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
• • 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]
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N21/00—Investigating or analysing materials by the use of optical means, i.e. using sub-millimetre waves, infrared, visible or ultraviolet light
  • G01N21/17—Systems in which incident light is modified in accordance with the properties of the material investigated
  • G01N21/47—Scattering, i.e. diffuse reflection
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N30/00—Investigating or analysing materials by separation into components using adsorption, absorption or similar phenomena or using ion-exchange, e.g. chromatography or field flow fractionation
  • G01N30/02—Column chromatography
• • 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
  • G01N33/53—Immunoassay; Biospecific binding assay; Materials therefor
  • G01N33/536—Immunoassay; Biospecific binding assay; Materials therefor with immune complex formed in liquid phase
• • 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
• • 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]
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N21/00—Investigating or analysing materials by the use of optical means, i.e. using sub-millimetre waves, infrared, visible or ultraviolet light
  • G01N21/17—Systems in which incident light is modified in accordance with the properties of the material investigated
  • G01N21/47—Scattering, i.e. diffuse reflection
  • G01N2021/4704—Angular selective
  • G01N2021/4711—Multiangle measurement
• • G—PHYSICS
  • G01—MEASURING; TESTING
  • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
  • G01N30/00—Investigating or analysing materials by separation into components using adsorption, absorption or similar phenomena or using ion-exchange, e.g. chromatography or field flow fractionation
  • G01N30/02—Column chromatography
  • G01N2030/022—Column chromatography characterised by the kind of separation mechanism
• • 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

• the properties of circulating immune complexes formed with target antigens should be considered when developing a monoclonal antibody, e.g, for use in therapeutic applications. Valency of such complexes can affect clearance, effector function, and uptake by phagocytic cells.
• the safety profiles of traditional monoclonal antibodies used in diagnosis and/or therapy of diseases may be change or evolve if they form multivalent immune complexes in vivo in the presence of secondary antibodies. Therefore, consideration must be given when a recipient is exposed to more than one antibody that binds to a monovalent target at different sites, potentially leading to the formation of multivalent immune complexes.
• PNH paroxysmal nocturnal hemoglobinuria
• aHUS atypical hemolytic uremic syndrome
• a human patient having a complement mediated disorder who has been or is being treated with a first anti-C5 antibody and is then treated with a second (different) anti-C5 antibody.
• the disclosure is based, in part, on the discovery that large multivalent immune complexes are formed when an antigen-antibody complex (e.g., C5-eculizumab complex) is contacted (e.g., administered) with a second antibody that non-competitively associates with the complex, e.g., due to the ability of the second antibody to also bind to the antigen (e.g., C5) at an epitope that is different from the epitope of the first antibody e.g., eculizumab).
• an antigen-antibody complex e.g., C5-eculizumab complex
• a second antibody that non-competitively associates with the complex, e.g., due to the ability of the second antibody to also bind to the antigen (e.g., C5) at an epitope that is different from the epitope of the first antibody e.g., eculizumab).
• the inventors of the instant application found that in situations where the concentration of the first antibody (e.g., eculizumab) was at or above its therapeutic dose (e.g., dose sufficient to attain minimal plasma concentration (Cmin) for C5 inhibition), administration of a second non-competitive antibody (e.g., crovalimab or Polimab) resulted in the formation of high molecular weight (HMW) complexes, with the molecular weight (MW) of some species exceeding 1500 kDa. Surprisingly, these HMW complexes were not observed when the second antibody competed with the first antibody for the same epitope (e.g., eculizumab and ravulizumab).
• a second non-competitive antibody e.g., crovalimab or Polimab
• the instant application discloses several strategies that could be adopted to minimize risk of toxicity and/or improve safety/efficacy.
• One such measure involves using a weaning off period during which the first antibody is allowed to clear from the system (e.g., blood or another target tissue), prior to administration of the second antibody.
• Another potential strategy may involve use of apheresis procedure to remove the first antibody from the system (e.g., using a surface coated with a polypeptide comprising the antigenic determinants to which the first antibody binds).
• a third method may involve administering complement C5 antigen fragments containing epitopes for binding to the first antibody but not to the second antibody (in vivo or ex vivo).
• the systems and methods of the instant disclosure are particularly applicable in the antibody therapy of complement-mediated disorders, e.g., PNH or aHUS, wherein the patient is switched from a first anti-C5 antibody to a second, non-competitive anti-C5 antibody.
• complement-mediated disorders e.g., PNH or aHUS
• first antibody examples include, e.g., eculizumab or ravulizumab
• second antibody include, e.g., 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, Polimab, tesidolumab, crovalimab, ABP 959 antibody, ELIZARIA®, BCD-148 and/or SB12 or antigen-binding fragments thereof; preferably, 305LO5, SKY59, Polimab, tesidolumab, crovalimab, or ABP 959.
• provided herein are methods for safely treating a patient suffering from a complement mediated disorder, wherein the patient is being treated with or had been treated with a first anti-C5 antibody, the method comprising administering a therapeutically effective amount of a second anti-C5 antibody that is non-competitive with the first anti-C5 antibody after a washout sufficient to reduce levels of the first anti-C5 antibody in the patient’s system such that formation of multivalent immune complexes comprising the first and the second anti-C5 antibodies and complement C5 is prevented or reduced.
• the system comprises bodily fluid such as blood or ocular fluid.
• the first antibody is eculizumab or ravulizumab.
• the washout involves use of a weaning off period, e.g., a period that is equal to or greater than the half life (t 1/2 ) of the first antibody, e.g, a period > at least 1, 2, 3 or more half-lives of the first antibody.
• the washout comprises a weaning off period of at least about 7.8 days (100 kg adult) and 19.5 days (40 kg adult), with an average weaning off period of at least about 12 days (e.g., one t 1/2 of eculizumab).
• the washout comprises a weaning off period of at least about 31 days (100 kg adult) to about 80 days (40 kg adult), with an average weaning off period of at least about 42 days (e.g, one t 1/2 of ravulizumab).
• the washout involves removal of the first antibody from the patient, e.g, using plasma apheresis.
• the washout involves use of peptide antigens that bind to the antigen-binding regions of the first but not the second antibody.
• the first and the second antibodies are non-competitive (e.g, do not substantially bind to the same epitope of the antigen).
• sufficiency of the washout is determined by measuring a characteristic (e.g., mass) of the multivalent immune complex in the system.
• the multivalent immune complex comprises at least one first antibody and at least one second antibody that are specifically bound to a single or a plurality of C5 antigens.
• a method for treating a patient suffering from a complement mediated disorder wherein the patient has been or is being treated with a first anti-C5 antibody, and wherein the method comprises:
• an adjusted regimen antibody e.g, a regimen to prevent or minimize formation of multivalent immune complexes
• a second anti-C5 to treat a patient suffering from a complement mediated disorder, wherein the patient has been or is being treated with a first anti-C5 antibody
• the method comprising:
• the methods further comprise weaning (e.g, withdrawing) the patient from treatment with the first anti-C5 antibody therapy.
• a method for switching a patient having a complement mediated disorder who has been or is being treated with a first anti-C5 antibody to treatment with a second (different) anti-C5 antibody comprising:
• the second anti-C5 antibody is administered at a reduced dose and/or a reduced frequency until the threshold is no longer exceeded.
• the adjusted regimen comprises a modification of a clinically effective dosing or scheduling regimen.
• the adjusted regimen is a dose which is lower than a standard therapeutic dose, e.g., a sub-therapeutic dose.
• the adjusted regimen comprises administration at a rate or interval that is moderated compared to standard scheduling, e.g., via slower rate of administration and/or less frequent administration.
• Additional techniques can be used in combination with the methods described herein to clear or enhance clearance of the first anti-C5 antibody before switching to treatment with a second anti-C5 antibody.
• Exemplary techniques include, but are not limited to, plasmapheresis or blood transfusions.
• the first and/or second anti-C5 antibodies are selected from the group consisting of a full-length antibody or antigen binding fragment thereof, humanized antibody, bispecific antibody, an immunoconjugate, a chimeric antibody, a protein scaffold with antibody-like properties, such as fibronectin or ankyrin repeats, a Fab, Fab’2, scFv, affibody, avimer, nanobody, and a domain antibody.
• the first and/or second anti-C5 antibody is a monoclonal antibody.
• the first and second anti-C5 antibodies are antibodies that bind different epitopes on C5.
• the first and second anti-C5 antibodies are antibodies that do not compete for binding to C5; more preferably wherein the first and/or the second anti-C5 antibodies are antibodies that bind to different domains in C5, e.g., wherein the first antibody binds to MG7 domain in C5 and the second antibody binds to MG1 or MG6 domain in C5.
• Eculizumab (also known as SOLIRIS®) is an anti-C5 antibody comprising heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 1, 2, and 3, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively.
• Eculizumab comprises a heavy chain variable region having the amino acid sequence set forth in SEQ ID NO: 7 and a light chain variable region having the amino acid sequence set forth in SEQ ID NO: 8.
• Eculizumab comprises a heavy chain comprising the amino acid sequence set forth in SEQ ID NO: 10 and a light chain having the amino acid sequence set forth in SEQ ID NO: 11.
• the antibody comprises the heavy and light chain complementarity determining regions (CDRs) or variable regions (VRs) of eculizumab. Accordingly, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the heavy chain variable (VH) region of eculizumab having the sequence shown in SEQ ID NO: 7, and the CDR1, CDR2 and CDR3 domains of the light chain variable (VL) region of eculizumab having the sequence shown in SEQ ID NO: 8.
• the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2, and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively.
• the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO:7 and SEQ ID NO: 8, respectively.
• the antibody comprises a heavy chai comprising the amino acid sequence set forth in SEQ ID NO: 10 and a light chain having the amino acid sequence set forth in SEQ ID NO: 11.
• Another exemplary anti-C5 antibody is ravulizumab (ULTOMIRIS®) comprising the heavy and light chains having the sequences shown in SEQ ID NOs: 14 and 11, respectively, or antigen binding fragments and variants thereof.
• the antibody comprises the heavy and light chain complementarity determining regions (CDRs) or variable regions (VRs) of ravulizumab.
• the antibody comprises the CDR1, CDR2 and CDR3 domains of the heavy chain variable (VH) region of ravulizumab having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the light chain variable (VL) region of ravulizumab having the sequence shown in SEQ ID NO: 8.
