WO2022182574A1 - KETOHEXOKINASE (KHK) iRNA COMPOSITIONS AND METHODS OF USE THEREOF - Google Patents

KETOHEXOKINASE (KHK) iRNA COMPOSITIONS AND METHODS OF USE THEREOF Download PDF

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WO2022182574A1
WO2022182574A1 PCT/US2022/016890 US2022016890W WO2022182574A1 WO 2022182574 A1 WO2022182574 A1 WO 2022182574A1 US 2022016890 W US2022016890 W US 2022016890W WO 2022182574 A1 WO2022182574 A1 WO 2022182574A1
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Prior art keywords
nucleotide
nucleotides
ome
antisense strand
strand
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English (en)
French (fr)
Inventor
Leila NOETZLI
James D. MCININCH
Frederic Tremblay
Mark K. SCHLEGEL
Adam CASTORENO
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Alnylam Pharmaceuticals Inc
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Alnylam Pharmaceuticals Inc
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Priority to JP2023552130A priority Critical patent/JP2024515423A/ja
Priority to EP22709463.8A priority patent/EP4298218A1/en
Priority to MX2023009704A priority patent/MX2023009704A/es
Priority to CA3211059A priority patent/CA3211059A1/en
Priority to CN202280027340.6A priority patent/CN117751187A/zh
Priority to IL305153A priority patent/IL305153A/en
Priority to AU2022226098A priority patent/AU2022226098A1/en
Priority to KR1020237032771A priority patent/KR20230150844A/ko
Priority to BR112023016645A priority patent/BR112023016645A2/pt
Application filed by Alnylam Pharmaceuticals Inc filed Critical Alnylam Pharmaceuticals Inc
Publication of WO2022182574A1 publication Critical patent/WO2022182574A1/en
Priority to US18/060,990 priority patent/US11926832B2/en
Anticipated expiration legal-status Critical
Priority to CONC2023/0012562A priority patent/CO2023012562A2/es
Priority to US18/487,302 priority patent/US12404508B2/en
Priority to US19/252,346 priority patent/US20260028631A1/en
Ceased legal-status Critical Current

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    • A61P3/08—Drugs for disorders of the metabolism for glucose homeostasis
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    • C12Y—ENZYMES
    • C12Y207/00—Transferases transferring phosphorus-containing groups (2.7)
    • C12Y207/01—Phosphotransferases with an alcohol group as acceptor (2.7.1)
    • C12Y207/01003—Ketohexokinase (2.7.1.3)

Definitions

  • Fructose is almost exclusively metabolized in the liver, and unlike the glucose metabolism pathway, the fructose metabolism pathway is not regulated by feedback inhibition by the product (Khaitan Z et al ., (2013) J. Nutr. Metab. 2013, Article ID 682673, 1-12). While hexokinase and phosphofructokinase (PFK) regulate the production of glyceraldehyde-3-P from glucose, fructokinase or ketohexokinase (KHK), which is responsible for phosphorylation of fructose to fructose-1-phosphate in the liver, it is not down regulated by increasing concentrations of fructose-1-phosphate.
  • PFK phosphofructokinase
  • the phosphorylation of fructose by KHK is associated with diseases, disorders or conditions such as liver disease (e.g., fatty liver, steatohepatitis), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver, steatohepatitis
  • dyslipidemia e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglycerid
  • the invention provides a double stranded ribonucleic acid (dsRNA) agent for inhibiting expression of ketohexokinase (KHK) in a cell, wherein the dsRNA agent comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than 0, 1, 2, or 3 nucleotides from the nucleotide sequence of SEQ ID NO:1 and the antisense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, 21, 22 or 23, contiguous nucleotides differing by no more than 1, 2, or 3 nucleotides from the nucleotide sequence of SEQ ID NO:2.
  • dsRNA double stranded ribonucleic acid
  • the dsRNA agent comprises at least one thermally destabilizing nucleotide modification, e.g., an abasic modification; a mismatch with the opposing nucleotide in the duplex; and destabilizing sugar modification, a 2’-deoxy modification, an acyclic nucleotide, an unlocked nucleic acids (UNA), or a glycerol nucleic acid (GNA), e.g., the antisense strand comprises at least one thermally destabilizing nucleotide modification.
  • the present invention provides a double stranded ribonucleic acid (dsRNA) for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the antisense strand comprises a region of complementarity to an mRNA encoding KHK, and wherein the region of complementarity comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, 21, 22 or 23,contiguous nucleotides differing by no more than 0, 1, 2, or 3 nucleotides from any one of the antisense nucleotide sequences in any one of Tables 2, 3, 5, 6, and 8-13.
  • dsRNA double stranded ribonucleic acid
  • the dsRNA agent comprises a sense strand comprising at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than two nucleotides from any one of the nucleotide sequences of the sense strands in any one of Tables 2, 3, 5, 6 and 8-13 and an antisense strand comprising at least 15, e.g., 15, 16, 17, 18, 19, 20, 21, 22 or 23, contiguous nucleotides differing by no more than two nucleotides from any one of the nucleotide sequences of the antisense strands in any one of Tables 2, 3, 5, 6 and 8-13.
  • the dsRNA agent comprises a sense strand comprising or consisting of a nucleotide sequence selected from the group consisting of any one of the nucleotide sequences of the sense strands in any one of Tables 2, 3, 5, 6 and 8-13 and an antisense strand comprising or consisting of a nucleotide sequence selected from the group consisting of any one of the nucleotide sequences of the antisense strands in any one of Tables 2, 3, 5, 6 and 8-13.
  • the present invention provides a double stranded ribonucleic acid (dsRNA) for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than 0, 1, 2, or 3 nucleotides from any one of the nucleotide sequence of nucleotides 120-162; 164-188; 181-207; 193-217; 209-231; 283-306; 508-546; 568-603; 596-632; 640-674; 746-806; 806-835; 917-942; 936- 084; 1016-1041; 1100-1123; 1149-1175; 1160-1193; 1205-1229; 1252-1283; 1334-1356; 1407-1429; 1472
  • the present invention provides a double stranded ribonucleic acid (dsRNA) for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than 0, 1, 2, or 3 nucleotides from any one of the nucleotide sequence of nucleotides 517-539; 521-543; 524-546; 517-546; 581-603; 610-632; 747-769; 749-771; 752-774; 755-777; 757-779; 758-780; 764-786; 776- 798; 781-803; 747-803; 920-942; 941-963; 944-966; 950-972; 962-984; 920-984; 11
  • the present invention provides a double stranded ribonucleic acid (dsRNA) for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than 0, 1, 2, or 3 nucleotides from any one of the nucleotide sequence of nucleotides 517-539; 524-546; 517-546; 753-775; 757-779; 753-779; 764-786; 767-789; 768-790; 769-791; 764-791; 773-795; 781-803; 773- 803; 753-803; 808-830; 937-959; 941-963; 944-966; 941-966; 948-970; 950-972;
  • the antisense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, 21, 22 or 23, contiguous nucleotides differing by nor more than 0, 1, 2, or 3 nucleotides from any one of the antisense strand nucleotide sequences of a duplex selected from the group consisting of AD- 1613400; AD-1613243; AD-1290757.3; AD-1290878.3; AD-1290969.3; AD-1423317.2; AD- 1423327.2; AD-1423336.2; AD-1290599.3; AD-1523172.1; AD-1290837.3; AD-1523173.1; AD- 1290884.3; AD-1523174.1; AD-1290959.3; AD-1523175.1; AD-1423311.2; AD-1423324.2; AD- 1523176.1; AD-1423329.2; AD-1423333.2; AD-1423330.2; AD-1523177.1; AD-1290885.3; AD- 1523178.1; AD-1423334.2; AD-1523179
  • the present invention provides a double stranded ribonucleic acid (dsRNA) agent for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than three, e.g., 3, 2, 1, or 0, nucleotides from any one of the nucleotide sequence of nucleotides 495- 517, 492-517, 500-529, 514-551, 517-539, 524-546, 517-548, 614-643, 625-647, 625-660, 642-664, 642-672, 753-811, 754-780, 762-791, 764-786, 772-800, 781-803, 805-827, 808-830, 809-831,
  • the present invention provides a double stranded ribonucleic acid (dsRNA) agent for inhibiting expression of ketohexokinase (KHK) in a cell, wherein said dsRNA comprises a sense strand and an antisense strand forming a double stranded region, wherein the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than three, e.g., 3, 2, 1, or 0, nucleotides from any one of the nucleotide sequence of nucleotides 513- 556, 753-813, 936-981, 1155-1193, 1200-1229, 1704-1727, 1747-1787, 1850-1873, 1936-1964, 1960- 1990, 1936-1990, 2015-2048, 2060-2095, 2090-2118, 2060-2118, 2124-2160, 2181-2220, 2221-2249, 2181-2249, 2240-2262, 2221-2262
  • the sense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, or 21, contiguous nucleotides differing by no more than three, e.g., 3, 2, 1, or 0, nucleotides from the nucleotide sequence of nucleotides 1207-1229 of SEQ ID NO: 1
  • the antisense strand comprises at least 15, e.g., 15, 16, 17, 18, 19, 20, 21, 22, or 23, contiguous nucleotides differing by no more than 3, e.g., 3, 2, 1, or 0, from the corresponding nucleotide sequence of SEQ ID NO:2.
  • the dsRNA agent comprises at least one modified nucleotide.
  • the thermally destabilizing nucleotide modification is selected from the group consisting of an abasic modification; a mismatch with the opposing nucleotide in the duplex; and destabilizing sugar modification, a 2’-deoxy modification, an acyclic nucleotide, an unlocked nucleic acids (UNA), and a glycerol nucleic acid (GNA).
  • the modified nucleotide comprises a short sequence of 3’-terminal deoxythimidine nucleotides (dT).
  • the double stranded region may be 19-30 nucleotide pairs in length; 19-25 nucleotide pairs in length;19-23 nucleotide pairs in length; 23-27 nucleotide pairs in length; or 21-23 nucleotide pairs in length.
  • each strand is independently no more than 30 nucleotides in length.
  • the sense strand is 21 nucleotides in length and the antisense strand is 23 nucleotides in length.
  • the region of complementarity may be at least 17 nucleotides in length; between 19 and 23 nucleotides in length; or 19 nucleotides in length.
  • at least one strand comprises a 3’ overhang of at least 1 nucleotide.
  • the dsRNA agent further comprises a ligand.
  • the ligand is conjugated to the 3’ end of the sense strand of the dsRNA agent.
  • the ligand is an N-acetylgalactosamine (GalNAc) derivative.
  • the ligand is one or more GalNAc derivatives attached through a monovalent, bivalent, or trivalent branched linker. In one embodiment, the ligand is .
  • the dsRNA agent is conjugated to the ligand as shown in the following schematic and, wherein X is O or S. In one embodiment, the X is O. In one embodiment, the dsRNA agent further comprises at least one phosphorothioate or methylphosphonate internucleotide linkage. In one embodiment, the phosphorothioate or methylphosphonate internucleotide linkage is at the 3’-terminus of one strand, e.g., the antisense strand or the sense strand.
  • the phosphorothioate or methylphosphonate internucleotide linkage is at the 5’-terminus of one strand, e.g., the antisense strand or the sense strand. In one embodiment, the phosphorothioate or methylphosphonate internucleotide linkage is at the both the 5’- and 3’-terminus of one strand. In one embodiment, the strand is the antisense strand. In one embodiment, the base pair at the 1 position of the 5′-end of the antisense strand of the duplex is an AU base pair.
  • the present invention provides a double stranded ribonucleic acid (dsRNA) agent for inhibiting expression of ketohexokinase (KHK) in a cell, or a pharmaceutically acceptable salt thereof, comprising a sense strand and an antisense strand forming a double stranded region, wherein a) the nucleotide sequence of the sense strand differs by no more than 4 bases from the nucleotide sequence 5’-gscsaggaagCfAfCfugagauucgu-3’ and the nucleotide sequence of the antisense strand differs by no more than 4 bases from the nucleotide sequence 5’- asdCsgadAudCucagdTgCfuuccugcsasc-3’, wherein a, g, c and u are 2′-O-methyl (2′-OMe) A, G, C, and U; Cf and Uf are 2′-deoxy-2’-
  • nucleotide sequence of the sense strand differs by no more than 3 bases from the nucleotide sequence 5’-gscsaggaagCfAfCfugagauucgu-3’ and the nucleotide sequence of the antisense strand differs by no more than 3 bases from the nucleotide sequence 5’- asdCsgadAudCucagdTgCfuuccugcsasc-3’, wherein a, g, c and u are 2′-O-methyl (2′-OMe) A, G, C, and U; Cf and Uf are 2′-deoxy-2’-fluoro (2’-F) C and U; dC, dA, and dT are 2′-deoxy C, A, and T; and s is a phosphorothioate linkage; or b) the nucleotide sequence of the sense strand differs by no more than 3 bases from the nucleo
  • nucleotide sequence of the sense strand differs by no more than 2 bases from the nucleotide sequence 5’-gscsaggaagCfAfCfugagauucgu-3’ and the nucleotide sequence of the antisense strand differs by no more than 2 bases from the nucleotide sequence 5’- asdCsgadAudCucagdTgCfuuccugcsasc-3’, wherein a, g, c and u are 2′-O-methyl (2′-OMe) A, G, C, and U; Cf and Uf are 2′-deoxy-2’-fluoro (2’-F) C and U; dC, dA, and dT are 2′-deoxy C, A, and T; and s is a phosphorothioate linkage; or b) the nucleotide sequence of the sense strand differs by no more than 2 bases from the nucleo
  • nucleotide sequence of the sense strand differs by no more than 1 base from the nucleotide sequence 5’-gscsaggaagCfAfCfugagauucgu-3’ and the nucleotide sequence of the antisense strand differs by no more than 1 base from the nucleotide sequence 5’- asdCsgadAudCucagdTgCfuuccugcsasc-3’, wherein a, g, c and u are 2′-O-methyl (2′-OMe) A, G, C, and U; Cf and Uf are 2′-deoxy-2’-fluoro (2’-F) C and U; dC, dA, and dT are 2′-deoxy C, A, and T; and s is a phosphorothioate linkage; or b) the nucleotide sequence of the sense strand differs by no more than 1 base from the nucleo
  • nucleotide sequence of the sense strand comprises the nucleotide sequence 5’- gscsaggaagCfAfCfugagauucgu-3’ and the nucleotide sequence of the antisense strand comprises the nucleotide sequence 5’- asdCsgadAudCucagdTgCfuuccugcsasc-3’, wherein a, g, c and u are 2′-O- methyl (2′-OMe) A, G, C, and U; Cf and Uf are 2′-deoxy-2’-fluoro (2’-F) C and U; dC, dA, and dT are 2′-deoxy C, A, and T; and s is a phosphorothioate linkage; or b) the nucleotide sequence of the sense strand comprises the nucleotide sequence 5’- csusacggagAfCfGfuggu
  • the dsRNA agent further comprises a ligand.
  • the ligand is conjugated to the 3’ end of the sense strand of the dsRNA agent.
  • the ligand is an N-acetylgalactosamine (GalNAc) derivative.
  • the ligand is one or more GalNAc derivatives attached through a monovalent, bivalent, or trivalent branched linker.
  • the ligand is In one embodiment, the dsRNA agent is conjugated to the ligand as shown in the following schematic and, wherein X is O or S. In one embodiment, X is O.
  • the present invention also provides cells containing any of the dsRNA agents of the invention and pharmaceutical compositions comprising any of the dsRNA agents of the invention.
  • the pharmaceutical composition of the invention may include dsRNA agent in an unbuffered solution, e.g., saline or water, or the pharmaceutical composition of the invention may include the dsRNA agent is in a buffer solution, e.g., a buffer solution comprising acetate, citrate, prolamine, carbonate, or phosphate or any combination thereof; or phosphate buffered saline (PBS).
  • the present invention provides a method of inhibiting expression of a ketohexokinase (KHK) gene in a cell.
  • KHK ketohexokinase
  • the method includes contacting the cell with any of the dsRNAs of the invention or any of the pharmaceutical compositions of the invention, thereby inhibiting expression of the KHK gene in the cell.
  • the cell is within a subject, e.g., a human subject, e.g., a subject having a ketohexokinase (KHK)-associated disorder, such as a KHK-associate disorder selected from the group consisting of liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the K
  • contacting the cell with the dsRNA agent inhibits the expression of KHK by at least 50%, 60%, 70%, 80%, 90%, or 95%. In one embodiment, inhibiting expression of KHK decreases KHK protein level in serum of the subject by at least 50%, 60%, 70%, 80%, 90%, or 95%.
  • the present invention provides a method of treating a subject having a disorder that would benefit from reduction in ketohexokinase (KHK) expression. The method includes administering to the subject a therapeutically effective amount of any of the dsRNAs of the invention or any of the pharmaceutical compositions of the invention, thereby treating the subject having the disorder that would benefit from reduction in KHK expression.
  • the KHK-associated disorder is dyslipidemia, e.g., elevated serum triglycerides, elevated serum LDL, elevated serum cholesterol, lowered serum HDL, postprandial hypertriglyceridemia.
  • the KHK-associated disorder is a disorder of glycemic control, e.g., insulin resistance not resulting from an immune response against insulin, glucose resistance, type 2 diabetes.
  • the KHK- associated disorder is a cardiovascular disease, e.g., hypertension, endothelial cell dysfunction.
  • the KHK-associated disorder is a kidney disease, e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease.
  • the administration of the dsRNA causes a decrease in fructose metabolism in the subject. In certain embodiments, the administration of the dsRNA causes a decrease in the level of uric acid, e.g., serum uric acid, in a subject with elevated serum uric acid, e.g., elevated serum uric acid associated with gout. In certain embodiments, the administration of the dsRNA causes a normalization of serum lipids, e.g., triglycerides including postprandial triglycerides, LDL, HDL, or cholesterol, in a subject with at least one abnormal serum lipid level.
  • serum lipids e.g., triglycerides including postprandial triglycerides, LDL, HDL, or cholesterol
  • the administration of the dsRNA causes a normalization of lipid deposition, e.g., a decrease of lipid deposition in the liver (e.g., decrease of NAFLD or NASH), a decrease of visceral fat deposition, a decrease in body weight.
  • the administration of the dsRNA causes a normalization of insulin or glucose response in a subject with abnormal insulin response not related to an immune response to insulin, or abnormal glucose response.
  • the administration of the dsRNA results in an improvement of kidney function, or a stoppage or reduction of the rate of loss of kidney function.
  • the dsRNA causes a reduction of hypertension, i.e., elevated blood pressure.
  • the invention further comprises administering an additional agent to a subject with a KHK-associated disease.
  • treatments known in the art for the various KHK-associated diseases are used in combination with the RNAi agents of the invention. Such treatments are discussed below.
  • the subject is human.
  • the dsRNA agent is administered to the subject at a dose of about 0.01 mg/kg to about 50 mg/kg.
  • the dsRNA agent is administered to the subject subcutaneously.
  • the methods of the invention include further determining the level of KHK in a sample(s) from the subject.
  • the level of KHK in the subject sample(s) is a KHK protein level in a blood or serum sample(s).
  • the methods of the invention further comprise measuring the uric acid level, especially serum uric acid level, in the subject. In one embodiment, the methods of the invention further comprise measuring the urine fructose level in the subject. In one embodiment, the methods of the invention further comprise measuring a serum lipid level in a subject. In certain embodiments, the methods of the invention further include measuring insulin or glucose sensitivity in a subject. In certain embodiments, a decrease in the levels of expression or activity of fructose metabolism indicates that the KHK-associated disease is being treated or prevented.
  • kits comprising any of the dsRNAs of the invention or any of the pharmaceutical compositions of the invention, and optionally, instructions for use.
  • RNAi agent also includes a 5’-terminal phosphate or a 5’- terminal vinylphosphonate group
  • the RNAi agent may be provided as a salt having up to 44 cations (e.g, 44 sodium cations).
  • TG triglycerides
  • Aldo B aldolase B
  • FES fatty acid synthase
  • uric acid produced from the nucleotide turnover that occurs during the phosphorylation of fructose to fructose-1-phosphate results in the generation of mitochondrial oxidative stress (mtROS), which causes a decrease in the activity of aconitase (ACO2) in the Krebs cycle.
  • mtROS mitochondrial oxidative stress
  • ACO2 substrate citrate
  • ACL ATP citrate lyase
  • AMPD2 AMP deaminase 2
  • IMP inosine monophosphate
  • PO 4 phosphate (from Johnson et al . (2013) Diabetes.
  • Figure 2 is a graph depicting the effect of administration of a single 3 mg/kg dose of the indicated duplexes on the level of KHK mRNA and KHK protein at Day 29 post-dose. The level of mRNA and protein are depicted as % remining normalized to the pre-dose level of mRNA and protein.
  • Figure 3 is a graph depicting the effect of administration of a single 3 mg/kg dose of the indicated duplexes on the level of KHK mRNA at Day 50 post-dose. The level of mRNA is depicted as % remining normalized to the pre-dose level of mRNA.
  • the present invention provides methods for treating and preventing a ketohexokinase (KHK)-associated disorder, e.g., liver disease (e.g., fatty liver, steatohepatitis, non- alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving, using iRNA compositions which effect the RNA-induced silencing complex (RISC)-mediated
  • the iRNAs of the invention include an RNA strand (the antisense strand) having a region which is up to about 30 nucleotides or less in length, e.g., 19-30, 19-29, 19-28, 19-27, 19-26, 19-25, 19-24, 19-23, 19-22, 19-21, 19-20, 20-30, 20-29, 20-28, 20-27, 20-26, 20-25, 20-24,20-23, 20-22, 20- 21, 21-30, 21-29, 21-28, 21-27, 21-26, 21-25, 21-24, 21-23, or 21-22 nucleotides in length, which region is substantially complementary to at least part of an mRNA transcript of a KHK gene.
