccine against Escherichia bacteria, e.g. said vaccine comprises strains of £. coli bacteria, and, a second egg yolk product obtained from avians immunized with a vaccine against Salmonella bacteria, e.g. of strains of S. typhimurium bacteria.

Another unexpected finding of the present inventors is that therapeutic efficacy can be obtained by mixing egg yolk products from only and no more than two groups of avians immunized with two distinct gram-negative bacteria. In particular, said IgY composition may not comprise egg yolk product obtained by immunizing avians with bacterial toxins such as alpha and beta toxins of Clostridium perfringens. In a preferred sub-embodiment, said IgY composition may not comprise egg yolk product obtained by immunizing avians with bacteria other than £. coli and S. typhimurium. As used herein, the term“egg yolk product” preferably refers to any product that is derived from egg yolk of avians (typically egg yolk of egg-producing hens) and which comprises IgY specific of gram-negative bacteria, in particular IgY specific of either Escherichia or Salmonella bacteria.

In a preferred embodiment, said IgY composition for use as disclosed herein essentially consists of said first and second egg yolk products, and,

the first egg yolk product (with specific Escherichia IgY, preferably E. coli ) represent between 30% and 70% (weight % of the dried powder) of the IgY composition.

The amount of IgY specific of Escherichia or Salmonella bacteria in each egg yolk product respectively may be determined by titration, for example using immunoassays such as ELISA assay, allowing the detection of the binding of IgY to the Escherichia or to Salmonella antigens. Coating antigens for the ELISA are generated from the same antigens as used in the vaccine.

In a specific embodiment, said first egg yolk product contains at least 60% (titer based activity percent) of (polyclonal) IgY specific for Escherichia, e.g. for E. coli, and said second egg yolk product contains at least 40% (titer based activity percent) of (polyclonal) IgY specific for Salmonella, e.g. for S. typhimurium.

Preferably, the minimum titer of IgY specific of Escherichia bacteria antigens in the first egg yolk product is 1024, 512 or 256 and the minimum titer of IgY specific Salmonella bacteria antigens in the second egg yolk product is 512, 256 or 128, said minimum titers being measured using ELISA assay with the antigens used in the respective vaccine for immunizing the avians.

In specific embodiments, the egg yolk is an egg yolk powder. Egg yolk powder may be obtained using techniques well-known in the art. For example, most eggs are spray-dried by heating at an inlet temperature between 121 °C and 232°C. Atomizing is accomplished by spraying with high-pressure nozzles [500--6000 psi (Ib/in. 2)] into a hot-air stream that evaporates water instantly. Generally, indirect heating such as steam coils are preferred to prevent off-flavors or formation of nitric oxides, which may be formed by direct heat using natural gas or propane. Powder separates from the drying chamber, and the air is removed by an exhaust fan. After drying, the powder is cooled and sifted prior to packaging. Both horizontal and vertical spray driers are used today. Such egg yolk powder may also be advantageously pasteurized.

The IgY composition obtained from egg yolk may also comprise, for example, lipoproteins, such as HDL and LDL, and the water-soluble proteins of the egg yolk, olivetin (80 kDa), b-livetin (45 kDa) and/or y-livetin (150 kDa), which also comprise most of the enzymes found in the egg (Ternes, Acker and Scholtyssek, Ei und Eiprodukte, 1994).

In certain embodiments, the egg yolk product is a delipidated or partially delipidated egg yolk powder. The term“partial delipidation” refers to a step of reducing fat and cholesterol content from the egg yolk material. For example, at least a reduction of 50%, 60%, 70%, 80%, or even at least 90% of fat is obtained by partial delipidation. Similarly, at least a reduction of 50%, 60%, 70%, 80%, or even at least 90% of cholesterol is obtained by partial delipidation. Such step of partial delipidation is not mandatory but may be needed for patients at risk for products with fat and cholesterol contents.

Delipidated or partially delipidated egg yolk powder is obtained by standard processes (removal of fat from liquid egg yolk or dried egg yolk powder), preferably by using ultrafiltration, water dilution, filtration, gel electrophoresis, chromatography, hexane or supercritical C0₂.

The present disclosure also relates to the IgY compositions as described above and their use as a drug. The IgY compositions as described above are particularly useful for treating patients suffering from fibromyalgia with at least one co-morbidity selected among migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders, in particular with comorbidity selected among migraine, irritable bowel syndrome and joint diseases.

The disclosure also relates to the methods of manufacturing such IgY compositions in the preparation of a drug for use in treating fibromyalgia with at least one co-morbidity selected among migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders, in particular with comorbidity selected among migraine, irritable bowel syndrome and joint disease.

In a specific embodiment, the disclosure relates to an IgY composition for use as a drug in patients, obtained by mixing a first egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria, a second egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria, wherein said IgY composition essentially consists of said first and second egg yolk product, and, wherein the first egg yolk product represent between 30% and 70% (weight percent) of the IgY composition.