• the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively.
• the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.
• the antibody comprises a heavy chain constant region as set forth in SEQ ID NO: 13.
• the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13.
• the antibody comprises a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met429Leu and Asn435Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each according to the EU numbering convention.
• FcRn human neonatal Fc receptor
• the antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met429Leu and Asn435Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each according to the EU numbering convention.
• the antibody comprises ravulizumab or a biosimilar thereof.
• the first and the second anti-C5 antibodies bind to different epitopes in complement C5.
• the first anti-C5 antibody is an antibody that binds to MG7 domain in C5 and the second anti-C5 antibody is an antibody that binds to a domain other than MG7, e.g., MG1 domain or MG6 domain of C5.
• the first anti-C5 antibody is an antibody that binds to MG1 domain in C5 and the second anti- C5 antibody is an antibody that binds to a domain other than MG1, e.g., MG7 domain or MG6 domain of C5.
• the first anti-C5 antibody is an antibody that binds to MG6 domain in C5 and the second anti-C5 antibody is an antibody that binds to a domain other than MG6, e.g., MG7 domain or MG1 domain of C5.
• the anti-C5 antibody binding to MG7 domain of C5 may comprise eculizumab or ravulizumab; the antibody binding to MG1 domain may comprise crovalimab; and the antibody binding to MG6 domain may comprise Aerolimab.
• the first and/or second anti-C5 antibody is an antibody selected from the group consisting of 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, and Polimab (REGN3918 antibody), Tesidolumab (LFG316), Crovalimab (RG6107), ABP 959 antibody, ELIZARIA®, BCD-148 (JSC BIOCAD) and SB12 or antigen binding fragments thereof comprising, for example, the heavy and light chain CDRs of the respective antibody or a biosimilar thereof.
• the first or, preferably, second antibody is Crovalimab, 39limab, or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of the BNJ421 antibody (described in WO2015134894 and US Patent No. 9,079,949).
• the antibody comprises the BNJ421 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see US Patent Nos. 8,241,628 and 8,883,158).
• the antibody comprises the 7086 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody (see US Patent Nos. 8,241,628 and 8,883,158).
• the antibody comprises the 7086 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody (see US Patent No. 9,765,135).
• the antibody comprises the 7086 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody comprises the SKY59 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of Dalimab (REGN3918 antibody). In another embodiment, the antibody comprises Aerolimab or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of tesidolumab (LFG316). In another embodiment, the antibody comprises tesidolumab or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of crovalimab (RG6107). In another embodiment, the antibody comprises crovalimab or a biosimilar thereof. In another embodiment, the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of ABP 959 antibody. In another embodiment, the antibody comprises the ABP 959 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of ELIZARIA®. In another embodiment, the antibody comprises ELIZARIA® or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of antibody SB 12.
• the antibody comprises the antibody SB 12 or a biosimilar thereof.
• the first anti-C5 antibody is ravulizumab (ULTOMIRIS®).
• the first anti-C5 antibody is ravulizumab (ULTOMIRIS®) and the second antibody is 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, Dalimab (REGN3918 antibody), Tesidolumab (LFG316), Crovalimab (RG6107), ABP 959 antibody, ELIZARIA®, BCD-148 (JSC BIOCAD), SB12, antigen binding fragments thereof, or biosimilars thereof.
• the first anti-C5 antibody is ravulizumab (ULTOMIRIS®) and the second antibody is Crovalimab, 39limab, or a biosimilar thereof.
• the antibody competes for binding with, and/or binds to the same epitope on C5 as any of the above-mentioned antibodies.
• the antibody has at least about 90% variable region amino acid sequence identity to any of the above-mentioned antibodies (e.g, at least about 90%, 95% or 99% variable region identity with SEQ ID NO: 12 or SEQ ID NO: 8).
• the antibody binds to human C5 at pH 7.4 and 25°C with an affinity dissociation constant (KD) that is in the range 0.1 nM ⁇ KD ⁇ 1 nM. In another embodiment, the antibody binds to human C5 at pH 7.4 and 25°C with an affinity dissociation constant (KD) of about 0.5 nM. In another embodiment, the antibody binds to human C5 at pH 6.0 and 25°C with a KD > 10 nM. In another embodiment, the antibody binds to human C5 at pH 6.0 and 25°C with a KD of about 22 nM.
• KD affinity dissociation constant
• the [(KD of the antibody or antigen-binding fragment thereof for human C5 at pH 6.0 and at 25°C)/(KD of the antibody or antigen-binding fragment thereof for human C5 at pH 7.4 and at 25°C)] of the antibody is greater than 25.
• the threshold level is based on a minimum mass of the multivalent immune complexes.
• the threshold level is a mass of more than about 500 kDa, 510 kDa, 520 kDa, 530 kDa, 540 kDa, 550 kDa, 560 kDa, 570 kDa, 580 kDa, 590 kDa, 600 kDa, 610 kDa, 620 kDa, 630 kDa, 640 kDa, 650 kDa, 660 kDa, 670 kDa, 680 kDa, 690 kDa, 700 kDa, 710 kDa, 720 kDa, 730 kDa, 740 kDa, 750 kDa, 760 kDa, 770 kDa, 780 kDa, 790 kDa, 800 kDa,
• the threshold level is a mass of more than about 532 kDa, 540 kDa, 569 kDa, 907 kDa, 913 kDa, 921 kDa, 963 kDa, 1277 kDa, 1278 kDa, 1286 kDa, 1314 kDa, 1574 kDa, 1649 kDa, 1659 kDa, or 1788 kDa.
• the threshold level is based on formation of multivalent immune complexes comprising more than 2 anti-C5 antibodies specifically bound to 1 molecule of complement C5 (e.g., immune complexes comprising antibody: antigen stoichiometric ratios). In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 3 anti-C5 antibodies and 2 C5 molecules. In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 4 anti-C5 antibodies and 3 C5 molecules. In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 5 anti- C5 antibodies and 4 C5 molecules.
• threshold level can be determined by any suitable assay or technique.
• threshold level is determined by size exclusion chromatography (SEC) and/or multi-angle light scattering (MALS).
• administration of the second anti- C5 antibody to the patient is deferred to allow for clearance of the first anti-C5 antibody from the patient.
• administration of the second anti-C5 antibody to the patient is deferred by 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 days.
• the first and/or second anti-C5 antibodies can be administered according to any suitable dosing regimen.
• the dose of the anti-C5 antibody, or antigen binding fragment thereof is based on the weight of the patient.
• dosage regimens are adjusted to provide the optimum desired response (e.g, an effective response).
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NOTO and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered at a dose of: 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter.
• the patient e.g., adult patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8;
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered at a dose of: 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NOTO and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered to the patient (e.g., adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• the patient has aHUS and the first or second anti-C5 antibody
• (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs: 1, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8;
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered to the patient (e.g., adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• the patient has myasthenia gravis (MG) and the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered to the patient (e.g, adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• SOLIRIS® is SOLIRIS®, administered to the
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• the adjusted regimen comprises an adjustment in the therapeutic regimen for therapy of the complement mediated disorder in the patient (e.g., an adult patient).
• the therapeutic regimen comprises a dose of 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter for the treatment of PNH.
• the therapeutic regimen comprises a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter for the treatment of aHUS. In another embodiment, the therapeutic regimen comprises a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter for the treatment of MG.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered to the patient (e.g., a pediatric patient) at a dose of:
• the patient e.g., a pediatric patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8;
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered to the patient at a dose of:
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• the therapeutic regimen comprises an adjustment in the therapeutic regimen for therapy of the complement mediated disorder in the patient (e.g., a pediatric patient).
• the therapeutic regimen comprises administration of the second antibody to the patient at a dose of:
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (
• the patient e.g, adult patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively
• (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11
• (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (e)
• the therapeutic regimen comprises administration of the second antibody to the patient at a dose of: (a) once on Day 1 of the administration cycle at a dose of: 2400 mg to a patient weighing > 40 to ⁇ 60 kg, 2700 mg to a patient weighing > 60 to ⁇ 100 kg, or 3000 mg to a patient weighing > 100 kg; and (b) on Day 15 of the administration cycle and every eight weeks thereafter at a dose of 3000 mg to a patient weighing > 40 to ⁇ 60 kg, 3300 mg to a patient weighing > 60 to ⁇ 100 kg or 3600 mg to a patient weighing > 100 kg.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (
• the patient e.g., pediatric patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively
• (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11
• (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (e)
• the therapeutic regimen comprises administration of the second antibody to the patient (e.g., pediatric patient) at a dose of: (a) once on Day 1 at a dose of 600 mg to a patient weighing > 5 to ⁇ 10 kg, 600 mg to a patient weighing > 10 to
• ⁇ 40 kg 3000 mg to a patient weighing > 40 to ⁇ 60 kg, 3300 mg to a patient weighing > 60 to ⁇ 100 kg, or 3600 mg to a patient weighing > 100 kg.
• the first and/or second anti-C5 antibody can be administered to the patient via any suitable means or art recognized technique. In one embodiment, the first and/or second anti- C5 antibody is administered intravenously to the patient. In another embodiment, the first and/or second anti-C5 antibody is administered subcutaneously to the patient.
• any biological sample can be used in the treatment methods described herein.
• Exemplary biological samples include but are not limited to blood, serum, plasma, urine, saliva, lymph, spinal fluid, intercellular fluid, vitreous humor, and sweat.
• the biological fluid is blood.
• the biological sample from the patient is contacted with the therapeutic dose of a second anti-C5 antibody in vivo. In one embodiment, the biological sample from the patient is contacted with the therapeutic dose of a second anti-C5 antibody ex vivo. In another embodiment, the biological sample from the patient is contacted with the therapeutic dose of a second anti-C5 antibody in vitro.
• complement mediated disorders include, but are not limited to rheumatoid arthritis, antiphospholipid antibody syndrome, lupus nephritis, ischemia-reperfusion injury, atypical hemolytic uremic syndrome (aHUS), typical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria (PNH), dense deposit disease, neuromyelitis optica, multifocal motor neuropathy, multiple sclerosis, macular degeneration, HELLP syndrome, spontaneous fetal loss, thrombotic thrombocytopenic purpura, Pauci- immune vasculitis, epidermolysis bullosa, recurrent fetal loss, traumatic brain injury, myocarditis, a cerebrovascular disorder, a peripheral vascular disorder, a renovascular disorder, a mesenteric/enteric vascular disorder, vasculitis, Henoch-Schonlein purpura nephriti
• the efficacy of the treatment methods provided herein can be assessed using any suitable means.