  • one or both of the strands of the double stranded RNAi agents of the invention is up to 66 nucleotides in length, e.g., 36-66, 26-36, 25-36, 31-60, 22-43, 27-53 nucleotides in length, with a region of at least 19 contiguous nucleotides that is substantially complementary to at least a part of an mRNA transcript of a KHK gene.
  • such iRNA agents having longer length antisense strands can, for example, include a second RNA strand (the sense strand) of 20-60 nucleotides in length wherein the sense and antisense strands form a duplex of 18-30 contiguous nucleotides.
  • iRNAs of the invention enables the targeted degradation of mRNAs of the corresponding gene (KHK gene) in mammals.
  • KHK gene the corresponding gene
  • the present inventors have demonstrated that iRNAs targeting a KHK gene can potently mediate RNAi, resulting in significant inhibition of expression of a KHK gene.
  • a KHK-associated disorder e.g., liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)
  • dyslipidemia e.g
  • the present invention provides methods and combination therapies for treating a subject having a disorder that would benefit from inhibiting or reducing the expression of a KHK gene, e.g., a KHK-associated disorder, such as liver disease (e.g., fatty liver, steatohepatitis, non- alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving, using iRNA compositions
  • the present invention also provides methods for preventing at least one symptom in a subject having a disorder that would benefit from inhibiting or reducing the expression of a KHK gene, e.g., liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver,
  • compositions containing iRNAs to inhibit the expression of a KHK gene as well as compositions, uses, and methods for treating subjects that would benefit from inhibition and/or reduction of the expression of a KHK gene, e.g., subjects susceptible to or diagnosed with a KHK-associated disorder.
  • certain terms are first defined.
  • values and ranges intermediate to the recited values are also intended to be part of this invention.
  • an element means one element or more than one element, e.g., a plurality of elements.
  • the term “including” is used herein to mean, and is used interchangeably with, the phrase “including but not limited to”.
  • the term “or” is used herein to mean, and is used interchangeably with, the term “and/or,” unless context clearly indicates otherwise.
  • the term “at least” , “no less than”, or “or more” prior to a number or series of numbers is understood to include the number adjacent to the term “at least”, and all subsequent numbers or integers that could logically be included, as clear from context.
  • the number of nucleotides in a nucleic acid molecule must be an integer.
  • “at least 19 nucleotides of a 21 nucleotide nucleic acid molecule” means that 19, 20, or 21 nucleotides have the indicated property.
  • nucleotide overhang As used herein, “no more than” or “or less” is understood as the value adjacent to the phrase and logical lower values or integers, as logical from context, to zero. For example, a duplex with an overhang of “no more than 2 nucleotides” has a 2, 1, or 0 nucleotide overhang. When “no more than” is present before a series of numbers or a range, it is understood that “no more than” can modify each of the numbers in the series or range. As used herein, ranges include both the upper and lower limit. As used herein, methods of detection can include determination that the amount of analyte present is below the level of detection of the method.
  • the gene is also known as fructokinase.
  • Exemplary nucleotide and amino acid sequences of KHK can be found, for example, at GenBank Accession No. XM_017004061.1 (Homo sapiens KHK; SEQ ID NO:1; reverse complement, SEQ ID NO:2); NM_006488.3 (Homo sapiens KHK; SEQ ID NO:3; reverse complement, SEQ ID NO:4); NM_000221.3 (Homo sapiens KHK; SEQ ID NO:5; reverse complement, SEQ ID NO:6); GenBank Accession No. NM_001310524.1 (Mus musculus KHK; SEQ ID NO:7; reverse complement, SEQ ID NO:8); GenBank Accession No.
  • NM_031855.3 (Rattus norvegicus KHK; SEQ ID NO:9; reverse complement, SEQ ID NO:10); GenBank Accession No. XM_005576322.2 (Macaca fascicularis KHK, SEQ ID NO:11; reverse complement, SEQ ID NO:12).
  • the KHK (Ketohexokinase ) gene is located on chromosome 2p23 and encodes ketohexokinase, also known as fructokinase.
  • KHK is a phosphotransferase enzyme with an alcohol as the phosphate acceptor.
  • KHK belongs to the ribokinase family of carbohydrate kinases (Trinh et al ., ACTA Cryst., D65: 201-211).
  • Two isoforms of ketohexokinase have been identified, KHK-A and KHK-C, that result from alternative splicing of the full length mRNA. These isoforms differ by inclusion of either exon 3a or 3c, and differ by 32 amino acids between positions 72 and 115.
  • KHK-C mRNA is expressed at high levels, predominantly in the liver, kidney and small intestine.
  • KHK-C has a much lower K m for fructose binding than KHK-A, and as a result, is highly effective in phosphorylating dietary fructose.
  • the sequence of a human KHK-C mRNA transcript may be found at, for example, GenBank Accession No. NM_006488.3 (Homo sapiens KHK; SEQ ID NO:3).
  • the sequence of a human KHK-A mRNA transcript may be found at, for example GenBank Accession No. NM_000221.3; SEQ ID NO:5).
  • the sequence of full-length human KHK mRNA is provided in GenBank Accession No. GI: XM_017004061.1 (SEQ ID NO:1).
  • the target sequence can be about 19-30 nucleotides, 19-30, 19-29, 19-28, 19-27, 19-26, 19-25, 19-24, 19-23, 19-22, 19-21, 19-20, 20-30, 20-29, 20-28, 20-27, 20-26, 20- 25, 20-24, 20-23, 20-22, 20-21, 21-30, 21-29, 21-28, 21-27, 21-26, 21-25, 21-24, 21-23, or 21-22 nucleotides in length.
  • the target sequence is 19-23 nucleotides in length, optionally 21-23 nucleotides in length. Ranges and lengths intermediate to the above recited ranges and lengths are also contemplated to be part of the disclosure.
  • RNAi agent RNA agent
  • RISC RNA-induced silencing complex
  • Dicer a ribonuclease-III-like enzyme, processes the dsRNA into 19- 23 base pair short interfering RNAs with characteristic two base 3' overhangs (Bernstein, et al ., (2001) Nature 409:363).
  • the siRNAs are then incorporated into an RNA-induced silencing complex (RISC) where one or more helicases unwind the siRNA duplex, enabling the complementary antisense strand to guide target recognition (Nykanen, et al ., (2001) Cell 107:309).
  • RISC RNA-induced silencing complex
  • the invention Upon binding to the appropriate target mRNA, one or more endonucleases within the RISC cleave the target to induce silencing (Elbashir, et al ., (2001) Genes Dev.15:188).
  • siRNA single stranded RNA
  • the term “siRNA” is also used herein to refer to an iRNA as described above.
  • an “iRNA” for use in the compositions, uses, and methods of the invention is a double stranded RNA and is referred to herein as a “double stranded RNA agent,” “double stranded RNA (dsRNA) molecule,” “dsRNA agent,” or “dsRNA”.
  • the duplex region is 19-21 base pairs in length, e.g., 21 base pairs in length. Ranges and lengths intermediate to the above recited ranges and lengths are also contemplated to be part of the disclosure.
  • the two strands forming the duplex structure may be different portions of one larger RNA molecule, or they may be separate RNA molecules. Where the two strands are part of one larger molecule, and therefore are connected by an uninterrupted chain of nucleotides between the 3’-end of one strand and the 5’-end of the respective other strand forming the duplex structure, the connecting RNA chain is referred to as a “hairpin loop.”
  • a hairpin loop can comprise at least one unpaired nucleotide.
  • RNAi may comprise one or more nucleotide overhangs.
  • at least one strand comprises a 3’ overhang of at least 1 nucleotide.
  • the antisense strand of a dsRNA has a 1-10 nucleotide, e.g., 0-3, 1-3, 2-4, 2-5, 4-10, 5-10, e.g., a 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 nucleotide, overhang at the 3’-end or the 5’- end.
  • the sense strand of a dsRNA has a 1-10 nucleotide, e.g., a 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 nucleotide, overhang at the 3’-end or the 5’-end.
  • RNAi agent for a 23 nucleotide RNAi agent, the strand which is complementary to a region of a KHK gene, generally does not contain any mismatch within the central 13 nucleotides.
  • the methods described herein or methods known in the art can be used to determine whether an RNAi agent containing a mismatch to a target sequence is effective in inhibiting the expression of a KHK gene. Consideration of the efficacy of RNAi agents with mismatches in inhibiting expression of a KHK gene is important, especially if the particular region of complementarity in a KHK gene is known to have polymorphic sequence variation within the population.
  • sense strand or “passenger strand” as used herein, refers to the strand of an iRNA that includes a region that is substantially complementary to a region of the antisense strand as that term is defined herein.
  • substantially all of the nucleotides are modified are largely but not wholly modified and can include not more than 5, 4, 3, 2, or 1 unmodified nucleotides.
  • cleavage region refers to a region that is located immediately adjacent to the cleavage site. The cleavage site is the site on the target at which cleavage occurs. In some embodiments, the cleavage region comprises three bases on either end of, and immediately adjacent to, the cleavage site.
  • sequences can be referred to as “fully complementary” with respect to each other herein.
  • first sequence is referred to as “substantially complementary” with respect to a second sequence herein
  • the two sequences can be fully complementary, or they can form one or more, but generally not more than 5, 4, 3, or 2 mismatched base pairs upon hybridization for a duplex up to 30 base pairs, while retaining the ability to hybridize under the conditions most relevant to their ultimate application, e.g., inhibition of gene expression, in vitro or in vivo.
  • two oligonucleotides are designed to form, upon hybridization, one or more single stranded overhangs, such overhangs shall not be regarded as mismatches with regard to the determination of complementarity.
  • a dsRNA comprising one oligonucleotide 21 nucleotides in length and another oligonucleotide 23 nucleotides in length, wherein the longer oligonucleotide comprises a sequence of 21 nucleotides that is fully complementary to the shorter oligonucleotide, can yet be referred to as “fully complementary” for the purposes described herein.
  • “Complementary” sequences, as used herein, can also include, or be formed entirely from, non-Watson-Crick base pairs or base pairs formed from non-natural and modified nucleotides, in so far as the above requirements with respect to their ability to hybridize are fulfilled.
  • the antisense polynucleotides disclosed herein are substantially complementary to a fragment of a target KHK sequence and comprise a contiguous nucleotide sequence which is at least 80% complementary over its entire length to a fragment of SEQ ID NO: 1 selected from the group of nucleotides 120-162; 164-188; 181-207; 193-217; 209-231; 283-306; 508- 546; 568-603; 596-632; 640-674; 746-806; 806-835; 917-942; 936-084; 1016-1041; 1100-1123; 1149-1175; 1160-1193; 1205-1229; 1252-1283; 1334-1356; 1407-1429; 1472-1497; 1506-1533; 1539-1561; 1704-1727; 1747-1787; 1850-1873; 1936-1964; 1960-1990; 2015-2048; 2060-2095; 2090-2118; 2124-2160; 2181-2200; 2221-2262 of SEQ ID NO: 1
  • the antisense polynucleotides disclosed herein are substantially complementary to a fragment of a target KHK sequence and comprise a contiguous nucleotide sequence which is at least 80% complementary over its entire length to a fragment of SEQ ID NO: 1 selected from the group of nucleotides 517-539; 524-546; 517-546; 753-775; 757-779; 753-779; 764- 786; 767-789; 768-790; 769-791; 764-791; 773-795; 781-803; 773-803; 753-803; 808-830; 937-959; 941-963; 944-966; 941-966; 948-970; 950-972; 948-972; 1160-1182; 1161-1183; 1160-1183; and 1207-1229 of SEQ ID NO: 1, such as about 85%, about 90%, about 91%, about 92%, about 93%, about 94%, about 95%, about 96%, about 9
  • the iRNA may be put into physical contact with the cell by the individual performing the method, or alternatively, the iRNA may be put into a situation that will permit or cause it to subsequently come into contact with the cell.
  • Contacting a cell in vitro may be done, for example, by incubating the cell with the iRNA.
  • Contacting a cell in vivo may be done, for example, by injecting the iRNA into or near the tissue where the cell is located, or by injecting the iRNA into another area, e.g., the bloodstream or the subcutaneous space, such that the agent will subsequently reach the tissue where the cell to be contacted is located.
  • the iRNA may contain or be coupled to a ligand, e.g., GalNAc, that directs the iRNA to a site of interest, e.g., the liver.
  • a ligand e.g., GalNAc
  • a cell may also be contacted in vitro with an iRNA and subsequently transplanted into a subject.
  • contacting a cell with an iRNA includes “introducing” or “delivering the iRNA into the cell” by facilitating or effecting uptake or absorption into the cell. Absorption or uptake of an iRNA can occur through unaided diffusion or active cellular processes, or by auxiliary agents or devices.
  • a “subject” is an animal, such as a mammal, including a primate (such as a human, a non-human primate, e.g., a monkey, and a chimpanzee), a non-primate (such as a cow, a pig, a horse, a goat, a rabbit, a sheep, a hamster, a guinea pig, a cat, a dog, a rat, or a mouse), or a bird that expresses the target gene, either endogenously or heterologously.
  • a primate such as a human, a non-human primate, e.g., a monkey, and a chimpanzee
  • a non-primate such as a cow, a pig, a horse, a goat, a rabbit, a sheep, a hamster, a guinea pig, a cat, a dog, a rat, or a mouse
  • the subject is a human, such as a human being treated or assessed for a disease or disorder that would benefit from reduction in KHK expression; a human at risk for a disease or disorder that would benefit from reduction in KHK expression; a human having a disease or disorder that would benefit from reduction in KHK expression; or human being treated for a disease or disorder that would benefit from reduction in KHK expression as described herein.
  • the subject is a female human.
  • the subject is a male human.
  • the subject is an adult subject.
  • the subject is a pediatric subject.
  • treating refers to a beneficial or desired result, such as reducing at least one sign or symptom of a KHK-associated disorder in a subject.
  • Treatment also includes a reduction of one or more sign or symptoms associated with unwanted KHK expression; diminishing the extent of unwanted KHK activation or stabilization; amelioration or palliation of unwanted KHK activation or stabilization.
  • Treatment can also mean prolonging survival as compared to expected survival in the absence of treatment.
  • the term “lower” in the context of the level of KHK in a subject or a disease marker or symptom refers to a statistically significant decrease in such level.
  • “lower” is the decrease in the difference between the level of a marker or symptom for a subject suffering from a disease and a level accepted within the range of normal for an individual, e.g., the level of decrease in bodyweight between an obese individual and an individual having a weight accepted within the range of normal.
  • liver disease e.g., fatty liver, steatohepatitis including non-alcoholic steatohepatitis (NASH)
  • dyslipidemia e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia
  • disorders of glycemic control e.g., insulin resistance not related to immune response to insulin, type 2 diabetes
  • cardiovascular disease e.g., hypertension, endothelial cell dysfunction
  • kidney disease e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease
  • metabolic syndrome disease of lipid deposition or dysfunction (e.g., adipocyte dysfunction, visceral adipose deposition, obesity), disease of elevated uric acid (e.g., hyperuricemia, gout), and eating disorders such as excessive sugar craving.
  • ketohexokinase (KHK)-associated disease or “KHK-associated disorder,” is a disease or disorder that is caused by, or associated with KHK gene expression or KHK protein production.
  • KHK-associated disease includes a disease, disorder or condition that would benefit from a decrease in KHK gene expression, replication, or protein activity.
  • a KHK-associated disease is associated with elevated uric acid (e.g. hyperuricemia, gout).
  • a KHK-associated disease is associated with elevated lipid levels (e.g., fatty liver, steatohepatitis including non-alcoholic steatohepatitis (NASH), dyslipidemia).
  • “Therapeutically effective amount,” as used herein, is intended to include the amount of an RNAi agent that, when administered to a subject having a KHK-associated disease, is sufficient to effect treatment of the disease (e.g., by diminishing, ameliorating, or maintaining the existing disease or one or more symptoms of disease).
  • the "therapeutically effective amount” may vary depending on the RNAi agent, how the agent is administered, the disease and its severity and the history, age, weight, family history, genetic makeup, the types of preceding or concomitant treatments, if any, and other individual characteristics of the subject to be treated. “Prophylactically effective amount,” as used herein, is intended to include the amount of an RNAi agent that, when administered to a subject having a KHK-associated disorder, is sufficient to prevent or ameliorate the disease or one or more symptoms of the disease. Ameliorating the disease includes slowing the course of the disease or reducing the severity of later-developing disease.
  • the “prophylactically effective amount” may vary depending on the RNAi agent, how the agent is administered, the degree of risk of disease, and the history, age, weight, family history, genetic makeup, the types of preceding or concomitant treatments, if any, and other individual characteristics of the patient to be treated.
  • a “therapeutically-effective amount” or “prophylactically effective amount” also includes an amount of an RNAi agent that produces some desired effect at a reasonable benefit/risk ratio applicable to any treatment.
  • the iRNA employed in the methods of the present invention may be administered in a sufficient amount to produce a reasonable benefit/risk ratio applicable to such treatment.
  • phrases "pharmaceutically acceptable” is employed herein to refer to those compounds (including salts), materials, compositions, or dosage forms which are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human subjects and animal subjects without excessive toxicity, irritation, allergic response, or other problem or complication, commensurate with a reasonable benefit/risk ratio.
  • pharmaceutically-acceptable carrier means a pharmaceutically- acceptable material, composition, or vehicle, such as a liquid or solid filler, diluent, excipient, manufacturing aid (e.g., lubricant, talc magnesium, calcium or zinc stearate, or steric acid), or solvent encapsulating material, involved in carrying or transporting the subject compound from one organ, or portion of the body, to another organ, or portion of the body.
  • manufacturing aid e.g., lubricant, talc magnesium, calcium or zinc stearate, or steric acid
  • solvent encapsulating material involved in carrying or transporting the subject compound from one organ, or portion of the body, to another organ, or portion of the body.
  • Each carrier must be “acceptable” in the sense of being compatible with the other ingredients of the formulation and not injurious to the subject being treated.
  • Pharmaceutically acceptable carriers include carriers for administration by injection.
  • the term “lower” in the context of the level of KHK gene expression or KHK protein production in a subject, or a disease marker or symptom refers to a statistically significant decrease in such level.
  • the decrease can be, for example, at least 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95%, or below the level of detection for the detection method.
  • the expression of the target is normalized, i.e., decreased towards or to a level accepted as within the range of normal for an individual without such disorder, e.g., normalization of body weight, blood pressure, or a serum lipid level.
  • lower in a subject can refer to lowering of gene expression or protein production in a cell in a subject does not require lowering of expression in all cells or tissues of a subject.
  • lowering in a subject can include lowering of gene expression or protein production in the liver of a subject.
  • the term “lower” can also be used in association with normalizing a symptom of a disease or condition, i.e. decreasing the difference between a level in a subject suffering from a KHK-associated disease towards or to a level in a normal subject not suffering from a KHK-associated disease.
  • a subject with a normal weight of 70 kg weighs 90 kg prior to treatment (20 kg overweight) and 80 kg after treatment (10 kg overweight), the subject’s weight is lowered towards a normal weight by 50% (10/20 x 100%).
  • the HDL level of a woman is increased from 50 mg/dL (poor) to 57 mg/dL, with a normal level being 60 mg/dL, the difference between the prior level of the subject and the normal level is decreased by 70% (difference of 10 mg/dL between subject level and normal is decreased by 7 mg/dL, 7/10 x 100%).
  • “normal” is considered to be the upper limit of normal.
  • sample includes a collection of similar fluids, cells, or tissues isolated from a subject, as well as fluids, cells, or tissues present within a subject.
  • biological fluids include blood, serum and serosal fluids, plasma, cerebrospinal fluid, ocular fluids, lymph, urine, saliva, and the like.
  • Tissue samples may include samples from tissues, organs, or localized regions. For example, samples may be derived from particular organs, parts of organs, or fluids or cells within those organs.
  • samples may be derived from the liver (e.g., whole liver or certain segments of liver or certain types of cells in the liver, such as, e.g., hepatocytes).
  • a “sample derived from a subject” refers to urine obtained from the subject.
  • a “sample derived from a subject” can refer to blood (which can be readily converted to plasma or serum) drawn from the subject.
  • the iRNA includes double stranded ribonucleic acid (dsRNA) molecules for inhibiting the expression of a KHK gene in a cell, such as a cell within a subject, e.g., a mammal, such as a human having or susceptible to developing a KHK-associated disease.
  • the dsRNAi agent includes an antisense strand having a region of complementarity which is complementary to at least a part of an mRNA formed in the expression of a KHK gene.
  • the region of complementarity is about 30 nucleotides or less in length (e.g., about 30, 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, or 18 nucleotides or less in length).
  • the iRNA Upon contact with a cell expressing the KHK gene, the iRNA inhibits the expression of the KHK gene (e.g., a human, a primate, a non-primate, or a rat KHK gene) by at least about 50% as assayed by, for example, a PCR or branched DNA (bDNA)-based method, or by a protein-based method, such as by immunofluorescence analysis, using, for example, western blotting or flow cytometric techniques.
  • inhibition of expression is determined by the qPCR method provided in the examples herein with the siRNA at, e.g., a 10 nM concentration, in an appropriate organism cell line provided therein.
  • the target sequence can be derived from the sequence of an mRNA formed during the expression of a KHK gene.
  • the other strand includes a region that is complementary to the antisense strand, such that the two strands hybridize and form a duplex structure when combined under suitable conditions.
  • the complementary sequences of a dsRNA can also be contained as self- complementary regions of a single nucleic acid molecule, as opposed to being on separate oligonucleotides.
