Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K39/395—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum
  • A61K39/39533—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals
  • A61K39/3955—Antibodies; Immunoglobulins; Immune serum, e.g. antilymphocytic serum against materials from animals against proteinaceous materials, e.g. enzymes, hormones, lymphokines
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/22—Hormones
  • A61K38/26—Glucagons
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K45/00—Medicinal preparations containing active ingredients not provided for in groups A61K31/00 - A61K41/00
  • A61K45/06—Mixtures of active ingredients without chemical characterisation, e.g. antiphlogistics and cardiaca
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P3/00—Drugs for disorders of the metabolism
  • A61P3/04—Anorexiants; Antiobesity agents
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K16/00—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies
  • C07K16/18—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans
  • C07K16/28—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants
  • C07K16/2863—Immunoglobulins [IG], e.g. monoclonal or polyclonal antibodies against material from animals or humans against receptors, cell surface antigens or cell surface determinants against receptors for growth factors, growth regulators
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/505—Medicinal preparations containing antigens or antibodies comprising antibodies
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/54—Medicinal preparations containing antigens or antibodies characterised by the route of administration
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K39/00—Medicinal preparations containing antigens or antibodies
  • A61K2039/545—Medicinal preparations containing antigens or antibodies characterised by the dose, timing or administration schedule
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/20—Immunoglobulins specific features characterized by taxonomic origin
  • C07K2317/24—Immunoglobulins specific features characterized by taxonomic origin containing regions, domains or residues from different species, e.g. chimeric, humanized or veneered
• • C—CHEMISTRY; METALLURGY
  • C07—ORGANIC CHEMISTRY
  • C07K—PEPTIDES
  • C07K2317/00—Immunoglobulins specific features
  • C07K2317/70—Immunoglobulins specific features characterized by effect upon binding to a cell or to an antigen
  • C07K2317/76—Antagonist effect on antigen, e.g. neutralization or inhibition of binding

Definitions

• the disclosure relates to the dual administration of ActRII pathway agents, e.g., ActRII receptor antagonists, e.g., ActRII receptor antibodies, and glucagon-like peptide-1 receptor (GLP-1) agonists for the treatment of metabolic disorders.
• ActRII pathway agents e.g., ActRII receptor antagonists, e.g., ActRII receptor antibodies, and glucagon-like peptide-1 receptor (GLP-1) agonists for the treatment of metabolic disorders.
• the combination treatments of the disclosure comprising an ActRII pathway antibody and a GLP-1 agonist were found to reduce fat mass and maintain or increase lean mass.
• the combination treatments provided herein may improve metabolic dysfunction by reducing fat mass, increasing lean mass, improving glycemic control, and may also improve the tolerability and/or efficacy of one or both of these agents in subjects.
• a metabolic disorder in a subject, comprising administering to the subject in need thereof an ActRII receptor antibody and a glucagon-like peptide-1 receptor (GLP-1) agonist.
• the metabolic disorder is selected from the group consisting of: obesity, diabetes, metabolic syndrome, anti-psychotic drug-associated obesity, glucocorticoid-induced obesity, hypothalamic obesity associated with craniopharyngioma, Prader-Willi syndrome, and a monogenetic disorder associated with obesity.
• the diabetes is Type I diabetes or Type II diabetes.
• the monogenetic disorder associated with obesity is one of Bardet- Biedl syndrome, or obesity resulting from mutations in one or more of the genes comprising: ADCY3, ALMS1, ARL6, BBS1, BBS2, BBS4, BBS5, BBS7, BBS9, BBS10, BBS12, BDNF, CCDC28B,CEP290, CREBBP, EP300, GNAS, IER3IP1, MC3R, MKKS, MKS1, MRAP2, NTRK2, PCSK1, PHF6, POMC, SH2B1, SIM1, TMEM67, TRIM32, TTC8 and VPS13B.
• the genes comprising: ADCY3, ALMS1, ARL6, BBS1, BBS2, BBS4, BBS5, BBS7, BBS9, BBS10, BBS12, BDNF, CCDC28B,CEP290, CREBBP, EP300, GNAS, IER3IP1, MC3R, MKKS, MKS1, MRAP2, NTRK2, PCSK1, P
• the treatment is useful for an obesity related co-morbidity, wherein the condition is selected from the group of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, osteoporosis, renal disease, obstructive sleep apnea, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidemia, hypertension, heart failure, coronary heart disease, stroke, and/or gallstones.
• the condition is selected from the group of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, osteoporosis, renal disease, obstructive sleep apnea, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidemia, hypertension, heart failure, coronary heart disease, stroke, and/or gallstones.
• the subject has a body mass index (BMI) of 30 or greater. In some embodiments, the subject has a BMI of 27 or greater and has one or more obesity -related co-morbidities. In some embodiments, the subject is overweight. In some embodiments, the subject is 18 years of age or older. In some embodiments, the subject is 45 years of age or older. In some embodiments, the subject is a child 0-17 years of age, inclusive.
• BMI body mass index
• the treatment reduces body weight in the subject. In some embodiments, the treatment reduces fat mass in the subject. In some embodiments, the treatment increases lean mass in the subject. In some embodiments, the treatment reduces fat mass and increases lean mass in the subject. In some embodiments, the treatment reduces fat mass and maintains lean mass in the subject. In some embodiments, the treatment reduces central adiposity in the subject. In some embodiments, the treatment improves glycemic control in the subject.
• the treatment improves the safety, efficacy, and/or tolerability of the ActRII receptor antibody and/or the glucagon-like peptide-1 receptor (GLP-1) agonist.
• GLP-1 glucagon-like peptide-1 receptor
• the efficacy of the treatment is measured by at least one of the following: body weight; bioelectrical impedance analysis (BIA); dual X-ray absorptiometry (DXA); waist circumference; decreased BMI; waist to hip ratio; wait to height ratio; blood lipids profile; leptin, adiponectin, and adipsin levels; urine biomarkers; hemoglobin Ale (HgbAlc) levels; hand dynamometry demonstrating muscle strength; glucose levels; insulin levels; short physical performance battery (SPPB); Impact of Weight on Quality of Life (IWQoL-Lite for CT) assessment; Short Form (36) Health Survey (SF-36) assessment; homeostasis model assessment 2 (HOMA2); and physical activity monitoring via actigraphy.
• body weight bioelectrical impedance analysis
• DXA dual X-ray absorptiometry
• waist circumference decreased BMI
• BMI waist to hip ratio
• wait to height ratio blood lipids profile
• the antibody comprises the amino acid sequence of SEQ ID NOS: 1-6. In some embodiments, the antibody comprises the amino acid sequence of SEQ ID NO: 7, or a sequence with sequence identity of at least 90% thereto; and comprises the amino acid sequence of SEQ ID NO: 8, or a sequence with sequence identity of at least 90% thereto. In some embodiments, the antibody comprises the amino acid sequence of SEQ ID NO: 9, or a sequence with sequence identity of at least 90% thereto; and comprises the amino acid sequence of SEQ ID NO: 10, or a sequence with sequence identity of at least 90% thereto.
• the antibody is specific for ActRIIA and ActRIIB.
• the GLP-1 agonist is an antibody, small molecule, peptide, or aptamer.
• the GLP-1 agonist is selected from the group consisting of exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin (e.g., mazdutide), retatrutide, albiglutide, beinaglutide and PEG-loxenatide, pemvidutide, and danuglipron.
• the GLP-1 agonist is a dual GLP-1 agonist and GIP agonist. In some embodiments, the GLP-1 agonist is a dual GLP-1 agonist and GCG agonist. In some embodiments, the GLP-1 agonist is a triagonist of GIP/GLP-l/glucagon receptors.
• the ActRII receptor antibody is administered in a dose of about 3 mg/kg to about 50 mg/kg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 10 mg/kg to about 30 mg/kg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 10 mg/kg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 30 mg/kg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 200 mg to about 400 mg once weekly.
• the ActRII receptor antibody is administered in a dose of about 300 mg once weekly.
• the ActRII receptor antibody administration includes the administration of at least one loading dose of an ActRII receptor antibody at day 0 or week 0, prior to the administration of the ActRII receptor antibody and the GLP-1 agonist.
• the loading dose of the ActRII receptor antibody is administered in a dose of about 10 mg/kg to about 30 mg/kg.
• the ActRII receptor antibody is administered at least once a day, at least once a week, at least twice a week, at least thrice a week, at least once every 2 weeks, at least once every 4 weeks, at least once every 6 weeks, or at least once every 12 weeks. In some embodiments, the ActRII receptor antibody is administered at week 0, at about week 4, and at least once every 12 weeks thereafter. [0020] In some embodiments, the GLP-1 agonist is administered in a dose of about 0.005 mg to about 3.0 mg weekly.
