WO2024156884A1

WO2024156884A1 - Glucagon-like-peptide-2 (glp-2) analogues and their medical uses for the treatment of short bowel syndrome (sbs)

Info

Publication number: WO2024156884A1
Application number: PCT/EP2024/051935
Authority: WO
Inventors: Thor SCHÜTT SVANE NIELSEN; Birgitte BIILMANN RØNN; Lykke BJERGLUND GRAFF
Original assignee: Zealand Pharma A/S
Priority date: 2023-01-27
Filing date: 2024-01-26
Publication date: 2024-08-02

Abstract

Glucagon-like-peptide-2 (GLP-2) analogues and their medical uses the treatment of short bowel syndrome (SBS) are disclosed, in particular medical uses of glepaglutide identied in the EASE SBS 1 trial demonstrating improved patient Quality of Life (QoL) and/or an early reduction in the parenteral support (PS) required by patients as their treatment with glepaglutide progressed.

Description

GLUCAGON-LIKE-PEPTIDE-2 (GLP-2) ANALOGUES AND THEIR MEDICAL USES FOR THE TREATMENT OF SHORT BOWEL SYNDROME (SBS)

Field of the Invention

The present invention relates to glucagon-like-peptide-2 (GLP-2) analogues and their medical uses for the treatment of short bowel syndrome (SBS), and in particular to the treatments using glepaglutide that result in improved Quality of Life (QoL) of patients and/or an early or signficant reduction in the parenteral support (PS) required by patients undergoing GLP-2 therapy.

Background of the Invention

Human GLP-2 is a 33-amino-acid peptide with the following sequence: Hy-His-Ala-Asp- Gly-Ser-Phe-Ser-Asp-Glu-Met-Asn-Thr-lle-Leu-Asp-Asn-Leu-Ala-Ala-Arg-Asp-Phe-lle- Asn-Trp-Leu-lle-GIn-Thr-Lys-lle-Thr-Asp-OH. It is derived from specific post-translational processing of proglucagon in the enteroendocrine L cells of the intestine and in specific regions of the brainstem. GLP-2 binds to a single G-protein-coupled receptor belonging to the class II glucagon secretin family.

GLP-2 has been reported to induce significant growth of the small intestinal mucosal epithelium via the stimulation of stem cell proliferation in the crypts, and by inhibition of apoptosis in the villi (Drucker et al., 1996, Proc. Natl. Acad. Sci. USA 93: 7911-7916). GLP-2 also has growth effects on the colon. Furthermore, GLP-2 inhibits gastric emptying and gastric acid secretion (Wojdemann et al., 1999, J. Clin. Endocrinol. Metab. 84: 2513-2517), enhances intestinal barrier function (Benjamin et al., 2000, Gut 47: 112- 119), stimulates intestinal hexose transport via the upregulation of glucose transporters (Cheeseman, 1997, Am. J. Physiol. R1965-71), and increases intestinal blood flow (Guan et al., 2003, Gastroenterology, 125: 136-147).

It has been recognised in the art that glucagon-like peptide-2 receptor analogues have therapeutic potential for the treatment of intestinal diseases. However, the native hGLP- 2, a 33 amino acid gastrointestinal peptide, is not a useful in a clinical setting due to its very short half-life in humans of around 7 minutes for full length GLP-2 [1-33] and 27 minutes for truncated GLP-2 [3-33], In large part, the short half-life is due to degradation by the enzyme dipeptidylpeptidase IV (DPP-IV). Accordingly, there have been attempts in the art to develop GLP-2 receptor agonists with better pharmacokinetic characteristics, in particular to improve the half-life of GLP-2 molecules. By way of example, GLP-2 analogues with substitutions have been suggested such as e.g. GLP-2 analogues containing Gly substitution at position 2 ([hGly2] GLP-2, teduglutide) which increases the half-life from seven minutes (native GLP-2) to about two hours. Teduglutide is approved for the treatment of short bowel syndrome under the name Gattex (in the United States) and Revestive (in Europe).

WO 2006/117565 (Zealand Pharma A/S) describes GLP-2 analogues which comprise one of more substitutions as compared to [hGly2]GLP-2 and which improved biological activity in vivo and/or improved chemical stability, e.g. as assessed in in vitro stability assays. Among the molecules disclosed in WO 2006/117565 is ZP1848 (glepaglutide) which has been designed to be stable in liquid formulations. Dosage regimes for GLP-2 analogues including ZP1848 and its metabolites are described in WO 2018/229252, which also shows that these compounds are effective to increase longitudinal growth of the intestines. Ready-to use formulations of ZP1848 are described in WO 2020/065064.

Summary of the Invention

Broadly, the present invention is based on the surprising findings arising from the EASE SBS 1 trial, which is a multi-center, placebo-controlled, randomized, parallel-group, double-blind phase 3 clinical trial (NCT:03690206) that looked at the safety and effectiveness of treatment for short bowel syndrome (SBS) using glepaglutide, in particular in relation to end points of the trial relating to patient Quality of Life (QoL) and/or the parenteral support (PS) required by patients as their treatment with glepaglutide progressed. The parameters associated with changes in the PS required by patients include (a) the early occurrence of a significant improvement in reduction in PS volume compared to baseline and (b) the time to a clinical response as defined by the time to a reduction in PS volume of at least 20% compared to baseline.

The results of this EASE SBS 1 trial included the surprising finding that a secondary end point of the trial using Patient Global Impression of Change (PGIC), a PRO (patientreport outcome) tool, where patients rate their change in overall status since start of the trial on a 7-point Likert scale (see https://www.fda.gov/media/116277/download and https://www.fda.gov/media/116281/download), led to improvement and significant differences relative to placebo for both glepaglutide when administered twice weekly (TW) and once weekly (OW) when PGIC was assessed at week 24.

Furthermore, the EASE SBS 1 trial found that there was a significant reduction of PS volume after 12 weeks, a secondary end point of the trial, in particular for patients treated in the twice weekly (TW) arm of the trial. This early effect is faster than the effect of alternative therapies using GLP-2 analogues, such as teduglutide, and is faster than previously reported patient response to treatment with glepaglutide that demonstrated a reduction in PS volume after 20-24 weeks. The early effect is further supported by the significantly faster time to clinical response with glepaglutide TW compared with placebo.

Without wishing to be bound by any particular theory, the present inventors believe that the rapid reduction in the PS volume required by patients may be linked to the response felt by the patients, for example as represented by improvements in PGIC, possibly with a lag time between the reduction in PS volume and the benefit experienced by the patients.

In the trial, the patients received 10 mg of glepaglutide in both the twice weekly (TW) and once weekly (OW) arms of the trial.

Accordingly, in a first aspect, the present invention provides a glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the method comprises administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment results in an improvement in quality of life (QoL) of the patient.

In a further aspect, the present invention provides the use of a glucagon-like peptide 2 (GLP-2) analogue in the preparation of a medicament for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the use comprises administering the GLP- 2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment results in an improvement in quality of life (QoL) of the patient.

In a further aspect, the present invention provides a provides a method for treating a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), the method comprising administering to the patient a glucagon-like peptide 2 (GLP-2) analogue represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, wherein administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time results in an improvement in quality of life (QoL) of the patient.

In these aspects of the invention, the improvement in quality of life (QoL) of the patient is assessed using a Patient Global Impression of Change (PGIC) status, for example using a 7-point Likert Scale with responding patients reporting a much improved or very much improved status as compared to treatment with placebo. In some cases, the improved PGIC status of the patient is observable at week 24 of the treatment.

