阅读说明：本技术 用于治疗自身抗体介导的自身免疫疾病的抗-cd38抗体及其药物组合物 (anti-CD 38 antibodies and pharmaceutical compositions thereof for the treatment of autoantibody mediated autoimmune diseases ) 是由 D·克隆克 R·博克斯哈默 S·哈特尔 S·施泰德尔 T·亚鲁塔特 于 2020-03-13 设计创作，主要内容包括：本发明涉及对CD38具有特异性的抗体或抗体片段在预防和/或治疗自身抗体介导的自身免疫病中的用途。根据本发明,抗-CD38抗体可有效治疗抗-PLA2R阳性的膜性肾小球肾病。(The present invention relates to the use of antibodies or antibody fragments specific for CD38 in the prevention and/or treatment of autoantibody mediated autoimmune diseases. According to the present invention, anti-CD 38 antibodies are effective in treating anti-PLA 2R positive membranous glomerulonephritis.)

1. An antibody or antibody fragment specific for CD38 for use in the treatment of autoantibody mediated membranous nephropathy.

2. The antibody or antibody fragment for use according to claim 1, wherein the autoantibody mediated membranous nephropathy is anti-PLA 2R and/or anti-THSD 7A positive membranous nephropathy.

3. The antibody or antibody fragment for use according to any one of the preceding claims, wherein the antibody depletes plasma cells via ADCC and/or ADCP.

4. The antibody or antibody fragment for use according to any one of the preceding claims, wherein the antibody exhibits significantly higher specific cell killing on plasma cells than low expressing CD38 cells (e.g., NK cells).

5. The antibody or antibody fragment for use according to any one of the preceding claims, wherein antibody administration results in a reduction of endogenous autoantibody titers.

6. The antibody or antibody fragment for use according to claim 5, wherein the endogenous autoantibody titres comprise anti-PLA 2R and/or anti-THSD 7A autoantibodies.

7. The antibody or antibody fragment specific for CD38 for use according to any one of the preceding claims, wherein the antibody or antibody fragment specific for CD38 is a human antibody.

8. The antibody or antibody fragment specific for CD38 for use according to any one of the preceding claims, wherein the antibody or antibody fragment specific for CD38 is IgG 1.

9. The antibody or antibody fragment specific for CD38 for use according to any one of the preceding claims, wherein the antibody comprises the amino acid sequence SEQ ID NO: 1, HCDR1 region, amino acid sequence SEQ ID NO: 2, the HCDR2 region of amino acid sequence SEQ ID NO: 3, HCDR3 region, amino acid sequence SEQ ID NO: 4, the amino acid sequence of SEQ ID NO: 5 and the amino acid sequence of SEQ ID NO: LCDR3 zone of 6.

10. The antibody or antibody fragment specific for CD38 for use according to any one of the preceding claims, wherein the antibody or antibody fragment specific for CD38 comprises the amino acid sequence of SEQ ID NO: 7 and the variable heavy chain region of SEQ ID NO: 8, variable light chain region.

11. The antibody or antibody fragment for use according to any one of the preceding claims in combination with an additional therapeutic agent.

12. The antibody or antibody fragment for use according to claim 11, wherein the additional therapeutic agent is an agent for the prevention and/or treatment of an autoantibody-mediated autoimmune disease.

13. The antibody or antibody fragment for use according to claim 12, wherein the additional therapeutic agent is an immunosuppressive drug, such as dexamethasone, azathioprine, mycophenolic acid, methotrexate, or a proteasome inhibitor, such as bortezomib.

14. The antibody or antibody fragment for use according to any one of the preceding claims, wherein the antibody or antibody fragment is administered intravenously.

15. The antibody or antibody fragment for use according to any one of the preceding claims, wherein the antibody or antibody fragment is administered at 16mg/kg once weekly in a first treatment cycle.

Technical Field

The present invention relates to antibodies or antibody fragments specific for CD38, which are useful for the treatment and/or prevention of autoantibody mediated Autoimmune Disease (AD). In particular, the invention provides methods of reducing autoantibody titers by depleting antibody secreting cells using an anti-CD 38 antibody alone or in combination with one or more immunosuppressive drugs. According to the present invention, anti-CD 38 antibodies, alone or in combination, can be effective in the treatment and/or prevention of anti-PLA 2R positive membranous nephropathy (aMN). anti-CD 38 antibodies include, but are not limited to, MOR 202.

Background

Autoimmune diseases and autoantibodies

Autoimmune Disease (AD) comprises more than 70 different diseases, affecting approximately 5% of the population in western countries (Lleo et al Autoimmiture Reviews 2010 Mar; 9(5): A259-66). AD is a clinical condition caused by the activation of autoreactive T cells or autoreactive B cells or both. Certain AD is characterized by the production of pathogenic autoantibodies. Autoantibodies are immunoglobulins that react with self-antigens. Such autoantigens may include proteins, nucleic acids, carbohydrates, lipids, or various combinations thereof, and may be present in all cells (e.g., DNA), or in a particular cell type that is highly restricted to one organ of an organism. In autoantibody-mediated humoral AD, autoantibodies often appear in high titers in patient serum. For many AD, clear and clear associations of autoantibody formation, specificity and pathogenesis have been demonstrated (Suurmond and Diamond, J Clin invest.2015Jun 1; 125(6): 2194-. Pathogenic autoantibodies affect disease pathways in a variety of ways, including deposition and inflammation of Immune Complexes (IC), stimulation or inhibition of receptor function, stimulation or inhibition of enzyme function, promotion of antigen uptake, cell lysis, microthrombosis and neutrophil activation (Ludwig et al, front.

Systemic Lupus Erythematosus (SLE)

For example, Systemic Lupus Erythematosus (SLE) is a polygenic autoimmune disease that affects approximately 50 out of 100,000 people, with women having a higher prevalence than men. Central immunological disorders in SLE patients are inappropriate activation and proliferation of autoreactive memory B cells, leading to the expansion of antibody secreting cells and the production of multiple autoantibodies. The major autoantigens in SLE are nuclear components, such as DNA or Ribonucleoproteins (RNPs), and autoantibodies reactive with these antigens have high affinity, are somatically mutated, and have an IgG isotype. SLE patients show high levels of serum antinuclear antibodies (ANA). Autoantibodies to cytoplasmic antigens, cell membrane antigens, phospholipid-associated antigens, blood cells, endothelial cells, nervous system antigens, plasma proteins, matrix proteins and other antigens may also be present (figure 12). In SLE, many of these autoantibodies can lead to the formation of ICs that appear to be directly pathogenic after deposition in several tissues.

Therapeutic options for SLE include antimalarial, steroidal and nonsteroidal anti-inflammatory agents, immunosuppressive drugs, including Cyclophosphamide (CTX), azathioprine (AZA), mycophenolic acid (MMF), and Methotrexate (MTX), and immune cell-targeted therapies (Yildirim-Toruner C, Allergy Clin immunol.2011feb; 127(2): 303-12). These immunosuppressive or cytotoxic drugs, as well as anti-CD 20-mediated B cell depletion, can induce remission in SLE patients. However, current treatment regimens often fail to prevent relapse (Stichweh, D.Curr. Opin. Rheumatotol.200416: 577-587.5).

Graves' disease (Morbus) Basedow)

Graves' Disease, also known as toxic diffuse goiter, is an autoimmune Disease affecting the thyroid gland. Graves' disease will occur in approximately 0.5% of men and 3% of women (Burch HB, Cooper DS,2015, JAMA 314(23): 2544-54). In the united states, it often causes and is the most common cause of hyperthyroidism (about 50% to 80% of cases). Symptoms of hyperthyroidism may include dysphoria, muscle weakness, sleep problems, increased heart beat, poor tolerance to heat, diarrhea, involuntary weight loss, thickening of the tibial skin (known as pre-tibial myxedema), and ocular ballooning (a condition caused by graves' ophthalmopathy). The direct cause of graves' disease is autoantibodies directed against the Thyroid Stimulating Hormone Receptor (TSHR)). Autoantibodies to thyroglobulin and the thyroid hormones T3 and T4 can also be generated. TSHR autoantibodies mimic TSH and activate TSHR in an unregulated manner, causing hyperthyroidism. Treatment options for graves' disease include antithyroid drugs (thionamides), ablation of the thyroid by radioactive iodine, and surgery (thyroidectomy). However, the challenge in treating graves' disease remains to inhibit the development or sustained production of TSHR autoantibodies.

Myasthenia Gravis (MG)

Myasthenia Gravis (MG) affects 50 to 200 people per million. The number of newly diagnosed people is three to thirty parts per million each year. MG is a long-term neuromuscular AD that can cause varying degrees of skeletal muscle weakness and abnormal fatigability, and is caused by the presence of autoantibodies that are reactive with components of the postsynaptic muscle end plate located at the neuromuscular junction (the nerve-muscle junction). In particular, these autoantibodies block or destroy nicotinic acetylcholine receptors, thereby preventing nerve impulses from triggering muscle contractions. Other autoantibodies to related proteins called MuSK, a muscle specific kinase, and LRP4, Agrin, and titin (titin) were also found. MG is commonly treated with drugs known as acetylcholinesterase inhibitors, such as neostigmine (neostigmine) and pyridostigmine (pyridostigmine). Immunosuppressive agents such as prednisone (prednisone) or azathioprine (azathioprine) are also often used. In some cases, surgical removal of the thymus may ameliorate disease symptoms. During the sudden onset of the condition, plasma apheresis and high dose intravenous immunoglobulin (IVIG) can be used to remove putative autoantibodies from circulation, or to dilute and bind antibodies in circulation, respectively. Both of these treatments have relatively short-lived benefits, usually measured in weeks, and are usually associated with high costs. Mechanical ventilation may be required if the respiratory muscles become significantly weakened.

anti-PLA 2R positive membranous glomerulonephritis (aMN)

anti-PLA 2R autoantibody mediated membranous nephropathy (aMN), historically commonly referred to as idiopathic membranous glomerulonephritis or Idiopathic Membranous Nephropathy (IMN), is a primary membranous nephropathy and a major cause of adult nephrotic syndrome (Ronco P, Debiec H Lancet.2015May 16; 385(9981): 1983-92). Approximately 80% of membranous nephropathy is idiopathic, while 20% is associated with other diseases or exposures. The global overall incidence is estimated to be 1.2 per 100,000 per year. Although the disease usually progresses slowly, approximately 30% to 40% of patients eventually develop end stage renal disease. Patients with MN-residual nephropathy are at increased risk of thromboembolism and cardiovascular events. However, although not all aspects of MN pathogenesis are understood, the disease is no longer considered idiopathic. M-type phospholipase A2 receptor (PLA2R) is a transmembrane protein expressed on podocytes and has been defined as the major autoantigen for MN (Beck LH Jr et al, N Engl JMed.2009Jul 2; 361(1): 11-21). Autoantibodies that bind to PLA2R antigen are highly specific for primary MN. Recent studies have shown that anti-PLA 2R autoantibodies, which are closely related to disease activity, are present in about 75% of IMN patients (Bomback AS, Clin J Am Soc Nephrol.2018May 7; 13(5): 784-. The fact that the disease defining changes in the glomerular basement comprises both PLA2R protein and antibody complex deposition provides evidence that anti-PLA 2R antibody plays a major causative role in MN. Another 5% of patients who are anti-PLA 2R antibody negative have antibodies to another podocyte antigen type 1 thrombospondin 7A domain (Tomas NM et al, N Engl J Med 2014; 371: 2277-2287). In rare neonatal MN cases, Neutral Endopeptidase (NEP) located at the podocyte foot process membrane and tubular brush border has been identified as a relevant antigen (Ronco P et al, J Am Soc Nephrol. (2005)16: 1205-13). In total, approximately 80% of IMN patients have antibodies to specific identifiable podocyte antigens. Symptoms of membranous nephropathy include, but are not limited to, swelling of the legs and ankles, increased urine protein, edema, hypoalbuminemia, elevated blood lipids, especially high cholesterol. Thus, autoimmune membranous nephropathy is an immune-mediated glomerular disease characterized by the presence of anti-PLA 2R autoantibodies and/or anti-THSD 7A autoantibodies. In neonatal autoimmune MN, autoantibodies to NEP are present which are transferred from the mother.

