Classifications

• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/5005—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving human or animal cells
  • G01N33/5091—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving human or animal cells for testing the pathological state of an organism
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2803—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the immunoglobulin superfamily
  • C07K16/2809—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against the immunoglobulin superfamily against the T-cell receptor (TcR)-CD3 complex
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
  • A61P3/10—Drugs for disorders of the metabolism for glucose homeostasis for hyperglycaemia, e.g. antidiabetics
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N33/00—Investigating or analysing materials by specific methods not covered by groups G01N1/00 - G01N31/00
  • G01N33/48—Biological material, e.g. blood, urine; Haemocytometers
  • G01N33/50—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing
  • G01N33/68—Chemical analysis of biological material, e.g. blood, urine; Testing involving biospecific ligand binding methods; Immunological testing involving proteins, peptides or amino acids
  • G01N33/6854—Immunoglobulins
• • 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
  • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
  • G01N2333/435—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans
  • G01N2333/705—Assays involving receptors, cell surface antigens or cell surface determinants
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
  • G01N2333/435—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans
  • G01N2333/705—Assays involving receptors, cell surface antigens or cell surface determinants
  • G01N2333/70503—Immunoglobulin superfamily, e.g. VCAMs, PECAM, LFA-3
  • G01N2333/7051—T-cell receptor (TcR)-CD3 complex
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
  • G01N2333/435—Assays involving biological materials from specific organisms or of a specific nature from animals; from humans
  • G01N2333/705—Assays involving receptors, cell surface antigens or cell surface determinants
  • G01N2333/70503—Immunoglobulin superfamily, e.g. VCAMs, PECAM, LFA-3
  • G01N2333/70517—CD8
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/04—Endocrine or metabolic disorders
  • G01N2800/042—Disorders of carbohydrate metabolism, e.g. diabetes, glucose metabolism
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/50—Determining the risk of developing a disease
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N2800/00—Detection or diagnosis of diseases
  • G01N2800/52—Predicting or monitoring the response to treatment, e.g. for selection of therapy based on assay results in personalised medicine; Prognosis

Definitions

• T1D clinical type 1 diabetes
• BACKGROUND Type 1 diabetes (T1D) is caused by the autoimmune destruction of insulin producing beta cells in the islets of Langerhans leading to dependence on exogeneous insulin injections for survival.
• T1D progresses through asymptomatic stages prior to overt hyperglycemia, characterized first by the appearance of autoantibodies (Stage 1) and then dysglycemia (Stage 2).
• Stage 2 metabolic responses to a glucose load are impaired but other metabolic indices, for example glycosylated hemoglobin, are normal and insulin treatment is not needed.
• These immunologic and metabolic features identify individuals who are at high- risk for development of clinical disease with overt hyperglycemia and requirement for insulin treatment (Stage 3).
• Several immune interventions have been shown to delay decline in beta cell function when studied in recent-onset clinical T1D.
• One promising therapy is the FcR non- binding anti-CD3 monoclonal antibody teplizumab, as several studies have shown that short- term treatment reduces loss of ⁇ cell function durably, with an observable effect seen as long as 7 years after diagnosis and treatment.
• a method of preventing or delaying the onset of clinical type 1 diabetes comprising: providing a non-diabetic subject who is at risk for T1D; administering a prophylactically effective amount of an anti-CD3 antibody to the non-diabetic subject; and determining, prior to or after the administering step, that the non-diabetic subject has more than about 5% to more than about 10% TIGIT+KLRG1+CD8+ T- cells in all CD3+ T cells, which is indicative of successful prevention or delay of the onset of clinical T1D.
• the non-diabetic subject is a relative of a patient with T1D.
• the method further includes determining that the non-diabetic subject (1) is substantially free of antibodies against zinc transporter 8 (ZnT8), (2) is HLA- DR4+, and/or (3) is not HLA-DR3+.
• the non-diabetic subject has 2 or more diabetes-related autoantibodies selected from islet cell antibodies (ICA), insulin autoantibodies (IAA), and antibodies to glutamic acid decarboxylase (GAD), tyrosine phosphatase (IA-2/ICA512) or ZnT8.
• the non-diabetic subject has abnormal glucose tolerance on oral glucose tolerance test (OGTT).
• the abnormal glucose tolerance on OGTT is a fasting glucose level of 110-125 mg/dL, or 2 hour plasma of ⁇ 140 and ⁇ 200 mg/dL, or an intervening glucose value at 30, 60, or 90 minutes on OGTT > 200 mg/dL.
• the non-diabetic subject does not have antibodies against ZnT8.
• the non-diabetic subject is HLA-DR4+ and is not HLA-DR3+.
• the anti-CD3 antibody is selected from teplizumab, otelixizumab or foralumab.
• the prophylactically effective amount of the antibody comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion or oral administration of the anti-CD3 antibody at 10-1000 micrograms/meter squared ( ⁇ g/m 2 ), preferably a 14-day course IV infusion at 51 ⁇ g/m 2 , 103 ⁇ g/m 2 , 207 ⁇ g/m 2 , and 413 ⁇ g/m 2 , on days 0–3, respectively, and one dose of 826 ⁇ g/m 2 on each of days 4-13.
• SC subcutaneous
• IV intravenous
• the prophylactically effective amount delays median time to clinical diagnosis of T1D by at least 50%, at least 80%, or at least 90%, or at least 12 months, at least 18 months, at least 24 months, at least 36 months, at least 48 months, or at least 60 months.
• the determining of TIGIT+KLRG1+CD8+ T-cells is by flow cytometry.
• the method further includes determining a decrease in a percentage of CD8+ T cells expressing proliferation markers Ki67 and/or CD57.
• a method of prognosing responsiveness of an anti-CD3 antibody in preventing or delaying the onset of type 1 diabetes comprising: providing a non-diabetic subject who is at risk for T1D; administering a prophylactically effective amount of an anti-CD3 antibody to the non-diabetic subject; and determining C-peptide area under the curve (AUC): glucose AUC ratio, wherein an increase in said ratio indicates responsiveness to the anti-CD3 antibody and/or non- progression to clinical T1D.
• AUC C-peptide area under the curve
• FIG. 1A shows a consort diagram of at-risk individuals enrolled into the teplizumab prevention study.
• FIG.1B shows that teplizumab treatment is associated with a sustained effect on Type 1 Diabetes progression over 923 days of follow-up.
• Updated Kaplan-Meier Curve based on 923 days of follow up (range 74-3,119 days).
• the median time to diabetes was 24.4 (or 27.1 months according to Sims et al., Sci. Transl. Med. 13, eabc8980 (2021), incorporated herein by reference) and 59.6 months in the placebo and teplizumab treatment groups respectively.
• FIG. 3A shows OGTT classifications for participants in each group over 36 months of follow-up. The data are shown to 36 months because of loss of placebo treated participants because of the clinical diagnosis of T1D (for individual participants see Figures 2A-2B).
• FIG. 3B shows a boxplot displaying median and interquartile ranges for on-study OGTT glucose AUC mean for participants from placebo and teplizumab treated groups.
• FIG. 4 shows the average on-study Hemoglobin A1c levels in the treatment groups in a boxplot displaying median and interquartile ranges for average on-study Hemoglobin A1c AUC for participants from placebo and teplizumab treated groups.
• FIG.5 shows that teplizumab treatment was associated with increased average on-study C-peptide AUC.
• FIG.5 shows a boxplot displaying median and interquartile ranges for average on-study OGTT C-peptide AUC mean for participants from placebo and teplizumab treated groups.
• FIG.6 shows the relationship of average on-study C-peptide AUC with age and average on-study glucose AUC.