• the GLP-1 agonist dose is increased incrementally weekly from according to of the following regimens: from about 0.2 mg to about 3.0 mg, from about 0.1 to about 1.0 mg, from about 0.25 mg to about 2.4 mg, and from about 0.25 mg to about 0.5 mg.
• the GLP-1 agonist dose is administered weekly in a dose of about 0.25 mg from about week 0 to about week 4, and in a dose of about 0.5 mg at week 5 and thereafter.
• the GLP-1 agonist dose is administered weekly in a dose of about 0.25 mg from about week 0 to about week 4, in a dose of about 0.5 mg from about week 5 to about week 8, in a dose of about 1.0 mg from about week 8 to about week 12, in a dose of about 1.7 mg from about week 12 to about week 15, in a dose of about 2.4 mg from about week 16 to about week 20, and a dose of about 2.4 mg from about week 20 and thereafter.
• the GLP-1 agonist dose is administered weekly in a dose of about 5.0 mg, about 10 mg, or about 15 mg.
• the ActRII receptor antibody and/or GLP-1 agonist are administered intravenously. In some embodiments, the ActRII receptor antibody and/or GLP-1 agonist are administered subcutaneously.
• the ActRII receptor antibody is administered prior to the GLP-1 agonist. In some embodiments, the ActRII receptor antibody is administered at least 12 weeks prior, at least 10 weeks prior, at least 8 weeks prior, at least 6 weeks prior, at least 4 weeks prior, at least 2 weeks prior, at least 1 week prior, at least 1 day prior, or at least 1 hour prior to the administration of the GLP-1 agonist. [0025] In some embodiments, the GLP-1 agonist is administered prior to the ActRII receptor antibody.
• the GLP-1 agonist is administered at least 2 weeks prior, at least 1 week prior, at least 5 days prior, at least 4 days prior, at least 2 days prior, at least 1 day prior, at least 6 hours prior, or at least 1 hour prior to the ActRII receptor antibody.
• the ActRII receptor antibody and the GLP-1 agonist are co-administered.
• Also provided herein is a combination comprising an ActRII receptor antibody and a GLP-1 agonist.
• the ActRII receptor antibody comprises the amino acid sequence of SEQ ID NOS: 1-6. In some embodiments, the ActRII receptor antibody comprises the amino acid sequence of SEQ ID NO: 7, or a sequence with sequence identity of at least 90% thereto; and comprises the amino acid sequence of SEQ ID NO: 8, or a sequence with sequence identity of at least 90% thereto. In some embodiments, the ActRII receptor antibody comprises the amino acid sequence of SEQ ID NO: 9, or a sequence with sequence identity of at least 90% thereto; and comprises the amino acid sequence of SEQ ID NO: 10, or a sequence with sequence identity of at least 90% thereto.
• the ActRII receptor antibody comprises a human IgGl Fc domain with a modification selected from the group consisting of 2591, 252Y, 307Q, 308F, 428L, 434H, 434F, 434Y, 434A, 434M, and 434S, relative to a human IgGl Fc domain according to the EU numbering scheme.
• the ActRII receptor antibody comprises a human IgGl Fc domain with a modification selected from M428L and/or N434S relative to a human IgGl Fc domain according to the EU numbering scheme.
• composition comprising the combination of an ActRII receptor antibody and a GLP-1 agonist, and a pharmaceutically acceptable excipient.
• FIG. 1 is a schematic of a clinical study designed to compare the effects of an exemplary ActRII receptor antibody, bimagrumab, and a glucagon-like peptide-1 receptor (GLP-1) agonist, semaglutide, on fat loss, when given in combination or singly.
• FIG. 2 is an outline of the pre-clinical study of the effects of an ActRII receptor antibody and GLP1 agonists in diet-induced obese mice.
• FIG. 3 is a bar graph of the effects of the GLP1 agonist semaglutide and an ActRII receptor antibody, alone and in combination, on circulating Activin A in diet-induced obese mice.
• FIGS. 4A-4C are bar graphs of the effects of the GLP1 agonist semaglutide and an ActRII receptor antibody, alone and in combination, on fat mass measured by MRI, inguinal fat weight measured post mortem at the end of the study, and circulating leptin levels in diet-induced obese mice.
• FIG. 5 is a bar graph of the effects of the GLP1 agonist semaglutide and an ActRII receptor antibody, alone and in combination, on lean muscle mass in diet-induced obese mice, assessed by weighing a gastrocnemius muscle post-mortem at the end of the study.
• FIG. 6 is a chart of mRNA transcript level changes, as assessed by RNAseq, in response to the combination of the GLP1 agonist semaglutide and an ActRII receptor antibody, in the inguinal fat of diet- induced obese mice.
• FIG. 7 is a line plot of the effects of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on body weight over time, with a change in dose of tirzepatide at day 11 in both tirzepatide groups to induce better food intake, in diet- induced obese mice.
• FIG. 8 is a line plot of the effects of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on body fat over time measured by MRI in diet-induced obese mice.
• FIG. 9 a bar graph of the effects of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on the weight of peri-renal fat collected at the end of the study in diet-induced obese mice.
• FIG. 10 is a line plot of the effects over time of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on food intake in diet- induced obese mice.
• FIG. 11 is a line plot of the effects over time of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on lean mass in diet-induced obese mice.
• FIG. 12A is a line plot of the effects of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on distance traveled in quantitative open field tests of diet-induced obese mice.
• FIG. 12B is a line plot of the effects of the GLP1 agonists semaglutide, tirzepatide, and liraglutide, alone and in combination with an ActRII receptor antibody, on speed in quantitative open field tests of diet-induced obese mice.
• FIG. 13 is a line plot of the effects of the GLP1 agonist tirzepatide, alone and in combination with an ActRII receptor antibody, on fat mass in diet-induced obese mice.
• FIG. 14 is a line plot of the effects of the GLP1 agonist tirzepatide, alone and in combination with an ActRII receptor antibody, on lean mass in diet-induced obese mice.
• compositions and methods of the disclosure provide combinations comprising an ActRII pathway agent, e.g., an ActRII receptor antagonist, e.g., an ActRII receptor antibody, and a glucagon-like peptide-1 receptor (GLP-1) agonist for use in treating metabolic disorders, including obesity.
• an ActRII pathway agent e.g., an ActRII receptor antagonist, e.g., an ActRII receptor antibody
• GLP-1 glucagon-like peptide-1 receptor
• the present disclosure demonstrates the surprising effect that combinations of an ActRII receptor antagonist and glucagon-like peptide-1 receptor (GLP-1) agonists resulted in significant and synergistic reductions in fat mass, while at the same time, maintaining or increasing lean mass.
• GLP-1 glucagon-like peptide-1 receptor
• the term “approximately” or “about” refers to a range of values that fall within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, or less in either direction (greater than or less than) of the stated reference value unless otherwise stated or otherwise evident from the context (except where such number would exceed 100% of a possible value).
• polypeptide As used herein, the terms “polypeptide,” “peptide,” and “protein” refer to polymers of amino acids of any length. The terms also encompass an amino acid polymer that has been modified; for example, to include disulfide bond formation, glycosylation, lipidation, phosphorylation, or conjugation with a labeling component.
• identity refers to the percentage of exact matching residues in an alignment of a sequence provided herein to a reference sequence, such as an alignment generated by a BLAST algorithm or other alignment algorithms known in the art. Identity may be calculated based on an alignment of a full-length sequence provided herein and a full length reference sequence. Identity may also be calculated based on a partial alignment of a sequence provided herein and a reference sequence, if the reference sequence is longer than a sequence provided herein. Identity may also be calculated based on a partial alignment of a sequence provided herein and a reference sequence, if the reference sequence is shorter than a sequence provided herein.
• a query sequence “shares at least x % identity to” a subject sequence if in the alignment of the two sequences, at least x % (rounded down) of the residues in the subject sequence are aligned as an exact match to a corresponding residue in the query sequence, wherein the numerator is the number of exact matches and the denominator is the length of the query sequence.
• the denominator may alternatively be the length of the query sequence minus any gaps of two or more non-matching residues.
• treatment generally mean obtaining a desired pharmacologic and/or physiologic effect with a therapeutic agent.
• the effect may be prophylactic in terms of completely or partially preventing a disease or symptom thereof, e.g., reducing the likelihood that the disease or symptom thereof occurs in the subject, and/or may be therapeutic in terms of completely or partially reducing a symptom, or a partial or complete cure for a disease and/or adverse effect attributable to the disease.
• Treatment covers any treatment of a disease in a mammal, and includes: (a) preventing the disease from occurring in a subject which may be predisposed to the disease but has not yet been diagnosed as having it; (b) inhibiting or slowing the onset or development of the disease; or (c) relieving the disease, e.g., causing regression of the disease or symptoms associated with the disease.
• the therapeutic agent may be administered before, during or after the onset of disease.
• the treatment of ongoing disease where the treatment stabilizes or reduces the undesirable clinical symptoms of the patient, may be of particular interest.