In a further aspect, the present invention provides a glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the method comprises administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment leads to a reduction in PS volume at 12 weeks from the start of treatment with the GLP-2 analogue.

In a further aspect, the present invention provides the use of glucagon-like peptide 2 (GLP-2) analogue in the preparation of a medicament for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the method comprises administering to the patient a GLP-2 analogue represented by the formula: H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the method comprises administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment leads to a reduction in PS volume at 12 weeks from the start of treatment with the GLP-2 analogue.

In a further aspect, the present invention provides a method for treating a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the method comprises administering to the patent a GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, wherein administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time leads to a reduction in PS volume at 12 weeks from the start of treatment with the GLP-2 analogue.

By way of example, in the present invention, the treatment may lead to a significant and earlier reduction in PS volume of -2.42 placebo at 12 weeks from the start of treatment with the GLP-2 analogue.

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the method comprises administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment leads to an early onset of effect, with a median time to clinical response as defined by a reduction in PS volume of at least 20% of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide. In a further aspect, the present invention provides the use of a glucagon-like peptide 2 (GLP-2) analogue in the prearation of a medicament for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, the method comprises administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time, wherein the treatment leads to an early onset of effect, with a median time to clinical response as defined by a reduction in PS volume of at least 20% of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide.

In a further aspect, the present invention provides a method for treating a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the method comprises administering to the patient a GLP-2 analogue is represented by the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2, (ZP1848, SEQ ID NO: 1) or a pharmaceutically acceptable salt thereof, wherein administering the GLP-2 analogue to the patient once weekly or twice weekly for a period of time leads to an early onset of effect, with a median time to clinical response as defined by a reduction in PS volume of at least 20% of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide.

The results discosed herein also show that in some patients the treatment with the GLP- 2 analogue enables parenteral support to be completely withdrawn, for example such that the patient does not require parenteral support after 24 weeks of the treatment. This is also referred to a patient achieving oral or enteral autonomy.

In the present context, the term "parenteral support" or "PS" includes the provision of nutrients and/or fluids to the subject receiving GLP-2 therapy as a means of providing the subject with the nutrients and/or fluids that they require, but are unable to absorb fully due to their condition.

In the present context, the terms achieving "oral or enteral autonomy" refers to patients who had been receiving PS and GLP-2 therapy to improve their gastrointestinal function to the extent that all PS is withdrawn (i.e., PS ceases to be a part of their treatment regimen).

The terms "subject" and "patient" are used interchangeably in this specification. It will be understood that the subject (or patient) is a mammal, and typically a human.

ZP1848 is also effective in increasing intestinal mass and longitudinal intestinal growth, particularly in the small intestine.

The ZP1848 or pharmaceutically acceptable salt will typically be provided as a pharmaceutical composition, comprising ZP1848 or said salt in combination with a pharmaceutically acceptable carrier or excipient.

The individual doses may be for administration via a dosing regime as described elsewhere in this specification.

WO 2018/229252 describes that ZP1848 has an unexpectedly long half-life which may enable alternative regimes, such as once or twice weekly administration, especially when delivered by subcutaneous injection. These results arose from a Phase 2 clinical study in humans using ZP1848 that found that the terminal plasma half-life of the molecule is in fact between 5 and 17 days. The terminal plasma half-life is the time required to divide the plasma concentration by two after reaching pseudo-equilibrium. Without wishing to be bound by theory, it is believed that the half-life of ZP1848 may be due to the combination of the formation of a subcutaneous depot and the formation of metabolites which are slowly released from the subcutaneous depot and which are also agonistic on the GLP-2 receptor. The subcutaneous depot may be formed on administration through a reaction between the lysine tail of ZP1848 and hyaluronic acid in the subcutaneous compartment.

Thus the once weeky or twice weekly dosing regime may comprise a plurality or course of doses separated in time by 2 days, 2.5 days, 3 days, 3.5 days, 4 days, 5 days, 6 days or 7 days. As will be appreciated in the art, the time between doses may be varied to some extent so that each and every doses is not separated by precisely the same time. This will often be directed under the discretion of the physician separated in time by a clinically acceptable range of times.

In some cases, it may be desirable to divide a total dose into a plurality (e.g. two or three) separate doses or administrations, for example for administration at spaced apart injection sites, for example spacing the injection sites at least 5 cm apart. Such spatially separate administrations will typically be provided at substantially the same time, e.g. on the same day, within one hour of each other, or even closer in time.

In the present context, the term “parental support" or "PS" includes the provision of nutrients and/or fluids to the subject receiving GLP-2 therapy as a means of providing the subject with the nutrients and/or fluids that they require, but are unable to absorb fully due to their condition. The detemination of the correct amount or volume of PS to provide to subjects with SBS who are receiving GLP-2 therapy is a challenge because if PS volume is not adjusted in a timely and appropriate way, patients may experience fluid overload, are at risk of dehydration and may not achieve optimal clinical responses to the therapy. This is further complicated as the PS volume required by a subject will typically vary during the course of GLP-2 therapy depending on their response to the therapy. Typically, the assessment of the amount of PS volume required by the subject as GLP-2 therapy progresses is dependent on how long the therapy has continued and the responsiveness of individual patients to it. In view of this variation, an initial assessment of PS volume may be carried out within the first few days of GLP-2 therapy, and is typically then followed by a weekly assessment during the first month, a monthly assessment over the next 1-3 months, and thereafter an assessment every 3-6 months until the treatment is concluded. This is important as subjects may experience a rapid initial response to GLP-2 therapy, as shown in the examples below, improving the function of the small intestine, for example even before any increase in the length of the intestine is observed. This in turn enables the PS volume to be reduced, thereby avoiding the risk of side effects, such as fluid overload. Accordingly, in the medical uses disclosed herein, as a subject's need for PS reduces the method or uses may include the step of (a) determining the volume of PS required by the subject at that point in the treatment, (b) comparing it to a baseline PS volume determined at the start of therapy with the GLP-2 analogue and (c) reducing the frequency or volume of the PS where the subject demonstrates improved function of the intestine, such as the small intestine. Optionally, the reduction of a frequency or volume of the parenteral support (PS) can be performed using the algorithm described in the examples.

By way of illustration of the relationship between the amount of parenteral support required by patients and the degree of improvement in intestinal function, it is presently believed that a 40% increase in length and width of the small intestine would result in at least a further 10% improvement in function or absorptive capacity of the small intestine. Generally, the GLP-2 therapy according to the present invention leads to improved function or absorptive capacity of the small intestine of at least 10%, more preferably at least 20%, more preferably at least 30% more preferably at least 40%, and most preferably at least 50%. Additionally or alternatively, the amount of the reduction of parenteral support over the course of GLP-2 therapy is at least 10%, more preferably at least 20%, more preferably at least 30%, more preferably at least 40% and most preferably at least 50%. In a preferred embodiment, the reduction of parenteral support is at least 20%.

In a further related aspect, the present invention addresses one of the challenges facing patients and physicians when initiating GLP-2 therapy, namely the appropriate and individualized adjustment in volume of parenteral support (PS) provided to the patient. This is important because if the PS volume is not adjusted in a timely and appropriate way, patients may experience fluid overload, risks of dehydration and may not achieve optimal clinical responses with the therapy.