  • the duplex structure is 15 to 30 base pairs in length, e.g., 15-29, 15-28, 15-27, 15- 26, 15-25, 15-24, 15-23, 15-22, 15-21, 15-20, 15-19, 15-18, 15-17, 18-30, 18-29, 18-28, 18-27, 18-26, 18-25, 18-24, 18-23, 18-22, 18-21, 18-20, 19-30, 19-29, 19-28, 19-27, 19-26, 19-25, 19-24, 19-23, 19- 22, 19-21, 19-20, 20-30, 20-29, 20-28, 20-27, 20-26, 20-25, 20-24,20-23, 20-22, 20-21, 21-30, 21-29, 21-28, 21-27, 21-26, 21-25, 21-24, 21-23, or 21-22 base pairs in length.
  • the duplex structure is 18 to 25 base pairs in length, e.g., 18-25, 18-24, 18-23, 18-22, 18-21, 18-20, 19-25, 19-24, 19-23, 19-22, 19-21, 19-20, 20-25, 20-24,20-23, 20-22, 20-21, 21-25, 21-24, 21-23, 21-22, 22- 25, 22-24, 22-23, 23-25, 23-24 or 24-25 base pairs in length, for example, 19-21 basepairs in length. Ranges and lengths intermediate to the above recited ranges and lengths are also contemplated to be part of the disclosure.
  • the duplex structure is 19 to 30 base pairs in length.
  • the region of complementarity to the target sequence is 19 to 30 nucleotides in length.
  • the dsRNA is about 19 to about 23 nucleotides in length, or about 25 to about 30 nucleotides in length.
  • the dsRNA is long enough to serve as a substrate for the Dicer enzyme. For example, it is well-known in the art that dsRNAs longer than about 21-23 nucleotides in length may serve as substrates for Dicer.
  • the duplex region is a primary functional portion of a dsRNA, e.g., a duplex region of about 19 to about 30 base pairs, e.g., about 19-30, 19-29, 19-28, 19-27, 19-26, 19-25, 19-24, 19-23, 19-22, 19-21, 19-20, 20-30, 20-29, 20-28, 20-27, 20-26, 20- 25, 20-24,20-23, 20-22, 20-21, 21-30, 21-29, 21-28, 21-27, 21-26, 21-25, 21-24, 21-23, or 21-22 base pairs.
  • an RNA molecule or complex of RNA molecules having a duplex region greater than 30 base pairs is a dsRNA.
  • a miRNA is a dsRNA.
  • a dsRNA is not a naturally occurring miRNA.
  • an iRNA agent useful to target KHK gene expression is not generated in the target cell by cleavage of a larger dsRNA.
  • dsRNAs having a duplex structure of about 20 to 23 base pairs, e.g., 21, base pairs have been hailed as particularly effective in inducing RNA interference (Elbashir et al ., EMBO 2001, 20:6877-6888).
  • RNA duplex structures can also be effective (Chu and Rana (2007) RNA 14:1714-1719; Kim et al . (2005) Nat Biotech 23:222-226).
  • oligonucleotide sequences provided in any one of Tables 2, 3, 5, 6, and 8-13.
  • dsRNAs described herein can include at least one strand of a length of minimally 21 nucleotides. It can be reasonably expected that shorter duplexes having any one of the sequences in any one of Tables 2, 3, 5, 6, and 8- 13 minus only a few nucleotides on one or both ends can be similarly effective as compared to the dsRNAs described above.
  • dsRNAs having a sequence of at least 19, 20, 21, 22, 23 or more contiguous nucleotides derived from any one of the sequences of any one of Tables 2, 3, 5, 6, and 8- 13, and differing in their ability to inhibit the expression of a KHK gene by not more than about 5, 10, 15, 20, 25, or 30 % inhibition from a dsRNA comprising the full sequence, are contemplated to be within the scope of the present invention.
  • the RNAs provided in Tables 2, 3, 5, 6, and 8-13 identify a site(s) in a KHK transcript that is susceptible to RISC-mediated cleavage. As such, the present invention further features iRNAs that target within one of these sites.
  • the RNA of an iRNA of the invention is chemically modified to enhance stability or other beneficial characteristics.
  • substantially all of the nucleotides of an iRNA of the invention are modified.
  • all of the nucleotides of an iRNA or substantially all of the nucleotides of an iRNA are modified, i.e., not more than 5, 4, 3, 2, or 1 unmodified nucleotides are present in a strand of the iRNA.
  • the iRNAs e.g., dsRNAs, featured herein can include one of the following at the 2'-position: OH; F; O-, S-, or N-alkyl; O-, S-, or N-alkenyl; O-, S- or N-alkynyl; or O-alkyl-O-alkyl, wherein the alkyl, alkenyl and alkynyl can be substituted or unsubstituted C 1 to C 10 alkyl or C 2 to C 10 alkenyl and alkynyl.
  • Exemplary suitable modifications include O[(CH 2 ) n O] m CH 3 , O(CH 2 ).
  • Another exemplary modification is 2'- dimethylaminooxyethoxy, i.e., a O(CH 2 ) 2 ON(CH 3 ) 2 group, also known as 2'-DMAOE, as described in examples herein below, and 2'-dimethylaminoethoxyethoxy (also known in the art as 2'-O- dimethylaminoethoxyethyl or 2'-DMAEOE), i.e., 2'-O--CH 2 --O--CH 2 --N(CH 3 ) 2 .
  • nucleobase of nucleobase
  • nucleobases are particularly useful for increasing the binding affinity of the oligomeric compounds featured in the invention.
  • These include 5-substituted pyrimidines, 6-azapyrimidines and N-2, N-6 and 0-6 substituted purines, including 2-aminopropyladenine, 5-propynyluracil and 5-propynylcytosine.5- methylcytosine substitutions have been shown to increase nucleic acid duplex stability by 0.6-1.2°C (Sanghvi, Y. S., Crooke, S. T.
  • the asymmetric blunt end at the 5’-end of the antisense strand and 3’-end overhang of the antisense strand favor the guide strand loading into RISC process.
  • the dsRNAi agent is a double blune-ended of 19 nucleotides in length, wherein the sense strand contains at least one motif of three 2’-F modifications on three consecutive nucleotides at positions 7, 8, and 9 from the 5’end.
  • the antisense strand contains at least one motif of three 2’-O-methyl modifications on three consecutive nucleotides at positions 11, 12, and 13 from the 5’end.
  • the antisense strand contains at least one motif of three 2’- O-methyl modifications on three consecutive nucleotides at or near the cleavage site.
  • the dsRNAi agent comprises sense and antisense strands, wherein the dsRNAi agent comprises a first strand having a length which is at least 25 and at most 29 nucleotides and a second strand having a length which is at most 30 nucleotides with at least one motif of three 2’-O-methyl modifications on three consecutive nucleotides at position 11, 12, 13 from the 5’ end; wherein the 3’ end of the first strand and the 5’ end of the second strand form a blunt end and the second strand is 1-4 nucleotides longer at its 3’ end than the first strand, wherein the duplex region which is at least 25 nucleotides in length, and the second strand is sufficiently complementary to a target mRNA along at least 19 nucleotide of the second strand length to reduce target gene expression when the RNA
  • the sense strand of the dsRNAi agent may contain more than one motif of three identical modifications on three consecutive nucleotides.
  • the first motif may occur at or near the cleavage site of the strand and the other motifs may be a wing modification.
  • the term “wing modification” herein refers to a motif occurring at another portion of the strand that is separated from the motif at or near the cleavage site of the same strand. The wing modification is either adjacent to the first motif or is separated by at least one or more nucleotides.
  • the wing modifications may fall on the same end of the duplex region, and have an overlap of one, two, or three nucleotides.
  • the sense strand and the antisense strand of the dsRNAi agent each contain at least two wing modifications, the sense strand and the antisense strand can be so aligned that two modifications each from one strand fall on one end of the duplex region, having an overlap of one, two, or three nucleotides; two modifications each from one strand fall on the other end of the duplex region, having an overlap of one, two or three nucleotides; two modifications one strand fall on each side of the lead motif, having an overlap of one, two or three nucleotides in the duplex region.
  • each residue of the sense strand and antisense strand is independently modified with LNA, CRN, cET, UNA, HNA, CeNA, 2’-methoxyethyl, 2’- O-methyl, 2’-O-allyl, 2’- C- allyl, 2’-deoxy, 2’-hydroxyl, or 2’-fluoro.
  • the strands can contain more than one modification.
  • each residue of the sense strand and antisense strand is independently modified with 2’- O-methyl or 2’-fluoro. At least two different modifications are typically present on the sense strand and antisense strand. Those two modifications may be the 2’- O-methyl or 2’-fluoro modifications, or others.
  • the type of modifications contained in the alternating motif may be the same or different.
  • the alternating pattern i.e., modifications on every other nucleotide
  • each of the sense strand or antisense strand can be selected from several possibilities of modifications within the alternating motif such as “ABABAB...”, “ACACAC...” “BDBDBD...” or “CDCDCD...,” etc.
  • the dsRNAi agent of the invention comprises the modification pattern for the alternating motif on the sense strand relative to the modification pattern for the alternating motif on the antisense strand is shifted.
  • the shift may be such that the modified group of nucleotides of the sense strand corresponds to a differently modified group of nucleotides of the antisense strand and vice versa.
  • the sense strand when paired with the antisense strand in the dsRNA duplex the alternating motif in the sense strand may start with “ABABAB” from 5’to 3’ of the strand and the alternating motif in the antisense strand may start with “BABABA” from 5’ to 3’ of the strand within the duplex region.
  • the alternating motif in the sense strand may start with “AABBAABB” from 5’ to 3’ of the strand and the alternating motif in the antisense strand may start with “BBAABBAA” from 5’ to 3’ of the strand within the duplex region, so that there is a complete or partial shift of the modification patterns between the sense strand and the antisense strand.
  • the alternating motif in the sense strand is “ABABAB” sfrom 5’ 3’ of the strand, where each A is an unmodified ribonucleotide and each B is a 2’-Omethyl modified nucleotide.
  • the alternating motif in the sense strand is “ABABAB” sfrom 5’ 3’ of the strand and the alternating motif in the antisense strand is “BABABA” from 3’-5’of the strand, where each A is a 2’-deoxy-2’-fluoro modified nucleotide and each B is a 2’-Omethyl modified nucleotide.
  • the phosphorothioate or methylphosphonate internucleotide linkage modification may occur on any nucleotide of the sense strand, antisense strand, or both strands in any position of the strand.
  • the internucleotide linkage modification may occur on every nucleotide on the sense strand or antisense strand; each internucleotide linkage modification may occur in an alternating pattern on the sense strand or antisense strand; or the sense strand or antisense strand may contain both internucleotide linkage modifications in an alternating pattern.
  • the 2-nucleotide overhang is at the 3’-end of the antisense strand, and there are two phosphorothioate internucleotide linkages between the terminal three nucleotides, wherein two of the three nucleotides are the overhang nucleotides, and the third nucleotide is a paired nucleotide next to the overhang nucleotide.
  • the dsRNAi agent may additionally have two phosphorothioate internucleotide linkages between the terminal three nucleotides at both the 5’-end of the sense strand and at the 5’-end of the antisense strand.
  • the first 1, 2, or 3 base pair within the duplex region from the 5’- end of the antisense strand is an AU base pair.
  • the first base pair within the duplex region from the 5’-end of the antisense strand is an AU base pair.
  • the nucleotide at the 3’-end of the sense strand is deoxythimidine (dT) or the nucleotide at the 3’-end of the antisense strand is deoxythimidine (dT).
  • there is a short sequence of deoxythimidine nucleotides for example, two dT nucleotides on the 3’-end of the sense, antisense strand, or both strands.
  • the sense strand sequence may be represented by formula (I): 5' n p -N a -(X X X ) i -N b -Y Y Y -N b -(Z Z Z ) j -N a -n q 3' (I) wherein: i and j are each independently 0 or 1; p and q are each independently 0-6; each N a independently represents an oligonucleotide sequence comprising 0-25 modified nucleotides, each sequence comprising at least two differently modified nucleotides; each N b independently represents an oligonucleotide sequence comprising 0-10 modified nucleotides; each n p and n q independently represent an overhang nucleotide; wherein Nb and Y do not have the same modification; and XXX, YYY, and ZZZ each independently represent one motif of three identical modifications on three consecutive nucleotides.
  • the sense strand can therefore be represented by the following formulas: 5' n p -N a -YYY-N b -ZZZ-N a -n q 3' (Ib); 5' n p -N a -XXX-N b -YYY-N a -n q 3' (Ic); or 5' n p -N a -XXX-N b -YYY-N b -ZZZ-N a -n q 3' (Id).
  • each N a independently can represent an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • the antisense strand sequence of the RNAi may be represented by formula (II): 5' n q’ -N a ′-(Z’Z′Z′) k -N b ′-Y′Y′Y′-N b ′-(X′X′X′) l -N′ a -n p ′ 3' (II) wherein: k and l are each independently 0 or 1; p’ and q’ are each independently 0-6; each N a ′ independently represents an oligonucleotide sequence comprising 0-25 modified nucleotides, each sequence comprising at least two differently modified nucleotides; each N b ′ independently represents an oligonucleotide sequence comprising 0-10 modified nucleotides; each
  • Y′Y′Y′ motif is all 2’-OMe modified nucleotides.
  • k is 1 and l is 0, or k is 0 and l is 1, or both k and l are 1.
  • the antisense strand can therefore be represented by the following formulas: 5' n q’ -N a ′-Z′Z′Z′-N b ′-Y′Y′Y′-N a ′-n p’ 3' (IIb); 5' n q’ -N a ′-Y′Y′Y′-N b ′-X′X′X′-n p’ 3' (IIc); or 5' n q’ -N a ′- Z′Z′Z′-N b ′-Y′Y′Y′-N b ′- X′X′X′-N a ′-n p’ 3' (IId).
  • N b represents an oligonucleotide sequence comprising 0-10, 0-7, 0-10, 0-7, 0-5, 0-4, 0-2, or 0 modified nucleotides.
  • Each N a ’ independently represents an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • N b ’ represents an oligonucleotide sequence comprising 0-10, 0-7, 0-10, 0-7, 0-5, 0-4, 0-2, or 0 modified nucleotides.
  • Each N a ’ independently represents an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • each N b ’ independently represents an oligonucleotide sequence comprising 0-10, 0-7, 0-10, 0-7, 0-5, 0-4, 0-2, or 0 modified nucleotides.
  • Each N a ’ independently represents an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • N b is 0, 1, 2, 3, 4, 5, or 6.
  • each N a ’ independently represents an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • Each of X′, Y′ and Z′ may be the same or different from each other.
  • Each nucleotide of the sense strand and antisense strand may be independently modified with LNA, CRN, UNA, cEt, HNA, CeNA, 2’-methoxyethyl, 2’-O-methyl, 2’-O-allyl, 2’-C- allyl, 2’- hydroxyl, or 2’-fluoro.
  • each nucleotide of the sense strand and antisense strand is independently modified with 2’-O-methyl or 2’-fluoro.
  • Each X, Y, Z, X′, Y′, and Z′ in particular, may represent a 2’-O-methyl modification or a 2’-fluoro modification.
  • the sense strand of the dsRNAi agent may contain YYY motif occurring at 9, 10, and 11 positions of the strand when the duplex region is 21 nt, the count starting from the first nucleotide from the 5’-end, or optionally, the count starting at the first paired nucleotide within the duplex region, from the 5’- end; and Y represents 2’-F modification.
  • the sense strand may additionally contain XXX motif or ZZZ motifs as wing modifications at the opposite end of the duplex region; and XXX and ZZZ each independently represents a 2’-OMe modification or 2’-F modification.
  • the antisense strand may contain Y′Y′Y′ motif occurring at positions 11, 12, 13 of the strand, the count starting from the first nucleotide from the 5’-end, or optionally, the count starting at the first paired nucleotide within the duplex region, from the 5’- end; and Y′ represents 2’-O-methyl modification.
  • the antisense strand may additionally contain X′X′X′ motif or Z′Z′Z′ motifs as wing modifications at the opposite end of the duplex region; and X′X′X′ and Z′Z′Z′ each independently represents a 2’-OMe modification or 2’-F modification.
  • the dsRNAi agents for use in the methods of the invention may comprise a sense strand and an antisense strand, each strand having 14 to 30 nucleotides, the iRNA duplex represented by formula (III): sense: 5' n p -N a -(X X X) i -N b - Y Y Y -N b -(Z Z Z) j -N a -n q 3' antisense: 3' n p ’ -N a ’ -(X’X′X′) k -N b ’ -Y′Y′Y′-N b ’ -(Z′Z′Z′) l -N a ’ -n q ’ 5' (III) wherein: i, j, k, and l are each independently 0 or 1; p, p′, q, and q′ are each independently 0-6; each N a and N a
  • Exemplary combinations of the sense strand and antisense strand forming an iRNA duplex include the formulas below: 5' n p - N a -Y Y Y -N a -n q 3' 3' n p ’ -N a ’ -Y′Y′Y′ -N a ’ n q ’ 5' (IIIa) 5' n p -N a -Y Y Y -N b -Z Z Z -N a -n q 3' 3' n p ’ -N a ’ -Y′Y′Y′-N b ’ -Z′Z′Z′-N a ’ n q ’ 5' (IIIb) 5' n p -N a - X X X -N b -Y Y Y - N a -n q 3' 3' n p ’ -N a ’
  • Each N a independently represents an oligonucleotide sequence comprising 2-20, 2-15, or 2-10 modified nucleotides.
  • each N b , N b ’ independently represents an oligonucleotide sequence comprising 0-10, 0-7, 0-10, 0-7, 0-5, 0-4, 0-2, or 0 modified nucleotides.
  • Each N a , N a ’ independently represents an oligonucleotide sequence comprising 2-20, 2- 15, or 2-10 modified nucleotides.
  • Each of N a , N a ’, N b, and N b ’ independently comprises modifications of alternating pattern.
  • each of X, Y, and Z in formulas (III), (IIIa), (IIIb), (IIIc), and (IIId) may be the same or different from each other.
  • the dsRNAi agent is represented by formula (III), (IIIa), (IIIb), (IIIc), and (IIId)
  • at least one of the Y nucleotides may form a base pair with one of the Y′ nucleotides.
  • at least two of the Y nucleotides form base pairs with the corresponding Y′ nucleotides; or all three of the Y nucleotides all form base pairs with the corresponding Y′ nucleotides.
  • the dsRNAi agent is represented by formula (IIIb) or (IIId)
  • at least one of the Z nucleotides may form a base pair with one of the Z′ nucleotides.
  • at least two of the Z nucleotides form base pairs with the corresponding Z′ nucleotides; or all three of the Z nucleotides all form base pairs with the corresponding Z′ nucleotides.
  • at least one of the X nucleotides may form a base pair with one of the X′ nucleotides.
  • the X nucleotides form base pairs with the corresponding X′ nucleotides; or all three of the X nucleotides all form base pairs with the corresponding X′ nucleotides.
  • the modification on the Y nucleotide is different than the modification on the Y’ nucleotide
  • the modification on the Z nucleotide is different than the modification on the Z’ nucleotide
  • the modification on the X nucleotide is different than the modification on the X’ nucleotide.
  • the N a modifications are 2′-O-methyl or 2′-fluoro modifications.
  • the N a modifications are 2′-O-methyl or 2′-fluoro modifications and n p ′ >0 and at least one n p ′ is linked to a neighboring nucleotide a via phosphorothioate linkage.
  • the N a modifications are 2′-O-methyl or 2′-fluoro modifications , n p ′ >0 and at least one n p ′ is linked to a neighboring nucleotide via phosphorothioate linkage, and the sense strand is conjugated to one or more GalNAc derivatives attached through a bivalent or trivalent branched linker (described below).
  • the N a modifications are 2′-O- methyl or 2′-fluoro modifications , n p ′ >0 and at least one n p ′ is linked to a neighboring nucleotide via phosphorothioate linkage, the sense strand comprises at least one phosphorothioate linkage, and the sense strand is conjugated to one or more GalNAc derivatives attached through a bivalent or trivalent branched linker.
  • the N a modifications are 2′-O-methyl or 2′-fluoro modifications , n p ′ >0 and at least one n p ′ is linked to a neighboring nucleotide via phosphorothioate linkage, the sense strand comprises at least one phosphorothioate linkage, and the sense strand is conjugated to one or more GalNAc derivatives attached through a bivalent or trivalent branched linker.
  • the dsRNAi agent is a multimer containing at least two duplexes represented by formula (III), (IIIa), (IIIb), (IIIc), and (IIId), wherein the duplexes are connected by a linker.
  • the linker can be cleavable or non-cleavable.
  • the multimer further comprises a ligand.
  • Each of the duplexes can target the same gene or two different genes; or each of the duplexes can target same gene at two different target sites.
  • the dsRNAi agent is a multimer containing three, four, five, six, or more duplexes represented by formula (III), (IIIa), (IIIb), (IIIc), and (IIId), wherein the duplexes are connected by a linker.
  • the linker can be cleavable or non-cleavable.
  • the multimer further comprises a ligand.
  • Each of the duplexes can target the same gene or two different genes; or each of the duplexes can target same gene at two different target sites.
  • two dsRNAi agents represented by at least one of formulas (III), (IIIa), (IIIb), (IIIc), and (IIId) are linked to each other at the 5’ end, and one or both of the 3’ ends, and are optionally conjugated to a ligand.
  • Each of the agents can target the same gene or two different genes; or each of the agents can target same gene at two different target sites.
  • an RNAi agent of the invention may contain a low number of nucleotides containing a 2’-fluoro modification, e.g., 10 or fewer nucleotides with 2’-fluoro modification.