Currently, there is no approved standard treatment for MN. Current treatment regimens include primarily the use of various non-immunosuppressive and immunosuppressive drugs for the off-indication. Patients diagnosed with MN and >3.5g proteinuria per day initially received combined supportive therapy of Angiotensin Converting Enzyme Inhibitor (ACEi) or angiotensin II receptor blocker (ARB), statins and diuretics according to current clinical standards. If proteinuria is not significantly reduced within months, an escalation to immunosuppressive therapy (IST) is suggested. Immunosuppressive therapy includes corticosteroids alternating with alkylating agents (e.g., cyclophosphamide), and calcineurin inhibitors (CNI, such as cyclosporin a, tacrolimus (FK506)), mycophenolate mofetil (mmf), or Rituximab (Rituximab), even though none of these drugs is approved for use with MN. To a lesser extent, adrenocorticotropic hormone (ACTH) has been used. The therapeutic effect of these drug combinations appears to be similar: in contrast to a remission rate of about 30% in the control group treated with supportive therapy only (spontaneous remission), remission of proteinuria may be expected in about 50 to 60% of patients in the first year, and in about 70 to 80% of patients in 2 to 3 years.

Of all patients with primary membranous nephropathy who do not receive IST, 30% to 40% of patients progress to end stage renal disease within 10 years after onset. IST reduces the rate of progression to below 10%. In about 25% of patients previously treated with IST, a recurrence of proteinuria is observed. These cases are usually retreated with different IST combinations. The disadvantage of the above-mentioned ISTs is that they exhibit considerable toxicity and are associated with significant side effects and a high recurrence rate. 25% of patients treated with cyclophosphamide showed adverse reactions, including infection, infertility, hematologic toxicity and malignancy later in life. Disadvantages of CNI include long-term nephrotoxicity, the need to closely monitor drug levels, and increased risk of hypertension and diabetes. The recurrence rate of calcineurin inhibitors appeared to be higher than that of cyclophosphamide (40-50% versus 25%). Since there is a great deal of evidence that anti-PLA 2R antibodies are associated with disease activity, previously established therapeutic algorithms are changing.

The recently introduced indication for the therapeutic anti-CD 20 antibody rituximab, the use of therapy in addition allows for a more specific approach to IST by depleting the B cell population involved as progenitor cells in the production of pathogenic anti-PLA 2R autoantibodies. The response rate of rituximab appears to be similar to that of alkylating agents and CNI, while side effects appear to be lower than other drugs used in IST. However, CD20 (the target of rituximab) is not present on mature long-lived antibody secreting plasma cells (the main source of endogenous immunoglobulins). There was only a small residual CD20 expression on early plasma cells compared to CD20 expression on mature B cells. This is a possible explanation for the poor efficacy of rituximab therapy in MN patients with high anti-PLA 2R antibody titers.

In this regard, direct targeting of plasmablasts as well as plasma cells generally results in a more pronounced reduction of immunoglobulins and thus autoantibodies. aMN most anti-PLA 2R antibodies are likely produced by a long-lived plasma cell pool with a CD20 negative but CD38 positive immunophenotype that is independent of continuous recruitment of differentiated B cells. Thus, direct plasma cell targeting strategies may have a far greater impact on the inhibition of pathogenic autoantibodies. Especially for patients who do not respond adequately to rituximab (anti-CD 20) therapy (maintain high levels of autoantibody titers despite B cell depletion).

Pemphigus

Pemphigus vulgaris is an autoimmune cutaneous and oroepidermal mucocutaneous disease, resulting in the formation of blisters. The incidence of lesions increases from 0.5 to 3.2 per 100,000 people per year. These lesions occur predominantly between the ages of 40 and 60 with equal gender preferences. Pemphigus patients present circulating autoantibodies against pemphigus antigens on epithelial keratinized cells (desmoglein 3, desmoglein 1, desmoglein, plakoglobin). Disruption of these antigens by antigen-autoantibody reactions has a significant impact on the integrity of the epidermis, leading to cell detachment (loosening of the spinous layer of the skin), basal cleft (subasalar cleviding), and subsequent bullous formation. The binding of autoantibodies to keratinocytes also results in the release of proteases and plasminogen activators (converting plasminogen to plasmin) from the cells, further enhancing the release of the skin acanthosis. Treatment options for high-grade disease include systemic glucocorticoids, as well as combinations of corticosteroids, immunosuppressants, pulse therapy, photophoresis, and plasmapheresis.

Sicca syndrome

Sjogren's syndrome is a systemic autoimmune disease characterized by focal infiltration of lymphocytes into the exocrine glands and lacrimal glands, leading to dry mouth (xerostomia) and dry eye (keratoconjunctivitis sicca), respectively. In sjogren's syndrome, the presence of lesions is associated with chronic inflammatory infiltrates, releasing autoantibodies directed against salivary gland epithelial cells. Other autoantibodies in sjogren's syndrome are directed against ribonucleoprotein autoantigens Ro/SS-A and lA/SS-B, coiled-coil containing molecules, members of the golgi protein family, poly (ADP) ribose polymerase (PARP) and muscarinic type 3 receptors. Currently, there is no targeted therapy for sjogren's syndrome, and current treatments are only symptomatic treatment of dry and fatigue symptoms, such as with pilocarpine, bromhexine, and hydroxychloroquine, respectively.

anti-NMDA encephalitis

The most common antibody-mediated acute autoimmune encephalitis is anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis (Granerod J et al, Lancet infection Dis 2010,10: 835-44). The incidence is estimated to be 3-5 per 1,000,000 per year. anti-NMDA encephalitis represents a model disease of a group of syndromes characterized by the detection of autoantibodies targeting synaptic structures. anti-NMDAR antibodies are most common, followed by leucine-rich glioma inactivating 1(LGI1), contact protein-related protein-like 2(Caspr2), alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), gamma-aminobutyric acid (GABA) -a and-B receptors, dipeptidyl peptidase-like protein 6(DPPX), and glycine receptor (GlyR) antibodies are other examples of neuronal cell surface antibodies. anti-NMDAR encephalitis occurs preferentially in young adults and children, mainly in women (80%). Approximately 70% of patients develop prodromal symptoms (e.g., headache, fever, rapid changes in behavior, anxiety, hallucinations, and psychosis). This is followed by abnormal movements (such as orofacial dyskinesia, chorea and stereotypy) as well as decreased consciousness, coma and severe global autonomic dysfunction (sometimes leading to hypoventilation and cardiac arrest). Epilepsy and status epilepticus may occur at any stage of the disease. Approximately 50% of patients respond better to IVIG, steroids or plasma exchange, and the other 50% require rituximab alone or in combination with cyclophosphamide. However, in some patients recovery is incomplete, may take years, and mortality due to intensive care complications may be as high as 7%.

The presence of pathogenic autoantibodies in the autoantibody-mediated autoimmune diseases exemplified above is the result of failure or malfunction of central and/or peripheral B cell tolerance to the corresponding autoantigens.

Central and peripheral B cell tolerance

B cell development begins in the bone marrow. There, a nascent membrane-bound B Cell Receptor (BCR) pool is produced by somatic recombination of immunoglobulin heavy and light chain gene segments. The downside of generating this enormous diversity in the early BCR pool by recombinant host cell V (D) J is the simultaneous production of potentially pathogenic autoantibodies. There are at least three mechanisms that prevent the development of autoimmunity. First, autoreactive B cells are deleted by apoptosis. Second, autoreactive B cells alter the VL domain through secondary Ig light chain recombination, a process called receptor editing, thereby reducing their BCR autoreactive affinity. A third mechanism of silencing autoreactive B cells is disability, which renders such cells unresponsive to antigens. These central tolerance mechanisms occur in the bone marrow. Thus, in B cells expressing autoreactive antibodies, the autoreactivity of the emerging antibody repertoire is prevented by apoptosis, receptor editing and incapacitation induction (Wardemann and Nussenzweig, Adv Immunol.2007; 95: 83-110).

During B cell differentiation, transitional B cells emerging from the bone marrow continue to mature in peripheral lymphoid organs (e.g., spleen, lymph nodes) and establish additional peripheral tolerance mechanisms there. The exact mechanism of peripheral tolerance is still under investigation, but involves recognition of ligands (antigens) by BCR, similar to central tolerance checkpoints in bone marrow. They may also be involved in the controlled migration and limited availability of BAFF, CD22, Siglec-G, miRNA and follicular regulatory T cells (Tregs).

The final product of B cell differentiation is antibody secreting plasma cells. After antigen activation, mature naive B cells develop directly (independently of T cells) into antibody-secreting cells, or differentiate into sessile non-dividing plasma cells or memory B cells during T cell-dependent immune responses at the germinal center via proliferating pro-and plasmablasts. Both plasmablasts and plasma cells produce and secrete antibodies, thereby providing humoral immunity. Plasmablasts and plasma cells contribute to the production of autoantibodies when they are derived from autoreactive B cells (Hiepe and Radbruch, Nat Rev Nephrol.2016Apr; 12(4): 232-40).

Failure of one or more central and/or peripheral tolerance mechanisms leads to an increase in the number of autoreactive B cells (i.e., autoantibody-expressing B cells) and autoreactive plasmablasts and plasma cells (i.e., cells that express and secrete autoantibodies) in the circulation, contributing to the development of autoantibody-mediated AD. Once autoantibody production begins, their level of production is maintained by continued activation of autoreactive B cells (leading to the continued formation of short-lived plasma cells) or by the formation of long-lived plasma cells, or both (Manz RA et al, Annu Rev Immunol (2005)23: 367-86).

Since autoantibodies are often the underlying cause of autoimmune pathologies, B cells, plasmablasts and plasma cells are promising therapeutic targets in AD. Short-lived plasma cells respond to conventional immunosuppressive drugs, which directly inhibit proliferating plasma blasts and B cells. Non-proliferative short-lived plasma cells disappear within a few days after the start of these therapies because they are no longer replenished. B cell targeting therapies such as anti-CD 20 (rituximab) and anti-BAFF (belimumab) (see, e.g., WO2002002641, WO2009052293a1) reduce B cell levels in patients in need of reduced B cell levels, thus reducing the production of short-lived plasma cells and plasma cells, but such therapies do not affect the long-lived memory plasma cell compartment. In cases where autoantibody production is not affected by this therapeutic strategy, it is contemplated that autoantibodies may be secreted by long-lived memory plasma cells. Furthermore, it can be hypothesized that blocking factors or cells that stimulate autoreactive B cells, for example by targeting type I Interferons (IFNs), TH cells or regulatory t (treg) cells, will prevent the development of short-lived plasma-forming cells and plasma cells, but not the development of plasma cell memory.

In humans, a population of long-lived bone marrow-derived plasma cells is phenotypically defined as CD19-, CD38hi, CD138+ (Halliley JL et al, immunity.2015Jul 21; 43(1): 132-45). The well-known common pan-B cell marker CD20 is not normally expressed on human plasma-forming cells (Ellebedy AH et al, Nat Immunol.2016Oct; 17(10):1226-34) or long-lived human plasma cells (Halleley JL et al, Immunity.2015Jul 21; 43(1): 132-45).

The underlying mechanisms of maintenance of long-term antibody responses can generally be divided into memory B-cell dependent and memory B-cell independent models. In rhesus monkey animal models, it has been shown that after surgical removal of potential B cell pools from solid tissues (e.g., spleen and lymph nodes) and depletion of all detectable tetanus-specific memory B cells from circulation using anti-CD 20 antibodies, tetanus-specific serum antibody titers continue to remain above the protective threshold for immune host life, with decay rate kinetics that are indistinguishable from untreated controls (Hammarlund E et al, Nat Communn.2017; 8: 1781). Thus, the antibody response following tetanus vaccination is long-lasting and provides life-long protective immunity against the disease. Further analysis of tetanus-specific plasma cells showed that after 10 years of immunization, long-lived vaccine-induced plasma cells were preferentially recognized in certain bone marrow compartments. Taken together, these studies provide a framework in which maintenance of long-term serum antibody responses appears to be maintained by long-lived plasma cells independent of memory B cells.

As noted above, current treatment options for AD include systemic immunosuppression (i.e., high doses of corticosteroids, such as dexamethasone). Cytotoxic drug cyclophosphamideInhibition of T helper cell function has been shown, where B cell depletion is prolonged, because B lymphocytes recover from alkylating agents at a slower rate, and cyclophosphamide inhibits B cell activation. Other immunosuppressive drugs include, but are not limited to, azathioprine, mycophenolic acid, and methotrexate. Proteasome inhibitors such as bortezomib have been shown to consume short-lived and long-lived plasma cells, and the first clinical trial using bortezomib for the treatment of SLE and thrombotic thrombocytopenic purpura is promising (Alexander T et al, Ann Rheum Dis (2015)74: 1474-8; Patriquin et al, Br J Haematol (2016)173: 779-85).