In another specific embodiment, the disclosure relates to an IgY composition for use as a drug in patients, obtained by mixing a first egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria,

a second egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria, wherein said first egg yolk product contains at least 60% (titer based activity percent) of (polyclonal) IgY specific for Escherichia, e.g. for £. coli, and said second egg yolk product contains at least 40% (titer based activity percent) of (polyclonal) IgY specific for Salmonella, e.g. for S. typhimurium.

In specific sub-embodiments of the previous embodiment, said first and second egg yolk product are dried egg yolk powder, optionally formulated as a drink or capsule for oral administration.

The vaccine for use in immunizing avians

As explained above, the IgY composition for use as disclosed herein may be prepared by immunizing at least two distinct groups of avians, typically two groups of hens, for example one with a vaccine against Escherichia bacteria and a second with a vaccine against Salmonella bacteria. The bacteria which serve as immunogens in the vaccines are preferably killed or live attenuated.

As used herein, the term“vaccine against bacteria” refers to a composition that is capable of inducing an immune response in an avian for the production of IgY in their eggs, said IgY specifically recognizing antigens of such bacteria.

In one specific embodiment, said vaccine of Escherichia bacteria comprises an immunogenic amount of inactivated Escherichia bacteria, preferably inactivated strains of Escherichia coli, and, optionally, one or more adjuvant and excipients. In another specific embodiment that may be combined with the previous embodiment, said vaccine of Salmonella bacteria comprises an immunogenic amount of inactivated Salmonella bacteria, preferably inactivated strains of Salmonella typhimurium, and, optionally, one or more adjuvants and excipients.

Methods for preparing vaccine for avians in order to obtain IgY products are well known in the art and described for example in Marcq et al. 2013, Vol 17(3) 483-493.

For example, the vaccine is prepared by the following steps:

1 ) growing the bacteria, Salmonella or Escherichia in a suitable growth medium,

2) adding an efficient amount of an inactivating compound in the growth medium, e.g.

0.5% formalin, in order to inactivate (kill) the bacteria,

3) collecting the inactivated bacteria,

4) optionally washing the inactivated bacteria,

5) resuspending an immunogenic amount of said inactivated bacteria in a suitable vehicle, optionally together with other adjuvants and/or excipients, thereby obtaining a vaccine against such bacteria for IgY production.

The immunogenic amount of the inactivated bacteria is optimized by the skilled person, typical amount of inactivated bacteria to be administered in a given vaccine dose is in the range of 0.01 mg to 1 mg, or 10⁸ - 10¹⁰ colony forming units/dose.

In order to ensure effective immune response, the antigen solution comprising the inactivated bacteria may be combined with an adjuvant. The adjuvant may be selected among adjuvants well-known in the art (for a review see e.g. Stills, 2005 or Wison-Welder et al 2009). One example of a suitable adjuvant is the Freund’s incomplete adjuvant or any other water in oil emulsion.

In preferred embodiments, high yield IgY production in the egg (also referred as hyperimmune egg product) is achieved by administering an initial immunizing amount of the vaccine to the avian (e.g. hens), followed by periodic boosters with the immunogens to produce IgY in the egg product. For example, IgY production in the egg may be obtained by repeated booster administration of an appropriate dosage at fixed time intervals, for example 1-10 weeks intervals. The immunization schedules and parameters to be considered in order to optimize IgY production are well known in the art and for example reviewed in Marcq et al. 2013, Vol 17(3) 483-493. Formulations of anti-LPS or IgY composition and their combined use with other therapeutic agents

The anti-LPS or IgY compositions for use as disclosed above can be formulated for a topical, oral, intranasal, intraocular, intravenous, intramuscular or subcutaneous administration and the like. Preferably, the anti-LPS or IgY compositions can be formulated for an oral administration.

The pharmaceutical compositions can take the form of powders, tablets, pills, capsules, semisolids, sustained release formulations, solutions, suspensions, emulsions, syrups, elixirs, aerosols, or any other appropriate compositions; and comprise at least the anti-LPS immunoglobulins or preferably the IgY compositions as described in the previous sections.

In a specific embodiment, an oral formulation of an IgY composition for use according to the present disclosure is a powder (for example, packaged as a fixed dose sachet of 2 g) or a drink, typically comprising diluted egg yolk powder.

Alternatively, because of their ease in administration, tablets and capsules may represent advantageous oral dosage unit form, in which case solid pharmaceutical carriers are obviously employed. If desired, tablets may be sugar coated or enteric coated by standard techniques. The tablets or pills can be coated to provide a dosage form affording the advantage of prolonged action. For example, the tablet or pills can comprise an inner dosage and an outer dosage component, the latter being in the form of an envelope over the former. The two components can be separated by an enteric layer, which serves to resist disintegration in the stomach and permits the inner component to pass intact into the duodenum or to be delayed in release. A variety of material can be used for such enteric layers or coatings, such materials including a number of polymeric acids with such materials as shellac, cetyl alcohol and cellulose acetate.