• FIG.7 shows C-peptide over time in the two treatment arms over the first year. The log- transformed mean C-peptide AUC is shown. Arrows indicate individual drop out from OGTT monitoring due to diabetes development after each timepoint. Median value for “pre-baseline” timepoint was 24.
• FIGS. 8A-8G show insulin secretion following treatment with teplizumab or placebo. Estimated slopes for the insulin secreted (pmol) secreted during the total (FIG. 8A), first hour (FIG.8B), and second hour (FIG.8C) of the OGTT at the visits before enrollment and over the first 6 months following study drug treatment.
• FIGS.8D and 8E show representative insulin secretion rates during serial OGTTs for 2 teplizumab participants who were not diagnosed with T1D (age 11 and 12 years) and (FIG.8F and FIG.8G) two placebo treated individuals (both age 13 years) who were diagnosed with T1D. The color lines indicate the time of the visits in relationship to study drug administration.
• FIGS.9A-9E show that teplizumab preserves C-peptide over the course of the study until the period surrounding diagnosis. For all panels, data from teplizumab-treated participants are shown in blue, and placebo-treated participants are shown in maroon.
• FIG.9E shows slopes of C-peptide AUC for 6-month period before diagnosis in those that developed T1D, and the last 6 months of study in individuals remaining T1D-free. [0029]
• FIG.10A and FIG.10B show that C-peptide values are similar between treatment groups at the time of diagnosis.
• FIG.10A and FIG.10B show that C-peptide values are similar between treatment groups at the time of diagnosis.
• FIG. 10A shows C-peptide AUC/Glucose AUC at the time of clinical diagnosis of T1D.
• FIG. 10B shows C-peptide AUC at the time of clinical diagnosis of T1D. Values were obtained from the first of two consecutive diagnostic OGTTs consistent with a classification of T1D.
• FIGS. 11A-11C show that functional changes in T cells are associated with improvements in metabolic function.
• FIG. 11A shows the changes in TIGIT+KLRG1+CD45RO+CD8+ T cells between baseline and 3 months and the change in the C-peptide AUC between the baseline and 6 months are shown.
• the frequency of the IFN ⁇ and TNF ⁇ producing cells were reduced in the teplizumab treated participants (paired T-test, ***p ⁇ 0.0001).
• FIG. 12 shows teplizumab treated subjects with the best outcome have more TIGIT+KLRG1+ CD8 T cells.
• FIG.13 and FIG.14 show total TIGIT+KLRG1+ CD8 T cells resemble exhausted cells.
• FIG.15 and FIG.16 show total TIGIT+KLRG1+ CD8 T cells are heterogeneous.
• FIG. 17 shows TIGIT+KLRG1+ T cells are spread across much of the memory CD8 landscape in the teplizumab TrialNet Stage 2 trial.
• FIGS.18-21 shows TIGIT+KLRG1+ subsets differ in response and outcome.
• FIG.22 shows OGTT patterns of 30 to 120 minute glucose and C-peptide.
• FIG. 23 shows 2D plots of mean glucose and C-peptide values identify distinct longitudinal OGTT patterns among “Progressors” and “NonProgressors” within DPT-1.
• FIG.24 shows 2D plots of mean glucose and C-peptide values for 30-120 minute OGTT timepoints show distinct patters at 3 month visit.
• FIG. 25 shows 3-month change in ratio of C-peptide AUC/Glucose AUC shows most significant differences compared to other metabolic measures.
• FIG. 26 Predicted Mean Teplizumab Serum Concentration Versus Time Profile Following 14-Day Regimen Across Different Body Weights.
• T1D clinical type 1 diabetes
• a method of preventing or delaying the onset of clinical type 1 diabetes comprising: providing a non-diabetic subject who is at risk for T1D; administering a prophylactically effective amount of an anti-CD3 antibody to the non- diabetic subject; and determining, prior to or after the administering step, that the non-diabetic subject has more than about 5% to more than about 10% TIGIT+KLRG1+CD8+ T-cells in all CD3+ T cells, which is indicative of successful prevention or delay of the onset of clinical T1D.
• a method of prognosing responsiveness of an anti-CD3 antibody in preventing or delaying the onset of T1D.
• the method can include: providing a non-diabetic subject who is at risk for T1D; administering a prophylactically effective amount of the anti-CD3 antibody, e.g., teplizumab, to the non-diabetic subject; and determining C-peptide area under the curve (AUC): glucose AUC ratio, wherein an increase in said ratio indicates responsiveness to the anti-CD3 antibody.
• AUC C-peptide area under the curve
• the articles “a” and “an” refer to one or more than one, e.g., to at least one, of the grammatical object of the article.
• the use of the words “a” or “an” when used in conjunction with the term “comprising” herein may mean “one,” but it is also consistent with the meaning of "one or more,” “at least one,” and “one or more than one.”
• “about” and “approximately” generally mean an acceptable degree of error for the quantity measured given the nature or precision of the measurements. Exemplary degrees of error are within 20 percent (%), typically, within 10%, and more typically, within 5% of a given range of values.
• substantially means more than 50%, preferably more than 80%, and most preferably more than 90% or 95%.
• the term “comprising” or “comprises” is used in reference to compositions, methods, and respective component(s) thereof, that are present in a given embodiment, yet open to the inclusion of unspecified elements.
• the term “consisting essentially of” refers to those elements required for a given embodiment. The term permits the presence of additional elements that do not materially affect the basic and novel or functional characteristic(s) of that embodiment of the disclosure.
• the term “consisting of” refers to compositions, methods, and respective components thereof as described herein, which are exclusive of any element not recited in that description of the embodiment.
• the term “antibody” herein is used in the broadest sense and encompasses various antibody structures, including but not limited to monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), and antibody fragments so long as they exhibit the desired antigen-binding activity.
• An “antibody fragment” refers to a molecule other than an intact antibody that comprises a portion of an intact antibody that binds the antigen to which the intact antibody binds.
• antibody fragments include but are not limited to Fv, Fab, Fab', Fab'-SH, F(ab')2; diabodies; linear antibodies; single-chain antibody molecules (e.g. scFv); and multispecific antibodies formed from antibody fragments.
• prolactic agent refer to CD3 binding molecules such as teplizumab which can be used in the prevention, treatment, management or amelioration of one or more symptoms of T1D.
• onset of disease with reference to Type-1 diabetes refers to a patient meeting the criteria established for diagnosis of Type-1 diabetes by the American Diabetes Association (see, Mayfield et al., 2006, Am. Fam.
• a “protocol” includes dosing schedules and dosing regimens.
• the protocols herein are methods of use and include prophylactic and therapeutic protocols.
• a “dosing regimen” or “course of treatment” may include administration of several doses of a therapeutic or prophylactic agent over 1 to 20 days.
• the terms “subject” and “patient” are used interchangeably.
• the terms “subject” and “subjects” refer to an animal, preferably a mammal including a non-primate (e.g., a cow, pig, horse, cat, dog, rat, and mouse) and a primate (e.g., a monkey or a human), and more preferably a human.
• a non-primate e.g., a cow, pig, horse, cat, dog, rat, and mouse
• a primate e.g., a monkey or a human
• a prophylactically effective amount preferably refers to the amount of teplizumab that delays a subject's onset of T1D by at least 20%, by at least 25%, by at least 30%, by at least 35%, by at least 40%, by at least 45%, by at least 50%, by at least 55%, by at least 60%, by at least 65%, by at least 70%, by at least 75%, by at least 80%, by at least 85%, by at least 90%, by at least 95%.
• anti-CD3 antibody and “an antibody that binds to CD3” refer to an antibody or antibody fragment that is capable of binding cluster of differentiation 3 (CD3) with sufficient affinity such that the antibody is useful as a prophylactic, diagnostic and/or therapeutic agent in targeting CD3.