  • the RNAi agent may contain 10, 9, 8, 7, 6, 5, 4, 3, 2, 1 or 0 nucleotides with a 2’-fluoro modification.
  • the RNAi agent of the invention contains 10 nucleotides with a 2’-fluoro modification, e.g., 4 nucleotides with a 2’-fluoro modification in the sense strand and 6 nucleotides with a 2’-fluoro modification in the antisense strand.
  • the RNAi agent may contain 2 nucleotides with a 2’-fluoro modification, e.g., 0 nucleotides with a 2-fluoro modification in the sense strand and 2 nucleotides with a 2’-fluoro modification in the antisense strand.
  • Various publications describe multimeric iRNAs that can be used in the methods of the invention. Such publications include WO2007/091269, U.S. Patent No.7,858,769, WO2010/141511, WO2007/117686, WO2009/014887, and WO2011/031520 the entire contents of each of which are hereby incorporated herein by reference.
  • compositions and methods of the disclosure include a vinyl phosphonate (VP) modification of an RNAi agent as described herein.
  • a vinyl phosphonate of the instant disclosure may be attached to either the antisense or the sense strand of a dsRNA of the disclosure.
  • a vinyl phosphonate of the instant disclosure is attached to the antisense strand of a dsRNA, optionally at the 5’ end of the antisense strand of the dsRNA.
  • Vinyl phosphonate modifications are also contemplated for the compositions and methods of the instant disclosure.
  • the iRNA that contains conjugations of one or more carbohydrate moieties to an iRNA can optimize one or more properties of the iRNA.
  • the carbohydrate moiety will be attached to a modified subunit of the iRNA.
  • the ribose sugar of one or more ribonucleotide subunits of a iRNA can be replaced with another moiety, e.g., a non-carbohydrate (such as, cyclic) carrier to which is attached a carbohydrate ligand.
  • a ribonucleotide subunit in which the ribose sugar of the subunit has been so replaced is referred to herein as a ribose replacement modification subunit (RRMS).
  • RRMS ribose replacement modification subunit
  • a cyclic carrier may be a carbocyclic ring system, i.e., all ring atoms are carbon atoms, or a heterocyclic ring system, i.e., one or more ring atoms may be a heteroatom, e.g., nitrogen, oxygen, sulfur.
  • the cyclic carrier may be a monocyclic ring system, or may contain two or more rings, e.g. fused rings.
  • the cyclic carrier may be a fully saturated ring system, or it may contain one or more double bonds.
  • the ligand may be attached to the polynucleotide via a carrier.
  • the carriers include (i) at least one “backbone attachment point,” such as, two “backbone attachment points” and (ii) at least one “tethering attachment point.”
  • a “backbone attachment point” as used herein refers to a functional group, e.g. a hydroxyl group, or generally, a bond available for, and that is suitable for incorporation of the carrier into the backbone, e.g., the phosphate, or modified phosphate, e.g., sulfur containing, backbone, of a ribonucleic acid.
  • a “tethering attachment point” in some embodiments refers to a constituent ring atom of the cyclic carrier, e.g., a carbon atom or a heteroatom (distinct from an atom which provides a backbone attachment point), that connects a selected moiety.
  • the moiety can be, e.g., a carbohydrate, e.g. monosaccharide, disaccharide, trisaccharide, tetrasaccharide, oligosaccharide, or polysaccharide.
  • the selected moiety is connected by an intervening tether to the cyclic carrier.
  • the cyclic carrier will often include a functional group, e.g., an amino group, or generally, provide a bond, that is suitable for incorporation or tethering of another chemical entity, e.g., a ligand to the constituent ring.
  • the iRNA may be conjugated to a ligand via a carrier, wherein the carrier can be cyclic group or acyclic group.
  • the cyclic group is selected from pyrrolidinyl, pyrazolinyl, pyrazolidinyl, imidazolinyl, imidazolidinyl, piperidinyl, piperazinyl, [1,3]dioxolane, oxazolidinyl, isoxazolidinyl, morpholinyl, thiazolidinyl, isothiazolidinyl, quinoxalinyl, pyridazinonyl, tetrahydrofuryl, and decalin.
  • the acyclic group is a serinol backbone or diethanolamine backbone. i.
  • a dsRNA molecule can be optimized for RNA interference by incorporating thermally destabilizing modifications in the seed region of the antisense strand.
  • seed region means at positions 2-9 of the 5’-end of the referenced strand or at positions 2-8 of the 5’-end of the refrenced strand.
  • thermally destabilizing modifications can be incorporated in the seed region of the antisense strand to reduce or inhibit off-target gene silencing.
  • thermally destabilizing modification(s) includes modification(s) that would result with a dsRNA with a lower overall melting temperature (Tm) than the Tm of the dsRNA without having such modification(s).
  • the thermally destabilizing modification(s) can decrease the Tm of the dsRNA by 1 – 4 °C, such as one, two, three or four degrees Celcius.
  • the term “thermally destabilizing nucleotide” refers to a nucleotide containing one or more thermally destabilizing modifications. It has been discovered that dsRNAs with an antisense strand comprising at least one thermally destabilizing modification of the duplex within the first 9 nucleotide positions, counting from the 5’ end, of the antisense strand have reduced off-target gene silencing activity.
  • the antisense strand comprises at least one (e.g., one, two, three, four, five or more) thermally destabilizing modification of the duplex within the first 9 nucleotide positions of the 5’ region of the antisense strand.
  • one or more thermally destabilizing modification(s) of the duplex is/are located in positions 2-9, such as, positions 4-8, from the 5’-end of the antisense strand.
  • the thermally destabilizing modification(s) of the duplex is/are located at position 6, 7 or 8 from the 5’-end of the antisense strand.
  • the thermally destabilizing modification of the duplex is located at position 7 from the 5’-end of the antisense strand. In some embodiments, the thermally destabilizing modification of the duplex is located at position 2, 3, 4, 5 or 9 from the 5’-end of the antisense strand.
  • An iRNA agent comprises a sense strand and an antisense strand, each strand having 14 to 40 nucleotides.
  • the RNAi agent may be represented by formula (L): ( ),
  • B1, B2, B3, B1’, B2’, B3’, and B4’ each are independently a nucleotide containing a modification selected from the group consisting of 2’-O-alkyl, 2’-substituted alkoxy, 2’-substituted alkyl, 2’-halo, ENA, and BNA/LNA.
  • B1, B2, B3, B1’, B2’, B3’, and B4’ each contain 2’-OMe modifications.
  • B1, B2, B3, B1’, B2’, B3’, and B4’ each contain 2’-OMe or 2’-F modifications.
  • At least one of B1, B2, B3, B1’, B2’, B3’, and B4’ contain 2'-O-N-methylacetamido (2'-O-NMA, , 2’O-CH2C(O)N(Me)H) modification.
  • C1 is a thermally destabilizing nucleotide placed at a site opposite to the seed region of the antisense strand (i.e., at positions 2-8 of the 5’-end of the antisense strand or at positions 2-9 of the 5’- end of the refrenced strand). For example, C1 is at a position of the sense strand that pairs with a nucleotide at positions 2-8 of the 5’-end of the antisense strand.
  • C1 is at position 15 from the 5’-end of the sense strand.
  • C1 nucleotide bears the thermally destabilizing modification which can include abasic modification; mismatch with the opposing nucleotide in the duplex; and sugar modification such as 2’-deoxy modification or acyclic nucleotide e.g., unlocked nucleic acids (UNA) or glycerol nucleic acid (GNA); and 2’-5’-linked ribonucleotides (“3’-RNA”).
  • UNA unlocked nucleic acids
  • GNA glycerol nucleic acid
  • 3’-RNA 2’-5’-linked ribonucleotides
  • C1 has thermally destabilizing modification selected from the group consisting of: i) mismatch with the opposing nucleotide in the antisense strand; ii) abasic modification selected from the group consisting of: ; and iii) sugar modification selected from the group consisting of: , , , , , and , wherein B is a modified or unmodified nucleobase, R 1 and R 2 independently are H, halogen, OR3, or alkyl; and R3 is H, alkyl, cycloalkyl, aryl, aralkyl, heteroaryl or sugar.
  • the thermally destabilizing modification in C1 is a mismatch selected from the group consisting of G:G, G:A, G:U, G:T, A:A, A:C, C:C, C:U, C:T, U:U, T:T, and U:T; and optionally, at least one nucleobase in the mismatch pair is a 2’-deoxy nucleobase.
  • the thermally destabilizing modification in C1 is GNA or T1, T1’, T2’, and T3’ each independently represent a nucleotide comprising a modification providing the nucleotide a steric bulk that is less or equal to the steric bulk of a 2’-OMe modification.
  • a steric bulk refers to the sum of steric effects of a modification. Methods for determining steric effects of a modification of a nucleotide are known to one skilled in the art.
  • the modification can be at the 2’ position of a ribose sugar of the nucleotide, or a modification to a non-ribose nucleotide, acyclic nucleotide, or the backbone of the nucleotide that is similar or equivalent to the 2’ position of the ribose sugar, and provides the nucleotide a steric bulk that is less than or equal to the steric bulk of a 2’-OMe modification.
  • T1, T1’, T2’, and T3’ are each independently selected from DNA, RNA, LNA, 2’-F, and 2’-F-5’-methyl.
  • T1 is DNA.
  • T1’ is DNA, RNA or LNA.
  • T2’ is DNA or RNA.
  • T3’ is DNA or RNA.
  • n 1 , n 3 , and q 1 are independently 4 to 15 nucleotides in length.
  • n 5 , q 3 , and q 7 are independently 1-6 nucleotide(s) in length.
  • n 4 , q 2 , and q 6 are independently 1-3 nucleotide(s) in length; alternatively, n 4 is 0.
  • q 5 is independently 0-10 nucleotide(s) in length.
  • n 2 and q 4 are independently 0-3 nucleotide(s) in length.
  • n 4 is 0-3 nucleotide(s) in length.
  • n 4 can be 0.
  • n 4 is 0, and q 2 and q 6 are 1.
  • n 4 is 0, and q 2 and q 6 are 1, with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothioate internucleotide linkage modifications within positions 18-23 of the antisense strand (counting from the 5’-end of the antisense strand).
  • n 4 , q 2 , and q 6 are each 1.
  • n 2 , n 4 , q 2 , q 4 , and q 6 are each 1.
  • C1 is at position 14-17 of the 5’-end of the sense strand, when the sense strand is 19-22 nucleotides in length, and n 4 is 1. In one embodiment, C1 is at position 15 of the 5’- end of the sense strand In one embodiment, T3’ starts at position 2 from the 5’ end of the antisense strand. In one example, T3’ is at position 2 from the 5’ end of the antisense strand and q 6 is equal to 1. In one embodiment, T1’ starts at position 14 from the 5’ end of the antisense strand. In one example, T1’ is at position 14 from the 5’ end of the antisense strand and q 2 is equal to 1.
  • T3’ starts from position 2 from the 5’ end of the antisense strand and T1’ starts from position 14 from the 5’ end of the antisense strand.
  • T3’ starts from position 2 from the 5’ end of the antisense strand and q 6 is equal to 1 and T1’ starts from position 14 from the 5’ end of the antisense strand and q 2 is equal to 1.
  • T1’ and T3’ are separated by 11 nucleotides in length (i.e. not counting the T1’ and T3’ nucleotides).
  • T1’ is at position 14 from the 5’ end of the antisense strand.
  • T1’ is at position 14 from the 5’ end of the antisense strand and q 2 is equal to 1, and the modification at the 2’ position or positions in a non-ribose, acyclic or backbone that provide less steric bulk than a 2’-OMe ribose.
  • T3’ is at position 2 from the 5’ end of the antisense strand.
  • T3’ is at position 2 from the 5’ end of the antisense strand and q 6 is equal to 1, and the modification at the 2’ position or positions in a non-ribose, acyclic or backbone that provide less than or equal to steric bulk than a 2’-OMe ribose.
  • T1 is at the cleavage site of the sense strand. In one example, T1 is at position 11 from the 5’ end of the sense strand, when the sense strand is 19-22 nucleotides in length, and n 2 is 1. In an exemplary embodiment, T1 is at the cleavage site of the sense strand at position 11 from the 5’ end of the sense strand, when the sense strand is 19-22 nucleotides in length, and n 2 is 1, In one embodiment, T2’ starts at position 6 from the 5’ end of the antisense strand. In one example, T2’ is at positions 6-10 from the 5’ end of the antisense strand, and q 4 is 1.
  • T1 is at the cleavage site of the sense strand, for instance, at position 11 from the 5’ end of the sense strand, when the sense strand is 19-22 nucleotides in length, and n 2 is 1; T1’ is at position 14 from the 5’ end of the antisense strand, and q 2 is equal to 1, and the modification to T1’ is at the 2’ position of a ribose sugar or at positions in a non-ribose, acyclic or backbone that provide less steric bulk than a 2’-OMe ribose; T2’ is at positions 6-10 from the 5’ end of the antisense strand, and q 4 is 1; and T3’ is at position 2 from the 5’ end of the antisense strand, and q 6 is equal to 1, and the modification to T3’ is at the 2’ position or at positions in a non-ribose, acyclic or backbone that provide less than or equal to steric bulk than
  • T2’ starts at position 8 from the 5’ end of the antisense strand. In one example, T2’ starts at position 8 from the 5’ end of the antisense strand, and q 4 is 2. In one embodiment, T2’ starts at position 9 from the 5’ end of the antisense strand. In one example, T2’ is at position 9 from the 5’ end of the antisense strand, and q 4 is 1.
  • B1’ is 2’-OMe or 2’-F
  • q 1 is 9, T1’ is 2’-F
  • q 2 is 1
  • B2 is 2’-OMe or 2’-F
  • q 3 is 4, T2’ is 2’-F
  • q 4 is 1
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 6
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothioate internucleotide linkage modifications within positions 18-23 of the antisense strand (counting from the 5’-end of the antisense strand).
  • n 4 is 0, B3 is 2’-OMe, n 5 is 3, B1’ is 2’-OMe or 2’-F, q 1 is 9, T1’ is 2’-F, q 2 is 1, B2’ is 2’-OMe or 2’-F, q 3 is 4, T2’ is 2’-F, q 4 is 1, B3’ is 2’-OMe or 2’-F, q 5 is 6, T3’ is 2’-F, q 6 is 1, B4’ is 2’-OMe, and q 7 is 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothioate internucleotide linkage modifications within positions 18-23 of the antisense strand (counting from the 5’-end of the antisense strand).
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7
  • n 4 0,
  • B3 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-OMe
  • q 7 1
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 2, B3’ is 2’-OMe or 2’-F, q 5 is 5, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications
  • B1 is 2’-OMe or 2’-F
  • n 1 is 6, T1 is 2’F
  • n 2 is 3, B2 is 2’-OMe, n 3 is 7, n 4 is 0, B3 is 2’OMe, n 5 is 3, B1’ is 2’-OMe or 2’-F, q 1 is 7, T1’ is 2’-F, q 2 is 1, B2’ is 2’-OMe or 2’-F, q 3 is 4, T2’ is 2’-F, q 4 is 2, B3’ is 2’-OMe or 2’-F, q 5 is 5, T3’ is 2’-F, q 6 is 1, B4’ is 2’-OMe, and q 7 is 1.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 6, T1 is 2’F
  • n 2 is 3, B2 is 2’-OMe, n 3 is 7, n 4 is 0, B3 is 2’-OMe, n 5 is 3, B1’ is 2’-OMe or 2’-F, q 1 is 7, T1’ is 2’-F, q 2 is 1, B2’ is 2’-OMe or 2’-F, q 3 is 4, T2’ is 2’-F, q 4 is 2, B3’ is 2’-OMe or 2’-F, q 5 is 5, T3’ is 2’-F, q 6 is 1, B4’ is 2’-OMe, and q 7 is 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phospho
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7
  • n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 1, B3’ is 2’-OMe or 2’-F
  • q 5 6
  • T3’ is 2’-F
  • q 7 1
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 1, B3’ is 2’-OMe or 2’-F
  • q 5 6
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7
  • n 4 0,
  • B3 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 5, T2’ is 2’-F
  • q 4 1, B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ 2’-F
  • q 7 is 1; optionally with at least 2 additional TT at the 3’-end of the antisense strand.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 1, B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ 2’-F
  • q 7 is 1; optionally with at least 2 additional TT at the 3’-end of the antisense strand; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7
  • T3’ 2’-F
  • q 7 1
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothioate internucle
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7
  • n 4 0,
  • B3 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-F
  • q 7 1
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 2, B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7
  • T3’ 2’-F
  • q 7 1
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within positions 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothio
  • the RNAi agent can comprise a phosphorus-containing group at the 5’-end of the sense strand or antisense strand.
  • the 5’-end phosphorus-containing group can be 5’-end phosphate (5’-P), 5’-end phosphorothioate (5’-PS), 5’-end phosphorodithioate (5’-PS 2 ), 5’-end vinylphosphonate (5’- VP), 5’-end methylphosphonate (MePhos), or 5’-deoxy-5’-C-malonyl ( ).
  • the 5’-VP can be either 5’-E-VP isomer (i.e., trans-vinylphosphonate, ), 5’-Z-VP isomer (i.e., cis- vinylphosphonate, ), or mixtures thereof.
  • the RNAi agent comprises a phosphorus-containing group at the 5’-end of the sense strand. In one embodiment, the RNAi agent comprises a phosphorus-containing group at the 5’-end of the antisense strand. In one embodiment, the RNAi agent comprises a 5’-P.
  • the RNAi agent comprises a 5’-P in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-PS. In one embodiment, the RNAi agent comprises a 5’-PS in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-VP. In one embodiment, the RNAi agent comprises a 5’-VP in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-E-VP in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-Z-VP in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-PS 2 .
  • the RNAi agent comprises a 5’-PS 2 in the antisense strand. In one embodiment, the RNAi agent comprises a 5’-PS 2 . In one embodiment, the RNAi agent comprises a 5’-deoxy-5’-C-malonyl in the antisense strand.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7
  • n 4 0,
  • B3 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-OMe
  • q 7 1
  • the RNAi agent also comprises a 5’-PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-OMe
  • q 7 1
  • the RNAi agent also comprises a 5’-P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-OMe
  • q 7 1
  • the RNAi agent also comprises a 5’-VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 3 4
  • T2’ is 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-OMe
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F
  • q 4 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 6 1
  • B4’ is 2’-OMe
  • q 7 1
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1
  • the RNAi agent also comprises a 5’-P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand
  • the RNAi agent also comprises a 5’-PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand
  • the RNAi agent also comprises a 5’-VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1; with two phosphorot
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 is 1
  • B2’ is 2’-OMe or 2’-F
  • q 3 4
  • q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the RNAi agent also comprises a 5’-P.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1
  • B2’ is 2’-OMe or 2’-F
  • q 3 4
  • q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the dsRNA agent also comprises a 5’-PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1
  • B2’ is 2’-OMe or 2’-F
  • q 3 4
  • q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the RNAi agent also comprises a 5’-VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 is 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1
  • B2’ is 2’-OMe or 2’-F
  • q 3 4
  • q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1.
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1, B4’ is 2’-OMe
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end
  • the RNAi agent also comprises a 5’-P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end), and two phosphorothioate internucleotide
  • the RNAi agent also comprises a 5’-PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end), and two phosphorothioate internucleotide
  • the RNAi agent also comprises a 5’-VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1; with two phosphorothioate internucleotide link
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end), and two phosphorothioate internucleotide linkage
  • the RNAi agent also comprises a 5’-deoxy-5’- C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the RNAi agent also comprises a 5’- P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1.
  • the RNAi agent also comprises a 5’- PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1.
  • the RNAi agent also comprises a 5’- VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the dsRNAi RNA agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1, B2’ is 2’-OMe or 2’-F
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1-5
  • the RNAi agent also comprises a 5’- P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand),
  • the RNAi agent also comprises a 5’- PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand),
  • the RNAi agent also comprises a 5’- VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F, q 2 is 1, B2’ is 2’-OMe or 2’-F, q 3 is 4, T2’ is 2’-F, q 4 is 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1; with two phosphorothioate
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 2,
  • B3’ is 2’-OMe or 2’-F
  • q 5 5
  • T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 is 1
  • B2’ is 2’-OMe or 2’-F
  • q 3 4
  • q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the RNAi agent also comprises a 5’- P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7
  • T3’ 2’-F
  • q 7 1
  • the RNAi agent also comprises a 5’- PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7
  • T3’ 2’-F
  • q 7 1
  • the RNAi agent also comprises a 5’- VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 is 1, B2’ is 2’-OMe or 2’-F
  • q 3 is 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1.
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-
  • the RNAi agent also comprises a 5’- P.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide
  • the RNAi agent also comprises a 5’- PS.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide
  • the RNAi agent also comprises a 5’- VP.
  • the 5’-VP may be 5’-E-VP, 5’-Z-VP, or combination thereof.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3,
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications
  • the RNAi agent also comprises a 5’- PS 2 .
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 3 4, q 4 is 0,
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 7, T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-F
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand),
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl.
  • B1 is 2’-OMe or 2’-F
  • n 1 is 8
  • T1 is 2’F
  • n 2 is 3
  • B2 is 2’-OMe
  • n 3 is 7,
  • n 4 is 0,
  • B3 is 2’-OMe
  • n 5 is 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9, T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 is 2
  • B3’ is 2’-OMe or 2’-F
  • q 5 is 5
  • T3’ is 2’-F
  • q 6 is 1
  • B4’ is 2’-OMe
  • q 7 is 1; with two phosphorothioate internucleotide linkage modifications within position 1
  • the RNAi agent also comprises a 5’-P and a targeting ligand.
