WO2023021006A1

WO2023021006A1 - Il-1 targeting agents for treatment of pitiyriasis rubra pilaris

Info

Publication number: WO2023021006A1
Application number: PCT/EP2022/072790
Authority: WO
Inventors: Antonios Alexandros Georgios KOLIOS; Emmanuel CONTASSOT
Original assignee: Universität Zürich; Universität Basel
Priority date: 2021-08-16
Filing date: 2022-08-15
Publication date: 2023-02-23

Abstract

The invention relates to the use of an agent for use in treatment of Pityriasis rubra pilaris (PRP). The agent is selected from a ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1, and a nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1. In particular embodiments, the invention relates to the use of anakinra in treatment of PRP, particularly therapy-refractive PRP.

Description

IL-1 Targeting Agents for Treatment of Pitiyriasis Rubra Pilaris

This application claims the benefit of priority of European Patent Applications EP 21191522.8 and EP 21191564.0, each filed 16 August 2021 , both of which are incorporated by reference herein.

The present invention relates to the use of anakinra, a human interleukin 1 receptor antagonist protein derived drug, in treatment of Pityriasis rubra pilaris (PRP).

Background of the Invention

PRP is a rare inflammatory skin disease phenotypically presenting features within the spectrum of psoriasis and atopic eczema. The pathogenesis is not fully understood but an activation of the interleukin (IL)-23 T-helper (Th) 17 axis has been shown, which currently presents as a promising treatment option.

No unitary, consistently effective therapy for PRP exists. Retinoids and metodextrate are employed in treatment, and some biologies have been tested in studies. Efficacy ranges from 40 to 60%. Biologies that have been tested in clinical trials include Ustekinumab (IL-12 inhibitor), infliximab (TNF-a inhibitor), etanercept (TNF-a inhibitor), adalimumab (TNF-a inhibitor), and ixekizumab (PMID: 32293641 ). - Case reports exist for anti-IL-17 (secukinumab, brodalumab), p19 IL-23 blockers (guselkumab, risankizumab, tildrakizumab), and immunosuppressants such as azathioprine, cyclosporine, apremilast.

Synthetic disease-modifying antirheumatic drugs (sDMARDs) currently used in treatment of PRP include methotrexate, cyclosporine, azathiprin or apremilast. Anti-proliferative drugs include retinoids like acitretin or alitretinoin. Biological DMARDs (bDMARDs) include TNF-a inhibitors (infliximab, etanercept, adalimumab), IL-17 inhibitors (secukinumab, ixekizumab, brodalumab), IL-12/23 inhibitor (ustekinumab) and IL-23 p19 inhibitors (guselkumab, risankizumab, tildrakizumab).

Anakinra (CAS No 143090-92-0; commercialized as “Kineret”), is a biopharmaceutical for treatment of rheumatoid arthritis, cryopyrin-associated periodic syndromes, familial Mediterranean fever, and Still's disease. The drug is a recombinant and slightly modified version of the human interleukin 1 receptor antagonist protein, and is administered by subcutaneous injection of 100mg syringes.

Other biopharmaceutical drugs capable of targeting an interleukin-1 I interleukin-1 receptor interaction are approved or undergoing clinical development and regulatory approval. These include, but are not limited to: Canakinumab (CAS NO 914613-48-2) is a clinically approved human monoclonal antibody targeted at interleukin-1 beta, with no cross-reactivity with other members of the interleukin- 1 family, including interleukin-1 alpha.

Rilonacept (CAS NO 501081-76-1 ) is a dimeric fusion protein consisting of the ligandbinding domains of the extracellular portions of the human interleukin-1 receptor component (IL-1 R1 ) and IL-1 receptor accessory protein (IL-1 RAcP) linked in-line to the fragment- crystallizable portion (Fc region) of human lgG1 that binds and neutralizes IL-1. The drug is approved for use in cryopyrin-associated periodic syndromes, including familial cold autoinflammatory syndrome, and Muckle-Wells syndrome; deficiency of interleukin-1 receptor antagonist; and recurrent pericarditis.

Bermekimab (MABp1 CAS NO 1401965-15-8) is a human monoclonal antibody of lgG1 k isotype targeting Interleukin 1 alpha (IL1A).

Gevokizumab (CAS NO 1129435-60-4) is a monoclonal antibody that binds to interleukin- 1 beta (IL-1 beta).

Lutikizumab (ABT-981 ) is an anti-interleukin-1 a/p (anti-IL-1 a/p ) dual variable domain immunoglobulin (see Fleischmann et al., Arthritis Rheumatol. 2019 Jul;71 (7):1056-1069. doi: 10.1002/art.40840.)

Based on the above-mentioned state of the art, the objective of the present invention is to provide means and methods to provide means and methods for treatment of PRP. This objective is attained by the subject-matter of the independent claims of the present specification, with further advantageous embodiments described in the dependent claims, examples, figures and general description of this specification.

Summary of the Invention

The invention relates to the use of agents capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , in treatment of PRP, particularly therapy-refractory PRP.

Alternatively, the invention provides a nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 , in treatment of PRP, particularly therapyrefractory PRP.

In a particularly advantageous embodiment, the invention provides anakinra in treatment of PRP, particularly therapy-refractory PRP.

As evidenced by the data comprised herein, drugs targeting the IL-1/IL-1 receptor interaction, as exemplified by anakinra, are a fast-acting treatment modality providing a first line intervention, which is expected to achieve a fast resolution of PRP over 6-12 weeks directly after onset of symptoms.