For example, in a previous 24-week treatment study (see Center for Drug and Evaluation and Research, application number 203441 Grig 1s000, page 16) with the GLP-2 analogue teduglutide, an attempt to reduce the parental nutrition volume by 10% was done at the earliest at week 4, 8, 12, 16, and 20 after start of treatment, if the urine output increased by at least 10% from baseline. Many of the patients in this study suffered from fluid overload and stopped drinking (Jeppesen et al. 2011 , Gut 2011 ;60:902-914). In a follow- up study, a 24-week study of patients with SBS-IF who were given subcutaneous teduglutide (Jeppesen et al. 2012, Gastroenterology 2012;143:1473-1481), the reduction of parental nutrition to at least 10%, but not more than 30%, was recommended every week if the urine output increases by at least 10% from baseline. However, in this study, the patients also suffered from fluid overload, in particular at the beginning of the treatment.

Consequently, as carried out in the EASE SBS 1 trial described in the example, the present invention enables early assessment of altered PS fluid needs (for example, within a few days of initiating GLP-2 therapy) and provides algorithms for adjusting of PS volume during a course of GLP-2 therapy, in the trial achieving an early onset of clinical response (i.e. > 20% reduction in PS volume) and a significant reduction in PS after 12 weeks. By way of example, an early onset of effect was achieved, with median time to clinical response (reduction in PS volume of at least 20%) of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide. It will be appreciated by those skilled in the art that this approach using the algorithm to adjust the PS volume provides a personalised adjustment of the PS volume for each patient. This aspect of the present invention is applicable to GLP-2 therapies using the GLP-2 analogues disclosed herein or using GLP-2 analogues known elsewhere in the art, such as teduglutide or apraglutide. Accordingly, the algorithm for adjusting PS volume disclosed in the examples may be used in any aspect of the present invention.

In all aspects of the present invention, the method of administering the glucagon-like peptide 2 (GLP-2) analogue optionally comprises administering a plurality of doses of the GLP-2 analogue to the patient, wherein the doses are separated in time by one week or half a week. In some cases, it may be desirable to divide a total dose into a plurality (e.g. two or three) separate doses, for example for administration at spaced apart injection sites, for example spacing the injection sites at least 5 cm apart.

Preferably, the doses of the GLP-2 analogues used in accordance with the present invention are in the range between 0.5 mg and 25 mg inclusive per patient once or twice weekly, optionally between 1 mg and 20 mg inclusive per patient once or twice weekly, optionally between 1 mg and 10 mg inclusive per patient once or twice weekly, optionally between 2 mg and 7 mg inclusive per patient once or twice weekly, optionally between 5 mg and 7 mg inclusive per patient once or twice weekly, or optionally between 2 mg and 5 mg inclusive per patient once or twice weekly. In one embodiment, the dose of the GLP-2 analogues used in accordance with the present invention is 10 mg inclusive per patient once or twice weekly. In a course of treatment, the doses taken by the patient may either be the same or different in accordance with the instructions from the physician.

Preferably, the glucagon-like peptide 2 (GLP-2) analogue are administered to patients by injection, most typically by subcutaneous injection or intramuscular injection. In some preferred embodiments, the GLP-2 analogue may be administered using an injection pen, which allow patients to self-administer the analogue. In some aspects, administration of the GLP-2 analogue causes formation of a subcutaneous depot from which the GLP-2 analogue, or metabolites thereof, are released. Without wishing to be bound by any particular explanation, the subcutaneous depot may form through the interaction of the GLP-2 analogues administered in accordance with the present invention, in particular where the analogues comprise a lysine tail, through a reaction between the analogues and with hyaluronic acid in the subcutaneous compartment.

Embodiments of the present invention will now be described by way of example and not limitation with reference to the accompanying figures. However, various further aspects and embodiments of the present invention will be apparent to those skilled in the art in view of the present disclosure.

“and/or” where used herein is to be taken as specific disclosure of each of the two specified features or components with or without the other. For example “A and/or B” is to be taken as specific disclosure of each of (i) A, (ii) B and (iii) A and B, just as if each is set out individually herein.

Unless context dictates otherwise, the descriptions and definitions of the features set out above are not limited to any particular aspect or embodiment of the invention and apply equally to all aspects and embodiments which are described.

Brief Description of the Figure

Figure 1 depicts the trial design described in the examples. This phase 3 trial was a pivotal, multicenter, placebo-controlled, randomized, parallel-group, double-blind and fixed dose, designed to confirm the efficacy of glepaglutide in reducing the parenteral support (PS) volume in SBS patients and to evaluate the efficacy of glepaglutide on other efficacy endpoints as well as the safety and tolerability of glepaglutide in patients with SBS. A 3-arm treatment, parallel- group design with a 1 :1:1 randomization scheme (2 active treatment groups [once and twice weekly] and placebo) was chosen to compare the dosing regimen. The clinical trial is registered at clinicaltrials.gov: NCT03690206.

Figure 2 shows the PS volume (L/week) change from Baseline by visit - treatment policy estimand - primary statistical analysis (Ml CR) in a LSmeans plot. Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; CR: copyreference; Ml: multiple imputation; PS: parenteral support. Notes: MMRM model includes treatment group, visit, stratification factor, treatment-by-visit interaction as factors and Baseline PS volume (L/Week) as covariate. Variance estimation is based on an unstructured covariance matrix within treatment group. Stratification factor: weekly PS volume requirements <12 L/week and >- 12 L/week.

Figure 3 shows PS volume (L/week) change from Baseline by visit - treatment policy estimand - primary statistical analysis (Ml CR) - LSmeans plot, following exclusion of one technical outlier. Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; CR: copy-reference; Ml: multiple imputation; PS: parenteral support. Notes: MMRM model includes treatment group, visit, stratification factor, treatment-by-visit interaction as factors and Baseline PS volume (L/Week) as covariate. Variance estimation is based on an unstructured covariance matrix within treatment group. Stratification factor: weekly PS volume requirements <12 L/week and >- 12 L/week.

Detailed Description of the Invention

Definitions

Throughout the description and claims the conventional one-letter for natural amino acids are used. All amino acid residues in the compounds described are typically of the L- configuration.

Compounds

ZP1848 is a peptide having the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKKKKKK-NH2 as described e.g. in WO 2006/117565. It will be understood that the N-terminal "H-" indicates the hydrogen of a free N-terminal amine (NH₂ group). The C-terminal "NH2-" indicates a C-terminal amide group. The terms "ZP1848" and "glepaglutide" may be used interchangeably.

The present invention relates to the use of pharmaceutically acceptable salts of ZP1848, as described in more detail below. Any suitable salt may be used, although acetate may be preferred.

When ZP1848 is injected into the subcutaneous (SC) compartment, two functionally active metabolites are formed, ZP2469 and ZP2711, both C-terminal truncated analogs of ZP1848. The overall PK profile of ZP1848 therefore comprises the effect of ZP1848 and its two main metabolites.

ZP2469 is a peptide having the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDK-OH

ZP2711 is a peptide having the formula:

H-HGEGTFSSELATILDALAARDFIAWLIATKITDKK-OH where the N-terminal "H-" is as described above, and the C-terminal "-OH" indicates a free C-terminal carboxylic acid group.

Teduglutide is a peptide having the formula:

H-HGDGSFSDEMNTILDNLAARDFINWLIQTKITD-OH where the N-terminal "H-" and C-terminal "-OH" are as described above.