WO2012092612 discloses anti-CD 38 antibodies and claims their possible therapeutic use for a variety of autoimmune diseases. Indeed, WO2012092612 determined an anti-tetanus response in a HuScid mouse model and only shows experiments performed with a surrogate mouse anti-CD 38 antibody in collagen-induced arthritis and SLE autoimmune mouse models. WO2012092612 does not mention the determination of antibody titers in human samples after anti-CD 38 treatment and does not mention or show any data on anti-PLA 2R positive membranous nephropathy treated with anti-CD 38 antibody.

Schuetz C et al (Blood adv.2018; 2(19):2550-2553) describe the use of the anti-CD 38 antibody daratumumab (daratumumab) for the treatment of autoimmune hemolytic anemia. Cole S et al, Arthritis Res Ther.2018; 20(1) 85 the therapeutic potential of daratumab in RA and SLE patients was evaluated.

Beck LH et al (J Am Soc nephrol.2011; 22(8):1543-50) discloses the use of the anti-CD 20 antibody rituximab to deplete B cells in patients with idiopathic membranous nephropathy. The publication does not teach or suggest depleting plasma cells in these patients with an anti-CD 38 antibody.

However, AD patients still suffer from high morbidity and increased mortality. Despite advances in the development of novel anti-autoimmune agents (e.g., bortezomib), the prognosis for AD mediated by many autoantibodies, most likely involving CD38 positive autoantibody secreting cells, remains poor. All of the above mentioned treatment options have disadvantages, side effects, or their use is limited to certain types of patient groups.

Thus, there remains a high and unmet medical need for new and improved methods of treatment for patients suffering from autoantibody mediated AD.

The present inventors have identified that CD38 represents an excellent and potent antigen that directly targets antibody secreting cells such as plasmablasts and plasma cells in autoantibody mediated autoimmune diseases (e.g., SLE, ann). First, CD38 showed very high expression on plasmablasts and plasma cells (fig. 4), and second, CD38 was not expressed, or was significantly less expressed, on other cell types than plasmablasts and plasma cells. Thus, the use of anti-CD 38 antibodies can be a sustainable therapeutic approach to target the source of pathogenic autoantibodies with potentially long-lasting effects due to the elimination of short-lived and long-lived plasma cells. Essentially, this targeting effect can be summarized as follows: an antibody specific for the CD38 surface antigen of the antibody secreting cells is administered to the patient. These anti-CD 38 antibodies specifically bind to CD38 antigen of both antibody secreting cells that produce normal antibodies and pathogenic autoantibodies. Antibodies that bind to the CD38 surface antigen then cause the destruction and depletion of these cells. Regardless of which method is used, the primary goal is to reduce autoantibody producing cells.

Endogenous anti-tetanus antibody titers as markers to assess the effects of MOR202 on plasma cell function

Longitudinal studies conducted in mice (Manz RA et al, Nature. 1997; 388:133-134) and humans (Hammallund E et al, Nat Med. 2003Sep; 9(9):1131-7) highlight the advantage of inducing and maintaining effective serum antibody concentrations (antibody titers) that persist and are protective for long periods until the immune system is lifelong. Protective humoral immunity can be conferred, for example, by stable titers of specific antibodies generated by conventional vaccination against, for example, measles, mumps, tetanus, diphtheria, or smallpox, and the like. Plasma cells and their immediate precursors are referred to as the cellular basis of this humoral immunity and, since serum-specific antibody titers are valuable markers of the humoral arm, they can be used as an indicator of the presence and/or activity of the plasma cells producing these antibodies. A study of mice that have been treated with anti-CD 20 to deplete naive and memory B cells shows that even over time, loss of B cells does not significantly affect the plasma cell pool (Ahuja A et al, Proc Natl Acad Sci U A.2008Mar 25; 105(12): 4802-7). Similarly, humans undergoing B-cell ablation therapy maintain serum antibody titers against common antigens for at least one year (Cambridge G et al, Arthritis Rheum. 2006Mar; 54(3): 723-32). Thus, these reports indicate that (long-lived) plasma cells are an important component of persistent humoral memory in mice and humans. It is recognized that plasma cells can persist for longer periods of time even without the influx of newly activated naive or memory B cells. Here, the inventors show for the first time that administration of MOR202 results in a reduction in the endogenous anti-tetanus toxoid antibody titers in human subjects, and describe in the examples how to put treatment of autoantibody-mediated membranous nephropathy, particularly anti-PLAR 2 positive autoimmune MN, with MOR202 into practice.

Disclosure of Invention

The present invention provides antibodies or antibody fragments specific for CD38 for use in the treatment and/or prevention of autoantibody mediated autoimmune diseases and related disorders. In particular, the anti-CD 38 antibody or antibody fragment is for use in the treatment and/or prevention of idiopathic membranous glomerulonephritis. Preferably, the anti-CD 38 antibody or antibody fragment is for use in the treatment and/or prevention of anti-PLA 2R positive membranous glomerulonephritis. In some aspects, the anti-CD 38 antibody or antibody fragment is used to treat and/or prevent Systemic Lupus Erythematosus (SLE).

Furthermore, the present invention provides a pharmaceutical composition comprising a therapeutically effective amount of an antibody or antibody fragment specific for CD38 for the treatment and/or prevention of an autoantibody mediated autoimmune disease. In particular, the anti-CD 38 antibody or antibody fragment of the pharmaceutical composition is for use in the treatment and/or prevention of idiopathic membranous glomerulonephritis. Preferably, the anti-CD 38 antibody or antibody fragment of the pharmaceutical composition is for use in the treatment and/or prevention of anti-PLA 2R positive membranous glomerulonephritis. In some aspects, the anti-CD 38 antibody or antibody fragment of the pharmaceutical composition is for use in the treatment and/or prevention of Systemic Lupus Erythematosus (SLE).

The monoclonal human anti-CD 38 antibody MOR202 targets antibody secreting cells such as plasma cells and plasma cells primarily through antibody dependent cell mediated cytotoxicity (ADCC) and antibody dependent cell mediated phagocytosis (ADCP). During clinical trials of MOR202, high killing efficiency was demonstrated for tumor plasma cells (i.e., multiple myeloma cells) as well as benign plasma cells. Depletion of plasma cells by MOR202 in patients with Multiple Myeloma (MM) results in a significant reduction in M-protein. The M-protein, also known as M component, M spike, spike protein, accessory protein or myeloma protein, is an immunoglobulin (antibody) or fragment thereof secreted by malignant plasma cell clones. Due to abnormal monoclonal proliferation of malignant plasma cells in MM, M-protein is produced in large excess, resulting in a variety of deleterious effects on MM signs (e.g., impaired immune function, abnormally high blood viscosity, and kidney damage). MOR202 was effective in eliminating plasma cells that were the source of M-protein, thus resulting in a decrease in M-protein titer.

The effect of MOR202 on plasma cells was demonstrated by assessing anti-tetanus toxoid (anti-TT) antibody titers in serum as markers of specific plasma cell depletion. Following MOR202 administration, serum anti-TT antibody levels were significantly reduced compared to baseline prior to MOR202 administration.

In general, the inventors demonstrated that MOR202 efficiently reduced levels of malignant (M-protein) and/or protective antibodies (anti-TT) in human serum, indicating a long-term depletion of plasmablasts and plasma cells. In contrast to other anti-CD 38 antibodies, MOR202 is expected to retain cells (e.g., NK cells) with low CD38 expression, thus providing optimal safety.

This observed effect of MOR202 on reducing serum antibody titers is novel and the prior art does not teach, suggest or provide any rationality for using MOR202 for the treatment of autoantibody-mediated AD.

In a particular aspect of the invention, the antibody or antibody fragment comprises the amino acid sequence SEQ ID NO: 1, HCDR1 region, amino acid sequence SEQ ID NO: 2, the HCDR2 region of amino acid sequence SEQ ID NO: 3, HCDR3 region, amino acid sequence SEQ ID NO: 4, the amino acid sequence of SEQ ID NO: 5 and the amino acid sequence of SEQ ID NO:6 for use in the treatment and/or prevention of an autoantibody mediated autoimmune disease, in particular for use in the treatment and/or prevention of Systemic Lupus Erythematosus (SLE) or idiopathic membranous glomerulonephritis, preferably for use in the treatment and/or prevention of anti-PLA 2R positive membranous glomerulonephritis.

The present disclosure also provides a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and a suitable pharmaceutical carrier, excipient or diluent for use in the prevention and/or treatment of an autoantibody mediated autoimmune disease.

In another particular aspect, the pharmaceutical composition may additionally comprise other therapeutically active ingredients suitable for use in combination with the antibodies or antibody fragments of the invention. In a more specific aspect, the additional therapeutically active ingredient is an agent for the treatment of an autoantibody mediated autoimmune disease.

In one aspect of the invention, the invention provides a method for the prevention and/or treatment of autoantibody mediated AD in a subject, particularly a human, in need thereof, which method comprises administering to said subject an effective amount of a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment.

The present invention also provides a method of preventing and/or treating idiopathic membranous glomerulonephritis (IMN) in a subject in need thereof, the method comprising administering to the subject an effective amount of a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment.

In particular, the present invention provides a method of preventing and/or treating anti-PLA 2R positive membranous glomerulonephritis (aMN) in a subject in need thereof, the method comprising the step of administering to the subject an effective amount of a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment.

In one aspect, the invention provides a method of preventing and/or treating Systemic Lupus Erythematosus (SLE) in a subject in need thereof, the method comprising the step of administering to the subject an effective amount of a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment.

In one aspect, the invention provides an antibody or antibody fragment specific for CD38 for use in the prevention and/or treatment of autoantibody mediated AD in a mammal, particularly a human, suffering from said autoimmune disease.

Other objects and advantages will become apparent to those skilled in the art in view of the detailed description that follows.

In addition, antibodies or antibody fragments specific for CD38 that can be used in the pharmaceutical compositions and methods of treatment disclosed herein are pharmaceutically acceptable for preparation and use.

Drawings

Figure 1 schematically shows the major cell types of B cell differentiation and the levels of CD19, CD20, and CD38 expression. Expression of CD38 is tightly regulated during B cell ontogeny: CD38 is present on bone marrow precursor B cells, but is lost on mature B cells. CD38 may prevent apoptosis on germinal center B cells, but memory B cells lack or only have reduced levels of antigen after leaving germinal centers. CD38 is one of the few surface antigens present on terminally differentiated, short-lived and long-lived plasma cells as antibody secreting cells and is highly expressed (Hamblin TJ, Blood 2003102: 1939-.

Figure 2 schematically shows the major B cell types targeted by anti-CD 20B cell depleting antibody therapy (e.g., treatment with rituximab).

Figure 3 schematically shows the primary antibody secreting cell types targeted by anti-CD 38 antibody therapy (e.g., treatment with MOR 202).

Figure 4 shows high CD38 expression on plasma cells of healthy individuals and patients with multiple myeloma as determined by FACS.

Figure 5 shows the change (%) in anti-tetanus toxoid (anti-TT) antibody titres in subjects following administration of MOR202 at day 15 of cycle 1 (i.e. 2 weeks after the start of MOR202 treatment) compared to baseline.

Figure 6 shows the change (%) in anti-tetanus toxoid (anti-TT) antibody titres in subjects following administration of MOR202 at day 15 of cycle 2 (i.e. 6 weeks after the start of MOR202 treatment) compared to baseline.

Figure 7 shows the change (%) in M-protein levels (optimal response) in the group of patients treated once weekly with MOR202 in combination with dexamethasone compared to baseline.

Figure 8 shows the change (%) in M-protein levels (best response) in the group of patients treated once weekly with MOR202 in combination with lenalidomide/dexamethasone compared to baseline.

Figure 9 shows the change (%) in M-protein levels (best response) in the group of patients treated once weekly with MOR202 in combination with pomalidomide/dexamethasone as compared to baseline.

Figure 10 shows the specific killing of MOR202 on a CD 38-highly expressing multiple myeloma plasma cell line, while retaining NK cells that underexpress CD38, compared to the anti-CD 38 antibodies daratumumab (Dara) and ixabendazole.

Figure 11 shows the MOR202 clinical trial schedule tested in subjects with aMN.

Figure 12 illustrates various autoantibodies that can be detected in patients with Systemic Lupus Erythematosus (SLE).

Detailed Description

Definition of

The following terms are intended to have the meanings presented below and are useful in understanding the description and intended scope of the invention.