  • the 5’-P is at the 5’-end of the antisense strand
  • the targeting ligand is at the 3’-end of the sense strand.
  • the RNAi agent also comprises a 5’-PS and a targeting ligand.
  • the 5’- PS is at the 5’-end of the antisense strand
  • the targeting ligand is at the 3’-end of the sense strand.
  • the RNAi agent also comprises a 5’-VP (e.g., a 5’-E-VP, 5’-Z-VP, or combination thereof), and a targeting ligand.
  • a 5’-VP e.g., a 5’-E-VP, 5’-Z-VP, or combination thereof
  • a targeting ligand is at the 3’-end of the sense strand.
  • B1 is 2’-OMe or 2’-F
  • n 1 8
  • T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 4 2, B3’ is 2’-OMe or 2’-F, q 5 is 5, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications
  • the RNAi agent also comprises a 5’-P and a targeting ligand.
  • the 5’-P is at the 5’-end of the antisense strand
  • the targeting ligand is at the 3’-end of the sense strand.
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothio
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothio
  • B1 is 2’-OMe or 2’-F
  • n 1 8 T1 is 2’F
  • n 2 3
  • B2 is 2’-OMe
  • n 3 7, n 4 is 0,
  • B3 is 2’-OMe
  • n 5 3
  • B1’ is 2’-OMe or 2’-F
  • q 1 9
  • T1’ is 2’-F
  • q 2 1, B2’ is 2’-OMe or 2’-F
  • q 3 4, q 4 is 0, B3’ is 2’-OMe or 2’-F
  • q 5 7, T3’ is 2’-F
  • q 7 1; with two phosphorothioate internucleotide linkage modifications within position 1-5 of the sense strand (counting from the 5’-end of the sense strand), and two phosphorothioate internucleotide linkage modifications at positions 1 and 2 and two phosphorothio
  • the RNAi agent also comprises a 5’-deoxy-5’-C-malonyl and a targeting ligand.
  • the 5’-deoxy-5’-C-malonyl is at the 5’-end of the antisense strand
  • the targeting ligand is at the 3’-end of the sense strand.
  • a RNAi agent of the present invention comprises: (a) a sense strand having: (i) a length of 21 nucleotides; (ii) an ASGPR ligand attached to the 3’-end, wherein said ASGPR ligand comprises three GalNAc derivatives attached through a trivalent branched linker; (iii) 2’-F modifications at positions 1, 3, 5, 7, 9 to 11, and 13, and 2’-OMe modifications at positions 2, 4, 6, 8, 12, and 14 to 21; and (iv) phosphorothioate internucleotide linkages between nucleotide positions 1 and 2, and between nucleotide positions 2 and 3 (counting from the 5’ end); and (b) an antisense strand having: (i) a length of 23 nucleotides; (ii) 2’-OMe modifications at positions 1, 3, 5 to 7, 9, 11 to 13, 15, 17 to 19, and 21 to 23, and 2’-F modifications at positions 2, 4, 8, 10, 14, 16, and 20 (counting from the 5
  • a RNAi agent of the present invention comprises: (a) a sense strand having: (i) a length of 19 nucleotides; (ii) an ASGPR ligand attached to the 3’-end, wherein said ASGPR ligand comprises three GalNAc derivatives attached through a trivalent branched linker; (iii) 2’-OMe modifications at positions 1 to 4, 6, and 10 to 19, and 2’-F modifications at positions 5, and 7 to 9; and (iv) phosphorothioate internucleotide linkages between nucleotide positions 1 and 2, and between nucleotide positions 2 and 3 (counting from the 5’ end); and (b) an antisense strand having: (i) a length of 21 nucleotides; (ii) 2’-OMe modifications at positions 1, 3 to 5, 7, 10 to 13, 15, and 17 to 21, and 2’-F modifications at positions 2, 6, 8, 9, 14, and 16 (counting from the 5’ end); and (iii)
  • EDTA lipophilic molecules, e.g., cholesterol, cholic acid, adamantane acetic acid, 1-pyrene butyric acid, dihydrotestosterone, 1,3-Bis-O(hexadecyl)glycerol, geranyloxyhexyl group, hexadecylglycerol, borneol, menthol, 1,3-propanediol, heptadecyl group, palmitic acid, myristic acid,O3- (oleoyl)lithocholic acid, O3-(oleoyl)cholenic acid, dimethoxytrityl, or phenoxazine)and peptide conjugates (e.g., antennapedia peptide, Tat peptide), alkylating agents, phosphate, amino, mercapto, PEG (e.g., PEG-40K), MPEG, [MPEG] 2 , polyamino, alkyl,
  • the ligand can be a substance, e.g., a drug, which can increase the uptake of the iRNA agent into the cell, for example, by disrupting the cell’s cytoskeleton, e.g., by disrupting the cell’s microtubules, microfilaments, or intermediate filaments.
  • the drug can be, for example, taxol, vincristine, vinblastine, cytochalasin, nocodazole, japlakinolide, latrunculin A, phalloidin, swinholide A, indanocine, or myoservin.
  • a ligand attached to an iRNA as described herein acts as a pharmacokinetic modulator (PK modulator).
  • PK modulator pharmacokinetic modulator
  • Oligonucleotides that comprise a number of phosphorothioate linkages are also known to bind to serum protein, thus short oligonucleotides, e.g., oligonucleotides of about 5 bases, 10 bases, 15 bases, or 20 bases, comprising multiple of phosphorothioate linkages in the backbone are also amenable to the present invention as ligands (e.g. as PK modulating ligands).
  • ligands e.g. as PK modulating ligands
  • aptamers that bind serum components are also suitable for use as PK modulating ligands in the embodiments described herein.
  • the oligonucleotides or linked nucleosides of the present invention are synthesized by an automated synthesizer using phosphoramidites derived from ligand-nucleoside conjugates in addition to the standard phosphoramidites and non-standard phosphoramidites that are commercially available and routinely used in oligonucleotide synthesis.
  • the ligand or conjugate is a lipid or lipid-based molecule.
  • a lipid or lipid-based molecule may bind a serum protein, e.g., human serum albumin (HSA).
  • HSA binding ligand allows for distribution of the conjugate to a target tissue, e.g., a non-kidney target tissue of the body.
  • the target tissue can be the liver, including parenchymal cells of the liver.
  • Other molecules that can bind HSA can also be used as ligands. For example, naproxen or aspirin can be used.
  • a lipid or lipid-based ligand can (a) increase resistance to degradation of the conjugate, (b) increase targeting or transport into a target cell or cell membrane, or (c) can be used to adjust binding to a serum protein, e.g., HSA.
  • a lipid based ligand can be used to inhibit, e.g., control the binding of the conjugate to a target tissue. For example, a lipid or lipid-based ligand that binds to HSA more strongly will be less likely to be targeted to the kidney and therefore less likely to be cleared from the body. A lipid or lipid-based ligand that binds to HSA less strongly can be used to target the conjugate to the kidney.
  • a peptidomimetic (also referred to herein as an oligopeptidomimetic) is a molecule capable of folding into a defined three-dimensional structure similar to a natural peptide.
  • the attachment of peptide and peptidomimetics to iRNA agents can affect pharmacokinetic distribution of the iRNA, such as by enhancing cellular recognition and absorption.
  • the peptide or peptidomimetic moiety can be about 5-50 amino acids long, e.g., about 5, 10, 15, 20, 25, 30, 35, 40, 45, or 50 amino acids long.
  • a peptide or peptidomimetic can be, for example, a cell permeation peptide, cationic peptide, amphipathic peptide, or hydrophobic peptide (e.g., consisting primarily of Tyr, Trp, or Phe).
  • the peptide moiety can be a dendrimer peptide, constrained peptide or crosslinked peptide.
  • the peptide moiety can include a hydrophobic membrane translocation sequence (MTS).
  • An exemplary hydrophobic MTS-containing peptide is RFGF having the amino acid sequence AAVALLPAVLLALLAP (SEQ ID NO: 14).
  • a peptide or peptidomimetic can be encoded by a random sequence of DNA, such as a peptide identified from a phage-display library, or one-bead-one-compound (OBOC) combinatorial library (Lam et al ., Nature, 354:82-84, 1991).
  • OBOC one-bead-one-compound
  • Examples of a peptide or peptidomimetic tethered to a dsRNA agent via an incorporated monomer unit for cell targeting purposes is an arginine-glycine-aspartic acid (RGD)-peptide, or RGD mimic.
  • a peptide moiety can range in length from about 5 amino acids to about 40 amino acids.
  • a “cell permeation peptide” is capable of permeating a cell, e.g., a microbial cell, such as a bacterial or fungal cell, or a mammalian cell, such as a human cell.
  • a microbial cell-permeating peptide can be, for example, an ⁇ -helical linear peptide (e.g., LL-37 or Ceropin P1), a disulfide bond- containing peptide (e.g., ⁇ -defensin, ⁇ -defensin or bactenecin), or a peptide containing only one or two dominating amino acids (e.g., PR-39 or indolicidin).
  • the carbohydrate conjugate comprises one or more GalNAc derivatives.
  • the GalNAc derivatives may be attached via a linker, e.g., a bivalent or trivalent branched linker.
  • the GalNAc conjugate is conjugated to the 3’ end of the sense strand.
  • the GalNAc conjugate is conjugated to the iRNA agent (e.g., to the 3’ end of the sense strand) via a linker, e.g., a linker as described herein.
  • the GalNAc conjugate is conjugated to the 5’ end of the sense strand.
  • the GalNAc or GalNAc derivative is attached to an iRNA agent of the invention via a tetravalent linker.
  • the double stranded RNAi agents of the invention comprise one GalNAc or GalNAc derivative attached to the iRNA agent.
  • the double stranded RNAi agents of the invention comprise a plurality (e.g., 2, 3, 4, 5, or 6) GalNAc or GalNAc derivatives, each independently attached to a plurality of nucleotides of the double stranded RNAi agent through a plurality of monovalent linkers.
  • each unpaired nucleotide within the hairpin loop may independently comprise a GalNAc or GalNAc derivative attached via a monovalent linker.
  • the hairpin loop may also be formed by an extended overhang in one strand of the duplex.
  • a carbohydrate conjugate for use in the compositions and methods of the invention is a monosaccharide.
  • the monosaccharide is an N- acetylgalactosamine, such as Formula II.
  • the RNAi agent is attached to the carbohydrate conjugate via a linker as shown in the following schematic, wherein X is O or S .
  • the RNAi agent is conjugated to L96 as defined in Table 1 and shown below: .
  • the GalNAc or GalNAc derivative is attached to an iRNA agent of the invention via a trivalent linker.
  • the double stranded RNAi agents of the invention comprise one or more GalNAc or GalNAc derivative attached to the iRNA agent.
  • the GalNAc may be attached to any nucleotide via a linker on the sense strand or antsisense strand.
  • the GalNac may be attached to the 5’-end of the sense strand, the 3’ end of the sense strand, the 5’-end of the antisense strand, or the 3’ – end of the antisense strand.
  • the GalNAc is attached to the 3’ end of the sense strand, e.g., via a trivalent linker.
  • the double stranded RNAi agents of the invention comprise a plurality (e.g., 2, 3, 4, 5, or 6) GalNAc or GalNAc derivatives, each independently attached to a plurality of nucleotides of the double stranded RNAi agent through a plurality of linkers, e.g., monovalent linkers.
  • each unpaired nucleotide within the hairpin loop may independently comprise a GalNAc or GalNAc derivative attached via a monovalent linker.
  • the carbohydrate conjugate further comprises one or more additional ligands as described above, such as, but not limited to, a PK modulator or a cell permeation peptide.
  • a cleavable linkage group such as a disulfide bond can be susceptible to pH.
  • the pH of human serum is 7.4, while the average intracellular pH is slightly lower, ranging from about 7.1-7.3. Endosomes have a more acidic pH, in the range of 5.5-6.0, and lysosomes have an even more acidic pH at around 5.0.
  • Some linkers will have a cleavable linking group that is cleaved at a selected pH, thereby releasing a cationic lipid from the ligand inside the cell, or into the desired compartment of the cell.
  • a linker can include a cleavable linking group that is cleavable by a particular enzyme.
  • the suitability of a candidate cleavable linking group can be evaluated by testing the ability of a degradative agent (or condition) to cleave the candidate linking group. It will also be desirable to also test the candidate cleavable linking group for the ability to resist cleavage in the blood or when in contact with other non-target tissue.
  • a degradative agent or condition
  • the candidate cleavable linking group for the ability to resist cleavage in the blood or when in contact with other non-target tissue.
  • the evaluations can be carried out in cell free systems, in cells, in cell culture, in organ or tissue culture, or in whole animals.
  • useful candidate compounds are cleaved at least about 2, 4, 10, 20, 30, 40, 50, 60, 70, 80, 90, or 100 times faster in the cell (or under in vitro conditions selected to mimic intracellular conditions) as compared to blood or serum (or under in vitro conditions selected to mimic extracellular conditions).
  • a cleavable linking group is a redox cleavable linking group that is cleaved upon reduction or oxidation.
  • An example of reductively cleavable linking group is a disulphide linking group (-S-S-).
  • a candidate cleavable linking group is a suitable “reductively cleavable linking group,” or for example is suitable for use with a particular iRNA moiety and particular targeting agent
  • a candidate can be evaluated by incubation with dithiothreitol (DTT), or other reducing agent using reagents know in the art, which mimic the rate of cleavage which would be observed in a cell, e.g., a target cell.
  • DTT dithiothreitol
  • the candidates can also be evaluated under conditions which are selected to mimic blood or serum conditions. In one, candidate compounds are cleaved by at most about 10% in the blood.
  • useful candidate compounds are degraded at least about 2, 4, 10, 20, 30, 40, 50, 60, 70, 80, 90, or about 100 times faster in the cell (or under in vitro conditions selected to mimic intracellular conditions) as compared to blood (or under in vitro conditions selected to mimic extracellular conditions).
  • the rate of cleavage of candidate compounds can be determined using standard enzyme kinetics assays under conditions chosen to mimic intracellular media and compared to conditions chosen to mimic extracellular media.
  • Phosphate-based cleavable linking groups In other embodiments, a cleavable linker comprises a phosphate-based cleavable linking group.
  • a phosphate-based cleavable linking group is cleaved by agents that degrade or hydrolyze the phosphate group.
  • An example of an agent that cleaves phosphate groups in cells are enzymes such as phosphatases in cells.
  • Examples of phosphate-based linking groups are -O-P(O)(ORk)-O-, -O- P(S)(ORk)-O-, -O-P(S)(SRk)-O-, -S-P(O)(ORk)-O-, -O-P(O)(ORk)-S-, -S-P(O)(ORk)-S-, -O- P(S)(ORk)-S-, -O-P(S)(ORk)-O-, -O-P(O)(Rk)-O-, -O-P(S)(Rk)-O-, -S-P(O)(Rk)-O-, -S
  • Exemplary embodiments include -O- P(O)(OH)-O-, -O-P(S)(OH)-O-, -O-P(S)(SH)-O-, -S-P(O)(OH)-O-, -O-P(O)(OH)-S-, -S-P(O)(OH)-S- , -O-P(S)(OH)-S-, -S-P(S)(OH)-O-, -O-P(O)(H)-O-, -O-P(S)(H)-O-, -S-P(O)(H)-O-, -S-P(O)(H)-O-, -S-P(O)(H)-O-, - S-P(O)(H)-S-, and -O-P(S)(H)-S-.
  • a phosphate-based linking group is -O- P(O)(OH)-O-. These candidates can be evaluated using methods analogous to those described above.
  • a cleavable linker comprises an acid cleavable linking group.
  • An acid cleavable linking group is a linking group that is cleaved under acidic conditions.
  • acid cleavable linking groups are cleaved in an acidic environment with a pH of about 6.5 or lower (e.g., about 6.0, 5.5, 5.0, or lower), or by agents such as enzymes that can act as a general acid.
  • acid cleavable linking groups include but are not limited to hydrazones, esters, and esters of amino acids.
  • An exemplary embodiment is when the carbon attached to the oxygen of the ester (the alkoxy group) is an aryl group, substituted alkyl group, or tertiary alkyl group such as dimethyl pentyl or t-butyl.
  • a cleavable linker comprises an ester-based cleavable linking group.
  • An ester-based cleavable linking group is cleaved by enzymes such as esterases and amidases in cells.
  • Examples of ester-based cleavable linking groups include, but are not limited to, esters of alkylene, alkenylene and alkynylene groups.
  • Ester cleavable linking groups have the general formula -C(O)O-, or -OC(O)-. These candidates can be evaluated using methods analogous to those described above. v.
  • a cleavable linker comprises a peptide-based cleavable linking group.
  • a peptide-based cleavable linking group is cleaved by enzymes such as peptidases and proteases in cells.
  • Peptide-based cleavable linking groups are peptide bonds formed between amino acids to yield oligopeptides (e.g., dipeptides, tripeptides etc.) and polypeptides.
  • Peptide-based cleavable groups do not include the amide group (-C(O)NH-).
  • the amide group can be formed between any alkylene, alkenylene or alkynelene.
  • a peptide bond is a special type of amide bond formed between amino acids to yield peptides and proteins.
  • the peptide based cleavage group is generally limited to the peptide bond (i.e., the amide bond) formed between amino acids yielding peptides and proteins and does not include the entire amide functional group.
  • Peptide-based cleavable linking groups have the general formula – NHCHRAC(O)NHCHRBC(O)-, where RA and RB are the R groups of the two adjacent amino acids. These candidates can be evaluated using methods analogous to those described above.
  • an iRNA of the invention is conjugated to a carbohydrate through a linker.
  • Non-limiting examples of iRNA carbohydrate conjugates with linkers of the compositions and methods of the invention include, but are not limited to,
  • a ligand is one or more “GalNAc” (N-acetylgalactosamine) derivatives attached through a bivalent or trivalent branched linker.
  • a dsRNA of the invention is conjugated to a bivalent or trivalent branched linker selected from the group of structures shown in any of formula (XLV) – (XLVI): Formula XXXXV Formula XLVI , ; Formula XLVII Formula XLVIII wherein: q2A, q2B, q3A, q3B, q4A, q4B, q5A, q5B and q5C represent independently for each occurrence 0-20 and wherein the repeating unit can be the same or different; P 2A , P 2B , P 3A , P 3B , P 4A , P 4B , P 5A , P 5B , P 5C , T 2A , T 2B , T 3A , T 3B , T 4A , T 4B , T 4A , T 5B , T 5C are each independently for each occurrence absent, CO, NH, O, S,
  • Suitable bivalent and trivalent branched linker groups conjugating GalNAc derivatives include, but are not limited to, the structures recited above as formulas II, VII, XI, X, and XIII.
  • Representative U.S. Patents that teach the preparation of RNA conjugates include, but are not limited to, U.S.
  • the present invention also includes iRNA compounds that are chimeric compounds.
  • “Chimeric” iRNA compounds or “chimeras,” in the context of this invention, are iRNA compounds, such as, dsRNAi agents, that contain two or more chemically distinct regions, each made up of at least one monomer unit, i.e., a nucleotide in the case of a dsRNA compound.
  • iRNAs typically contain at least one region wherein the RNA is modified so as to confer upon the iRNA increased resistance to nuclease degradation, increased cellular uptake, or increased binding affinity for the target nucleic acid.
  • An additional region of the iRNA can serve as a substrate for enzymes capable of cleaving RNA:DNA or RNA:RNA hybrids.
  • RNase H is a cellular endonuclease which cleaves the RNA strand of an RNA:DNA duplex. Activation of RNase H, therefore, results in cleavage of the RNA target, thereby greatly enhancing the efficiency of iRNA inhibition of gene expression.
  • Acids Res., 1990, 18:3777 a polyamine or a polyethylene glycol chain (Manoharan et al ., Nucleosides & Nucleotides, 1995, 14:969), or adamantane acetic acid (Manoharan et al ., Tetrahedron Lett., 1995, 36:3651), a palmityl moiety (Mishra et al ., Biochim. Biophys. Acta, 1995, 1264:229), or an octadecylamine or hexylamino-carbonyl-oxycholesterol moiety (Crooke et al ., J. Pharmacol. Exp.
  • RNA conjugation protocols involve the synthesis of RNAs bearing an aminolinker at one or more positions of the sequence. The amino group is then reacted with the molecule being conjugated using appropriate coupling or activating reagents. The conjugation reaction can be performed either with the RNA still bound to the solid support or following cleavage of the RNA, in solution phase. Purification of the RNA conjugate by HPLC typically affords the pure conjugate. V.
  • an iRNA of the invention Delivery of an iRNA of the Invention
  • a cell e.g., a cell within a subject, such as a human subject (e.g., a subject in need thereof, such as a subject susceptible to or diagnosed with a KHK-associated disorder, as described herein)
  • delivery may be performed by contacting a cell with an iRNA of the invention either in vitro or in vivo.
  • In vivo delivery may also be performed directly by administering a composition comprising an iRNA, e.g., a dsRNA, to a subject.
  • in vivo delivery may be performed indirectly by administering one or more vectors that encode and direct the expression of the iRNA.
  • any method of delivering a nucleic acid molecule in vitro or in vivo can be adapted for use with an iRNA of the invention (see e.g., Akhtar S. and Julian RL. (1992) Trends Cell. Biol.2(5):139-144 and WO94/02595, which are incorporated herein by reference in their entireties).
  • factors to consider in order to deliver an iRNA molecule include, for example, biological stability of the delivered molecule, prevention of non-specific effects, and accumulation of the delivered molecule in the target tissue.