• the extent of binding of an anti-CD3 antibody to an unrelated, non-CD3 protein is less than about 10% of the binding of the antibody to CD3 as measured, e.g., by a radioimmunoassay (RIA).
• RIA radioimmunoassay
• an antibody that binds to CD3 has a dissociation constant (Kd) of ⁇ 1 ⁇ , ⁇ 100 nM, ⁇ 10 nM, ⁇ 1 nM, ⁇ 0.1 nM, ⁇ 0.01 nM, or ⁇ 0.001 nM (e.g. 10 -8 M or less, e.g. from 10 -8 M to 10 -13 M, e.g., from 10 -9 M to 10 -13 M).
• an anti-CD3 antibody binds to an epitope of CD3 that is conserved among CD3 from different species.
• the anti-CD3 antibody can be ChAglyCD3 (otelixizumab).
• Otelixizumab is a humanized Fc nonbinding anti-CD3, which was evaluated initially in phase 2 studies by the Belgian Diabetes Registry (BDR) and then developed by Tolerx, which then partnered with GSK to conduct the phase 3 DEFEND new onset T1D trials (NCT00678886, NCT01123083, NCT00763451). Otelixizumab is administered IV with infusions over 8 days. See, e.g., Wiczling et al., J. Clin. Pharmacol.
• the anti-CD3 antibody can be visilizumab (also called HuM291; Nuvion).
• Visilizumab is a humanized anti-CD3 monoclonal antibody characterized by a mutated IgG2 isotype, lack of binding to Fc ⁇ receptors, and the ability to induce apoptosis selectively in activated T cells. It was evaluated in patients in graft-versus-host disease (NCT00720629; NCT00032279) and in ulcerative colitis (NCT00267306) and Crohn’s Disease (NCT00267709). See, e.g., Sandborn et al., Gut 59 (11) (Nov 2010) 1485–1492, incorporated herein by reference.
• the anti-CD3 antibody can be foralumab, a fully human anti-CD3 monoclonal antibody being developed by Tiziana Life Sciences, PLC in NASH and T2D (NCT03291249). See, e.g., Ogura et al., Clin Immunol. 2017;183:240-246; Ishikawa et al., Diabetes.2007;56(8):2103-9; Wu et al., J Immunol.2010;185(6):3401-7; all incorporated herein by reference.
• the anti-CD3 antibody can be teplizumab.
• Teplizumab also known as hOKT3yl(Ala-Ala) (containing an alanine at positions 234 and 235) is an anti-CD3 antibody that had been engineered to alter the function of the T lymphocytes that mediate the destruction of the insulin-producing beta cells of the islets of the pancreas. Teplizumab binds to an epitope of the CD3 ⁇ chain expressed on mature T cells and by doing so changes their function. Sequences and compositions of teplizumab are disclosed in U.S. Patent Nos. 6,491,916; 8,663,634; and 9,056,906, each incorporated herein by reference in its entirety. The full sequences of light and heavy chains are set forth below.
• Teplizumab Light Chain SEQ ID NO: 1
• Teplizumab Heavy Chain SEQ ID NO: 2
• pharmaceutically acceptable means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans.
• carrier refers to a diluent, adjuvant (e.g., Freund's adjuvant (complete and incomplete)), excipient, or vehicle with which the therapeutic is administered.
• adjuvant e.g., Freund's adjuvant (complete and incomplete)
• excipient or vehicle with which the therapeutic is administered.
• Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like. Water is a preferred carrier when the pharmaceutical composition is administered intravenously.
• Saline solutions and aqueous dextrose and glycerol solutions can also be employed as liquid carriers, particularly for injectable solutions.
• Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, dried skim milk, glycerol, propylene, glycol, water, ethanol and the like (See, for example, Handbook of Pharmaceutical Excipients, Arthur H. Kibbe (ed., 2000, which is incorporated by reference herein in its entirety), Am. Pharmaceutical Association, Washington, D.C. [0064]
• the composition if desired, can also contain minor amounts of wetting or emulsifying agents, or pH buffering agents.
• compositions can take the form of solutions, suspensions, emulsion, tablets, pills, capsules, powders, sustained release formulations and the like.
• Oral formulation can include standard carriers such as pharmaceutical grades of mannitol, lactose, starch, magnesium stearate, sodium saccharine, cellulose, magnesium carbonate, etc. Examples of suitable pharmaceutical carriers are described in "Remington's Pharmaceutical Sciences” by E. W. Martin.
• Such compositions will contain a prophylactically or therapeutically effective amount of a prophylactic or therapeutic agent preferably in purified form, together with a suitable amount of carrier so as to provide the form for proper administration to the patient.
• the formulation should suit the mode of administration.
• the pharmaceutical compositions are sterile and in suitable form for administration to a subject, preferably an animal subject, more preferably a mammalian subject, and most preferably a human subject.
• a subject preferably an animal subject, more preferably a mammalian subject, and most preferably a human subject.
• care must be taken to use materials to which the anti-CD3 antibody does not absorb.
• the composition can be delivered in a vesicle, in particular a liposome (see Langer, Science 249:1527-1533 (1990); Treat et al., in Liposomes in the Therapy of Infectious Disease and Cancer, Lopez-Berestein and Fidler (eds.), Liss, New York, pp. 353- 365 (1989); Lopez-Berestein, ibid., pp.317-327; see generally ibid.).
• the composition can be delivered in a controlled release or sustained release system.
• a pump may be used to achieve controlled or sustained release (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed.
• polymeric materials can be used to achieve controlled or sustained release of the antibodies of the invention or fragments thereof (see e.g., Medical Applications of Controlled Release, Langer and Wise (eds.), CRC Pres., Boca Raton, Fla. (1974); Controlled Drug Bioavailability, Drug Product Design and Performance, Smolen and Ball (eds.), Wiley, New York (1984); Ranger and Peppas, 1983, J., Macromol. Sci. Rev. Macromol. Chem.
• polymers used in sustained release formulations include, but are not limited to, poly(2-hydroxy ethyl methacrylate), poly(methyl methacrylate), poly(acrylic acid), poly(ethylene-co-vinyl acetate), poly(methacrylic acid), polyglycolides (PLG), polyanhydrides, poly(N-vinyl pyrrolidone), poly(vinyl alcohol), polyacrylamide, poly(ethylene glycol), polylactides (PLA), poly(lactide-co-glycolides) (PLGA), and polyorthoesters.
• the polymer used in a sustained release formulation is inert, free of leachable impurities, stable on storage, sterile, and biodegradable.
• a controlled or sustained release system can be placed in proximity of the therapeutic target, i.e., the lungs, thus requiring only a fraction of the systemic dose (see, e.g., Goodson, in Medical Applications of Controlled Release, supra, vol.2, pp.115-138 (1984)).
• Controlled release systems are discussed in the review by Langer (1990, Science 249:1527-1533). Any technique known to one of skill in the art can be used to produce sustained release formulations comprising one or more antibodies of the invention or fragments thereof. See, e.g., U.S. Pat. No. 4,526,938; PCT Publication No. WO 91/05548; PCT Publication No.
• a pharmaceutical composition can be formulated to be compatible with its intended route of administration.
• routes of administration include, but are not limited to, parenteral, e.g., intravenous, intradermal, subcutaneous, oral, intranasal (e.g., inhalation), transdermal (topical), transmucosal, and rectal administration.
• the composition is formulated in accordance with routine procedures as a pharmaceutical composition adapted for intravenous, subcutaneous, intramuscular, oral, intranasal or topical administration to human beings.
