Classifications

• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/24—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against cytokines, lymphokines or interferons
  • C07K16/244—Interleukins [IL]
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/395—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/22—Heterocyclic compounds, e.g. ascorbic acid, tocopherol or pyrrolidones
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P1/00—Drugs for disorders of the alimentary tract or the digestive system
  • A61P1/04—Drugs for disorders of the alimentary tract or the digestive system for ulcers, gastritis or reflux esophagitis, e.g. antacids, inhibitors of acid secretion, mucosal protectants
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/24—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against cytokines, lymphokines or interferons
  • C07K16/241—Tumor Necrosis Factors
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/505—Medicinal preparations containing antigens or antibodies comprising antibodies
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/505—Medicinal preparations containing antigens or antibodies comprising antibodies
  • A61K2039/507—Comprising a combination of two or more separate antibodies
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/54—Medicinal preparations containing antigens or antibodies characterised by the route of administration
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/26—Carbohydrates, e.g. sugar alcohols, amino sugars, nucleic acids, mono-, di- or oligo-saccharides; Derivatives thereof, e.g. polysorbates, sorbitan fatty acid esters or glycyrrhizin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0019—Injectable compositions; Intramuscular, intravenous, arterial, subcutaneous administration; Compositions to be administered through the skin in an invasive manner
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/08—Solutions
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
  • C07K2317/21—Immunoglobulins specific features characterized by taxonomic origin from primates, e.g. man
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/30—Immunoglobulins specific features characterized by aspects of specificity or valency
  • C07K2317/31—Immunoglobulins specific features characterized by aspects of specificity or valency multispecific
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/50—Immunoglobulins specific features characterized by immunoglobulin fragments
  • C07K2317/56—Immunoglobulins specific features characterized by immunoglobulin fragments variable (Fv) region, i.e. VH and/or VL
  • C07K2317/565—Complementarity determining region [CDR]
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/70—Immunoglobulins specific features characterized by effect upon binding to a cell or to an antigen
  • C07K2317/76—Antagonist effect on antigen, e.g. neutralization or inhibition of binding

Definitions

• This application contains a sequence listing, which is submitted electronically via EFS- Web as an ASCII formatted sequence listing with a file name
• JBI6091WOPCT1SEQLIST.TXT and a creation date of May 20, 2020 and having a size of 18 kb.
• the sequence listing submitted via EFS-Web is part of the specification and is herein incorporated by reference in its entirety.
• IBD Inflammatory bowel diseases
• CD Crohn’s disease
• UC ulcerative colitis
• GWAS Genome- wide association studies
• IL23R IL-23 receptor gene
• risankizumab BI 655066
• brazikumab MEDI2070, AMG-139
• One aspect of the invention is a method of treating an inflammatory bowel disease in a patient (subject).
• the method comprises administering a first co-therapeutically effective amount of an IL-23 inhibitor and administering a second co-therapeutically effective amount of a TNF-a inhibitor.
• the method is effective to treat the inflammatory bowel disease, and the first and second co-therapeutically effective amounts are the same or different.
• the inflammatory bowel disease is ulcerative colitis (UC). In some embodiments, the inflammatory bowel disease is Crohn’s disease. In some embodiments, the inflammatory bowel disease is indeterminate colitis. In some embodiments, the subject was previously treated with a TNF-a inhibitor alone and the inflammatory bowel disease did not undergo remission after the previous treatment. In some embodiments, the subject was previously treated with IL-23 inhibitor alone and the inflammatory bowel disease did not undergo remission after the previous treatment.
• the IL-23 inhibitor comprises a pharmaceutical composition of an anti-IL-23pl9 antibody (also referred to herein as anti-pl9 or anti-IL-23) or an antigen binding fragment thereof.
• the TNF-a inhibitor comprises a
• the anti-IL-23pl9 antibody comprises a human antibody or a humanized antibody.
• the anti-TNF-a antibody comprises a human antibody or a humanized antibody.
• the IL-23 inhibitor comprises the guselkumab antibody (also referred to as CNT01959) (marketed by Janssen Biotech, Inc. as Tremfya®) or an antigen binding fragment thereof comprising the guselkumab CDR sequences of: (i) the heavy chain CDR ammo acid sequences of SEQ ID NO: 1 (CDRHl), SEQ ID NO: 2 (CDRH2), and SEQ ID NO: 3 (CDRH3); and (ii) the light chain CDR amino acid sequences of SEQ ID NO: 4 (CDRLl), SEQ ID NO: 5 (CDRL2), and SEQ ID NO: 6 (CDRL3) at 100 mg/mL; 7.9% (w/v) sucrose, 4.0mM Histidine, 6.9 mM L-Histidine monohydrochloride monohydrate; 0.053% (w/v)
• Polysorbate 80 of the pharmaceutical composition wherein the diluent is water at standard state.
• Another aspect of the method of the invention comprises administering a pharmaceutical composition
• a pharmaceutical composition comprising an isolated anti-IL-23 specific antibody having the guselkumab heavy chain variable region amino acid sequence of SEQ ID NO: 7 and the guselkumab light chain variable region amino acid sequence of SEQ ID NO: 8 at 100 mg/mL; 7.9% (w/v) sucrose, 4.0mM Histidine, 6.9 mM L-Histidine monohydrochloride monohydrate; 0.053% (w/v)
• Polysorbate 80 of the pharmaceutical composition wherein the diluent is water at standard state.
• a further aspect of the method of the invention comprises administering a pharmaceutical composition comprising an isolated anti-IL-23 specific antibody having the guselkumab heavy chain amino acid sequence of SEQ ID NO: 9 and the guselkumab light chain amino acid sequence of SEQ ID NO: 10 at 100 mg/mL; 7.9% (w/v) sucrose, 4.0mM Histidine, 6.9 mM L- Histidine monohydrochloride monohydrate; 0.053% (w/v) Polysorbate 80 of the pharmaceutical composition; wherein the diluent is water at standard state.
• the guselkumab sequences are as follows:
• the TNF-a inhibitor comprises the golimumab antibody (marketed by Janssen Biotech, Inc. as Simponi®) or an antigen-binding fragment thereof comprising the sequences shown in SEQ ID NOS:
• CDRH1 Amino acid sequence of anti-TNF-a antibody complementarity determining region heavy chain 1 (CDRH1): (SEQ ID NO: l 1)
• CDRH3 Amino acid sequence of anti-TNF-a antibody complementarity determining region heavy chain 3 (CDRH3): (SEQ ID NO: 13)
• DRGIAAGGNYYYYGMDV Amino acid sequence of anti-TNF-a antibody complementarity determining region light chain 1 (CDRLl): (SEQ ID NO: 14)
• CDRL2 Amino acid sequence of anti-TNF-a antibody complementarity determining region light chain 2 (CDRL2): (SEQ ID NO: 15)
• CDRL3 Amino acid sequence of anti-TNF-a antibody complementarity determining region light chain 3 (CDRL3): (SEQ ID NO: 16)
• the anti-TNFa antibody and the anti-IL-23pl9 antibody are administered in a ratio of from 1 :2 to 2: 1 (w/w). In some embodiments, the anti-TNFa antibody and the anti-IL-23pl9 antibody are administered in a ratio of from 15: 1 to 400: 1 (w/w), or a range of from 2: 1 to 14: 1.
• the anti-IL-23pl9 antibody and the anti-TNFa antibody are administered simultaneously or on the same day for the initial dose and administration is staggered between the two antibodies by two or more weeks for subsequence doses. In some embodiments, the anti-IL-23pl9 antibody and the anti-TNFa antibody are administered sequentially. In some embodiments, the anti-IL-23pl9 antibody and the anti-TNFa antibody are administered within one day of one another.
• a method of reducing inflammation of the colon in a subject who has inflammatory bowel disease comprises administering a first co
• the method is effective to reduce inflammation of the colon of the subject to a level comparable to the colon of a normal patient.
• the first and second co-inflammation reducing effective amounts are the same or different.
• the inflammation is very minimal or normal in a tissue sample from the colon of the subject after administration of the anti-IL-23pl9 antibody and the anti- TNFa antibody.
• the gland loss is very minimal or normal in a tissue sample from the colon of the subject after administration of the anti-IL-23pl9 antibody and the anti-TNFa antibody.
• the erosion is very minimal or normal in a tissue sample from the colon of the subject after administration of the anti-IL-23pl9 antibody and the anti-TNFa antibody.
• the mucosal thickness and hyperplasia are independently very minimal or normal in a tissue sample from the colon of the subject after administration of the anti-IL-23p!9 antibody and the anti-TNFa antibody.
• the histopathology of the colon is about identical (or identical) to that of normal tissue.
• a method of both treating inflammatory bowel disease in a subject and reducing weight loss in the subject comprises: (a) administering a first co-therapeutically and weight loss reducing effective amount of an anti-IL-23pl9 antibody or an antigen-binding fragment thereof; and (b) administering a second co-therapeutically and weight loss reducing effective amount of an anti-TNF-a antibody or an antigen-binding fragment thereof; wherein said first and second co-therapeutically and weight loss reducing effective amount are the same or different.
• a method of treating inflammatory bowel disease in a human subject comprises: (a) administering 0.0005 to 0.002 mg/kg of an anti-IL- 23pl9 antibody or an antigen-binding fragment thereof; and (b) administering 0.020 to 0.125 mg/kg of an anti-TNF-a antibody or an antigen-binding fragment thereof.
• the method is effective to treat the inflammatory bowel disease.
• the inflammatory bowel disease is ulcerative colitis. In some
• the inflammatory bowel disease is Crohn’s disease. In some embodiments, the inflammatory bowel disease is indeterminate colitis. In some embodiments, the method is effective to inhibit weight loss (e.g., weight loss associated with the inflammatory bowel disease.)
• a method of preventing inflammation of the colon in a subject who has inflammatory bowel disease comprising: (a) administering a first co-inflammation reducing effective amount of an IL-23 inhibitor; and (b) administering a second co-inflammation reducing effective amount of a TNF-a inhibitor.
• the method is effective to reduce inflammation of the colon of the subject to a level comparable to the colon of a normal patient.
• the first and second co-inflammation reducing effective amounts are the same or different.
• guselkumab is administered to UC patients in an initial intravenous dose of 200 mg, intravenous doses of 200 mg at weeks 4 and 8 and subsequent subcutaneous doses of 100 mg every 8 weeks; golimumab is administered in an initial subcutaneous dose of 200 mg and subsequent subcutaneous doses of 100 mg at weeks 2, 6 and 10.
• the UC patient will be evaluated by Mayo Score to determine clinical response or remission.
• Clinical response measured at Week 12 is defined as a decrease from baseline in the Mayo score >30% and >3 points with either a decrease in rectal bleeding subscore (RBS) >1 or a RBS of 0 or 1.
• Clinical remission measured at Week 12 is defined as a Mayo score ⁇ 2 with no individual subscore >1. Additional measures of clinical response are used within the scope of the invention.