  • RNA interference has also shown success with local delivery to the CNS by direct injection (Dorn, G., et al . (2004) Nucleic Acids 32:e49; Tan, PH., et al (2005) Gene Ther.12:59-66; Makimura, H., et al (2002) BMC Neurosci.3:18; Shishkina, GT., et al (2004) Neuroscience 129:521-528; Thakker, ER., et al (2004) Proc. Natl. Acad. Sci. U.S.A. 101:17270-17275; Akaneya,Y., et al (2005) J. Neurophysiol.93:594-602).
  • RNA or the pharmaceutical carrier can also permit targeting of the iRNA to the target tissue and avoid undesirable off-target effects.
  • iRNA molecules can be modified by chemical conjugation to lipophilic groups such as cholesterol to enhance cellular uptake and prevent degradation.
  • lipophilic groups such as cholesterol to enhance cellular uptake and prevent degradation.
  • an iRNA directed against ApoB conjugated to a lipophilic cholesterol moiety was injected systemically into mice and resulted in knockdown of apoB mRNA in both the liver and jejunum (Soutschek, J., et al (2004) Nature 432:173-178).
  • the iRNA can be delivered using drug delivery systems such as a nanoparticle, a dendrimer, a polymer, liposomes, or a cationic delivery system.
  • Positively charged cationic delivery systems facilitate binding of an iRNA molecule (negatively charged) and also enhance interactions at the negatively charged cell membrane to permit efficient uptake of an iRNA by the cell.
  • Cationic lipids, dendrimers, or polymers can either be bound to an iRNA, or induced to form a vesicle or micelle (see e.g., Kim SH, et al (2008) Journal of Controlled Release 129(2):107- 116) that encases an iRNA. The formation of vesicles or micelles further prevents degradation of the iRNA when administered systemically.
  • DOTAP Disposalmitoyl-N-(2-aminoethyl)-2-aminoethyl-N-(2-aminoethyl)-2-aminoethyl-N-(2-aminoethyl)-2-aminoethyl-N-(2-aminoethyl)-2-aminoethyl-N-(2-aminoethyl)-2-limiting lipid particles
  • cardiolipin Choen, PY, et al (2006) Cancer Gene Ther.12:321-328; Pal, A, et al (2005) Int J. Oncol.26:1087-1091
  • polyethyleneimine Bonnet ME, et al (2008) Pharm. Res. Aug 16 Epub ahead of print; Aigner, A. (2006) J. Biomed.
  • an iRNA forms a complex with cyclodextrin for systemic administration.
  • Methods for administration and pharmaceutical compositions of iRNAs and cyclodextrins can be found in U.S. Patent No.7,427,605, which is herein incorporated by reference in its entirety. A.
  • Vector encoded iRNAs of the Invention iRNA targeting the KHK gene can be expressed from transcription units inserted into DNA or RNA vectors (see, e.g., Couture, A, et al ., TIG. (1996), 12:5-10; Skillern, A, et al ., International PCT Publication No. WO 00/22113, Conrad, International PCT Publication No. WO 00/22114, and Conrad, U.S. Patent No.6,054,299). Expression can be transient (on the order of hours to weeks) or sustained (weeks to months or longer), depending upon the specific construct used and the target tissue or cell type.
  • transgenes can be introduced as a linear construct, a circular plasmid, or a viral vector, which can be an integrating or non-integrating vector.
  • the transgene can also be constructed to permit it to be inherited as an extrachromosomal plasmid (Gassmann, et al ., Proc. Natl. Acad. Sci. USA (1995) 92:1292).
  • Viral vector systems which can be utilized with the methods and compositions described herein include, but are not limited to, (a) adenovirus vectors; (b) retrovirus vectors, including but not limited to lentiviral vectors, moloney murine leukemia virus, etc.; (c) adeno- associated virus vectors; (d) herpes simplex virus vectors; (e) SV 40 vectors; (f) polyoma virus vectors; (g) papilloma virus vectors; (h) picornavirus vectors; (i) pox virus vectors such as an orthopox, e.g., vaccinia virus vectors or avipox, e.g.
  • pox virus vectors such as an orthopox, e.g., vaccinia virus vectors or avipox, e.g.
  • the constructs can include viral sequences for transfection, if desired.
  • the construct can be incorporated into vectors capable of episomal replication, e.g. EPV and EBV vectors.
  • Constructs for the recombinant expression of an iRNA will generally require regulatory elements, e.g., promoters, enhancers, etc., to ensure the expression of the iRNA in target cells. Other aspects to consider for vectors and constructs are known in the art. VI.
  • compositions of the Invention also includes pharmaceutical compositions and formulations which include the iRNAs of the invention.
  • pharmaceutical compositions containing an iRNA, as described herein, and a pharmaceutically acceptable carrier are useful for treating a disease or disorder associated with the expression or activity of a KHK gene.
  • Such pharmaceutical compositions are formulated based on the mode of delivery.
  • the pharmaceutical compositions of the invention may be administered in dosages sufficient to inhibit expression of a KHK gene.
  • the pharmaceutical compositions of the invention are sterile.
  • the pharmaceutical compositions of the invention are pyrogen free.
  • the pharmaceutical compositions of the invention may be administered in dosages sufficient to inhibit expression of a KHK gene.
  • a suitable dose of an iRNA of the invention will be in the range of about 0.001 to about 200.0 milligrams per kilogram body weight of the recipient per day, generally in the range of about 1 to 50 mg per kilogram body weight per day.
  • a suitable dose of an iRNA of the invention will be in the range of about 0.1 mg/kg to about 5.0 mg/kg, about 0.3 mg/kg and about 3.0 mg/kg.
  • a repeat-dose regimen may include administration of a therapeutic amount of iRNA on a regular basis, such as every month, once every 3-6 months, or once a year.
  • the iRNA is administered about once per month to about once per six months. After an initial treatment regimen, the treatments can be administered on a less frequent basis. Duration of treatment can be determined based on the severity of disease. In other embodiments, a single dose of the pharmaceutical compositions can be long lasting, such that doses are administered at not more than 1, 2, 3, or 4 month intervals. In some embodiments of the invention, a single dose of the pharmaceutical compositions of the invention is administered about once per month. In other embodiments of the invention, a single dose of the pharmaceutical compositions of the invention is administered quarterly (i.e., about every three months). In other embodiments of the invention, a single dose of the pharmaceutical compositions of the invention is administered twice per year (i.e., about once every six months).
  • compositions of the present invention include, but are not limited to, solutions, emulsions, and liposome-containing formulations.
  • compositions can be generated from a variety of components that include, but are not limited to, preformed liquids, self-emulsifying solids, and self-emulsifying semisolids.
  • Formulations include those that target the liver.
  • the pharmaceutical formulations of the present invention which can conveniently be presented in unit dosage form, can be prepared according to conventional techniques well known in the pharmaceutical industry. Such techniques include the step of bringing into association the active ingredients with the pharmaceutical carrier(s) or excipient(s). In general, the formulations are prepared by uniformly and intimately bringing into association the active ingredients with liquid carriers.
  • A. Additional Formulations i. Emulsions
  • the compositions of the present invention can be prepared and formulated as emulsions.
  • Emulsions are typically heterogeneous systems of one liquid dispersed in another in the form of droplets usually exceeding 0.1 ⁇ m in diameter (see e.g., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Allen, LV., Popovich NG., and Ansel HC., 2004, Lippincott Williams & Wilkins (8th ed.), New York, NY; Idson, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 1, p.199; Rosoff, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., Volume 1, p.245; Block in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 2, p.335
  • Emulsions are often biphasic systems comprising two immiscible liquid phases intimately mixed and dispersed with each other.
  • emulsions can be of either the water-in-oil (w/o) or the oil-in-water (o/w) variety.
  • w/o water-in-oil
  • o/w oil-in-water
  • Emulsions can contain additional components in addition to the dispersed phases, and the active drug which can be present as a solution either in the aqueous phase, oily phase or itself as a separate phase.
  • Pharmaceutical excipients such as emulsifiers, stabilizers, dyes, and anti-oxidants can also be present in emulsions as needed.
  • Pharmaceutical emulsions can also be multiple emulsions that are comprised of more than two phases such as, for example, in the case of oil-in-water-in-oil (o/w/o) and water-in-oil-in-water (w/o/w) emulsions.
  • Such complex formulations often provide certain advantages that simple binary emulsions do not.
  • Emulsions in which individual oil droplets of an o/w emulsion enclose small water droplets constitute a w/o/w emulsion.
  • a system of oil droplets enclosed in globules of water stabilized in an oily continuous phase provides an o/w/o emulsion.
  • Emulsions are characterized by little or no thermodynamic stability. Often, the dispersed or discontinuous phase of the emulsion is well dispersed into the external or continuous phase and maintained in this form through the means of emulsifiers or the viscosity of the formulation.
  • Other means of stabilizing emulsions entail the use of emulsifiers that can be incorporated into either phase of the emulsion.
  • Emulsifiers can broadly be classified into four categories: synthetic surfactants, naturally occurring emulsifiers, absorption bases, and finely dispersed solids (see e.g., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Allen, LV., Popovich NG., and Ansel HC., 2004, Lippincott Williams & Wilkins (8th ed.), New York, NY; Idson, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 1, p.199).
  • Synthetic surfactants also known as surface active agents, have found wide applicability in the formulation of emulsions and have been reviewed in the literature (see e.g., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Allen, LV., Popovich NG., and Ansel HC., 2004, Lippincott Williams & Wilkins (8th ed.), New York, NY; Rieger, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 1, p.285; Idson, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), Marcel Dekker, Inc., New York, N.Y., 1988, volume 1, p.199).
  • Surfactants are typically amphiphilic and comprise a hydrophilic and a hydrophobic portion.
  • the ratio of the hydrophilic to the hydrophobic nature of the surfactant has been termed the hydrophile/lipophile balance (HLB) and is a valuable tool in categorizing and selecting surfactants in the preparation of formulations.
  • HLB hydrophile/lipophile balance
  • Surfactants can be classified into different classes based on the nature of the hydrophilic group: nonionic, anionic, cationic, and amphoteric (see e.g., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Allen, LV., Popovich NG., and Ansel HC., 2004, Lippincott Williams & Wilkins (8th ed.), New York, NY Rieger, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 1, p.285).
  • a large variety of non-emulsifying materials are also included in emulsion formulations and contribute to the properties of emulsions.
  • compositions of iRNAs and nucleic acids are formulated as microemulsions.
  • a microemulsion can be defined as a system of water, oil, and amphiphile which is a single optically isotropic and thermodynamically stable liquid solution (see e.g., Ansel's Pharmaceutical Dosage Forms and Drug Delivery Systems, Allen, LV., Popovich NG., and Ansel HC., 2004, Lippincott Williams & Wilkins (8th ed.), New York, NY; Rosoff, in Pharmaceutical Dosage Forms, Lieberman, Rieger and Banker (Eds.), 1988, Marcel Dekker, Inc., New York, N.Y., volume 1, p.245).
  • microemulsions are systems that are prepared by first dispersing an oil in an aqueous surfactant solution and then adding a sufficient amount of a fourth component, generally an intermediate chain-length alcohol to form a transparent system. Therefore, microemulsions have also been described as thermodynamically stable, isotropically clear dispersions of two immiscible liquids that are stabilized by interfacial films of surface-active molecules (Leung and Shah, in: Controlled Release of Drugs: Polymers and Aggregate Systems, Rosoff, M., Ed., 1989, VCH Publishers, New York, pages 185-215).
  • iii. Microparticles An iRNA of the invention may be incorporated into a particle, e.g., a microparticle.
  • Microparticles can be produced by spray-drying, but may also be produced by other methods including lyophilization, evaporation, fluid bed drying, vacuum drying, or a combination of these techniques.
  • Penetration Enhancers employs various penetration enhancers to effect the efficient delivery of nucleic acids, particularly iRNAs, to the skin of animals.
  • Most drugs are present in solution in both ionized and nonionized forms. However, usually only lipid soluble or lipophilic drugs readily cross cell membranes. It has been discovered that even non-lipophilic drugs can cross cell membranes if the membrane to be crossed is treated with a penetration enhancer.
  • Penetration enhancers In addition to aiding the diffusion of non-lipophilic drugs across cell membranes, penetration enhancers also enhance the permeability of lipophilic drugs.
  • Penetration enhancers can be classified as belonging to one of five broad categories, i.e., surfactants, fatty acids, bile salts, chelating agents, and non-chelating non-surfactants (see e.g., Malmsten, M. Surfactants and polymers in drug delivery, Informa Health Care, New York, NY, 2002; Lee et al ., Critical Reviews in Therapeutic Drug Carrier Systems, 1991, p.92).
  • Each of the above mentioned classes of penetration enhancers and their use in manufacture of pharmaceutical compositions and delivery of pharmaceutical agents are well known in the art.
  • a “pharmaceutical carrier” or “excipient” is a pharmaceutically acceptable solvent, suspending agent, or any other pharmacologically inert vehicle for delivering one or more nucleic acids to an animal.
  • the excipient can be liquid or solid and is selected, with the planned manner of administration in mind, so as to provide for the desired bulk, consistency, etc., when combined with a nucleic acid and the other components of a given pharmaceutical composition. Such agent are well known in the art. vi.
  • Other Components The compositions of the present invention can additionally contain other adjunct components conventionally found in pharmaceutical compositions, at their art-established usage levels.
  • compositions can contain additional, compatible, pharmaceutically-active materials such as, for example, antipruritics, astringents, local anesthetics or anti-inflammatory agents, or can contain additional materials useful in physically formulating various dosage forms of the compositions of the present invention, such as dyes, flavoring agents, preservatives, antioxidants, opacifiers, thickening agents and stabilizers.
  • additional materials useful in physically formulating various dosage forms of the compositions of the present invention, such as dyes, flavoring agents, preservatives, antioxidants, opacifiers, thickening agents and stabilizers.
  • such materials when added, should not unduly interfere with the biological activities of the components of the compositions of the present invention.
  • the formulations can be sterilized and, if desired, mixed with auxiliary agents, e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, colorings, flavorings, or aromatic substances, and the like which do not deleteriously interact with the nucleic acid(s) of the formulation.
  • auxiliary agents e.g., lubricants, preservatives, stabilizers, wetting agents, emulsifiers, salts for influencing osmotic pressure, buffers, colorings, flavorings, or aromatic substances, and the like which do not deleteriously interact with the nucleic acid(s) of the formulation.
  • Aqueous suspensions can contain substances which increase the viscosity of the suspension including, for example, sodium carboxymethylcellulose, sorbitol, or dextran.
  • the suspension can also contain stabilizers.
  • compositions featured in the invention include (a) one or more iRNA and (b) one or more agents which function by a non-iRNA mechanism and which are useful in treating a KHK-associated disorder, e.g., liver disease (e.g., fatty liver, steatohepatitis, non- alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • the dosage can vary within this range depending upon the dosage form employed and the route of administration utilized.
  • the prophylactically effective dose can be estimated initially from cell culture assays.
  • a dose can be formulated in animal models to achieve a circulating plasma concentration range of the compound or, when appropriate, of the polypeptide product of a target sequence (e.g., achieving a decreased concentration of the polypeptide) that includes the IC50 (i.e., the concentration of the test compound which achieves a half-maximal inhibition of symptoms) or higher levels of inhibition as determined in cell culture.
  • IC50 i.e., the concentration of the test compound which achieves a half-maximal inhibition of symptoms
  • levels of inhibition as determined in cell culture.
  • Levels in plasma can be measured, for example, by high performance liquid chromatography.
  • the iRNAs featured in the invention can be administered in combination with other known agents used for the prevention or treatment of a KHK-associated disorder, e.g., liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver, steatohepatit
  • the present invention also provides methods of inhibiting expression of a KHK gene in a cell.
  • the methods include contacting a cell with an RNAi agent, e.g., double stranded RNAi agent, in an amount effective to inhibit expression of KHK in the cell, thereby inhibiting expression of KHK in the cell.
  • RNAi agent e.g., double stranded RNAi agent
  • Contacting of a cell with an iRNA, e.g., a double stranded RNA agent may be done in vitro or in vivo.
  • Contacting a cell in vivo with the iRNA includes contacting a cell or group of cells within a subject, e.g., a human subject, with the iRNA. Combinations of in vitro and in vivo methods of contacting a cell are also possible. Contacting a cell may be direct or indirect, as discussed above. Furthermore, contacting a cell may be accomplished via a targeting ligand, including any ligand described herein or known in the art. In some embodiments, the targeting ligand is a carbohydrate moiety, e.g., a GalNAc 3 ligand, or any other ligand that directs the RNAi agent to a site of interest.
  • a targeting ligand is a carbohydrate moiety, e.g., a GalNAc 3 ligand, or any other ligand that directs the RNAi agent to a site of interest.
  • the term “inhibiting,” as used herein, is used interchangeably with “reducing,” “silencing,” “downregulating”, “suppressing”, and other similar terms, and includes any level of inhibition.
  • the phrase “inhibiting expression of a KHK” is intended to refer to inhibition of expression of any KHK gene (such as, e.g., a mouse KHK 3 gene, a rat KHK gene, a monkey KHK gene, or a human KHK gene) as well as variants or mutants of a KHK gene.
  • the KHK gene may be a wild-type KHK gene, a mutant KHK gene, or a transgenic KHK gene in the context of a genetically manipulated cell, group of cells, or organism.
  • “Inhibiting expression of a KHK gene” includes any level of inhibition of a KHK gene, e.g., at least partial suppression of the expression of a KHK gene.
  • the expression of the KHK gene may be assessed based on the level, or the change in the level, of any variable associated with KHK gene expression, e.g., KHK mRNA level or KHK protein level. This level may be assessed in an individual cell or in a group of cells, including, for example, a sample derived from a subject. Inhibition may be assessed by a decrease in an absolute or relative level of one or more variables that are associated with KHK expression compared with a control level.
  • the control level may be any type of control level that is utilized in the art, e.g., a pre-dose baseline level, or a level determined from a similar subject, cell, or sample that is untreated or treated with a control (such as, e.g., buffer only control or inactive agent control). It is understood that the degree and duration of elevation of a sign of a KHK-associated disease will vary depending upon the sign. For example, lipid signs, e.g., fasting lipid levels, NAFLD, NASH, obesity; signs of liver and kidney function, and glucose or insulin response, are durable signs that will not vary in a clinically significant manner within a day or even within a week.
  • lipid signs e.g., fasting lipid levels, NAFLD, NASH, obesity
  • signs of liver and kidney function, and glucose or insulin response are durable signs that will not vary in a clinically significant manner within a day or even within a week.
  • Fructose metabolism has demonstrated to be different depending on the source of fructose, e.g., in high fructose corn syrup vs. in natural fruit, and at high concentrations, such as those provided by soft drinks, glucose can be converted to fructose by the polyol pathway. However, fructose will have more metabolic effects than glucose. Body composition, e.g., lean body mass, has also been demonstrated to affect fructose metabolism. Therefore, both the timing of testing and controls must be carefully selected. In some embodiments of the methods of the invention, expression of a KHK gene is inhibited by at least 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95%, or to below the level of detection of the assay.
  • expression of a KHK gene is inhibited by at least 70%.
  • expression level is determined using the assay method provided in Example 2 with a 10 nM siRNA concentration in the appropriate species matched cell line.
  • inhibition of expression in vivo is determined by knockdown of the human gene in a rodent expressing the human gene, e.g., an AAV-infected mouse expressing the human target gene (i.e., KHK), e.g., when administered as a single dose, e.g., at 3 mg/kg at the nadir of RNA expression.
  • Knockdown of expression of an endogenous gene in a model animal system can also be determined, e.g., after administration of a single dose at, e.g., 3 mg/kg at the nadir of RNA expression. Such systems are useful when the nucleic acid sequence of the human gene and the model animal gene are sufficiently close such that the human iRNA provides effective knockdown of the model animal gene.
  • RNA expression in liver is determined using the PCR methods provided in Example 2.
  • Inhibition of the expression of a KHK gene may be manifested by a reduction of the amount of mRNA expressed by a first cell or group of cells (such cells may be present, for example, in a sample derived from a subject) in which a KHK gene is transcribed and which has or have been treated (e.g., by contacting the cell or cells with an iRNA of the invention, or by administering an iRNA of the invention to a subject in which the cells are or were present) such that the expression of a KHK gene is inhibited, as compared to a second cell or group of cells substantially identical to the first cell or group of cells but which has not or have not been so treated (control cell(s) not treated with an iRNA or not treated with an iRNA targeted to the gene of interest).
  • the inhibition is assessed by the method provided in Example 2 using a 10nM siRNA concentration in the species matched cell line and expressing the level of mRNA in treated cells as a percentage of the level of mRNA in control cells, using the following formula:
  • inhibition of the expression of a KHK gene may be assessed in terms of a reduction of a parameter that is functionally linked to KHK gene expression, e.g., KHK protein level in blood or serum from a subject.
  • KHK gene silencing may be determined in any cell expressing KHK, either endogenous or heterologous from an expression construct, and by any assay known in the art.
  • Inhibition of the expression of a KHK protein may be manifested by a reduction in the level of the KHK protein that is expressed by a cell or group of cells or in a subject sample (e.g., the level of protein in a blood sample derived from a subject).
  • a subject sample e.g., the level of protein in a blood sample derived from a subject.
  • the inhibition of protein expression levels in a treated cell or group of cells may similarly be expressed as a percentage of the level of protein in a control cell or group of cells, or the change in the level of protein in a subject sample, e.g., blood or serum derived therefrom.
  • a control cell, a group of cells, or subject sample that may be used to assess the inhibition of the expression of a KHK gene includes a cell, group of cells, or subject sample that has not yet been contacted with an RNAi agent of the invention.
  • the control cell, group of cells, or subject sample may be derived from an individual subject (e.g., a human or animal subject) prior to treatment of the subject with an RNAi agent or an appropriately matched population control.