• treatment is performed prior to complete loss of function in the affected tissues.
• the subject therapy will be administered during the symptomatic stage of the disease, and in some embodiments, after the symptomatic stage of the disease.
• loading dose refers to one or more doses of a therapeutic agent that are administered in addition to the combination therapies provided herein.
• a “loading dose” may refer to one or more doses of an ActRII receptor antibody which are the same concentration, a lower concentration, or a higher concentration than the doses of an ActRII receptor antibody that are a part of the combination therapy.
• the terms “individual,” “subject,” and “patient” are used interchangeably herein and refer to any subject for whom treatment or therapy is desired.
• the subject may be a mammalian subject.
• Mammalian subjects include, e. g., humans, non-human primates, rodents, ( e.g., rats, mice), lagomorphs (e.g, rabbits), ungulates (e.g., cows, sheep, pigs, horses, goats, and the like), etc.
• the subject is a human.
• the subject is a non-human primate, for example a cynomolgus monkey.
• the subject is a companion animal (e.g, cats, dogs).
• a metabolic disorder as used herein refers to a disorder affecting dysregulation of mammalian metabolism, including but not limited to: obesity, diabetes (Type I and II), metabolic syndrome, antipsychotic drug-associated obesity, glucocorticoid-induced obesity, hypothalamic obesity associated with craniopharyngioma, and monogenetic disorder associated obesity.
• the monogenetic disorders associated with obesity in humans may include but are not limited to Bardet-Biedl syndrome, and a disorder arising from a mutation in one or more of the following genes ADCY3, ALMS1, ARL6, BBS1, BBS2, BBS4, BBS5, BBS7, BBS9, BBS10, BBS12, BDNF, CCDC28B, CEP290, CREBBP, EP300, GNAS, IER3IP1, MC3R, MKKS, MKS1, MRAP2, NTRK2, PCSK1, PHF6, POMC, SH2B1, SIM1, TMEM67, TRIM32, TTC8 and VPS13B, or combinations thereof.
• a metabolic disorder may also be associated with a complex genetic disorder, e.g., Prader-Willi syndrome.
• Body Mass Index is calculated as weight in kilograms (kg) divided by height in meters squared (m 2 ), rounded to one decimal place.
• “obesity” in adult humans is defined as a BMI greater than or equal to 30 kg/m 2 .
• “Obesity” in human youth is defined as a BMI greater than or equal to the age- and sex-specific 95th percentile of the 2000 CDC growth charts.
• the term "overweight" is defined as a BMI of greater than or equal to 25 and less than 30.
• the terms “obesity related co-morbidity,” “obesity related condition” and “obesity related disorder” may be used interchangeably and refer to a health condition depending from the obesity of the subject. In some embodiments, the obesity related co-morbidity or condition increases the mortality risk of the subject.
• Obesity related co-morbidities include but are not limited to: high blood pressure (hypertension), high LDL cholesterol, low HDL cholesterol, high levels of triglycerides (dyslipidemia), Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, breathing problems, cancer, gastroesophageal reflux disease, severe COVID-19, overall mortality, lower quality of life, mental illness such as clinical depression, anxiety, and other mental disorders, and body pain and difficulty with physical functioning.
• Lean mass is defined as total body mass of a subject minus the fat mass and minus the bone mass of the subject. Lean mass and fat mass may be measured by, for example, bioelectrical impedance analysis (BIA), magnetic resonance imaging (MRI) or dual X-ray absorptiometry (DXA).
• BIOA bioelectrical impedance analysis
• MRI magnetic resonance imaging
• DXA dual X-ray absorptiometry
• antibody includes reference to an immunoglobulin molecule immunologically reactive with a particular antigen, and includes both polyclonal and monoclonal antibodies.
• the term includes humanized antibodies, chimeric antibodies e.g, murine variable region with a human constant region) and conjugated antibodies.
• antibody also includes antigen binding forms of antibodies, including fragments that retain antigen-binding capability (e.g., Fab', F(ab')2, Fab, single chain variable fragments (scFv) containing VH and VL sequences linked together in one chain, single chain antibody fragments (scAb). Fragment crystallizable regions (Fc) may also be linked to any of the aforementioned antigen-binding fragments.
• the term antibody also includes bivalent or bispecific molecules, diabodies, triabodies, and tetrabodies.
• Activin receptor II B is a receptor for myostatin, activin, and bone morphogenetic proteins (BMPs). The interaction between myostatin and this receptor regulates the inhibition of skeletal muscle differentiation via the Smad-dependent pathway. It is thought that by inhibiting or preventing myostatin from binding to ActRIIB, e.g, via an ActRII receptor antibody, the formation of skeletal muscle can be induced. Regulation of the activin receptor II A (ActRIIA) also plays a role in the regulation of muscle growth (Morvan et al. 2017).
• Exemplary ActRII receptor antibodies that bind to ActRIIA and ActRIIB were shown to not only increase lean muscle mass, but also to decrease fat mass and improve glycemic control in human clinical studies (W02010125003A1, WO2018116201A1, the contents of which are incorporated in their entirety, and Heymsfield et al. 2021;4(l):e2033457, JAMA ).
• Exemplary ActRII receptor antibodies that may be used in some embodiments include the human recombinant antibodies, isolated and structurally characterized, as described in W02010125003A1.
• exemplary antibodies of the disclosure include the sequences of Bimagrumab (BYM338).
• BYM338 The below table provides the relevant CDR, VH, VL, HC, and LC amino acid sequences for Bimagrumab.
• exemplary ActRII receptor antibodies of the disclosure comprise a variable heavy chain comprising the CDR amino acid sequences of SEQ ID NO: 1 (CDRH1), SEQ ID NO: 2 (CDRH2), and SEQ ID NO: 3 (CDRH3).
• exemplary ActRII receptor antibodies of the disclosure comprise a variable light chain comprising the CDR amino acid sequences of SEQ ID NO: 4 (CDRL1), SEQ ID NO: 5 (CDRL2), and SEQ ID NO: 6 (CDRL3).
• exemplary ActRII receptor antibodies of the disclosure comprise a variable heavy chain comprising the CDR amino acid sequences of SEQ ID NO: 1 (CDRH1), SEQ ID NO: 2 (CDRH2), and SEQ ID NO: 3 (CDRH3); and comprise a variable light chain comprising the CDR amino acid sequences of SEQ ID NO: 4 (CDRL1), SEQ ID NO: 5 (CDRL2), and SEQ ID NO: 6 (CDRL3).
• exemplary ActRII receptor antibodies of the disclosure comprise a variable heavy chain comprising the amino acid sequence of SEQ ID NO: 7, or an amino acid sequence of at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence identity thereto; and/or a variable light chain comprising the amino acid sequence of SEQ ID NO: 8, or an amino acid sequence of at least 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence identity thereto.
• exemplary ActRII receptor antibodies of the disclosure comprise a heavy chain comprising the amino acid sequence of SEQ ID NO: 9, or an amino acid sequence of at least 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence identity thereto; and/or a light chain comprising the amino acid sequence of SEQ ID NO: 10, or an amino acid sequence of at least 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence identity thereto.
• the ActRII receptor antibodies of the disclosure have an Fc domain, for example a human IgGl Fc domain, a human IgG2 Fc domain, a human IgG3, Fc domain, or a human IgG4 Fc domain.
• the Fc domain is wild type.
• the Fc domain is modified, e.g. modified to increase serum half-life.
• the Fc domain is a human IgGl Fc domain, and modified to increase serum half-life.
• the modifications that increase serum half-life include one or more of 2591, 252Y, 307Q, 308F, 428L, 434H, 434F, 434Y, 434A, 434M, and 434S relative to a human IgGl Fc domain according to the EU numbering scheme.
• the modifications include one or more of 259I/434S, 308F/434S, 308F/428L/434S, 259I/308F/434S, 307Q/308F/434S, 250I/308F/434S, and 308F1319L/434S relative to a human IgGl Fc domain according to the EU numbering scheme.
• the ActRII receptor antibody binds to ActRIIB with a KD of 100 nM or less, 10 nM or less, 1 nM or less.
• an ActRII receptor antibody binds to ActRIIB with an affinity of 100 pM or less (i.e. 100 pM, 50 pM, 10 pM, 1 pM or less).
• the ActRII receptor antibody binds to ActRIIB with an affinity of between 10 and 20 pM.
• the ActRII receptor antibody binds to ActRIIB with a 5 -fold greater affinity than to ActRIIA, more preferably 10-fold, still more preferably 50-fold, still more preferably 100-fold. In some embodiments, the ActRII receptor antibody binds to ActRIIA with an affinity of 100 pM or more (i.e. 250 pM, 500 pM, 1 nM, 5 nM or more).
• the combination treatments described herein include an agent that binds an ActrRII receptor ligand, e.g., binds myostatin or activin directly.