• Figures 1 A and IB show the results of a body weight loss analysis performed on mice after low dose (FIG. 1A at 50pg) and high dose (FIG. IB at 500pg) anti-TNF-a and anti-IL- 23pl9 antibody treatment alone or in combination.
• Disease was induced by administration of anti-CD40 antibody (BioXCell, Cat. No. BE0016-2, Agonist CD40 Ab clone FGK4.55, lot# 5345/0515).
• Figures 2A and 2B show the results of a histopathology study performed on the colon of mice treated with low dose (FIG. 2B at 50pg/mouse) anti-TNF-a and/or anti-IL-23pl9 antibody and high dose (FIG. 2B at 500pg/mouse) anti-TNF-a and/or anti-IL-23pl9 antibody, respectively.
• Disease was induced by administration of anti-CD40 antibody.
• Figure 3 A shows humanized treatment signatures of anti-TNFa or anti-IL-23pl9 monotherapy from the anti-CD40 model of murine colitis projected onto the Crohn’s Evaluation of Response to Ustekinumab Anti-Interleukin- 12/23 for Induction (CERTIFI) human IBD gene expression network.
• Figure 3 A shows the overlap between genes present in the anti-TNFa and anti-IL-23pl9 subnetworks as illustrated by a Venn diagram.
• Figure 3B illustrates the largest connected component of the shared anti-TNFa and anti-IL-23pl9 subnetworks.
• Figures 4A, 4B, 4C and 4D show the results of a body weight loss analysis performed on female RAG2 mice dosed ip with isotype control antibody (FIG. 4A), or anti-IL-23pl9 antibody (FIG. 4B) at 50, 15, 5, 1.5. 0.5, 0. 15pg/mouse, or an anti-TNFa antibody (FIG. 4C) at 150 and 15 pg/mouse. Disease was induced by administration of anti-CD40 antibody. As shown in Figure 4D, statistics were generated comparing each group to the isotype control.
• Figures 5A, 5B and 5C show the results of a histopathology study performed on the colon of female RAG2 mice dosed ip with isotype control antibody (FIG. 5A), anti-IL-23pl9 antibody at 50, 15, 5, 1.5. 0.5, 0.15pg/mouse (FIG. 5B), or an anti-TNFa antibody at 150 and 15 pg/mouse (FIG. 5C). Disease was induced by administration of anti-CD40 antibody.
• Figures 6A, 6B, 6C and 6D show the results of a body weight loss analysis performed on mice dosed with control antibody (FIG. 6A), 500 pg/mouse anti-TNFa antibody alone (FIG.
• FIG. 6B 1.5, 5, or 25 pg/mouse anti-IL-23pl9 antibody alone
• FIG. 6D a combination of 500 pg/mouse anti-TNFa antibody with 1.5, 5, or 25 pg/mouse anti-IL-23pl9 antibody
• Figure 6E shows a compilation of the data from the different groups.
• Figures 7A, 7B and 7C show the results of a histopathology study performed on the colon of mice dosed with 500 pg/mouse anti-TNFa antibody alone, mouse anti-IL-23pl9 antibody alone, or a combination of 500 pg/mouse anti-TNFa antibody with mouse anti-IL-23pl9 antibody at an anti-IL23pl9 antibody concentration of: 1.5 pg (FIG 7A), 5 pg (FIG. 7B), or 25 pg (FIG. 7C). Disease was induced by administration of anti-CD40 antibody.
• Figure 8 shows the results of a network analysis based on humanized colonic gene expression signatures of anti-TNFa (500pg) or high dose anti-IL-23pl9 (25pg) monotherapies that were intersected with a gene expression signature from the combination therapy (500pg anti- TNFa with 1.5pg anti-IL-23pl9).
• the analysis was performed to determine whether the molecular response to anti-TNFa and low dose anti-IL-23pl9 antibody combination treatment was additive or unique compared with either therapy alone.
• a unique subnetwork was identified of about 200 genes; the subnetwork was enriched in fibroblasts and extracellular matrix organization, cell types and pathways involved in wound repair and mucosal healing.
• administering refers to contact of an exogenous pharmaceutical, therapeutic, diagnostic agent, or composition to the animal, human, subject, cell, tissue, organ, or biological fluid.“Administration” and“treatment” can refer, e.g., to therapeutic,
• Treatment of a cell encompasses contact of a reagent to the cell, as well as contact of a reagent to a fluid, where the fluid is in contact with the cell.
• “Administration” and“treatment” also means in vitro and ex vivo treatments, e.g., of a cell, by a reagent, diagnostic, binding composition, or by another cell.
• Treatment refers to therapeutic treatment, prophylactic or preventative measures, to research and diagnostic applications.
• Treatment as it applies to a human, veterinary, or research subject, or cell, tissue, or organ, encompasses contact of an agent with animal subject, a cell, tissue, physiological compartment, or physiological fluid.“Treatment of a cell” also encompasses situations where the agent contacts a target, such as IL-23 receptor, e.g., in the fluid phase or colloidal phase, but also situations where the agonist or antagonist does not contact the cell or the receptor.
• a target such as IL-23 receptor
• Treat” or“treating” may also refer to administration of a therapeutic agent, such as a composition described herein, internally or externally to a patient in need of the therapeutic agent.
• the agent is administered in an amount effective to prevent or alleviate one or more disease symptoms, or one or more adverse effects of treatment with a different therapeutic agent, whether by preventing the development of, inducing the regression of, or inhibiting the progression of such symptom(s) or adverse effect(s) by any clinically measurable degree.
• the amount of a therapeutic agent that is effective to alleviate any particular disease symptom or adverse effect may vary according to factors such as the disease state, age, and weight of the patient, the ability of the therapeutic agent to elicit a desired response in the patient, the overall health of the patient, the method, route and dose of administration, and the severity of side effects.
• an“inhibitor,” as used herein, is any agent that reduces the activity of a targeted molecule.
• an antagonist of IL-23 or TNF-a is an agent that reduces the biological activity of IL-23 or TNF-a, for example by blocking binding of IL-23 or TNF-a to its receptor or otherwise reducing its activity (e.g. as measured in a bioassay).
• an“anti-IL-23 specific antibody,”“anti-IL-23 antibody,”“antibody portion,” or“antibody fragment” and/or“antibody variant” and the like include any protein or peptide containing molecule that comprises at least a portion of an immunoglobulin molecule, such as but not limited to, at least one complementarity determining region (CDR) of a heavy or light chain or a ligand binding portion thereof, a heavy chain or light chain variable region, a heavy chain or light chain constant region, a framework region, or any portion thereof, or at least one portion of an IL-23 receptor or binding protein, which can be incorporated into an antibody of the present invention.
• CDR complementarity determining region
• Such antibody optionally further affects a specific ligand, such as but not limited to, where such antibody modulates, decreases, increases, antagonizes, agonizes, mitigates, alleviates, blocks, inhibits, abrogates and/or interferes with at least one IL-23 activity or binding, or with IL-23 receptor activity or binding, in vitro, in situ and/or in vivo.
• a suitable anti-IL-23 antibody, specified portion or variant of the present invention can bind at least one IL-23 molecule, or specified portions, variants or domains thereof.
• a suitable anti-IL-23 antibody, specified portion, or variant can also optionally affect at least one of IL-23 activity or function, such as but not limited to, RNA, DNA or protein synthesis, IL-23 release, IL-23 receptor signaling, membrane IL-23 cleavage, IL-23 activity, IL- 23 production and/or synthesis.
• IL-23 activity or function such as but not limited to, RNA, DNA or protein synthesis, IL-23 release, IL-23 receptor signaling, membrane IL-23 cleavage, IL-23 activity, IL- 23 production and/or synthesis.
• antibody is further intended to encompass antibodies, digestion fragments, specified portions and variants thereof, including antibody mimetics or comprising portions of antibodies that mimic the structure and/or function of an antibody or specified fragment or portion thereof, including single chain antibodies and fragments thereof.
• Functional fragments include antigen-binding fragments that bind to a mammalian IL-23.
• antibody fragments capable of binding to IL-23 or portions thereof include, but are not limited to, Fab (e.g., by papain digestion), Fab' (e.g., by pepsin digestion and partial reduction) and F(ab')2 (e.g., by pepsin digestion), facb (e.g., by plasmin digestion), pFc' (e.g., by pepsin or plasmin digestion), Fd (e.g., by pepsin digestion, partial reduction and reaggregation), Fv or scFv (e.g., by molecular biology techniques) fragments.
• Fab e.g., by papain digestion
• Fab' e.g., by pepsin digestion and partial reduction
• F(ab')2 e.g., by pepsin digestion
• facb e.g., by plasmin digestion
• pFc' e.g., by pepsin or plasmin digestion
• Such fragments can be produced by enzymatic cleavage, synthetic or recombinant techniques, as known in the art and/or as described herein.
• Antibodies can also be produced in a variety of truncated forms using antibody genes in which one or more stop codons have been introduced upstream of the natural stop site.
• a combination gene encoding a F(ab')2 heavy chain portion can be designed to include DNA sequences encoding the CHI domain and/or hinge region of the heavy chain.
• the various portions of antibodies can be joined together chemically by conventional techniques, or can be prepared as a contiguous protein using genetic engineering techniques.
• Humanized antibody refers to an antibody in which the antigen binding sites are derived from non-human species and the variable region frameworks are derived from human immunoglobulin sequences. Humanized antibody may include substitutions in the framework so that the framework may not be an exact copy of expressed human immunoglobulin or human immunoglobulin germline gene sequences.
• Human antibody refers to an antibody having heavy and light chain variable regions in which both the framework and the antigen binding site are derived from sequences of human origin. If the antibody contains a constant region or a portion of the constant region, the constant region also is derived from sequences of human origin.
• Subject or“patient” as used interchangeably includes any human or nonhuman animal “Nonhuman animal” includes all vertebrates, e.g., mammals and non-mammals, such as nonhuman primates, sheep, dogs, cats, horses, cows, chickens, amphibians, reptiles, etc.
• TNF-a tumor necrosis factor-a
• TNF-a tumor necrosis factor-a
• TNF-a a multifunctional pro-inflammatory cytokine.
• TNF-a triggers pro- inflammatory pathways that result in tissue injury, such as degradation of cartilage and bone, induction of adhesion molecules, induction of pro-coagulant activity on vascular endothelial cells, an increase in the adherence of neutrophils and lymphocytes, and stimulation of the release of platelet activating factor from macrophages, neutrophils and vascular endothelial cells.
• TNF-a is found as a soluble protein as well as a precursor form called transmembrane TNF-a that is expressed as a cell surface type II polypeptide.
• Transmembrane TNF-a is processed by metalloproteinases such as TNF-a-converting enzyme (TACE) between residues Ala76 and Val77, resulting in the release of the soluble form of TNF-a of 157 amino acid residues.