• the treatment resolves at least one sign or symptom of the complement-mediated disorder without toxicity associated with multivalent immune complexes formed as a result of administration of the second anti-C5 antibody.
• the disclosure relates to use of a therapeutically effective amount of a second anti-C5 antibody that is non-competitive with a first anti-C5 antibody, for the treatment of a complement-mediated disease (e.g, aHUS, PNH, HSCT-TMA, CM-TMA, NMOSD, gMG or ALS) in a patient who is being treated or has been treated with the first anti-C5 antibody, wherein the second anti-C5 antibody is administered after a washout sufficient to reduce levels of the first anti-C5 antibody in the patient’s system (e.g, blood) such that formation of multivalent immune complexes comprising the first and the second anti-C5 antibodies and complement C5 is prevented or reduced.
• a complement-mediated disease e.g, aHUS, PNH, HSCT-TMA, CM-TMA, NMOSD, gMG or ALS
• the multivalent immune complex comprises at least one first antibody and at least one second antibody that are specifically bound to a complement C5 antigen, and optionally, additional C5 antigens.
• the disclosure relates to a use, according to the foregoing, of a therapeutically effective amount of a second antibody that is non-competitive with a first antibody selected from eculizumab and ravulizumab or a biosimilar of the first antibody.
• the disclosure relates to a use, according to the foregoing, of a therapeutically effective amount of a second antibody that is non-competitive with eculizumab or ravulizumab, wherein the second antibody is selected from 305LO5, SKY59, Dalimab, tesidolumab, crovalimab, or ABP 959 or a biosimilar thereof; preferably, wherein the second antibody is Polimab, tesidolumab, or crovalimab.
• FIGs. 1A-1D show that recombinant anti-C5 monoclonal antibodies crovalimab mimetic and Polimab mimetic bind to human C5 non-competitively with eculizumab.
• Data are shown for the following different second antibodies: mAb N19/8 which is known to bind to a different site on C5 to eculizumab (FIG. 1A), ravulizumab (FIG. IB), mAb crovalimab mimetic (FIG. 1C), and mAb Polimab mimetic (FIG ID).
• the scale bar shows the deflection corresponding to a biosensor signal of 1.0 nm.
• FIGs. 2A-2D show that crovalimab mimetic induces formation of very large complexes in the presence of eculizumab and C5 at eculizumab and C5 concentrations mimicking those in human blood as eculizumab approaches Cmin.
• crovalimab mimetic 700 nM
• C5 400 nM
• FIGs. 3A-3D show that Dolimab mimetic induces formation of very large complexes in the presence of eculizumab plus C5 at concentrations of eculizumab and C5 mimicking those in human blood as eculizumab approaches Cmin.
• FIG. 3A shows that
• C5 400 nM
• FIGs. 4A-4D show that ravulizumab forms only 1:1 and 1:2 complexes with C5 both in the absence or presence of eculizumab.
• ravulizumab alone migrated as a single peak, but in the presence of C5 or C5 plus eculizumab three peaks were observed.
• the last peak to elute in the composition of C5 plus eculizumab and ravulizumab corresponds to unbound antibody and had a shoulder because free eculizumab and ravulizumab had slightly different retention times.
• the compositions comprising ravulizumab and C5 (FIG. 4C), and ravulizumab and C5 plus eculizumab (FIG. 4D) exhibited masses by MALS consistent with the formation of only 1:1 and 1:2 mAb:C5 complexes.
• FIG. 5 shows that masses of the complexes formed between eculizumab, C5 and either of the anti-C5 mAbs, crovalimab mimetic or Polimab mimetic are consistent with formation of complexes containing multiple antibody and C5 molecules.
• the term “plurality” can be 2, 3, 4, 5, 6, 7, 8, 9, 10, or more.
• first and second are not to be construed as having a relation in time or space but merely relate to distinction therebetween, e.g, in structure, property, or function.
• substantially means sufficient to work for the intended purpose.
• the term “substantially” thus allows for minor, insignificant variations from an absolute or perfect state, dimension, measurement, result, or the like such as would be expected in the field that do not appreciably affect overall performance (e.g., +/- 10%).
• the term “marker” refers to a characteristic that can be objectively measured as an indicator of normal biological processes, pathogenic processes or a pharmacological response to a therapeutic intervention, e.g, treatment with anti-C5 antibody.
• a “panel” refers to a group of two or more distinct molecular species that have shown to be indicative of or otherwise correlated with a particular disease or health condition.
• Such “molecular species” may be referred to as “biomarkers”, with the term “biomarker” being understood to mean a biological molecule, the presence or absence or level of which serves as an indicator of a particular biological state, for example, the occurrence (or likelihood) of toxicity due to build-up of immune complexes in a subject.
• a biomarker is a characteristic that can objectively-measured and evaluated as an indicator of normal biologic processes, pathogenic processes, or pharmacologic responses to a drug.
• modulate refers to enhancement (e.g, an increase) or inhibition (e.g, a decrease) in the specified level or activity.
• inhibit refers to an increase in the specified parameter (e.g, mass of immune complexes) of at least about 1.25- fold, 1.5-fold, 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 8-fold, 10-fold, twelvefold, or even fifteenfold.
• inhibitor or “reduce” or grammatical variations thereof refers to a decrease or diminishment in the specified level or activity of the target, e.g, litle or essentially no detectible level or activity of the target (at most, an insignificant amount).
• reducing refers to a decrease or lessening by an appreciable, e.g, statistically significant, amount or quality. In embodiments, reducing refers to either partially or completely inhibiting an activity or decreasing or lowering an activity. In other embodiments, “reducing” means a decrease by at least 10% compared to a reference level, for example a decrease by at least about 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, or up to and including a 100% decrease compared to a reference level.
• the term “reducing the incidence” and “improving function” refer to a beneficial effect, e.g., amelioration or an improvement over baseline. Frequently the improvement over baseline is statistically significant.
• “reducing the incidence” and “improving function” may refer to an amelioration of at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100%, as compared to a reference level, or at least about a 1.5-fold, 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold, 10-fold, or more, e.g, 20-fold, as compared to a control.
• diagnosis refers to methods by which a determination can be made as to whether a subject is likely to be suffering from a given disease or condition, e.g., complement-mediated diseases.
• a given disease or condition e.g., complement-mediated diseases.
• diagnostic indicators e.g., a marker, the presence, absence, amount, or change in amount of which is indicative of the presence, severity, or absence of the disease or condition.
• Other diagnostic indicators can include patient history; physical symptoms, e.g, unexplained changes in vitals, or phenotypic, genotypic or environmental or heredity factors.
• diagnostic refers to an increased probability that certain course or outcome will occur; that is, that a course or outcome is more likely to occur in a patient exhibiting a given characteristic, e.g, the presence or level of a diagnostic indicator, when compared to individuals not exhibiting the characteristic. Diagnostic methods of the disclosure can be used independently, or in combination with other diagnosing methods, to determine whether a course or outcome is more likely to occur in a patient exhibiting a given trait.
• the term “detecting,” refers to the process of determining a value or set of values associated with a sample by measurement of one or more parameters in a sample and may further comprise comparing a test sample against reference sample.
• the detection of antibody-mediated rejection may include identifying, assaying, measuring and/or quantifying a marker, e.g., formation of multivalent immune complexes.
• determining refers to the process of scientifically measuring a phenomenon as it relates to a process, e.g, formation of immune complexes in vivo. It assumes one skilled in the art will be making tests within that skill to observe and measure the phenomenon.
• monitoring refers to determining the progression of the condition or determining the effectiveness of a particular treatment protocol (e.g, weaning off antibody therapy) or a composition (e.g., administration of neutralizing peptides).
• the term “likelihood,” as used herein, generally refers to a probability, a relative probability, a presence or an absence, or a degree.
• the term “at risk” for a disease or disorder refers to a subject (e.g., a human) that is predisposed to experiencing a particular disease. This predisposition may be genetic or environmental. Thus, it is not intended that the present disclosure be limited to any particular risk.
• the term “outcome” means a specific result or effect of diagnosis or therapy that can be measured.
• control refers to a reference for a test sample, such as control healthy subjects or untreated subjects, and the like.
• a “reference sample,” as used herein, refers to a sample of tissue or cells that may or may not have a disease that are used for comparisons. Thus a “reference” sample may provide a basis to which another sample, for example, a sample of a patient who was treated in accordance with the present disclosure, can be compared.
• a “test sample” refers to a sample compared to a reference sample.
• the reference sample need not be disease free, such as when reference and test samples are obtained from the same patient who were treated in accordance with the present methods (e.g, incorporating a washout before administration of the second antibody) or not (e.g, not incorporating the washout).
• threshold refers to a parameter (e.g, level or amount) of the marker (e.g, multivalent immune complex) in a particular setting (e.g, in a sample from a subject that has received a monotherapy of anti-C5 antibody).
• level can refer to binary (e.g, absent/present), qualitative (e.g, absent/low/medium/high), or quantitative information (e.g, a value proportional to number, frequency, or concentration) indicating the presence of a particular molecular species.
• the term “subject” or “patient” is a human patient (e.g, a patient having a complement mediated disorder, such as PNH or aHUS).
• the term “pediatric” patient is a human patient that has been classified by a physician or caretaker as belonging to a non-adult category and can include, e.g, newborn (both preterm and of term), infants, children, and adolescents. Typically, pediatric patients are patients under 18 years of age ( ⁇ 18 years of age).
• adult patient is a human patient that has been classified by a physician or caretaker as such, e.g, one who is not a newborn, infant, child or adolescent, e.g, based on age, developmental status, physiological features, etc. Typically, adult patients are patients who are 18 years of age or older (>18 years of age).
• a subject “in need of prevention,” “in need of treatment,” or “in need thereof,” refers to one, who by the judgment of an appropriate medical practitioner (e.g, a doctor, a nurse, or a nurse practitioner in the case of humans), would reasonably benefit from a given treatment, e.g, a particular therapeutic or prophylactic agent to treat a condition.
• the term “treat” or “treating” refers to providing an intervention, e.g, providing any type of medical or surgical management of a subject.