Suitable carrier materials are not only inorganic carrier materials, but also organic carrier materials. Thus, for example, lactose, corn starch or derivatives thereof, talc, stearic acid or its salts can be used as carrier materials for tablets, coated tablets, dragees and hard gelatine capsules. Suitable carrier materials for soft gelatine capsules are, for example, vegetable oils, waxes, fats and semi-solid and liquid polyols (depending on the nature of the active ingredient no carriers might, however, be required in the case of soft gelatine capsules). Suitable carrier materials for the production of solutions and syrups are, for example, water, polyols, sucrose, invert sugar and the like. Suitable carrier materials for injection solutions are, for example, water, alcohols, polyols, glycerol and vegetable oils. Suitable carrier materials for suppositories are, for example, natural or hardened oils, waxes, fats and semi-liquid or liquid polyols. Suitable carrier materials for topical preparations are glycerides, semi-synthetic and synthetic glycerides, hydrogenated oils, liquid waxes, liquid paraffins, liquid fatty alcohols, sterols, polyethylene glycols and cellulose derivatives.

Usual stabilizers, preservatives, wetting and emulsifying agents, consistency-improving agents, flavor-improving agents, salts for varying the osmotic pressure, buffer substances, solubilizers, colorants and masking agents and antioxidants come into consideration as pharmaceutical adjuvants.

The doses used for the administration can be adapted as a function of various parameters, and in particular as a function of the mode of administration used, of the relevant pathology, or alternatively of the desired duration of treatment. It will be appreciated that appropriate dosages of the compositions comprising the anti-LPS immunoglobulins or IgY, can vary from patient to patient. Determining the optimal dosage will generally involve the balancing of the level of therapeutic benefit against any risk or deleterious side effects of the treatments described herein. The selected dosage level will depend on a variety of factors including, but not limited to, the activity of the particular compound, the route of administration, the time of administration, the rate of excretion of the compound, the duration of the treatment, other drugs, compounds, and/or materials used in combination, and the age, sex, weight, condition, general health, and prior medical history of the patient. The amount of compound and route of administration will ultimately be at the discretion of the physician, although generally the dosage will be to achieve local concentrations at the site of action which achieve the desired effect without causing substantial harmful or deleterious side effects.

For adult patients a daily dosage of about 1 to 10 g of a product consisting of dried egg yolk powder, especially about 2 to 8 g, for example 4 g may be considered. Depending on severity of the disease and the precise pharmacokinetic profile the compound could be administered with one or several daily dosage units, e.g. in 1 to 3 dosage units, typically 4 g / day administered as 2 g twice daily.

The treatment may be carried out with a daily administration for at least 6 weeks.

In addition, the anti-LPS immunoglobulin or IgY composition for use according to the present disclosure may also be useful in combination or association, simultaneously, separately or sequentially with another agent for preventing or treating fibromyalgia, migraine, or an associated disorder.

Examples of such known compounds include but are not limited to analgesic compounds in order to reduce pain sensation, including without limitation paracetamol (acetaminophen). Other compounds used for treatment belong to the therapeutic classes of anti-depressants (e.g. amitriptyline, duloxetine, milnacipran) and anti-epileptics (e.g. pregabalin).

As used herein, the term“combination” refers to either a fixed dose combination in one unit dosage form, non-fixed dose combination, or a kit of parts for the combined administration where the anti-LPS immunoglobulin or IgY composition, and one or more combination partners (e.g. another analgesic compound) may be administered independently at the same time or separately within time intervals.

The term“fixed dose combination” means that the active ingredients are both administered to a patient simultaneously in the form of a single entity or dosage.

The term “non-fixed dose combination” means that the active ingredients, e.g. IgY composition, and one or more combination partners (e.g. analgesic compound), are both administered to a patient as separate entities either simultaneously or sequentially, with no specific time limits, wherein such administration provides therapeutically effective levels of the two compounds in the body of the patient.

Additionally, the methods described herein may also include co-administration of at least one other therapeutic agent for the treatment of another disease directly or indirectly related to fibromyalgia, including but not limited to: migraine, irritable bowel syndrome and/or joint diseases.

Such additional therapeutic agents include, but are not limited to, non-steroidal anti inflammatory drugs (NSAIDs), triptans, cannabinoids, prebiotics and/or probiotics.

The terms“co-administration” or“combined administration” as used herein, are meant to encompass administration of the selected combination partner to a single patient therein, and are intended to include treatment regimens in which the agents are not necessarily administered by the same route of administration or at the same time.

The term“jointly therapeutically effective” means that the therapeutic agents may be given separately (in a chronologically staggered manner, especially a sequence-specific manner) in such time intervals to show a (preferably synergistic) interaction (i.e. joint therapeutic effect).

The following examples further illustrate preferred embodiments of the disclosed IgY compositions and their use. EXAMPLES

1. Preparation of IgY compositions and modes of administration

Step 1 : Production of immunizing antigen

Purpose: Production of antigen-formulation inducing high humoral response specific for Escherichia coli and Salmonella typhimurium Escherichia coli and Salmonella typhimurium were grown in tryptic soya broth in Erlenmeyer Flasks. The bacteria were inactivated by addition of 0,5% Formalin and incubation. The antigen was concentrated by centrifugation and washed with phosphate buffered saline. Inactivated antigen was emulsified with mineral oil containing adjuvant to give a water in oil emulsion. Step 2: Immunization of layer chickens

Purpose: immunize layer chickens in a manner to induce high and long lasting humoral immune response to the antigens

With each immunizing antigen a group of layer chickens was repeatedly immunized at intervals of 1-10 weeks. Eggs were collected from 2 weeks after second immunization. Eggs were stored cooled until further processing

Step 3: Separation of eggs, pasteurization and spray drying

Purpose: Partial purification of the antibodies by removing albumen and egg shell.