• Soluble TNF-a is a homotrimer of 17-kDa cleaved monomers.
• Transmembrane TNF-a also exists as a homotrimer of 26-kD uncleaved monomers.
• a method of treating an inflammatory bowel disease in a subject comprises administering a first co-therapeutically effective amount of an IL-23 inhibitor and administering a second co-therapeutically effective amount of a TNF-a inhibitor.
• the method is effective to treat the inflammatory bowel disease, and the first and second co-therapeutically effective amounts are the same or different.
• the combination of an anti-TNFa antibody and an anti-IL-23pl9 antibody may provide a systemic impact as well as a local impact on the bowel or colon.
• the combination may provide a greater systemic impact than by treatment with either anti-TNFa antibody or an anti-IL-23pl9 antibody alone.
• the combination can provide for superior anti-inflammatory activity in treating IBD in a human.
• An anti-IL-23pl9 antibody can be highly efficacious in blocking the development of IBD (e.g., colitis and Crohn’s disease), but not in blocking anti-CD40-induced body weight loss, while an anti-TNFa antibody can provide substantial protection against anti- CD40-induced body weight loss with some degree of protection against IBD.
• Each antibody, and the combination may provide for a differential effect on local versus systemic inflammation.
• anti-IL-23 antibodies may be used, such as any of the anti-IL-23 antibodies described in U.S. Patent No. 7,491,391, issued on Feb. 17, 2009, and U.S. Patent Publication No. 2018/0094052, published on April 5, 2018, both of which are incorporated by reference herein.
• anti-TNFa antibodies may be used.
• any of the anti-IL-23 antibodies described in U.S. Patent No. 7,250,165, issued on July 31, 2007, and U.S. Patent Publication No. 2017/0218092, published on Aug. 3, 2017, both of which are incorporated by reference herein, may be used.
• Various host animals may be used to produce anti-TNF-a antibodies.
• anti-TNF-a antibodies For example,
• Balb/c mice may be used to generate mouse anti-human TNF-a antibodies.
• the antibodies made in Balb/c mice and other non-human animals may be humanized using various technologies to generate more human-like sequences.
• Anti-IL-23 antibodies can optionally be characterized by high affinity binding to IL-23 and, optionally, having low toxicity.
• Anti-TNFa antibodies can optionally be characterized by high affinity binding to TNFa and, optionally, having low toxicity.
• an antibody, specified fragment or variant of the antibody may be used in where the individual components, such as the variable region, constant region and framework, individually and/or collectively, optionally and preferably possess low immunogenicity.
• “low immunogenicity” can also be defined as the incidence of titrable levels of antibodies to the anti-IL-23 antibody in patients treated with anti-IL-23 antibody as occurring in less than 25% of patients treated, preferably, in less than 10% of patients treated with the recommended dose for the recommended course of therapy during the treatment period.
• “low immunogenicity” can also be defined as the incidence of titratable levels of antibodies to the anti-TNFa antibody in patients treated with anti-TNFa antibody as occurring in less than 25% of patients treated, preferably, in less than 10% of patients treated with the recommended dose for the recommended course of therapy during the treatment period.
• At least one anti-IF-23 antibody and anti-TNFa used in the methods described herein can be produced by a cell line, a mixed cell line, an immortalized cell or clonal population of immortalized cells, as well known in the art. See, e.g., Ausubel, et al., ed., Current Protocols in Molecular Biology, John Wiley & Sons, Inc., NY (1987-2001); Sambrook, et al, Molecular Cloning: A Faboratory Manual, 2nd Edition, Cold Spring Harbor, N.Y. (1989); Harlow and Fane, Antibodies, a Faboratory Manual, Cold Spring Harbor, N.Y.
• An anti-IF-23 antibody and/or an anti-TNF-a antibody can also be generated by immunization of a transgenic animal (e.g., mouse, rat, hamster, non-human primate, and the like) capable of producing a repertoire of human antibodies, as described herein and/or as known in the art.
• a transgenic animal e.g., mouse, rat, hamster, non-human primate, and the like
• Cells that produce a human anti-IF-23 antibody can be isolated from such animals and immortalized using suitable methods, such as the methods described herein.
• the anti-IL-23 antibodies used in the methods described herein can also be prepared using at least one anti-IL-23 antibody encoding nucleic acid to provide transgenic animals or mammals, such as goats, cows, horses, sheep, rabbits, and the like, that produce such antibodies in their milk.
• the anti-TNF-a antibodies used in the methods described herein can also be prepared using at least one anti-TNF-a antibody encoding nucleic acid to provide transgenic animals or mammals, such as goats, cows, horses, sheep, rabbits, and the like, that produce such antibodies in their milk.
• transgenic animals or mammals such as goats, cows, horses, sheep, rabbits, and the like, that produce such antibodies in their milk.
• Such animals can be provided using known methods. See, e.g., but not limited to, U.S. Patent Nos. 5,827,690; 5,849,992; 4,873,316; 5,849,992; 5,994,616; 5,565,362; 5,304,489, and the like, each of which is entirely incorporated herein by reference.
• the anti-IL-23 antibodies can bind human IL-23 with a wide range of affinities (KD).
• KD affinities
• a human mAh can optionally bind human IL-23 with high affinity.
• a human mAh can bind human IL-23 with a KD equal to or less than about KG 7 M, such as but not limited to, 0.1-9.9 (or any range or value therein) X KG 7 , KG 8 , KG 9 , KG 10 , KG 11 , 1CT 12 , 1CT 13 or any range or value therein.
• the anti-TNF-a antibodies can bind human TNF-a with a wide range of affinities (KD).
• a human mAh can optionally bind human TNF-a with high affinity.
• a human mAh can bind human TNF-a with a KD equal to or less than about KG 7 M, such as but not limited to, 0.1 -9.9 (or any range or value therein) X KG 7 , KG 8 , KG 9 , KG 10 , 1CT 11 , 1CT 12 , 1CT 13 or any range or value therein.
• the anti-IL-23 antibodies may be an IgGl, IgG2, IgG3 or IgG4 isotype.
• the anti-TNF-a antibodies may be an IgGl, IgG2, IgG3 or IgG4 isotype.
• the benefits of combining an anti-IL-23pl9 antibody with an anti-TNFa antibody can arise from distinct gene expression changes induced by each antibody.
• distinct intestinal gene expression changes were observed in mice when blocking IL-23pl9 compared to blocking TNFa. These gene expression changes may apply to human disease as well. Integration of‘humanized’ murine anti-TNFa and anti-IL- 23pl9 gene signatures with a human intestinal biopsy gene network can allow for focus only on genes that were expressed and varied in human intestinal tissues.
• Effectiveness of treatment according to the methods described herein can be determined, for example, by assessing the degree of weight loss, nutrient absorption, and histopathological studies of tissue samples. Histopathological studies can include measurement of one or more of submucosal edema, inflammation, gland loss, erosion, mucosal thickness, and hyperplasia. Submucosal edema can be quantified by measuring thickness from the muscularis mucosa to the internal border of the outer muscle layer (e.g., in a nontang ential area thought to best represent the severity of this change). Inflammation scoring can reflect the extent of macrophage, lymphocyte, and neutrophil infiltration into the colon.
• Gland loss of the crypt epithelium and remaining gland epithelium can be quantitated by assessing the percentage of the mucosa affected. Erosion reflects a loss of surface epithelium and can be scored by assessing the percentage of mucosa that is affected (e.g., by mucosal hemorrhage). Mucosal thickness can be assessed by measuring a non-tangential area of the section that best represents the overall mucosal thickness. Increased thickness reflects gland elongation and mucosal hyperplasia.
• An overall histopathology score can be derived from measurements of one or more of submucosal edema, inflammation, gland loss, erosion, mucosal thickness, and hyperplasia.
• An exemplary scoring system for mice is described in Example 1. A similar system can be used for human and other mammalian subjects.
• the inflammatory bowel disease is colitis, e.g., ulcerative colitis.
• Colitis can involve irritation, swelling and other signs of inflammation of the colon. Sores and ulcers are present in ulcerative colitis.
• the inflammatory bowel disease is Crohn’s disease.
• Crohn’s disease may be confined to the colon, but may also be present in other tissues such as the small intestine. Crohn’s disease can involve inflammation of the colon and small intestine. There may even be inflammation of the mouth, anus, skin, eyes, joints, and/or liver.
• the subject was previously treated with a TNF-a inhibitor alone and the inflammatory bowel disease did not undergo remission after the previous treatment.
• the subject was previously treated with IL-23 inhibitor alone and the inflammatory bowel disease did not undergo remission after the previous treatment.
• the methods described herein may be beneficial for subjects who did not respond to monotherapy treatments with either TNF-a inhibitor (e.g., an anti-TNF-a antibody) or IL-23 inhibitor (e.g., an anti-IL-23pl9 antibody).
• the IL-23 inhibitor comprises an anti-IL-23pl9 antibody or an antigen-binding fragment thereof. These can bind to the pi 9 subunit of IL-23.
• the TNF-a inhibitor comprises an anti-TNF-a antibody or an antigen-binding fragment thereof.
• the anti-IL-23pl9 antibody comprises a human antibody or a humanized antibody.
• the anti-TNF-a antibody comprises a human antibody or a humanized antibody.
• Anti-IL-23 antibodies and/or anti-TNFa antibodies can also be humanized or prepared as human antibodies engineered with retention of high affinity for the antigen and other favorable biological properties.
• Humanized (or human) antibodies can be optionally prepared by a process of analysis of the parental sequences and various conceptual humanized products using three- dimensional models of the parental and humanized sequences. Three-dimensional
• immunoglobulin models are commonly available and are familiar to those skilled in the art.
• Computer programs are available which illustrate and display probable three-dimensional conformational structures of selected candidate immunoglobulin sequences. Inspection of these displays permits analysis of the likely role of the residues in the functioning of the candidate immunoglobulin sequence, i.e., the analysis of residues that influence the ability of the candidate immunoglobulin to bind its antigen.
• framework (FR) residues can be selected and combined from the consensus and import sequences so that the desired antibody characteristic, such as increased affinity for the target antigen(s), is achieved.
• a method of reducing inflammation of the colon in a subject who has inflammatory bowel disease comprises administering a first co
• the method is effective to reduce inflammation of the colon of the subject to a level comparable to the colon of a normal patient.
• the first and second co-inflammation reducing effective amounts are the same or different. Prevention or reduction of inflammation can be measured by histopathological analysis, degree of weight loss, and degree of inflammation.
• the inflammation score is very minimal or normal. Very minimal inflammation may reflect the presence of just one or two small foci, with mononuclear inflammatory cells (MNIC) likely background mucosal lymphoid aggregates.
• MNIC mononuclear inflammatory cells
• the gland loss score is very minimal or normal. Very minimal gland loss may involve only one or two small focal areas of gland loss.
• the erosion score is very minimal or normal. Very minimal erosion may involve only one or two small focal areas of mucosal erosion.