  • the level of KHK mRNA that is expressed by a cell or group of cells may be determined using any method known in the art for assessing mRNA expression.
  • the level of expression of KHK in a sample is determined by detecting a transcribed polynucleotide, or portion thereof, e.g., mRNA of the KHK gene.
  • RNA may be extracted from cells using RNA extraction techniques including, for example, using acid phenol/guanidine isothiocyanate extraction (RNAzol B; Biogenesis), RNeasy TM RNA preparation kits (Qiagen®) or PAXgene TM (PreAnalytix TM , Switzerland).
  • Typical assay formats utilizing ribonucleic acid hybridization include nuclear run-on assays, RT-PCR, RNase protection assays, northern blotting, in situ hybridization, and microarray analysis.
  • the level of expression of KHK is determined using a nucleic acid probe.
  • probe refers to any molecule that is capable of selectively binding to a specific KHK. Probes can be synthesized by one of skill in the art, or derived from appropriate biological preparations. Probes may be specifically designed to be labeled. Examples of molecules that can be utilized as probes include, but are not limited to, RNA, DNA, proteins, antibodies, and organic molecules. Isolated mRNA can be used in hybridization or amplification assays that include, but are not limited to, Southern or northern analyses, polymerase chain reaction (PCR) analyses and probe arrays.
  • PCR polymerase chain reaction
  • One method for the determination of mRNA levels involves contacting the isolated mRNA with a nucleic acid molecule (probe) that can hybridize to KHK mRNA.
  • the mRNA is immobilized on a solid surface and contacted with a probe, for example by running the isolated mRNA on an agarose gel and transferring the mRNA from the gel to a membrane, such as nitrocellulose.
  • the probe(s) are immobilized on a solid surface and the mRNA is contacted with the probe(s), for example, in an Affymetrix® gene chip array.
  • a skilled artisan can readily adapt known mRNA detection methods for use in determining the level of KHK mRNA.
  • An alternative method for determining the level of expression of KHK in a sample involves the process of nucleic acid amplification or reverse transcriptase (to prepare cDNA) of for example mRNA in the sample, e.g., by RT-PCR (the experimental embodiment set forth in Mullis, 1987, U.S. Patent No.4,683,202), ligase chain reaction (Barany (1991) Proc. Natl. Acad. Sci. USA 88:189-193), self sustained sequence replication (Guatelli et al . (1990) Proc. Natl. Acad. Sci. USA 87:1874-1878), transcriptional amplification system (Kwoh et al . (1989) Proc. Natl. Acad. Sci.
  • the level of expression of KHK is determined by quantitative fluorogenic RT-PCR (i.e., the TaqMan TM System).
  • expression level is determined by the method provided in Example 2 using, e.g., a 10nM siRNA concentration, in the species matched cell line.
  • the expression levels of KHK mRNA may be monitored using a membrane blot (such as used in hybridization analysis such as northern, Southern, dot, and the like), or microwells, sample tubes, gels, beads or fibers (or any solid support comprising bound nucleic acids). See U.S. Patent Nos.5,770,722, 5,874,219, 5,744,305, 5,677,195 and 5,445,934, which are incorporated herein by reference.
  • the determination of KHK expression level may also comprise using nucleic acid probes in solution.
  • the level of mRNA expression is assessed using branched DNA (bDNA) assays or real time PCR (qPCR). The use of these methods is described and exemplified in the Examples presented herein.
  • expression level is determined by the method provided in Example 2 using a 10nM siRNA concentration in the species matched cell line.
  • the level of KHK protein expression may be determined using any method known in the art for the measurement of protein levels.
  • Such methods include, for example, electrophoresis, capillary electrophoresis, high performance liquid chromatography (HPLC), thin layer chromatography (TLC), hyperdiffusion chromatography, fluid or gel precipitin reactions, absorption spectroscopy, a colorimetric assays, spectrophotometric assays, flow cytometry, immunodiffusion (single or double), immunoelectrophoresis, western blotting, radioimmunoassay (RIA), enzyme-linked immunosorbent assays (ELISAs), immunofluorescent assays, electrochemiluminescence assays, and the like.
  • the efficacy of the methods of the invention are assessed by a decrease in KHK mRNA or protein level (e.g., in a liver biopsy).
  • the iRNA is administered to a subject such that the iRNA is delivered to a specific site within the subject.
  • the inhibition of expression of KHK may be assessed using measurements of the level or change in the level of KHK mRNA or KHK protein in a sample derived from fluid or tissue from the specific site within the subject (e.g., liver or blood).
  • the terms detecting or determining a level of an analyte are understood to mean performing the steps to determine if a material, e.g., protein, RNA, is present.
  • methods of detecting or determining include detection or determination of an analyte level that is below the level of detection for the method used.
  • KHK-associated disorder e.g., liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney
  • liver disease e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)
  • dyslipidemia e.g., hyperlipidemia, high LDL cholesterol,
  • the cell may be contacted with the siRNA in vitro or in vivo, i.e., the cell may be within a subject.
  • a cell suitable for treatment using the methods of the invention may be any cell that expresses a KHK gene, e.g., a liver cell.
  • a cell suitable for use in the methods of the invention may be a mammalian cell, e.g., a primate cell (such as a human cell, including human cell in a chimeric non- human animal, or a non-human primate cell, e.g., a monkey cell or a chimpanzee cell), or a non- primate cell.
  • the cell is a human cell, e.g., a human liver cell.
  • KHK expression is inhibited in the cell by at least 50, 55, 60, 65, 70, 75, 80, 85, 90, or 95, or to a level below the level of detection of the assay.
  • the in vivo methods of the invention may include administering to a subject a composition containing an iRNA, where the iRNA includes a nucleotide sequence that is complementary to at least a part of an RNA transcript of the KHK gene of the mammal to which the RNAi agent is to be administered.
  • compositions can be administered by any means known in the art including, but not limited to oral, intraperitoneal, or parenteral routes, including intracranial (e.g., intraventricular, intraparenchymal, and intrathecal), intravenous, intramuscular, subcutaneous, transdermal, airway (aerosol), nasal, rectal, and topical (including buccal and sublingual) administration.
  • intracranial e.g., intraventricular, intraparenchymal, and intrathecal
  • intravenous intramuscular
  • subcutaneous e.g., transdermal
  • nasal rectal
  • topical including buccal and sublingual
  • the compositions are administered by intravenous infusion or injection.
  • the compositions are administered by subcutaneous injection.
  • the compositions are administered by intramuscular injection.
  • the present invention also provides methods for inhibiting the expression of an KHK gene in a mammal.
  • the methods include administering to the mammal a composition comprising a dsRNA that targets a KHK gene in a cell of the mammal and maintaining the mammal for a time sufficient to obtain degradation of the mRNA transcript of the KHK gene, thereby inhibiting expression of the KHK gene in the cell.
  • Reduction in gene expression can be assessed by any methods known in the art and by methods, e.g. qRT-PCR, described herein, e.g., in Example 2.
  • Reduction in protein production can be assessed by any methods known it the art, e.g. ELISA.
  • a puncture liver biopsy sample serves as the tissue material for monitoring the reduction in the KHK gene or protein expression.
  • a blood sample serves as the subject sample for monitoring the reduction in the KHK protein expression.
  • a reduction in the expression of KHK may also be assessed indirectly by measuring a decrease in fructose metabolism by detecting one or more indicators of fructose metabolism, e.g., the presence of fructose in the urine indicating lack of fructose metabolism.
  • the present invention further provides methods of treatment in a subject in need thereof, e.g., a subject diagnosed with a KHK-associated disorder, such as, liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver, steatohepatitis
  • the present invention further provides methods of prophylaxis in a subject in need thereof.
  • the treatment methods of the invention include administering an iRNA of the invention to a subject, e.g., a subject that would benefit from a reduction of KHK expression, in a prophylactically effective amount of an iRNA targeting a KHK gene or a pharmaceutical composition comprising an iRNA targeting a KHK gene.
  • the present invention provides methods of treating a subject having a disorder that would benefit from reduction in KHK expression, e.g., a KHK-associated disease, such as liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • a KHK-associated disease such as liver disease (e.g.,
  • the KHK-associated disorder is a liver disease, e.g., fatty liver disease such as NAFLD or NASH.
  • the KHK-associated disorder is dyslipidemia, e.g., elevated serum triglycerides, elevated serum LDL, elevated serum cholesterol, lowered serum HDL, postprandial hypertriglyceridemia.
  • the KHK-associated disorder is a disorder of glycemic control, e.g., insulin resistance not resulting from an immune response against insulin, glucose resistance, type 2 diabetes.
  • the KHK- associated disorder is a cardiovascular disease, e.g., hypertension, endothelial cell dysfunction.
  • the KHK-associated disorder is a kidney disease, e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease.
  • the disease is metabolic syndrome.
  • the KHK- associated disorder is a disease of lipid deposition or dysfunction, e.g., visceral adipose deposition, fatty liver, obesity.
  • the KHK-associated disorder is a disease of elevated uric acid, e.g., gout, hyperuricemia.
  • the KHK-associated disorder is an eating disorder such as excessive sugar craving.
  • An iRNA of the invention may be administered as a “free iRNA.”
  • a free iRNA is administered in the absence of a pharmaceutical composition.
  • the naked iRNA may be in a suitable buffer solution.
  • the buffer solution may comprise acetate, citrate, prolamine, carbonate, or phosphate, or any combination thereof.
  • the buffer solution is phosphate buffered saline (PBS).
  • PBS phosphate buffered saline
  • the pH and osmolarity of the buffer solution containing the iRNA can be adjusted such that it is suitable for administering to a subject.
  • an iRNA of the invention may be administered as a pharmaceutical composition, such as a dsRNA liposomal formulation.
  • Subjects that would benefit from an inhibition of KHK gene expression are subjects susceptible to or diagnosed with an KHK-associated disorder, such as liver disease (e.g., fatty liver, steatohepatitis, non-alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • liver disease e.g., fatty liver, steatohepatitis, non-alcoholic steatohe
  • the method includes administering a composition featured herein such that expression of the target a KHK gene is decreased, such as for about 1, 2, 3, 4, 5, 6, 1-6, 1-3, or 3-6 months per dose.
  • the composition is administered once every 3-6 months.
  • the iRNAs useful for the methods and compositions featured herein specifically target RNAs (primary or processed) of the target a KHK gene. Compositions and methods for inhibiting the expression of these genes using iRNAs can be prepared and performed as described herein.
  • Administration of the iRNA according to the methods of the invention may result prevention or treatment of a KHK-associated disorder, e.g., liver disease (e.g., fatty liver, steatohepatitis, non- alcoholic steatohepatitis (NASH)), dyslipidemia (e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia), disorders of glycemic control (e.g., insulin resistance, type 2 diabetes), cardiovascular disease (e.g., hypertension, endothelial cell dysfunction), kidney disease (e.g., acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, chronic kidney disease), metabolic syndrome, adipocyte dysfunction, visceral adipose deposition, obesity, hyperuricemia, gout, eating disorders, and excessive sugar craving.
  • a KHK-associated disorder e.g., liver disease (e.g., fatty liver
  • the iRNA is administered about once per month to about once every three months, or about once every three months to about once every six months.
  • the invention further provides methods and uses of an iRNA agent or a pharmaceutical composition thereof for treating a subject that would benefit from reduction and/or inhibition of KHK gene expression, e.g., a subject having an KHK-associated disease, in combination with other pharmaceuticals and/or other therapeutic methods, e.g., with known pharmaceuticals and/or known therapeutic methods, such as, for example, those which are currently employed for treating these disorders.
  • the methods which include either a single iRNA agent of the invention further include administering to the subject one or more additional therapeutic agents.
  • the iRNA agent and an additional therapeutic agent and/or treatment may be administered at the same time and/or in the same combination, e.g., parenterally, or the additional therapeutic agent can be administered as part of a separate composition or at separate times and/or by another method known in the art or described herein.
  • IX. Diagnostic Criteria and Treatment for KHK-Associated diseases Diagnostic criteria, therapeutic agents, and considerations for treatment for various KHK- associated diseases are provided below.
  • A. Hyperuricemia Serum uric acid levels are not routinely obtained as clinical lab values.
  • hyperuricemia is associated with a number of diseases and conditions including gout, NAFLD, NASH, metabolic disorder, insulin resistance (not resulting from an immune response to insulin), cardiovascular disease, hypertension, and type 2 diabetes. It is expected that decreasing KHK expression can be useful in the prevention or treatment of one or more conditions associated with elevated serum uric acid levels. Further, it is expected that a subject would derive clinical benefit from normalization of serum uric acid levels towards or to a normal serum uric acid level, e.g., no more than 6.8 mg/dl, such as, no more than 6 mg/dl, even in the absence of overt signs or symptoms of one or more conditions associated with elevated uric acid.
  • Animal models of hyperuricemia include, for example, high fructose diet, e.g., in rats and mice, which can induce one or more of fat accumulation including fatty liver, insulin resistance, type 2 diabetes, obesity including visceral obesity, metabolic syndrome, decreased adiponectin secretion, reduced renal function, and inflammation (see, e.g., Johnson et al . (2013) Diabetes.62:3307-3315).
  • Administration of oxonic acid, a uricase inhibitor can also be used to induce hyperuricemia (see, e.g.,Mazalli et al . (2001) Hypertens.38:1101-1106).
  • hyperuricemia Genetic models of hyperuricemia include the B6;129S7-Uox tm1Bay /J mouse available from Jackson Laboratory (/jaxmice.jax.org/strain/002223.html) which develops hyperuricemia, with 10-fold higher levels of serum uric acid levels.
  • Various treatments for hyperuricemia are known in the art. However, some of the agents can only be used in limited populations.
  • allopurinol is a xanthine oxidase inhibitor that is used to reduce serum uric acid levels for the treatment of a number of conditions, e.g., gout, cardiovascular disease including ischemia-reperfusion injury, hypertension, atherosclerosis, and stroke, and inflammatory diseases (Pacher et al ., (2006) Pharma. Rev.58:87-114).
  • cardiovascular disease including ischemia-reperfusion injury, hypertension, atherosclerosis, and stroke, and inflammatory diseases
  • inflammatory diseases Pieris of uric acid
  • the use of allopurinol is contraindicated in subjects with impaired renal function, e.g., chronic kidney disease, hypothyroidism, hyperinsulinemia, or insulin resistance; or in subjects predisposed to kidney disease or impaired renal function, e.g., subjects with hypertension, metabolic disorder, diabetes, and the elderly.
  • compositions and methods of the invention are used in combination with other compositions and methods to treat hyperuricemia, e.g., allopurinol, oxypurinol, febuxostat.
  • the compositions and methods of the invention are used for treatment of subjects with reduced kidney function or susceptible to reduced kidney function, e.g., due to age, comorbidities, or drug interactions.
  • B. Gout Gout affects approximately 1 in 40 adults, most commonly men between 30-60 years of age.
  • Gout less commonly affects women. Gout is one of a few types of arthritis where future damage to joints can be avoided by treatment. Gout is characterized by recurrent attacks of acute inflammatory arthritis caused by an inflammatory reaction to uric acid crystals in the joint due to hyperuricemia resulting from insufficient renal clearance of uric acid or excessive uric acid production. Fructose associated gout is sometimes associated with variants of transporters expressed in the kidney, intestine, and liver. Gout is characterized by the formation and deposition of tophi, monosodium urate (MSU) crystals, in the joints and subcutaneously. Pain associated with gout is not related to the size of the tophi, but is a result of an immune response against the MSU crystals.
  • MSU monosodium urate
  • gout does not require complete clearance of tophi or resolution of all symptoms, e.g., joint pain and swelling, inflammation, but simply a reduction in at least one sign or symptom of gout, e.g., reduction in severity or frequency of gout attacks, in conjunction with a reduction in serum urate levels.
  • Animal models of gout include oxonic acid- induced hyperuricemia (see, e.g., Jang et al . (2014) Mycobiology.42:296-300).
  • Currently available treatments for gout are contraindicated or ineffective in a number of subjects.
  • Allopurinol a common first line treatment to reduce uric acid levels in subjects with gout, is contraindicated in a number of populations, especially those with compromised renal function, as discussed above. Further, a number of subjects fail treatment with allopurinol, e.g., subjects who suffer gout flares despite treatment, or subjects who suffer from rashes or hypersensitivity reactions associated with allopurinol.
  • the compositions and methods of the invention are used in combination with other agents to reduce serum uric acid.
  • the compositions and methods of the invention are used in combination with agents for treatment of symptoms of gout, e.g., analgesic or anti-inflammatory agents, e.g., NSAIDS.
  • compositions and methods of the invention are used for treatment of subjects with reduced kidney function or susceptible to reduced kidney function, e.g., due to age, comorbidities, or drug interactions.
  • C. Liver disease NAFLD is associated with hyperuricemia (Xu et al . (2015) J. Hepatol.62:1412-1419) which, in turn, is associated with elevated fructose metabolism.
  • NAFLD nonalcoholic fatty liver disease
  • NAFLD nonalcoholic fatty liver
  • NASH nonalcoholic steatohepatitis
  • NAFLD Genetic models of NAFLD include the B6.129S7-Ldlr tm1Her /J and the B6.129S4-Pten tm1Hwu /J mice available from The Jackson Laboratory.
  • Treatment of NAFLD is typically to manage the conditions that resulted in development of NAFLD. For example, patients with dyslipidemia are treated with agents to normalize cholesterol or triglycerides, as needed, to treat or prevent further progression of NAFLD. Patients with type 2 diabetes are treated with agents to normalize glucose or insulin sensitivity. Lifestyle changes, e.g., changes in diet and exercise, are also used to treat NAFLD.
  • compositions and methods of the invention are used in combination with other agents to reduce serum uric acid.
  • compositions and methods of the invention are used in combination with agents for treatment of symptoms of NAFLD.
  • the compositions and methods of the invention are used for treatment of subjects with reduced kidney function or susceptible to reduced kidney function, e.g., due to age, comorbidities, or drug interactions. D.
  • Dyslipidemia disorders of glycemic control, metabolic syndrome, and obesity
  • Dyslipidemia e.g., hyperlipidemia, high LDL cholesterol, low HDL cholesterol, hypertriglyceridemia, postprandial hypertriglyceridemia
  • disorders of glycemic control e.g., insulin resistance, type 2 diabetes
  • metabolic syndrome e.g., adipocyte dysfunction, visceral adipose deposition, obesity, and excessive sugar craving are associated with elevated fructose metabolism. Characteristics or diagnostic criteria for the conditions are provided below.
  • Animal models of metabolic disorder and the component features include various high fat- or high fructose-fed animal models.
  • Genetic models include leptin deficient B6.Cg-Lep ob /J, commonly known as ob or ob/ob mice, which are available from The Jackson Laboratory.
  • Postprandial hypertriglyceridemia is principally initiated by overproduction or decreased catabolism of triglyceride-rich lipoproteins (TRLs) and is a consequence of predisposing genetic variations and medical conditions such as obesity and insulin resistance.
  • Insulin resistance is characterized by the presence of at least one of: 1. A fasting blood glucose level of 100-125 mg/dL taken at two different times; or 2. An oral glucose tolerance test with a result of a glucose level of 140-199 mg/dL at 2 hours after glucose consumption.
  • insulin resistance does not include a lack of response to insulin as a result of an immune response to administered insulin as often occurs in late stages of insulin dependent diabetes, especially type 1 diabetes.
  • Type 2 diabetes is characterized by at least one of: 1. A fasting blood glucose level ⁇ 126 mg/dL taken at two different times; 2. A hemoglobin A1c (A1C) test with a result of ⁇ 6.5% or higher; or 3. An oral glucose tolerance test with a result of a glucose level ⁇ 200 mg/dL at 2 hours after glucose consumption.
  • Pharmacological treatments for type 2 diabetes and insulin resistance include treatment with agents to normalize blood sugar such as metformin (e.g., glucophage, glumetza), sulfonylureas (e.g., glyburide, glipizide, glimepiride), meglitinides (e.g., repaglinide, nateglinide), thiazolidinediones (rosiglitazone, pioglitazone), DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin), GLP-1 receptor antagonists (exenatide, liraglutide), and SGLT2 inhibitors (e.g., canagliflozin, dapagliflozin).
  • metformin e.g., glucophage, glumetza
  • sulfonylureas e.g., glyburide, glipizide, gli
  • Obesity is characterized as disease of excess body fat.
  • Body mass index (BMI) which is calculated by dividing body weight in kilograms (kg) by height in meters (m) squared, provides a reasonable estimate of body fat for most, but not all, people.
  • BMI Body mass index
  • a BMI below 18.5 is characterized as underweight, 18-.5 to24.9 is normal, 25.0-29.9 is overweight, 30.0-34.9 is obese (class I), 35-39.9 is obese (class II), and 40.0 and higher is extremely obese (class III).
  • visceral fat are provided, for example, in Wajchenberg (2000) Subcutaneous and visceral adipose tissue: their relation to the metabolic syndrome, Endocr Rev.21:697-738, which is incorporated herein by reference.
  • Metabolic syndrome is characterized by a cluster of conditions defined as at least three of the five following metabolic risk factors: 1. Large waistline ( ⁇ 35 inches for women or ⁇ 40 inches for men); 2. High triglyceride level ( ⁇ 150 mg/dl); 3. Low HDL cholesterol ( ⁇ 50 mg/dl for women or ⁇ 40 mg/dl for men); 4. Elevated blood pressure ( ⁇ 130/85) or on medicine to treat high blood pressure; and 5. High fasting blood sugar ( ⁇ 100 mg/dl) or being in medicine to treat high blood sugar.
  • the agents for treatment of metabolic syndrome depend on the specific risk factors present, e.g., normalize lipids when lipids are abnormal, normalize glucose or insulin sensitivity when they are abnormal.