Reduction of bioburden within the product (pasteurization) and stabilization of the matrix and antibodies) by rapid drying (stop microbial growth, enzymatic activities). The collected eggs from each group were submitted to a commercial harvesting procedure. Eggs were broken in an automatic machine and egg yolk and albumen were separated. The yolk material was homogenized and filtered. The material was immediately pasteurized in a continuous pasteurizer at 142°F (61 ,1 °C) for 3,5 minutes.

After pasteurization the egg yolk was spray dried in a commercial process (inlet temperature 250°F = 121 , 1 °C, outlet temperature 175°F = 79,4°C, duration 8 minutes). Egg yolk powder was filled in plastic backs, packed in boxes and transferred at ambient temperatures.

Step 4: Partial de-lipidation of egg yolk powder

Purpose: Reduction of fat- and cholesterol content for patients at risk

The egg yolk powder was resuspended in Ethanol, stirred and filtered. The retentate was introduced in a supercritical fluid extractor. Extraction of the lipids was performed at 104°F (40°C) for 3 hours using supercritical carbon dioxide at 150 bar.

Step 5: Mixing

Purpose: Production of homogeneous mixture, that uniformly contains the intended content of antibodies for both antigens The partially de-lipidated egg yolk powders of each specimen ( ant\-Escherichia coli and anti -Salmonella typhimurium) were mixed according to their respective monospecific antibody titres. The homogenous powder was filled into drums.

Step 6: Primary packaging

Purpose: Allow safe and protected storage (light, humidity) as well as proper dosage The mixed partially de-lipidated egg yolk powder was filled into sachets of 2 g.

The primary packaging material was 3-layer foil (PET/Alu/PE) offering protection from light and humidity.

Step 7: Administration

The medication was recommended to be administered in a milk product such as Ayran and Yoghurt in order to have some taste masking and to allow suitable intake. 2. Clinical Protocol: Randomized, double-blind, Placebo-controlled exploratory trial to investigate safety and efficacy of an IgY composition, IGN-ES001, in patients with chronic widespread pain with or without Fibromyalgia

A clinical trial was conducted to assess safety and efficacy of an IgY composition in patients with chronic widespread pain with or without fibromyalgia.

A total of 23 centers in Turkey took part in the trial; 22 of them randomized totally 230 patients.

The details of the clinical trials and a summary of the main results are given hereafter:

Main Criteria for Inclusion: Patients must have met ALL of the following criteria:

1. Male or female out-patient > 18 years and < 70 years of age.

2. Patient willing and able (e.g. mental and physical condition) to participate in all aspects of the trial, including use of investigational product, subjective completion of diaries and questionnaires, attending scheduled visits, completing telephone interviews, and compliant with protocol requirements as evidenced by providing signed written informed consent.

3. History of Chronic Widespread Pain (for at least three months prior to Screening visit V1 ).

4. a.) For Fibromyalgia (FM) patients: Widespread Pain Index (WPI) > 7 and Symptom Severity (SS) > 5 or WPI 3-6 and SS > 9 (original preliminary Fibromyalgia criteria of the American College of Rheumatology (ACR) 2010).

4. b.) For non-FM Chronic Widespread Pain (CWP) patients: WPI 3-6 and SS 5-8 (modified from the preliminary Fibromyalgia criteria of the ACR 2010).

5. Use of prior and concomitant medications/ therapies (if not excluded, see exclusion criteria no 6 and no 7), non-pharmacological therapies and lifestyle habits (e.g. diet changes, Ramadan participation, etc.) that could influence the efficacy assessments must have been stable for at least 30 days prior to Screening visit V1 and were anticipated to be at a stable regimen throughout the trial until visit V9. Main Criteria for Exclusion:

Patients were to be excluded from the trial for ANY ONE of the following reasons:

1. Patients without a basic and stable CWP therapy, which started at least 30 days before Screening visit V1 , i.e. treatment-naive patients, first diagnosis 6. Immune response modulating medication/ therapy, e.g. systemic corticosteroids, antibodies other than investigational product from a period starting 90 days before Screening visit V1

7. WHO step-ll and step-ill opioids (except occasional use of codeine as cough medication) from a period starting 60 days before Screening visit V1 Duration of T reatment for the Individual Patient:

6 weeks

Test Product, Dose and Mode of Administration:

2 g partially delipidated avian egg yolk powder - containing polyclonal avian immunoglobulin IgY with specific IgY against Escherichia coli (E. coli F18ab) and Salmonella typhimurium (S. typhimurium), said egg yolk powder being obtained as described above in the Examples“Preparation of an IgY composition”.

Application and dosing: Sachet containing a fixed 2 g dosage of IGN-ES001. One entire 2 g fixed dose sachet twice daily (bid). Oral application.