• agents include, but are not limited to, a myostatin inhibitor (e.g., a myostatin antibody, or a myostatin small molecule antagonist), an activin inhibitor (e.g., an activin antibody, or an activin small molecule antagonist), or a soluble extracellular portion of ActRIIB or ActRIIA that can act as a “ligand sink” optionally further stabilized with an Fc.
• a metabolic disorder of the disclosure comprising administering to a subject in need a Actrll pathway agent (other than an ActRII receptor antibody) in combination with a GLP-1 agonist, wherein the agent is selected from the group consisting of a myostatin inhibitor, an activin inhibitor, or a soluble portion of an ActRII receptor.
• administering exhibits a beneficial effect
• an ActRII pathway agent other than an ActRII receptor antibody
• a GLP-1 agonist exhibits a beneficial effect
• an ActRII pathway agent other than an ActRII receptor antibody
• administered as part of a treatment with a GLP-1 agonist decreases the dosage of a GLP-1 agonist required to see an effect, and/or increases the therapeutic effect of the GLP-1 agonist, relative to the GLP-1 agonist alone.
• a beneficial effect is demonstrated wherein a GLP-1 agonist decreases the dosage of the ActRII pathway agent (other than an ActRII receptor antibody) required to see an effect, and/or increases the therapeutic effect of the ActRII pathway agent, relative to administration of the ActRII pathway agent alone.
• the beneficial effect is increased safety of the combination relative to an ActRII pathway agent or a GLP-1 agent alone.
• the beneficial effect is increased efficacy of the combination relative to an ActRII pathway agent or a GLP-1 agent alone.
• the beneficial effect is increased tolerability relative to an ActRII pathway agent or a GLP-1 agent alone.
• the glucagon-like peptide- 1 receptor is a pancreatic beta cell receptor that stimulates insulin secretion upon binding of the hormone glucagon-like peptide 1 (GLP-1).
• GLP-1 is a type of incretin hormone, all of which regulate insulin release in response to blood sugar.
• GLP-1 agonists mimic the action of GLP-1 peptide and activate the GLP-1 receptor upon binding, stimulating insulin secretion.
• GLP-1 agonists exhibit significant side effects and tolerability issues at effective doses. GLP-1 agonists have also been shown to decrease lean mass of a subject during treatment.
• Warnings and precautions for GLP-1 agonists include but are not limited to: thyroid C-cell tumors, acute pancreatitis, acute gallbladder disease, hypoglycemia, acute kidney injury, severe adverse gastrointestinal reactions, hypersensitivity, e.g., anaphylactic reactions and angioedema, diabetic retinopathy complications in subjects Type 2 Diabetes, heart rate increase, and suicidal behavior and ideation.
• Adverse reactions reported in at least 5% of subjects treated with a GLP-1 agonist include nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, eructation, hypoglycemia in patients with type 2 diabetes, flatulence, gastroenteritis, and gastroesophageal reflux disease.
• GLP-1 agonist e.g., semaglutide
• the GLP-1 agonist of the disclosure may be a peptide, antibody, small molecule, or an aptamer.
• the GLP-1 agonist is a peptide or peptide analog, including but not limited to: exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, cotadutide, oxyntomodulin, or pemvidutide.
• the GLP-1 agonist is a small molecule non-peptide agonist, e.g, danuglipron.
• the GLP-1 agonist is a dual agonist that binds and activates or deactivates a second receptor in addition to a GLP-1 receptor, wherein the second receptor is glucosedependent insulinotropic (GIP) receptor or a glucagon (GCG) receptor.
• GIP glucosedependent insulinotropic
• GCG glucagon
• An exemplary dual acting GLP-1 agonist that binds both GLP-1 receptor and GIP receptor is tirzepatide.
• Exemplary dual acting GLP-1 agonists that binds both GLP-1 receptor and GCG receptor are cotadutide, noiiglutide, and oxyntomodulin, and are included in this disclosure as possible therapeutic agents to be used in combination with the ActRII receptor antibodies.
• the GLP-1 agonist is also a GIP antagonist.
• the GLP-1 agonist is also a GCG antagonist.
• the GLP-1 agonist is a triagonist of GIP/GLP-l/glucagon receptor, e.g., a GGG triagonist, e.g., LY343794.
• a combination therapy, or a “combination” contemplated herein includes the co-administration of an ActRII receptor antibody (or other ActRII pathway agent) and a GLP-1 agonist, wherein the ActRII receptor antibody (or other ActRII pathway agent) may be administered prior to, after, or at the same time as the GLP-1 agonist.
• Such combination therapy may further include an initial loading dose of the ActRII receptor antibody (or other ActRII pathway agent).
• the coadministration includes administering an ActRII receptor antibody comprising the amino acid sequence of SEQ ID NOS: 1-6 and/or SEQ ID NOS: 7 and 8 (or a sequence with sequence identity of at least 90% thereto).
• the co-administration includes administering an ActRII receptor antibody comprising the sequence of SEQ ID NOS: 1-6 and/or SEQ ID NOS: 7 and 8 (or a sequence with sequence identity of at least 90% thereto), and any of the GLP-1 agonists semaglutide, tirzepatide, or liraglutide.
• the combination therapy of the disclosure comprising an ActRII receptor antibody and a GLP- 1 agonist may be administered via any route.
• the ActRII receptor antibody and/or the GLP-1 agonist is delivered orally, subcutaneously, intravenously, intranasally, transdermally, intraperitoneally, intramuscularly, intrapulmonary, vaginally, rectally, or intraocularly.
• the ActRII receptor antibody is administered intravenously (IV) and/or subcutaneously
• the GLP-1 agonist is administered subcutaneously.
• an ActRII receptor antibody is administered in a dose of about 3 mg/kg per the subject’s body weight to about 50 mg/kg per the subject’s body weight to a subject in need thereof.
• an ActRII receptor antibody is administered in a dose of about 3 mg/kg per the subject’s body weight to about 50 mg/kg per the subject’s body weight to a subject intravenously.
• an ActRII receptor antibody is administered to a subject in need thereof in a dose of about 3mg/kg; in some embodiments in a dose of about 4 mg/kg; in some embodiments in a dose of about 5 mg/kg; in some embodiments in a dose of about 6 mg/kg; in some embodiments in a dose of about 7 mg/kg; in some embodiments in a dose of about 8 mg/kg; in some embodiments in a dose of about 9 mg/kg; in some embodiments in a dose of about 10 mg/kg; in some embodiments in a dose of about 11 mg/kg; in some embodiments in a dose of about 12 mg/kg; in some embodiments in a dose of about 13 mg/kg; in some embodiments in a dose of about 14 mg/kg
• the ActRII receptor antibody is administered to a subject in need thereof in a dose of 10 mg/kg. In some embodiments the ActRII receptor antibody is administered to a subject in need thereof in a dose of 30 mg/kg. In some embodiments the ActRII receptor antibody is administered to a subject in need thereof in a dose of 10 mg/kg intravenously. In some embodiments the ActRII receptor antibody is administered to a subject in need thereof in a dose of 30 mg/kg intravenously.
• the ActRII receptor antibody is administered to a subject in need thereof two, three, four, or five or more times.
• the ActRII receptor antibody is administered in a dosing regimen of once a week, twice a week, thrice a week, every two weeks, every four weeks, every six weeks, every twelve weeks, or every fifteen weeks.
• the ActRII receptor antibody is administered every quarter of a year.
• the ActRII receptor antibody is administered every 12 weeks in a dose of about 10 mg/kg.
• the ActRII receptor antibody is administered every 12 weeks in a dose of 30 mg/kg.
• the ActRII receptor antibody is administered every 12 weeks in a dose of about 10 mg/kg intravenously. In some embodiments, the ActRII receptor antibody is administered every 12 weeks in a dose of 30 mg/kg intravenously.
• an ActRII receptor antibody is administered in a dosing regimen of about 100 to about 600 mg, once, twice, three, or more times weekly. In some embodiments an ActRII receptor antibody is administered in a dosing regimen of about 200 to about 400 mg, for example, about 300 mg, once, twice, three, or more times weekly, or once every 2 weeks.
• an ActRII receptor antibody is administered in a dosing regimen of about 200 to about 400 mg subcutaneously. In exemplary embodiments, an ActRII receptor antibody is administered in a dose of about 300 mg subcutaneously.
• the ActRII receptor antibody is administered in a dose of about 200 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 200 mg once weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 200 mg twice weekly. In some embodiments the ActRII receptor antibody is administered in a dose of 200 mg thrice weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 200 mg every 2 weeks. In some embodiments, the ActRII receptor antibody is administered in a dose of about 200 mg subcutaneously.
• the ActRII receptor antibody is administered in a dose of about 300 mg. In exemplary embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg once weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg twice weekly. In some embodiments the ActRII receptor antibody is administered in a dose of 300 mg thrice weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg every 2 weeks. In exemplary embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg subcutaneously. In exemplary embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg once weekly subcutaneously.