• a pharmaceutical composition is formulated in accordance with routine procedures for subcutaneous administration to human beings.
• compositions for intravenous administration are solutions in sterile isotonic aqueous buffer.
• compositions may also include a solubilizing agent and a local anesthetic such as lignocamne to ease pain at the site of the injection.
• a solubilizing agent such as lignocamne to ease pain at the site of the injection.
• the compositions may be formulated for parenteral administration by injection, e.g., by bolus injection or continuous infusion. Formulations for injection may be presented in unit dosage form, e.g., in ampoules or in multi-dose containers, with an added preservative.
• the compositions may take such forms as suspensions, solutions or emulsions in oily or aqueous vehicles, and may contain formulatory agents such as suspending, stabilizing and/or dispersing agents.
• the active ingredient may be in powder form for constitution with a suitable vehicle, e.g., sterile pyrogen-free water, before use.
• a suitable vehicle e.g., sterile pyrogen-free water
• the disclosure provides dosage forms that permit administration of the anti-CD3 antibody continuously over a period of hours or days (e.g., associated with a pump or other device for such delivery), for example, over a period of 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 16 hours, 20 hours, 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days or 14 days.
• the invention provides dosage forms that permit administration of a continuously increasing dose, for example, increasing from 51 ug/m 2 /day to 826 ug/m 2 /day over a period of 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days or 14 days.
• the compositions can be formulated as neutral or salt forms.
• compositions disclosed herein are supplied either separately or mixed together in unit dosage form, for example, as a dry lyophilized powder or water free concentrate in a hermetically sealed container such as an ampoule or sachette indicating the quantity of active agent.
• composition is to be administered by infusion
• it can be dispensed with an infusion bottle containing sterile pharmaceutical grade water or saline.
• an ampoule of sterile water for injection or saline can be provided so that the ingredients may be mixed prior to administration.
• the disclosure provides that the anti-CD3 antibodies, or pharmaceutical compositions thereof, can be packaged in a hermetically sealed container such as an ampoule or sachette indicating the quantity of the agent.
• the anti-CD3 antibody, or pharmaceutical compositions thereof is supplied as a dry sterilized lyophilized powder or water free concentrate in a hermetically sealed container and can be reconstituted, e.g., with water or saline to the appropriate concentration for administration to a subject.
• the anti-CD3 antibody, or pharmaceutical compositions thereof is supplied as a dry sterile lyophilized powder in a hermetically sealed container at a unit dosage of at least 5 mg, more preferably at least 10 mg, at least 15 mg, at least 25 mg, at least 35 mg, at least 45 mg, at least 50 mg, at least 75 mg, or at least 100 mg.
• the lyophilized prophylactic agents, or pharmaceutical compositions herein should be stored at between 2 oC and 8 oC in its original container and the prophylactic or therapeutic agents, or pharmaceutical compositions of the invention should be administered within 1 week, preferably within 5 days, within 72 hours, within 48 hours, within 24 hours, within 12 hours, within 6 hours, within 5 hours, within 3 hours, or within 1 hour after being reconstituted.
• the pharmaceutical composition is supplied in liquid form in a hermetically sealed container indicating the quantity and concentration of the agent.
• the liquid form of the administered composition is supplied in a hermetically sealed container at least 0.25 mg/ml, more preferably at least 0.5 mg/ml, at least 1 mg/ml, at least 2.5 mg/ml, at least 5 mg/ml, at least 8 mg/ml, at least 10 mg/ml, at least 15 mg/ml, at least 25 mg/ml, at least 50 mg/ml, at least 75 mg/ml or at least 100 mg/ml.
• the liquid form should be stored at between 2 oC and 8 oC in its original container.
• the disclosure provides that the composition of the invention is packaged in a hermetically sealed container such as an ampoule or sachette indicating the quantity of the anti-CD3 antibody.
• the compositions may, if desired, be presented in a pack or dispenser device that may contain one or more unit dosage forms containing the active ingredient.
• the pack may, for example, comprise metal or plastic foil, such as a blister pack.
• the amount of the composition of the invention which will be effective in the prevention or amelioration of one or more symptoms associated with T1D can be determined by standard clinical techniques. The precise dose to be employed in the formulation will also depend on the route of administration and the seriousness of the condition, and should be decided according to the judgment of the practitioner and each patient's circumstances.
• Effective doses may be extrapolated from dose-response curves derived from in vitro or animal model test systems.
• Methods and Use [0078]
• the present disclosure encompasses administration of anti-human CD3 antibodies such as teplizumab to individuals predisposed to develop type 1 diabetes or with pre-clinical stages of type 1 diabetes, but who do not meet the diagnosis criteria as established by the American Diabetes Association or the Immunology of Diabetes Society to prevent or delay the onset of type 1 diabetes and/or to prevent or delay the need for administration of insulin to such patients.
• high-risk factors for identification of predisposed subjects include having first or second degree relatives with diagnosed type-1 diabetes, an impaired fasting glucose level (e.g., at least one determination of a glucose level of 100-125 mg/dl after fasting (8 hours with no food)), an impaired glucose tolerance in response to a 75 g OGTT (e.g., at least one determination of a 2-hr glucose level of 140-199 mg/dl in response to a 75 g OGTT), an HLA type of DR3, DR4 or DR7 in a Caucasian, an HLA type of DR3 or DR4 in a person of African descent, an HLA type of DR3, DR4 or DR9 in a person of Japanese descent, exposure to viruses (e.g., coxsackie B virus, enteroviruses, adenoviruses, rubella, cytomegalovirus, Epstein-Barr virus), a positive diagnosis according to art accepted criteria of at least one other autoimmune disorder (e.g.
• viruses
• the subject identified as predisposed to developing type 1 diabetes has at least one of the risk factors described herein and/or as known in the art.
• the present disclosure also encompasses identification of subjects predisposed to development of type 1 diabetes, wherein said subject presents a combination of two or more, three or more, four or more, or more than five of the risk factors disclosed herein or known in the art.
• Serum autoantibodies associated with type 1 diabetes or with a predisposition for the development of type 1 diabetes are islet-cell autoantibodies (e.g., anti-ICA512 autoantibodies), glutamic acid decarbamylase autoantibodies (e.g., anti-GAD65 autoantibodies), IA2 antibodies, ZnT8 antibodies and/or anti-insulin autoantibodies.
• islet-cell autoantibodies e.g., anti-ICA512 autoantibodies
• glutamic acid decarbamylase autoantibodies e.g., anti-GAD65 autoantibodies
• IA2 antibodies e.g., ZnT8 antibodies and/or anti-insulin autoantibodies.
• the invention encompasses the treatment of an individual with detectable autoantibodies associated with a predisposition to the development of type 1 diabetes or associated with early stage type 1 diabetes (e.g., anti-IA2, anti-ICA512, anti-GAD or anti- insulin autoantibodies), wherein said individual has not been diagnosed with type 1 diabetes and/or is a first or second degree relative of a type-1 diabetic.
• the presence of the autoantibodies is detected by ELISA, electrochemoluminescence (ECL), radioassay (see, e.g., Yu et al., 1996, J. Clin. Endocrinol. Metab.
• ⁇ -cell function prior to, during, and after therapy may be assessed by methods described herein or by any method known to one of ordinary skill in the art.
• DCCT Diabetes Control and Complications Trial
• characterization of daily insulin needs, C-peptide levels/response, hypoglycemic episodes, and/or FPIR may be used as markers of ⁇ -cell function or to establish a therapeutic index (See Keymeulen et al., 2005, N. Engl. J. Med.352:2598-2608; Herold et al., 2005, Diabetes 54:1763-1769; U.S. Pat. Appl. Pub. No. 2004/0038867 A1; and Greenbaum et al., 2001, Diabetes 50:470-476, respectively).