When describing the present invention, which may include antibodies, antibody fragments, pharmaceutical compositions comprising such antibodies or antibody fragments, and methods of using such antibodies, antibody fragments, and compositions, the following terms (if present) have the following meanings, unless otherwise indicated.

The articles "a" and "an" may be used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. For example, "an analog" refers to one or more than one analog.

The term "CD 38" refers to the protein known as CD38, with the following synonyms: ADP-ribosyl cyclase 1, cADPr hydrolase 1, cyclic ADP-ribosyl hydrolase 1, T10.

Human CD38(UniProt P28907) has the following amino acid sequence:

MANCEFSPVSGDKPCCRLSRRAQLCLGVSILVLILVVVLAVVVPRWRQQWSGPGTTKRFPETVLARCVKYTEIHPEMRHVDCQSVWDAFKGAFISKHPCNITEEDYQPLMKLGTQTVPCNKILLWSRIKDLAHQFTQVQRDMFTLEDTLLGYLADDLTWCGEFNTSKINYQSCPDWRKDCSNNPVSVFWKTVSRRFAEAACDVVHVMLNGSRSKIFDKNSTFGSVEVHNLQPEKVQTLEAWVIHGGREDSRDLCQDPTIKELESIISKRNIQFSCKNIYRPDKFLQCVKNPEDSSCTSEI(SEQ ID NO:9)。

CD38 is a type II transmembrane glycoprotein and is an example of an antigen that is highly expressed on antibody-secreting cells, including autoantibody-secreting plasmablasts and plasma cells. The functions ascribed to CD38 include both receptor-mediated adhesion and signaling events, and (extracellular) enzymatic activity. As an extracellular enzyme, CD38 forms cyclic ADP-ribose (cADPR) and ADPR using NAD + as a substrate, and also forms nicotinamide and nicotinic acid-adenine dinucleotide phosphate (NAADP). cADPR and NAADP have been shown to act as Ca²⁺An mobilized second messenger. By converting NAD + into cADPR, CD38 regulates extracellular NAD + concentration and thus cell survival by regulating NAD-induced cell death (NCID). Except by Ca²⁺In addition to signaling, CD38 signaling also occurs through interaction with antigen receptor complexes on T and B cells or other types of receptor complexes such as MHC molecules, in such a way as to participate in several cellular responses, but also in the conversion and secretion of IgG antibodies.

As used herein, the term "anti-CD 38 antibody" includes in its broadest sense anti-CD 38 binding molecules; including any molecule that specifically binds to CD38 or inhibits the activity or function of CD38, or exhibits therapeutic effect on CD38 in any other way. Including any molecule that interferes with or inhibits the function of CD 38. The term "anti-CD 38 antibody" includes, but is not limited to, antibodies that specifically bind to CD38, alternative protein scaffolds that bind to CD38 (e.g., fibronectin scaffolds, ankyrins, large antibody/avimers, protein a-derived molecules, anticalins, affilins, Protein Epitope Mimetics (PEM), etc.), nucleic acids specific for CD38 (including aptamers), or small organic molecules specific for CD 38.

Antibodies specific for CD38 are described, for example, in WO199962526(Mayo Foundation); WO200206347(Crucell Holland); US2002164788(Jonathan Ellis), which is incorporated by reference in its entirety; WO2005103083(MorphoSys AG), U.S. No. 10/588,568, which is incorporated by reference in its entirety; WO2006125640(MorphoSys AG), U.S. No. 11/920,830, which is incorporated by reference in its entirety; and WO2007042309(MorphoSys AG), U.S. No. 12/089,806, which is incorporated by reference in its entirety; WO2006099875(Genmab), U.S. No. 11/886,932, which is incorporated by reference in its entirety; and WO2008047242(Sanofi-Aventis), U.S. No. 12/441,466, which is incorporated by reference in its entirety.

Combinations of antibodies and other agents specific for CD38 are described, for example, in WO200040265(Research Development Foundation); WO2006099875 and WO2008037257 (Genmab); and WO2010061360, WO2010061359, WO2010061358 and WO2010061357(Sanofi Aventis), all of which are incorporated by reference in their entirety.

Preferably, the anti-CD 38 antibody for use described herein is an antibody specific for CD 38. More preferably, the anti-CD 38 antibody is an antibody or antibody fragment, such as a monoclonal antibody, that specifically binds to CD38 and depletes antibody secreting cells. Such antibodies may be of any type, e.g., mouse, rat, chimeric, humanized or human.

As used herein, "human antibodies" or "human antibody fragments" are antibodies and antibody fragments having variable regions with framework regions and CDR regions derived from human sequences. If the antibody comprises constant regions, the constant regions are also derived from these sequences. Human sources include, but are not limited to, human germline sequences or mutated versions of human germline sequences or antibodies comprising consensus framework sequences derived from human framework sequence analysis, e.g., as described in Knappik et al, (2000) J Mol Biol 296: 57-86. Human antibodies can also be isolated from synthetic libraries or from transgenic mice (e.g., XenoMouse). If the sequence of an antibody or antibody fragment is human, the antibody or antibody fragment is human, regardless of the species from which the antibody is physically derived, isolated, or manufactured.

The structure and position of immunoglobulin variable domains, e.g., CDRs, can be defined using well-known numbering schemes, e.g., Kabat numbering scheme, Chothia numbering scheme, or a combination of Kabat and Chothia, see, e.g., Sequences of Proteins of Immunological Interest, u.s.department of Health and Human Services (1991), Kabat et al; lazikani et al, (1997) J.mol.Bio.273: 927-948; kabat et al, (1991) Sequences of Proteins of Immunological Interest, 5 th edition, NIH publication No. 91-3242U.S. department of Health and Human Services; chothia et al (1987) J.mol.biol.196: 901-917; chothia et al, (1989) Nature 342: 877-883; and Al-Lazikani et Al, (1997) J.mol.biol.273: 927-948.

A "humanized antibody" or "humanized antibody fragment" is defined herein as an antibody molecule having constant and variable antibody regions or portions thereof derived from human sequences, or CDRs derived from another species only. For example, a humanized antibody may be CDR-grafted, wherein the CDRs of the variable domains are from non-human origin, while one or more frameworks of the variable domains are of human origin, and the constant domains (if any) are of human origin.

The term "chimeric antibody" or "chimeric antibody fragment" is defined herein as an antibody molecule having a constant antibody region derived from or corresponding to a sequence found in one species and a variable antibody region derived from another species. Preferably, the constant antibody region is derived from or corresponds to a sequence found in humans, while the variable antibody region (e.g., VH, VL, CDR or FR region) is derived from a sequence found in a non-human animal such as a mouse, rat, rabbit or hamster.

The term "isolated antibody" refers to an antibody or antibody fragment that is substantially free of other antibodies or antibody fragments having different antigenic specificities. Furthermore, the isolated antibody or antibody fragment may be substantially free of other cellular material and/or chemicals. Thus, in some aspects, the antibodies provided are isolated antibodies that have been isolated from antibodies with different specificities. The isolated antibody may be a monoclonal antibody. The isolated antibody may be a recombinant monoclonal antibody. However, an isolated antibody that specifically binds to an epitope, isoform or variant of a target may cross-react with other relevant antigens, e.g., from other species (e.g., species homologs).

As used herein, the term "monoclonal antibody" refers to a preparation of antibody molecules of single molecular composition. Monoclonal antibody compositions display unique binding sites with unique binding specificity and affinity for a particular epitope.

Further, an "immunoglobulin" (Ig), as used herein, is defined as a protein belonging to the IgG, IgM, IgE, IgA, or IgD class (or any subclass thereof), and includes all conventionally known antibodies and functional fragments thereof. A preferred class of immunoglobulins for use in the present invention is IgG.

The phrase "antibody fragment" as used herein refers to one or more portions of an antibody that retain the ability to specifically interact with an antigen (e.g., by binding, steric hindrance, stabilized spatial distribution). Examples of binding fragments include, but are not limited to, monovalent fragment Fab fragments consisting of the VL, VH, CL and CH1 domains; a bivalent fragment f (ab)2 fragment comprising two Fab fragments linked by a disulfide bridge of the hinge region; an Fd fragment consisting of the VH and CH1 domains; (ii) an Fv fragment consisting of the VL and VH domains of a single arm of an antibody; dAb fragments consisting of VH domains (Ward et al, (1989) Nature 341: 544-546); and an isolated Complementarity Determining Region (CDR). Furthermore, although the two domains of the Fv fragment, VL and VH, are encoded by separate genes, they can be joined using recombinant methods by synthesizing a linker that enables them to be made into a single protein chain in which the VL and VH regions pair to form a monovalent molecule (referred to as "single chain fragment Fv (scFv)"; see, e.g., Bird et al, (1988) Science242:423 + 426; and Huston et al, (1988) Proc. Natl. Acad. Sci.85:5879 + 5883). Such single chain antibodies are also intended to be encompassed within the term "antibody fragment". These antibody fragments are obtained using conventional techniques known to those skilled in the art and the fragment screening is performed for utility in the same manner as that used for intact antibodies. Antibody fragments may also be incorporated into single domain antibodies, large antibodies (maxibodies), miniantibodies, intrabodies, diabodies, triabodies, tetrabodies, v-NARs, and bis-scFvs (see, e.g., Hollinger and Hudson, (2005) Nature Biotechnology 23: 1126-1136). Antibody fragments can be grafted into scaffolds based on polypeptides such as fibronectin type III (Fn3) (see U.S. patent No. 6,703,199 which describes fibronectin polypeptide mabs). Antibody fragments can be incorporated into single chain molecules comprising a pair of tandem Fv fragments (VH-CH1-VH-CH1) that together with a complementary light chain polypeptide form a pair of antigen binding sites (Zapata et al, (1995) Protein Eng.8: 1057-1062; and U.S. Pat. No. 5,641,870).

The present disclosure provides methods of treatment comprising administering a therapeutically effective amount of an anti-CD 38 antibody as disclosed to a subject in need of such treatment. As used herein, "therapeutically effective amount" or "effective amount" refers to the amount of antibody specific for CD38 needed to elicit a desired biological response. According to the present disclosure, a therapeutically effective amount is the amount of antibodies specific for CD38 required for the treatment and/or prevention of autoantibody mediated autoimmune diseases and symptoms associated with said AD. The effective amount for a particular individual may vary depending on a variety of factors such as the condition being treated, the overall health of the patient, the route and dosage of administration, and the severity of side effects (Maynard et al, (1996) A Handbook of SOPs for Good Clinical Practice, Interpharm Press, Boca Raton, Fla.; Dent (2001) Good Laboratory and Good Clinical Practice, London, UK).

As used herein, the terms "treat," "treating" or "treatment," and the like, refer to alleviating a symptom, temporarily or permanently eliminating the cause of the symptom, or preventing or slowing the appearance of the symptoms of the disease or disorder.

"preventing" or "prevention" refers to reducing the risk of acquiring or developing a disease or condition (i.e., causing at least one clinical symptom of the disease not to occur in a subject who may be exposed to a pathogenic agent or predisposed to the disease prior to onset). "preventing" also refers to a method that is intended to prevent the onset of a disease or its symptoms or delay the onset of a disease or its symptoms.

The term "prevention" in relation to "prevention" means a measure or procedure aimed at preventing, rather than treating or curing, a disease. Non-limiting examples of prophylactic measures can include administration of a vaccine; administering low molecular weight heparin to hospitalized patients at risk for thrombosis due to, for example, immobilization; prior to visiting a geographical area where malaria prevalence or risk of infection is high, an antimalarial agent such as chloroquine is administered in advance.

By "alleviating" one or more symptoms of autoantibody-mediated AD is meant alleviating the extent of one or more undesirable clinical manifestations in an individual or population of individuals having autoantibody-mediated AD.

"administration" or "administering" includes, but is not limited to, drug delivery by injectable forms such as intravenous, intramuscular, intradermal, or subcutaneous routes, or mucosal routes, e.g., as a nasal spray or aerosol for inhalation or as an ingestible solution, capsule, or tablet. Preferably, administration is via injectable form.

As used herein, the terms "subject," "subject in need thereof," and the like refer to a human or non-human animal that exhibits one or more symptoms or indications of an autoantibody-mediated autoimmune disease and/or is diagnosed with an autoantibody-mediated autoimmune disease. Preferably, the subject is a primate, most preferably a human patient diagnosed with an autoantibody-mediated autoimmune disease.