• the ActRII receptor antibody is administered in a dose of about 400 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of about 400 mg once weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 400 mg twice weekly. In some embodiments the ActRII receptor antibody is administered in a dose of 400 mg thrice weekly. In some embodiments, the ActRII receptor antibody is administered in a dose of about 400 mg every 2 weeks. In some embodiments, the ActRII receptor antibody is administered in a dose of about 400 mg once weekly subcutaneously.
• the ActRII receptor antibody is administered in a dose of 600 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 600 mg once weekly, twice weekly, or thrice weekly, or every 2 weeks. In some embodiments, the ActRII receptor antibody is administered in a dose of about 600 mg subcutaneously.
• the ActRII receptor antibody is administered in a dosing regimen of about 600 mg to about 3000 mg, for example, about 1000 mg once, twice, three or four times monthly. In some embodiments the ActRII receptor antibody is administered in a dosing regimen of about 600 mg to about 3000 mg subcutaneously. In some embodiments the ActRII receptor antibody is administered in a dosing regimen of about 600 mg to about 3000 mg, once, twice, three or four times monthly subcutaneously.
• the ActRII receptor antibody is administered in a dose of 750 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 750 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 900 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 900 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 1050 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1050 mg once monthly.
• the ActRII receptor antibody is administered in a dose of 1200 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1200 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 1350 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1350 mg once monthly. [0097] In some embodiments, the ActRII receptor antibody is administered in a dose of 1500 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1500 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 1650 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1650 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 1800 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1800 mg once monthly.
• the ActRII receptor antibody is administered in a dose of 1950 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 1950 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 2100 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2100 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 2250 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2250 mg once monthly.
• the ActRII receptor antibody is administered in a dose of 2400 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2400 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 2550 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2550 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 2700 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2700 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 2850 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 2850 mg once monthly. In some embodiments, the ActRII receptor antibody is administered in a dose of 3000 mg. In some embodiments, the ActRII receptor antibody is administered in a dose of 3000 mg once monthly.
• the administration of a loading dose of an ActRII receptor antibody in addition to the combination therapy may improve the outcome of the combination treatment. Without being bound by theory, it is thought that administration of a loading dose could maintain the level of the ActRII receptor antibody in the serum of the subject over time and further optimize the combination therapy. Accordingly, in some embodiments, a loading dose of an ActRII receptor antibody is administered.
• one or more loading doses of an ActRII receptor antibody are administered to a subject in need thereof at day 0 or week 0 prior to the start of the combination therapy.
• one or more loading doses of an ActRII receptor antibody are provided 1 day, about 2 days, about 3 days, about 4 days, about 5 days, about 6 days, about 1 week, about 2 weeks, about 3 weeks, about 4 weeks, about 5 weeks, about 6 weeks, about 7 weeks, about 8 weeks, about 9 weeks, about 10 weeks, about 11 weeks, or about 12 weeks before the combination therapy is administered.
• a loading dose is administered about 4 weeks before the start the combination therapy.
• a second administration of one or more loading doses are given after about 6 months, about 8 months, about 10 months, about 12 months, about 14 months, about 16 months, about 18 months, about 20 months, or about 24 months of administration of the combination therapy.
• one or more loading doses are administered periodically or on a regular basis in addition to the combination therapy.
• a loading dose is administered first about 4 weeks prior to the start of the combination therapy, and administered about yearly thereafter.
• a subject is administered one or more loading doses followed by the combination therapy, and is then administered a second round of treatment, e.g. a second administration of one or more loading doses, followed by repeated combination therapy; likewise the treatment could include yet a third set of one or more loading doses, followed by a third round of the combination therapy, and so on and so forth.
• a loading dose is a dose of an ActRII receptor antibody the same concentration, a lower concentration, or a higher concentration as the dose of ActRII receptor antibody administered in the combination therapy. Accordingly, a loading dose may be about 3 mg/kg per the subject’s body weight to about 50 mg/kg per the subject’s body weight, and all amounts in between. In some embodiments, a loading dose may be administered at about 3 mg/kg per the subject’s body weight to about 50 mg/kg per the subject’s body weight, intravenously.
• a loading dose of an ActRII receptor antibody is administered to a subject in need thereof in a dose of about 3mg/kg; in some embodiments in a dose of about 4 mg/kg; in some embodiments in a dose of about 5 mg/kg; in some embodiments in a dose of about 6 mg/kg; in some embodiments in a dose of about 7 mg/kg; in some embodiments in a dose of about 8 mg/kg; in some embodiments in a dose of about 9 mg/kg; in some embodiments in a dose of about 10 mg/kg; in some embodiments in a dose of about 11 mg/kg; in some embodiments in a dose of about 12 mg/kg; in some embodiments in a dose of about 13 mg/kg; in some embodiments in a dose of about 14 mg/kg; in some embodiments in a dose of about 15 mg/kg; in some embodiments in a dose of about 16 mg/kg; in some embodiments in a dose of about 17 mg/kg; in some embodiments
• an ActRII receptor antibody loading dose is about 10 mg/kg per the subject’s body weight. In other exemplary embodiments, an ActRII receptor antibody loading dose is about 30 mg/kg per the subject’s body weight. In some embodiments, an ActRII receptor loading dose of about 10 mg/kg per the subject’s body weight is administered subcutaneously. In some embodiments, an ActRII receptor loading dose of about 10 mg/kg per the subject’s body weight is administered intravenously. In some embodiments, an ActRII receptor loading dose is about 30 mg/kg per the subject’s body weight and is administered intravenously.
• an ActRII receptor antibody loading dose is about 200-400 mg per dose. In some exemplary embodiments, an ActRII receptor antibody loading dose is about 300 mg per dose. In some exemplary embodiments, an ActRII receptor antibody loading dose is about 200- 400 mg per dose, and is administered subcutaneously.
• a GLP-1 agonist is administered to a subject in need thereof in a dose of about 0.005 mg to about 3.0 mg, e.g, a dose of about 0.005 mg, about 0.01 mg, about 0.05 mg, about 0.1 mg, about 0.5 mg, about Img, about 1.5mg, about 2 mg, about 2.5 mg, or about 3.0 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of about 0.005 mg to about 3.0 mg subcutaneously.
• a GLP-1 agonist administered to a subject in need thereof in a dose of about 1 to about 20 mg weekly, e.g., a dose of about 1 mg, about 2 mg, about 3 mg, about 4 mg, about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17 mg, about 18 mg, about 19 mg, or about 20 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of about 5 mg, about 10 mg, or about 15 mg subcutaneously.
• the GLP-1 agonist is increased incrementally according to one of the following regimens: e.g, from about 0.2 mg to about 3.0 mg, from about 0.1 to about l.Omg, from about 0.25 mg to about 2.4 mg, or from about 0.25 mg to about 0.5 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of 0.5 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of 1.0 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of 1.7 mg.
• the GLP-1 agonist is administered to a subject in need thereof in a dose of 2.4 mg.
• the GLP-1 agonist is increased incrementally and is administered subcutaneously.
• a GLP-1 agonist is administered daily, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, every week, every 2 weeks, every 3 weeks, or every 4 weeks. In some embodiments the GLP-1 agonist is administered in a dose of 0.5 mg once weekly. In some embodiments the GLP-1 agonist is administered to a subject in need thereof in a dose of 1.0 mg once weekly. In some embodiments the GLP-1 agonist is administered to a subject in need thereof in a dose of 1.7 mg once weekly. In some embodiments the GLP-1 agonist is administered in a dose of 2.4 mg once weekly.
• the GLP-1 agonist is administered weekly in a dose of about 0.25 mg from about week 0 to about week 4, and in a dose of about 0.5 mg at week 5 and weekly thereafter.
• the GLP-1 agonist dose is administered weekly in a dose of about 0.25 mg from about week 0 to about week 4, in a dose of about 0.5 mg from about week 5 to about week 8, in a dose of about 1.0 mg from about week 8 to about week 12, in a dose of about 1.7 mg from about week 12 to about week 15, in a dose of about 2.4 mg from about week 16 to about week 20, and a dose of about 2.4 mg from about week 20 and weekly thereafter.
• a GLP-1 agonist is administered daily, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, every week, every 2 weeks, every 3 weeks, or every 4 weeks. In some embodiments the GLP-1 agonist is administered in a dose of 5 mg once weekly. In some embodiments the GLP-1 agonist is administered in a dose of 10 mg once weekly. In some embodiments the GLP-1 agonist is administered in a dose of 15 mg once weekly.
• the combination therapy of an ActRII receptor antibody and a GLP-1 agonist includes: a loading dose of an ActRII receptor antibody administered at week 0, followed by an ActRII receptor antibody in a dose of about 30 mg/kg administered intravenously 4 weeks after the loading dose, and every 12 weeks thereafter for the course of the treatment; and a GLP-1 agonist administered weekly and subcutaneously.