The treatment according to the invention promises to reduce hospitalization rates and costs, as well as dramatically shorten disease course.

Terms and definitions

For purposes of interpreting this specification, the following definitions will apply and whenever appropriate, terms used in the singular will also include the plural and vice versa. In the event that any definition set forth below conflicts with any document incorporated herein by reference, the definition set forth shall control.

The terms “comprising”, “having”, “containing”, and “including”, and other similar forms, and grammatical equivalents thereof, as used herein, are intended to be equivalent in meaning and to be open-ended in that an item or items following any one of these words is not meant to be an exhaustive listing of such item or items, or meant to be limited to only the listed item or items. For example, an article “comprising” components A, B, and C can consist of (i.e., contain only) components A, B, and C, or can contain not only components A, B, and C but also one or more other components. As such, it is intended and understood that “comprises” and similar forms thereof, and grammatical equivalents thereof, include disclosure of embodiments of “consisting essentially of” or “consisting of.”

Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit, unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range, is encompassed within the disclosure, subject to any specifically excluded limit in the stated range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the disclosure.

Reference to “about” a value or parameter herein includes (and describes) variations that are directed to that value or parameter per se. For example, description referring to “about X” includes description of “X.”

As used herein, including in the appended claims, the singular forms “a”, “or” and “the” include plural referents unless the context clearly dictates otherwise.

"And/or" where used herein is to be taken as specific recitation of each of the two specified features or components with or without the other. Thus, the term "and/or" as used in a phrase such as "A and/or B" herein is intended to include "A and B," "A or B," "A" (alone), and "B" (alone). Likewise, the term "and/or" as used in a phrase such as "A, B, and/or C" is intended to encompass each of the following aspects: A, B, and C; A, B, or C; A or C; A or B; B or C; A and C; A and B; B and C; A (alone); B (alone); and C (alone). Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art (e.g., in cell culture, molecular genetics, nucleic acid chemistry, hybridization techniques and biochemistry, organic synthesis). Standard techniques are used for molecular, genetic, and biochemical methods (see generally, Sambrook et aL, Molecular Cloning: A Laboratory Manual, 4th ed. (2012) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, N.Y. and Ausubel et aL, Short Protocols in Molecular Biology (2002) 5th Ed, John Wiley & Sons, Inc.) and chemical methods.

General Molecular Biology: Nucleic Acid Sequences, Expression

The terms gene expression or expression, or alternatively the term gene product, may refer to either of, or both of, the processes - and products thereof - of generation of nucleic acids (RNA) or the generation of a peptide or polypeptide, also referred to transcription and translation, respectively, or any of the intermediate processes that regulate the processing of genetic information to yield polypeptide products. The term gene expression may also be applied to the transcription and processing of a RNA gene product, for example a regulatory RNA or a structural (e.g. ribosomal) RNA. If an expressed polynucleotide is derived from genomic DNA, expression may include splicing of the mRNA in a eukaryotic cell. Expression may be assayed both on the level of transcription and translation, in other words mRNA and/or protein product.

The term Nucleotides in the context of the present specification relates to nucleic acid or nucleic acid analogue building blocks, oligomers of which are capable of forming selective hybrids with RNA or DNA oligomers on the basis of base pairing. The term nucleotides in this context includes the classic ribonucleotide building blocks adenosine, guanosine, uridine (and ribosylthymine), cytidine, the classic deoxyribonucleotides deoxyadenosine, deoxyguanosine, thymidine, deoxyuridine and deoxycytidine. It further includes analogues of nucleic acids such as phosphotioates, 2’0-methylphosphothioates, peptide nucleic acids (PNA; N-(2-aminoethyl)-glycine units linked by peptide linkage, with the nucleobase attached to the alpha-carbon of the glycine) or locked nucleic acids (LNA; 2’0, 4’C methylene bridged RNA building blocks). Wherever reference is made herein to a hybridizing sequence, such hybridizing sequence may be composed of any of the above nucleotides, or mixtures thereof.

The terms capable of forming a hybrid or hybridizing sequence in the context of the present specification relate to sequences that under the conditions existing within the cytosol of a mammalian cell, are able to bind selectively to their target sequence. Such hybridizing sequences may be contiguously reverse-complimentary to the target sequence, or may comprise gaps, mismatches or additional non-matching nucleotides. The minimal length for a sequence to be capable of forming a hybrid depends on its composition, with C or G nucleotides contributing more to the energy of binding than A or T/U nucleotides, and on the backbone chemistry.

In the context of the present specification, the term hybridizing sequence encompasses a polynucleotide sequence comprising or essentially consisting of RNA (ribonucleotides), DNA (deoxyribonucleotides), phosphothioate deoxyribonucleotides, 2’-O-methyl-modified phosphothioate ribonucleotides, LNA and/or PNA nucleotide analogues. In certain embodiments, a hybridizing sequence according to the invention comprises 8, 9, 10, 11 , 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 , 22, 23, 24, 25, 26, 27, 28, 29 or 30 nucleotides. In certain embodiments, the hybridizing sequence comprises deoxynucleotides, phosphothioate deoxynucleotides, LNA and/or PNA nucleotides or mixtures thereof.

The term antisense oligonucleotide in the context of the present specification relates to an oligonucleotide having a sequence substantially complimentary to, and capable of hybridizing to, an RNA. Antisense action on such RNA will lead to modulation, particular inhibition or suppression of the RNA’s biological effect. If the RNA is an mRNA, expression of the resulting gene product is inhibited or suppressed. Antisense oligonucleotides can consist of DNA, RNA, nucleotide analogues and/or mixtures thereof. The skilled person is aware of a variety of commercial and non-commercial sources for computation of a theoretically optimal antisense sequence to a given target. Optimization can be performed both in terms of nucleobase sequence and in terms of backbone (ribo, deoxyribo, analogue) composition. Many sources exist for delivery of the actual physical oligonucleotide, which generally is synthesized by solid state synthesis.