• the mucosal thickness and hyperplasia score are independently very minimal or normal. Very minimal mucosal thickness may involve less than a 25% increase in mucosal thickness as compared to the thickness of normal mucosal tissue.
• the histopathology of the colon is about identical (or identical) to that of normal tissue. The histopathology can be assessed by measuring one or more of submucosal edema, inflammation, gland loss, erosion, mucosal thickness, and hyperplasia. Any or all of these parameters may be measured and scored. An exemplary scoring system is described in Example 1
• the IL-23 inhibitor is an anti-IL-23pl9 antibody or an antigen binding fragment thereof.
• Exemplary anti-IL-23pl9 antibodies and fragments are described in U.S. Patent No. 7,491,391, issued on Feb. 17, 2009 and incorporated by reference herein in its entirety.
• the TNF-a inhibitor is an anti-TNF-a antibody or an antigen binding fragment thereof.
• the anti-TNFa antibody and the anti-IL-23pl9 antibody are administered in a ratio of from 1 :2 to 2: 1 (w/w). The ratio may be calculated from the dosage of one antibody in a patient in mg/kg and the dosage of the other antibody in the same patient in mg/kg. In some embodiments, the anti-TNFa antibody and the anti-IL-23pl9 antibody are administered in a ratio of from 15: 1 to 400: 1 (w/w). The ratio may be calculated from the dosage of one antibody in a patient in mg/kg and the dosage of the other antibody in the same patient in mg/kg.
• a subject e.g., human patient
• the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 :2 to 1 : 1.8 (w/w).
• the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.9 to 1 : 1.7 (w/w).
• the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.8 to 1 : 1.6 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.7 to 1 : 1.5 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.6 to 1 : 1.4 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.5 to 1 : 1.3 (w/w).
• the ratio of anti- TNFa antibody to anti-IL-23pl 9 antibody is from 1 : 1.4 to 1 : 1.2 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.3 to 1 : 1.1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl 9 antibody is from 1 : 1.2 to 1 : 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1 : 1.1 to 1.1 : 1 (w/w).
• the ratio of anti-TNFa antibody to anti-IL-23pl 9 antibody is from 1 : 1 to 1.2: 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.1 : 1 to 1.3: 1 (w/w). In some embodiments, the ratio of anti- TNFa antibody to anti-IL-23pl9 antibody is from 1.2: 1 to 1.4: 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.3: 1 to 1.5: 1 (w/w).
• the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.4: 1 to 1.6: 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.5: 1 to 1.7: 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.6: 1 to 1.8: 1 (w/w). In some embodiments, the ratio of anti-TNFa antibody to anti-IL-23pl9 antibody is from 1.7: 1 to 1.9: 1 (w/w).
• the ratio of anti- TNFa antibody to anti-IL-23pl9 antibody is from 1.8: 1 to 2: 1 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is about 1 :2, 1 : 1.8, 1 : 1.5, 1 : 1.2, 1 : 1, 1.2: 1, 1.5: 1, 1.8: 1 or 2: 1 (w/w).
• a minimally active dose of an anti-IL-23pl9 antibody can be administered to the subject (e.g., human patient) with a larger dose of anti-TNFa antibody to prevent development of inflammatory bowel disease (e.g., colitis and Crohn’s disease).
• the ratio of the minimally active dose of anti-IL-23pl9 to the ratio of the larger dose of anti-TNFa antibody can range from 1 :400 to 1 : 15 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :400 to 1 :350 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti- TNFa antibody is from 1 :370 to 1 :320 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :350 to 1 :300 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :300 to 1 :250 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :280 to 1 :230 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :250 to 1 :200 (w/w). In some embodiments, the ratio of anti-IL-23pl 9 antibody to anti-TNFa antibody is from 1 :220 to 1 : 170 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 170 to 1 : 120 (w/w). In some embodiments, the ratio of anti-IL-23pl 9 antibody to anti-TNFa antibody is from 1 : 150 to 1 : 100 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 120 to 1 :80 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 100 to 1 :60 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :80 to 1 :40 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 60 to 1 :30 (w/w).
• the ratio of anti-IL- 23pl9 antibody to anti-TNFa antibody is from 1 :50 to 1 :25 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :40 to 1 :20 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :35 to 1 : 15 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is about 1 :400, 1 :300, 1 :200, 1 : 150, 1 : 100, 1 :75, 1 :50, 1 :25, or 1 : 15 (w/w).
• the anti-TNFa antibody and the anti-IL-23pl9 antibody are administered in a ratio of from 15: 1 to 400: 1 (w/w).
• the a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen binding fragment thereof are administered simultaneously.
• the a) anti-IL- 23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment thereof are administered sequentially.
• the a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment thereof may be administered within one hour, two hours, three hours, six hours, 12 hours, one day, two days, three days, or four days of one another.
• the combination of the a) anti-IL-23pl9 antibody or the antigen binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-TNF-a antibody alone without significant remission of the inflammatory bowel disease. In some embodiments, the combination of the a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-IL-23pl9 antibody alone without significant remission of the inflammatory bowel disease.
• a method of treating inflammatory bowel disease in a human subject comprises: (a) administering 0.0005 to 0.002 mg/kg of an anti-IL- 23pl9 antibody or an antigen-binding fragment thereof; and (b) administering 0.020 to 0.125 mg/kg of an anti-TNF-a antibody or an antigen-binding fragment thereof.
• the method is effective to treat the inflammatory bowel disease.
• the inflammatory bowel disease is colitis.
• the inflammatory bowel disease is Crohn’s disease.
• the method is effective to inhibit weight loss (e.g., weight loss associated with the inflammatory bowel disease.)
• the (a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the (b) anti- TNF-a antibody or the antigen-binding fragment thereof may be administered simultaneously, sequentially, or within one day of one another.
• administration to a subject of 0.020 to 0.125 mg/kg anti-TNFa antibody and 0.020 to 0.125 mg/kg of an anti-IL-23pl9 antibody can provide for enhanced treatment of IBD (e.g., colitis and Crohn’s disease) in the subject.
• IBD colitis and Crohn’s disease
• Initial results from evaluating the combination of 50pg each anti-TNFa and anti-IL-23pl9 in mice suggest that the combination provides enhanced protection against colitis versus single treatments at the same dose. See Example 1.
• 0.020 to 0.040 mg/kg anti- TNFa antibody and 0.020 to 0.040 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.030 to 0.050 mg/kg anti-TNFa antibody and 0.030 to 0.050 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.040 to 0.060 mg/kg anti-TNFa antibody and 0.040 to 0.060 mg/kg of an anti-IL- 23pl9 antibody are administered to a human subject.
• 0.050 to 0.070 mg/kg anti-TNFa antibody and 0.050 to 0.070 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.060 to 0.080 mg/kg anti-TNFa antibody and 0.060 to 0.080 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.070 to 0.090 mg/kg anti-TNFa antibody and 0.070 to 0.090 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.080 to 0.100 mg/kg anti-TNFa antibody and 0.080 to 0.100 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.090 to 0.110 mg/kg anti- TNFa antibody and 0.090 to 0.110 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• 0.100 to 0.125 mg/kg anti-TNFa antibody and 0.100 to 0.125 mg/kg of an anti-IL-23pl9 antibody are administered to a human subject.
• the anti-IL-23pl9 antibody is administered to the subject (e.g., human patient) daily, every two days, every three days, every four days, every five days, every six days, or once every week.
• the anti-TNFa antibody is administered to the subject (e.g., human patient) daily, every two days, every three days, every four days, every five days, every six days, or once every week.
• both the anti-IL- 23pl9 antibody and the anti-TNFa antibody are administered daily, every two days, every three days, every four days, every five days, every six days, or once every week.
• the anti-IL-23pl9 antibody and the anti-TNFa antibody can be administered conjointly to the subject (e.g., human patient).
• the anti-IL-23pl9 antibody and the anti- TNFa antibody can be administered separately to the subject. If administered separately, the antibodies may be administered within three hours, six hours, twelve hours, one day, two days, three days, or four days of one another.
• the combination of the a) anti-IL-23pl9 antibody or the antigen binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-TNF-a antibody alone without significant remission of the inflammatory bowel disease. In some embodiments, the combination of the a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-IL-23pl9 antibody alone without significant remission of the inflammatory bowel disease.
• a minimally active dose of an anti-IL-23pl9 antibody can be administered with a larger dose of anti-TNFa antibody to prevent relapse of inflammatory bowel disease (e.g., ulcerative colitis, indeterminate colitis and/or Crohn’s disease) when the subject is in remission from inflammatory bowel disease.
• the ratio of the minimally active dose of anti- IL-23pl9 to the ratio of the larger dose of anti-TNFa antibody can range from 1 :400 to 1 : 15 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :400 to 1 :350 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :370 to 1 :320 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :350 to 1 :300 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :300 to 1 :250 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :280 to 1 :230 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :250 to 1 :200 (w/w). In some embodiments, the ratio of anti-IL-23pl 9 antibody to anti-TNFa antibody is from 1 :220 to 1 : 170 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 170 to 1 : 120 (w/w). In some embodiments, the ratio of anti-IL-23pl 9 antibody to anti-TNFa antibody is from 1 : 150 to 1 : 100 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 120 to 1 :80 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 100 to 1 :60 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :80 to 1 :40 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 : 60 to 1 :30 (w/w).
• the ratio of anti-IL- 23pl9 antibody to anti-TNFa antibody is from 1 :50 to 1 :25 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :40 to 1 :20 (w/w). In some embodiments, the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is from 1 :35 to 1 : 15 (w/w).
• the ratio of anti-IL-23pl9 antibody to anti-TNFa antibody is about 1 :400, 1 :300, 1 :200, 1 : 150, 1 : 100, 1 :75, 1 :50, 1 :25, or 1 : 15 (w/w).
• both the anti-IL-23pl9 antibody and the anti-TNFa antibody are administered daily, every two days, every three days, every four days, every five days, every six days, or once every week.
• the anti-IL-23pl9 antibody and the anti-TNFa antibody can be administered conjointly.
• the anti-IL-23pl9 antibody and the anti-TNFa antibody can be administered separately.
• Combining anti-TNFa antibody (500 pg/mouse) treatment with minimally active doses of anti-IL-23pl9 antibody can provide superior efficacy in preventing development of colitis when compared to either single antibody treatment at these doses. See, e.g., Example 5.
• An analysis of colonic gene signatures of this combination therapy versus anti-TNFa or anti-IL- 23pl9 monotherapy identified a unique set of genes modulated by combination therapy enriched in fibroblasts and extracellular matrix organization, cell types and pathways involved in wound repair. This novel finding indicates that a combination treatment of antibodies against TNFa and IL-23pl9 can provide for superior efficacy in treating colitis and inflammatory bowel syndrome. Further, a combination treatment of antibodies against TNFa and IL-23pl9 may have synergistic effects due to modulation of specific gene networks implicated in mucosal healing.