• the GLP-1 agonist is administered weekly in a dose of about 2.4 mg or in a dose of about 15 mg.
• the GLP-1 agonist of the combination therapy e.g., semaglutide, is administered weekly in a dose of about 2.4 mg.
• the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 0.5 mg. In some embodiments, the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 1.0 mg. In some embodiments, the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 2 mg. In other preferred embodiments, the GLP-1 agonist of the combination therapy, e.g., tirzepatide, is administered weekly in a dose of about 15 mg. In other embodiments, the GLP-1 agonist, e.g., tirzepatide, is administered weekly in a dose of about 5 mg. In other embodiments, the GLP- 1 agonist, e.g., tirzepatide, is administered weekly in a dose of about 10 mg.
• the combination therapy of an ActRII receptor antibody and a GLP-1 agonist includes: an ActRII receptor antibody in a dose of about 300 mg administered once weekly, twice weekly, or once every two weeks and administered subcutaneously; and a GLP-1 agonist administered weekly and subcutaneously.
• the GLP-1 agonist is administered weekly in a dose of about 2.4 mg or about 15 mg.
• the GLP-1 agonist of the combination therapy e.g., semaglutide
• the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 0.5 mg.
• the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 1.0 mg. In some embodiments, the GLP-1 agonist, e.g., semaglutide is administered weekly in a dose of about 2 mg. In other exemplary embodiments, the GLP-1 agonist of the combination therapy, e.g., tirzepatide, is administered weekly in a dose of about 15 mg. In other embodiments, the GLP-1 agonist, e.g., tirzepatide, is administered weekly in a dose of about 5 mg. In other embodiments, the GLP- 1 agonist, e.g., tirzepatide, is administered weekly in a dose of about 10 mg.
• the ActRII receptor antibody is administered at least 12 weeks prior, at least 10 weeks prior, at least 8 weeks prior, at least 6 weeks prior, at least 4 weeks prior, at least 2 weeks prior, at least 1 week prior, at least 1 day prior, or at least 1 hour prior to the administration of the GLP-1 agonist.
• the ActRII receptor antibody dosing regimen may further be preceded by the administration of a loading dose.
• the GLP-1 agonist is administered at least 2 weeks prior, at least 1 week prior, at least 5 days prior, at least 4 days prior, at least 3 days prior, at least 2 days prior, at least 1 day prior, at least 6 hours prior, or at least 1 hour prior to the antibody.
• the ActRII receptor antibody is administered in a dose of about 10 mg/kg every 12 weeks, optionally for 2 or more doses and the GLP-1 agonist is administered in a dose of about 0.5 mg to 2.4 mg every week. In some embodiments, the ActRII receptor antibody is administered in a dose of about 300 mg once a week, for 2 or more doses and the GLP-1 agonist is administered in a dose of about 0.5 mg to 2.4 mg every week. In some embodiments, administration of the GLP-1 agonist begins before the first administration of the ActRII receptor antibody. In some embodiments, administration of the GLP-1 agonist begins after the first administration of the ActRII receptor antibody.
• the ActRII receptor antibody dosing regimen may further be preceded by the administration of a loading dose.
• the ActRII receptor antibody and the GLP-1 agonist are coadministered, i.e. administered at the same time.
• the ActRII receptor antibody and the GLP-1 agonist are co-formulated and co-administered at the same time with a single injection.
• the ActRII receptor antibody dosing regimen may further be preceded by the administration of a loading dose.
• the combination therapy is useful for the treatment of a metabolic disorder in a subject in need thereof.
• Metabolic disorders of the disclosure include but are not limited to obesity (e.g., glucocorticoid induced obesity), diabetes (Type I or Type II diabetes), metabolic syndrome, Prader- Willi syndrome, and hypertrophic lipodystrophy.
• the metabolic disorder is treated with an ActRII receptor antibody comprising the sequence of SEQ ID NOS: 1-6 and/or SEQ ID NOS: 7 and 8, or a sequence with sequence identity of at least 90% thereto, and a GLP-1 agonist selected from semaglutide, tirzepatide, and liraglutide.
• a subject in need of the combination treatments described herein is a subject who is overweight.
• a subject in need of the combination treatments described herein includes a subject with a BMI of 30 or greater.
• a subject in need of treatment includes a subject with a BMI of 27 or greater with an obesity related co-morbidity.
• a subject in need of treatment lacks glycemic control.
• Subjects can be of any age, including youth. In some embodiments, the subject is over 20 years old, over 30 years old, over 40 years old, over 45 years old, over 50 years old, over 60 years old, or over 80 years old. In exemplary embodiments the subject is 45 or older. In some embodiments, the subject is 18 or older.
• an ActRII receptor antibody is administered as part of a treatment program with a GLP-1 agonist.
• administration of both an ActRII receptor antibody and a GLP-1 agonist treats one or more metabolic disorders, e.g., obesity and obesity related conditions.
• the obesity related condition includes but is not limited to one or more of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, osteoporosis, renal disease, obstructive sleep apnea, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidaemia, hypertension, heart failure, coronary heart disease, stroke, gastroesophageal reflux disease and/or gallstones.
• administration of both an ActRII receptor antibody and a GLP-1 agonist improves glycemic control and/or treats Type II Diabetes.
• administering exhibits a beneficial effect, wherein an ActRII receptor antibody administered as part of a treatment with a GLP-1 agonist decreases the dosage of a GLP-1 agonist required to see an effect, and/or increases the therapeutic effect of the GLP-1 agonist, relative to the GLP-1 agonist alone.
• a beneficial effect is demonstrated wherein a GLP-1 agonist decreases the dosage of the ActRII receptor antibody required to see an effect, and/or increases the therapeutic effect of the ActRII receptor antibody, relative to administration of the ActRII receptor antibody alone.
• the beneficial effect is increased safety of the combination of the ActRII receptor antibody and the GLP-1 agonist relative to either of an ActRII receptor antibody or a GLP-1 agent alone. In some embodiments the beneficial effect is increased efficacy of the combination of the ActRII receptor antibody and the GLP-1 agonist relative to either of an ActRII receptor antibody or a GLP-1 agent alone.
• the increased safety and/or tolerability of an agent is determined by 100%, 90%, 80%, 75%, 50%, or 25% lower risk of adverse reactions, side effects, number of warnings and precautions, or number of contraindications.
• the level of the patient or physician reported side effects of the GLP-1 agonist are reduced at least 1.5x, 2x, 3x, 4x, 5x, or lOx when the GLP-1 agonist is administered as part of a treatment with an ActRII receptor antibody, relative to the GLP-1 agonist alone.
• the beneficial effect is increased efficacy of the combination of the ActRII receptor antibody and the GLP-1 agonist relative to either of an ActRII receptor antibody or a GLP-1 agent alone.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist exhibits an additive therapeutic effect, wherein administration of both agents increases the efficacy of the treatment.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist exhibits a synergistic therapeutic effect, wherein administration of both agents increases the efficacy more than the sum of the effect of each agent individually.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces fat mass in a subject.
• the treatment reduces fat mass in a subject (relative to pre-treatment) by at least 5%, at least 6%, at least 7%, at least 8%, at least 9%, at least 10%, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34% at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%,
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist increases lean mass in the subject.
• the treatment increases lean mass in a subject by at least 5%, at least 6%, at least 7%, at least 8%, at least 9%, at least 10%, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34% at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%,
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces fat mass and increases lean mass in a subject.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces fat mass and increases lean mass in an additive or synergistic manner.
• the treatment reduces fat mass in a subject by at least 5% (e.g., 5%-50%) and increases lean mass by at least 5% (e.g., 5%-50%) over the treatment period.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist maintains lean mass in a subject.
• a combined treatment of an ActRII receptor antibody and a GLP-1 agonist reduces fat mass and maintains lean mass in the subject in an additive or synergistic manner.
• the combination treatment reduces fat mass in a subject by at least 5% (e.g., 5%-50%) and maintains lean mass over the treatment period.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces body weight in the subject.
• the treatment reduces body weight in a subject by at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period.
• the combined treatment reduces body weight to a greater extent relative to treatment with either alone.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces the BMI of the subject.
• the treatment reduces BMI in a subject by at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period.
• the combined treatment reduces BMI to a greater extent relative to treatment with either alone.
• a combined treatment of an ActRII receptor antibody and a GLP-1 agonist reduces body weight in a synergistic manner.
• a combined treatment of an ActRII receptor antibody and a GLP-1 agonist reduces central adiposity in the subject.
• the treatment reduces central adiposity in a subject by at least 5% (e.g., 5%-50%) over the treatment period.
• the combined treatment reduces central adiposity to a greater extent relative to treatment with either alone.