In this context, "subject" or "species" refers to any mammal, including rodents, such as mice or rats, and primates, such as cynomolgus monkeys (Macaca fascicularis), rhesus monkeys (Macaca mulatta), or humans (Homo sapiens). Preferably, the subject is a primate, most preferably a human.

As used herein, the term "autoantibody-mediated autoimmune disease" includes "autoantibody-associated autoimmune disease" and refers to a group of diseases characterized by the presence of autoantibodies (autoantibody positive), wherein (i) the causative relevance and direct contribution of autoantibodies to disease and its associated symptoms are given, or (ii) the causative relevance and direct contribution of autoantibodies to disease and its associated symptoms are less clear but can be given. Autoantibody-mediated autoimmune diseases include, but are not limited to, the diseases exemplarily listed in table 1.

TABLE 1 examples of autoantibody mediated autoimmune diseases

As used herein, the term "about," when used with reference to a particular recited value, means that the value may differ from the recited value by no more than 1%. For example, as used herein, the expression "about 100" includes 99 and 101 and all values in between (e.g., 99.1, 99.2, 99.3, 99.4, etc.).

As used herein, "pharmacokinetics" or "PK" describes how the body affects a drug after administration through mechanisms such as absorption and distribution, as well as the effects and pathways of metabolic changes of a particular drug in the body and excretion of metabolites of the drug. The pharmacokinetic properties of a drug may be affected by the route of administration and the dosage administered.

"pharmaceutically acceptable" means approved or approvable by a regulatory agency of the federal or a state government or a corresponding agency in a country outside the united states or listed in the U.S. pharmacopeia or other generally recognized pharmacopeia for use in animals, and more particularly in humans.

By "pharmaceutically acceptable carrier" is meant a diluent, adjuvant, excipient, or carrier with which the antibody or antibody fragment is administered.

Throughout this specification, unless the context requires otherwise, the words "comprise", "having" and "comprises", and variations thereof, will be understood to imply the inclusion of a stated element or integer or group of elements or integers but not the exclusion of any other element or integer or group of elements or integers.

"MOR 202" is an anti-CD 38 antibody, also referred to as "MOR 03087" or "MOR 3087". These terms are used interchangeably in this disclosure. MOR202 has an IgG1 Fc region.

MOR202 HCDR1 has the amino acid sequence according to Kabat:

SYYMN(SEQ ID NO:1)。

MOR202 HCDR2 has the amino acid sequence according to Kabat:

GISGDPSNTYYADSVKG(SEQ ID NO:2)。

MOR202 HCDR3 has the amino acid sequence according to Kabat:

DLPLVYTGFAY(SEQ ID NO:3)。

MOR202 LCDR1 was the amino acid sequence according to Kabat:

SGDNLRHYYVY(SEQ ID NO:4)。

MOR202 LCDR2 was the amino acid sequence according to Kabat:

GDSKRPS(SEQ ID NO:5)。

the amino acid sequence of MOR202 LCDR3 was: QTYTGGASL (SEQ ID NO: 6).

The amino acid sequence of the MOR202 variable heavy domain is:

QVQLVESGGGLVQPGGSLRLSCAASGFTFSSYYMNWVRQAPG KGLEWVSGISGDPSNTYYADSVKGRFTISRDNSKNTLYLQMNSLRA EDTAVYYCARDLPLVYTGFAYWGQGTLVTVSS(SEQ ID NO:7)。

the amino acid sequence of the MOR202 variable light domain is:

DIELTQPPSVSVAPGQTARISCSGDNLRHYYVYWYQQKPGQAP VLVIYGDSKRPSGIPERFSGSNSGNTATLTISGTQAEDEADYYCQTYT GGASLVFGGGTKLTVLGQ(SEQ ID NO:8)。

the DNA sequence encoding the MOR202 variable heavy domain is:

CAGGTGCAATTGGTGGAAAGCGGCGGCGGCCTGGTGCAACCGGGCGGCAGCCTGCGTCTGAGCTGCGCGGCCTCCGGATTTACCTTTTCTTCTTATTATATGAATTGGGTGCGCCAAGCCCCTGGGAAGGGTCTCGAGTGGGTGAGCGGTATCTCTGGTGATCCTAGCAATACCTATTATGCGGATAGCGTGAAAGGCCGTTTTACCATTTCACGTGATAATTCGAAAAACACCCTGTATCTGCAAATGAACAGCCTGCGTGCGGAAGATACGGCCGTGTATTATTGCGCGCGTGATCTTCCTCTTGTTTATACTGGTTTTGCTTATTGGGGCCAAGGCACCCTGGTGACGGTTAGCTCA(SEQ ID NO:10)。

the DNA sequence encoding the MOR202 variable light domain is:

GATATCGAACTGACCCAGCCGCCTTCAGTGAGCGTTGCACCAGGTCAGACCGCGCGTATCTCGTGTAGCGGCGATAATCTTCGTCATTATTATGTTTATTGGTACCAGCAGAAACCCGGGCAGGCGCCAGTTCTTGTGATTTATGGTGATTCTAAGCGTCCCTCAGGCATCCCGGAACGCTTTAGCGGATCCAACAGCGGCAACACCGCGACCCTGACCATTAGCGGCACTCAGGCGGAAGACGAAGCGGATTATTATTGCCAGACTTATACTGGTGGTGCTTCTCTTGTGTTTGGCGGCGGCACGAAGTTAACCGTTCTTGGCCAG(SEQ ID NO:11)。

the invention

The present invention relates to antibodies or antibody fragments specific for CD38, useful for the prevention and/or treatment of autoantibody mediated autoimmune diseases. In some aspects, the antibody is MOR202 and the autoantibody mediated AD is any one selected from table 1. In one aspect, the antibody is MOR202 and the autoantibody-mediated AD is SLE. In a particular aspect, the antibody is MOR202 and the autoantibody mediated AD is idiopathic membranous glomerulonephritis, preferably anti-PLA 2R positive membranous glomerulonephritis.

The present invention also provides a method for preventing and/or treating an autoantibody-mediated autoimmune disease, the method comprising administering to a subject in need thereof an antibody or antibody fragment specific for CD 38. In some aspects, the antibody or antibody fragment specific for CD38 used in the methods is MOR202, and the autoantibody-mediated AD is selected from table 1. In one aspect, the antibody or antibody fragment specific for CD38 used in the method is MOR202 and the autoantibody mediated AD is SLE. In a particular aspect, the antibody or antibody fragment specific for CD38 used in the method is MOR202 and the autoantibody mediated AD is idiopathic membranous glomerulonephritis, preferably anti-PLA 2R positive membranous glomerulonephritis.

The invention also provides pharmaceutical compositions comprising the antibodies or antibody fragments specific for CD38, and methods of preventing and/or treating autoantibody-mediated autoimmune diseases by administering the antibodies or antibody fragments specific for CD 38.

Pharmaceutical composition

When used as a medicament, antibodies or antibody fragments specific for CD38 are typically administered in a pharmaceutical composition. Such compositions may be prepared in a manner well known in the pharmaceutical art and comprise antibodies or antibody fragments specific for CD 38. Typically, an antibody or antibody fragment specific for CD38 is administered in an effective amount. The actual amount of antibody or antibody fragment specific for CD38 administered will generally be determined by a physician, in the light of the relevant circumstances, including the condition to be treated, the chosen route of administration, the actual antibody or antibody fragment administered, the age, weight, and response of the individual patient, the severity of the patient's symptoms, and the like.

The compositions of the present disclosure are preferably pharmaceutical compositions comprising MOR202 and a pharmaceutically acceptable carrier, diluent or excipient for use in the treatment of autoantibody mediated autoimmune diseases.

The pharmaceutically acceptable carrier should be suitable for intravenous, intramuscular, subcutaneous, parenteral, spinal or epidermal administration (e.g., by injection or infusion). The pharmaceutical carrier enhances or stabilizes the composition, or facilitates preparation of the composition. Pharmaceutically acceptable carriers include physiologically compatible solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like.

The composition should be sterile and fluid. Proper fluidity can be maintained, for example, by the use of a coating such as lecithin, by the maintenance of the required particle size in the case of dispersions and by the use of surfactants. In many cases, it will be preferable to include isotonic agents, for example, sugars, polyalcohols such as mannitol or sorbitol in the composition and sodium chloride. Prolonged absorption of the injectable compositions can be brought about by including in the composition an agent which delays absorption, for example, aluminum monostearate or gelatin.

The pharmaceutical compositions of the present disclosure may be administered by a variety of routes known in the art. The route of administration selected for the antibodies or antibody fragments of the present disclosure includes intravenous, intramuscular, intradermal, intraperitoneal, subcutaneous, spinal, or other parenteral routes of administration, e.g., by injection or infusion. Parenteral administration may refer to modes of administration other than enteral and topical administration, typically by injection, including, but not limited to, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intraocular, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural, intracerebral, intralesional and intrasternal injection and infusion. Alternatively, the compositions of the present disclosure may be administered by a non-parenteral route, such as topical, epidermal, dermal, or mucosal route of administration, such as intranasal, oral, vaginal, rectal, sublingual, transdermal, or topical administration. Furthermore, the antibody or antibody fragment may be administered as a slow release formulation, in which case less frequency of administration is required. In addition, pulmonary administration may also be employed, for example, by using an inhaler or nebulizer and formulation with a nebulizer.

The antibody or antibody fragment specific for CD38 is preferably formulated as an injectable composition. In a preferred aspect, the anti-CD 38 antibodies of the present disclosure are administered intravenously. In other aspects, the anti-CD 38 antibodies of the present disclosure are administered subcutaneously, intra-articularly, or intraspinally.

Depending on the route of administration, the active compounds, i.e., antibodies, antibody fragments, bispecific and multispecific molecules, may be coated in a material to protect the compound from the action of acids and other natural conditions that may inactivate the compound.

Injectable compositions are typically based on injectable sterile saline or phosphate buffered saline or other injectable carriers known in the art. As previously mentioned, the antibody or antibody fragment specific for CD38 in such compositions is typically a minor component, typically about 0.05-10% by weight, with the remainder being an injectable carrier or the like. If necessary, the composition may further comprise a solubilizing agent and a local anesthetic, such as lidocaine, to relieve pain at the injection site.

In one aspect, the disclosure relates to compositions comprising an anti-CD 38 antibody for use in treating autoantibody mediated AD, the compositions further comprising one or more pharmaceutically acceptable carriers and/or diluents.

An important aspect of the present disclosure is a pharmaceutical composition capable of mediating killing of antibody-secreting cells (e.g., plasmablasts, plasma cells) expressing CD38 by ADCC and ADCP.

Method of treatment

In one embodiment, the invention provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of an autoantibody mediated autoimmune disease.

In one embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of Systemic Lupus Erythematosus (SLE).

In another embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of idiopathic membranous nephropathy.

In one embodiment, the invention provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of autoimmune membranous nephropathy.

In a specific embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of anti-PLA 2R-positive membranous nephropathy.

In another aspect, the present disclosure provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the prevention and/or treatment of membranous nephropathy in a patient having anti-PLA 2R antibody titers.

In another embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38, for use in the preparation of a medicament for the prevention and/or treatment of an autoantibody mediated autoimmune disease.

In one aspect, the disclosure provides the use of an anti-CD 38 antibody in the manufacture of a medicament for the treatment and/or prevention of Systemic Lupus Erythematosus (SLE).

In another aspect, the present disclosure provides the use of an anti-CD 38 antibody in the manufacture of a medicament for the treatment and/or prevention of idiopathic membranous nephropathy.

In another aspect, the present disclosure provides the use of an anti-CD 38 antibody in the manufacture of a medicament for the treatment and/or prevention of autoantibody mediated membranous nephropathy.

In a preferred aspect, the present disclosure provides the use of an anti-CD 38 antibody in the manufacture of a medicament for the treatment and/or prevention of anti-PLA 2R positive membranous nephropathy.

In other aspects, the present disclosure provides for the use of MOR202 in the manufacture of a medicament for the treatment and/or prevention of an autoantibody-mediated autoimmune disease.

In other aspects, the present disclosure provides for the use of MOR202 in the preparation of a medicament for the treatment and/or prevention of Systemic Lupus Erythematosus (SLE).

In other aspects, the present disclosure provides for the use of MOR202 in the manufacture of a medicament for the treatment and/or prevention of idiopathic membranous nephropathy.

In other aspects, the present disclosure provides for the use of MOR202 in the manufacture of a medicament for the treatment and/or prevention of autoantibody mediated membranous nephropathy.