Reference Product, Dose and Mode of Administration: Placebo matching IGN-ES001 partially delipidated avian egg yolk powder.

2 g partially delipidated avian egg yolk powder - containing polyclonal avian

immunoglobulin IgY with unspecific IgY.

Application and dosing: Sachet containing a fixed 2 g dosage of Placebo, one entire 2 g fixed dose sachet twice daily (bid). Oral application. Rescue Medication: ®

Paracetamol/ acetaminophen 500 mg/ tablet (Parol ) was available as rescue

medication for relieving pain. The permitted maximum doses were

1 tablet or 500 mg per single dose intake

- 4 tablets or 2000 mg per day

- 4 tablets or 2000 mg per day on 4 consecutive days in a 7-day period

16 tablets or 8000 mg on 7 consecutive days

Patients were not allowed to take rescue medication within 24 hours prior to an on-site visit.

Criteria for Evaluation: Efficacy:

Pain intensity was assessed and documented by the patient in a pain diary once daily in the evening after dinner and after having taken the investigational product. The patient judged and quantified the pain level according to the 11 -point numeric rating scale whereby 0 = “no pain” and 10 = “worst possible pain”. Accordingly, the patient self- assessed and noted down the pain perceived during the last 24 hours into the pain diary. The patient did that for each of the three pain sites and two activity levels as well as for the Overall Pain resulting in a total of six numbers or pain qualities and the Overall Pain between 0 and 10 per day.

Other efficacy assessments included the Revised Fibromyalgia Impact Questionnaire (FIQ-R), Short-Form-36 Quality-of-Life questionnaire version 2 (SF-36v2™), Medical Outcomes Study-Sleep Scale (MOS-SS), Fatigue Severity Scale (FSS) and Patient Global Impression of Change (PGIC).

Comorbidities:

The presence of three frequent comorbidities (e.g. Irritable Bowel Syndrome, Migraine, Joint Diseases) was documented at Screening visit V1. At the end of treatment visit V9 the patient was asked if any of the comorbidities present at visit V1 had changed.

Safety:

The safety assessments included Adverse Events, physical examinations, vital signs and safety laboratory tests. Statistical Methods:

Sample size estimation:

Estimation of sample size was based on the primary efficacy variable (percent change of Overall Pain from Baseline to visit V9). A Wilcoxon-Mann-Whitney test for superiority of the trial treatment IGN-ES001 as compared to Placebo at level 0.025 one-sided (corresponding to level 0.05 two-sided), based on the robust Mann-Whitney statistic as MW = 0.64 (“medium-sized” superiority in accordance to Cohen benchmarks), achieves a power of 90% with a sample size of 2 x 92 patients per group. The sample size was enhanced by 25% due to usual ambiguities of multicenter chronic pain studies (drop out, rescue medication, center variability, etc.), resulting in a total sample size of 230 patients.

The following procedures were operationalized before unblinding the trial:

First Line Efficacy Analysis Although this trial was intended to be of exploratory nature, the first line analysis was based on confirmatory principles.

To address the multidimensional breadth of pain recovery in patients with Chronic Widespread Pain / Fibromyalgia, a multidimensional pain endpoint was defined in the statistical analysis plan as primary hypothesis, combining the various pain dimensions by a global, multidimensional, correlation-sensitive approach:

1. Pain, combined dimensions (Overall Pain, Pain at Rest, Pain Perceived During Physical Strain, SF-36v2^m subscale Bodily Pain), multivariate analysis, generalized Wilcoxon-Mann- Whitney test (Wei-Lachin procedure).

Additionally, three subsequent hypotheses were defined as co-primary, to be evaluated in hierarchically order:

2. Overall Pain, final percent change from Baseline, univariate analysis, Wilcoxon-Mann-Whitney test 3. ‘Pain at Rest’ and ‘Pain Perceived During Physical Strain’, final percent change from Baseline, multivariate analysis, generalized Wilcoxon-Mann- Whitney test (Wei-Lachin procedure)

4. Pain, final responder rate (percent decrease from Baseline of Overall Pain ³ 30%), Unconditional Exact Roehmel-Mansmann test

This way, multiplicity was controlled by means of the principle of a priori ordered hypotheses. The procedure of a priori ordered hypothesis is most powerful with full control of alpha (for control of alpha using stepwise testing, see Maurer W, Hothorn LA, LehmacherW 1995).

The effect size measure directly associated to the Wilcoxon-Mann- Whitney test (WMW test) is the Mann-Whitney estimator (MW). It is a robust but highly sensitive effect size measure to determine the magnitude and direction of the treatment effects.

Technically, the MW gives the probability that a randomly chosen patient of the test group has a better outcome than a randomly chosen patient of the comparison group (with the probability ranging from 0 to 1 , with 0.5 indicating equality); it is statistically defined as: P (X<Y) + 0.5 P (X=Y).

The relevant benchmarks for the Mann-Whitney effect size measure (MW) are as follows:

• 0.29 large inferiority

• 0.36 medium-sized inferiority

• 0.44 small inferiority

• 0.50 equality

• 0.56 small superiority

• 0.64 medium-sized superiority

• 0.71 large superiority

In addition, results were provided per treatment group by means of classic and robust descriptive statistics.