Pharmaceutical Compositions and Administration

The GLP-2 analogue as used herein may be formulated as pharmaceutical compositions prepared for storage or administration, and which comprise a therapeutically effective amount of the GLP-2 analogue in a pharmaceutically acceptable carrier.

Suitable salts include acid addition salts and basic salts. Examples of acid addition salts include hydrochloride salts, citrate salts, chloride salts and acetate salts. Preferably, the salt is acetate. In general, it is preferred that the salt is not a chloride salt. Examples of basic salts include salts where the cation is selected from alkali metals, such as sodium and potassium, alkaline earth metals, such as calcium, and ammonium ions +N (R3) 3(R4), where R3 and R4 independently designates optionally substituted C1-6-alkyl, optionally substituted C2-6-alkenyl, optionally substituted aryl, or optionally substituted heteroaryl.

Acetate salts may be particularly preferred. In the present context, the term "ZP1848- acetate" refers to the ZP1848 molecule is in the form of an acetate salt. The acetate salts of ZP1848 30 may be represented by the formula (ZP1848), x(CH3COOH) where x is 1.0 to 8.0, i.e. where x is 1.0, 2.0, 3.0, 4.0, 5.0, 6.0, 7.0 or 8.0. In any composition, there may be molecules with different number of acetate molecules so that x is not necessarily a whole integer. In some cases, x is from 4.0 to 8.0, x is from 6.0 to 8.0, or x is from 4.0 to 6.5. In some cases, x is from 4.0 to 6.0, x is from 2.0 to 7.0, x is from 3.0 to 6.0, x is from 4.0 to 6.0 or x is 4.0 to 8.0.

When administration is to be parenteral, such as subcutaneous or intramuscular injectable pharmaceutical compositions can be prepared in conventional forms. Glepaglutide is generally provided as aqueous liquid formulations, for example as described in WO 2020/065064 and WO 2020/065063, the contents of which are incorporated by reference in their entirety. Subcutaneous administration may be particularly preferred, e.g. by injection.

The therapeutic dosing and regimen most appropriate for patient treatment will of course vary with the disease or condition to be treated, and according to the patient parameters. Without wishing to be bound by any particular theory, it is expected that doses, between 0.1 and 25 mg per patient, and shorter or longer duration or frequency of treatment may produce therapeutically useful results, such as a statistically significant increase particularly in small bowel mass. In some instances, the therapeutic regimen may include the administration of maintenance doses appropriate for preventing tissue regression that occurs following cessation of initial treatment. The dosage sizes and dosing regimen most appropriate for human use may be guided by the results obtained by the present invention, and may be confirmed in further clinical trials.

A human dose (total dose) of ZP1848 may be from about such as between and including 0.1 mg and 25 mg per patient between and including 0.5 mg and 20 mg per patient, such as between and including 1 mg and 15 mg per patient, such as between and including 1 mg and 10 mg per patient once or twice weekly or as a plurality of doses as defined herein separated in time by 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 or 14 days. In some instances, a fixed dose of ZP1848 may be used in accordance with a dosing pattern disclosed herein, i.e. a dose which is the same regardless of the body weight of the patient, given once or twice weekly. By way of example, the fixed dose may be a dose of 1.25 mg, 2.5 mg, 5 mg, 6 mg, 7 mg, 8 mg, 9, mg, 10 mg, 11 mg, 12 mg, 13 mg, 14 mg or 15 mg. Conveniently, a fixed dose of 10 mg may be used as done in the EASE SBS 1 trial reported in the examples. The use of fixed dosing has the advantage of increasing compliance and reducing the risk of patient dosing errors, including risks of miscalculating a weight based dose to be administered.

In preferred embodiments, the formulation is a ready-to-use formulation as described in WO 2020/065064. The term "ready-to-use" as used herein refers to a formulation that does not require constitution or dilution with a prescribed amount of diluent, e.g., water for injection or other suitable diluent, before use by the designated route of administration.

As described herein, the liquid formulations of the GLP-2 analogues of the present invention include a buffer, a non-ionic tonicity modifier and arginine q.s. to provide the pH of the final formulation. In accordance with normal pharmaceutical practice, the formulations of the present invention are sterile and/or free from reducing agent. In preferred cases, the liquid formulations of the present invention are aqueous, liquid formulations. In some cases, the liquid formulations of the present invention are nonaqueous, liquid formulations.

The term "buffer" as used herein denotes a pharmaceutically acceptable excipient which stabilizes the pH of a pharmaceutical formulation. Suitable buffers are well known in the art and can be found in the literature. The screening experiments in the examples show that the formulations of the present invention preferably include a buffer selected from a histidine buffer, mesylate buffer, acetate buffer, glycine buffer, lysine buffer, TRIS buffer, Bis-Tris buffer and MOPS buffer as these buffers provided stable formulations in which the GLP-2 analogues dissolved and did not become viscous, cloudy or precipitate the peptide drug. In preferred embodiments, the buffer is a histidine buffer, e.g. L-histidine. Generally, the buffer will be present at a concentration of about 5 mM to about 50 mM, more preferably at a concentration of about 5 mM to about 25 mM, and most preferably at a concentration of about 15 mM. Preferably the buffer is not a phosphate buffer, a citrate buffer, citrate/Tris buffer and/or succinate buffer.

The term "tonicity modifier" as used herein denotes pharmaceutically acceptable tonicity agents that are used to modulate the tonicity of the formulation. The formulations of the present invention are preferably isosmotic, that is they have an osmotic pressure that is substantially the same as human blood serum. The tonicity modifiers used in the formulations are preferably non-ionic tonicity modifiers and are preferably selected from the group consisting of mannitol, sucrose, glycerol, sorbitol and trehalose. A preferred non-ionic tonicity modified is mannitol, e.g. D-mannitol. The concentration of the tonicity modifier will be dependent on the concentration of other components of the formulation, especially where the formulation is intended to be isosmotic. Typically, the non-ionic tonicity modifier will be employed at a concentration of about 90 mM to about 360 mM, more preferably at a concentration of about 150 mM to about 250 mM, and most preferably at a concentration of about 230 mM.

Generally, the components and amounts of the liquid formulations are chosen to provide a formulation with a pH of about 6.6 to about 7.4, more preferably a pH of about 6.8 to about 7.2, and most preferably a pH of about 7.0. Arginine may be added quantum sufficit (q.s.) to adjust pH so that it is within a desired pH range. It is preferred that the pH adjustment is not done using hydrochloric acid or sodium hydroxide.

In one embodiment, the liquid formulations consist of ZP1848, e.g. an acetate salt thereof, at a concentration of about 2 mg/ml to about 30 mg/ml a buffer selected from the group consisting of a histidine buffer, mesylate buffer, acetate buffer, glycine buffer, lysine buffer, TRIS buffer, Bis-Tris buffer and MOPS buffer, the buffer being present at a concentration of about 5 mM to about 50 mM, a non-ionic tonicity modifier selected from the group consisting of mannitol, sucrose, glycerol, sorbitol and trehalose at a concentration of about 90 mM to about 360 mM, arginine q.s. to provide a pH of about 6.6 to about 7.4.

In one embodiment, the liquid formulations consist of ZP1848, e.g. an acetate salt thereof, at a concentration of about 2 mg/ml to about 30 mg/ml, a buffer selected from the group consisting of a histidine buffer, mesylate buffer and acetate buffer, the buffer being present at a concentration of about 5 mM to about 50 mM, a non-ionic tonicity modifier selected from the group consisting of mannitol, sucrose, glycerol and sorbitol at a concentration of about 90 mM to about 360 mM, arginine q.s. to provide a pH of about 6.6 to about 7.4.