The term siRNA (small/short interfering RNA) in the context of the present specification relates to an RNA molecule capable of interfering with the expression (in other words: inhibiting or preventing the expression) of a gene comprising a nucleic acid sequence complementary or hybridizing to the sequence of the siRNA in a process termed RNA interference. The term siRNA is meant to encompass both single stranded siRNA and double stranded siRNA. siRNA is usually characterized by a length of 17-24 nucleotides. Double stranded siRNA can be derived from longer double stranded RNA molecules (dsRNA). According to prevailing theory, the longer dsRNA is cleaved by an endo-ribonuclease (called Dicer) to form double stranded siRNA. In a nucleoprotein complex (called RISC), the double stranded siRNA is unwound to form single stranded siRNA. RNA interference often works via binding of an siRNA molecule to the mRNA molecule having a complementary sequence, resulting in degradation of the mRNA. RNA interference is also possible by binding of an siRNA molecule to an intronic sequence of a pre-mRNA (an immature, non-spliced mRNA) within the nucleus of a cell, resulting in degradation of the pre-mRNA. The term shRNA (small hairpin RNA) in the context of the present specification relates to an artificial RNA molecule with a tight hairpin turn that can be used to silence target gene expression via RNA interference (RNAi).

The term sgRNA (single guide RNA) in the context of the present specification relates to an RNA molecule capable of sequence-specific repression of gene expression via the CRISPR (clustered regularly interspaced short palindromic repeats) mechanism.

The term miRNA (microRNA) in the context of the present specification relates to a small noncoding RNA molecule (containing about 22 nucleotides) that functions in RNA silencing and post-transcriptional regulation of gene expression.

The term nucleic acid expression vector in the context of the present specification relates to a plasmid, a viral genome or an RNA, which is used to transfect (in case of a plasmid or an RNA) or transduce (in case of a viral genome) a target cell with a certain gene of interest, or -in the case of an RNA construct being transfected- to translate the corresponding protein of interest from a transfected mRNA. For vectors operating on the level of transcription and subsequent translation, the gene of interest is under control of a promoter sequence and the promoter sequence is operational inside the target cell, thus, the gene of interest is transcribed either constitutively or in response to a stimulus or dependent on the cell’s status. In certain embodiments, the viral genome is packaged into a capsid to become a viral vector, which is able to transduce the target cell.

Binding; Binders Ligands Antibodies:

The term specific binding in the context of the present invention refers to a property of ligands that bind to their target with a certain affinity and target specificity. The affinity of such a ligand is indicated by the dissociation constant of the ligand. A specifically reactive ligand has a dissociation constant of < 10'⁷mol/L when binding to its target, but a dissociation constant at least three orders of magnitude higher in its interaction with a molecule having a globally similar chemical composition as the target, but a different three-dimensional structure.

In the context of the present specification, the term dissociation constant (KD) is used in its meaning known in the art of chemistry and physics; it refers to an equilibrium constant that measures the propensity of a complex composed of [mostly two] different components to dissociate reversibly into its constituent components. The complex can be e.g. an antibodyantigen complex AbAg composed of antibody Ab and antigen Ag. KD is expressed in molar concentration [mol/l] and corresponds to the concentration of [Ab] at which half of the binding sites of [Ag] are occupied, in other words, the concentration of unbound [Ab] equals the concentration of the [AbAg] complex. The dissociation constant can be calculated according to the following formula:

[Ab]: concentration of antibody; [Ag]: concentration of antigen; [AbAg]: concentration of antibodyantigen complex

In the context of the present specification, the terms off-rate (Koff;[1/sec]) and on-rate (Kon; [L/sec*mol]) are used in their meaning known in the art of chemistry and physics; they refer to a rate constant that measures the dissociation (Koff) or association (Kon) of 5 an antibody with its target antigen. Koff and Kon can be experimentally determined using methods well established in the art. A method for determining the Koff and Kon of an antibody employs surface plasmon resonance. This is the principle behind biosensor systems such as the Biacore® or the ProteOn® system. They can also be used to determine the dissociation constant KD by using the following formula:

The natural upper limit for the on-rate K_on is 10⁹ L/sec*mol.

In the context of the present specification, the term antibody refers to whole antibodies including but not limited to immunoglobulin type G (IgG), type A (IgA), type D (IgD), type E (IgE) or type M (IgM), any antigen binding fragment or single chains thereof and related or derived constructs. A whole antibody is a glycoprotein comprising at least two heavy (H) chains and two light (L) chains inter-connected by disulfide bonds. Each heavy chain is comprised of a heavy chain variable region (VH) and a heavy chain constant region (CH). The heavy chain constant region of IgG is comprised of three domains, CH1 , CH2 and CH3. Each light chain is comprised of a light chain variable region (abbreviated herein as VL) and a light chain constant region (CL). The light chain constant region is comprised of one domain, CL. The variable regions of the heavy and light chains contain a binding domain that interacts with an antigen. The constant regions of the antibodies may mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component of the classical complement system. Similarly, the term encompasses a so- called nanobody or single domain antibody, an antibody fragment consisting of a single monomeric variable antibody domain.