• the treatment can be provided to reverse, alleviate, inhibit the progression of, prevent or reduce the likelihood of a disorder or condition, or to reverse, alleviate, inhibit or prevent the progression of, prevent or reduce the likelihood of one or more symptoms or manifestations of a disorder or condition.
• Prevent refers to causing a disorder or condition, or symptom or manifestation of such not to occur for at least a period of time in at least some individuals.
• Treating can include administering a therapeutic agent (e.g., an anti-C5 antibody) to the subject following the development of one or more symptoms or manifestations indicative of condition, e.g, to reverse, alleviate, reduce the severity of, and/or inhibit or prevent the progression of the condition and/or to reverse, alleviate, reduce the severity of, and/or inhibit or one or more symptoms or manifestations of the condition.
• a composition can be administered to a subject who has developed a complement-mediated disorder or is at increased risk of developing the complement-mediated disorder relative to a member of the general population.
• Such a composition can be administered prophylactically, e.g, before development of any symptom or manifestation of the condition.
• the composition is administered therapeutically, e.g., after development of any symptom or manifestation of the condition.
• symptom refers to an indication of disease, illness, injury, or that something is not right in the body. Symptoms are felt or noticed by the individual experiencing the symptom, but may not easily be noticed by others.
• signal refers an indication that something is not right in the body, which can be seen by a doctor, nurse, or other health care professional.
• administering when used in conjunction with an agent, e.g., drug, means to deliver the agent directly into or onto a cell or target tissue or to provide the agent to a patient whereby it impacts the tissue to which it is targeted.
• agent e.g., anti-C5 antibody
• target e.g, C5
• contact means binding of the agent to the target.
• transfusion refers to an act of transferring blood, blood products, or other fluid, e.g, saline, into the circulatory system of a subject.
• intravenous generally means “within a vein” and refers to accessing a subject’s target cells or tissue via the vasculature system.
• IV intravenous
• liquid substances are administered directly into a vein.
• the intravenous route is probably the fastest way to deliver agents throughout a body.
• Some medications, blood transfusions, and parenteral (e.g, non-alimentary) nutrients are administered intravenously using standard delivery systems.
• effective treatment refers to treatment producing a beneficial effect, e.g, amelioration of at least one symptom of a disease or disorder.
• a beneficial effect can take the form of an improvement over baseline, e.g, an improvement over a measurement or observation made prior to initiation of therapy according to the method.
• Effective treatment may refer to alleviation of at least one sign/symptom of a complement-mediated disorder (e.g, PNH, aHUS, HSCT-TMA, CM-TMA, NMOSD, gMG or ALS).
• a complement-mediated disorder e.g, PNH, aHUS, HSCT-TMA, CM-TMA, NMOSD, gMG or ALS.
• effective treatment may refer to alleviation of at least one sign/symptom of PNH (e.g, pallor, fatiguejaundice, anemia, cytopenia, abdominal pain, dyspnea, dysphagia, chest pain or erectile dysfunction).
• effective treatment may refer to alleviation of at least one sign/symptom of aHUS (e.g, severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal function impairment (e.g, acute renal failure)).
• PNH e.g, pallor, fatiguejaundice, anemia, cytopenia, abdominal pain, dyspnea, dysphagia, chest pain or erectile dysfunction.
• effective treatment may refer to alleviation of at least one sign/symptom of aHUS (e.g, severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangi
• effective treatment may refer to alleviation of at least one sign/symptom of hematopoietic stem cell transplantation (HSCT)- TMA, e.g, TMA after HSCT (e.g, elevated serum creatinine, reduced glomerular filtration rate (GFR); hypertension requiring medication(s); and elevated proteinuria or urine protein creatinine ratio).
• effective treatment may refer to alleviation of at least one sign/symptom of complement-mediated TMA (CM-TMA), e.g, abdominal pain, confusion, fatigue, edema, nausea, vomiting and diarrhea.
• CM-TMA complement-mediated TMA
• effective treatment may refer to alleviation of at least one sign/symptom of NMO selected from loss of vision and spinal cord function (e.g, decreased visual acuity, possibly with loss of color vision; blindness in one or both eyes in five years; overall muscle weakness and reduced sensation; and loss of bladder and bowel control).
• effective treatment may refer to alleviation of at least one sign/symptom of generalized myasthenia gravis (gMG), e.g, ocular weakness, causing ptosis (drooping eyelids) and/or diplopia (double vision), leg weakness, dysphagia and slurred or nasal speech, especially wherein the symptoms worsen with various stressors, such as, e.g, exertion, heat and infection.
• gMG generalized myasthenia gravis
• effective treatment may refer to alleviation of at least one sign/symptom of amyotrophic lateral sclerosis (ALS) (e.g, stiff muscles, muscle weakness, muscle wasting, difficulty speaking, difficulty swallowing, difficulty breathing, difficulty chewing, difficulty walking, fasciculations, cramps, or any combination thereol).
• ALS amyotrophic lateral sclerosis
• an “effective amount” refers to an amount of an agent that provides the desired biological, therapeutic and/or prophylactic result. That result can be reduction, amelioration, palliation, lessening, delaying and/or alleviation of one or more of the signs, symptoms or causes of a disease, or any other desired alteration of a biological system.
• an “effective amount” is the amount of anti-C5 antibody, or antigen binding fragment thereof, clinically proven to alleviate at least one sign/symptom of the complement-mediated disorder (e.g, PNH, aHUS, HSCT-TMA, CM-TMA, NMOSD, gMG or ALS), as provided above.
• An effective amount can be administered in one or more administrations.
• the term “loading dose” refers to the first dose administered (e.g., during an administration cycle).
• the terms “maintenance” and “maintenance phase” are used interchangeably and refer to the second phase of treatment. In certain embodiments, treatment is continued as long as clinical benefit is observed or until unmanageable toxicity or disease progression occurs.
• therapeutic dose means any suitable amount or concentration of the drug to be administered to a subject as part of a prescribed regimen that is effective for treating a complement-mediated disorder. The specific dosage is a matter of design choice and may vary with the traits of the subject.
• sub-therapeutic refers to an amount/dose of a drug (e.g, anti-C5 antibody) that is below the amount of the drug that is conventionally used to treat a complement-mediated disease.
• a sub-therapeutic amount is an amount less than that defined by the manufacturer as being required or recommended for therapy of a disorder.
• serum trough level refers to the lowest level that the agent (e.g, the anti-C5 antibody, or antigen binding fragment thereol) or medicine is present in the serum.
• a “peak serum level,” refers to the highest level of the agent in the serum.
• the “average serum level,” refers to the mean level of the agent in the serum over time.
• inhibitor refers to a substance that interferes with the effects of another substance.
• Functional or physiological antagonism occurs when two substances produce opposite effects on the same physiological function.
• Chemical antagonism or inactivation is a reaction between two substances to neutralize their effects, e.g., binding of an antibody to an antigen, which prevents the antigen from acting on its target.
• Dispositional antagonism is the alteration of the disposition of a substance (its absorption, biotransformation, distribution, or excretion) so that less of the agent reaches the target or its persistence there is reduced.
• antibody describes a polypeptide comprising at least one antibody-derived antigen binding site (e.g, VH/VL region or Fv, or CDR).
• Antibodies include known forms of antibodies, e.g., the antibody can be a human antibody, a humanized antibody, a bispecific antibody or a chimeric antibody.
• the antibody also can be a Fab, Fab’2, ScFv, SMIP, AFFIBODY®, nanobody or a single-domain antibody.
• the antibody also can be of any of the following isotypes: IgGl, IgG2, IgG3, IgG4, IgM, IgAl, IgA2, IgAsec, IgD, IgE or combinations thereof.
• the antibody can be a naturally occurring antibody or an antibody that has been altered by a protein engineering technique (e.g., by mutation, deletion, substitution, conjugation to a non-antibody moiety).
• An antibody can include, for example, one or more variant amino acids (compared to a naturally occurring antibody) that change a property (e.g, a functional property) of the antibody. Numerous such alterations are known in the art that affect, e.g, half-life, effector function, and/or immune responses to the antibody in a patient.
• the term antibody also includes artificial or engineered polypeptide constructs that comprise at least one antibody-derived antigen binding site.
• Antibodies that are “competitive” “compete” with another antibody for binding to a target refer to antibodies that inhibit (partially or completely) the binding of the other antibody to the target.
• competitive antibodies are capable of displacing each other from the antigen-antibody complex.
• antibodies that are “non-competitive” do not compete with another antibody for binding to the target, i.e., do not inhibit (partially or completely) the binding of the other antibody to the target.
• noncompetitive antibodies are incapable of displacing each other from the complex.
• biosimilar refers to a biological product that is highly similar, e.g., in primary structure, such as amino acid sequence, to a licensed reference biological product.
• eculizumab biosimilars include, e.g, ABP 959 (Amgen); Elizaria (Generium); and SB 12 (Samsung).
• the term “k a ” refers to the rate constant for association of an antibody to an antigen.
• the term “ka” refers to the rate constant for dissociation of an antibody from the antibody/ antigen complex.
• KD refers to the equilibrium dissociation constant of an antibody-antigen interaction.
• Such determinations preferably are measured at 25° C or 37°C (see the working examples).
• the kinetics of antibody binding to human C5 can be determined at pH 8.0, 7.4, 7.0, 6.5 and 6.0 via surface plasmon resonance (SPR) on a BIAcore 3000 instrument using an anti-Fc capture method.
• C5 inhibition relates to inhibition or antagonism of complement C5 in the complement pathway.
• Suitable methods for measuring inhibition of C5 cleavage are known in the art.
• the concentration and/or physiologic activity' of C5a and/or C5b in a body fluid can be measured, e.g., chemotaxis assays, lAs, or ELlSAs (for C5a); and hemolytic assays or assay s for soluble C5b-9 (for C5b).
• Other assays for measuring TCC formation, inhibition of complement component C5, which modulates cell lysis can be measured using a conventional hemolytic assay.
• washout refers to, in the broadest sense, a reduction in the level (e.g, amount or concentration) or activity (e.g, neutralizing property) of a composition (e.g, a drug such as an anti-C5 antibody) from a system (e.g, blood).