The multiple level alpha of the trial (global level for the whole trial) was defined as alpha = 0.025, one-sided test for superiority, corresponding to a two-sided test with alpha = 0.05. For practical reasons, P-values were provided two-sided, with two-sided 95% confidence intervals. Clinical Target Populations

Recent research highlighted the importance of comorbidities in Fibromyalgia and concluded that there is a clear need for more evidence for adults with Fibromyalgia and multiple comorbidity conditions (Agency for Healthcare Research and Quality [AHQR] Treatments for Fibromyalgia in Adult Subgroups. AHQR Publication No. 15-EHC-006- EF 2015). Thus, before unblinding, four clinically relevant target subsets were defined in the final statistical analysis plan to assess the efficacy profile in the presence of common accompanying diseases. The analyses were to be performed for all endpoints of the first line analysis, applying the same procedures:

1. Clinical Target Population Any Comorbidity (at least one comorbidity)

2. Clinical Target Population High Disease Activity (at least one or a combination of the comorbidities Irritable Bowel Syndrome, Migraine and/or Joint Diseases and Baseline Overall Pain > 7)

3. Clinical Target Population Migraine

4. Clinical Target Population Irritable Bowel Syndrome

Second Line Efficacy Analysis

1. Responder rate, alternative definition (based on diary)

2. Change in FIQ-R score from Baseline

3. Change in SF-36v2™ score from Baseline

4. Change in MOS-SS score from Baseline

5. Change in FSS score from Baseline

6. PGIC

7. Consumption of rescue medication

8. Time to first rescue medication (days)

9. Combined, correlation-sensitive analysis of all efficacy endpoints (generalized

Wilcoxon-Mann-Whitney test, Wei- Lachin procedure)

3. RESULTS

Efficacy Results:

Treatment groups were similar with respect to demographic criteria. Regarding anamnestic characteristics a significant Baseline inferiority of the IGN-ES001 group was found in the complete FAS population (‘Combined anamnestic criteria’, P_combine = 0.0060, two-sided, generalized Wilcoxon-Mann-Whitney test), with more severe cases in the IGN-ES001 group and less severe cases in the Placebo group. This Baseline inhomogeneity in the complete FAS population was absent in the more homogeneous predefined clinical target subsets (all P_combined > 0.4, two-sided). The‘Combined pain dimensions’ revealed no statistically significant differences in the complete FAS population (P_combined > 0.2, two-sided), however, in three of the four predefined clinical target subsets statistically significant superiority of IGN-ES001 as compared to Placebo was shown:

Any Comorbidity. MW = 0.60, P_combine = 0.0475, two-sided High Disease Activity: MW = 0.68, P_combined = 0.007, two-sided

Migraine: MW = 0.65, P_combine = 0.0457, two-sided

Floor effects in the complete FAS population (reduced assay sensitivity), and a worse anamnestic Baseline status in the IGN-ES001 group might have contributed to the failed result as compared to the positive results in the three responsive clinical target populations.

In the complete FAS population, Overall Pain decreased by -15% (median) in both treatment groups (P > 0.2, two-sided, Wilcoxon-Mann- Whitney test). The Per Protocol (PP) set, slightly less burdened with Baseline inhomogeneity, shows a median percent decrease of -17.5% in the IGN-ES001 group as compared to -13.7% in the Placebo group (P > 0.2), with superiority of IGN-ES001 in two of the predefined four clinical target subsets (P < 0.05, two-sided P-values):

Target Population Any Comorbidity: median Overall Pain decrease -16.3% in the IGN- ES001 group as compared to -7.3% in the Placebo group in FAS (P = 0.1948) and - 18.0% versus -6.4% in PP (P = 0.0887). Target Population High Disease Activity: median Overall Pain decrease -19.8% in the IGN-ES001 group as compared to -7.3% in the Placebo group in FAS (P = 0.0710) and - 20.1 % versus -6.0% in PP (P = 0.01 16). Target Population Migraine : median Overall Pain decrease -21.5% in the IGN-ES001 group as compared to 0.0% (!) in the Placebo group in FAS (P = 0.1532) and -22.7% versus 0.0% (!) in PP (P = 0.0434).

Target Population Irritable Bowel Syndrome : median Overall Pain decrease -18.4% in the IGN-ES001 group as compared to -8.3% in the Placebo group in FAS (P = 0.4714) and -20.1 % versus -8.3% in PP (P = 0.4443).

The predefined responder analysis (at least 30% decrease of Overall Pain from Baseline) revealed a clinically relevant group difference of 20.2% in FAS for the target population High Disease Activity with 30.8% responders in IGN-ES001 versus 10.5% responders in Placebo (FAS), and a group difference of 30.4% in the corresponding PP set (30.4% responders in IGN-ES001 versus 0.0% responders in Placebo).

Regarding the secondary efficacy criteria, there were no statistically significant differences in the complete FAS population. However, with respect to the predefined clinical target subsets, single statistically significant results were only observed in favor of the IGN-ES001 group, no single significant result was observed in favor of the Placebo group.