In the context of the present specification, the term humanized antibody refers to an antibody originally produced by immune cells of a non-human species, the protein sequences of which have been modified to increase their similarity to antibody variants produced naturally in humans. The term humanized antibody as used herein includes antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, have been grafted onto human framework sequences. Additional framework region modifications may be made within the human framework sequences as well as within the CDR sequences derived from the germline of another mammalian species.

The term antibody-like molecule in the context of the present specification refers to a molecule capable of specific binding to another molecule or target with high affinity / a Kd < 10E-8 mol/L An antibody-like molecule binds to its target similarly to the specific binding of an antibody. The term antibody-like molecule encompasses a repeat protein, such as a designed ankyrin repeat protein (Molecular Partners, Zurich), an engineered antibody mimetic protein exhibiting highly specific and high-affinity target protein binding (see US2012142611 , US2016250341 , US2016075767 and US2015368302, all of which are incorporated herein by reference). The term antibody-like molecule further encompasses, but is not limited to, a polypeptide derived from armadillo repeat proteins, a polypeptide derived from leucine-rich repeat proteins and a polypeptide derived from tetratricopeptide repeat proteins. The term antibody-like molecule further encompasses a specifically binding polypeptide derived from a protein A domain, a fibronectin domain FN3, a consensus fibronectin domain, a lipocalin (see Skerra, Biochim. Biophys. Acta 2000, 1482(1 -2):337-50), a polypeptide derived from a Zinc finger protein (see Kwan et al. Structure 2003, 11 (7):803-813), a Src homology domain 2 (SH2) or Src homology domain 3 (SH3), a PDZ domain, a gamma-crystallin, ubiquitin, a cysteine knot polypeptide or a knottin, cystatin, Sac7d, a triple helix coiled coil (also known as alphabodies), a Kunitz domain or a Kunitz-type protease inhibitor and a carbohydrate binding module 32-2.

The term protein A domains derived polypeptide refers to a molecule that is a derivative of protein A and is capable of specifically binding the Fc region and the Fab region of immunoglobulins.

The term armadillo repeat protein refers to a polypeptide comprising at least one armadillo repeat, wherein an armadillo repeat is characterized by a pair of alpha helices that form a hairpin structure.

The term humanized camelid antibody in the context of the present specification refers to an antibody consisting of only the heavy chain or the variable domain of the heavy chain (VHH domain) and whose amino acid sequence has been modified to increase their similarity to antibodies naturally produced in humans and, thus show a reduced immunogenicity when administered to a human being. A general strategy to humanize camelid antibodies is shown in Vincke et al. “General strategy to humanize a camelid single-domain antibody and identification of a universal humanized nanobody scaffold”, J Biol Chem. 2009 Jan 30;284(5):3273-3284, and US2011165621 A1.

In the context of the present specification, the term fragment crystallizable (Fc) region is used in its meaning known in the art of cell biology and immunology; it refers to a fraction of an antibody comprising, if applied to IgG, two identical heavy chain fragments comprised of a CH2 and a CH3 domain, covalently linked by disulfide bonds.

As used herein, the term treating or treatment of any disease or disorder (e.g. cancer) refers in one embodiment, to ameliorating the disease or disorder (e.g. slowing or arresting or reducing the development of the disease or at least one of the clinical symptoms thereof). In another embodiment "treating" or "treatment" refers to alleviating or ameliorating at least one physical parameter including those which may not be discernible by the patient. In yet another embodiment, "treating" or "treatment" refers to modulating the disease or disorder, either physically, (e.g., stabilization of a discernible symptom), physiologically, (e.g., stabilization of a physical parameter), or both. Methods for assessing treatment and/or prevention of disease are generally known in the art, unless specifically described hereinbelow.

Detailed Description of the Invention

Anakinra

A first aspect of the invention relates to a human interleukin 1 receptor antagonist protein, particularly anakinra, for use in treatment of Pityriasis rubra pilaris (PRP).

In certain embodiments, prior to administration of anakinra, the patient was diagnosed as treatment refractory, in other words the patient had been treated with, and not responded to, a drug used for immune downmodulation in PRP.

In particular embodiments, the drug used for immune downmodulation in PRP is selected from methotrexate, and an antibody reactive to TNF-alpha, interleukin-23 (p19 or p40), and interleukin-17A. In certain embodiments, the antibody against TNF-alpha is selected from etanercept, infliximab, adalimumab, certolizumab-pegol and golimumab.

In certain embodiments, the antibody against interleukin-23 p19 is selected from risankizumab- rzaa, guselkumab, and tildrakizumab, and p40 ustekinumab.

In certain embodiments, the antibody against interleukin-17 is selected from secukinumab, ixekizumab and the IL-17 receptor antibody brodalumab.

In certain embodiments, anakinra for use according to the invention is administered by s.c. injection at a dose of at least 100mg/d (in patients weighing 50kg or more, below that 1- 2mg/kg/d). The dosage according to the EMA label for conventionally treated conditions is 100mg/d in rheumatoid arthritis, in CAPS 1-2mg/kg/d up to a maximum of 8mg/kg/d, in FMF or Stills disease 100mg/d in persons weighing 50kg or more, below that 1-2mg/kg/d.

In certain particular embodiments, anakinra for use according to the invention is administered by s.c. injection at a dose of at 250 to 300mg/d. The data presented herein indicate that a dosing on the high end of the recommended spectrum shows better clinical improvement of the patient.

In certain embodiments, anakinra for use according to the invention is administered over a time course of at least 6 weeks, particularly over 12 weeks or more.