In a preferred aspect, the present disclosure provides the use of MOR202 in the manufacture of a medicament for the treatment and/or prevention of anti-PLA 2R positive membranous nephropathy.

In one embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38 and another therapeutic agent, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and another therapeutic agent, for use in the prevention and/or treatment of an autoantibody mediated autoimmune disease, preferably autoantibody mediated membranous nephropathy.

In another embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38 and another therapeutic agent, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and another therapeutic agent, for use in the prevention and/or treatment of Systemic Lupus Erythematosus (SLE).

In another embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38 and another therapeutic agent, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and another therapeutic agent, for use in the prevention and/or treatment of idiopathic membranous nephropathy.

In a preferred embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38 and another therapeutic agent, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and another therapeutic agent, for use in the prevention and/or treatment of anti-PLA 2R-positive membranous nephropathy.

In one embodiment, the present disclosure provides an antibody or antibody fragment specific for CD38 and another therapeutic agent, or a pharmaceutical composition comprising an antibody or antibody fragment specific for CD38 and another therapeutic agent, for use in the manufacture of a medicament for the prevention and/or treatment of an autoantibody mediated autoimmune disease, preferably autoantibody mediated membranous nephropathy.

In other aspects, the present disclosure provides the use of an anti-CD 38 antibody and another therapeutic agent or a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment in the manufacture of a medicament for the treatment and/or prevention of an autoantibody mediated autoimmune disease, preferably autoantibody mediated membranous nephropathy.

In a preferred aspect, the present disclosure provides the use of an anti-CD 38 antibody and another therapeutic agent or a pharmaceutical composition comprising the anti-CD 38 antibody or antibody fragment in the manufacture of a medicament for the treatment and/or prevention of Systemic Lupus Erythematosus (SLE).

In a preferred aspect, the present disclosure provides the use of an anti-CD 38 antibody and another therapeutic agent or a pharmaceutical composition comprising an anti-CD 38 antibody or antibody fragment in the manufacture of a medicament for the treatment and/or prevention of idiopathic membranous nephropathy.

In other aspects, the present disclosure provides the use of MOR202 and another therapeutic agent or a pharmaceutical composition comprising MOR202 in the manufacture of a medicament for the treatment and/or prevention of an autoantibody mediated autoimmune disease, preferably autoantibody mediated membranous nephropathy.

In one aspect, the present disclosure provides use of MOR202 and another therapeutic agent or a pharmaceutical composition comprising MOR202 in the preparation of a medicament for the treatment and/or prevention of Systemic Lupus Erythematosus (SLE).

In a particular aspect, the present disclosure provides use of MOR202 and another therapeutic agent or a pharmaceutical composition comprising MOR202 in the manufacture of a medicament for the treatment and/or prevention of idiopathic membranous nephropathy.

In a particular aspect, the present invention provides the use of MOR202 and another therapeutic agent or a pharmaceutical composition comprising MOR202 in the manufacture of a medicament for the treatment and/or prevention of anti-PLA 2R positive membranous nephropathy.

In a specific embodiment, the other therapeutic agent is an autoimmune disease therapeutic agent. In a specific embodiment, the agent is an immunosuppressant and is selected from steroids (e.g., clobetasol propionate, desoximetasone, hydrocortisone, methylprednisolone, prednisone, prednisolone, budesonide, or dexamethasone), proteasome inhibitors (e.g., bortezomib), cytostatics (e.g., cyclophosphamide, azathioprine, methotrexate), drugs that act on immunophilins (e.g., cyclosporine, tacrolimus, sirolimus), and other immunosuppressants.

In a further method of treatment aspect, the invention provides a method of preventing and/or treating a mammal having an autoantibody mediated autoimmune disease, the method comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions as described herein for the treatment and/or prevention of said condition.

In one aspect, the invention provides a method for treating autoantibody-mediated AD, preferably autoantibody-mediated membranous nephropathy, comprising administering to the subject an anti-CD 38 antibody.

In one embodiment, the present disclosure provides a method of preventing and/or treating a mammal having an autoantibody-mediated autoimmune disease, wherein the method comprises administering an additional therapeutic agent with an antibody or antibody fragment specific for CD 38. In a specific embodiment, the additional therapeutic agent is an autoimmune disease therapeutic agent. In a specific embodiment, the agent is an immunosuppressive agent.

In the methods of treatment or use described herein, the autoimmune disease is in particular an autoantibody mediated autoimmune disease (e.g. SLE, graves' disease, myasthenia gravis, pemphigus vulgaris, autoimmune encephalitis, idiopathic membranous glomerulonephritis, anti-PLA 2R positive membranous glomerulonephritis).

In a particular aspect, the present disclosure provides a method for treating and/or preventing anti-PLA 2R-positive membranous glomerulonephritis in a subject, the method comprising administering to the subject an anti-CD 38 antibody.

In one embodiment, the present disclosure provides a method of preventing and/or treating a subject having moderate to severe autoantibody mediated AD comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions as described herein for treating and/or preventing the disorder.

In some embodiments, the present disclosure provides methods of preventing and/or treating a subject having autoantibody-mediated AD, wherein the subject is resistant to treatment with other immunosuppressant therapies including corticosteroid or calcineurin inhibitors or B cell depleting therapies (e.g., using rituximab or any other anti-CD 20 antibody or anti-BAFF antibody), comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein for treating and/or preventing the disorder.

In one aspect, the invention provides methods of using an anti-CD 38 antibody or antibody fragment to achieve a prophylactic or therapeutic benefit in a patient having an autoantibody mediated autoimmune disease, preferably autoantibody mediated membranous nephropathy.

Another aspect provided herein is a method of treating and/or preventing a condition mediated by an autoantibody-mediated autoimmune disease using an anti-CD 38 antibody.

Another aspect provided herein is a method for reducing the incidence of, ameliorating, inhibiting, reducing and/or delaying the onset, development or progression of an autoantibody-mediated disease condition in a subject, comprising administering to the subject an effective amount of an anti-CD 38 antibody.

In preferred embodiments, the present disclosure provides methods for treating patients exhibiting elevated levels of specificity for one or more autoantibodies associated with autoimmune diseases.

In other aspects, the present disclosure provides methods for treating and/or preventing SLE caused by the presence of anti-nuclear or anti-DNA autoantibodies or any other SLE autoantibodies as set forth in figure 12.

In other aspects, the invention provides methods for treating and/or preventing SLE associated with the presence of anti-nuclear or anti-DNA autoantibodies or any other SLE autoantibodies as set forth in figure 12.

In other aspects, the disclosure provides methods for treating and/or preventing diseases caused by the presence of anti-phospholipase a2 receptor (PLA2R) autoantibodies. In other aspects, the invention provides methods for treating and/or preventing diseases associated with the presence of anti-phospholipase a2 receptor (PLA2R) autoantibodies.

In other aspects, the disclosure provides methods for treating and/or preventing diseases caused by the presence of autoantibodies against the 7A domain of thrombospondin type 1. In other aspects, the invention provides a method for treating and/or preventing a disease associated with autoantibodies against the 7A domain of thrombospondin type 1.

In other embodiments, the present disclosure provides methods of reducing the titer of autoantibodies in the serum of a subject having an autoantibody-mediated autoimmune disease, the method comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein.

In a preferred embodiment, the present disclosure provides a method of reducing autoantibody titers in the serum of a subject having idiopathic membranous glomerulonephritis comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein. For example, the methods provided herein comprise administering an anti-CD 38 antibody to a patient having elevated levels of anti-PLA 2R and/or anti-thrombospondin type 1 7A domain autoantibodies.

In one embodiment, the reduction (alteration) in serum autoantibody titer in a subject with anti-PLA 2R positive membranous glomerulonephritis after administration of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein is at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45% or at least 50% compared to baseline.

In another embodiment, the present disclosure provides a method for treating and/or preventing proteinuria associated with anti-PLA 2R positive membranous glomerulonephritis in an individual, the method comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein.

In another aspect, the present disclosure provides a method for preventing decreased kidney function in an individual having anti-PLA 2R-positive membranous nephropathy, the method comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein.

In another aspect, the present disclosure provides a method for treating and/or preventing hypercholesterolemia (high cholesterol) in a subject suffering from membranous nephropathy, the method comprising administering an effective amount of an antibody or antibody fragment specific for CD38 or one or more pharmaceutical compositions described herein.

In one embodiment, the disclosure relates to the use of an antibody or antibody fragment specific for CD38 in the treatment of an autoantibody-mediated autoimmune disease, wherein the antibody or antibody fragment binds to a plasma cell expressing CD 38.

In other embodiments, the disclosure relates to a method of treating an autoantibody-mediated autoimmune disease in a subject comprising administering to the subject a pharmaceutical composition comprising an antibody or antibody fragment that binds to a CD 38-expressing cell and causes depletion of such CD 38-expressing cell.

In a preferred embodiment, the present disclosure relates to a method of treating an autoantibody-mediated autoimmune disease in a subject comprising administering to the subject a pharmaceutical composition comprising an antibody or antibody fragment that binds to and causes depletion of CD 38-expressing antibody-secreting cells while retaining other low CD 38-expressing (non-antibody-secreting) cells, such as NK cells.

In a particular preferred embodiment, the present disclosure relates to a method of treating an autoantibody mediated autoimmune disease in a subject comprising administering to the subject a pharmaceutical composition comprising an antibody or antibody fragment that binds to and causes depletion of antibody secreting cells expressing CD38 while retaining NK cells, i.e. wherein the antibody has significantly higher specific cell killing of the antibody secreting cells than NK cells.

In one embodiment, the disclosure relates to a method of treating an autoantibody-mediated autoimmune disease in a subject comprising administering to the subject a pharmaceutical composition comprising an antibody or antibody fragment that binds to antibody-secreting cells that express CD38 and causes depletion of such CD 38-expressing antibody-secreting cells while retaining other low CD 38-expressing (non-antibody-secreting) cells, e.g., NK cells, wherein specific cell killing of the antibody-secreting plasma cells is at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, and wherein specific cell killing of the non-antibody-secreting NK cells is less than 30%, less than 25%, less than 20%, or less than 15%, as determined in a standard ADCC assay.

Antibodies or antibody fragments specific for CD38 may be administered as the sole active agent or may be administered in combination with other therapeutic agents. In a particular embodiment, co-administration of two (or more) drugs allows for a significant reduction in the dosage of each drug used, thereby reducing the side effects seen.

In one embodiment, the antibody or antibody fragment specific for CD38 or a pharmaceutical composition comprising the antibody or antibody fragment specific for CD38 is administered as a medicament. In a particular embodiment, the pharmaceutical composition further comprises other active ingredients.

It will be apparent to those skilled in the art that co-administration includes any manner of delivering two or more therapeutic agents to a patient as part of the same treatment regimen. Although the two or more agents may be administered simultaneously in a single formulation, i.e. as a single pharmaceutical composition, this is not essential. The agents may be administered at different times in different formulations.

The therapies (e.g., prophylactic or therapeutic agents) of the combination therapies of the present disclosure can be administered to a subject concomitantly or sequentially.

The therapies (e.g., prophylactic or therapeutic agents) of the combination therapies of the present disclosure can also be administered cyclically. Cycling therapy involves administering a first therapy (e.g., a first prophylactic or therapeutic agent) for a period of time, followed by a second therapy (e.g., a second prophylactic or therapeutic agent) for a period of time, and repeating the sequential administration, i.e., the cycle, to reduce the development of resistance to one of the therapies (e.g., agents), avoid or reduce side effects of one of the therapies (e.g., agents), and/or improve the efficacy of the therapy.

The therapies (e.g., prophylactic or therapeutic agents) of the combination therapies of the present disclosure can be administered to a subject concurrently. The term "simultaneously" is not limited to administration of therapies (e.g., prophylactic or therapeutic agents) at exactly the same time, but means that a pharmaceutical composition comprising an antibody or antibody fragment of the disclosure is administered to a subject in a sequence and at intervals such that the antibody of the disclosure can act with other therapies to provide increased benefit compared to administering them otherwise.

Antibodies

In certain embodiments of the present disclosure, an antibody or antibody fragment specific for CD38 according to the present disclosure comprises a variable heavy chain variable region, a variable light chain region, a heavy chain, a light chain, and/or CDRs comprising any of the amino acid sequences of a CD 38-specific antibody as described in WO 2007/042309.