Safety Results:

Altogether, 194 out of 229 patients of the Safety population (84.7%) suffered from 335 Adverse Events. At least one Adverse Event was experienced by 100 patients out of 1 15 patients (87.0%) of the IGN-ES001 group, and by 94 patients out of 114 patients (82.5%) of the Placebo group The differences between the two treatment groups can easily be explained by random variation (P = 0.3845, Unconditional Exact Roehmel- Mansmann test, two-sided, Safety population).

The most common Adverse Event was“Headache” (170) with 63 events in 35/ 115 patients in the IGN-ES001 group and with 107 events in 34/ 1 14 patients in the Placebo group. The differences between the two treatment groups regarding the number of patients with “Headache” are easily explained by random fluctuation (P = 0.9667, Unconditional Exact Roehmel-Mansmann test, two-sided, Safety population).

A sensitivity analysis based on patients with at least one Adverse Event“Headache” and/or at least one Adverse Event “Migraine” showed again only marginal group differences with such 39 patients (33.9%) in the IGN-ES001 group and 36 patients (31.6%) in the Placebo group (P = 0.7396, Unconditional Exact Roehmel-Mansmann test, two-sided, Safety population).

No Serious Adverse Events were reported by any patient and in any treatment group. There were no fatal Adverse Events. Out of 115 patients of the IGN-ES001 group, a total of 7 patients (6.1 %) discontinued the trial prematurely due to Adverse Events or due to the combination of an Adverse Event with‘Lack of Efficacy’ as compared to 9 out of 114 patients of the Placebo group (7.9%).

In general, an excellent safety and tolerability can be assessed for IGN-ES001.

In conclusion, for the primary efficacy hypothesis (‘Combined pain dimensions’), superiority of IGN-ES001 compared to Placebo could not be proven in the complete FAS population. Floor effects in the complete FAS population (reduced assay sensitivity), and a worse anamnestic Baseline status in the IGN-ES001 group might have contributed to the failed overall result.

By contrast, superiority of IGN-ES001 as compared to Placebo could be well demonstrated in the following three of four predefined clinical target populations:

Any Comorbidity : MW = 0.60, P = 0.0475, two-sided

High Disease Activity: MW = 0.68, P = 0.007, two-sided

Migraine: MW = 0.65, P = 0.0457, two-sided

The results of this exploratory trial are promising, and both efficacy and safety results suggest a favorable benefit-risk relation.

4. Discussion and overall conclusions

A multicenter, randomized, double-blind, Placebo-controlled exploratory trial was performed to investigate efficacy and safety of the IgY composition IGN-ES001 during six weeks of treatment in patients with Chronic Widespread Pain (CWP) with or without Fibromyalgia (FM).

Overall, 230 patients were randomized in 22 centers in Turkey and all except one patient in the Placebo group received at least one dose of investigational medication. Hence, the Safety set consists of 229 randomized patients (IGN-ES001 : 1 15 patients, Placebo: 114 patients).

With respect to demographic criteria the treatment groups are well comparable. Regarding anamnestic characteristics a significant Baseline inferiority of the IGN-ES001 group was found in the complete FAS population (combined anamnestic criteria, P_combine = 0.0060, two-sided, generalized Wilcoxon-Mann-Whitney test), with less severe cases in the Placebo group. This Baseline inhomogeneity was solved in the predefined clinical target subsets (all P_combined > 0.4, two-sided).

While the‘Combined pain dimensions’ revealed no statistically significant differences in the complete FAS population (P_combined > 0.2, two-sided), three of the four predefined clinical target subsets showed statistically significant superiority of IGN-ES001 as compared to Placebo:

Any Comorbidity. MW = 0.60, P_combine = 0.0475, two-sided

High Disease Activity: MW = 0.68, P_combine = 0.007, two-sided

Migraine: MW = 0.65, P_combine = 0.0457, two-sided

Floor effects in the complete FAS population (reduced assay sensitivity), and a worse anamnestic baseline status in the IGN-ES001 group might have contributed to the failed result as compared to the positive results in the three responsive clinical target populations listed above.

The primary single efficacy endpoint was the Overall Pain, assessed and documented by the patient in a pain diary as pain perceived during the last 24 hours. In the complete FAS population, Overall Pain decreased by -15% in both treatment groups (medians; P > 0.2, two-sided, Wilcoxon-Mann-Whitney test). The Per Protocol (PP) set, slightly less burdened with Baseline inhomogeneity, shows a median percent decrease of -17.5% in the IGN-ES001 group as compared to -13.7% in the Placebo group (P > 0.2, two-sided), with superiority of IGN-ES001 in two of the predefined four clinical target subsets (P < 0.05, two-sided P-values):

Any Comorbidity. median Overall Pain decrease -16.3% in the IGN-ES001 group as compared to -7.3% in the Placebo group in FAS (P = 0.1948, two-sided) and -18.0% versus -6.4% in PP (P = 0.0887, two-sided); High Disease Activity: median Overall Pain decrease -19.8% in the IGN-ES001 group as compared to -7.3% in the Placebo group in FAS (P = 0.0710, two-sided) and -20.1% versus -6.0% in PP (P = 0.01 16, two-sided);