Other agents distinct from Anakinra

An alternative aspect of the invention relates to a ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , for use in treatment of Pityriasis rubra pilaris (PRP).

An alternative of this aspect of the invention relates to a nucleic acid agent capable of downregulating or inhibiting the physiological activity of interleukin-1 , for use in treatment of Pityriasis rubra pilaris (PRP).

In certain embodiments, prior to administration of the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 , the patient was diagnosed as treatment refractory, in other words the patient had been treated with, and not responded to, a drug used for immune downmodulation in PRP.

In particular embodiments, the drug used for immune downmodulation in PRP, and to which the patient is determined to be refractory to, is selected from methotrexate, and an antibody reactive to TNF-alpha, interleukin-23 (p19 or p40), and interleukin-17A. In certain embodiments, the antibody against TNF-alpha is selected from etanercept, infliximab, adalimumab, certolizumab-pegol and golimumab.

In certain embodiments, the antibody against interleukin-23 p19 is selected from Risankizumab-rzaa, guselkumab, and tildrakizumab, and p40 ustekinumab.

In certain embodiments, the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 for use according to the invention is administered over a time course of at least 6 weeks, particularly over 12 weeks or more. In certain embodiments, the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is administered to a patient not having received prior medication in treatment of PRP (first-line use).

In certain embodiments, the interleukin-1 being targeted by the ligand or nucleic acid agent for use according to the invention, is interleukin-1 alpha.

In certain embodiments, the interleukin-1 being targeted by the ligand or nucleic acid agent for use according to the invention, is interleukin-1 beta.

In certain embodiments, both interleukin-1 alpha and interleukin-1 beta are targeted.

In certain embodiments, the ligand is a monoclonal antibody or an antibody-like molecule, particularly wherein the ligand is selected from canakinumab, rilonacept, bemekimab, gevokinzumab and lutikizumab, more particularly wherein the ligand is one of canakinumab and rilonacept.

In certain embodiments, the nucleic acid agent targets expression one of IL-1 alpha, IL-1 beta, IL-1 receptor type I (CD121a) and IL-1 receptor accessory protein.

IL-1 alpha may be targeted by antisense or RNAi agents targeting the IL-1 alpha coding mRNA sequence. Alternatively, the nucleic acid agent is designed to target a non-translated RNA sequence in an unprocessed IL-1 alpha transcript.

IL-1 beta may be targeted by antisense or RNAi agents targeting the IL-1 beta coding mRNA sequence. Alternatively, the nucleic acid agent is designed to target a non-translated RNA sequence in an unprocessed IL-1 beta transcript.

CD121 a may be targeted by antisense or RNAi agents targeting the CD121 a coding mRNA sequence. Alternatively, the nucleic acid agent is designed to target a non-translated RNA sequence in an unprocessed CD121 a transcript.

In certain embodiments, the nucleic acid agent is an antisense oligonucleotide.

The nucleic acid agent may be an antisense ODN comprising protected, non-physiological components such as thiophosphate bonds, LNA or PNA backbone modifications or other modifications known to increase binding and/or inhibit breakdown of ODN.

It has been demonstrated that inhibition of IL-1 signalling by antisense oligonucleotide- mediated exon skipping of IL-1 receptor accessory protein (IL-1 RAcP) resulted in a substantial inhibition of IL-1 signalling (Yilmaz-Elis et aL, Molecular Therapy Nucleic Acids 2, 2013, https://doi.org/10.1038/mtna.2012.58).

In certain embodiments, the nucleic acid agent is an si-RNA / RNAi agent. In certain embodiments, the nucleic acid agent is an expression vector expressing the RNAi I si RNA agent according to the invention. Such vector may be a viral (AAV, AV, retroviral) vector, or an expression plasmid. Alternatively, direct injection of RNA agents has found high acceptance as vaccine modality in the course of the COVID-19 I Sars-CoV2 pandemic and may be used as a vector to generate nucleic acid agents for use according to the invention.

Here the inventors present an in-depth molecular analysis of cytokine tissue profiling (nanostring) of patients with PRP (during and post-inflammation) comparing to healthy controls. The inventors could show that beside proinflammatory cytokines like TNF-alpha, IL- 23 and IL-17, also IL-1 alpha and IL-1 beta were upregulated during disease course, which normalized after resolution of skin inflammation.

Based their findings, two patients with a therapy-refractory PRP were treated with anakinra over 12 weeks. Skin severity at week 8 measured by PASI improved in patient 1 from PASI 11 .4 to 2.6 (APASI 77% reduction) and patient 2 from PASI 21 .4 to 5.7 (APASI 73% reduction).

In summary the inventors could show for the first time, that targeting IL-1 in human PRP could a be a treatment option in this subgroup of treatment-refractory patients.

In general, the invention provides anakinra, or the ligands and nucleic agents as specified in the alternative aspects of the invention, for treatment of PRP. In certain embodiment, “treatment” includes prevention of PRP, or prevention of recurrence of PRP.

In certain particular embodiments, the treatment is provided for treatment-refractory PRP. The examples relate to administration of anakinra in that (both) did not respond well to biological treatment, which is already one step ahead of convention DMARDS (disease modifying antirheumatic drugs, like methotrexate). Patient 1 was refractory to adalimumab (anti-TNF-alpha) and guselkumab (anti-IL-23 p19). Patient 2 was refractory to secukinumab (anti-IL-17A) and risankizumab (anti-IL-23 p19).