In a further preferred embodiment, the liquid formulations comprise ZP1848, e.g. an acetate salt thereof, at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM, and arginine q.s. to provide a pH of about 7.0.

In a further embodiment, the liquid formulations comprise ZP1848, e.g. an acetate salt thereof, at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM and the pH is about 7.0.

In a further embodiment, the liquid formulations comprise ZP1848-acetate or H- HGEGTFSSEIATIIDAIAARDFIAWLIATKITDKKKKKK-NH2 acetate (SEQ ID NO: 1) at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM, and arginine q.s. to provide a pH of about 7.0.

In a further embodiment, the liquid formulations comprise ZP1848-acetate or H- HGEGTFSSEIATIIDAIAARDFIAWLIATKITDKKKKKK-NH2 acetate (SEQ ID NO: 1) at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM and the pH is about 7.0.

The skilled person will appreciate that is cases where a formulation comprises the GLP-2 analogue at a concentration of 20 mg/mL, a patient can be administered a 0.5 ml dose to treat them with 10 mg of the GLP-2 analogue.

In a further embodiment, the liquid formulations comprise an acetate salt of a glucagon- like peptide 2 (GIP-2) analogue having the formula:

(H-HGEGTFSSEIATIIDAIAARDFIAWLIATKITDKKKKKK-NH2), X(CH₃COOH) where x is 1.0 to 8.O., at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM and the pH is about 7.0. In a further embodiment, the liquid formulations comprise an acetate salt of a glucagon- like peptide 2 (GIP-2) analogue having the formula:

(H-HGEGTFSSEIATIIDAIAARDFIAWLIATKITDKKKKKK-NH2), x(CH₃COOH) where x is 1.0 to 8.O., at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM and the pH is about 7.0, in a once or twice daily dosing regimen.

(H-HGEGTFSSEIATIIDAIAARDFIAWLIATKITDKKKKKK-NH2), x(CH₃COOH) where x is 1.0 to 8.O., at a concentration of about 20 mg/ml, histidine buffer at a concentration of about 15 mM, mannitol at a concentration of about 230 mM and the pH is about 7.0, in a once or twice weekly dosing regimen.

In some cases, the liquid formulations of the present invention further comprise a preservative. In some cases, the preservative is one selected from the group consisting of benzalkonium chloride, chloro butanol, methyl paraben and potassium sorbate. Generally, the preservative is present in a concentration of about 0.1 % to about 1% of the final formulation volume.

Medical Conditions

The peptides of the present invention are useful as a pharmaceutical agent for treating an individual suffering from short-bowel syndrome. Accordingly, ZP1848 or a salt thereof may be useful therapeutically and/or prophylactically for the treatment of short bowel syndrome (SBS), also known as short gut syndrome or simply short gut, which results from surgical resection, congenital defect or disease-associated loss of absorption in the bowel in which patients are subsequently unable to maintain fluid, electrolyte, and nutrient balances on a conventional diet. Despite an adaptation that occurs generally in the two years after resection, SBS patients have reduced dietary uptake and fluid loss. The class of human patients with SBS includes patients having SBS-intestinal failure (SBS-IF) and patients who are on the border between having SBS-intestinal insufficiency (SBS-II) and SBS-intestinal failure (SBS-IF). In some cases, patients having SBS- intestinal failure (SBS-IF) are also called SBS-PS when they are dependent on parenteral support, and the patients having SBS-intestinal insufficiency (SBS-II) are also called SBS non-PS if they are not depending on parenteral support. In the EASE SBS 1 phase 3 clinical trial reported herein, the patients recruited for the trial to assess the efficiacy and safety (EASE) of glepaglutide had SBS chronic intestinal failure (SBS-CIF). The aim of the trial was to reduce the need for PS and to improve quality of life (QoL).

Patients with SBS may be further categorised in different SBS classes based on their remaining bowel sections and the present invention may be used to treat each of these patient groups for example where the patient has undergone an end-jejunostomy or ileostomy, a jejuna-colic anastomosis or a jejuna-ilea-colic anastomosis.

In the medical uses of the present invention, patients receiving PS may be categorised using at an ESPEN guideline level of any one of A1 , B1 , C1 , D1 , A2, B2, C2, D2, A3, B3, C3, D3, A4, B4, C4, or D4. This categorises patients on the basis of the energy and volume of the required PS, the patients are categorized into combinations (adapted from Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin. Nutr., 35(2): 247-307; 2016 see the Table below).

Clinical classification of Chronic Intestinal Failure (CIF) and the volume of the required intravenous supplementation, CIF is categorized into 16 combinations:

^a Calculated as daily mean of the total volume infused per week% (volume per day of infusion x number of infusions per week)/7. ^b Calculated as daily mean the total energy infused per week% (energy per day of infusion x number of infusions per week)/7/Kg. The assessment of the volume of PS a patient requires can be determined as set out the the section in the Examples titled "Procedures" and "Treatment Phase". The approach can be used to calculate clinical parameters used in the present invention to define the physiological and pathological responses of classes of patient treated for SBS with glepaglutide. These parameters include (a) the early time where a statistically significant improvement in reduction in PS volume compared to baseline is observed. In the present invention reported to be 12 weeks for treatment TW with 10 mg glepaglutide, which is than that observed in previous studies 20 to 24 weeks previously), and (b) the median time to clinical response as defined by a reduction in PS volume of at least 20% of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide.

As set out in the examples, QoL may be assessment using a Patient Global Impresson of Change (PGIC) scale (see https://www.fda.gOv/media/116277/download and https://www.fda.gov/media/116281/download). The PGIC evaluates overall health status as perceived by the patient in a seven-point single-item scale ranging from 'very much worse' to 'very much improved', i.e. yes/no meaning that the patients are responders if they have ticked either "very much improved" or "much improved "in their PGIC questionnaire. The PGIC scale used in the EASE-SBS trial program was a 7-point Likert scale with patients asked to tick one box in response to the question:

Since the start of the trial, my overall status is:

(1) Very Much Improved

(2) Much Improved

(3) Minimally Improved

(4) No Change

(5) Minimally Worse

(6) Much Worse

(7) Very Much Worse

PGIC improvement was defined as patients reporting a “much improved” or “very much improved” on the 7-point Likert Scale for each of the weeks 4, 12, 20, and 24. The difference between each glepaglutide treatment regimen compared to placebo was tested using the CMH test adjusting for the stratification factor.

In the results of the EASE SBS 1 clinical trial reported in the Examples found that glepaglutide treatment of SBS-CIF patients was safe, well-tolerated and resulted in improvement in clinically and patient-centric meaningful outcomes (PS needs, enteral autonomy, and PRO). The onset of effect was suprisingly early for treatment with GLP-2 with a median time to clinical response of just 8 weeks with TW. There was a significant improvement in the patient reported outcome measure, PGIC, for treatment with glepaglutide both TW and OW. The population of SBS patients is considered very heterogenuous and the finding is surprising with treatment of GLP-2.