In one embodiment, the antibody or antibody fragment specific for CD38 comprises: comprises the amino acid sequence of SEQ ID NO: 1, a HCDR1 region comprising the amino acid sequence of SEQ ID NO: 2, a HCDR2 region comprising the amino acid sequence of SEQ ID NO: 3, a HCDR3 region comprising the amino acid sequence of SEQ ID NO: 4, a LCDR1 region comprising the amino acid sequence of SEQ ID NO: 5 and an LCDR2 region comprising the amino acid sequence of SEQ ID NO:6, LCDR3 region of amino acid sequence.

In one embodiment, the antibody or antibody fragment specific for CD38 comprises the amino acid sequence of SEQ ID NO: 1, HCDR1 region of SEQ ID NO: 2, HCDR2 region of SEQ ID NO: 3, HCDR3 region of SEQ ID NO: LCDR1 region of 4, SEQ ID NO: 5 and the LCDR2 region of SEQ ID NO: LCDR3 zone of 6.

In one embodiment, the antibody or antibody fragment specific for CD38 comprises the amino acid sequence of SEQ ID NO: 7 and the variable heavy chain region of SEQ ID NO: 8, variable light chain region.

In another embodiment, the antibody or antibody fragment comprises SEQ ID NO: 7 and the variable heavy chain region of SEQ ID NO: 8 or a variable light chain region corresponding to SEQ ID NO: 7 and a variable heavy chain region corresponding to SEQ ID NO: 8 has at least 60%, at least 70%, at least 80%, at least 90%, or at least 95% identity to the variable heavy chain region and the variable light chain region.

Comprising a polypeptide comprising SEQ ID NO: 7 and a variable heavy chain region comprising the amino acid sequence of SEQ ID NO: 8 is the human anti-CD 38 antibody known as MOR 202.

In one embodiment, the present disclosure relates to a nucleic acid composition comprising one or more nucleic acid sequences encoding the antibody or antibody fragment specific for CD38, wherein the antibody or antibody fragment comprises the amino acid sequence of SEQ ID NO: 1, HCDR1 region of SEQ ID NO: 2, HCDR2 region of SEQ ID NO: 3, HCDR3 region of SEQ ID NO: LCDR1 region of 4, SEQ ID NO: 5 and the LCDR2 region of SEQ ID NO: LCDR3 zone of 6.

In another embodiment, the present disclosure relates to a nucleic acid encoding an isolated monoclonal antibody or fragment thereof, wherein the nucleic acid comprises SEQ ID NO: 10 and the VH and SEQ ID NO: 11 VL.

In one embodiment, the disclosed antibody or antibody fragment specific for CD38 is a monoclonal antibody or antibody fragment.

In one embodiment, the disclosed antibody or antibody fragment specific for CD38 is a human, humanized or chimeric antibody.

In certain embodiments, the antibody or antibody fragment specific for CD38 is an isolated antibody or antibody fragment.

In another embodiment, the antibody or antibody fragment is a recombinant antibody or antibody fragment.

In another embodiment, the antibody or antibody fragment is a recombinant human antibody or antibody fragment.

In another embodiment, the recombinant human antibody or antibody fragment is an isolated recombinant human antibody or antibody fragment.

In another embodiment, the recombinant human antibody or antibody fragment or isolated recombinant human antibody or antibody fragment is monoclonal.

In one embodiment, the disclosed antibody or antibody fragment is of the IgG isotype.

In another embodiment, the antibody is IgG 1.

In one embodiment, the antibody fragment is a bivalent antibody fragment.

In a particular aspect of the invention, the anti-CD 38 antibody is MOR 202.

In one embodiment, the present disclosure relates to a pharmaceutical composition comprising MOR202, or a fragment thereof, specific for CD38 and a pharmaceutically acceptable carrier or excipient.

In certain embodiments, the antibody or antibody fragment specific for CD38 is an antibody or antibody fragment that specifically binds CD 38.

In certain embodiments, the antibody or antibody fragment specific for CD38 is an antibody or antibody fragment that specifically binds to human CD 38.

In certain embodiments, the antibody or antibody fragment specific for CD38 is an isolated monoclonal antibody or antibody fragment that specifically binds to human CD 38.

In another embodiment, the disclosure provides an antibody or antibody fragment specific for CD38 that depletes antibody-secreting cells expressing CD 38.

In a preferred aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing serum autoantibody levels in a subject with SLE, said agent comprising an anti-CD 38 antibody as an active ingredient.

In a preferred aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing serum autoantibody levels in a subject with aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

In a particular aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing serum anti-PLA 2R autoantibody levels in a subject with aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

In another aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing anti-PLA 2R autoantibodies deposited in the kidney of a subject with aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

In another aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing proteinuria in a subject having aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

In another aspect, the present disclosure provides a prophylactic and/or therapeutic agent for reducing hyperlipidemia (e.g., hypercholesterolemia, high cholesterol) in a subject having aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

In another aspect, the present disclosure provides a prophylactic and/or therapeutic agent for restoring, improving or normalizing renal function as indicated by glomerular filtration rate (eGFR) based on the CKD-epi equation in a subject with aMN, the agent comprising an anti-CD 38 antibody as an active ingredient.

Working examples

An exemplary antibody specific for CD38 used in the examples below is the human antibody MOR 202.

Example 1: efficacy of MOR202 against preexisting antibody titers of tetanus toxoid as a vaccine antigen.

To assess the effect of MOR202 treatment on pre-existing antibody titers, the inventors determined anti-tetanus toxoid titers in human serum collected from subjects at defined time points after MOR202 administration.

1.1. Design of research

The following bioanalytical evaluation is part of an open label, multi-center, dose escalation clinical study to characterize the safety and primary efficacy of human anti-CD 38 antibody MOR03087 in adult subjects with relapsed/refractory multiple myeloma. The objective of this experiment was to quantify the anti-tetanus toxoid (anti-TT) IgG antibody titers in human serum samples obtained during the study to demonstrate that monoclonal anti-CD 38 antibodies (MOR03087 ═ MOR202) were effective in reducing pre-existing antibody titers. Human serum samples were analyzed for anti-tetanus toxoid (anti-TT) IgG levels by ELISA (table 4).

1.2. Determination of anti-tetanus toxoid IgG by quantitative ELISA

Serum samples were stored at-75 ± 15 ℃ until analysis. For the measurement of anti-tetanus toxoid IgG in the sample, a commercially available immunoassay kit (Vacczyme) was used^TMBinding Site, product code MK 010). Prior to sample analysis, the assay was qualified at the bioanalytical test site and all measurements were made according to the manufacturer's recommendations. The kit provides two Quality Control (QC) samples with lot-specific target values and ranges. QC target value (high QC/low QC): 1.31/0.22IU/mL (batch 1), 1.32/0.23IU/mL (batch 2), 1.39/0.25IU/mL (batch 3), 1.3/0.25IU/mL (batch 4), 1.27/0.28IU/mL (batch 5). In qualified runs, additional 3 concentration levels were evaluated based on the results of the qualified runs: ULOQ (7IU/mL), LLOQ (0.01IU/mL), HQC (2.8-3.5 IU/mL) (ULOQ: upper limit of quantitation, LLOQ: lower limit of quantitation, HQC: high quality control). The calibration standard is provided with the kit and can be used immediately. One set of calibration standards consists of: 0.01, 0.03, 0.09, 0.26, 0.78, 2.33, 7 IU/mL.

1.2.1. Measurement of Performance

The samples were analysed in duplicate in runs (one 96-well plate) together with one set of calibration standard samples and two sets of QC samples provided in the assay kit. anti-TT IgG ELISA was performed without sample treatment (work up). The samples were measured after dilution with sample diluent (minimum required dilution 1: 101).

1.2.2. Principle of testing

VaccZyme^TMThe IgG enzyme immunoassay kit for resisting tetanus toxoid is a two-step enzyme-linked immunosorbent assay. The wells of the 12-split 8-well slats were coated with tetanus toxoid from tetanus bacillus. Calibrators, controls and diluted serum samples were added to the wells and antibodies recognizing tetanus toxoid antigen were conjugated during the first incubation. After washing the wells to remove any unbound protein, purified peroxidase was addedLabeled rabbit anti-human IgG (gamma chain specific) conjugates. The conjugate binds to the captured human antibody and excess unbound conjugate is removed by a further washing step. The bound conjugate was visualized with a 3,3 ', 5, 5' Tetramethylbenzidine (TMB) substrate, which produced a blue reaction product whose intensity was directly proportional to the concentration of antibody in the sample. Phosphoric acid was added to each well to terminate the reaction. This will produce a yellow end point color, which is read at 450 nm.

1.2.3. Data evaluation

Magellan using TECAN Austria GmbH using 4 parameter logic^TMSoftware version 6.6 data reduction was performed on microplate reader readings. The optical density of the quality control and study samples was converted to concentration (IU/mL) using a standard curve. Extrapolation (extrapolation factor 1.1) was performed to enable calculation of concentrations close to the upper and lower limit of quantitation. All measured and calculated concentration data are reported in 3 significant figures.

1.2.4. Results

Human serum samples were analyzed in 22 assay runs. In 22 accepted runs, accuracy and precision data between assays were evaluated from calibration standard samples. The accuracy (expressed as deviation) and precision (expressed as coefficient of variation; CV) data are shown in Table 2.

TABLE 2 accuracy and precision of calibration standards

The inter-assay accuracy and precision data were evaluated from up to 22 QC samples in 22 accepted runs. The accuracy (expressed as deviation) and precision (expressed as coefficient of variation; CV) data are shown in Table 3.

TABLE 3 accuracy and precision of quality control samples

Table 4 shows the anti-TT concentrations (IU/mL) of serum samples from 74 subjects for which the baseline and at least one of the "cycle 1, day 15" or "cycle 2, day 15" data points are available. Subjects receiving a combination (e.g., IVIG administration or booster vaccination) during a clinical study were not included in the analysis because these combination factors lead to a bias in outcome.

TABLE 4 anti-TT antibody concentrations in human serum samples following MOR202 administration

To determine the effect of MOR202 on anti-TT antibody titers, serum samples obtained at day 0 (prior to MOR202 treatment, indicated as "baseline" in table 4), day 15 (cycle 1), and day 43(═ cycle 2, day 15) post MOR202 administration were analyzed. At day 15 of cycle 1 following MOR202 treatment, anti-TT antibody titers in most subjects showed a significant decrease compared to baseline at day 0. The% change in anti-TT concentration of the "baseline" samples obtained on day 0 compared to the anti-TT concentration of the samples obtained on day 15 of cycle 1 (labeled "cycle 1, day 15") is shown in FIG. 5. The% change in anti-TT concentration of the "baseline" samples obtained on day 0 compared to the anti-TT concentration of the samples obtained on day 15 of cycle 2 (labeled "cycle 2, day 15") is shown in FIG. 6. In most subjects treated with MOR202, anti-TT antibody titers were further reduced (i.e., a higher percent change from cycle 1, day 15 to cycle 2, day 15), indicating a long-term effect of MOR202 on antibody titers.

Taken together, these data demonstrate that MOR202 is effective in reducing serum antibody titers. Thus, effective treatment and/or prevention of autoantibody mediated AD using anti-CD 38 antibodies (e.g., MOR202) is highly reasonable.

Example 2: determination of M-protein level

2.1. Design of research

The M-protein level in serum samples from multiple myeloma patients (participating in the test of example 1) was quantified by Capillary Electrophoresis (CE) assays, in particular Serum Protein Electrophoresis (SPEP) and Urine Protein Electrophoresis (UPEP).

2.2. Capillary electrophoresis-test principle

Charged molecules are separated by their electrophoretic mobility at a specific pH in an alkaline buffer. Separation occurs according to electrolyte pH and electroosmotic flow. Each sample was diluted in dilution buffer and the capillary was filled with separation buffer; the sample is then injected into the anode end of the capillary by suction. Followed by high voltage protein separation. Direct detection and quantification of different protein fractions was then performed at the cathode end of the capillary at specific wavelengths.

Other assays to assess M-protein levels include, but are not limited to, immuno-fixation electrophoresis (IFE), serum-free light chain (sFLC) assays, and total protein assays (Keren DF and Schroeder L, Clin Chem Lab Med.2016Jun 1; 54 (6): 947-61). In addition, an IFE-based REFELX assay as described in WO/2017/149122 may be performed.

2.3 results:

figure 7 shows the change in M-protein levels in percent [% ] in multiple myeloma patients after MOR202 treatment.

The effect of MOR202 in reducing M-protein indirectly suggests the destruction and depletion of malignant plasma cells producing M-protein. In addition to the results of example 1 shown in fig. 5 and 6, the reduction of M-protein following MOR202 administration (fig. 7-9) provided further evidence that MOR202 was effective in reducing antibody titers.