In the past, the course of PRP was unaltered for 2-3 years, in spite of treatment with retinoids or conventional disease-modifying antirheumatic drugs (cDMARDs). Since the regulatory approval of biologicals such as anti-TNF-a, anti-IL-17, anti-IL-23, these drugs were used in treatment of PRP, but with variable success.

The approach of using an IL-1 blocking agent interferes more upstream in disease pathogenesis compared to other targeted biologicals listed above (not to mention that IL-17 biologicals as IL-17 blockade also inhibits keratinocytes). The clinical appearance of the disease is characterized by a strong keratinocyte involvement. IL-1 b upregulation was shown in type I PRP (Feldmeyer L, JAMA Dermatol 2017, PMID 28122069), and more specifically IL- 1a and IL-1 b in keratinocytes of a patient suffering from type V (inherited, new variant of a CARD14 mutation) PRP (Danis J et al, FIMMU 2018, PMID 30018619). We analyzed and treated type I PRP (adult-type) without a confirmed CARD14 mutation.

Medical treatment, Dosage Forms and Salts

Similarly, within the scope of the present invention is a method or treating PRP in a patient in need thereof, comprising administering to the patient anakinra according to the above description.

Again, also encompassed by the invention is a method or treating PRP in a patient in need thereof, comprising administering to the patient the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 according to the above description.

In certain embodiments, the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 is an antibody, antibody fragment, an antibody-like molecule or a protein A domains derived polypeptide.

In certain embodiments, the the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is an immunoglobulin consisting of two heavy chains and two light chains. In some embodiments, the the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is a single domain antibody, consisting of an isolated variable domain from a heavy or light chain. In some embodiments, the the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is a heavy-chain antibody consisting of only heavy chains such as antibodies found in camelids.

In certain embodiments, the the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is an antibody fragment. In certain embodiments, the the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 is a Fab fragment, i.e. the antigen-binding fragment of an antibody, or a single-chain variable fragment, i.e. a fusion protein of the variable region of heavy and the light chain of an antibody connected by a peptide linker. Medical treatment

Similarly, the invention encompasses a method for the prevention or treatment of PRP, comprising administering to a patient in need thereof, anakinra, or the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 , according to any of the above aspects or embodiments of the invention.

Pharmaceutical Compositions, Administration/Dosage Forms and Salts

Similarly, a dosage form for the prevention or treatment of PRP is provided, comprising an agent as described herein as the active agent of treatment, specifically, anakinra or the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 according to any of the above aspects or embodiments of the invention.

According to one aspect of the compound according to the invention, the agent is provided as a pharmaceutical composition, pharmaceutical administration form, or pharmaceutical dosage form for use in treatment of PRP.

Certain embodiments of the invention relate to a dosage form for parenteral administration, such as subcutaneous, intravenous, intrahepatic or intramuscular injection forms. Optionally, a pharmaceutically acceptable carrier and/or excipient may be present.

Certain embodiments of the invention relate to a dosage form for topical administration. The skilled artisan is aware of a broad range of possible recipes for providing topical formulations, as exemplified by the content of Benson and Watkinson (Eds.), Topical and Transdermal Drug Delivery: Principles and Practice (1st Edition, Wiley 2011 , ISBN-13: 978-0470450291 ); and Guy and Handcraft: Transdermal Drug Delivery Systems: Revised and Expanded (2^nd Ed., CRC Press 2002, ISBN-13: 978-0824708610); Osborne and Amann (Eds.): Topical Drug Delivery Formulations (1^st Ed. CRC Press 1989; ISBN-13: 978-0824781835). In embodiments of the invention relating to topical uses of the compounds of the invention, the pharmaceutical composition is formulated in a way that is suitable for topical administration such as aqueous solutions, suspensions, ointments, creams, gels or sprayable formulations, e.g., for delivery by aerosol or the like, comprising the active ingredient together with one or more of solubilizers, stabilizers, tonicity enhancing agents, buffers and preservatives that are known to those skilled in the art.

The dosage regimen for the compounds of the present invention will vary depending upon known factors, such as the pharmacodynamic characteristics of the particular agent and its mode and route of administration; the species, age, sex, health, medical condition, and weight of the recipient; the nature and extent of the symptoms; the kind of concurrent treatment; the frequency of treatment; the route of administration, the renal and hepatic function of the patient, and the effect desired. In certain embodiments, the compounds of the invention may be administered in a single daily dose, or the total daily dosage may be administered in divided doses of two, three, or four times daily.

In certain embodiments, the pharmaceutical composition or combination of the present invention can be in unit dosage of about 1-1000 mg of active ingredient(s) for a subject of about 50-70 kg. The therapeutically effective dosage of a compound, the pharmaceutical composition, or the combinations thereof, is dependent on the species of the subject, the body weight, age and individual condition, the disorder or disease or the severity thereof being treated. A physician, clinician or veterinarian of ordinary skill can readily determine the effective amount of each of the active ingredients necessary to prevent, treat or inhibit the progress of the disorder or disease.

Method of Manufacture (Swiss type claim)

The invention further encompasses, as an additional aspect, the use of anakinra or the ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or the nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 as identified herein, for use in a method of manufacture of a medicament for the treatment or prevention of PRP.

Wherever alternatives for single separable features are laid out herein as “embodiments”, it is to be understood that such alternatives may be combined freely to form discrete embodiments of the invention disclosed herein.

The invention is further illustrated by the following examples and figures, from which further embodiments and advantages can be drawn. These examples are meant to illustrate the invention but not to limit its scope.

Items of the invention

The following items are explicitly encompassed by the invention:

Anakinra

1 . Anakinra for use in treatment of Pityriasis rubra pilaris (PRP).