• Example 5 demonstrates that combination treatment with antibodies against TNFa and IL-23pl9 can provide superior protection against colitis, as compared to treatment with either antibody as monotherapy.
• the colitis may be acute colitis.
• transcriptomics and gene network analyses identified both overlapping and distinct molecular effects for each monotherapy and revealed a unique set of genes influenced by the combination treatment that are implicated in wound repair processes.
• combination therapy with anti-TNFa and anti-IL-23pl9 antibodies can provide a synergistic impact on alleviating intestinal inflammation.
• the synergistic impact may arise through the targeting of common inflammatory pathways.
• the synergistic impact may arise from treatment of distinct cell types implicated in IBD pathogenesis with an impact on genes involved in tissue restoration.
• the combination of the a) anti-IL-23pl9 antibody or the antigen binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-TNF-a antibody alone without significant remission of the inflammatory bowel disease. In some embodiments, the combination of the a) anti-IL-23pl9 antibody or the antigen-binding fragment thereof and the b) anti-TNF-a antibody or the antigen-binding fragment is effective to treat a subject who was previously treated with an anti-IL-23pl9 antibody alone without significant remission of the inflammatory bowel disease.
• Each of the anti-TNFa and anti-IL-23 (e.g., anti-IL-23pl9) antibodies may be present in stable formulations.
• the stable formulations may comprise a phosphate buffer with saline or a chosen salt, as well as preserved solutions and formulations containing a preservative as well as multi-use preserved formulations suitable for pharmaceutical or veterinary use, comprising an anti-IL-23 (e.g., anti-IL-23pl9) antibody in a pharmaceutically acceptable formulation.
• Preserved formulations may contain at least one known preservative or optionally selected from the group consisting of at least one phenol, m-cresol, p-cresol, o-cresol, chlorocresol, benzyl alcohol, phenylmercuric nitrite, phenoxyethanol, formaldehyde, chlorobutanol, magnesium chloride (e.g., hexahydrate), alkylparaben (methyl, ethyl, propyl, butyl and the like), benzalkonium chloride, benzethonium chloride, sodium dehydroacetate and thimerosal, polymers, or mixtures thereof in an aqueous diluent.
• any suitable concentration or mixture can be used, such as about 0.0015%, or any range, value, or fraction therein.
• Non-limiting examples include, without preservative, about 0.1-2% m-cresol (e.g., 0.2, 0.3. 0.4, 0.5, 0.9, 1.0%), about 0.1-3% benzyl alcohol (e.g., 0.5, 0.9, 1.1, 1.5, 1.9, 2.0, 2.5%), about 0.001-0.5% thimerosal (e.g., 0.005, 0.01), about 0.001-2.0% phenol (e.g., 0.05, 0.25, 0.28, 0.5, 0.9, 1.0%), 0.0005-1.0% alkylparaben(s) (e.g., 0.00075, 0.0009, 0.001, 0.002, 0.005, 0.0075, 0.009, 0.01, 0.02, 0.05,
• the aqueous diluent may further comprise a pharmaceutically acceptable preservative.
• Preferred preservatives include those selected from the group consisting of phenol, m-cresol, p- cresol, o-cresol, chlorocresol, benzyl alcohol, alkylparaben (methyl, ethyl, propyl, butyl and the like), benzalkonium chloride, benzethonium chloride, sodium dehydroacetate and thimerosal, or mixtures thereof.
• concentration of preservative used in the formulation is a concentration sufficient to yield an anti-microbial effect. Such concentrations are dependent on the
• preservative selected and are readily determined by the skilled artisan.
• excipients e.g., isotonicity agents, buffers, antioxidants, and preservative enhancers
• An isotonicity agent such as glycerin
• a physiologically tolerated buffer is preferably added to provide improved pH control.
• the formulations can cover a wide range of pHs, such as from about pH 4 to about pH 10, and preferred ranges from about pH 5 to about pH 9, and a most preferred range of about 6.0 to about 8.0.
• the formulations of the present invention have a pH between about 6.8 and about 7.8.
• Preferred buffers include phosphate buffers, most preferably, sodium phosphate, particularly, phosphate buffered saline (PBS).
• additives such as a pharmaceutically acceptable solubilizers like Tween 20 (polyoxyethylene (20) sorbitan monolaurate), Tween 40 (polyoxyethylene (20) sorbitan monopalmitate), Tween 80 (polyoxyethylene (20) sorbitan monooleate), Pluronic F68
• polyoxyethylene polyoxypropylene block copolymers and PEG (polyethylene glycol) or non ionic surfactants, such as polysorbate 20 or 80 or poloxamer 184 or 188, Pluronic® polyls, other block co-polymers, and chelators, such as EDTA and EGTA, can be added to the formulations or compositions to reduce aggregation.
• PEG polyethylene glycol
• Pluronic® polyls other block co-polymers
• chelators such as EDTA and EGTA
• the formulations of the present invention can be prepared by a process that comprises mixing at least one anti-IL-23 antibody or anti-TNFa antibody with a selected buffer.
• the buffer can be a phosphate buffer containing saline or a chosen salt.
• Mixing the at least one anti-IL-23 antibody and buffer in an aqueous diluent is carried out using conventional dissolution and mixing procedures.
• a suitable formulation for example, a measured amount of at least one antibody in water or buffer is combined with the desired buffering agent in water in quantities sufficient to provide the protein and buffer at the desired concentrations. Variations of this process would be recognized by one of ordinary skill in the art. For example, the order the components are added, whether additional additives are used, the temperature and pH at which the formulation is prepared, are all factors that can be optimized for the concentration and means of administration used.
• Stable or preserved formulations comprising one or both of anti-IL-23 antibody and anti- TNFa antibody can be provided to patients as clear solutions or as dual vials comprising a vial of lyophilized at least one antibody that is reconstituted with a second vial containing a preservative or buffer and excipients in an aqueous diluent.
• Either a single solution vial or dual vial requiring reconstitution can be reused multiple times and can suffice for a single or multiple cycles of patient treatment and thus provides a more convenient treatment regimen than currently available.
• the anti-IL-23 antibody or anti-TNFa antibody can be formulated as a solution, suspension, emulsion, particle, powder, or lyophilized powder in association, or separately provided, with a pharmaceutically acceptable parenteral vehicle.
• Examples of such vehicles are water, saline, Ringer's solution, dextrose solution, and about 1- 10% human serum albumin. Liposomes and nonaqueous vehicles, such as fixed oils, can also be used.
• the vehicle or lyophilized powder can contain additives that maintain isotonicity (e.g., sodium chloride, mannitol) and chemical stability (e.g., buffers and preservatives). The formulation is sterilized by known or suitable techniques.
• Suitable pharmaceutical carriers are described in the most recent edition of Remington's Pharmaceutical Sciences, A. Osol, a standard reference text in this field. Many known and developed modes can be used according to the present invention for administering pharmaceutically effective amounts of at least one anti-IL-23 antibody or anti- TNFa antibody. While pulmonary administration is used in the following description, other modes of administration can be used according to the present invention with suitable results.
• IL- 23pl9 antibodies of the present invention can be delivered in a carrier, as a solution, emulsion, colloid, or suspension, or as a dry powder, using any of a variety of devices and methods suitable for administration by inhalation or other modes described here within or known in the art.
• Formulations for parenteral administration may comprise a common excipient.
• Exemplary common excipients include, but are not limited to, sterile water or saline,
• polyalkylene glycols such as polyethylene glycol, oils of vegetable origin, hydrogenated naphthalenes and the like.
• Aqueous or oily suspensions for injection can be prepared by using an appropriate emulsifier or humidifier and a suspending agent, according to known methods.
• Agents for injection can be a non-toxic, non-orally administrable diluting agent, such as aqueous solution, a sterile injectable solution or suspension in a solvent.
• a non-toxic, non-orally administrable diluting agent such as aqueous solution, a sterile injectable solution or suspension in a solvent.
• the usable vehicle or solvent water, Ringer's solution, isotonic saline, etc. are allowed; as an ordinary solvent or suspending solvent, sterile involatile oil can be used.
• any kind of involatile oil and fatty acid can be used, including natural or synthetic or semisynthetic fatty oils or fatty acids; natural or synthetic or semisynthtetic mono- or di- or tri-glycerides.
• Formulations for oral administration may include the co-administration of adjuvants (e.g., resorcinols and nonionic surfactants, such as polyoxyethylene oleyl ether and n- hexadecylpolyethylene ether) to increase artificially the permeability of the intestinal walls, as well as the co-administration of enzymatic inhibitors (e.g., pancreatic trypsin inhibitors, diisopropylfluorophosphate (DFF) and trasylol) to inhibit enzymatic degradation.
• adjuvants e.g., resorcinols and nonionic surfactants, such as polyoxyethylene oleyl ether and n- hexadecylpolyethylene ether
• enzymatic inhibitors e.g., pancreatic trypsin inhibitors, diisopropylfluorophosphate (DFF) and trasylol
• Formulations for delivery of hydrophilic agents including proteins and antibodies and a combination of at least two surfactants intended for oral, buccal, mucosal, nasal, pulmonary, vaginal transmembrane, or rectal administration are taught in U.S. Patent No. 6,309,663.
• the active constituent compound of the solid-type dosage form for oral administration can be mixed with at least one additive, including sucrose, lactose, cellulose, mannitol, trehalose, raffinose, maltitol, dextran, starches, agar, arginates, chitins, chitosans, pectins, gum tragacanth, gum arabic, gelatin, collagen, casein, albumin, synthetic or semisynthetic polymer, and glyceride.
• at least one additive including sucrose, lactose, cellulose, mannitol, trehalose, raffinose, maltitol, dextran, starches, agar, arginates, chitins, chitosans, pectins, gum tragacanth, gum arabic, gelatin, collagen, casein, albumin, synthetic or semisynthetic polymer, and glyceride.
• These dosage forms can also contain other type(s) of additives, e.g., inactive diluting agent, lubricant, such as magnesium stearate, paraben, preserving agent, such as sorbic acid, ascorbic acid, a-tocopherol, antioxidant such as cysteine, disintegrator, binder, thickener, buffering agent, sweetening agent, flavoring agent, perfuming agent, etc.
• additives e.g., inactive diluting agent, lubricant, such as magnesium stearate, paraben, preserving agent, such as sorbic acid, ascorbic acid, a-tocopherol, antioxidant such as cysteine, disintegrator, binder, thickener, buffering agent, sweetening agent, flavoring agent, perfuming agent, etc.