  • Metabolic syndrome, insulin resistance, and type 2 diabetes are often associated with decreased renal function or the potential for decreased renal function.
  • the compositions and methods of the invention are for use in treatment of subjects with dyslipidemia, disorders of glycemic control, metabolic syndrome, and obesity.
  • the compositions and methods of the invention are for use in subjects with metabolic syndrome, insulin resistance, or type 2 diabetes and chronic kidney disease.
  • compositions and methods are for use in subjects with metabolic syndrome, insulin resistance, or type 2 diabetes who are suffering from one or more of cardiovascular disease, hypothyroidism, or inflammatory disease; or elderly subjects (e.g., over 65).
  • the compositions and methods are for use in subjects with metabolic syndrome, insulin resistance, or type 2 diabetes who are also taking a drug that can reduce kidney function as demonstrated by the drug label.
  • the compositions and methods of the invention are for use in subjects with metabolic syndrome, insulin resistance, or type 2 diabetes who are being treated with oral coagulants or probencid.
  • compositions and methods of the invention are for use in subjects with metabolic syndrome, insulin resistance, or type 2 diabetes who are being treated with diuretics, especially thiazide diuretics.
  • the compositions and methods of the invention are used in combination with other agents to reduce serum uric acid.
  • the compositions and methods of the invention are used in combination with agents for treatment of symptoms of metabolic syndrome, insulin resistance, or type 2 diabetes.
  • subjects are treated with e.g., agents to decrease blood pressure, e.g., diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha blockers, alpha-2 receptor antagonists, combined alpha- and beta-blockers, central agonists, peripheral adrenergic inhibitors, and blood vessel dialators; agents to decrease cholesterol, e.g., statins, selective cholesterol absorption inhibitors, resins, or lipid lowering therapies; or agents to normalize blood sugar, e.g., metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor antagonists, and SGLT2 inhibitors.
  • agents to decrease blood pressure e.g., diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha blockers, alpha-2 receptor antagonists, combined alpha- and beta-block
  • compositions and methods of the invention are used for treatment of subjects with reduced kidney function or susceptible to reduced kidney function, e.g., due to age, comorbidities, or drug interactions.
  • the iRNA and additional therapeutic agents may be administered at the same time or in the same combination, e.g., parenterally, or the additional therapeutic agent can be administered as part of a separate composition or at separate times or by another method known in the art or described herein.
  • E. Cardiovascular disease In certain embodiments, the compositions and methods of the invention are for use in treatment of subjects with cardiovascular disease. For example, in certain embodiments, the compositions and methods of the invention are for use in subjects with cardiovascular disease and chronic kidney disease.
  • the compositions and methods are for use in subjects with cardiovascular disease who are suffering from one or more of metabolic disorder, insulin resistance, hyperinsulinemia, diabetes, hypothyroidism, or inflammatory disease.
  • the compositions and methods are for use in subjects with cardiovascular disease who are also taking a drug that can reduce kidney function as demonstrated by the drug label.
  • the compositions and methods of the invention are for use in subjects with cardiovascular disease who are being treated with oral coagulants or probencid.
  • the compositions and methods of the invention are for use in subjects with cardiovascular disease who are being treated with diuretics, especially thiazide diuretics.
  • compositions and methods of the invention are for use in subjects with cardiovascular disease who have failed treatment with allopurinol.
  • the compositions and methods of the invention are used in combination with other agents to reduce serum uric acid.
  • the compositions and methods of the invention are used in combination with agents for treatment of symptoms of cardiovascular disease, e.g., agents to decrease blood pressure, e.g., diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha blockers, alpha-2 receptor antagonists, combined alpha- and beta-blockers, central agonists, peripheral adrenergic inhibitors, and blood vessel dialators; or agents to decrease cholesterol, e.g., statins, selective cholesterol absorption inhibitors, resins, or lipid lowering therapies.
  • agents to decrease blood pressure e.g., diuretics, beta-blockers, ACE inhibitors, angiotensin II receptor blockers, calcium channel blockers, alpha blockers, alpha-2 receptor antagonists, combined
  • Kidney disease includes, for example, acute kidney disorder, tubular dysfunction, proinflammatory changes to the proximal tubules, and chronic kidney disease.
  • Acute kidney (renal) failure occurs when the kidneys suddenly become unable to filter waste products from the blood resulting in accumulation of dangerous levels of wastes in serum and systemic chemical imbalance.
  • Acute kidney failure can develop rapidly over a few hours or a few days, and is most common in individuals who are already hospitalized, particularly in critically ill individuals who need intensive care. Acute kidney failure can be fatal and requires intensive treatment. However, acute kidney failure may be reversible. If you're otherwise in good health, you may recover normal or nearly normal kidney function.
  • Chronic kidney disease also called chronic kidney failure, describes the gradual loss of kidney function.
  • kidney disease When chronic kidney disease reaches an advanced stage, dangerous levels of fluid, electrolytes and wastes can accumulate in the body. Signs and symptoms of kidney disease may include nausea, vomiting, loss of appetite, fatigue and weakness, sleep problems, changes in urine output, decreased mental sharpness, muscle twitches and cramps, hiccups, swelling of feet and ankles, persistent itching, chest pain, if fluid builds up around the lining of the heart, shortness of breath, if fluid builds up in the lungs, high blood pressure (hypertension) that's difficult to control. Signs and symptoms of chronic kidney disease are often nonspecific and can develop slowly, and may not appear until irreversible damage has occurred. Kidney disease is treated by removing the damaging agent or condition that is causing kidney damage, e.g.
  • Renal function is typically determined using one or more routine laboratory tests, BUN (blood urea nitrogen), creatinine (blood), creatinine (urine), or creatinine clearance (see, e.g., www.nlm.nih.gov/medlineplus/ency/article/003435.htm). The tests may also be diagnostic of conditions in other organs. Generally, a BUN level of 6 to 20 mg/dL is considered normal, although normal values may vary among different laboratories.
  • Elevated BUN level can be indicative of kidney disease, including glomerulonephritis, pyelonephritis, and acute tubular necrosis, or kidney failure.
  • a normal result for blood creatinine is 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women. Elevated blood creatinine can be indicative of compromised kidney function due to kidney damage or failure, infection, or reduced blood flow.
  • Urine creatinine (24-hour sample) values can range from 500 to 2000 mg/day. Results depend on age and amount of lean body mass. Normal results are 14 to 26 mg per kg of body mass per day for men and 11 to 20 mg per kg of body mass per day for women.
  • Abnormal results can be indicative of kidney damage, such as damage to the tubule cells, kidney failure, decreased blood flow to the kidneys, or kidney infection (pyelonephritis).
  • the creatinine clearance test helps provide information regarding kidney function by comparing the creatinine level in urine with the creatinine level in blood. Clearance is often measured as milliliters per minute (ml/min). Normal values are 97 to 137 ml/min. for men and 88 to 128 ml/min. for women. Lower than normal creatinine clearance can be indicative of kidney damage, such as damage to the tubule cells, kidney failure, decreased blood flow to the kidneys, or reduced glomerular filtration in the kidneys.
  • kits that include a suitable container containing a pharmaceutical formulation of a siRNA compound, e.g., a double-stranded siRNA compound, or siRNA compound, (e.g., a precursor, e.g., a larger siRNA compound which can be processed into a siRNA compound, or a DNA which encodes an siRNA compound, e.g., a double- stranded siRNA compound, or ssiRNA compound, or precursor thereof).
  • a suitable container containing a pharmaceutical formulation of a siRNA compound, e.g., a double-stranded siRNA compound, or siRNA compound, (e.g., a precursor, e.g., a larger siRNA compound which can be processed into a siRNA compound, or a DNA which encodes an siRNA compound, e.g., a double- stranded siRNA compound, or ssiRNA compound, or precursor thereof).
  • kits include one or more dsRNA agent(s) and instructions for use, e.g., instructions for administering a prophylactically or therapeutically effective amount of a dsRNA agent(s).
  • the dsRNA agent may be in a vial or a pre-filled syringe.
  • the kits may optionally further comprise means for administering the dsRNA agent (e.g., an injection device, such as a pre-filled syringe), or means for measuring the inhibition of KHK (e.g., means for measuring the inhibition of KHK mRNA, KHK protein, and/or KHK activity).
  • kits of the invention may optionally further comprise means for determining the therapeutically effective or prophylactically effective amount.
  • the individual components of the pharmaceutical formulation may be provided in one container, e.g., a vial or a pre-filled syringe.
  • the kit may be packaged in a number of different configurations such as one or more containers in a single box.
  • the different components can be combined, e.g., according to instructions provided with the kit.
  • the components can be combined according to a method described herein, e.g., to prepare and administer a pharmaceutical composition.
  • the kit can also include a delivery device.
  • This invention is further illustrated by the following examples which should not be construed as limiting. The entire contents of all references, patents and published patent applications cited throughout this application, as well as the informal Sequence Listing, are hereby incorporated herein by reference.
  • AD-959917 is equivalent to AD-959917.1.
  • siRNA Synthesis siRNAs were designed, synthesized, and prepared using methods known in the art. Briefly, siRNA sequences were synthesized on a 1 ⁇ mol scale using a Mermade 192 synthesizer (BioAutomation) with phosphoramidite chemistry on solid supports. The solid support was controlled pore glass (500-1000 ⁇ ) loaded with a custom GalNAc ligand (3’-GalNAc conjugates), universal solid support (AM Chemicals), or the first nucleotide of interest.
  • Phosphoramidites were prepared at a concentration of 100 mM in either acetonitrile or 9:1 acetonitrile:DMF and were coupled using 5-Ethylthio-1H-tetrazole (ETT, 0.25 M in acetonitrile) with a reaction time of 400 s.
  • Phosphorothioate linkages were generated using a 100 mM solution of 3- ((Dimethylamino-methylidene) amino)-3H-1,2,4-dithiazole-3-thione (DDTT, obtained from Chemgenes (Wilmington, MA, USA)) in anhydrous acetonitrile/pyridine (9:1 v/v). Oxidation time was 5 minutes.
  • oligonucleotide solution in aqueous methylamine was added 200 ⁇ L of dimethyl sulfoxide (DMSO) and 300 ⁇ L TEA.3HF and the solution was incubated for approximately 30 mins at 60 °C. After incubation, the plate was allowed to come to room temperature and crude oligonucleotides were precipitated by the addition of 1 mL of 9:1 acetontrile:ethanol or 1:1 ethanol:isopropanol. The plates were then centrifuged at 4 °C for 45 mins and the supernatant carefully decanted with the aid of a multichannel pipette.
  • DMSO dimethyl sulfoxide
  • the oligonucleotide pellet was resuspended in 20 mM NaOAc and subsequently desalted using a HiTrap size exclusion column (5 mL, GE Healthcare) on an Agilent LC system equipped with an autosampler, UV detector, conductivity meter, and fraction collector. Desalted samples were collected in 96 well plates and then analyzed by LC-MS and UV spectrometry to confirm identity and quantify the amount of material, respectively. Duplexing of single strands was performed on a Tecan liquid handling robot.
  • Sense and antisense single strands were combined in an equimolar ratio to a final concentration of 10 ⁇ M in 1x PBS in 96 well plates, the plate sealed, incubated at 100 °C for 10 minutes, and subsequently allowed to return slowly to room temperature over a period of 2-3 hours. The concentration and identity of each duplex was confirmed and then subsequently utilized for in vitro screening assays.
  • Example 2 In vitro screening methods HepG2 Cell culture and 96-well transfections HepG2 cells were grown to near confluence at 37°C in an atmosphere of 5% CO 2 in Eagle’s Minimum Essential Medium (Gibco) supplemented with 10% FBS (ATCC) before being released from the plate by trypsinization.
  • Transfection was carried out by adding 18.5 ⁇ l of Opti-MEM plus 0.25 ⁇ l of Lipofectamine RNAiMax per well (Invitrogen, Carlsbad CA. cat # 13778-150) to 5 ⁇ l of each siRNA duplex to an individual well in a 96-well plate. The mixture was then incubated at room temperature for 15 minutes. Eighty ⁇ l of complete growth media without antibiotic containing ⁇ 2 x10 4 HepG2 cells were then added to the siRNA mixture. Cells were incubated for 24 hours prior to RNA purification. Dose experiments were performed at 10 nM, 1 nM and 0.1 nM final duplex concentration.
  • RNA isolation using DYNABEADS mRNA Isolation Kit (InvitrogenTM, part #: 610-12) Cells were lysed in 75 ⁇ l of Lysis/Binding Buffer containing 3 ⁇ L of beads per well and mixed for 10 minutes on an electrostatic shaker. The washing steps were automated on a Biotek EL406, using a magnetic plate support. Beads were washed (in 90 ⁇ L) once in Buffer A, once in Buffer B, and twice in Buffer E, with aspiration steps in between. Following a final aspiration, complete 10 ⁇ L RT mixture was added to each well, as described below.
  • Real time PCR Two microlitre ( ⁇ l) of cDNA were added to a master mix containing 0.5 ⁇ l of human GAPDH TaqMan Probe (4326317E), 0.5 ⁇ l human KHK, 2 ⁇ l nuclease-free water and 5 ⁇ l Lightcycler 480 probe master mix (Roche Cat # 04887301001) per well in a 384 well plates (Roche cat # 04887301001).
  • Real time PCR was done in a LightCycler480 Real Time PCR system (Roche). To calculate relative fold change, data were analyzed using the ⁇ Ct method and normalized to assays performed with cells transfected with 10nM AD-1955, or mock transfected cells.
  • IC50s were calculated using a 4 parameter fit model using XLFit and normalized to cells transfected with AD-1955 or mock-transfected.
  • the sense and antisense sequences of AD-1955 are: sense: cuuAcGcuGAGuAcuucGAdTsdT (SEQ ID NO: 18) and antisense UCGAAGuACUcAGCGuAAGdTsdT (SEQ ID NO: 19).
  • the results of the transfection assays of the dsRNA agents listed in Tables 2 and 3 in HepG2 cells are shown in Table 4.
  • Table 1. Abbreviations of nucleotide monomers used in nucleic acid sequence representation.
  • Example 3 Design, Synthesis and In Vitro Screening of Additional dsRNA Duplexes
  • Additional siRNAs were designed, synthesized, and prepared using methods known in the art and described above in Example 1.
  • Detailed lists of the additional unmodified KHK sense and antisense strand nucleotide sequences are shown in Table 5.
  • Detailed lists of the modified KHK sense and antisense strand nucleotide sequences are shown in Table 6.
  • Hep3b cells ATCC, Manassas, VA
  • Gibco Minimum Essential Medium
  • FBS FBS
  • RNAiMax Lipofectamine RNAiMax per well (Invitrogen, Carlsbad CA. cat # 13778-150) to 2.5 ⁇ l of each siRNA duplex to an individual well in a 384-well plate. The mixture was then incubated at room temperature for 15 minutes. Forty ⁇ l of complete growth media without antibiotic containing ⁇ 1.5 x10 4 Hep3b cells were then added to the siRNA mixture. Cells were incubated for 24 hours prior to RNA purification. Single dose experiments were performed at 10 nM final duplex concentration. Total RNA isolation was performed using DYNABEADS.
  • cells were lysed in 10 ⁇ l of Lysis/Binding Buffer containing 3 ⁇ L of beads per well and mixed for 10 minutes on an electrostatic shaker.
  • the washing steps were automated on a Biotek EL406, using a magnetic plate support. Beads were washed (in 3 ⁇ L) once in Buffer A, once in Buffer B, and twice in Buffer E, with aspiration steps in between. Following a final aspiration, complete 12 ⁇ L RT mixture was added to each well, as described below.
  • Table 8 provides a list of the unmodified KHK sense and antisense strand nucleotide sequences of selected dsRNA agentes.
  • Table 9 provides a list of the modified KHK sense and antisense strand nucleotide sequences of selected dsRNA agents.
  • Example 4 Design, Synthesis and In Vitro Screening of Additional dsRNA Duplexes Additional siRNAs were designed, synthesized, and prepared using the methods described above in Example 1. Detailed lists of the additional unmodified KHK sense and antisense strand nucleotide sequences are shown in Table 10. Detailed lists of the modified KHK sense and antisense strand nucleotide sequences are shown in Table 11.
  • Example 5 Design, Synthesis and In Vitro Screening of Additional dsRNA Duplexes Based on the in vitro analyses, structure-active relationship (SAR) analyses were performed. In particular, additional duplexes were designed, synthesized, and assayed. siRNAs were designed, synthesized, and prepared using the methods described above. In vitro screening assays in Hep3B and PCH cells with these siRNAs were performed as described above. Detailed lists of the unmodified KHK sense and antisense strand nucleotide sequences are shown in Table 12. Detailed lists of the modified KHK sense and antisense strand nucleotide sequences are shown in Table 13.
  • Opti-MEM Opti-MEM plus 0.1 ⁇ l of Lipofectamine RNAiMax per well (Invitrogen, Carlsbad CA. cat # 13778-150) to 2.5 ⁇ l of each siRNA duplex to an individual well in a 384-well plate. The mixture was then incubated at room temperature for 15 minutes.
  • RNA isolation was performed using DYNABEADS. Briefly, cells were lysed in 10 ⁇ l of Lysis/Binding Buffer containing 3 ⁇ L of beads per well and mixed for 10 minutes on an electrostatic shaker. The washing steps were automated on a Biotek EL406, using a magnetic plate support. Beads were washed (in 3 ⁇ L) once in Buffer A, once in Buffer B, and twice in Buffer E, with aspiration steps in between.
  • RT-qPCR was performed as described above and relative fold change was calculated as described above.
  • the results of the transfection assays of the dsRNA agents listed in Tables 12 and 13 in Hep3B cells are shown in Table 14.
  • the results of the transfection assays of the dsRNA agents listed in Tables 12 and 13 in primary cynomolgus hepatocytes (PCH) are shown in Table 15.
  • PCH primary cynomolgus hepatocytes
  • Table 15 For Dual-Glo® Luciferase assay, cells (ATCC, Manassas, VA) were grown to near confluence at 37°C in an atmosphere of 5% CO2 in Eagle’s Minimum Essential Medium (Gibco) supplemented with 10% FBS (ATCC) before being released from the plate by trypsinization.
  • Dual- Glo® Luciferase constructs were generated in the psiCHECK2 plasmid containing the human KHK genomic sequence. Each dual-luciferase plasmid was co-transfected with siRNA (Tables 12 and 13) into approximately 2x10 4 cells using Lipofectamine 2000 (Invitrogen, Carlsbad CA. cat # 11668-019). For each well of a 96 well plate, 0.5 ⁇ l of Lipofectamine was added to 100 ng of plasmid vector and a single siRNA (Tables 12 and 13) in 14.8 ⁇ l of Opti-MEM and allowed to complex at room temperature for 15 minutes. The mixture was then added to the cells which were resuspended in 80 ⁇ l of fresh complete media.
  • Renilla luciferase activity was measured by adding 75 ⁇ l of room temperature Dual-Glo® Stop & Glo® Reagent to each well and the plates were incubated for 10-15 minutes before luminescence was again measured to determine the Renilla luciferase signal.
  • the Dual-Glo® Stop & Glo® Reagent quenches the firefly luciferase signal and sustaines luminescence for the Renilla luciferase reaction.
  • siRNA activity was determined by normalizing the Renilla (KHK) signal to the Firefly (control) signal within each well. The magnitude of siRNA activity was then assessed relative to cells that were transfected with the same vector but were not treated with siRNA or were treated with a non-targeting siRNA. All transfections were done in quadruplicates.
  • Table 16 shows the Dual-Glo® Luciferase assay results of a single dose screen in cells transfected with the indicated agents in Tables 12 and 13.
  • Example 6 Effects of siRNA –GalNAC Conjugates in Non-Human Primates
  • duplexes AD- 1613062, AD-1613073, AD-1613242, AD-1613243, AD-1613246, AD-1613247, AD-1613400, AD- 1634397, AD-1634424, and AD-1634425 were further investigated for their effectiveness in non- human primates.
  • AD-1613062, AD-1613073, AD-1613242, AD-1613243, AD-1613246, AD-1613247, AD-1613400, AD-1634397, AD-1634424, or AD-1634425 was subcutaneously administered to cynomolgous monkeys.
  • Sera and tissue samples were collected at Days 29, 50, and 78 post-dose.
  • mRNA was extracted from liver tissue by a magnetic bead-based extraction method using the NucleoMag RNA kit by Macherey-Nagel.
  • cDNA was generated using Applied Biosystems SuperScript IV VILO master mix.
  • Taqman probe-based qPCR was used to quantify KHK mRNA which was normalized to the geometric mean of two housekeeping genes, ARL6IP4 and PPIB.
  • Targeted quantitation of KHK protein in cynomolgus monkey liver was performed via liquid chromatography coupled to mass spectrometer (LC-MS) using parallel reaction monitoring (PRM) in positive ion mode.
  • the signature peptide sequence selected for quantitation was HLGFQSAGEALR (UniProtKB - A0A2K5V1R8-1, amino acid positions 198-209).
  • Figure 2 shows the effect of administration of a single 3 mg/kg dose of the selected duplexes on the level of KHK mRNA and protein at Day 29 post-dose.
  • Figure 3 shows the effect of administration of a single 3 mg/kg dose of the selected duplexes on the level of KHK mRNA at Day 50 post-dose.
  • Figure 4 shows the effect of administration of a single 3 mg/kg dose of the selected duplexes on the level of KHK mRNA at Day 78 post-dose.
  • the data demonstrate that the indicated agents, e.g., AD-1613400 and AD-1613243, are effective in durably and potently inhibiting KHK mRNA and protein expression.

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