2. Anakinra for use according to item 1 , wherein the patient prior to administration of anakinra had been treated with, and not responded to, a drug selected from methotrexate, and an antibody reactive to TNF-alpha, interleukin-23 p19, and interleukin-17A. 3. Anakinra for use according to item 1 or 2, administered to a patient not having received prior medication in treatment of PRP (first-line use).

4. Anakinra for use according to any one of the preceding items, administered by s.c. injection at a dose of at least 200mg/d, particularly at a dose of 250 to 300mg/d.

5. Anakinra for use according to any one of the preceding items, administered over a time course of at least 6 weeks, particularly over 12 weeks or more.

Ligands and nucleic acids a) A ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , or a nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 , for use in treatment of Pityriasis rubra pilaris (PRP). b) The ligand, or the nucleic acid agent for use according to item a), wherein the patient prior to administration of said ligand or nucleic acid agent, had been treated with, and not responded to, a drug selected from methotrexate, and an antibody reactive to TNF- alpha, interleukin-23 p19, and interleukin-17A. c) The ligand, or the nucleic acid agent for use according to item a) or b), administered to a patient not having received prior medication in treatment of PRP (first-line use). d) The ligand, or the nucleic acid agent for use according to any one of the preceding items, administered over a time course of at least 6 weeks, particularly over 12 weeks or more. e) The ligand, or the nucleic acid agent for use according to any one of the preceding items, wherein the interleukin-1 is interleukin-1 alpha. f) The ligand, or the nucleic acid agent for use according to any one of the preceding items a) to d), wherein the interleukin-1 is interleukin-1 beta. g) The ligand, or the nucleic acid agent for use according to any one of the preceding items, wherein both interleukin-1 alpha and interleukin-1 beta are targeted. h) The ligand according to any one of the preceding items, wherein the ligand is a monoclonal antibody or an antibody-like molecule, particularly wherein the ligand is selected from canakinumab, rilonacept, bemekimab, gevokinzumab and lutikizumab, more particularly wherein the ligand is one of canakinumab and rilonacept. i) The nucleic acid agent for use according to any one of the preceding items a) to g), wherein the nucleic acid agent targets expression one of IL-1 alpha, IL-1 beta, IL-1 receptor type I (CD121a) and IL-1 receptor accessory protein. j) The nucleic acid agent for use according to any one of the preceding items a) to g), or i), wherein the nucleic acid agent is an antisense oligonucleotide. k) The nucleic acid agent for use according to any one of the preceding items a) to g), or i), wherein the nucleic acid agent is an si-RNA I RNAi agent. l) The nucleic acid agent for use according to any one of the preceding items a) to g), wherein the nucleic acid agent is an expression vector encoding an si-RNA I RNAi agent targeting expression one of IL-1 alpha, IL-1 beta, IL-1 receptor type I (CD121a) and IL-1 receptor accessory protein.

Description of the Figures

Figure 1 shows skin transcriptomics in PRP vs. healthy patients. Upper panel: A significant upregulation of interleukin-1 A (IL-1 A) and IL-1 B RNA transcriptome is found in skin of Pityriasis rubra pilaris (PRP) patients (human skin samples) during active disease state (PRP-Pre, n=8) vs. resolution of disease (PRP-Post, n=6), where IL-1 A and IL-1 B are significantly downregulated.

PRP-Post has a similar expression pattern like healthy skin (n=6), which is also significantly lower than PRP-Pre in IL-1 A and IL-1 B.

Skin transcriptomics was assessed by NanoString® nCounter® immunology panel of formalin-fixed paraffin embedded (FFPE) skin biopsies.

Fig. 2 Current treatment approaches in PRP include blockade of IL-23, IL-17 or TNF- a by specific immune pathway inhibitors (biological pharmaceuticals), but there is a heterogenous response to any of these treatments, where only some patients respond in each group. The presented data underline that, as one example, for IL-23A there are three patients with high expression in PRP-Pre, vs. PRP-Post and healthy skin. In IL-17A and TNF, only one patient seems to present with high expression. This illustrates the finding of a heterogenous response.

Interleukin-1 (IL-1) is produced by stromal cells (like keratinocytes) or innate immune cells such as monocytes I macrophage. This inflammation is rather an early step in disease pathogenesis before an innate-driven involvement and activation of the adaptive immune system takes place. Involvement and activation of the adaptive immune system also includes upregulation of cytokines such as IL-23, IL-17 and TNF. For this reason, blockade of IL-1 is postulated to be a rather upstream interference in the disease pathogenesis, compared to other immune modulators assayed in Fig. 2. Fig. 3 illustrates numerically differential expression of IL-1 A and IL-1 B Pre vs. Posttreatment by heatmap. Specific comparison of Post-treatment vs. Pre-treatment by heatmap, which show significant differences for IL-1 A and IL-1 B.

Fig. 4 (upper panel) shows a graphical time-course by severity for patient 1. Based on the findings presented herein, PRP patient 1 , who was therapy-refractory to a previous therapy with a TNF-a blocker, was treated for 12 weeks with anakinra (100mg/d until week 6, afterwards 200mg/d).

Treatment response was rated by PASI (psoriasis area and severity index), BSA (body surface area) and pruitus based on a visual analogue scale (VAS). PASI is normally used for psoriasis but its qualities, erythema, scaling, infiltration and area involvement also appear in PRP.