• a composition e.g, a drug such as an anti-C5 antibody
• the term “level” refers to, in the broadest sense, a measure of the physical property 7 , such as amount (mass/weight) or concentration (amount/ volume) and also non-physical properties (e.g, activity as measured by enzyme kinetics, signaling activity).
• multivalent immune complex refers to an antigen-antibody complex that is formed, e.g, via recognition of a plurality of epitopes in a single antigen by a plurality of different antibodies that bind specifically thereto.
• Representative examples include antibody-antigen complexes indicating antibody:antigen stochiometric ratios that are greater than 2:1, e.g, 3:2, 4:3, 5:4, and more.
• Specific types of multivalent immune complexes comprising C5-aC5 antibodies, as determined by mass ratios, are provided in the Examples.
• half-life as used here in relation to a biological (such as an antibody) generally refers to the time taken for the concentration of the biological in the system (e.g., blood or similar bodily fluid) to be reduced by 50%, for example due to degradation of the biological an ''or clearance or sequestration of the biological by natural mechanisms.
• this parameter can be determined in any manner known per se, such as by pharmacokinetic (PK) analysis. Suitable techniques are described in U.S. Pat. No. 8,629,244 (and equivalent WO 2008/020079).
• PK pharmacokinetic
• the half-life can be expressed using parameters such as the t 1/2 -alpha, t 1/2 -beta and the area under the curve (AUC). Partly due to physiological factors, in vivo half-life of an antibody depends on the weight of the subject.
• apheresis encompasses a medical technology in which the blood of a subject (e.g, patient) is passed through an apparatus that separates out one particular’ constituent or component and returns the remainder to the circulation. It is thus an extracorporeal therapy. If plasma is separated, then the apheresis is called plasmapheresis.
• antigen-specific antibody apheresis antigen-specific antibodies are removed from the plasma from the patients by using antigen-specific determinants (e.g, peptides containing epitopes that are specific for a target antibody, e.g, C5 anitbody) and returning the other remaining components of plasma to the same patients.
• antigen-specific determinants e.g, peptides containing epitopes that are specific for a target antibody, e.g, C5 anitbody
• plasmapheresis or selective apheresis which nonspecifically removes total immunoglobulins from plasma, may also be used.
• cell refers to basic building blocks of tissue, such as cells from a human.
• antibody describes a polypeptide comprising at least one antibody-derived antigen binding site (e.g., VH/VL region or Fv, or CDR).
• Antibodies include known forms of antibodies, e.g., the antibody can be a human antibody, a humanized antibody, a bispecific antibody or a chimeric antibody.
• the antibody also can be a Fab, Fab’2, ScFv, SMIP, Affibody®, nanobody or a single-domain antibody.
• the antibody also can be of any of the following isotypes: IgGl, IgG2, IgG3, IgG4, IgM, IgAl, IgA2, IgAsec, IgD, IgE or combinations thereof.
• the antibody can be a naturally occurring antibody or an antibody that has been altered by a protein engineering technique (e.g., by mutation, deletion, substitution, conjugation to a non-antibody moiety).
• An antibody can include, for example, one or more variant amino acids (compared to a naturally occurring antibody) that change a property (e.g, a functional property) of the antibody. Numerous such alterations are known in the art that affect, e.g, half-life, effector function, and/or immune responses to the antibody in a patient.
• the term antibody also includes artificial or engineered polypeptide constructs that comprise at least one antibody-derived antigen binding site.
• Anti-C5 antibodies described herein bind to complement component C5 (e.g, human C5) and inhibit the cleavage of C5 into fragments C5a and C5b.
• complement component C5 e.g, human C5
• Anti-C5 antibodies (or VH/VL domains derived therefrom) suitable for use in the methods described herein can be generated using methods known in the art. Alternatively, art recognized anti-C5 antibodies can be used. Antibodies that compete for binding to C5 with any of these art recognized antibodies or antibodies described herein can also be used.
• An exemplary anti-C5 antibody is ravulizumab comprising heavy and light chains having the sequences shown in SEQ ID NOs:14 and 11, respectively, or antigen binding fragments and variants thereof.
• Ravulizumab also known as ULTOMIRIS®, BNJ441 and ALXN1210
• WO2015134894 and US Patent No: 9,079,949, the entire teachings of which are hereby incorporated by reference.
• the terms ravulizumab, BNJ441, and ALXN1210 may be used interchangeably throughout this document, but all refer to the same antibody.
• Ravulizumab selectively binds to human complement protein C5, inhibiting its cleavage to C5a and C5b during complement activation.
• the antibody comprises the heavy and light chain CDRs or variable regions of ravulizumab.
• the antibody comprises the CDR1, CDR2 and CDR3 domains of the VH region of ravulizumab having the sequence set forth in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the VL region of ravulizumab having the sequence set forth in SEQ ID NO: 8.
• the antibody comprises heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:19, 18 and 3, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:4, 5 and 6, respectively.
• the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.
• the antibody comprises ravulizumab or a biosimilar thereof.
• antibody BNJ421 comprising heavy and light chains having the sequences shown in SEQ ID NOs:20 and 11, respectively, or antigen binding fragments and variants thereof.
• BNJ421 also known as ALXN1211
• ALXN1211 is described in WO2015134894 and US Patent No.9,079,949, the entire teachings of which are hereby incorporated by reference.
• the antibody comprises the heavy and light chain CDRs or variable regions of BNJ421. Accordingly, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the VH region of BNJ421 having the sequence set forth in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the VL region of BNJ421 having the sequence set forth in SEQ ID NO: 8. In another embodiment, the antibody comprises heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:19, 18 and 3, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:4, 5 and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively. In another embodiment, the antibody comprises antibody BNJ421 or a biosimilar thereof.
• CDRs are defined differently according to different methods.
• the positions of the CDRs or framework regions within a light or heavy chain variable domain are as defined by Kabat et al. [(1991) “Sequences of Proteins of Immunological Interest.” NIH Publication No. 91-3242, U.S. Department of Health and Human Services, Bethesda, MD], In such cases, the CDRs can be referred to as “Kabat CDRs” (e.g., “Kabat LCDR2” or “Kabat HCDR1”).
• the positions of the CDRs of a light or heavy chain variable region are as defined by Chothia et al. (Nature, 342:877-83, 1989).
• these regions can be referred to as “Chothia CDRs” (e.g, “Chothia LCDR2” or “Chothia HCDR3”).
• the positions of the CDRs of the light and heavy chain variable regions can be defined by a Kabat-Chothia combined definition.
• these regions can be referred to as “combined Kabat-Chothia CDRs.” Thomas, C. et al. (Mol. Immunol., 33:1389-401, 1996) exemplifies the identification of CDR boundaries according to Kabat and Chothia numbering schemes.
• Another exemplary anti-C5 antibody is the 7086 antibody described in US Patent Nos. 8,241,628 and 8,883,158.
• the antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see US Patent Nos. 8,241,628 and 8,883,158).
• the antibody, or antigen binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:21, 22 and 23, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:24, 25 and 26, respectively.
• the antibody, or antigen binding fragment thereof comprises the VH region of the 7086 antibody having the sequence set forth in SEQ ID NO:27, and the VL region of the 7086 antibody having the sequence set forth in SEQ ID NO:28.
• the antibody comprises ravulizumab or a biosimilar thereof.
• the antibody comprises 7086 antibody or a biosimilar thereof.
• Another exemplary anti-C5 antibody is the 8110 antibody also described in US Patent Nos. 8,241,628 and 8,883,158.
• the antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody.
• the antibody, or antigen binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:29, 30 and 31, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:32, 33 and 34, respectively.
• the antibody comprises the VH region of the 8110 antibody having the sequence set forth in SEQ ID NO:35, and the VL region of the 8110 antibody having the sequence set forth in SEQ ID NO:36. In another embodiment, the antibody comprises 8110 antibody or a biosimilar thereof.
• the antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody.
• the antibody, or antigen binding fragment thereof comprises heavy chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:37, 38 and 39, respectively, and light chain CDR1, CDR2 and CDR3 domains having the sequences set forth in SEQ ID NOs:40, 41 and 42, respectively.
• the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO:43, and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO:44. In another embodiment, the antibody comprises 305LO5 antibody or a biosimilar thereof.
• Another exemplary anti-C5 antibody is the SKY59 antibody (Fukuzawa, T. et al., Sci. Rep., 7:1080, 2017).
• the antibody comprises the heavy and light chain CDRs or variable regions of the SKY59 antibody.
• the antibody, or antigen binding fragment thereof comprises a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.
• the antibody comprises SKY59 antibody or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain variable regions or heavy and light chains of the Polimab (REGN3918 antibody; see US Patent No. 10,633,434).
• the anti-C5 antibody, or antigen-binding fragment thereof comprises a heavy chain variable region sequence set forth in SEQ ID NO: 47 and a light chain variable region comprising the sequence set forth in SEQ ID NO: 48.
• the anti-C5 antibody, or antigen-binding fragment thereof comprises a heavy chain sequence set forth in SEQ ID NO: 49 and a light chain sequence set forth in SEQ ID NO: 50.
• the antibody comprises Wolimab or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of tesidolumab (LFG316). In another embodiment, the antibody comprises tesidolumab or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of crovalimab (RG6107). In another embodiment, the antibody comprises crovalimab or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of ABP 959 antibody.
• the antibody comprises ABP 959 or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of ELIZARIA®. In another embodiment, the antibody comprises ELIZARIA® or a biosimilar thereof.
• the anti-C5 antibody comprises the heavy and light chain CDRs or variable regions of antibody SB 12. In another embodiment, the antibody comprises antibody SB 12 or a biosimilar thereof.
• the first anti-C5 antibody is ravulizumab (ULTOMIRIS®). In another embodiment, the first anti-C5 antibody is ravulizumab (ULTOMIRIS®) and the second antibody is 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, Dalimab (REGN3918 antibody), Tesidolumab (LFG316), Crovalimab (RG6107), ABP 959 antibody, ELIZARIA®, BCD-148 (JSC BIOCAD), SB12, antigen binding fragments thereof, or biosimilars thereof. In another embodiment, the first anti-C5 antibody is ravulizumab (ULTOMIRIS®) and the second antibody is Crovalimab, 39limab, or a biosimilar thereof.