• a combined treatment of an ActRII receptor antibody and a GLP-1 agonist reduces central adiposity in a synergistic manner.
• a combination treatment of an ActRII receptor antibody and a GLP-1 agonist reduces waist circumference in the subject.
• the average waist circumference of a woman in the United States is 38.7 inches, and the average waist circumference of a man is 40.2 inches, according to the United States Centers for Disease Control and Prevention (CDC).
• the waist circumference may be decreased at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period.
• fat mass in response to the combined treatment of an ActRII receptor antibody and a GLP-1 agonist is measured with BIA and/or DXA.
• a combined treatment of an ActRII receptor antibody and a GLP-1 agonist improves glycemic control in the subject. In some embodiments, the combined treatment improves glycemic control to a greater extent relative to treatment with either alone. In some embodiments, a combined treatment of an ActRII receptor antibody and a GLP-1 agonist improves glycemic control in a synergistic manner.
• glycemic control in response to the combined treatment of an ActRII receptor antibody and a GLP-1 agonist is measured by glucose and insulin levels, and the HOMA2 model is applied (www.dtu.ox.ac.uk/homacalculator/).
• the increased efficacy of the combination effect in a subject is determined by an at least 2-fold, at least 3 -fold, at least 4-fold, at least 5 -fold, at least 10-fold, or at least 20-fold improvement in at least one of the following measurements, relative to either treatment alone: body weight; bioelectrical impedance analysis (BIA) of lean mass and/or fat mass; waist to hip ratio; waist to height ratio; dual X-ray absorptiometry (DXA) of lean mass and/or fat mass; waist circumference; decreased BMI; blood lipids profde; leptin, adiponectin, and adipsin levels; IL-8 and/or IL-6 levels; urine biomarkers; hemoglobin Ale (HgbAlc) levels; hand dynamometry demonstrating muscle strength; glucose levels; insulin levels; short physical performance battery (SPPB); Impact of Weight on Quality of Life (IWQoL-Lite for CT) assessment; Short Form (36) Health Survey
• the ActRII receptor antibody and the GLP-1 agonist are combined in a pharmaceutical composition.
• the composition includes an ActRII receptor antibody comprising the sequence of SEQ ID NOS: 1-6 and/or SEQ ID NOS: 7 and 8 (or a sequence with sequence identity of at least 90% thereto), and the GLP-1 agonist semaglutide.
• the composition includes an ActRII receptor antibody comprising the sequence of SEQ ID NOS: 1-6 and/or SEQ ID NOS: 7 and 8 (or a sequence with sequence identity of at least 90% thereto), and the GLP-1 agonist tirzepatide.
• the composition includes an excipient, or carrier, e.g, an aqueous carrier.
• aqueous carriers can be used, e.g, buffered saline.
• the compositions may contain pharmaceutically acceptable auxiliary substances as those required to approximate physiological conditions such as pH and buffering agents, toxicity countering agents, e.g., disodium phosphate dihydrate, monosodium phosphate, sodium acetate, sodium chloride, potassium chloride, calcium chloride, hydrochloric acid, sodium hydroxide, L-histidine, L-histidine hydrochloride, and sodium lactate.
• compositions can vary and are selected based on fluid volumes, viscosities, and body weight in accordance with the particular mode of administration selected and the patient's needs (e.g, Remington's Pharmaceutical Science (15th ed., 1980) and Goodman & Gillman, The Pharmacological Basis of Therapeutics (Hardman et al., eds., 1996)).
• the compositions may contain pharmaceutically acceptable auxiliary substances such as those that contribute to the stability and activity of the pharmacologically active agent or agents, including but not limited to trehalose, sucrose, or other sugars and polysorbate 20, polysorbate 60, polysorbate 80 or other emulsifiers or stabilizers.
• Example 1 Comparison of the safety and efficacy of bimagrumab with semaglutide in adults who are overweight or obese
• a randomized, placebo-controlled study was designed to compare the safety and efficacy of bimagrumab with that of open label semaglutide in adults 45 and older who are overweight or obese.
• the purpose of the study is to compare the effect of bimagrumab and semaglutide on fat loss, when given in combination or singly, in adults ages 45 and above who are obese or who are overweight with at least one obesity related co-morbidity.
• the following markers are assessed: waist circumference; blood pressure; fat mass by DXA; lean mass by DXA; body weight; BMI; lipids; HgbAlc levels; glucose levels; insulin levels; short physical performance battery (SPPB); physical activity monitoring via actigraphy; exploratory urine biomarkers; leptin, adiponectin, adipsin, IL- 18, and IL-6 as adipose tissue biomarkers, and Activin A as a pharmacodynamic (PD) biomarker.
• PD pharmacodynamic
• AEs clinically determined adverse events
• TEAEs treatment emergent adverse events
• SAEs serious adverse events
• the change from baseline of patient health markers from week 0 to week 24 are monitored, including: heart rate (bpm), amylase (U/L), lipase (U/L), Alkaline Phosphatase ALP (U/L), aspartate aminotransferase AST (U/L), and alanine aminotransferase ALT (U/L).
• the study is randomized, partially blinded, and placebo-controlled, with a 9-arm, multi-center design. Participants are randomized to one of the following treatment arms: a) Bimagrumab 30 mg/kg b) Bimagrumab placebo c) Low dose semaglutide (0.5 mg/1.0 mg) + bimagrumab 30 mg/kg d) High dose semaglutide (2.4 mg) + bimagrumab 30 mg/kg e) Low dose semaglutide (0.5 mg/1.0 mg) + bimagrumab placebo f) High dose semaglutide (2.4 mg) + bimagrumab placebo g) Bimagrumab 10 mg/kg h) Low dose semaglutide (0.5 mg/1.0 mg) + bimagrumab 10 mg/kg i) High dose semaglutide (2.4 mg) + bimagrumab 10 mg/kg
• bimagrumab is given in a dose of either 10 mg/kg or 30 mg/kg each dose by intravenous (IV) infusion, for a total number of 2 doses, every 12 weeks.
• IV intravenous
• the rationale for a 24 week exposure duration and primary endpoint assessment is that this duration allows time for observation of differential effects from the two bimagrumab doses and the two semaglutide doses relative to each other and to the placebo.
• the dose of semaglutide is incrementally increased from 0.25 mg subcutaneous weekly to 2.4 mg subcutaneous weekly according to the label instructions for the high dose group or from 0.25 mg to 0.5 mg subcutaneous weekly for the low dose group.
• the control arm for semaglutide is a no-treatment group and is not given a subcutaneous injection.
• the bimagrumab placebo includes dextrose 5% in water (D5W) and is administered by IV infusion in 2 doses, one dose at week 0 and the second dose at week 12.
• the study is up to 40 weeks in duration, including a 4-week screening period, a 24-week treatment period, and a 12 week follow up period.
• Highly effective contraception methods include: i. Total abstinence. Periodic abstinence (e.g., calendar, ovulation, symptothermal, postovulation methods) and withdrawal are not acceptable methods of contraception. ii. Female sterilization (surgical bilateral oophorectomy with or without hysterectomy) or tubal ligation at least 6 weeks before taking study treatment. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment. iii. Male sterilization (at least 6 months prior to screening). For female participants in the study, the vasectomized male partner should be the sole partner for that participant. iv.
• a+b or a+c or b+c Combination of any two of the following methods: a) Oral, injected or implanted hormonal methods of contraception or other forms of hormonal contraception with comparable efficacy (failure rate ⁇ 1%), e.g, hormone vaginal ring or transdermal hormone contraception. b) Intrauterine device or intrauterine system. c) Barrier methods of contraception e.g., condom or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/vaginal suppository.
• Women are considered post-menopausal and not of childbearing potential if they have had 12 months of natural (spontaneous) amenorrhea with an appropriate clinical profile (e.g., age appropriate, history of vasomotor symptoms) or have had surgical bilateral oophorectomy (with or without hysterectomy) or tubal ligation at least six weeks ago. In the case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment is the woman considered not of childbearing potential.
• Metabolic syndrome is not an exclusion, even if managed with an anti-diabetic drug such as metformin or an SGLT2 inhibitor.
• psychiatric disorder clinically manifest peripheral vascular disease or disorder, or systemic disorder which could affect any of the efficacy assessments (e.g., diabetic neuropathy, chronic fatigue syndrome, schizophrenia, bipolar disorder, severe depression, intermittent claudication).
• efficacy assessments e.g., diabetic neuropathy, chronic fatigue syndrome, schizophrenia, bipolar disorder, severe depression, intermittent claudication.
• ECG showing clinically significant abnormalities including any current supra- ventricular arrhythmia with an uncontrolled ventricular response (mean heart rate >100 beats per minute [bpm]) at rest despite medical or device therapy, or any history of spontaneous or induced sustained ventricular tachycardia (heart rate >100 bpm for 30 sec) despite medical or device therapy, or any history of resuscitated cardiac arrest or presence of an automated internal cardioverter-defibrillator.