PASI improved until week 6, but BSA and pruritus VAS did not. Therefore, the dose of anakinra was increased to 200mg/d. This led to a further reduction of PASI, BSA and pruritus VAS (see Table 2). Due to absent cost-coverage, anakinra was stopped and the patient was switched back to TNF-blocker, which resulted in subsequent loss of response. The delta-PASI compared to baseline is 77% by week 8.

Fig. 4 (lower panel) shows a graphical time-course by severity for patient 2. PRP patient 2, who was therapy-refractory to different previous biologicals (anti-IL-23 and anti- IL-17) and is treated by the same regimen like in Fig 4 (upper panel) (currently in week 11 , values see table 3). Delta-PASI by week 8 is 73%. For comparison, a PASI75, which corresponds to a 75% improvement is achieved in psoriasis by week 12 in 50-90% of cases according to the biological pharmaceutical. Greater cohorts are needed, but both patients achieved a roughly 75% improvement by week 8, which is in line with the more potent results in psoriasis of biologicals like IL-17 and IL-23 blockers. A PASI75 response within 8 weeks is a great improvement and achievement for PRP, which normally has a significantly longer disease course up to 2-3 years.

Fig. 5 shows Delta PASI scores over time. The scores overlap. Delta-PASI was calculated by referring all values to baseline being 100%. Dotted line refers to 75% improvement (PASI75).

Fig. 6 shows the results of an analysis of the Acanthosis (A) and Papillomatosis-Index (B) which are significantly improving in both patients treated. Tables

Table 1 : Differential expression of IL-1 b and IL-1 a Pre vs. Post-treatment

Specific comparison of Post-treatment vs. Pre-treatment by ratios, which show significant differences for IL-1 A and IL-1 B.

Table 2: severity time-course patient 1

Table 3: severity time-course patient 2

Examples

Example 1: Material and Methods

Patients

Patients with a diagnosis of pityriasis rubra pilaris (adult-type, type I), who were treated or evaluated in the Department of Dermatology, University Hospital Zurich (USZ) between January 1 , 2008 and March 31 , 2018 and received a skin biopsy (5mm punch) were included in the analysis.

Tissue transcriptomics

From all patients, FFPE (formalin-fixed paraffin-embedded) RNA tissue transcriptomics (NanoString® nCounter TM , immunology panel, 500 genes) from serial biopsies during active disease state (PRP-Pre, n=8) vs. resolution of disease (PRP-Post, n=6), compared to healthy skin (n=6), were analyzed. Data assessed by NanoString ® nSolver TM and GraphPad Prism software.

Treatment

Anakinra, an IL-1 receptor antibody (IL-1 Ra), blocking signalling of both cytokines, IL-1 a and IL-1 b, is available as 100mg injections. From week 0 to week 6, 100mg/d were applied subcutaneously (s.c.), followed by twice daily injections of 100mg anakinra (200mg/d subcutaneously) until week 12. Both patients received the same regimen.

Claims

1 . An agent for use in treatment of Pityriasis rubra pilaris (PRP), the agent being selected from: a ligand capable of specifically binding to, and inhibiting the physiological activity of, interleukin-1 , and a nucleic acid agent capable of down-regulating or inhibiting the physiological activity of interleukin-1 .

2. The agent for use according to claim 1 , wherein the patient prior to administration of said ligand or nucleic acid agent, had been treated with, and not responded to, a drug selected from methotrexate, and an antibody reactive to an cytokine selected from the group consisting of TNF- alpha, interleukin-23 p19, and interleukin-17A.

3. The agent for use according to claim 1 or 2, wherein the agent is administered to a patient not having received prior medication in treatment of PRP (first-line use).

4. The agent for use according to any one of the preceding claims, wherein the agent is administered over a time course of at least 6 weeks, particularly over 12 weeks or more.

5. The agent for use according to any one of the preceding claims, wherein the interleukin- 1 is interleukin-1 alpha.

6. The agent for use according to any one of the preceding claims, particularly according to claims 1 to 4, wherein the interleukin-1 is interleukin-1 beta.

7. The agent for use according to any one of the preceding claims, wherein both interleukin-1 alpha and interleukin-1 beta are targeted.

8. The agent for use according to any one of the preceding claims, wherein the agent is anakinra.

9. Anakinra for use according to claim 8, administered by s.c. injection at a dose of at least 200mg/d, particularly at a dose of 250 to 300mg/d.

10. Anakinra for use according to any one of the preceding claims 8 or 9, administered over a time course of at least 6 weeks, particularly over 12 weeks or more. The agent for use according to any one of the preceding claims 1 to 7, wherein the agent is a monoclonal antibody or an antibody-like molecule, particularly wherein the ligand is selected from canakinumab, rilonacept, bemekimab, gevokinzumab and lutikizumab, more particularly wherein the ligand is one of canakinumab and rilonacept. The agent for use according to any one of the preceding claims 1 to 7, wherein the agent is a nucleic acid agent that targets expression of a gene encoding one of the genes comprised in the group consisting of IL-1 alpha, IL-1 beta, IL-1 receptor type I (CD121 a) and IL-1 receptor accessory protein. The agent for use according to any one of the preceding claims 1 to 7, or 12, wherein the agent is an antisense oligonucleotide. The agent for use according to any one of the preceding claims 1 to 7, or 12, wherein the agent is an si-RNA Z RNAi agent. The agent for use according to any one of the preceding claims 1 to 7, wherein the agent is an expression vector encoding an si-RNA I RNAi agent targeting expression of one of the genes comprised in the group consisting of IL-1 alpha, IL-1 beta, IL-1 receptor type I (CD121a) and IL-1 receptor accessory protein.