• FPIR is calculated as the sum of insulin values at 1 and 3 minutes post IGTT, which are performed according to Islet Cell Antibody Register User's Study protocols (see, e.g., Bingley et al., 1996, Diabetes 45:1720-1728 and McCulloch et al., 1993, Diabetes Care 16:911- 915).
• the individuals predisposed to develop T1D can be a non-diabetic subject who is a relative of a patient with T1D.
• the non-diabetic subject has 2 or more diabetes-related autoantibodies selected from islet cell antibodies (ICA), insulin autoantibodies (IAA), and antibodies to glutamic acid decarboxylase (GAD), tyrosine phosphatase (IA-2/ICA512) or ZnT8.
• ICA islet cell antibodies
• IAA insulin autoantibodies
• GAD glutamic acid decarboxylase
• IA-2/ICA512 tyrosine phosphatase
• ZnT8 ZnT8.
• the non-diabetic subject has abnormal glucose tolerance on oral glucose tolerance test (OGTT).
• Abnormal glucose tolerance on OGTT is defined as a fasting glucose level of 110-125 mg/dL, or 2 hour plasma of ⁇ 140 and ⁇ 200 mg/dL, or an intervening glucose value at 30, 60, or 90 minutes on OGTT > 200 mg/dL.
• the non-diabetic subject who will respond to the anti-CD3 antibody such as teplizumab does not have antibodies against ZnT8.
• such non-diabetic subject is HLA-DR4+ and is not HLA-DR3+.
• such non- diabetic subject who will respond to the anti-CD3 antibody such as teplizumab demonstrates an increase, following administration (e.g., after 1 month, after 2 months, after 3 months, or longer or shorter), in the frequency (or relative amount) of TIGIT+KLRG1+CD8+ T-cells (e.g., by flow cytometry) in peripheral blood mononuclear cells.
• the prophylactically effective amount comprises a 10 to 14-day course of subcutaneous (SC) injection or intravenous (IV) infusion of the anti-CD3 antibody such as teplizumab at 10-1000 micrograms/meter squared ( ⁇ g/m 2 ).
• the prophylactically effective amount comprises a 14-day course IV infusion of the anti-CD3 antibody such as teplizumab at 51 ⁇ g/m 2 , 103 ⁇ g/m 2 , 207 ⁇ g/m 2 , and 413 ⁇ g/m 2 , on days 0–3, respectively, and one dose of 826 ⁇ g/m 2 on each of days 4–13.
• the prophylactically effective amount delays median time to clinical diagnosis of T1D by at least 50%, at least 80%, or at least 90%, or at least 12 months, at least 18 months, at least 24 months, at least 36 months, at least 48 months, or at least 60 months, or longer.
• the course of dosing with the anti-CD3 antibody such as teplizumab can be repeated at 2 month, 4 month, 6 month, 8 month, 9 month, 10 month, 12 month, 15 month, 18 month, 24 month, 30 month, or 36 month intervals.
• efficacy of the treatment with the anti-CD3 antibody such as teplizumab is determined as described herein, or as is known in the art, at 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, or 36 months subsequent to the previous treatment.
• a subject is administered one or more unit doses of approximately 0.5-50 ug/kg, approximately 0.5-40 ug/kg, approximately 0.5-30 ug/kg, approximately 0.5-20 ug/kg, approximately 0.5-15 ug/kg, approximately 0.5-10 ug/kg, approximately 0.5-5 ug/kg, approximately 1-5 ug/kg, approximately 1-10 ug/kg, approximately 20-40 ug/kg, approximately 20-30 ug/kg, approximately 22-28 ug/kg or approximately 25-26 ug/kg of the anti-CD3 antibody such as teplizumab to prevent, treat or ameliorate one or more symptoms of T1D.
• the anti-CD3 antibody such as teplizumab
• a subject is administered one or more unit doses of about 200 ug/kg, 178 ug/kg, 180 ug/kg, 128 ug/kg, 100 ug/kg, 95 ug/kg, 90 ug/kg, 85 ug/kg, 80 ug/kg, 75 ug/kg, 70 ug/kg, 65 ug/kg, 60 ug/kg, 55 ug/kg, 50 ug/kg, 45 ug/kg, 40 ug/kg, 35 ug/kg, 30 ug/kg, 26 ug/kg, 25 ug/kg, 20 ug/kg, 15 ug/kg, 13 ug/kg, 10 ug/kg, 6.5 ug/kg, 5 ug/kg, 3.2 ug/kg, 3 ug/kg, 2.5 ug/kg, 2 ug/kg, 1.6 ug/kg, 1.5 ug/kg, 1
• a subject is administered one or more doses of the anti-CD3 antibody such as teplizumab at about 5-1200 ug/m 2 , preferably, 51-826 ug/m 2 .
• a subject is administered one or more unit doses of 1200 ug/m 2 , 1150 ug/m 2 , 1100 ug/m 2 , 1050 ug/m 2 , 1000 ug/m 2 , 950 ug/m 2 , 900 ug/m 2 , 850 ug/m 2 , 800 ug/m 2 , 750 ug/m 2 , 700 ug/m 2 , 650 ug/m 2 , 600 ug/m 2 , 550 ug/m 2 , 500 ug/m 2 , 450 ug/m 2 , 400 ug/m 2 , 350 ug/m 2 , 300 u
• the subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the course of treatment is administered over 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days or 14 days.
• the treatment regimen comprises administering doses of the prophylactically effective amount every day, every 2nd day, every 3rd day or every 4th day.
• the treatment regimen comprises administering doses of the prophylactically effective amount on Monday, Tuesday, Wednesday, Thursday of a given week and not administering doses of the prophylactically effective amount on Friday, Saturday, and Sunday of the same week until 14 doses, 13 doses, 12 doses, 11 doses, 10 doses, 9 doses, or 8 doses have been administered.
• the dose administered is the same each day of the regimen.
• a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is 200 ug/kg/day, 175 ug/kg/day, 150 ug/kg/day, 125 ug/kg/day, 100 ug/kg/day, 95 ug/kg/day, 90 ug/kg/day, 85 ug/kg/day, 80 ug/kg/day, 75 ug/kg/day, 70 ug/kg/day, 65 ug/kg/day, 60 ug/kg/day, 55 ug/kg/day, 50 ug/kg/day, 45 ug/kg/day, 40 ug/kg/day, 35 ug/kg/day, 30 ug/kg/day, 26 ug/kg/day, 25 ug/kg/day, 20 u
• the total dosage over the duration of the regimen is preferably a total of less than 9000 ug/m 2 , 8000 ug/m 2 , 7000 ug/m 2 , 6000 ug/m 2 , and may be less than 5000 ug/m 2 , 4000 ug/m 2 , 3000 ug/m 2 , 2000 ug/m 2 , or 1000 ug/m 2 .
• the total dosage administered in the regimen is 100 ug/m 2 to 200 ug/m 2 , 100 ug/m 2 to 500 ug/m 2 , 100 ug/m 2 to 1000 ug/m 2 , or 500 ug/m 2 to 1000 ug/m 2 .
• the dose escalates over the first fourth, first half or first 2/3 of the doses (e.g., over the first 2, 3, 4, 5, or 6 days of a 10, 12, 14, 16, 18 or 20-day regimen of one dose per day) of the treatment regimen until the daily prophylactically effective amount of the anti-CD3 antibody such as teplizumab is achieved.