• the first anti-C5 antibody comprises eculizumab (SOLIRIS®) or ravulizumab (ULTOMIRIS®) or an antigen-binding fragment thereof (e.g, comprising heavy and light chain complementarity determining regions (HCDR1-3 and LCDR1-3, respectively) of eculizumab) and the second anti-C5 antibody is not a biosimilar of eculizumab (SOLIRIS®), e.g, is not an antibody selected from ABP 959 antibody (manufactured by Amgen Inc., USA), ELIZARIA® (manufactured by Generium JNC, Russia), or SB 12 (manufactured by Samsung Bioepis, Incheon, South Korea).
• SOLIRIS® eculizumab
• ULTOMIRIS® ravulizumab
• an antigen-binding fragment thereof e.g, comprising heavy and light chain complementarity determining regions (HCDR1-3 and LCDR1-3, respectively) of eculizum
• an anti-C5 antibody described herein comprises a heavy chain CDR1 comprising, or consisting of, the following amino acid sequence: GHIFSNYWIQ (SEQ ID NO: 19).
• an anti-C5 antibody described herein comprises a heavy chain CDR2 comprising, or consisting of, the following amino acid sequence: EILPGSGHTEYTENFKD (SEQ ID NO: 18).
• an anti-C5 antibody described herein comprises a heavy chain variable region comprising the following amino acid sequence:
• an anti-C5 antibody described herein comprises a light chain variable region comprising the following amino acid sequence:
• DIQMTQS PS S LSASVGDRVT ITCGASENIY GALNWYQQKP GKAPKLLIYG ATNLADGVPS RFSGSGTD FTLTI SSLQP EDFATYYCQN VLNTPLTFGQ GTKVEIK ( SEQ I D NO : 8 ) .
• An anti-C5 antibody described herein can, in some embodiments, comprise a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn) with greater affinity than that of the native human Fc constant region from which the variant human Fc constant region was derived.
• the Fc constant region can, for example, comprise one or more (c.g. two, three, four, five, six, seven, or eight or more) amino acid substitutions relative to the native human Fc constant region from which the variant human Fc constant region was derived. The substitutions can increase the binding affinity of an IgG antibody containing the variant Fc constant region to FcRn at pH 6.0, while maintaining the pH dependence of the interaction.
• substitutions that enhance the binding affinity of an antibody Fc constant region for FcRn include, e.g, (1) the M252Y/S254T/T256E triple substitution (Dall’Acqua, W. et al., J. Biol. Chem., 281:23514-24, 2006); (2) the M428L or T250Q/M428L substitutions (Hinton, P. et al., J. Biol. Chem.. 279:6213-6. 2004; Hinton, P. et al., J. Immunol., 176:346-56, 2006); and (3) the N434A or T307/E380A/N434A substitutions (Petkova, S.
• the variant constant region has a substitution at EU amino acid posaition 255 for valine. In some embodiments, the variant constant region has a substitution at EU amino acid position 309 for asparagine. In some embodiments, the variant constant region has a substitution at EU amino acid position 312 for isoleucine. In some embodiments, the variant constant region has a substitution at EU amino acid position 386.
• the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3 or 2) amino acid substitutions, insertions, or deletions relative to the native constant region from which it was derived.
• the variant Fc constant region comprises one or more amino acid substitutions selected from the group consisting of: M252Y, S254T, T256E, N434S, M428L, V259I, T250I and V308F.
• the variant human Fc constant region comprises a methionine at position 428 and an asparagine at position 434 of a native human IgG Fc constant region, each in EU numbering.
• the variant Fc constant region comprises a 428L/434S double substitution as described in, e.g, U.S. Patent No. 8,088,376.
• the precise location of these mutations may be shifted from the native human Fc constant region position due to antibody engineering.
• the 428L/434S double substitution when used in a IgG2/4 chimeric Fc may correspond to 429L and 435S as in the M429L and N435S variants found in ravulizumab and described in US Patent Number 9,079,949 the disclosure of which is incorporated herein by reference in its entirety.
• the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, 384, 385, 386, 387, 389, 424, 428, 433, 434 or 436 (EU numbering) relative to the native human Fc constant region.
• the substitution is selected from the group consisting of: methionine for glycine at position 237; alanine for proline at position 238; lysine for serine at position 239; isoleucine for lysine at position 248; alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan, or tyrosine for threonine at position 250; phenylalanine, tryptophan, or tyrosine for methionine at position 252; threonine for serine at position 254; glutamic acid for arginine at position 255; aspartic acid, glutamic acid, or glutamine for threonine at position 256; alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine, or valine for proline at position 257; histidine for
• Suitable anti-C5 antibodies for use in the methods described herein comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 14 and/or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11.
• the anti-C5 antibodies for use in the methods described herein in some embodiments, comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO:20 and/or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11.
• the antibody binds to C5 at pH 7.4 and 25°C (and, otherwise, under physiologic conditions) with an affinity dissociation constant (KD) that is at least 0.1 (e.g, at least 0.15, 0.175, 0.2, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0.7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, or 0.975) nM.
• KD affinity dissociation constant
• the antibody binds to C5 at pH 7.4 and 25°C (and, otherwise, under physiologic conditions) with an affinity dissociation constant (KD) that is about 0.5 nM.
• KD affinity dissociation constant
• the KD of the anti-C5 antibody, or antigen binding fragment thereof is no greater than 1 (e.g., no greater than 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, or 0.2) nM.
• the antibody binds to C5 at pH 6.0 and 25°C (and, otherwise, under physiologic conditions) with a KD that is about 22 nM.
• the [(KD of the antibody for C5 at pH 6.0 at 25°C)/(KD of the antibody for C5 at pH 7.4 at 25C)] is greater than 21 (e.g., greater than 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500 or 8000)
• binding of an antibody to a protein antigen can be detected and/or quantified using a variety of techniques such as, but not limited to, Western blot, dot blot, surface plasmon resonance (SPR) detection (e.g, BIAcore system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, N.J.), or enzyme-linked immunosorbent assay (ELISA; Benny K. C. Lo (2004) “Antibody Engineering: Methods and Protocols,” Humana Press (ISBN: 1588290921); Johne, B. et al., J.
• SPR surface plasmon resonance
• the term “k a ” refers to the rate constant for association of an antibody to an antigen.
• the term “ka” refers to the rate constant for dissociation of an antibody from the antibody/ antigen complex.
• KD refers to the equilibrium dissociation constant of an antibody-antigen interaction.
• Such determinations can be measured, for example, at 25C or 37C (see the working examples).
• the kinetics of antibody binding to human C5 can be determined, for example, at pH 8.0, 7.4, 7.0, 6.5 and 6.0 via SPR on a BIAcore 3000 instrument using an anti-Fc capture method to immobilize the antibody.
• the anti-C5 antibody, or antigen binding fragment thereof blocks the cleavage of C5 into C5a and C5b.
• this blocking effect for example, the pro-inflammatory effects of C5a and the generation of the C5b-9 membrane attack complex (MAC) at the surface of a cell are inhibited.
• MAC membrane attack complex
• Inhibition of human complement component C5 can reduce the cell-lysing ability of complement in a subject’s body fluids.
• Such reductions of the cell-lysing ability of complement present in the body fluid(s) can be measured by methods known in the art such as, for example, by a conventional hemolytic assay such as the hemolysis assay (Kabat and Mayer (eds.), “Experimental Immunochemistry, 2 nd Edition,” 135-240, Springfield, IL, CC Thomas (1961), pages 135-139), or a conventional variation of that assay such as the chicken erythrocyte hemolysis method (Hillmen, P. et al., N.
• Immunological techniques such as, but not limited to, ELISA can be used to measure the protein concentration of C5 and/or its split products to determine the ability of an anti-C5 antibody, or antigen binding fragment thereof, to inhibit conversion of C5 into biologically active products.
• C5a generation is measured.
• C5b-9 neoepitope-specific antibodies are used to detect MAC formation.
• Hemolytic assays can be used to determine the inhibitory activity of an anti-C5 antibody, or antigen binding fragment thereof, on complement activation.
• an anti-C5 antibody, or antigen binding fragment thereof, on classical complement pathway-mediated hemolysis in a serum test solution in vitro for example, sheep erythrocytes coated with hemolysin or chicken erythrocytes sensitized with anti-chicken erythrocyte antibody are used as target cells.
• the percentage of lysis is normalized by considering 100% lysis equal to the lysis occurring in the absence of the inhibitor.
• the classical complement pathway is activated by a human IgM antibody, for example, as utilized in the Wieslab® Classical Pathway Complement Kit (Wieslab® COMPL CP310, Euro-Diagnostica, Sweden).
• test serum is incubated with an anti-C5 antibody, or antigen binding fragment thereof, in the presence of a human IgM antibody.
• the amount of C5b-9 that is generated is measured by contacting the mixture with an enzyme conjugated anti-C5b-9 antibody and a fluorogenic substrate and measuring the absorbance at the appropriate wavelength.
• the test serum is incubated in the absence of the anti-C5 antibody, or antigen binding fragment thereof.
• the test serum is a C5-deficient serum reconstituted with a C5 polypeptide.
• the serum test solution is a C5-deficient serum reconstituted with a C5 polypeptide.
• the percentage of lysis is normalized by considering 100% lysis equal to the lysis occurring in the absence of the inhibitor.
• the alternative complement pathway is activated by lipopolysaccharide molecules, for example, as utilized in the Wieslab® Alternative Pathway Complement Kit (Wieslab® COMPL AP330, Euro-Diagnostica, Sweden).
• test serum is incubated with an anti-C5 antibody, or antigen binding fragment thereof, in the presence of lipopolysaccharide.
• the amount of C5b-9 that is generated is measured by contacting the mixture with an enzyme conjugated anti-C5b-9 antibody and a fluorogenic substrate and measuring the fluorescence at the appropriate wavelength.
• test serum is incubated in the absence of the anti-C5 antibody, or antigen binding fragment thereof.
• C5 activity, or inhibition thereof is quantified using a CH50eq assay.
• the CH50eq assay is a method for measuring the total classical complement activity in serum. This test is a lytic assay, which uses antibody-sensitized erythrocytes as the activator of the classical complement pathway and various dilutions of the test serum to determine the amount required to give 50% lysis (CH50). The percent hemolysis can be determined, for example, using a spectrophotometer.
• the CH50eq assay provides an indirect measure of terminal complement complex (TCC) formation, since the TCC themselves are directly responsible for the hemolysis that is measured.