• Prolonged QT syndrome or QTcF > 450 msec (Fridericia Correction) for males and > 470 msec for females at screening or baseline at repeated assessment.
• liver disease or liver injury as indicated by abnormal liver function tests such as SGOT (AST), SGPT (ALT), alkaline phosphatase, or serum bilirubin (except Gilbert’s Disease).
• SGOT AST
• SGPT ALT
• alkaline phosphatase alkaline phosphatase
• serum bilirubin except Gilbert’s Disease
• Any single transaminase may not exceed 3x times upper limit of normal (ULN).
• UPN upper limit of normal
• a single parameter elevated up to and including 3 x ULN should be re-checked as soon as possible, and in all cases, at least prior to randomization, to rule out any lab error.
• total bilirubin concentration is increased above 1.5x ULN, total bilirubin should be differentiated into the direct and indirect reacting bilirubin. In any case, serum bilirubin should not exceed the value of 1.6 mg/dL (27 pmol/L).
• Example 2 Comparison of the safety and efficacy of bimagrumab with semaglutide in adults who are overweight or obese
• Example 2 A study as described in Example 1, to compare the safety and efficacy of bimagrumab with that of open label semaglutide in adults 45 and older who are overweight or obese, may be modified as described herein. Unlike Example 2, this dosing paradigm includes the administration of a loading dose.
• efficacy endpoints noted in Example 1 are incorporated herein, additional efficacy endpoints include: lipid levels (total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), and trigylcerides (TG)), urine mibroalbumin levels, the Impact of Weight on Quality of Life (IWQoL-Lite for CT) assessment, and Short Form (36) Health Survey (SF-36) assessment.
• TC total cholesterol
• HDL high-density lipoprotein
• LDL low-density lipoprotein
• TG trigylcerides
• urine mibroalbumin levels urine mibroalbumin levels
• IWQoL-Lite for CT the Impact of Weight on Quality of Life
• SF-36 Short Form (36) Health Survey
• the study comprises visits and phone calls every 4 weeks during the treatment phase.
• Bimagrumab is given in a dose of either 10 mg/kg (low dose) or 30 mg/kg (high dose) each by intravenous (IV) infusion, at week 0 (loading dose), week 4, and week 16. This dosing regimen is every 12 weeks with the inclusion of a loading dose at week 0 prior to the start of the dosing regimen at week 4.
• the dose of semaglutide is incrementally increased from 0.25 mg subcutaneous weekly to 2.4 mg subcutaneous weekly according to the label instructions for the high dose group or from 0.25 mg to 0.5 mg subcutaneous weekly for the low dose group.
• the dose escalation of semaglutide for the low dose group may be as follows: 0.25 mg from week 0 to week 4, and 0.5 mg thereafter.
• the dose escalation of semaglutide for the high dose group is as follows: in a dose of 0.25 mg weekly from week 0 to week 4, in a dose of 0.5 mg weekly from week 5 to week 8, in a dose of 1.0 mg weekly from week 8 to week 12, in a dose of 1.7 mg weekly from week 12 to week 15, in a dose of 2.4 mg weekly from week 16 to week 20, and a dose of 2.4 mg weekly from week 20 to week 24. Patients who are unable to tolerate a weekly dose of 0.5 mg or higher may drop down to the preceding lower dose.
• exclusion criteria noted in Example 1 are incorporated herein, additional exclusion criterion of study participants includes a history of familial hypertriglyceridemia or history of fasting triglyceride greater than 500 mg/dl (5.65 mmol/L).
• Example 3 Effects of the combination treatment of an ActRII receptor antibody and a glucagon- like peptide-1 receptor (GLP-1) on fat mass and lean mass in obese mice: initial study
• the present disclosure describes the surprising result that a combination treatment of an ActRII receptor antibody, bimagrumab and a glucagon-like peptide-1 receptor (GLP-1), semaglutide, reduced fat mass to a greater extent than an ActRII receptor antibody alone, while also increasing lean mass, in obese mice.
• GLP-1 glucagon-like peptide-1 receptor
• mice at 5-6 weeks of age were fed a 60 % fat diet for 14 weeks and reached an average body weight of 49 grams at the start of dosing, as an obese mouse model.
• groups of mice received a murinized version of bimagrumab, CDD866, at 0. 3 mg/kg or 20 mg/kg intraperitoneally (i.p.) weekly and/or semaglutide at 5 pg/kg or 40 pg/kg subcutaneously (s.c.) daily.
• the high fat diet was continued through the treatment period, and food intake and body weight were monitored twice weekly. Clinical observations, body composition by MRI, and physical activity, were assessed once weekly.
• mice treated with semaglutide alone or together with CDD866 had an initial decrease in food intake that recovered to baseline or above by 2 weeks, and at that time there were no clinical observations of concern in any animal. Indeed, the animals receiving the high dose of both drugs trended towards being more active than the vehicle-alone groups. In the mice that received a dose of 20 mg/kg CDD866 alone, lean mass increased 13%. For the same 20 mg/kg dose of CDD866 in combination with a semaglutide dose of 40 pg/kg, lean mass increased by 5%, compared to a lean mass decrease of 4 % with semaglutide 40 ug/kg alone.
• Fat mass after 2 weeks of treatment decreased by 8 % for a 20 mg/kg dose of CDD866 and by 16 % for a 40 pg/kg dose of semaglutide alone.
• fat mass decreased by 31 % in the mice that received 20 mg/kg of CDD866 in combination with 40 pg/kg semaglutide.
• Bimagrumab and semaglutide when administered together have at least an additive efficacy with respect to fat loss in obese mice while simultaneously yielding a lean mass increase.
• Example 4 Pharmacokinetic effects of the combination of the ActRII receptor antibody CDD866 and the glucagon-like peptide-1 receptor (GLP-1) semaglutide
• Table 1 shows the effects of CDD866, administered in a dose of 20 mg/kg, on semaglutide PK, administered in a dose of 40 pg/kg.
• Table 1 Effects of CDD866 on semaglutide PK
• Table 2 shows the effects of semaglutide, administered in a dose of 40 gg/kg on CDD866 PK, administered in a dose of 20 mg/kg.
• Example 5 Effects of the combination treatment of an ActRII receptor antibody, CDD866, and a GLP-1 agonist, semaglutide, on fat mass and lean mass in mice: continued study
• the present disclosure provides the surprising result that the combination of an ActRII receptor antibody and a GLP-1 agonist reduced fat mass synergistically, while also maintaining or increasing lean mass.
• efficacy measurements of the combination of the ActRII receptor antibody and GLP-1 agonist included food consumption, body weight, clinical biomarkers, MRI, and physical activity levels in DIO mice during the 3 weeks of treatment.
• CDD866 in combination with semaglutide, administered to DIO mice demonstrated at least an additive effect on inguinal fat mass, and leptin levels, and a synergistic effect on fat mass loss (FIGS. 4A-4C, Table 3). Further, CDD866 in combination with semaglutide reversed the lean mass muscle loss of semaglutide alone (FIG. 5). These results demonstrate that the combination of CDD866 and the GLP-1 agonist semaglutide provides both a synergistic reduction of fat mass loss, and also serves to counter the decrease in lean mass exhibited by GLP-1 agonists alone.
• RNAseq of inguinal fat tissue RNA transcripts was also performed.
• the RNAseq transcript results are shown in FIG.6, and are consistent with a reduction in fat mass in adipocytes via lipid mobilization signaling.
• the RNA library for the RNAseq experiments contained about 44 -73 million reads per sample, and the 20 genes with the greatest changes in transcript levels in response to the CDD866 and semaglutide combination are shown in FIG. 6. These results demonstrate that the combination of CDD866 and semaglutide activates lipid mobilization and decreases new lipid storage in fat tissue.
• Example 6 Effects of the combination treatment of an ActRII receptor antibody, CDD866, and additional GLP-1 agonists on fat mass and lean mass in mice
• DIO mice received a murinized version of bimagrumab, CDD866, at 20 mg/kg intraperitoneally (i.p.) weekly in combination with semaglutide (40 pg/kg once daily), liraglutide (40 pg/kg twice daily), or tirzepatide at 45 pg/kg once daily and after day 11, 22.5 pg/kg once daily) subcutaneously (s.c.).
• semaglutide 40 pg/kg once daily
• liraglutide 40 pg/kg twice daily
• tirzepatide at 45 pg/kg once daily and after day 11, 22.5 pg/kg once daily subcutaneously (s.c.).
• the GLP-1 agonists in this study were not dose escalated.
• the tirzepatide dose was dropped to 22.5 pg/kg on day 11 to moderate the observed drop in food intake.
• FIGS. 13 and 14 show the significant effects of the combination of CDD866 and tirzepatide on fat mass loss and lean mass maintenance and/or increase.

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