• a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is increased by, e.g., 0.01 ug/kg, 0.02 ug/kg, 0.04 ug/kg, 0.05 ug/kg, 0.06 ug/kg, 0.08 ug/kg, 0.1 ug/kg, 0.2 ug/kg, 0.25 ug/kg, 0.5 ug/kg, 0.75 ug/kg, 1 ug/kg, 1.5 ug/kg, 2 ug/kg, 4 ug/kg, 5 ug/kg, 10 ug/kg, 15 ug/kg, 20 ug/kg, 25 ug/kg, 30 ug/kg, 35 ug/kg, 40 ug/kg, 45 ug/kg, 50 ug/kg, 55 u
• a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of the anti-CD3 antibody such as teplizumab, wherein the prophylactically effective amount is increased by a factor of 1.25, a factor of 1.5, a factor of 2, a factor of 2.25, a factor of 2.5, or a factor of 5 until the daily prophylactically effective amount of the anti-CD3 antibody such as teplizumab is achieved.
• a prophylactically effective amount of the anti-CD3 antibody such as teplizumab
• a subject is intramuscularly administered one or more doses of a 200 ug/kg or less, preferably 175 ug/kg or less, 150 ug/kg or less, 125 ug/kg or less, 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less,
• a subject is subcutaneously administered one or more doses of a 200 ug/kg or less, preferably 175 ug/kg or less, 150 ug/kg or less, 125 ug/kg or less, 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2
• a subject is intravenously administered one or more doses of a 100 ug/kg or less, preferably 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or
• the intravenous dose of 100 ug/kg or less, 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.2 ug/kg or less of the anti-CD3 antibody such
• a subject is orally administered one or more doses of a 100 ug/kg or less, preferably 95 ug/kg or less, 90 ug/kg or less, 85 ug/kg or less, 80 ug/kg or less, 75 ug/kg or less, 70 ug/kg or less, 65 ug/kg or less, 60 ug/kg or less, 55 ug/kg or less, 50 ug/kg or less, 45 ug/kg or less, 40 ug/kg or less, 35 ug/kg or less, 30 ug/kg or less, 25 ug/kg or less, 20 ug/kg or less, 15 ug/kg or less, 10 ug/kg or less, 5 ug/kg or less, 2.5 ug/kg or less, 2 ug/kg or less, 1.5 ug/kg or less, 1 ug/kg or less, 0.5 ug/kg or less, or 0.2
• the dose on day 1 of the regimen is 5-100 ug/m2/day, preferably 51 ug/m2/day and escalates to the daily dose as recited immediately above by day 3, 4, 5, 6 or 7.
• the subject is administered a dose of approximately 51 ug/m 2 /day, on day 2 approximately 103 ug/m 2 /day, on day 3 approximately 207 ug/m 2 /day, on day 4 approximately 413 ug/m 2 /day and on subsequent days of the regimen (e.g., days 5-14) 826 ug/m 2 /day.
• the subject on day 1, is administered a dose of approximately 227 ug/m 2 /day, on day 2 approximately 459 ug/m 2 /day, on day 3 and subsequent days, approximately 919 ug/m 2 /day. In some embodiments, on day 1, the subject is administered a dose of approximately 284 ug/m 2 /day, on day 2 approximately 574 ug/m 2 /day, on day 3 and subsequent days, approximately 1148 ug/m 2 /day. [0097] In some embodiments, the initial dose is 1/4, to 1/2, to equal to the daily dose at the end of the regimen but is administered in portions at intervals of 6, 8, 10 or 12 hours.
• a 13 ug/kg/day dose is administered in four doses of 3-4 ug/kg at intervals of 6 hours to reduce the level of cytokine release caused by administration of the antibody.
• the first 1, 2, 3, or 4 doses or all the doses in the regimen are administered more slowly by intravenous administration.
• a dose of 51 ug/m 2 /day may be administered over about 5 minutes, about 15 minutes, about 30 minutes, about 45 minutes, about 1 hour, about 2 hours, about 4 hours, about 6 hours, about 8 hours, about 10 hours, about 12 hours, about 14 hours, about 16 hours, about 18 hours, about 20 hours, and about 22 hours.
• the dose is administered by slow infusion over a period of, e.g., 20 to 24 hours.
• the dose is infused in a pump, preferably increasing the concentration of antibody administered as the infusion progresses.
• a set fraction of the doses for the 51 ug/m 2 /day to 826 ug/m 2 /day regimen described above is administered in escalating doses.
• the fraction is 1/10, 1/4, 1/3, 1/2, 2/3 or 3/4 of the daily doses of the regimens described above.
• the daily doses will be 5.1 ug/m 2 on day 1, 10.3 ug/m 2 on day 2, 20.7 g/m 2 on day 3, 41.3 ug/m 2 on day 4, and 82.6 ug/m 2 on days 5 to 14.
• the fraction is 1/4, the doses will be 12.75 ug/m 2 on day 1, 25.5 ug/m 2 on day 2, 51 ug/m 2 on day 3, 103 ug/m 2 on day 4, and 207 ug/m 2 on days 5 to 14.
• the doses When the fraction is 1/3, the doses will be 17 ug/m 2 on day 1, 34.3 ug/m 2 on day 2, 69 ug/m 2 on day 3, 137.6 ug/m 2 on day 4, and 275.3 ug/m 2 on days 5 to 14.
• the fraction When the fraction is 1/2, the doses will be 25.5 ug/m 2 on day 1, 51 ug/m 2 on day 2, 103 ug/m 2 on day 3, 207 ug/m 2 on day 4, and 413 ug/m 2 on days 5 to 14.
• the doses When the fraction is 2/3, the doses will be 34 ug/m 2 on day 1, 69 ug/m 2 on day 2, 137.6 ug/m 2 on day 3, 275.3 ug/m 2 on day 4, and 550.1 ug/m 2 on days 5 to 14.
• the fraction When the fraction is 3/4, the doses will be 38.3 ug/m 2 on day 1, 77.3 ug/m 2 on day 2, 155.3 ug/m 2 on day 3, 309.8 ug/m 2 on day 4, and 620 ug/m 2 on days 5 to 14.
• the regimen is identical to one of those described above but only over days 1 to 4, days 1 to 5, or days 1 to 6.
• the doses will be 17 ug/m 2 on day 1, 34.3 ug/m 2 on day 2, 69 ug/m 2 on day 3, 137.6 ug/m 2 on day 4, and 275.3 ug/m 2 on days 5 and 6.
• the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab, is not administered by daily doses over a number of days, but is rather administered by infusion in an uninterrupted manner over 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 15 hours, 18 hours, 20 hours, 24 hours, 30 hours or 36 hours.
• the infusion may be constant or may start out at a lower dosage for, for example, the first 1, 2, 3, 5, 6, or 8 hours of the infusion and then increase to a higher dosage thereafter. Over the course of the infusion, the patient receives a dose equal to the amount administered in the 5 to 20-day regimens set forth above.
• the speed and duration of the infusion is designed to minimize the level of free anti-CD3 antibody such as teplizumab, otelixizumab or foralumab in the subject after administration.
• the level of free anti-CD3 antibody such as teplizumab should not exceed 200 ng/ml free antibody.
• the infusion is designed to achieve a combined T cell receptor coating and modulation of at least 50%, 60%, 70%, 80%, 90%, 95% or of 100%.
• the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab is administered chronically to treat, prevent, or slow or delay the onset or progression, or ameliorate one or more symptoms of type 1 diabetes.
• a low dose of the anti-CD3 antibody such as teplizumab is administered once a month, twice a month, three times per month, once a week or even more frequently either as an alternative to the 6 to 14-day dosage regimen discussed above or after administration of such a regimen to enhance or maintain its effect.