The spectrum of patient types with SBS is reviewed in Jeppensen, Journal of Parenteral and Enteral Nutrition, 38(1), 8S-13S, May 2014, doi: 10.1177/0148607114520994. A further division of SBS patient types can be made along the lines described in Schwartz et al., Clinical and Translational Gastroenterology (2016) 7, e142; doi: 10.1038/ctg.2015.69. This separates SBS patients into early responders and late/slow responders. It is presently believed that the early responders are the ones who exhibit an early effect on treatment with a GLP-2 analogue such as ZP1848 caused by, among other effects, an increase in the width/diameter of the small intestine, while the late or slow responders are the patients which mostly or first benefit to the treatment with a GLP-2 analogue caused by an increase in the length of the small intestine. The determination of whether a subject is an early or a late responder may be used to determine the duration of the treatment regime with the GLP-2 analogue, the timing of any clinical decision to reduce parenteral support and the interval between testing to determine whether a reduction in parenteral support is possible. Accordingly, in one embodiment, the patient is a late or slow responder. The length of the small intestines may for example bemeasured by CT scan (computed tomography scan), MRI (magnetic resonance imaging), histology, laparoscopic or other measurements or techniques known in the art.

Further aspects of the invention relate to increasing the intestinal mass or longitudinal growth of the intestines in a patient, e.g. in a human patient, especially the small intestine. ZP1848 or a salt thereof is capable of increasing the longitudinal growth of the intestines relative to a control treatment, as shown in WO 2018/229252.

This capability is of particular value in patients with SBS as this will lead to increased absorptive capacity also after treatment is stopped. Such a patient would be treated for at least 1 to 3 years, such as at least 1 to 4 years, such as 1 to 10 years, such as 1 to 20 years, such as 1 to 35 years with the objective of inducing longitudinal growth of the intestines.

As already described herein, SBS patients who are on the border between intestinal insufficiency (SBS-II) or SBS-PS patients and intestinal failure (SBS-IF) or SBS non-PS may therefore have particular value from having their intestines lengthened over a 1 to 3 year treatment course, whereafter their risk if intestinal failure is decreased, for example involving weekly or twice weekly dosing over the period of treatment. This involves less risk for central catheter needs and the risk of sepsis associated with its use.

The active agents may also be used for the treatment of malnutrition, for example resulting from cachexia and anorexia.

Examples

The following examples are provided to illustrate preferred aspects of the invention and are not intended to limit the scope of the invention. The GLP-2 analogues administered according to the dosage regimes described herein can be made according to the methods such as solid phase peptide synthesis described in WO 2006/117565 and PCT/EP2022/087440 filed on 22.12.2022, the contents of which are expressly incorporated by reference in its entirety.

Trial design

This was a multinational, placebo-controlled, randomized, parallel-group, double-blind phase 3 trial to demonstrate the superiority of once-weekly (OW) and twice-weekly (TW) subcutaneous (SC) injections of 10 mg glepaglutide versus placebo in stable SBS patients. The trial (clinicaltrials.gov identifier: NCT03690206) was conducted at 29 hospital centers (number of centers in parenthesis) across the US (7), the UK (5), Belgium (1), Canada (3), Denmark (2), France (2), Germany (5), the Netherlands (1), and Poland (3). Patients were randomized 1:1:1 via an interactive web response system (IWRS) to 24 weeks of treatment with either glepaglutide TW, glepaglutide OW, or placebo, with trial drug administered SC in either abdomen or thigh. Randomization was performed using a block randomization scheme stratified by the patient’s weekly PS volume requirement at baseline (< 12 L per week versus > 12 L/week). To maintain the blind, all 3 treatment arms involved twice-weekly dosing (glepaglutide and/or placebo). The primary and key secondary endpoints aimed to confirm the efficacy of glepaglutide in reducing or eliminating the need for parenteral support (PS). Management of short bowel syndrome (SBS) with intestinal failure (IF) targets clinical patient-centric outcomes including reducing need of parenteral support (PS) and improved quality of life (QoL).

The trial was carried out in accordance with the Declaration of Helsinki, International Conference on Harmonization guidelines, and Good Clinical Practice. An Institutional Review Board or Independent Ethics Committee approved the trial at each center, and all participants gave written informed consent prior to undergoing any trial-related procedures or assessments.

Participants

Key inclusion criteria comprised diagnosis of SBS defined as remaining small bowel in continuity of estimated length of less than 200 cm or 79 inches (Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003;124(4):1111-34. DOI: 10.1053/gast.2003.50139a.); requirement for PS at least 3 days per week; presence of a stoma or a colon in continuity; and age 18-90 years. In addition, a number of exclusion criteria were defined (of which several where rechecked at time of randomization) to ensure the validity of efficacy assessments and to exclude patients with significant comorbidities that could bias the safety evaluation. These included having more than 2 SBS-related or PS-related hospitalizations within 6 months prior to screening; poorly controlled inflammatory bowel disease that was moderately or severely active or fistula interfering with measurements or examinations required in the trial; bowel obstruction; known radiation enteritis or significant villous atrophy; cardiac disease within the last 6 months prior to screening; clinically significant abnormal electrocardiogram; acute or unstable chronic liver disease; history of colon cancer; hepatic impairment; use of GLP-1, GLP-2, dipeptidyl peptidase (DPP)-4 inhibitors, human growth hormone, somatostatin, or analogs thereof, within 3 months prior to screening; and unstable biological therapy within 6 months prior to screening.

Procedures

Following informed consent and initial confirmation of eligibility, patients entered a run-in phase consisting of PS optimization and stabilization phases. This was to ensure a reliable baseline for assessing the efficacy of glepaglutide treatment in reducing PS requirements. During the optimization phase, the investigator could change the PS volume and content according to institutional standard practice if the patient was considered unstable or not optimized. Prior to each optimization visit, the patient was to measure his/her urine volume over 48 hours while adhering to a predefined 48-hour drinking menu. During this period the patient was to record urine volume and oral fluid intake in an eDiary. The effect of PS optimizations was investigated after 2 weeks. With no more than two rounds of PS optimization being allowed, this limited the optimization phase to a maximum duration of 4 weeks. During the optimization phase, the investigator and the patient was allowed to redefine and optimize the individual drinking menu to best fit the patient’s needs. Once the drinking menu had been set at the end of the optimization phase, the patient was required to adhere to this drinking menu during the 48-hour balance periods throughout the remainder of the trial.

A stabilization phase of 2 to 4 weeks of duration immediately followed the optimization phase (the last optimization phase visit could serve as the first stabilization phase visit). No changes in the prescribed weekly PS volume or schedule were allowed during this phase. Prior to each stabilization phase visit, the patient was to measure his/her urine volume over 48 hours while adhering to the set drinking menu and report the urine volume and oral fluid intake in the eDiary. Stabilization phase visits occurred every 2 weeks until fulfilling the following PS stability criteria that qualified for randomization to investigational product treatment:

• Actual PS usage (volume and content) matched prescribed PS (± 10% deviation in total volume is acceptable), and

• 48-hour urine volumes at 2 consecutive visits within a 2-week interval (± 4 days) were similar (up to ± 25% deviation was considered acceptable), while the oral fluid intake was constant (the two 48-hour oral intakes differed by less than 10%) and not exceeding 3.5 L per day, and

• Urine volume was on average > 1 L per day and < 2.5 L per day.

If stability could not be obtained during the 4-week period due to unforeseen events such as infections, illness or similar, a second stabilization phase of up to 4 weeks was allowed.

During the subsequent 24-week treatment phase, PS requirements were evaluated through the use of 48-hour balance periods pertaining to the 48 hours leading up to the treatment initiation visit as well as leading up to the site visits at weeks 1, 2, 4, 8, 12, 16, 20 and 24 following treatment initiation. The balance periods involved a fixed drinking menu (individually pre-defined during the optimization phase) and measurements of urine volume, based on which the PS volume could be adjusted according to the following predefined algorithm:

• IF: daily urine volume of the current visit is at least 10% higher than baseline urine volume.