• a dosage form can contain a pharmaceutically acceptable non-toxic salt of the compounds that has a low degree of solubility in body fluids, for example, (a) an acid addition salt with a polybasic acid, such as phosphoric acid, sulfuric acid, citric acid, tartaric acid, tannic acid, pamoic acid, alginic acid, polyglutamic acid, naphthalene mono- or di-sulfonic acids, polygalacturonic acid, and the like; (b) a salt with a polyvalent metal cation, such as zinc, calcium, bismuth, barium, magnesium, aluminum, copper, cobalt, nickel, cadmium and the like, or with an organic cation formed from e.g., N,N'-dibenzyl-ethylenedi
• the compounds of the present invention or, preferably, a relatively insoluble salt, such as those just described can be formulated in a gel, for example, an aluminum monostearate gel with, e.g., sesame oil, suitable for injection.
• a gel for example, an aluminum monostearate gel with, e.g., sesame oil, suitable for injection.
• Particularly preferred salts are zinc salts, zinc tannate salts, pamoate salts, and the like.
• Example 1 Dose range determination for single treatments with antibody against TNFa or IL-23pl9 and combination studies in the CD40 antibody- induced colitis model Three separate studies were conducted. In all three studies, animals were randomized by weight, assigned to treatment groups and labeled by a specific number from 1-10 for each group. Vehicle (PBS) and mAh treatments were administered as a single intraperitoneal (ip) injection one day before (day -1) disease was induced by injecting 0.2mg CD40 agonist antibody in 0.2ml PBS per animal ip (day 0).
• PBS intraperitoneal
• mAh treatments were administered as a single intraperitoneal (ip) injection one day before (day -1) disease was induced by injecting 0.2mg CD40 agonist antibody in 0.2ml PBS per animal ip (day 0).
• Naive control mice were not treated and were kept in a separate cage until termination at day 7. Observations for clinical signs of disease were conducted daily. Body weights were measured and recorded daily from day -1 until termination at day 7. At study termination (day 7), the animals were euthanized by CO2 overdose and colon tissues removed and processed accordingly for histological analysis.
• the colon defined as the intestinal segment between cecum and rectum, was excised and flushed with ice cold PBS to remove fecal content.
• a fixative solution (10% Neutral Buffered Formalin, NBF). After 24 hours the cassettes were removed from the fixative and transferred to 70% ethanol and stored refrigerated until processing.
• the remaining colon tissue was divided into three equal parts; the first third snap frozen in liquid nitrogen for PK analysis, the second third snap frozen in liquid nitrogen for cytokine analysis, and the last third (distal, close to rectum) stored in 1ml RNAlater (AmbionTM) on ice until all animals had been euthanized and tissues removed accordingly and then frozen for RNA extraction and gene expression analysis. All frozen samples were stored at -80°C until further processing.
• mice were randomized by weight, assigned to treatment groups and labeled by a specific number from 1-10 for each group.
• Vehicle (PBS) and mAh treatments were administered as a single intraperitoneal (ip) injection one day before (day -1) disease was induced by injecting 0.2mg CD40 agonist antibody in 0.2ml PBS per animal ip (day 0).
• Naive control mice were not treated and were kept in a separate cage until termination at day 7.
• Table 1 Evaluation of single antibody treatment against TNFa and IL-23pl9 versus combination (at equal high and low doses) in the CD40 colitis model / Study 1, ELN: Immunopharmacology WC-2018-00034
• CNTO 3723 is a murine anti-IL-23pl9 monoclonal antibody (neutralizing IL-23pl9 mAb).
• CNTO 5048 is a murine anti-TNFa monoclonal antibody (neutralizing TNFa mAb).
• CNTO 6601 refers to the isotype control used throughout the experiments. CNTO 6601 does not specifically bind to either TNFa or IL-23pl9.
• Ligation of the co-stimulatory receptor CD40 via an agonist antibody causes an acute innate systemic and colonic inflammatory response in lymphopenic (T and B cell-deficient) RAG2 mice where the inflammatory response in the colon peaks around day 7, followed by resolution (ELN).
• IL-23 drives local colonic inflammation in this model.
• TNFa While the expression of TNFa controls manifestations of systemic disease (e.g., body weight loss), TNFa has only modest effects on colitis development.
• the inventors sought to investigate the distinct molecular impact of anti-TNFa versus anti-IL-23pl9 antibody treatment on intestinal gene expression and determine whether combination treatment of anti-TNFa and anti-IL-23pl9 exhibited enhanced efficacy over either monotherapy.
• RAG2 mice were dosed once ip with 0.5mg or 0.05mg anti-TNFa antibody (CNTO5048), 0.5mg or 0.05mg anti-IL-23pl9 antibody (CNT03732), a combination of both antibodies (0.5mg or 0.05mg each), l.Omg isotype control antibody (CNTO6601), or lOml/kg PBS.
• CNTO5048 0.5mg or 0.05mg anti-TNFa antibody
• CNT03732 anti-IL-23pl9 antibody
• CNTO6601 l.Omg isotype control antibody
• PBS lOml/kg PBS.
• Body weight loss analysis was performed after low dose (50pg) and high dose (500pg) antibody treatment. Body weight was monitored from day -1, when the mice were injected with antibody or PBS, until termination on day 7.
• FIG. 1 A shows the low dose (50pg/mouse) and Figure IB shows the high dose antibody treatment (500pg/mouse).
• Statistical significance of differences in body weight loss between antibody treatment groups and the isotype control group as comparator were analyzed by 2-way ANOVA with Dunnett’s multiple comparison test and P-values for each time point are shown in the table. P-values indicating significance are highlighted in bold/italic.
• ELN Immunopharmacology WC-2018-00034, Immunopharmacology WC-2018-00033.
• the CD40 mAb-induced colitis model is characterized by a biphasic weight loss with an initial rapid body weight loss within 24-48 hours after the CD40-agonist antibody dosing followed by recovery and a second weight loss phase at days 5-7.
• Single treatment with anti-IL- 23pl9 antibody did not protect mice from the initial rapid body weight loss but promoted a faster recovery after day 2 with an overall dose-dependent partial protection against body weight loss during the second phase of the disease, as shown in Figures 1 A and IB.
• proximal colons two (2) pieces were cut and embedded in paraffin. Sections (5 pm) were cut and stained with hematoxylin & eosin (H&E). The two colon segments from each animal were evaluated for histopathology individually and average values per animal were used in group analysis. For each H&E stained section, submucosal edema was quantitated by measuring the thickness from the muscularis mucosa to the internal border of the outer muscle layer in a nontangential area thought to best represent the severity of this change.
• H&E hematoxylin & eosin
• the Inflammation Score reflected the extent of macrophage, lymphocyte, and neutrophil (PMN) infiltrate. A severity score was assigned according to the following criteria:
• 0.5 Very Minimal; one or two small foci, mononuclear inflammatory cells (MNIC) likely background mucosal lymphoid aggregates. However, if aggregates are Peyer’s patches, then they are not scored as abnormal
• gland loss score was determined. Crypt epithelial and remaining gland epithelial loss is scored based on the approximate percent of the mucosa that was affected as follows:
• 0.5 Very Minimal, 1 or 2 small focal areas of gland loss or mucosal erosion
• 0.5 Very Minimal, 1 or 2 small focal areas of gland loss or mucosal erosion
• Mucosal thickness and hyperplasia score were determined. Mucosal thickness was measured in a non-tangential area of the section that best represents the overall mucosal thickness. This parameter is indicative of gland elongation and mucosal hyperplasia.
• a hyperplasia score is derived from the measurement as follows:
• the histopathology score is a sum of inflammation, gland loss, erosion, and hyperplasia scores. The range is from 0 to 20.
• the histopathology scores are shown in Figures 2A and 2B. In these figures, each bar represents the group mean with standard error. No histopathological findings were observed in naive animals.
• Figure 2A shows the results for low dose antibody (50pg/mouse).
• Figure 2B depicts the results for the high dose treatment group (500pg/mouse). Differences between treatment groups and respective vehicle and isotype controls were analyzed for significance by One-way ANOVA and Sidak’s multiple comparisons test.
• ELN is a sum of inflammation, gland loss, erosion, and hyperplasia scores. The range is from 0 to 20.
• the histopathology scores are shown in Figures 2A and 2B. In these figures, each bar represents the group mean with standard error. No histopathological findings were observed in naive animals.
• Figure 2A shows the results for low dose
• a single dose of anti-IL-23pl9 antibody was highly efficacious at the high dose (500pg, Figure 2B), completely preventing the development of colitis.
• the monotreatment significantly reduced histopathology compared to the isotype group but did not completely prevent colitis.
• the high dose combination of both antibodies (500pg anti- TNFa + 500pg anti-IL-23pl 9/mouse, Figure 2B) completely prevented colitis in the disease model, similar to the high dose of a single anti-IL-23pl9 treatment.
• the low dose combination treatment (50pg anti-TNFa + 50pg anti-IF-23pl 9/mouse, Figure 2A) was significantly more efficacious than the single anti-TNFa treatment and showed a trend for improved protection compared to monotreatment against IF-23pl9, indicating potential superior efficacy for the combination.
• the anti-TNFa and anti-IF-23pl9 treatments show differential effects on readouts of systemic and local inflammation.
• an assessment was made whether the treatments of Example 1 above had distinct molecular effects on intestinal gene expression.
• mRNA was isolated from the distal colon and submitted for microarray analysis.
• RNA extraction tissue samples were thawed on ice and transferred into new tubes containing 900 m ⁇ of Qiazol (Qiagen) and one metal bead, followed by lysis using the
• TissueFyser II for disruption and homogenization of the tissue by running it lmin at a frequency of 30 S 1 .
• 180 m ⁇ of chloroform were added to each sample, vortexed for 30 seconds, incubated for two minutes at room temperature, and centrifuged at 14,000 rpm for 15 minutes at 4°C to separate the mix into an organic and an aqueous phase.
• 150 m ⁇ of the aqueous phase was used for RNA extraction using the RNeasy 96 well plate kit (Qiagen) including an on-column DNase digestion step all according to the manufacturer’s protocols.
• RNA Quality and quantity of the isolated RNA was determined by Nanodrop at a Nanodrop 8000 instrument (ThermoScientific) and by LabChip GX (DNA 5K/RNA/CZE Chip for use with GXTouch/GXR Touch HT) on Caliper instrument (Life Science) according to the manufacturer’s protocols.
• LabChip GX DNA 5K/RNA/CZE Chip for use with GXTouch/GXR Touch HT
• Nanodrop absorbance 260/280 protein amount to nucleic acid
• Nanodrop absorbance 260/230 salt amount to nucleic acid
• Caliper RIN RNA integrity number
• Murine gene signatures for each treatment were evaluated for overlap and enrichment in biological pathways (Enrichr: http://amp.pharm.mssm.edu/Enrichr/).
• the overlap of the individual gene signatures generated from anti-TNFa or anti-IL-23pl 9 treatment was relatively small, with only 11% of genes shared between the signatures, and did not show any specific pathway enrichment.
• the gene signature for anti-TNFa treatment (267 genes, FDR ⁇ 0.05, FC > 1.2) was enriched in metabolic pathways and cytokine-cytokine receptor interactions while the anti-IL-23pl9 gene signature (765 genes, FDR ⁇ 0.05, FC > 1.2) was enriched in circadian rhythm and p53 signaling.