• Such a low dose may be anywhere from 1 ug/m 2 to 100 ug/m 2 , such as approximately 5 ug/m 2 , 10 ug/m 2 , 15 ug/m 2 , 20 ug/m 2 , 25 ug/m 2 , 30 ug/m 2 , 35 ug/m 2 , 40 ug/m 2 , 45 ug/m 2 , or 50 ug/m 2 .
• the subject may be re-dosed at some time subsequent to administration of the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab dosing regimen, for example, based upon one or more physiological parameters or may be done as a matter of course.
• the anti-CD3 antibody such as teplizumab, otelixizumab or foralumab dosing regimen
• Such redosing may be administered and/or the need for such redosing evaluated 2 months, 4 months, 6 months, 8 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months or 3 years after administration of a dosing regimen and may include administering a course of treatment every 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months or 3 years indefinitely.
• Drug treatment reversed a decline in insulin secretion prior to enrollment followed by stabilization of the declining C-peptide AUC seen with placebo treatment.
• T1D Type 1 diabetes
• T1D is associated with a need for lifelong exogenous insulin administration for survival, increased morbidity and mortality due to immediate (e.g. hypoglycemia) and long-term complications (e.g. vascular, renal, and eye disease), and reduced life-span, life impairments, and considerable health-care-related costs (6-9).
• immediate e.g. hypoglycemia
• long-term complications e.g. vascular, renal, and eye disease
• 6-9 serious health-care-related costs
• beta cell function Changes in beta cell function precede the clinical diagnosis of T1D and have been studied in natural history cohorts of individuals who are identified as at-risk for the disease based on the presence of islet autoantibodies (10-12). Some studies suggest an ongoing and intermittently progressive decline in beta cell function, that begins years before clinical diagnosis at a time when glucose tolerance is normal. During this period there are signs of ongoing autoimmunity: Based on the findings of the natural history, individuals with two or more islet autoantibodies have been classified as stages of T1D, with further specification according to the level of metabolic dysfunction: Stage 1 prior to glucose abnormalities, Stage 2 with dysglycemia during an oral glucose tolerance test (OGTT), and Stage 3 at clinical presentation with hyperglycemia (2, 13, 14).
• OGTT oral glucose tolerance test
• teplizumab an Fc receptor-nonbinding anti-CD3 ⁇ monoclonal antibody, that showed reduced decline in stimulated C-peptide responses compared to placebo or control participants (19-25)
• TrialNet TN10 we conducted a randomized Phase II trial of teplizumab in individuals with Stage 2 disease, to test whether treatment would prevent or delay the clinical diagnosis of T1D (26).
• this time-to-event study we found a delay in the median time to diagnosis of 24 months with teplizumab vs placebo, and a reduction in the rate of diabetes diagnoses from 35.9% to 14.9% per year (26). This trial represented the first to show successful prevention or delay in the diagnosis of T1D with immune therapy (27-31).
• the C-peptide responses were stable compared to placebo until an abrupt decline in the response approximately 6 months prior to diagnosis in those who were diagnosed with clinical T1D.
• the improved C-peptide responses were associated with an increase in the frequency of TIGIT+KLRG1+ memory CD8 T cells, which exhibited reduced secretion of IFN ⁇ and TNF ⁇ , two inflammatory cytokines linked to beta cell destruction (32).
• Teplizumab treatment resulted in a sustained delay in T1D during extended follow- up studies: A total of 76 relatives at high-risk, but without a clinical diagnosis of T1D were enrolled into the teplizumab prevention study (26). The median age was 13 (range 8-49) and all participants had 2+ autoantibody tests within the 6 months prior to enrollment. We previously reported, after a median follow up of 742 days (range 74 to 2683) that 42 were diagnosed with T1D. We have since continued to follow the study participants for a median time of 923 days (range of 74-3,119) (Figure 1A).
• T1D T1D
• the median times to diagnosis of T1D were 59.6 and 24.4 (or 27.1 according to Sims et al., Sci. Transl. Med.13, eabc8980 (2021), incorporated herein by reference) months in the teplizumab and placebo treatment groups respectively.
• Ten of thirteen subjects followed beyond 60 months or 5 years were not diagnosed with T1D. Of these individuals, eight were in the teplizumab group and two were in the placebo group.
• Figure 3B Table 1
• Teplizumab treatment reverses declines in C-peptide AUC during the first 6 months of treatment: Because average on-study C-peptide AUC could obscure more pronounced between-group differences at individual study timepoints, we next analyzed the timing of the changes in C-peptide AUC relative to treatment and the insulin secretion patterns. As the participants had been recruited from the TN01 Natural History study, we were able to analyze the C-peptide response to OGTTs before enrollment, and compare these to values after enrollment in this study. Geometric-like group means over a median of 2.4 months prior to randomization, and over the 12 months after are shown in Figure 7 and Tables 3-4.
• post treatment slopes even after correction for age and the C-peptide at enrollment.
• there was a significant increase in the C-peptide AUC in the teplizumab treated participants at 6 months after enrollment (6 month mean C-peptide AUC of 2.06 pmol/ml (1.85, 2.29), paired t-test p 0.02).
• T cell exhaustion has been associated with reduced cytokine production following activation (39). We therefore measured intracellular cytokines after stimulation of PBMC with anti-CD3 and anti-CD28.
• the OGTTs did not uniformly normalize in those who were not diagnosed with T1D. Minor changes, such as in the kinetics of insulin secretion or host factors may change the outcomes of the OGTT which are categorically classified based on levels of glycemia associated with long-term microvascular complications and not necessarily beta cell function or insulin secretion (43). These clinical outcomes are similar to the effects of anti-CD3 mAb in the NOD model of T1D, prior to the diagnosis of diabetes, in which insulin granularity was improved but beta cell mass did not recover to normal levels (44, 45). Further studies with metabolic clamps might improve our analysis of the metabolic function, but such studies were impractical in this clinical trial setting.
• time-to-event design of the original study had some important implications for the analyses included here.
• We did not have OGTT analyses for most individuals after diagnosis of T1D which limited our ability to compare OGTT data between all members of placebo and teplizumab groups over the same time period, particularly for the placebo group, which exhibited more rapid progression to diabetes.
• the time-to-event design also limited our ability to compare the relationship between metabolic endpoints and T1D progression, as some individuals included in the study that did not progress to diabetes may ultimately develop T1D.
• teplizumab treatment preserved C-peptide in patients with recent-onset T1D (19-25), positive effects on C-peptide might also be expected to occur amongst individuals that developed diabetes during this study.
• OGTTs were performed at approximately 6-month intervals in islet autoantibody positive individuals (including anti- glutamic acid decarboxylase 65, micro insulin, anti-islet antigen 2, anti-zinc transporter 8, and/or islet-cell antibodies), and the glucose results from these tests were used to identify eligibility for the anti-CD3 prevention trial (TN10) and were used in this data analysis.
• Islet autoantibody testing, HLA genotyping, and OGTT testing were performed as previously described (4, 49).
• OGTT fasting glucose 110-125 mg/dL (6.1-6.9 mmol/L
• 2-hour postprandial plasma glucose level of > 140 mg/dL (7.8 mmol/L) and ⁇ 200 mg/dL (11.1 mmol/L)
• an intervening postprandial glucose level at 30, 60, or 90 minutes of > 200 mg/dL For participants who did not have a hemoglobin A1c available at the baseline visit, values obtained within the 3 months
• Teplizumab was dosed at 51 ⁇ g/m 2 on day 0, 103 ⁇ g/m 2 on day 1, 207 ⁇ g/m 2 on day 2, 413 ⁇ g/m 2 on day 3, followed by a dose of 826 ⁇ g/m 2 on days 4 through 13.
• OGTTs were performed 3 months and 6 months after the infusions and every 6 months thereafter. Random screening glucose levels were evaluated at 3-month intervals, and an OGTT was performed if the random glucose level was >200 mg/dL (11.1 mmol/).