• THEN: New PS volume (weekly) = Current PS volume (weekly) - 7 x absolute increase in daily urine volume from baseline.

The volume and type of PS actually used were recorded by the patient on an ongoing basis in an eDiary. In general, patients were to remain well hydrated during the trial. The urine production was to stay above 1 L per day for all patients, in accordance with treatment guidelines (Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016;35(2):247-307. DOI: 10.1016/j.clnu.2016.01.020). Once investigational product treatment had been initiated, PS volume could be adjusted at Weeks 1 , 2, 4, 8, 12, 16, 20, and 24 according to the pre-defined algorithm above. Changes to the content of PS were at the discretion of the investigator, and it was allowed to deviate from the algorithm for PS adjustment if clinical conditions like for instance dehydration or signs of fluid overload were present. The rationale for deviating from the algorithm was to be documented in the eCRF.

Unscheduled visits (preceded by a 48-hour measurement period) could be considered by the investigator to adjust PS.

Other efficacy parameters included body weight and patient-reported outcomes. Safety data were recorded throughout the trial period.

Participant recruitment was closed prematurely due to the continued uncertainty about the global prognosis for COVID-19 in 2022 and the possible consequences for trial conduct and completion. With the resulting final trial population of 106 patients and based only on a priori assumptions, the power to show superiority on the primary endpoint for either once- or twice-weekly glepaglutide relative to placebo was approximately 95%.

Statistical Analysis

For primary endpoint was change in actual weekly PS volume from baseline to Week 24, regardless of whether or not treatment was discontinued. The primary endpoint analysis applied a restricted maximum likelihood (REML)-based repeated-measures approach to compare treatment groups with respect to the mean change from baseline in actual weekly PS volume at Week 24. The model used actual weekly PS volume assessments at Weeks 1, 2, 4, 8, 12, 16, 20, and 24 (derived as the actual weekly PS volume received during a valid 7-day period) as an independent variable, and included the covariates of treatment group, baseline actual weekly PS volume, visit (categorical variable), stratification factor (weekly PS volume requirements <12 L/week versus >12 L/week), and visit-by-treatment group interaction. Variance estimation was based on an unstructured covariance matrix, which did not assume a particular correlation structure for repeated weekly PS volume measurements within patients over time. The primary comparisons were the contrasts (differences in least squares means) between the glepaglutide treatment groups and the placebo group at the Week 24 visit in this mixed- effects model for repeated measures (MM RM). Missing values were imputed using multiple imputation methods. Of the 4 key secondary endpoints, the 3 responder endpoints were analyzed using the Cochran-Mantel-Haenszel test adjusted for the stratification factor (baseline weekly PS volume requirement <12 L/week versus >12 L/week). Missing values for these endpoints were imputed as no response. For the remaining key secondary endpoint of reduction in weekly PS volume from baseline to Week 12, the difference between each glepaglutide treatment group versus placebo was analyzed using the mixed effects model for repeated measures (MMRM) described for the primary endpoint. A parallel gatekeeping testing procedure (testing hierarchy) was applied to protect the overall type I error rate of a (alpha) when testing the primary and key secondary endpoints across the two glepaglutide treatment groups versus placebo.

Patient Global Impresson of Change (PGIC) Patient-Reported Outcomes (PROs)

The PGIC was used to investigate the effects of treatment on health-related quality of life (HRQoL).

Questionnaires were completed in paper format at site visits prior to any other trial related assessment. The PROs were completed by patients enrolled in the trial without assistance of site personnel. The PROs were completed at home before the patient attended the visit to the clinic. Patients were instructed to complete the PRO in a private area without influence from trial team members or accompanied by family or friends. No one was allowed to answer or interpret items for the patient. The Investigator or a delegated trial team member was allowed to read items/answers options to the patient aloud if the patient was unable to read. The Investigator or delegated trial team member instructed the patient to complete every item in the PROs and explained that there are no right or wrong answers. The Investigator or a delegated trial team member instructed the patient to give the best answer they can and explained that all individual responses were to remain confidential.

Immediately after completion, the PROs were reviewed by the Investigator (or designee) for completeness and potential adverse events (AEs). When reviewing the PROs for AEs, the Investigator was instructed not to influence nor question the patient on the content of their response to PRO questions. The review of the PROs was documented. If entries were missing in the PROs, the patient was asked to answer all questions, with care taken not to bias the patient.

The Investigator and/or delegated trial team members received training and instruction in completion of the PROs prior to the conduct of the trial.

Patients reported in the eDiary their number of bowel movements/stoma bag emptying during the 48-hour balance periods.

Improvement at Weeks 4, 12, 20, and 24

The PGIC scale used in the EASE-SBS trial program was a 7-point Likert scale with patients asked to tick one box in response to the question:

"Since the start of the trial, my overall status is:

(1) Very Much Improved

(2) Much Improved

(3) Minimally Improved

(4) No Change

(5) Minimally Worse

(6) Much Worse

(7) Very Much Worse"

PGIC improvement was defined as responding “much improved” or “very much improved” on the 7-point Likert Scale for each of the weeks 4, 12, 20, and 24. Improvement between each glepaglutide treatment regimen compared to placebo was tested using the CMH test with stratification on the randomization stratification factor. Results

106 patients were randomized and 102 completed the trial. Treatment arms were overall well-balanced for patient demographics and baseline characteristics.

Glepaglutide was assessed to be safe and well-tolerated. More adverse events were reported in the glepaglutide treatment groups than for placebo, primarily attributable to mild injection site reactions.

PS Requirements

Glepaglutide TW treatment significantly reduced PS requirements versus placebo (mean change of -5.13 vs. -2.85 L/week; estimated difference of -2.28 L/week [-3.83; -0.73]95% Cl; p=0.0039). Glepaglutide TWwas also superior versus placebo for proportion of patients achieving clinical response (65.7% vs. 38.9%; estimated difference of 26.6% [4.3; 48.9]95% Cl; p=0.0243), and percentage of patients achieving a reduction in days on PS >1 day/week (51.4% vs. 19.4%; estimated difference of 31.7% [11.4; 51 ,9]95% Cl; p=0.0043).

TW treatment showed an early onset of effect, as time to clinical response was significantly shorter compared with placebo (p=0.0043) with median time to response of 55 days [ 29 ; 85]95%CI , as shown by the results reported in Table 1.

Table 1

Time to a clinical response (reduction in PS volume from baseline of at least 20%)

Notes: (1): Taking interval censoring into account. Reference for Sun test: Sun, J. (1996), A Nonparametric Test for Interval-Censored Failure Time Data with Application to AIDS Studies, Statistics in Medicine, 15, 1387-1395.

TW treatment with glepaglutide led to a significant and earlier improvement in reduction in PS volume at 12 weeks, as shown by the results reported in Table 2 and Figure 2. Table 2

PS volume (L/week) change from Baseline by visit - treatment policy estimand - primary statistical analysis (Ml CR)

Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; Cl: confidence interval; CR: copy- reference; Ml: multiple imputation; PS: parenteral support.

Notes: MMRM model includes treatment group, visit, stratification factor, treatment-by-visit interaction as factors and Baseline PS volume (L/Week) as covariate. Variance estimation is based on an unstructured covariance matrix within treatment group. Stratification factor: weekly PS volume requirements <12 L/week and >=12 L/week.