• Example 3 Anti-TNFa and anti-IL-23pl9 single antibody treatments impact overlapping and distinct portions of human IBD networks
• the gene signature for anti-TNFa treatment was enriched in cellular response to stress and lipids, reactive oxygen species metabolism, inflammatory response genes and genes upregulated in patient biopsies.
• the anti- IL-23pl9 treatment signature was enriched in cellular metabolism, regulation of proliferation and genes down-regulated in IBD patient biopsies.
• These treatment subnetworks contain genes modified by anti-TNFa or anti-IL-23pl9 treatment in the mouse model that are reflected in human IBD tissue and their immediate neighboring genes in the network. Thus, enrichment analysis of these subnetworks may provide insights into the biological pathways targeted by each therapeutic in the context of human disease tissue.
• Figures 3 A and 3B show humanized treatment signatures of anti-TNFa or anti-IF-23pl9 monotherapy from the anti-CD40 model of murine colitis projected onto the CERTIFI human IBD gene expression network.
• First neighbors of genes within the human IBD network were extracted to produce treatment subnetworks.
• the overlap between genes present in the anti- TNFa and anti-IF-23pl9 subnetworks is illustrated by the Venn diagram in the center.
• the largest connected component of the shared subnetwork of anti-TNFa and anti-IF-23pl9 is shown in Fig. 3B.
• the unique portion of the anti-TNF subnetwork was highly enriched in neutrophil and CDl lb + macrophage gene signatures (E-values 8.28e-10 and 2.41e-06, respectively) while the unique portion of the anti-IL-23pl9 subnetwork was highly enriched for colonic epithelial cells (E-value 1.27e-32), consistent with the role of IL-23 in promoting the expression of cytokines, such as IL-17A and IL-22, that impact epithelial cell biology.
• Example 4 Expanded dose range analysis for anti-TNFa and anti-IL-23pl9 antibody treatments in anti-CD40 antibody induced colitis (Study 2)
• proximal colon sections were removed, flushed, fixed and then stained with H&E.
• the stained samples were examined for histopathological changes by a blinded pathologist using a severity score from 0-20 using the protocol in Example 1 above. The data is shown in Figures 5A-C. No
• Colon histopathology demonstrated dose-dependent protection from colitis by anti-IL- 23pl9 antibody treatment, as shown in Figure 5B.
• anti-IL-23pl9 antibody treatment provided near complete protection. Partial protection was detected at antibody doses of 15pg and 5pg, and no protection was observed at doses of 1.5pg and lower. In contrast, no significant treatment effects were detected for the two dose levels of anti-TNFa antibody (150, 15 pg) on colon histopathology. See Figure 5C.
• Example 5 Determination of anti-inflammatory activity of a combination of fixed dose anti-TNFa antibody and varying doses of anti-IL-23pl9 antibody in the CD40 colitis model (Study 3)
• Table 3 Evaluation of single high dose TNFa antibody treatment and low doses of IL- 23pl9 alone versus in combination in the CD40 colitis model / Study 3, ELN: Immunopharmacology WC-2016-00066
• the data are shown in Figure 6.
• the significance of differences to isotype control group was analyzed by for each treatment group by 2- way ANOVA with Dunnett’s multiple comparison test. P-values for each study day are shown in the table and highlighted in bold/italic if they indicate significance.
• ELN Immunopharmacology WC-2016-00066, Immunopharmacology WC-2018-00033.
• proximal colon tissue samples were removed, flushed, fixed and then stained with H&E and examined for histopathological changes by a blinded pathologist using a severity score from 0-20, as described in Example 1 above. The data are shown in Figures 7A-7C. No histopathological findings were observed in naive animals. Differences between antibody treatment groups and respective isotype controls were analyzed for significance by One-way ANOVA-Sidak’s multiple comparisons test. The line depicts the group median. ELN:
• anti-TNFa antibody 500pg/mouse did not offer significant protection against colon histopathology as compared to the isotype control.
• the anti-IL-23pl9 antibody 1.5, 5 and 25pg/mouse treatment demonstrated dose-dependent protection from colitis, with no protection seen at the lowest dose (1.5 pg/mouse). Partial protection from colitis was observed with the two higher doses (5 and 25 pg/mouse).
• 1.5pg/mouse anti-IL-23pl9 is not statistically different from that observed in the isotype control group.
• Example 5 Combination anti-TNFa and anti-IL-23pl9 treatment impacts a unique subnetwork enriched in wound healing pathways
• the molecular impact of combination therapy with anti-TNFa and anti-IL-23pl9 antibodies versus monotherapy was determined.
• Humanized colonic gene expression signatures of anti-TNFa (500pg) or high dose anti-IL-23pl9 (25pg) monotherapies were intersected with a gene expression signature from the combination therapy (500pg anti-TNFa/1 5pg anti-IL-23pl9) to determine whether the molecular response to anti-TNFa and low dose anti-IL-23pl9 antibody combination treatment was additive or unique compared with either therapy alone.
• the 25pg dose of anti-IL-23pl 9 treatment was selected for comparison so as to compare the effect of combination treatment of anti-TNFa with a sub-optimal dose of anti-IL-23pl9 to that of a monotherapy dose of anti-IL-23pl9 that had efficacy in the model.
• Example 6 Clinical Study of anti-TNFa and anti-IL-23pl9 treatment in UC
• Guselkumab (CNTO 1959 or TREMFYA ® ) is a fully human immunoglobulin G1 lambda monoclonal antibody (mAb) that binds to the pi 9 subunit of human interleukin (IL)-23 with high specificity and affinity.
• mAb human immunoglobulin G1 lambda monoclonal antibody
• the binding of guselkumab to IL-23 blocks the binding of extracellular IL-23 to the cell surface IL-23 receptor, inhibiting IL-23-specific intracellular signaling and subsequent activation and cytokine production.
• Guselkumab is currently approved in the United States, European Union, Canada, and several other countries for the treatment of moderate to severe plaque psoriasis. In addition, guselkumab is also being evaluated in psoriatic arthritis (PsA) and Crohn’s disease globally.
• Golimumab (CNTO 148 or SIMPONI ® ) is a fully human anti -tumor necrosis factor alpha (TNFa) mAb that binds to TNFa with high affinity. This interaction prevents the binding of TNFa to its receptors, thereby inhibiting the biological activity of TNFa. Golimumab is approved for treatment of moderately to severely active ulcerative colitis (UC) in over 90 countries worldwide.
• UC ulcerative colitis
• golimumab is approved for 1 or more of the following indications around the world: rheumatoid arthritis (RA), PsA, ankylosing spondylitis (AS), nonradiographic axial spondyloarthritis (nr- Axial SpA), and polyarticular juvenile idiopathic arthritis (pJIA).
• RA rheumatoid arthritis
• PsA ankylosing spondylitis
• AS nonradiographic axial spondyloarthritis
• pJIA polyarticular juvenile idiopathic arthritis
• This study will consist of 2 distinct phases: a 12- week combination comparison phase followed by a 26-week monotherapy phase.
• PK pharmacokinetics
• PD pharmacodynamics
• Combination therapy with guselkumab and golimumab will result in a rate of clinical response at Week 12 that is superior to both monotherapy arms.
• the target population is men or women 18 to 65 years old with moderately to severely active UC, as defined by a Mayo score of 6 to 12, inclusive, at baseline, including an endoscopy subscore >2 as obtained during the central review of the video endoscopy.
• Participants must be naive to TNF antagonists and have failed or not tolerated conventional therapy with oral or intravenous (IV) corticosteroids or immunomodulators (6-mercaptopurine [6-MP] or azathioprine [AZA]).
• Immunomodulators (6-MP, AZA, and methotrexate [MTX]) must be discontinued for at least 2 weeks before the first dose of study intervention.
• the investigator For participants who are receiving oral corticosteroids at baseline, the investigator must begin tapering the daily dose of corticosteroids at Week 6. All participants will be evaluated for clinical worsening of UC throughout the study.
• doses of concomitant therapies for UC should remain stable through Week 38 (except for oral corticosteroid tapering beginning at Week 6), and concomitant therapies for UC should not be initiated unless considered medically necessary by the investigator. Initiation of prohibited therapies will result in discontinuation of study intervention.
• Endoscopy with central read is planned for screening/baseline, Week 12, and Week 38. Consenting participants will have an additional endoscopy at Week 4, which will also be assessed by a central reader. Efficacy, PK and PD parameters, biomarkers, and safety will be assessed according to the Schedule of Activities (SoA). A pharmacogenomic blood sample will be collected from participants who consent to this component of the protocol (where local regulations permit). Participation in pharmacogenomic research is optional.
• DBLs Database locks
• DMC Data Monitoring Committee
• a target of 210 participants will be enrolled in this study with 70 participants planned per intervention group.
• This study will consist of 2 distinct phases: a 12- week combination comparison phase followed by a 26-week monotherapy phase.
• a target of 210 participants will be randomized in a 1 : 1 : 1 ratio to either combination therapy with guselkumab and golimumab, guselkumab monotherapy, or golimumab monotherapy, stratified by the concomitant use of corticosteroids at baseline (Y/N).
• Participants randomized to combination therapy will receive guselkumab monotherapy after Week 12.
• Participants randomized to a monotherapy group will continue on their originally randomized monotherapy after Week 12.
• the combination therapy arm will employ the same dose regimens of guselkumab and golimumab being used in the respective monotherapy intervention groups to facilitate scientific interpretation of the results.
• Golimumab monotherapy golimumab 200 mg SC injection at Week 0, followed by golimumab 100 mg at Week 2 and then golimumab 100 mg every 4 weeks (q4w)
• Inflammatory PD markers including CRP and fecal calprotectin
• IBDQ Inflammatory Bowel Disease Questionnaire
• UAEIS Ulcerative Colitis Endoscopic Index of Severity
• Serum samples will be analyzed to determine concentrations of guselkumab and golimumab and detection of anti-guselkumab and anti-golimumab antibodies, respectively, using validated, specific, and sensitive immunoassay methods by or under the supervision of the sponsor.
• Biomarker assessments will be made to examine the biologic response to treatment and to identify biomarkers that are relevant to guselkumab and/or golimumab in the treatment of UC. Assessments will include the evaluation of relevant biomarkers in serum, stool, whole blood, and mucosal biopsy samples (RNA [ribonucleic acid], histology, and single cell isolation).
• RNA ribonucleic acid
• PHARMACOGENOMIC DNA
• a pharmacogenomic whole blood sample of approximately 5 mL will be collected (where local regulations permit) for genetic analyses as specified in the SoA. Only participants who sign the consent form to participate in the genetic assessment will have whole blood deoxyribonucleic acid (DNA) samples collected. Participation in the pharmacogenomic sub-study is optional.