• TCC terminal complement complex
• undiluted serum samples e.g, reconstituted human serum samples
• microassay wells containing the antibody-sensitized erythrocytes to thereby generate TCC.
• the activated sera are diluted in microassay wells, which are coated with a capture reagent (e.g., an antibody that binds to one or more components of the TCC).
• the TCC present in the activated samples bind to the monoclonal antibodies coating the surface of the microassay wells.
• the wells are washed and to each well is added a detection reagent that is detectably labeled and recognizes the bound TCC.
• the detectable label can be, e.g, a fluorescent label or an enzymatic label.
• the assay results are expressed in CH50 unit equivalents per milliliter (CH50 U Eq/mL).
• Inhibition e.g, as it pertains to terminal complement activity, includes at least a 5 (e.g, at least a 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55 or 60) % decrease in the activity of terminal complement in, e.g, a hemolytic assay or CH50eq assay as compared to the effect of a control antibody (or antigen-binding fragment thereof) under similar conditions and at an equimolar concentration.
• Substantial inhibition refers to inhibition of a given activity (e.g, terminal complement activity) of at least 40 (e.g, at least 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, or 95 or greater) %.
• an anti-C5 antibody described herein contains one or more amino acid substitutions relative to the CDRs of eculizumab (i.e., SEQ ID NOs:l-6), yet retains at least 30 (e.g., at least 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 55, 60, 65, 70, 75, 80, 85, 90 or 95) % of the complement inhibitory activity of eculizumab in a hemolytic assay or CH50eq assay.
• the antibody competes for binding with, and/or binds to the same epitope on C5 as an antibody described herein.
• the term “binds to the same epitope” with reference to two or more antibodies means that the antibodies bind to the same segment of amino acid residues, as determined by a given method.
• Techniques for determining whether antibodies bind to the same epitope on C5 with an antibody described herein include, for example, epitope mapping methods, such as, x-ray analyses of crystals of antigen: antibody complexes, and hydrogen/ deuterium exchange mass spectrometry (HDX-MS).
• Antibodies that “compete with another antibody for binding to a target” refer to antibodies that inhibit (partially or completely) the binding of the other antibody to the target. Whether two antibodies compete with each other for binding to a target, i.e., whether and to what extent one antibody inhibits the binding of the other antibody to a target, may be determined using known competition experiments. In certain embodiments, an antibody competes with, and inhibits binding of another antibody to a target by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or 100%. The level of inhibition or competition may be different depending on which antibody is the “blocking antibody” (i.e., the antibody that is incubated first with the target). Competing antibodies can bind to, for example, the same epitope, an overlapping epitope or to adjacent epitopes (e.g., as evidenced by steric hindrance).
• the first and the second anti-C5 antibodies of the disclosure bind to different domains in complement C5.
• the various domains in C5 include, e.g., Ml domain, M6 domain and M7 domain.
• Representative examples of anti-C5 antibodies binding to MG7 domain of C5 include, e.g., eculizumab and ravulizumab; representative examples of anti-C5 antibodies binding to MG1 domain of C5 include, e.g., crovalimab; and representative examples of anti-C5 antibodies binding to MG6 domain of C5 include, e.g, Polimab. See Schatz-Jakobsen et al. (J Immunol.
• the first anti-C5 antibody is an antibody that binds to MG7 domain in C5 and the second anti-C5 antibody is an antibody that binds to a domain other than MG7, e.g., MG1 domain or MG6 domain of C5.
• the first anti-C5 antibody is an antibody that binds to MG1 domain in C5 and the second anti-C5 antibody is an antibody that binds to a domain other than MG1, e.g., MG7 domain or MG6 domain of C5.
• the first anti-C5 antibody is an antibody that binds to MG6 domain in C5 and the second anti-C5 antibody is an antibody that binds to a domain other than MG6, e.g., MG7 domain or MG1 domain of C5.
• Anti-C5 antibodies, or antigen-binding fragments thereof described herein, used in the methods described herein can be generated using a variety of art-recognized techniques. Monoclonal antibodies can be obtained by various techniques familiar to those skilled in the art. Briefly, spleen cells from an animal immunized with a desired antigen are immortalized, commonly by fusion with a myeloma cell (Kohler, G. & Milstein, C., Eur. J. Immunol., 6:511-9, 1976)). Methods of immortalization include transformation with Epstein Barr Virus, oncogenes, or retroviruses or other methods known in the art.
• Colonies arising from single immortalized cells are screened for production of antibodies of the desired specificity and affinity for the antigen, and yield of the monoclonal antibodies produced by such cells may be enhanced by various techniques, including injection into the peritoneal cavity of a vertebrate host.
• the first and/or second anti-C5 antibody can be administered to the patient via any suitable means or art recognized technique. In one embodiment, the first and/or second anti- C5 antibody is administered intravenously to the patient. In another embodiment, the first and/or second anti-C5 antibody is administered subcutaneously to the patient.
• the methods described herein include a step of contacting a biological sample (e.g., blood, serum, plasma, urine, saliva, lymph, spinal fluid, intercellular fluid, vitreous humor, or sweat) from the patient with a therapeutic dose of a second anti-C5 antibody under conditions sufficient for formation of multivalent immune complexes comprising complement C5, the first anti-C5 antibody, and second anti-C5 antibody.
• a biological sample e.g., blood, serum, plasma, urine, saliva, lymph, spinal fluid, intercellular fluid, vitreous humor, or sweat
• the contacting step occurs in vivo.
• the contact step occurs ex vivo or in vitro.
• the methods further include a step of measuring a level of the multivalent immune complexes formed in the first contacting step.
• Levels of multivalent immune complexes can be determined by any suitable assay or technique.
• the level is determined by size exclusion chromatography (SEC).
• SEC also known as molecular sieve chromatography, is a chromatographic method in which molecules in solution are separated by their size, and in some cases molecular weight. It is usually applied to large molecules or macromolecular complexes such as proteins and industrial polymers.
• the level is determined by multi-angle light scattering (MALS). MALS is a technique for measuring the light scattered by a sample into a plurality of angles. It is used for determining both the absolute molar mass and the average size of molecules in solution, by detecting how they scatter light.
• the level is determined by SEC and MALS.
• the methods further include a step of determining if the measured level of multivalent immune complexes exceeds a threshold level.
• the threshold level is based on a minimum mass of the multivalent immune complexes.
• the threshold level is a mass of more than about 500 kDa, 510 kDa, 520 kDa, 530 kDa, 540 kDa, 550 kDa, 560 kDa, 570 kDa, 580 kDa, 590 kDa, 600 kDa, 610 kDa, 620 kDa, 630 kDa, 640 kDa, 650 kDa, 660 kDa, 670 kDa, 680 kDa, 690 kDa, 700 kDa, 710 kDa, 720 kDa, 730 kDa, 740 kDa, 750 kDa,
• the threshold level is based on formation of multivalent immune complexes comprising more than 2 anti-C5 antibodies specifically bound to 1 molecule of complement C5 (e.g., immune complexes comprising antibody: antigen stoichiometric ratios). In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 3 anti-C5 antibodies and 2 C5 molecules. In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 4 anti-C5 antibodies and 3 C5 molecules. In another embodiment, the threshold level is formation of multivalent immune complexes consisting of more than 5 anti- C5 antibodies and 4 C5 molecules.
• a human patient having a complement mediated disorder who has been or is being treated with a first anti-C5 antibody and is then treated with a second anti-C5 antibody.
• Patients treated according to the methods described herein have one or more complement mediated disorders.
• Exemplary complement mediated disorders include, but are not limited to rheumatoid arthritis, antiphospholipid antibody syndrome, lupus nephritis, ischemia-reperfusion injury, atypical hemolytic uremic syndrome (aHUS), typical hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria (PNH), dense deposit disease, neuromyelitis optica, multifocal motor neuropathy, multiple sclerosis, macular degeneration, HELLP syndrome, spontaneous fetal loss, thrombotic thrombocytopenic purpura, Pauci-immune vasculitis, epidermolysis bullosa, recurrent fetal loss, traumatic brain injury, myocarditis, a cerebrovascular disorder, a peripheral vascular disorder, a renovascular disorder, a mesenteric/enteric vascular disorder, vasculitis, Henoch- Schonlein purpura nephritis, systemic lupus erythematosus-
• the patient has been or is being treated with a first anti-C5 antibody and is then is treated with (e.g., switched to) a second (different) anti-C5 antibody.
• the first and/or second anti-C5 antibodies can be administered according to any suitable therapeutic regimen. In some embodiments, the first and/or second anti-C5 antibodies are administered according to a clinically effective dosing or scheduling regimen.
• the therapeutic regimen is adjusted, e.g., to prevent or minimize multivalent immune complex formation when the patient is transitioned from the first anti-C5 antibody to the second anti-C5 antibody.
• the adjusted regimen comprises a modification of a clinically effective dosing or scheduling regimen.
• the adjusted regimen is a dose which is lower than a standard therapeutic dose, e.g., a sub-therapeutic dose.
• the adjusted regimen comprises administration at a rate or interval that is moderated compared to standard scheduling, e.g., via slower rate of administration and/or less frequent administration.
• the adjusted regimen comprises administration at a dose that is moderated compared to standard scheduling, e.g., reduced dose.
• the second anti-C5 antibody is administered at a reduced dose and/or a reduced frequency until the threshold is no longer exceeded.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered at a dose of: 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter.
• the patient e.g., adult patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8;
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered at a dose of: 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered to the patient (e.g., adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• SOLIRIS® administered to the patient (e.g., adult patient) at a dose of 900 mg weekly
• the patient has aHUS and the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs: 1, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered to the patient (e.g., adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• SOLIRIS® is SOLIRIS®, administered to the patient (e.g.,
• the patient has myasthenia gravis (MG) and the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO:8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered to the patient (e.g, adult patient) at a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter.
• SOLIRIS® is SOLIRIS®, administered to the patient
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS® (eculizumab) and the adjusted regimen comprises an adjustment in the therapeutic regimen for therapy of the complement mediated disorder in the patient (e.g., an adult patient).
• the adjusted regimen comprises an adjustment in the therapeutic regimen for therapy of the complement mediated disorder in the patient (e.g., an adult patient).
• the therapeutic regimen comprises a dose of 600 mg weekly for four weeks, followed by 900 mg for the fifth dose one week later, then 900 mg every two weeks thereafter for the treatment of PNH.