No statistically significant difference was established for glepaglutide OW versus placebo for these endpoints, but a dose-dependent trend was observed. Of special notice, enteral autonomy was achieved for 5 (14%), 4 (12%) and 0 patients receiving glepaglutide TW, OW and placebo, respectively.

Early onset of effect is seen, with a significantly shorter time to clinical response with TW compared with placebo (p=0.0043), and the finding is further supported with significant reduction in PS need after 12 weeks of treatment with TW (p=0.0019).

In addition, the EASE SBS 1 trial examined the time to clinical response as defined by a reduction in PS volume from baseline (placebo) of at least 20%, a further clinical parameter that defines the nature of the response of SBS patients to treatment with glepaglutide 10mg TW or OW. The results of this analysis are set out in Table 1.

This shows that treatment with glepaglutide leads leads to an early onset of effect, with median time to clinical response (reduction in PS volume of at least 20%) of 55 days or 8 weeks for treatment TWwith 10 mg glepaglutide and 161 days or 23 weeks for treatment OWwith 10 mg glepaglutide.

PGIC Improvement

Improvement in PRO using PGIC was shown with significant differences relative to placebo for both glepaglutide TW (p=0.0020) and OW (p<0.0001) as shown in Tables 3 and 4.

Table 3

PGIC overall status by visit - treatment policy estimand (observed data)

Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; Cl: confidence interval; MMRM model includes treatment group, visit, stratification factor, treatment- by-visit interaction as factors. PGIC: patient global impression of change scale.

Notes: Variance estimation is based on an unstructured covariance matrix within treatment group. Stratification factor: weekly PS volume requirements <12 L/week and >=12 L/week.

Table 4

PGIC overall status (improved yes/no, much/very much improved yes/no) at week 24 - treatment policy estimand (observed data)- statistical analysis (NR)

Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; Cl: confidence interval; NR: non response imputation; PGIC: patient global impression of change scale.

Notes: The difference in percentage of responders between each glepaglutide treated group and placebo is tested using the Cochran-Mantel-Haenszel approach, adjusted for the stratification factor.

Improvement in the patient reported outcome, PGIC, was seen in 62.9% of patients with TW compared with 36.1% of patients with placebo. Further, improvement in PGIC was seen in 77.1% of patients with OW and the difference compared with placebo was staistically significant (CKO.0001).

Further Analysis

Further analysis of the results of the EASE SBS 1 trial revealed one technical outlier in the OW treatment arm where it was suspected at Database Lock (DBL) that the Week 20 and Week 24 PS volume data was erroneously high. This led to a re-evaluation of the trial results, leading to a further comparison in Table 5 below and Figure 3. Table 5

Abbreviations: TW: twice weekly; OW: once weekly; N: number of patients in Full Analysis Set; Cl: confidence interval; CR: copy- reference; Ml: multiple imputation; PS: parenteral support. Notes: MMRM model includes treatment group, visit, stratification factor, treatment-by-visit interaction as factors and Baseline PS volume (L/Week) as covariate. Variance estimation is based on an unstructured covariance matrix within treatment group. Stratification factor: weekly PS volume requirements <12 L/week and >=12 L/week. This re-evaluation did not lead to any change of the overall trial conclusion and there was a small change in the within arm PS reduction for the OW arm of the trial from baseline of 3.13 L/week to 3.76 L/week.

Conclusion

Glepaglutide treatment of SBS-CIF patients was safe, well-tolerated and resulted in improvement in clinically and patient-centric meaningful outcomes (PS needs, enteral autonomy, and PRO). The onset of effect was suprisingly early for treatment with GLP-2 analogue with a median time to clinical response of just 8 weeks with TW. There was a significant improvement in the patient reported outcome measure, PGIC, for treatment with glepaglutide both TW and OW. The population of SBS patients is considered very heterogenuous and the finding is surprising with treatment of GLP-2.

While the invention has been described in conjunction with the exemplary embodiments described above, many equivalent modifications and variations will be apparent to those skilled in the art when given this disclosure. Accordingly, the exemplary embodiments of the invention set forth are considered to be illustrative and not limiting. Various changes to the described embodiments may be made without departing from the spirit and scope of the invention. All documents cited herein are expressly incorporated by reference.

Claims

Claims:

1. A glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

2. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 1, wherein the improvement in quality of life (QoL) of the patient is assessed using a Patient Global Impression of Change (PGIC) status.

3. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 2, wherein the PGIC status uses a 7-point Likert Scale with responding patients reporting a much improved or very much improved status as compared to treatment with placebo.

4. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 1 to 3, wherein the improved PGIC status of the patient is observable at week 24 of the treatment.

5. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the treatment further comprises reducing a frequency or volume of the parenteral support received by the patient.

6. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 5, comprising reducing the frequency or volume of the parenteral support received by the patient at 12 weeks from the start of the treatment with the GLP-2 analogue, wherein the method comprises administering to the patient by subcutaneous injection 10 mg of the GLP-2 analogue twice weekly.

7. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the treatment leads to an early onset of effect, with a median time to clinical response as defined by a reduction in PS volume of at least 20% of 55 days or 8 weeks for treatment twice weekly with 10 mg glepaglutide and 161 days or 23 weeks for treatment once weekly with 10 mg glepaglutide.

8. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 6 or claim 7, wherein the patient does not require parenteral support after 24 weeks of the treatment.

9. A glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

10. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 9, wherein the treatment leads to a significant and earlier reduction in PS volume of -2.42 placebo at 12 weeks from the start of treatment with the GLP-2 analogue.

11. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the method comprises administering to the patient by subcutaneous injection 10 mg of the GLP-2 analogue once weekly.

12. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 1 to 10, wherein the method comprises administering to the patient by subcutaneous injection 10 mg of the GLP-2 analogue twice weekly.

13. A glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment of a human patient suffering from short bowel syndrome (SBS) and receiving parenteral support (PS), wherein the GLP-2 analogue is represented by the formula:

14. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 13, the treatment further results in an improvement in quality of life (QoL) of the patient.

15. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 14, wherein the improvement in quality of life (QoL) of the patient is assessed using a Patient Global Impression of Change (PGIC) status.

16. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to claim 15, wherein the PGIC status uses a 7-point Likert Scale with responding patients reporting a much improved or very much improved status as compared to treatment with placebo.

17. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 13 to 16, wherein improved PGIC status of the patient is observable at week 24 of the treatment.

18. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 13 to 17, wherein the patient does not require parenteral support after 24 weeks of the treatment.

19. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 13 to 18, wherein the method comprises administering to the patient by subcutaneous injection 10 mg of the GLP-2 analogue twice weekly.

20. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of claims 13 to 18, wherein the method comprises administering to the patient by subcutaneous injection 10 mg of the GLP-2 analogue once weekly.

21. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the patient has short bowel syndrome with intestinal failure (SBS-IF) or SBS chronic IF (SBS-CIF).

22. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the patient has undergone an end-jejunostomy or ileostomy, a jejuna-colic anastomosis or a jejuna-ilea- colic anastomosis.

23. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the method comprises administering the GLP-2 analogue using an injection pen.

24. The glucagon-like peptide 2 (GLP-2) analogue for use in a method for the treatment according to any one of the preceding claims, wherein the patient receives parenteral support at an ESPEN guideline level of any one of A1 , B1 , C1 , D1 , A2, B2, C2, D2, A3, B3, C3, D3, A4, B4, C4, or D4.