• DNA deoxyribonucleic acid
• Safety evaluations conducted at each study visit will include the assessment of adverse events (AEs, at the visit and those occurring between evaluation visits), a tuberculosis (TB) evaluation and other infection assessment, clinical laboratory blood tests (hematology and chemistry), vital signs, suicidality assessment, concomitant medication review, observations for injection-site reactions, AEs temporally associated with infusion, and/or hypersensitivity reactions.
• AEs adverse events
• TB tuberculosis
• a sample size of 210 participants (70 per intervention group) was determined by the power to detect a significant difference in the proportion of participants in clinical response at Week 12 (primary endpoint) between the combination therapy and both monotherapies using a 1 -sided chi- square test with 0.1 significance level for each comparison.
• the study is sized such that the combination therapy has approximately 80% power based on simulations to achieve both comparisons to monotherapy for the primary endpoint.
• the proportion of participants in clinical response at Week 12 is assumed to be 75% for the combination therapy, which is based on the additive effect from both monotherapies (20% improvement from each monotherapy relative to a historical placebo response of 35%).
• a CMH chi-square test (1 -sided) stratified by concomitant use of corticosteroids at baseline (Y/N) will be used to compare the efficacy of the combination therapy to each monotherapy for the major secondary endpoint. The testing will be done simultaneously at the 1 -sided 0.1 level of significance for each comparison.
• Safety data including but not limited to, AEs, serious adverse events (SAEs), infections, serious infections, changes in laboratory assessments, and changes in vital signs will be summarized.
• SAEs serious adverse events
• Treatment- emergent AEs will be summarized by treatment group and Medical Dictionary for Regulatory Activities (MedDRA) system organ class and preferred terms.
• Serum guselkumab and golimumab concentrations over time will be summarized for each treatment group over time using descriptive statistics.
• Population PK modeling may be conducted when appropriate. If these population PK analyses are conducted, the results of these analyses will be presented in a separate report.
• the incidence of antibodies to guselkumab and to golimumab will be summarized for all participants who receive at least 1 dose of guselkumab or golimumab and have appropriate samples for detection of antibodies to guselkumab and to golimumab (i.e., participants with at least 1 sample obtained after their first dose of guselkumab or golimumab, respectively).
• DNA analyses will be conducted only in participants who sign the consent form to participate in the pharmacogenomic sub-study. These analyses are considered
• An IL-23 inhibitor and a TNF-a inhibitor for use in the treatment of an inflammatory disease in a patient, wherein the inhibitors are in co-therapeutically effective amounts and the patient shows a clinical response.
• a clinical endpoint selected from the group consisting of Mayo score, partial Mayo score, Ulcerative Colitis Endoscopic Index of Severity (UCEIS), the markers CRP and/or fecal calprotectin and patient-reported outcome and symptom measures.
• IL-23 inhibitor and a TNF-a inhibitor for use according to any one of the preceding embodiments, wherein the IL-23 inhibitor comprises an anti-IL-23pl9 antibody or an antigen binding fragment thereof and the TNF-a inhibitor comprises an anti-TNF-a antibody or an antigen-binding fragment thereof.
• IL-23 inhibitor and a TNF-a inhibitor for use according to any one of the preceding embodiments, wherein the inflammatory bowel disease is ulcerative colitis (UC) or
• UC ulcerative colitis
• an IL-23 inhibitor and a TNF-a inhibitor for use according to any one of the preceding embodiments wherein the anti-IL-23p!9 antibody comprises: a) heavy chain complementarity determining region (CDR) amino acid sequences of SEQ ID NOS: 1-3 and light chain CDR amino acid sequences of SEQ ID NOS: 4-6; b) a heavy chain variable region amino acid sequence of SEQ ID NO: 7 and a light chain variable region amino acid sequence of SEQ ID NO: 8; or c) a heavy chain amino acid sequence of SEQ ID NO:9 and a light chain amino acid sequence of SEQ ID NO: 10.
• CDR complementarity determining region
• an IL-23 inhibitor and a TNF-a inhibitor for use according to any one of the preceding embodiments wherein the anti-IL-23pl9 antibody comprises: a) heavy chain complementarity determining region (CDR) amino acid sequences of SEQ ID NOS: 1-3 and light chain CDR amino acid sequences of SEQ ID NOS: 4-6; b) a heavy chain variable region amino acid sequence of SEQ ID NO: 7 and a light chain variable region amino acid sequence of SEQ ID NO: 8; or c) a heavy chain amino acid sequence of SEQ ID NO:9 and a light chain amino acid sequence of SEQ ID NO: 10, and the anti-TNFa antibody comprises: a) heavy chain CDR amino acid sequences of SEQ ID NOS: 11-13 and light chain CDR amino acid sequences of SEQ ID NOS: 14-16; b) a heavy chain variable region amino acid sequence of SEQ ID NO: 17 and a light chain variable region amino acid sequence of SEQ ID NO: 18; or c) a heavy chain amino acid
• an anti-IL-23 antibody or fragment thereof and an anti-TNF-a antibody or fragment thereof for use in the treatment of ulcerative colitis in a patient wherein the anti-IL-23pl9 antibody comprises (i) the heavy chain complementarity determining region (CDR) amino acid sequences of SEQ ID NOS: 1 -3 and the light chain CDR amino acid sequences of SEQ ID NOS: 4-6, (ii) the heavy chain variable region amino acid sequence of SEQ ID NO: 7 and the light chain variable region amino acid sequence of SEQ ID NO: 8, or (iii) the heavy chain amino acid sequence of SEQ ID NO: 9 and the light chain amino acid sequence of SEQ ID NO: 10; and the anti-TNF-a antibody comprises (i) the heavy chain CDR amino acid sequences of SEQ ID NOS: 11-13 and the light chain CDR amino acid sequences of SEQ ID NOS: 14-16, (ii) the heavy chain variable region amino acid sequence of SEQ ID NO: 17 and the light chain variable region amino acid sequence of SEQ ID NO:
• embodiments 12-14 wherein the anti-IL-23pl9 antibody and the anti-TNF-a antibody are administered simultaneously.
• embodiments 12-14 wherein the anti-IL-23pl9 antibody and the anti-TNF-a antibody are administered sequentially.
• embodiments 12-14 and 16 wherein the anti-IL-23pl9 antibody and the anti-TNF-a antibody are administered within one day of one another.
• embodiments 12-17 wherein the anti-IL-23pl9 antibody is administered in an initial intravenous dose of 200 mg, intravenous doses of 200 mg at weeks 4 and 8 and subsequent subcutaneous doses of 100 mg every 8 weeks and the anti-TNF-a antibody is administered in an initial subcutaneous dose of 200 mg and subsequent subcutaneous doses of 100 mg at weeks 2, 6 and 10. 19.
• a clinical endpoint selected from the group consisting of Mayo score, partial Mayo score, Ulcerative Colitis Endoscopic Index of Severity (UCEIS), the markers CRP and/or fecal calprotectin and patient- reported outcome and symptom measures.
• An anti-IL-23 antibody or fragment thereof and an anti-TNF-a antibody or fragment thereof for use in, reducing inflammation of the colon in a patient with inflammatory bowel disease wherein the antibodies are in co-therapeutically effective amounts and the use is effective to reduce inflammation of the colon of the patient to a level comparable to the colon of a normal subject.
• the anti-IL-23pl9 antibody or antigen-binding fragment thereof comprises: a) the heavy chain CDR amino acid sequences of SEQ ID NOS: 1-3 and the light chain CDR amino acid sequences of SEQ ID NOS: 4-6; b) the heavy chain variable region amino acid sequence of SEQ ID NO: 7 and the light chain variable region amino acid sequence of SEQ ID NO: 8; or c) the heavy chain amino acid sequence of SEQ ID NO: 9 and the light chain amino acid sequence of SEQ ID NO: 10; and the anti-TNF-a antibody or antigen-binding fragment thereof comprises d) the heavy chain CDR amino acid sequences of SEQ ID NOS: 11-13 and the light chain CDR amino acid sequences of SEQ ID NOS: 14-16; e) the heavy chain variable region amino acid sequence of SEQ ID NO: 17 and the light chain variable region amino acid sequence of SEQ ID NO: 18; or f) the heavy chain amino acid sequence of SEQ ID NO: 19 and the light chain amino acid sequence of
• embodiments 22-28 wherein the anti-TNFa antibody or antigen-binding fragment thereof and the anti-IL-23pl9 antibody or antigen-binding fragment thereof are administered in a ratio of from 1 :2 to 2: 1 (w/w).
• embodiments 22-28 wherein the anti-TNFa antibody or antigen-binding fragment thereof and the anti-IL-23pl9 antibody or antigen-binding fragment thereof are administered in a ratio of from 15: 1 to 400: 1 (w/w).
• embodiments 22-30 wherein the a) anti-IL-23pl9 antibody or antigen-binding fragment thereof and the b) anti-TNF-a antibody or antigen-binding fragment thereof are administered simultaneously.
• embodiments 22-30 wherein the a) anti-IL-23pl9 antibody or antigen-binding fragment thereof and the b) anti-TNF-a antibody or antigen-binding fragment thereof are administered within one day of one another.
• An anti-IL-23 antibody or fragment thereof and an anti-TNF-a antibody or fragment thereof for use in treating moderately to severely active ulcerative colitis in a human patient wherein the anti-IL-23pl9 antibody or an antigen-binding fragment thereof is administered at 0.0005 to 0.002 mg/kg and comprises the sequences of (i) the heavy chain CDR amino acid sequences of SEQ ID NOS: 1-3 and the light chain CDR amino acid sequences of SEQ ID NOS: 4-6; (ii) the heavy chain variable region amino acid sequence of SEQ ID NO: 7 and the light chain variable region amino acid sequence of SEQ ID NO: 8; or (iii) the heavy chain amino acid sequence of SEQ ID NO:9 and the light chain amino acid sequence of SEQ ID NO: 10 and the anti-TNF-a antibody or an antigen-binding fragment thereof is administered at 0.020 to 0.125 mg/kg and comprises the sequences of (iv) the heavy chain CDR amino acid sequences of SEQ ID NOS: 11-13 and the light chain
• UAEIS Ulcerative Colitis Endoscopic Index of Severity
• an anti-IL-23 antibody or antigen-binding fragment thereof and an anti-TNF-a antibody or antigen-binding fragment thereof for use according to any of embodiments 40-42 wherein the anti-IL-23pl9 antibody is in an aqueous solution in a pharmaceutical composition at 100 mg/mL; 7.9% (w/v) sucrose, 4.0mM Histidine, 6.9 mM L-Histidine monohydrochloride monohydrate; 0.053% (w/v) Polysorbate 80 of the composition, and the anti-TNF-a antibody is in an aqueous solution in a pharmaceutical composition at 100 mg/mL; 4.1% (w/v) sorbitol, 5.6 mM L- Histidine and L-Histidine monohydrochloride monohydrate; 0.015% (w/v) Polysorbate 80 of the composition.

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