Migraine : median Overall Pain decrease -21.5% in the IGN-ES001 group as compared to 0.0% (!) in the Placebo group in FAS (P = 0.1532, two-sided) and -22.7% versus 0.0% (!) in PP (P = 0.0434, two-sided);

Irritable Bowel Syndrome : median Overall Pain decrease -18.4% in the IGN-ES001 group as compared to -8.3% in the Placebo group in FAS (P = 0.4714, two-sided) and -20.1% versus -8.3% in PP (P = 0.4443, two-sided). Thus, the patient group with the highest burden of disease (predefined clinical target subset High Disease Activity) also showed the strongest treatment effects. Median pain decreases of -21.45% versus 0% (FAS) and -23.7% versus 0% (PP) in combination with differences in responder rates of 20.2% (IGN-ES001 versus Placebo, FAS) and 30.4% (IGN-ES001 versus Placebo, PP) suggest remarkable treatment potentials. With respect to Adverse Events, treatment groups were similar with regard to frequency, relationship, distribution, intensity, or premature termination. No Serious Adverse Events were reported by any patient in any treatment group. There were no fatal Adverse Events. There were no relevant differences between the treatment groups for any hematology and biochemistry parameter. Vital signs parameters remained stable during the trial.

Overall, all reported AEs are considered as not being clinically relevant. An excellent safety and tolerability can be assessed for IGN-ES001.

Claims

1. An anti-LPS immunoglobulin composition for use in the treatment of a patient suffering from fibromyalgia and at least one comorbidity selected among the following diseases: migraine, irritable bowel syndrome, joint diseases, bladder abnormalities, cognitive dysfunction, psychiatric conditions, and stress-related disorders.

2. The anti-LPS immunoglobulin composition for use according to Claim 1 , wherein said patient is suffering from fibromyalgia and migraine.

3. The anti-LPS immunoglobulin composition for use according to Claim 1 , wherein said patient is suffering from fibromyalgia and irritable bowel syndrome.

4. The anti-LPS immunoglobulin composition for use according to any one of Claims 1-3, wherein said anti-LPS immunoglobulin treatment is an IgY composition, preferably an IgY composition for oral administration.

5. The anti-LPS immunoglobulin composition for use according to Claim 4, wherein said IgY composition comprises a combination of polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria, and polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria.

6. The anti-LPS immunoglobulin composition for use according to any one of Claims 4-5, wherein said IgY composition is obtained by mixing

a first egg yolk product obtained from avians immunized with a vaccine against Escherichia bacteria, e.g. of inactivated strains of £. coli bacteria, a second egg yolk product obtained from avians immunized with a vaccine against Salmonella bacteria, e.g. of inactivated strains of S. typhimurium bacteria.

7. The anti-LPS immunoglobulin composition for use according to Claim 6, wherein said IgY composition essentially consists of said first and second egg yolk products, and,

the first egg yolk product represent between 30% and 70% (weight percent) of the IgY composition.

8. The anti-LPS immunoglobulin composition for use according to Claim 6 or 7, wherein said first and second egg yolk products are egg yolk powders, optionally partially delipidated.

9. The anti-LPS immunoglobulin composition for use according to any one of Claims 6-8, wherein said first egg yolk product contains at least 60% (titer based percent) of IgY specific for Escherichia, e.g. for E. coli, and said second egg yolk product contains at least 40% (titer based percent) of IgY specific for Salmonella, e.g. for S. typhimurium.

10. The anti-LPS immunoglobulin composition for use according to any one of Claims 6-9, wherein said vaccine against Escherichia bacteria comprises an immunogenic amount of inactivated Escherichia bacteria, preferably inactivated strains of Escherichia coli, and, optionally, one or more adjuvant and excipients.

1 1. The anti-LPS immunoglobulin composition for use according to any one of Claims 6-10, wherein said vaccine against Salmonella bacteria comprises an immunogenic amount of inactivated Salmonella bacteria, preferably inactivated strains of Salmonella typhimurium, and, optionally, one or more adjuvant and excipients.

12. The anti-LPS immunoglobulin composition for use according to any one of Claims 6-1 1 , wherein said patient receives a daily dose of said anti-LPS immunoglobulin composition of 1 to 10 g/day, 2 to 8 g/day, for example 4 g/day, typically 2 g administered twice daily.

13. The anti-LPS immunoglobulin composition for use according to any one of Claims 6-12, wherein a treatment is carried out by a daily administration for at least 6 weeks.

14. An IgY composition for use as a drug in patients, obtained by mixing

a first egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Escherichia bacteria, e.g. for E. coli bacteria,

a second egg yolk product comprising polyclonal avian immunoglobulin IgY specific for Salmonella bacteria, e.g. for S. typhimurium bacteria, wherein said IgY composition essentially consists of said first and second egg yolk product, and, wherein the first egg yolk product represent between 30% and 70% (weight percent) of the IgY composition.

15. The IgY composition for use according to Claim 14, wherein said first and second egg yolk product are dried egg yolk powder, optionally formulated as a drink or capsule for oral administration.