Example 3: evaluation of Natural Killer (NK) cell mediated ADCC

3.1 Experimental setup

To test the specific killing effect of natural killer cell mediated MOR202, daratuzumab and ixabendazole (Isatuximab, SAR650984) on (i) multiple myeloma cell line highly expressing CD38 (NCI-H929) and (ii) human NK cells lowly expressing CD38, ADCC assays were performed. NK cells were purified from human blood by MACS (Miltenyi Biotec, cat # 130-. NK cell purity was assessed by FACS using CD3/CD16+ CD56/CD45 TritestTM (Becton Dickinson, cat # 342411). NCI-H929 target cells were incubated with the respective antibodies at defined concentrations at a ratio of effector cells to target cells of 3:1 for 2-4H at 37 ℃. NK target cells were incubated with each antibody only for 2-4h at 37 ℃ since target cells and effector cells were identical for NK cell: NK cell set-up. To determine cytotoxicity, Propidium Iodide (PI) was added to the cell samples after incubation and PI uptake in dead cells was immediately assessed by flow cytometry.

3.2 results

FIG. 10 shows the results of specific killing [% ] of MOR202, daratumab and ixabelmb on NCI-929 and NK cells.

Example 4: evaluation of safety of MOR202 in subjects with anti-PLA 2R positive membranous nephropathy (aMN) And efficacy of

4.1 study design

The objective of this study was to evaluate the safety, tolerability and efficacy of the human anti-CD 38 antibody MOR202 in patients with anti-PLA 2R positive membranous nephropathy (aMN), and to evaluate the effect of MOR202 on serum anti-PLA 2R antibody levels.

The MOR202 dose was based on the results of the clinical study in Multiple Myeloma (MM) and the PK/PD modeling method of example 1. In example 1, MOR202 was administered intravenously at 0.1-16 mg/kg on a dose escalation schedule, once weekly (QW) or once biweekly (Q2W), including the loading dose on day 4 of cycle 1. MOR202 was used as a single agent (monotherapy) or in combination with DEX, POM/DEX or LEN/DEX. The overall treatment duration is based on clinical response, up to 3 years of continuous treatment. From the results, a population-based PK/PD model was established, taking into account the different target expression rates between MM and aMN subjects. This model was used to simulate drug exposure (i.e. at a dose of 16 mg/kg: 4 x QW, then 5 x Q4W) as expected in the study, and the results were compared to the study data of example 1, taking into account the same treatment time. In the study of example 1, 6 patients were dosed with 16mg/kg QW for at least 24 weeks, including the loading dose on day 4. This would result in a 2.4-fold excess of MOR202 exposure compared to the expected dose and dosing regimen in current studies with similar maximal serum concentrations. The purpose of this trial was to assess the safety and efficacy of the human anti-CD 38 antibody MOR202 in anti-PLA 2R positive membranous nephropathy (aMN) patients eligible for immunosuppressive therapy for the first time or who were non-responsive to immunosuppressive therapy (IST) including rituximab (anti-CD 20) therapy.

Example 5: M-PLACE: phase Ib/IIa multicenter open label study with MOR202 treatment of two groups of aMN patients (NCT04145440)

A phase Ib/IIa open label multicenter clinical trial has been initiated to evaluate the safety and efficacy of human anti-CD 38 antibody MOR202 in anti-PLA 2R antibody positive membranous nephropathy (aMN), with an estimated 30 participants enrolled, currently being recruited in at least 14 centers in the united states and 6 sites in europe. Gov identifier (NCT number): NCT 04145440.

5.1. Design of research

The objective of this study was to evaluate the safety, tolerability and efficacy of the human anti-CD 38 antibody MOR202 in patients with anti-PLA 2R positive membranous nephropathy (aMN), and to evaluate the effect of MOR202 on serum anti-PLA 2R antibody levels.

The main therapeutic principle is to reduce the disease-specific anti-PLA 2R antibody of Membranous Nephropathy (MN) by targeted depletion of autoantibody-producing plasma cells by the anti-CD 38 antibody MOR 202.

The patient population to be treated includes adult subjects with MN that was biopsy confirmed to be positive for the anti-PLA 2R antibody. Age eligible for study: 18 to 80 years old (adult, elderly). All sexes were eligible for the study.

Key inclusion criteria:

the ratio of urine protein to creatinine is greater than or equal to 3.0g/g (measured from a 24 hour urine collection)

Estimated glomerular filtration rate of 50mL/min/1.73m or more in renal biopsies obtained within the last six months prior to initiation of screening²Or>30 and<50mL/min/1.73m²and interstitial fibrosis and tubular atrophy scores below 25%.

Supportive treatment with at least an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker for at least 4 weeks prior to screening to reach a stable dose.

Systolic pressure not more than 150mmHg, diastolic pressure not more than 100mmHg

Pneumococcal vaccine was administered within the last three years prior to the day of informed consent (subjects could be vaccinated to meet this criteria during screening; the interval from the first dose of MOR202 must be at least 14 days).

Group 1a (newly diagnosed patient): serum anti-PLA 2R antibody was determined to be > 150.0 Reaction Units (RU)/mL by screening with a Euroimmun ELISA.

Group 1b, relapsing subjects: complete immune and/or clinical remission is necessary at the discretion of the investigator, and serum anti-PLA 2R antibody > 50.0RU/mL is determined by Euromimn ELISA screening.

Group 2: prior therapy failure, i.e., the subject never achieved complete immune and/or clinical remission during or after completion of the accepted IST comprising cyclosporine a, tacrolimus, mycophenolate mofetil, ACTH or an alkylating agent (e.g., cyclophosphamide) or rituximab, at the discretion of the investigator. Serum anti-PLA 2R antibody was determined to be ≧ 20.0RU/mL by Euroimmun ELISA screening.

Key exclusion criteria:

hemoglobin <90 g/L.

Thrombocytopenia: blood platelet<100.0×10⁹/L。

Neutropenia: neutrophils<1.5×10⁹/L。

Leukopenia: white blood cell<3.0×10⁹/L。

Hypogammaglobulinemia: the serum immunoglobulin is less than or equal to 5.0 g/L.

Reasons secondary to MN (e.g. systemic lupus erythematosus, pharmacotherapy, malignancy)

Associated kidney diseases other than MN (e.g., diabetic kidney disease, lupus nephritis, IgA nephropathy).

Group 1 included approximately 20 aMN patients who were stable to supportive care treatment with ACEI/ARB at screening with adverse prognostic characteristics qualifying for IST, such as proteinuria (>5g/24h) and high and stable serum titers of anti-PLA 2R antibody (> 150.00 Response Units (RU)/mL, EuroImmun ELISA), or subjects who relapsed after at least 6 months of complete or partial proteinuria response (including serum anti-PLA 2R antibody titers below 20 RU/mL). The subject may be newly diagnosed (group 1a) or relapsed after a previous proteinuria and immune response to IST (group 1 b).

Group 2 included approximately 10 aMN patients requiring 2-or 3-line IST who did not respond immunologically to the previous line therapy and were therefore considered refractory. Failure of previous therapy, i.e., subjects never reduced serum anti-PLA 2R antibody titers to below 20RU/mL during or after completion of a putative IST containing CSA, tacrolimus, MMF, ACTH, or alkylating agents (e.g., cyclophosphamide) or rituximab, as determined at least 6 months after initiation of therapy.

The exclusion criteria for groups 1 and 2 were active infection, secondary cause of MN (e.g. SLE, drug therapy, malignancy), type 1 or type 2 diabetes, pregnancy or breast feeding, known or suspected to be hypersensitivity to study drugs and their excipients.

MOR202 monotherapy in both groups was a 24-week treatment period followed by a 28-week observation follow-up period (figure 11).

Administration of MOR202(MOR03087)

MOR202 was provided as a lyophilized powder for reconstitution in labeled glass vials. The MOR202 had to be stored at 2-8 ℃ until use. For drug preparation, each vial had to be reconstituted with 4.8mL of water for injection (WFI). After reconstitution, each vial contained 325mg MOR202(MOR03087) in a 5mL extractable volume (65 mg/mL). For infusion, it was diluted in 250mL of 0.9% sodium chloride solution.

All subjects were treated for 24 weeks, with six 28-day treatment cycles being assigned. On the following treatment days, a total of 9 doses of MOR202 will be administered: days 1,8, 15 and 22 of cycle 1, and day 1 of cycles 2-6 (FIG. 11). During the first treatment cycle, MOR202 was administered at 16mg/kg once weekly (i.e., cycle 1 for a total of 4 doses). In treatment cycles 2-6, MOR202 was administered at 16mg/kg on the first day of each cycle once every 4 weeks (i.e., C2D1, C3D1 …; cycle 2-6 for a total of 5 doses).

The first intravenous infusion of MOR202 should be slow (about 90 minutes, about 3 mL/min). If no infusion reaction occurred, the infusion time could be shortened to 1 hour or less in subsequent infusions, but is limited to the shortened steps listed in Table 5. The infusion time should not be shorter than 30 minutes. Pre-administration of antihistamines and antipyretics (e.g., acetaminophen/acetaminophen) to a subject is recommended to prevent infusion-related reactions (IRR). As shown in table 5, for the first 3 applications, about 30 minutes prior to the start of MOR202 infusion, it was necessary to administer a combination with intravenous dexamethasone (or an intravenous equivalent of glucocorticoid) to prevent IRR.

Table 5: MOR202 infusion guidelines

Number of MOR202 infusions	1	2	3	4 th and after
					Minimum infusion time	90min	60min	30min	30min
Maximum infusion rate	3mL/min	4.5mL/min	9mL/min	9mL/min
					Intravenous dosage of dexamethasone	16mg	16mg	8mg	Without forcing

5.3. Safety, immunogenicity and pharmacokinetic assessments

Safety will be assessed in terms of physical examination, vital signs, blood oxygen saturation, electrocardiogram, blood and biochemical tests, adverse reactions and immunogenicity. Adverse reactions will be ranked according to NCI CTCAE version 4.03. To monitor immunogenicity and pharmacokinetics, the presence of anti-MOR 202 antibodies (anti-drug antibodies) and the serum concentration of MOR202 at selected time points, respectively, will be assessed during the study.

5.4. Efficacy assessment

The main efficacy evaluations included: (i) serum anti-PLA 2R antibody levels measured by ELISA to follow the course of immune responses before, during and after MOR202 treatment. (ii) Proteinuria measured during and after MOR202 treatment based on UPCR of 24 hours urine/urine spot. (iii) Renal function before, during and after MOR202 treatment was determined by estimating glomerular filtration rate (eGFR) based on the CKD-epi equation. (iv) Natriuresis was determined from 24h urine.

5.5. Biomarkers

The presence and titer of anti-PLA 2R antibody (i.e., the kinetics of anti-PLA 2R antibody titer) at selected time points will be determined for all subjects over the course of the study. Optionally, additional autoantibody titers (e.g., anti-thrombospondin type 1 domain, anti-THSD 7A), anti-tetanus toxoid and/or anti-EBV antibodies at selected time points may be monitored. Serum concentrations of total IgG, IgA, and IgM can be assessed by ELISA. Quantitative NK cell, B cell, T cell (including regulatory T cell), plasmablast cell, plasma cell numbers at selected time points can be determined by peripheral blood flow cytometry or ELISPOT assays.

5.6.KDQOL-36

Kidney disease quality of life (KDQOL-36)^TM) The survey was used to assess quality of life (QoL), defined as the change in score from baseline in autoimmune membranous nephropathy patients treated with MOR 202.

Example 6: determination of anti-PLA 2R antibody levels

Anti-phospholipase a2 receptor (PLA2R) antibody levels in human serum samples will be quantified by a monospecific ELISA (enzyme immunoassay with a single antigen, Euroimmune, order No. EA1254-G) according to the manufacturer's instructions. Briefly, a polystyrene microwell plate coated with purified PLA2R antigen was used as the solid phase. Serum dilutions 1:101 were prepared and incubated on the antigen bound to the wells of the microplate. If the sample is positive, specific antibodies in the diluted serum sample will attach to the PLA2R antigen bound to the solid phase. Unbound antibody was washed away and then in the next step, the attached anti-PLA 2R specific antibody was detected with peroxidase-labeled anti-human IgG. Bound antibody is visualized using a chromogen/substrate solution capable of promoting a chromogenic reaction. The intensity of the color produced is proportional to the concentration of antibody in the serum sample.

Sequence listing

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