• the therapeutic regimen comprises a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter for the treatment of aHUS.
• the therapeutic regimen comprises a dose of 900 mg weekly for four weeks, followed by 1200 mg for the fifth dose one week later, then 1200 mg every two weeks thereafter for the treatment of MG.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS®, administered to the patient (e.g., a pediatric patient) at a dose of:
• the patient e.g., a pediatric patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively;
• (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8;
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; and/or (d) is SOLIRIS®, administered to the patient at a dose of:
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:l, 2 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO:7 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 10 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11 ; and/or (d) is SOLIRIS® (eculizumab) and the adjusted regimen comprises an adjustment in the therapeutic regimen for therapy of the complement mediated disorder in the patient (e.g., a pediatric patient).
• the therapeutic regimen comprises administration of the second antibody to the patient at a dose of:
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (
• the patient e.g., adult patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively
• (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11
• (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (e)
• the therapeutic regimen comprises administration of the second antibody to the patient at a dose of: (a) once on Day 1 of the administration cycle at a dose of: 2400 mg to a patient weighing > 40 to ⁇ 60 kg, 2700 mg to a patient weighing > 60 to ⁇ 100 kg, or 3000 mg to a patient weighing > 100 kg; and (b) on Day 15 of the administration cycle and every eight weeks thereafter at a dose of 3000 mg to a patient weighing > 40 to ⁇ 60 kg, 3300 mg to a patient weighing > 60 to ⁇ 100 kg or 3600 mg to a patient weighing > 100 kg.
• the first or second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (
• the patient e.g., pediatric patient
• the first or second anti-C5 antibody comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively
• (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8
• (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11
• (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and
• the second anti-C5 antibody (a) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively; (b) comprises a heavy chain variable region depicted in SEQ ID NO: 12 and a light chain variable region depicted in SEQ ID NO: 8; (c) comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO: 11; (d) comprises CDR1, CDR2 and CDR3 heavy chain sequences as set forth in SEQ ID NOs:19, 18 and 3, respectively, and CDR1, CDR2 and CDR3 light chain sequences as set forth in SEQ ID NOs:4, 5 and 6, respectively and a heavy chain constant region as set forth in SEQ ID NO: 13 and/or (e)
• the therapeutic regimen comprises administration of the second antibody to the patient (e.g., pediatric patient) at a dose of: (a) once on Day 1 at a dose of 600 mg to a patient weighing > 5 to ⁇ 10 kg, 600 mg to a patient weighing > 10 to
• a method for treating a patient suffering from a complement mediated disorder wherein the patient has been or is being treated with a first anti-C5 antibody, and wherein the method comprises:
• the methods further comprise weaning (e.g., withdrawing) the patient from treatment with the first anti-C5 antibody therapy.
• an adjusted regimen antibody e.g., a regimen to prevent or minimize formation of multivalent immune complexes
• adjusted therapeutic dose and/or timing of administration of a second anti-C5 to treat a patient suffering from a complement mediated disorder, wherein the patient has been or is being treated with a first anti-C5 antibody comprising:
• the methods further comprise weaning (e.g., withdrawing) the patient from treatment with the first anti-C5 antibody therapy.
• a method for switching a patient having a complement mediated disorder who has been or is being treated with a first anti-C5 antibody to treatment with a second anti-C5 antibody comprising:
• the second anti-C5 antibody is administered at a reduced dose and/or a reduced frequency until the threshold is no longer exceeded.
• the adjusted regimen comprises a modification of a clinically effective dosing or scheduling regimen.
• the adjusted regimen is a dose which is lower than a standard therapeutic dose, e.g., a sub-therapeutic dose.
• the adjusted regimen comprises administration at a rate or interval that is moderated compared to standard scheduling, e.g., via slower rate of administration and/or less frequent administration.
• Additional techniques can be used in combination with the methods described herein to clear or enhance clearance of the first anti-C5 antibody before switching to treatment with a second anti-C5 antibody.
• Exemplary techniques include, but are not limited to, plasmapheresis or blood transfusions.
• the efficacy of the treatment methods provided herein can be assessed using any suitable means.
• the treatment resolves at least one sign or symptom of the complement-mediated disorder without toxicity associated with multivalent immune complexes formed as a result of administration of the second anti-C5 antibody.
• circulating immune complexes formed with target antigens should be considered when developing a monoclonal antibody (mAb). Valency of such complexes can affect clearance, effector function and uptake by phagocytic cells. Therefore, consideration must be given when a recipient is exposed to more than one immunoglobulin G antibody that bind to a monovalent target at different sites, potentially leading to the formation of multivalent immune complexes. Accordingly, the objective of the present study is to better understand the potential for formation of multivalent complexes in recipients of other noncompetitive anti-C5 antibodies, while maintaining detectable levels of eculizumab in circulation.
• Size exclusion chromatography in combination with multi-angle light scattering (MALS) was used to assess the size distribution of ternary complexes formed in vitro between eculizumab, C5 and two other anti-C5 monoclonal antibodies that have the same sequences as mAbs currently undergoing clinical trials, but which bind to different C5 epitopes.
• mAb crovalimab mimetic was generated using the sequences of a monoclonal antibody now known as crovalimab (Chugai Pharmaceutical, Tokyo, Japan),
• crovalimab Cholimab mimetic was based on the sequences of the monoclonal antibody now known as Polimab (Regeneron Pharmaceuticals, New York, NY, USA).
• Eculizumab was labeled with Alexa Fluor 488 Dye (Thermo Fisher Scientific, Waltham, MA, USA). The competition between anti-C5 mAbs was evaluated using bio-layer interferometry.
• Hemolysis was assessed by the release of soluble hemoglobin determined at 415 nm, following 30-minute incubations at 37°C of varying concentrations of anti-C5 monoclonal antibodies with 2.5 x 106 antibody sensitized chicken red blood cells in gelatin veronal buffered saline containing 0.15 mM CaC12 and 0.5 mM MgC12 (GVB++) and 15% (v/v) normal human serum. All C5 monoclonal antibodies were functional and had comparable half maximal inhibitory concentration (IC50) values (data not shown).
• purified eculizumab, human C5 and either crovalimab mimetic or Polimab mimetic were incubated together in varying molar ratios in phosphate buffered saline (PBS) for ⁇ 30 minutes at room temperature.
• PBS phosphate buffered saline
• eculizumab was replaced with labeled eculizumab and the incubations were performed in at least 80% (v/v) final human plasma with 35 pL injections onto the SEC column.
• the same chromatography method as described above for samples diluted in PBS was used, except that chromatography was monitored with in-line fluorescence detection using a fluorescence detector (Agilent), in which elution was monitored with excitation at 490 nm and emission at 525 nm.
• Biotinylated eculizumab was captured onto a streptavidin biosensor probe, washed (W) and treated with either purified human C5 (red and black traces) or buffer (blue traces) (See FIGS 1A-1D). Following an additional wash, probes, were treated with either eculizumab (black traces), or a different second antibody (red traces) or buffer (blue traces) (see FIGS. 1 A-1D).
• FIG 1A-D set forth the data for the following different second antibodies: FIG 1A: mAb N19/8 which is known to bind to a different site on C5 to eculizumab; FIG IB: ravulizumab; FIG 1C: mAb crovalimab mimetic; and FIG ID: mAb Dolimab mimetic.
• the scale bar shows the deflection corresponding to a biosensor signal of 1.0 nm. mAb, monoclonal antibody.
• compositions in PBS comprising either crovalimab mimetic (FIG. 2A and C) or Polimab mimetic (FIG 3A and C) together with C5 plus eculizumab at levels expected in vivo as eculizumab approaches the minimum plasma concentration (Cmin), contained a series of high molecular weight complexes with some larger than 1500 kDa, and were consistent with incorporation of up to four molecules of C5 and five molecules of mAb (FIG. 5).
• crovalimab mimetic 700 nM
• crovalimab mimetic 700 nM
• C5 400 nM
• C5 400 nM
• Reconstitution of crovalimab mimetic (700 nM) with eculizumab (700 nM) plus C5 (400 nM) resulted in the formation of a series of larger, earlier eluting peaks denoted with asterisks.
• FIG. 2A crovalimab mimetic (700 nM) alone migrated as a single peak and formed two additional species in the presence of C5 (400 nM) corresponding to 1:1 and 1:2 crovalimab mimetic:C5 complexes
• crovalimab mimetic induces formation of very large complexes in the presence of eculizumab and C5 at eculizumab and C5 concentrations mimicking those in human blood as eculizumab approaches Cmin.
• crovalimab mimetic induces formation of very large complexes in the presence of eculizumab and C5 at eculizumab and C5 concentrations mimicking those in human blood as eculizumab approaches Cmin.
• FIGs. 3A-3D the concentration of eculizumab and C5 mimicking those in human blood as eculizumab approaches Cmin.
• ravulizumab did not associate with eculizumab-bound C5 (FIG. IB) and did not form complexes beyond the sizes expected for 1:1 and 1:2 mAb:C5 complexes (FIGs. 4A- 4D).
• Ravulizumab forms only 1 : 1 and 1 :2 complexes with C5 both in the absence or presence of eculizumab.
• ravulizumab alone migrated as a single peak, but in the presence of C5 or C5 plus eculizumab three peaks were observed.
• the last peak to elute in the composition of C5 plus eculizumab and ravulizumab corresponds to unbound antibody and had a shoulder because free eculizumab and ravulizumab had slightly different retention times (FIG. 4B).
• the compositions comprising ravulizumab and C5 (FIG. 4C), and ravulizumab and C5 plus eculizumab (D) exhibited masses by multi-angle light scattering (MALS) consistent with the formation of only 1:1 and 1:2 mAb:C5 complexes. No complexes larger than these were observed.
• MALS multi-angle light scattering
• such complexes could potentially be proinflammatory via one or more of the mechanisms associated with polyvalent immune complexes, such as: avidity-driven reconstitution of Fey or Clq dependent effector functions, deposition of complexes in tissues, altered antigen processing and immunogenicity directed against the constituents associated with polyvalent interaction with the neonatal Fc receptor (FcRn), neutrophil activation, cytokine release, degranulation and NETosis.
• FcRn neonatal Fc receptor
• neutrophil activation neutrophil activation
• cytokine release degranulation
• NETosis NETosis

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