• T1D was diagnosed using ADA criteria during an OGTT but only after the diabetic OGTT was sequentially confirmed. The date of diagnosis was identified as the time of the first of the 2 diagnostic tests (50). Six participants were clinically diagnosed with T1D outside of OGTT monitoring. The original trial end date was May 2019. Participants who had not been diagnosed with T1D were transferred into the TrialNet Pathway to Prevention Natural History study (TN01) for follow up OGTT monitoring. Data from that follow up, between July 2011 and March 2020 are included in this analysis. Participants that did develop T1D were offered enrollment in TrialNet’s Long Term Investigational Follow-up (LIFT) study for continued metabolic follow-up.
• LIFT Long Term Investigational Follow-up
• OGTT C-peptide and glucose values were tested by Northwest Lipids Research Laboratories using the TOSOH and Roche C-peptide and glucose immunoassays, respectively. OGTT results were assigned to the nearest study visit timepoint (within 3 months of the official timepoint assignment. OGTT results were classified as normal, dysglycemic, or diabetic based on above definitions used for study entry. The baseline OGTT was the study at the time or immediately prior to randomization.
• AUC Area under the curve
• the on-study AUC means for C-peptide, glucose, and HbA1c were calculated by multiplying the AUC means for each OGTT visit and the visit intervals in days (as the trapezoidal base) to calculate a total study AUC, and then dividing by the days from the first to the last OGTT (confirmatory diabetic OGTT if developed T1D).
• Insulin secretory rates were calculated using the Chronobiological Series Analyzer (CSA) software, which uses a 2- compartment model for hormone clearance and standard kinetic parameters for C-peptide (51- 53). ISR calculations were performed using participant OGTT C-peptide and glucose values, as well as age, sex, height, and weight.
• PBMC Peripheral blood mononuclear cells
• NIDDK NIDDK repository
• Cryopreserved vials of PBMC were sent to ITN Core laboratory at Benaroya Research Institute for analysis by flow cytometry with antibody panels shown in Tables 7 and 8.
• T-cell phenotyping was performed on thawed PBMC and the frequency of CD45RO+CD8+ T-cells that were TIGIT+KLRG1+CD57- was determined as described previously (54).
• Intracellular cytokine expression was measured after 6 hours with stimulation of PBMC by plate-bound anti-CD3 (1 ⁇ g/ml) and soluble anti-CD28 (10 ⁇ g/ml) in the presence of equimolar amounts of Golgi- stop.
• the frequency of TIGIT+KLRG1+ CD8+ memory (CD45RA-) T cells that produce IFN ⁇ or TNF ⁇ were determined at baseline and month 3.
• Instrument standardization was performed using 8 peak rainbow calibration beads ( Spherotech, Lake Forest, IL) adjusting PMT voltages for consistent 7 th peak mean fluorescent intensities. All samples from the same subject were run on the same day, and an internal control arm from the same subject was run each week.
• metabolic parameters over the entire period of the trial included OGTT data in the visit immediately prior to and all OGTT data after study drug treatment (confirmatory diabetic OGTT for individuals diagnosed with diabetes, or last available OGTT for those remaining diabetes free).
• Slopes for changes in glucose and C-peptide prior to and after enrollment were calculated using linear regression analysis of available OGTT visit data for specified intervals.
• An impact of treatment on each endpoint was determined by fitting results to an ANCOVA model, with age, baseline value, and treatment group included as covariates. Wald tests were used to determine if covariates significantly impacted the model.
• Example 2 Anti-CD3 Antibody (Teplizumab), Delays Type 1 Diabetes Onset in Stage 2 Type 1 Diabetes [00137] As shown in Figures 12-21, in at-risk (Stage 2) relatives of T1D patients, a single course of teplizumab (as described in Example 1) increased TIGIT+ KLRG1+ exhausted CD8+T cells correlating with delay/prevention of clinical T1D.
• TIGIT+KLRG1+ CD8 T Cells are not homogeneous, but instead, vary across individuals in number and function.
• TIGIT+KLRG1+ cells are a mixture of less-and more-functional populations.
• teplizumab can be dosed repeatedly and used in combinations to increase the generation/maintenance of exhausted T cells and improve response and outcomes.
• teplizumab responsiveness can be predicted before dosing or shortly after dosing by determination of exhausted T cells.
• Example 3 2D Analysis of Glucose and C-peptide Shows a Teplizumab Effect in Individuals at Risk for T1D 3 Months after Treatment
• at-risk (Stage 2) relatives of T1D patients a single course of teplizumab (as described in Example 1) increased C-peptide AUC/glucose AUC ratio for at least 6 months.
• increase in teplizumab arm 1.5 ⁇ 2.9
• p 0.001
• DPTRS Diabetes Prevention Trial Risk Score
• the DPTRS can also be used to help guide re-dosing in at risk individuals.
• Teplizumab is a humanized monoclonal antibody that targets the cluster of differentiation 3 (CD3) antigen, which is co-expressed with the T-cell receptor (TCR) on the surface of T lymphocytes.
• CD3 cluster of differentiation 3
• TCR T-cell receptor
• Figure 26 shows plots of predicted mean teplizumab concentrations over time using a 14-day intravenous (IV) dosing regimen with a 4-day ramp-up followed by repeated doses of 826 ⁇ g/m2 on Days 5 to 14.
• the left panel represents a typical 60 kg male subject and the right panel represents a typical 40 kg and 90 kg male subject.
• Body surface area (BSA)-based dosing normalizes the exposure across body size.
• the repeated IV infusions resulted in increasing serum teplizumab levels, although steady-state PK was not achieved at the end of dosing (Day 14 with this dosing regimen).
• the average accumulation ratio for area under the curve (AUC) between Day 5 and Day 14 was 3.4.
• the predicted mean ( ⁇ SD) total AUC for the 14-day dosing regimen was 6421 ⁇ 1940 ng•day/mL with Cmax and Cmin of 826 ⁇ 391 and 418 ⁇ 225 ng/mL, respectively, on Day 14.
• Distribution The central and peripheral volume of distribution from population PK analysis was 3.4 L and 6.9 L, respectively.
• Elimination Teplizumab clearance is not dose-proportional, likely driven by its saturable binding to CD3 receptors on the T-cell surface. Teplizumab is expected to be degraded into smaller peptide fragments by catabolic pathways.
• the clearance of teplizumab following the 14-day dosing regimen was estimated from population PK analysis to be 2.3 L/day, with a terminal half-life of approximately 4 days.
• the planned commercial drug product is manufactured in a different facility from the clinical trial product and was not used in the clinical studies submitted to support efficacy and safety.
• a single-dose PK bridging study was conducted in healthy volunteers that evaluated the biocomparability of the commercial drug product with the clinical trial drug product.
• the mean AUC0-inf for the commercial product was less than half (48.5%, 90% CI: 43.6 to 54.1) of the AUC0-inf for the product used in the primary efficacy study.
• Type 1 Diabetes TrialNet Study Zinc transporter-8 autoantibodies improve prediction of type 1 diabetes in relatives positive for the standard biochemical autoantibodies. Diabetes Care 35, 1213-1218 (2012). 50. A. American Diabetes, 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019. Diabetes Care 42, S13-S28 (2019). 51. C. Steele, W. A. Hagopian, S. Gitelman, U. Masharani, M. Cavaghan, K. I. Rother, D. Donaldson, D. M. Harlan, J. Bluestone, K. C. Herold, Insulin Secretion in Type 1 Diabetes. Diabetes 53, 426-433 (2004). 52. K. S. Polonsky, J. Licinio-Paixao, B. D.

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